Ambulatory Cancer Center Research Articles

Use of cardiac biomarkers to improve initiation of cardioprotective therapy in patients with breast cancer receiving cardiotoxic chemotherapy in a multidisciplinary cancer center.

344 Background: Treatment for breast cancer commonly includes anthracyclines and anti-Her2 directed therapy, both of which carry a known cardiovascular risk. In high-risk patients, ESMO guidelines recommend consideration of cardiac biomarker (hs-cardiac troponin) testing for patients undergoing potentially cardiotoxic chemotherapy. Prophylactic use of cardioprotective medications such as angiotensin converting enzyme (ACE) inhibitors, angiotensin renin blockers (ARBs) or beta-blockers (BBs) can be considered to reduce development of cardiotoxicity. We aimed to identify the rates of cardiac biomarker testing performed and rates of abnormalities in patients considered to be high risk for cardiovascular disease undergoing breast cancer treatment with potentially cardiotoxic medication in hope of improving prevention efforts. Methods: We performed a retrospective chart review of patients with breast cancer treated with either anthracycline or anti-Her2 based therapy at our ambulatory cancer center from 2020 to 2023. Pre-treatment cardiovascular risk score was determined based on initial cardiac assessment at time of consultation with cardio-oncology. Completion of troponin biomarker testing and initiation of cardioprotective medication therapy was assessed. Patients who were not established with cardio-oncology or not on active cardiotoxic chemotherapy were excluded. Results: A total of 172 patients (66 on anthracycline based therapy and 106 on anti-HER2 therapy) were assessed. The average age of all patients was 57 years. 47 patients were assessed as high risk for cardiovascular disease. Of these high-risk patients, troponin was checked in 42 of 47 (89.4%) and found to be elevated in 23 of 42 (55%). Rate of troponin elevation was statistically significant for high risk patients compared to all other patients (p<0.05). Cardioprotective medications were utilized in 28 of the 47 patients considered to be high risk (59.6%). Conclusions: In patients with breast cancer who require treatment with a potentially cardiotoxic medication, a clinical risk assessment with cardiology can be utilized to select those who may benefit from additional cardiac biomarker monitoring and potential earlier initiation of cardioprotective therapy. This single center study reveals that the use of clinical assessment of high vs low/medium risk allows us to predict patients with increased risk of cardiotoxicity. Our population had cardiac biomarkers checked in nearly all high-risk patients and troponin was elevated 55% of the time. Further study is needed to investigate if biomarker directed initiation of cardio-protective therapy could reduce cardio-toxicity.

Impact of a Multidisciplinary Supportive Care Model Using Distress Screening at an Asian Ambulatory Cancer Center: A Cluster Randomized Controlled Trial.

The Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) program adopts a multidisciplinary supportive care model with routine distress screening to triage newly diagnosed cancer survivors for additional support on the basis of distress levels. This study aimed to evaluate the clinical impact of ACCESS over 1 year. We performed cluster random assignment at the oncologist level in a 1:1 ratio to receive ACCESS or usual care. Participants 21 years and older, newly diagnosed with breast or gynecologic cancer, and receiving care at National Cancer Centre Singapore were included. Outcomes assessed every 3 months for 1 year included quality of life (QoL) (primary), functioning, physical and psychological symptom burden, and activity levels. Data were analyzed using mixed-effects models. Participants from 16 clusters (control = 90, intervention = 83) were analyzed. The ACCESS program did not significantly improve QoL (primary outcome). However, compared with usual care recipients, ACCESS recipients reported higher physical functioning (P = .017), role functioning (P = .001), and activity levels (P < .001) at 9 months and lower psychological distress (P = .025) at 12 months. ACCESS recipients screened with high distress had poorer QoL, lower role and social functioning, and higher physical symptom distress at 3 months but had comparable scores with ACCESS recipients without high distress after 12 months. Compared with usual care, participation in the ACCESS program did not yield QoL improvement but showed earlier functioning recovery related to activities of daily living and reduced psychological distress. Routine distress screening is a promising mechanism to identify survivors with poorer health for more intensive supportive care.

Assessing the financial impact of cancer drug list (CDL) implementation on patients receiving chemotherapy in an ambulatory cancer centre in Singapore

Background On 1st September 2022, the Cancer Drug List (CDL) was implemented to ensure the long-term affordability of chemotherapy and insurance premiums. This project aimed to determine the financial impact of CDL on out-of-pocket expenses (OOPE), acceptability and financial toxicity (FT) after CDL implementation. Methods A cross-sectional study was conducted at National Cancer Center Singapore. We analyzed OOPE before and after implementation of CDL by reviewing billing transactions in Aug-Sept 2022. Acceptability and FT were determined using theoretical framework of acceptability (TFA) and COmprehensive Score for financial Toxicity (COST) tool respectively via survey. Results Of the 314 patients finalized bills examined, majority (68.8%) experienced no change in their OOPE, and 69.1% had no OOPE. Most patients (72.6%) were unaware of implementation of CDL. Among patients aware of CDL, majority (61.9%) were accepting, but unsure on how it benefits them. FT was reported as low (mean COST score = 22.4 ± 9.9), and patients ≥65 years old or have at least pre-university education were less likely to experience FT. Conclusion Despite best efforts from policymakers, it is challenging to achieve a one-size fits funding or subsidy framework that can cater to the needs of all patients. Some groups of patients would inevitably still experience high OOPE and FT due to their personal or clinical circumstances. Patients can be better empowered to seek financial assistance or resources.

Reducing wait times for initiation of chemotherapy at the Bellevue Cancer Center.

461 Background: The Bellevue Hospital Cancer Center is the primary oncologic referral center for the NYC Health and Hospitals System. It experiences high demand for infusion therapies requiring the resources of an infusion center and the expertise of chemotherapy registered nurses (RNs). From November 2021 to December 2022, there was a shortage in the number of chemotherapy RNs and the number of infusion chairs. This resulted in prolonged wait times for treatment initiation and difficulty accommodating requests to start treatment within 7 days. Here, we evaluate the impact of capacity building interventions on the success rate of treatment initiation within 7 days. Methods: We examined requests for initiation of infusion treatment within 7 days for all malignancies from December 2021 to December 2022. Our primary process measure was the percentage of requests fulfilled each month. We collected key variables for each chemotherapy request including number of RNs, number of infusion chairs, and the number of days between subsequent infusions. Finally, a root cause analysis was conducted to determine the causes for decreased RN and infusion care capacity. Using all the data above, a Plan-Do-Study-Act process was created to address key capacity deficiencies. Results: Our findings revealed an increase in successful treatment initiation within 7 days from December 2021 to December 2022. From August 2022 to December 2022, 100% of all requests within 7 days were successfully scheduled. There was also an increase in the number of available infusion chairs in this time interval, from a minimum of 18 in December 2021 to 22 in December 2022. There was also an increase in the number of chemotherapy certified RNs. These findings are summarized in the table below. There were key interventions to address capacity shortages. Facilities in the Ambulatory Cancer Center and the inpatient hematology/oncology unit were repurposed into additional infusion spaces. There were also additional pay lines created for chemotherapy RNs, increased recruitment, and hiring of Nursing Agency RNs. Conclusions: We describe the capacity limitations surrounding infusion therapy at the Bellevue Cancer Center. Key interventions included strategic recruitment, financial approval of new chemotherapy RN pay lines, hiring agency RNs, and repurposing ambulatory and inpatient spaces. This resulted in increased capacity and 100% fulfillment of urgent treatment initiation requests. As the number of patients requiring infusion services at the Bellevue Cancer Center grows, long-term capacity building solutions will be essential.[Table: see text]

Determining acceptance and perceptions of chemotherapy dose banding in an ambulatory cancer centre.

Despite the advantages of dose banding (DB) and numerous plans to adopt this practice, uptake of DB is still poor. As opinions of healthcare professionals were deemed essential in DB's acceptance, this study surveyed key stakeholders to determine the acceptance, facilitators, and barriers of DB in chemotherapy to improve its implementation. A cross-sectional study at the National Cancer Centre Singapore, involving physicians, nurses, and pharmacy staff, was conducted in February 2022. The Theory of Planned Behaviour was adapted to design a survey questionnaire to obtain the acceptance, facilitators, and barriers of DB. Additional questions on maximum acceptable dose variance and essential criteria for selecting drugs for DB were included. A total of 93 participants responded, with a mean 9.75 ± 7.37 years of clinical experience. Less than half have heard of DB while few had prior experience. Drug cost was the top selection criteria for DB, followed by toxicity, therapeutic index, frequency of use and drug wastage. Acceptance rate of DB was 41.9%, with majority agreeing to use DB in various drugs but to determine patient suitability before usage. Being greatly affected by subjective norms, having a positive outlook for DB's impacts, and no effect on toxicity significantly influenced acceptance. Prior to implementing DB at the institutional level, educational training addressing concerns over toxicity, and providing technological support can help improve acceptance. Future studies can involve patients' perspectives and more institutions for greater diversity in opinions.

Quantifying chemotherapy wastage in an ambulatory cancer centre in Singapore.

To ensure the efficient use of chemotherapy drugs, chemotherapy wastage is an area that can be investigated. This study aims to quantify current parenteral chemotherapy wastage and estimate parenteral chemotherapy wastage when dose banding is executed, using a chemotherapy wastage calculator in an ambulatory cancer centre. The study also examines the variables that significantly predict the total cost of chemotherapy wastage, investigates the reasons for wastage, and explores opportunities to reduce wastage. Data were collected from the pharmacy in National Cancer Centre Singapore over 9 months retrospectively. Chemotherapy wastage is the sum of wastage in the preparation phase and potential wastage in the administration phase. The calculator was created using Microsoft Excel and generated chemotherapy wastage in terms of cost and amount (mg) and analysed the reasons for potential wastage. The calculator reported a total of 2.22 million mg of chemotherapy wastage generated over 9 months, amounting to $2.05 million (Singapore Dollars, SGD). Regression analysis found that the cost of drug was the only independent variable that significantly predicted the total cost of chemotherapy wastage (P = 0.004). The study also identified low blood count (625 [29.06%]) as the top reason for potential wastage and no-show ($128,715.94 [15.97%]) as the reason that incurred the highest cost of potential wastage. The pharmacy has generated a considerable amount of chemotherapy wastage over 9 months. Interventions in both the preparation and administration phases are required to reduce chemotherapy wastage. The use of the chemotherapy wastage calculator in pharmacy operations could guide efforts to reduce chemotherapy wastage.

Implementation and evaluation of a shared care model between oncologists and pharmacists for breast cancer patients at a Canadian regional ambulatory cancer centre.

The introduction of CDK 4/6 inhibitors for breast cancer patients has contributed to increased ambulatory patient visits for oncologists. The Medication Assessment by Pharmacist program aims to evaluate the impact of oncology pharmacists performing medication assessment follow-up visits. Breast cancer patients on a CDK 4/6 inhibitor deemed suitable by their oncologist for pharmacist assessment could be booked for a pharmacist medication assessment appointment at alternate treatment cycles. Between February 2019 to November 2021, 29 of 128 patients (22.7%) were selected for 46 total Medication Assessment by Pharmacist visits resulting in 920 min of clinic time savings for physicians. There were similar rates of adhering to provincial protocols for scheduling visits (99% vs. 96%, p = 0.12) and monitoring investigations (98% vs. 98%, p = 0.96) between those enrolled in Medication Assessment by Pharmacist or not. Surveys completed by medical oncologists and pharmacists demonstrated that nine of nine oncologists felt Medication Assessment by Pharmacist reduced workload and wanted Medication Assessment by Pharmacist expanded to additional oncology drugs. Pharmacist-completed surveys revealed that nine of nine pharmacists felt Medication Assessment by Pharmacist increased job satisfaction, and allowed further application of clinical skills. All agreed that patients were receptive to meeting with pharmacists. According to survey results, 33% of oncologists versus 100% of pharmacists routinely asked about medication adherence, new medications or supplements. Integrating pharmacists into a shared care model reduces ambulatory patient visits for oncologists without deviating from provincial protocol guidelines for monitoring and visits for patients on CDK 4/6 inhibitors. Leveraging the medication expertise of pharmacists also increases the frequency of addressing medication adherence and concurrent therapies. Medication Assessment by Pharmacist may be an effective strategy in alleviating projected shortages of oncology providers.

Sequential Wipe Testing for Hazardous Drugs: A Quality Improvement Project.

Monitoring for the presence of hazardous drug (HD) residue is recommended as part of a comprehensive HD safety program. However, a single wipe test provides limited information without the ability to evaluate interventions. This quality improvement project was designed to evaluate the benefits of performing sequential HD wipe testing during a six-month period in an ambulatory cancer center. Four areas in the pharmacy department and two areas in the infusion department were selected for testing, which was conducted at three time points. Cyclophosphamide, doxorubicin, 5-fluorouracil, methotrexate, and paclitaxel were tested using liquid chromatography coupled with tandem mass spectrometry. The initial test demonstrated HD contamination on the legs of the IV pole and the pharmacy transport bin. All other areas were below the limit of detection. Changes were made to cleaning practices in the pharmacy and infusion departments prior to the subsequent tests at the three- and six-month time points, which produced levels below the limit of detection.

Antiviral Prescribing Among Patients at an Ambulatory Cancer Center With Laboratory-Confirmed Influenza.

Among 133 cancer outpatients diagnosed with influenza between 2016 and 2018, 110 (83%) were prescribed oseltamivir. Among 109 with a known symptom onset date, 53% presented for care and 31% were prescribed oseltamivir within 48 hours. Patient/provider education and rapid diagnostics are needed to improve early oseltamivir use among cancer patients with influenza.

Prescribing practices of oncology pharmacists working in ambulatory cancer centers in Alberta.

To describe and quantify independent prescribing of oncology pharmacists working in adult, ambulatory cancer centers in Alberta, Canada. A retrospective chart review of oncology pharmacists prescribing in the electronic health record, ARIA® was conducted. Prescriptions from January 1, 2018 to June 30, 2018 were analyzed. Descriptive statistics were used to quantify prescription volume and class of medications prescribed. A cross-sectional analysis was then performed on a random sample to determine the type of prescription intervention and evaluate pharmacist documentation. Over 6 months, 3474 prescriptions were ordered by 33 clinically deployed pharmacists. The median number of medications prescribed was 7 per month (interquartile range: 1.50-27.00; Range: 0.17-79.5). When prescribing was standardized by pharmacist's time clinically deployed, the median was 21.67 (interquartile range: 5.00-79.67; range: 0.67-216.67) prescriptions per month per full-time equivalent. The most prescribed class of medication was antiemetic (24.1%). From a sample of 346 prescriptions, 172 (50%) were new medications initiated, 160 (46%) were the continuation of existing prescriptions and 14 (4%) were prescription dosage adjustments. Adherence to the specified documentation standards was 47%. Oncology pharmacists utilize their independent prescribing to initiate and continue supportive care medications for cancer patients. The prescribing volume varied greatly among pharmacists. Opportunities exist to further engage pharmacist prescribing.

SG-APSIC1154: Evaluation of disposable antimicrobial curtains in an ambulatory cancer center

Objectives: The prevention of nosocomial infection is a challenge for all healthcare institutions. Privacy curtains are often changed infrequently, and they are difficult to clean. Contaminated curtains can be touched by healthcare providers and patients, which may result in indirect transmission of infectious disease. Hence, we evaluated the impact of the antimicrobial properties of disposable curtains and their cost-effectiveness. Methods: This descriptive exploratory study was conducted in an ambulatory cancer center in 2017. Privacy curtains were assigned to 2 cohorts, labelled E1 and E2. They were placed in the clinical areas for 6–12 months. Moist swab samples for MRSA, VRE, and CP-CRE cultures were obtained from the leading edges of the curtains during the evaluation period. Also, 10-cm × 10-cm swatches were cut from the high-touch areas of curtains and were tested for total aerobic count on the first of the month and quarterly thereafter. Results: All bacterial culture swabs obtained from the E1 and E2 cohorts of curtains were negative. The total bacterial plate count results from E1 curtains were negative for up to 1 year. However, the total bacterial plate count results for E2 curtains were positive in the sixth month. Using disposable curtains yielded an annual cost saving of ~50%. Conclusions: The use of appropriate impregnated antimicrobial disposable curtains can improve patient safety in the clinical areas. These curtains may eliminate potential sources of infection and thereby decrease the rate of nosocomial infection. They also save significant institutional costs by reducing frequent laundry and manpower requirements needed for the installation of curtains.

Improving cardiac monitoring in patients with early-stage breast cancer receiving cardiotoxic chemotherapy in a multidisciplinary cancer center.

191 Background: Patients with early stage breast cancer commonly receive anthracycline and anti-Her2 directed therapies which can result in cardiotoxicity, making cardiac monitoring crucial. In 2018, our rate of obtaining a follow up echocardiogram in this patient population was 38%. Subsequently, use of myocardial strain imaging in conjunction with echocardiography became available at our institution, allowing for potential earlier detection of cardiac dysfunction. We aimed to increase utilization of strain imaging and rate of follow up echocardiogram monitoring to at least 50% in hopes of enhancing prevention efforts. Methods: We developed a standardized protocol for cardiac monitoring in patients receiving cardiotoxic chemotherapy. We provided education to staff and workflow modification to include standard orders for strain echocardiogram in all relevant chemotherapy plans. Chart review for Stage 1-3 breast cancer patients who received anthracycline or trastuzumab based therapy at our ambulatory cancer center from January 2019 to December 2021 was performed. Completion of follow up echocardiogram and rate of strain imaging before and after July 2020 was assessed, as this is when strain imaging became widely available. Results: Rates of obtaining baseline echocardiogram were excellent. Rates of strain echocardiogram use improved from 26.3% to 97.9% following July 2020. Follow up echocardiograms were obtained regularly in those receiving trastuzumab based therapy before and after July 2020 at rates of 91.8% and 87.5%. Rates of follow up echocardiograms in those receiving anthracycline-based therapy also improved to our goal of greater than 50%, but was lower than the trastuzumab group at 57%. However, assessment of follow up cardiac imaging in the 2021 treatment group is still ongoing. Conclusions: We successfully implemented a program to standardize cardiac monitoring in patients undergoing cardiotoxic chemotherapy for breast cancer at our institution. We anticipate this will enhance detection of cardiotoxicity and utilization of consultative cardio-oncology services. Additional efforts to improve follow up cardiac imaging through collaboration with our survivorship program are ongoing.[Table: see text]

Ambulatory Oncology Nurses Weigh in About 12-Hour Shifts.

Studies conducted in hospital settings have associated negative clinical outcomes with 12-hour shifts. Despite this, 12-hour shifts are common in nursing and popular among nurses. Little is known about outcomes associated with 12-hour shifts in ambulatory care settings. A mixed-methods, quality improvement project was conducted in a large, ambulatory cancer center to evaluate oncology nursing staff perspectives on 12-hour shift work. One hundred ambulatory oncology nurses completed surveys and 11 participated in focus group interviews. Nurses expressed predominately positive perspectives about 12-hour shift work in ambulatory oncology care. Ambulatory oncology nurses perceived benefits to quality, safety, and satisfaction for both nurses and patients related to 12-hour shifts. Further evaluation of patient, nurse, and organizational outcomes unique to ambulatory settings is essential for nurse executives in formulating data-driven staffing plans. The incorporation of 12-hour shifts should be considered.

Cancer Clinic Redesign: Opportunities for Resource Optimization.

Ambulatory cancer centers face a fluctuating patient demand and deploy specialized personnel who have variable availability. This undermines operational stability through the misalignment of resources to patient needs, resulting in overscheduled clinics, budget deficits, and wait times exceeding provincial targets. We describe the deployment of a Learning Health System framework for operational improvements within the entire ambulatory center. Known methods of value stream mapping, operations research and statistical process control were applied to achieve organizational high performance that is data-informed, agile and adaptive. We transitioned from a fixed template model by an individual physician to a caseload management by disease site model that is realigned quarterly. We adapted a block schedule model for the ambulatory oncology clinic to align the regional demand for specialized services with optimized human and physical resources. We demonstrated an improved utilization of clinical space, increased weekly consistency and improved distribution of activity across the workweek. The increased value, represented as the ratio of monthly encounters per nursing worked hours, and the increased percentage of services delivered by full-time nurses were benefits realized in our cancer system. The creation of a data-informed demand capacity model enables the application of predictive analytics and business intelligence tools that will further enhance clinical responsiveness.

Antibiotic prescribing knowledge: A brief survey of providers and staff at an ambulatory cancer center during Antibiotic Awareness Week 2019.

We surveyed healthcare professionals at a cancer center regarding their knowledge and perceptions of antibiotic use. Most knew the term "antimicrobial stewardship." Nurses and other staff were less likely than pharmacists or providers to answer knowledge-based questions correctly. Opportunities exist to improve antibiotic knowledge among cancer center staff.

Patient satisfaction and behavioural intention in using the home medication delivery service in an ambulatory oncology centre.

The COVID-19 pandemic has increased usage of medication delivery service (MDS) significantly. MDS improves adherence to medication and clinical outcomes. To study behavioral change factors that affect adoption of MDS, determine existing patient satisfaction level, and make recommendations to improve MDS adoption. A single-institution, cross-sectional survey was conducted at the outpatient pharmacy of the largest ambulatory cancer centre in Singapore. The survey consisted of sections on demographics, Theory of Planned Behavior constructs and patient satisfaction questions. Descriptive analysis and logistic regression were used. A total of 881 patients responded. Respondents were mostly Chinese, female and subsidized patients, with a mean age of 62.4 years old. MDS use is strongly predicted by favourable attitude (OR 3.54, 95%CI 2.64-4.75; p < 0.001) and subjective norm (OR 3.07, 95%CI 2.30-4.09; p < 0.001) towards its use and greater perceived behavioral control (OR 2.48; 95%CI 1.86-3.30; p < 0.001). Being ill or frail has been identified as facilitators, while absence of face-to-face consultation and cost of delivery were barriers to the adoption of MDS. Encouragingly, the satisfaction level of our existing patients was generally high (80.2, SD16.7). Recommendation to improve MDS adoption targets facilitators and barriers identified and aims to further elevate patient satisfaction level. Establishment of a centralised pharmacy for MDS together with a call centre would be essential in the long run. MDS is becoming increasingly important, in line with our national strategy. Implementation of suggested short-term and long-term measures will encourage its use.

Baseline characteristics of breast and gynecological cancer patients enrolled in the trial of a multidisciplinary survivorship care model in an Asian national ambulatory cancer center.

37 Background: Accessible Cancer Care to Enable Support for Cancer Survivors (ACCESS) is a multidisciplinary survivorship care model launched at the National Cancer Centre Singapore (NCCS) in 2019. ACCESS employs routine distress and problem screening to triage cancer patients with varying care needs and complexities for tailored care. Here, we described the study design to evaluate ACCESS, and reported the baseline characteristics of our study cohort to characterize the profile of prospective target recipients of the new care model. Methods: A cluster randomized controlled trial was initiated to assess the effectiveness of ACCESS on quality of life and symptom burden, with each cluster unit defined at the oncologist level. Clusters were randomized in a 1:1 ratio to receive ACCESS or usual care. Eligible patients were ≥21 years, newly diagnosed with breast or gynecological cancer, and receiving follow-up care in NCCS. Patients were followed up for one year and patient-reported outcomes were collected every three months using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Rotterdam Symptom Checklist. Results: By May 2021, 91 patients and 89 patients in the usual care and ACCESS arm were recruited, respectively. Both groups (usual care vs. ACCESS) had comparable mean age (56.2±10.9 vs. 56.2±10.7, P = 0.998) and racial composition (P = 0.760). Employment status was similar in both arms (48.4% vs. 56.2% employed, P = 0.293) and most patients were covered by health insurance (89.8% vs. 88.1%, P = 0.920). At baseline, patients in both arms had comparable mean quality of life scores (65.1±19.8 vs. 66.9±17.6, P = 0.51) and reported high physical, role, emotional, cognitive, and social functioning levels (all mean scores &gt; 70). No statistically significant differences in physical symptom and psychological distress levels were observed. Prevalent symptoms reported included fatigue (82.4% vs. 71.9%), pain (68.1% vs. 55.1%), and insomnia (57.1% vs. 55.1%). Almost half of the cohort reported financial difficulties (45.1% vs. 46.1%). Conclusions: Comparable baseline characteristics suggested the absence of systematic differences in care needs and demand among patients cared by different oncologists. Despite high functioning statuses at baseline, participants reported impaired quality of life with active physical and financial problems. These results support our hypothesis that routine screening would be valuable to identify such problems promptly for management via standardized care pathways. Results from this ongoing trial will determine the effectiveness of ACCESS on quality of life and functional recovery through treatment and survivorship. Clinical trial information: NCT04014309.

Psychometric Properties of the Beck Depression Inventory (BDI-II) in Cancer Patients: Cancer Patients from Butaro Ambulatory Cancer Center, Rwanda.

BackgroundThe prevalence of depressive disorders remains high in patients with cancer and their diagnosis and treatment remain an epidemiologic concern. Without proper screening and diagnosis, the necessary care and follow-up would not be possible for these patients who need potential support to increase their quality of mental health. Hence, the screening tools for depression are prominent in diagnosing this mental health disorder; however, there are few studies conducted for assessing psychometric properties of Beck Depression Inventory (BDI-II) amongst the cancer patients from developing countries. We, therefore, determined psychometric properties of the BDI-II among cancer patients from Butaro Ambulatory Cancer Center (BACC).MethodsCross-sectional study design was conducted among 425 cancer patients from the BACC, Rwanda. Confirmatory and exploratory factor (CFA) analyses were performed to compare the fit indices of three-factor and two-factor models of the BDI-II. The eligible participants were administered the BDI-II instrument.ResultsAverage scores of depression was 16.3 (SD=9.8). Results showed an adequate consistency (Cronbach’s α=0.904) and high correlations with the subscales of this instrument. Our findings showed that the area under the curve of the receiver operating characteristics analysis of BDI-II was 0.805. Our CFA results revealed that three-factor model (χ2=1699.921, p<0.001) represented a better model fit than the two-factor model of BDI-II (χ2=2115.397, p<0.001). In addition, the goodness of fit indices were tested and showed that the Beck’s three-factor model had a better performance than the two-factor model. Kaiser–Meyer–Olin (KMO) measure of 0.916 demonstrated that the factor structure or sampling was adequate for analysis and the Bartlett’s test of sphericity was highly significant (χ2=3780, p<0.001) and this revealed that the items of BDI-II were significantly correlated and sufficiently large.ConclusionBDI-II presented a good reliability and validity that represent adequate psychometric properties. Its sensitivity and specificity were suitable. This psychometric measure is important in diagnosing and treating depression in cancer patients.

Hazardous Drug Contamination: Presence of Bathroom Contamination in an Ambulatory Cancer Center.

Many hazardous drugs (HDs) are excreted in urine and feces, and evidence has shown that bathrooms of patients receiving chemotherapy at home are contaminated with HDs. However, little information exists on bathroom contamination in ambulatory clinics where HDs are administered. This project aimed to determine the presence of HD residue in the patient and staff bathrooms of an ambulatory cancer center. A quality improvement project was initiated to examine potential contamination by the HDs 5-fluorouracil and oxaliplatin in a patient bathroom and a secured badge-access staff bathroom in the infusion department of an ambulatory comprehensive cancer center. Twice-daily wipe testing was conducted on the floor in front of the toilet and the flush handle for five consecutive days. Sixty-five percent of the samples from the floor of the patient bathroom were positive for at least one of the HDs. In the staff bathroom, 35% of the floor samples were positive for at least one HD. None of the flush handle samples were above the level of detection.

Assessing the risk of venous thromboembolism (VTE) in ambulatory patients with cancer: Rationale and implementation of a pharmacist-led VTE risk assessment program in an ambulatory cancer centre.

ObjectivesThe objectives of this paper were to identify and compare clinical prediction models used to assess the risk of venous thromboembolism (VTE) in ambulatory patients with cancer, as well as review the rationale and implementation of a pharmacist-led VTE screening program using the Khorana Risk Score model in an ambulatory oncology centre in Sault Ste. Marie, Ontario, Canada.Data SourcesPubMed was used to identify clinical practice guidelines and review articles discussing risk prediction models used to assess VTE risk in ambulatory patients with cancer.Data SummaryThree commonly used VTE risk prediction models in ambulatory patients with cancer: the Khorana Risk Score, Vienna Cancer and Thrombosis Study (CATS) and Protecht Score, were identified via literature review. After considering guideline recommendations, site-specific factors (i.e. laboratory costs, time pharmacists spent calculating VTE risk) and evidence from the CASSINI and AVERT trials, a novel pharmacist-led VTE risk assessment program using the Khorana Risk Score was developed during a fourth-year PharmD clinical rotation at the Algoma District Cancer Program (ADCP) [ambulatory cancer care centre]. ADCP patients with a Khorana Risk Score of were referred to the hematologist for a full VTE workup. Considering limitations, inclusion and exclusion criteria of the CASSINI and AVERT trials, the hematologist and pharmacy team decided on appropriate initiation of thromboprophylaxis with a direct oral anticoagulant (DOAC).ConclusionsThe Khorana Risk Score was the chosen model used for the pharmacist-led VTE risk assessment program due to its user-friendly scoring algorithm, evidence from validation studies and clinical trials, as well as ease of integration into pharmacy workflow. More research is needed to determine if pharmacist-led VTE risk assessment programs will impact patient outcomes, such as morbidity and mortality, secondary to cancer-associated thrombosis.