Cancer Care Pathway Research Articles

An eHealth Application in Head and Neck Cancer Survivorship Care: Health Care Professionals' Perspectives.

BackgroundAlthough many cancer survivors could benefit from supportive care, they often do not utilize such services. Previous studies have shown that patient-reported outcomes (PROs) could be a solution to meet cancer survivors’ needs, for example through an eHealth application that monitors quality of life and provides personalized advice and supportive care options. In order to develop an effective application that can successfully be implemented in current health care, it is important to include health care professionals in the development process.ObjectiveThe aim of this study was to investigate health care professionals’ perspectives toward follow-up care and an eHealth application, OncoKompas, in follow-up cancer care that monitors quality of life via PROs, followed by automatically generated tailored feedback and personalized advice on supportive care.MethodsHealth care professionals involved in head and neck cancer care (N=11) were interviewed on current follow-up care and the anticipated value of the proposed eHealth application (Step 1). A prototype of the eHealth application, OncoKompas, was developed (Step 2). Cognitive walkthroughs were conducted among health care professionals (N=21) to investigate perceived usability (Step 3). Interviews were recorded, transcribed verbatim, and analyzed by 2 coders.ResultsHealth care professionals indicated several barriers in current follow-up care including difficulties in detecting symptoms, patients’ perceived need for supportive care, and a lack of time to encourage survivors to obtain supportive care. Health care professionals expected the eHealth application to be of added value. The cognitive walkthroughs demonstrated that health care professionals emphasized the importance of tailoring care. They considered the navigation structure of OncoKompas to be complex. Health care professionals differed in their opinion toward the best strategy to implement the application in clinical practice but indicated that it should be incorporated in the HNC cancer care pathway to ensure all survivors would benefit.ConclusionsHealth care professionals experienced several barriers in directing patients to supportive care. They were positive toward the development and implementation of an eHealth application and expected it could support survivors in obtaining supportive care tailored to their needs. The cognitive walkthroughs revealed several points for optimizing the application prototype and developing an efficient implementation strategy. Including health care professionals in an early phase of a participatory design approach is valuable in developing an eHealth application and an implementation strategy meeting stakeholders’ needs.

How to evaluate the requirements for rehabilitation for cancer inpatients?

Objective To characterize and measure the requirement for rehabilitation for cancer inpatients in order to improve cancer care pathways. Population Data was obtained from the regional hospital discharge database. We analyzed all hospital stays in acute care in 2013 for cancer inpatients living in Rhone-Alpes. These hospital stays were selected according to the algorithm of the National Institute of Cancer (regardless of hospitalization for medical supervision, screening, cancer antecedents, carcinoma in situ and benign tumors). Methods Professionals involved in cancer treatment where first asked to define situations that require rehabilitation after acute care. This clinical definition was applied to select corresponding hospital stays. We analyzed where they were discharged after acute care: in rehabilitation service, home care or home. Results Cancer inpatients’ needs for rehabilitation care after cancer surgery are allogeneic hematopoietic allograft, palliative care and medical complications during chemotherapy or radiotherapy treatment. The need for rehabilitation depends on social and environmental conditions of patients. Only serious surgery or allogeneic hematopoietic allograft always require rehabilitation care for specific rehabilitation. Hospital discharge database: Among the 163,138 discharges of surviving cancer inpatients, 1,704 were related to a serious surgery or allogeneic hematopoietic allograft and should always be admitted in rehabilitation services. Only 31% were actually admitted in rehabilitation units, with discrepancies between hospitals, from 6% to 91%. For palliative care, (2,796 hospital stays), 27% were admitted in rehabilitation services and 22% in hospital at home with still large discrepancies according to areas. Discussion Characterizing requirement in rehabilitation for cancer after acute care hospitalization should contribute to elaborate cancer care pathway.

The patient-breast cancer care pathway: how could it be optimized?

BackgroundA care pathway is defined as patient-focused global care that addresses temporal (effective and coordinated management throughout the illness) and spatial issues (treatment is provided near the health territory in or around the patient’s home). Heterogeneity of the care pathways in breast cancer (BC) is presumed but not well evaluated. The OPTISOINS01 study aims to assess every aspect of the care pathway for early BC patients using a temporal and spatial scope.Methods/DesignAn observational, prospective, multicenter study in a regional health territory (Ile-de-France, France) in different types of structures: university or local hospitals and comprehensive cancer centers. We will include and follow during 1 year 1,000 patients. The study consists of 3 work-packages:- Cost of pathwayThe aim of this WP is to calculate the overall costs of the early BC pathway at 1 year from different perspectives (society, health insurance and patient) using a cost-of-illness analysis. Using a bottom-up method, we will assess direct costs, including medical direct costs and nonmedical direct costs (transportation, home modifications, home care services, and social services), and indirect costs (loss of production).- Patient satisfaction and work reintegrationThree questionnaires will assess the patients’ satisfaction and possible return to work: the occupational questionnaire for employed women; the questionnaire on the need for supportive care, SCNS-SF34 (‘breast cancer’ module, SCNS-BR8); and the OUTPASSAT-35 questionnaire.- Quality, coordination and access to innovationQuality will be evaluated based on visits and treatment within a set period, whether the setting offers a multidisciplinary consultative framework, the management by nurse coordinators, the use of a personalized care plan, the provision of information via documents about treatments and the provision of supportive care.The coordination between structures and caregivers will be evaluated at several levels. Day surgery, home hospitalization and one-stop breast clinic visits will be recorded to assess the patient’s access to innovation.DiscussionThe assessment of care pathways encourages the implementation of new payment models. Our approach could help health care professionals and policymakers to establish other cost-of-illness studies and plan the allocation of resources on a patient basis rather than a visit basis.

P180. Audit of referrals to a family history clinic

P180. Audit of referrals to a family history clinic

P181. Integration of physical activity into breast cancer care pathway “Can-Move” programme

P181. Integration of physical activity into breast cancer care pathway “Can-Move” programme

Strategies to improve the efficiency and utility of multidisciplinary team meetings in urology cancer care: a survey study.

BackgroundThe prevalence of multidisciplinary teams (MDT) for the delivery of cancer care is increasing globally. Evidence exists of benefits to patients and healthcare professionals. However, MDT working is time and resource intensive. This study aims to explore members’ views on existing practices of urology MDT working, and to identify potential interventions for improving the efficiency and productivity of the MDT meeting.MethodsMembers of urology MDTs across the UK were purposively recruited to participate in an online survey. Survey items included questions about the utility and efficiency of MDT meetings, and strategies for improving the efficiency of MDT meetings: treating cases by protocol, prioritising cases, and splitting the MDT into subspeciality meetings.Results173 MDT members participated (Oncologists n = 77, Cancer Nurses n = 54, Urologists n = 30, other specialities n = 12). 68% of respondents reported that attending the MDT meeting improves efficiency in care through improved clinical decisions, planning investigations, helping when discussing plans with patients, speciality referrals, documentation/patient records. Participants agreed that some cases including low risk, non-muscle invasive bladder cancer and localised, low-grade prostate cancer could be managed by pre-agreed pathways, without full MDT review. There was a consensus that cases at the MDT meeting could be prioritised by complexity, tumour type, or the availability of MDT members. Splitting the MDT meeting was unpopular: potential disadvantages included loss of efficiency, loss of team approach, unavailability of members and increased administrative work.ConclusionKey urology MDT members find the MDT meeting useful. Improvements in efficiency and effectiveness may be possible by prioritising cases or managing some low-risk cases according to previously agreed protocols. Further research is needed to test the effectiveness of such strategies on MDT meetings, cancer care pathways and patient outcomes in clinical practice.

577P - Reasons for Delay in Time to Initiation of Adjuvant Chemotherapy for Colon Cancer: a Multi-Institution Study

ABSTRACT Aim: Although adjuvant chemotherapy (AC) has been shown to improve survival in patients with colon cancer (CC), meta-analyses have suggested decreased survival with increasing Time To AC (TTAC). We examined the predominant factors leading to delayed TTAC in routine clinical practice. Methods: Individual medical records were reviewed for 1,608 patients with CC who initiated AC 2005-2012 at eight cancer centers in the Province of Ontario. Patient, disease, and treatment characteristics, plus time intervals between each step in the cancer care pathway from surgery to AC, were captured. Patients were then categorized into three groups for comparison: (I) inter-current illness and/or post-operative complications, (II) oncologist/patient-initiated delay, (III) no medical reason for delay. Groups were compared using chi square tests and one-way ANOVA. A multivariate logistic regression analysis (MVA) was used to determine factors associated with TTAC >8 weeks (wks) for each cohort. Results: The proportion of patients in each group was: (I) 24.7%, (II) 19.5%, (III) 55.8%; mean TTAC was: (I) 10.1 ± 2.7, (II) 10.5 ± 3.6, (III) 8.5 ± 2.1 wks (p>0.001); the proportion of cases with TTAC>8 wks was: (I) 76.4%; (II) 81.4%; (III) 57.9%. The most common post-operative complication in Group I was ileus (34.2%). The only significant predictor of TTAC >8 wks by MVA in group I was AC via central venous catheter (OR = 2.4, 95%, CI:1.2-4.9). Median length of stay in hospital after surgery was 10, 6 and 6 days for Group I, II, and III, respectively (p Conclusions: Although the majority of patients had no medical reason for delay, the average TTAC was > 8 wks. Our findings suggest that health-system factors such as waiting for consultations and chemotherapy booking cause the majority of delays in TTAC. These are modifiable and quality improvement initiatives should focus on how to reduce these delays. Disclosure: R. Burkes: Research Funding by Sanofi for myself; C. Brezden-Masley: Research Funding by Sanofi for myself; K. Zbuk: Honoraria Yes by Sanofi for myself. All other authors have declared no conflicts of interest.

Sustaining colorectal cancer nurses’ specialist practice

To function optimally in specialist practice, colorectal cancer nurses require sufficient resources as well as organisational support. The authors examined how well this is borne out in practice by conducting a small electronic survey with members of the National Colorectal Cancer Nurses Network in December 2013. Feedback from the 25 colorectal cancer nurse specialists (CRC CNS) who responded highlights that over half (60%) of the nurses perceive their services to be inadequately resourced. Many stated that their services were being stretched beyond their capacity to respond. Despite the majority identifying a need for additional staffing within their service, nearly all respondents were experiencing difficulty in securing such provision. In addition, many felt that their role was under threat. There was general agreement that managing increasingly complex colorectal cancer care pathways with inadequate administrative support was not sustainable. The implications of these findings are discussed by examining the contribution CRC CNSs can make and offering recommendations to sustain the CRC CNS in practice.

Use of complementary and alternative medical therapies (CAM) by patients attending a regional comprehensive cancer care centre

This study determined the prevalence, types, and attitudes towards complementary and alternative medicines (CAMs) and therapies in cancer patients actively undergoing conventional cancer treatment at a regional cancer centre. Data were collected using a self-administered questionnaire provided to adult cancer patients attending a comprehensive cancer care centre in regional Australia over a 3-month period. A participation rate of 89% was recorded over the 3-month period with 285 of 320 cancer patients providing completed data. Mean age was 64 years and slightly more females responded (56%). CAM types used by patients were classified according to US National Centre for Complementary and Alternative Medicine (NCCAM) domains. Overall prevalence of CAM use was 49% (140/285). The NCCAM domains of biologically-based treatments (mainly herbal and vitamin/mineral supplements) and manipulative/body-based methods (chiropractic and massage) were the most popular. Most patients (61%) who used CAM prior to cancer diagnosis continued complementary practices afterwards, and 33% of participants became first-time CAM users only after diagnosis. CAM use appeared to be associated with high patient acceptance and satisfaction which was not related to either cancer diagnosis or prognosis. Patients who used CAM were mainly willing to disclose (77%) this practice to their conventional health care providers. CAM use is prevalent in regional Australia. Collaborative integration of some CAM practices into conventional cancer care pathways (a process known as integrative oncology) is likely to have substantial patient support.

Socio-economic inequalities in patient, primary care, referral, diagnostic, and treatment intervals on the lung cancer care pathway: protocol for a systematic review and meta-analysis

BackgroundEarly diagnosis and treatment of cancer is thought to be important for improving survival. Longer time between the onset of cancer symptoms and receipt of treatment may help explain the poorer survival of UK cancer patients compared to that in other countries.Socio-economic inequalities in receipt of, and time to, treatment may contribute to socio-economic differences in cancer survival. Socio-economic inequalities in receipt of lung cancer treatment have been shown in a recent systematic review. However, no systematic review of the evidence for socio-economic inequalities in time to presentation (patient interval), time to first investigation (primary care interval), time to secondary care investigation (referral interval), time to diagnosis (diagnostic interval), and time to treatment (treatment interval) has been conducted.This review aims to assess the published and grey literature evidence for socio-economic inequalities in the length of time spent on the lung cancer diagnostic and treatment pathway, examining interim intervals on the pathway where inequalities might occur.MethodsSystematic methods will be used to identify relevant studies, assess study eligibility for inclusion, and evaluate study quality. The online databases of MEDLINE, EMBASE, and CINAHL will be searched to locate cohort studies of adults with a primary diagnosis of lung cancer; where the outcome is mean or median time to the interval endpoint (or a suitable proxy measure of this), or the likelihood of longer or shorter time to the endpoint; analysed by a measure of socio-economic position. Meta-analysis will be conducted if there are sufficient studies available with suitable data.DiscussionThis review will systematically determine if there are socio-economic inequalities in time from symptom onset to treatment for lung cancer. If such inequalities are present, our review evidence will help inform the development of interventions to reduce the time to diagnosis and treatment, ultimately helping to reduce socio-economic inequalities in survival.Trial registrationPROSPERO CRD42014007145

Breast cancer information and support needs for women with intellectual disabilities: a scoping study

To examine the compass and nature of relevant research and identify gaps in the current evidence in order to determine the priority of future research about breast cancer and intellectual disability (ID). A scoping study that comprised of a consultation exercise with a wide range of key stakeholders (n = 26) from one northern city (Sheffield) within the UK. This study identified numerous gaps in the current evidence base. It highlighted a dearth of research that focuses specifically on the information and support needs of women with IDs (and their carers) across the breast cancer patient pathway. Within the interviews, whilst 'reasonable adjustments' were being made and there was evidence of good practice, they were neither strategic nor systematic. Participants suggested that future research should focus on devising protocols to advise on the legal, ethical and clinical imperatives so that clinical governance in this area is assured. There remains a dearth of research or practice guidelines at every stage of the breast cancer care pathway for women with ID. This may arguably lead to late diagnosis, suboptimal treatment and management and overall survival rates for this group. Further research is needed to understand the specific information and support needs of both women with ID (and their formal and informal carers) through the breast care pathway and to identify appropriate protocols, strategies and interventions in order to address these.

Exploring Continuity of Care: The Patient Voice

Background: Oncology is one of the priorities of public health given its high incidence and prevalence. In 2010 there were 8 million deaths caused by cancer. In Italy neoplastic disease is the second highest cause of death. Considering these data, we need to guarantee appropriate, quality healthcare responses. In order to monitor the quality of cancer care pathways, we intend to explore continuity of care from patients’ perspective, identifying the dimensions that define continuity. Methods: Semi-structured interviews with 30 cancer patients (4 colorectal and 26 breast cancer) who received treatment at different service points of the Area Vasta Network (AVR), Italy. To identify the macro-categories of continuity, all interviews were transcribed and analysed using framework analysis, assisted by a computer software package for analysis of qualitative data (N-VIVO 10). Simultaneously, a literature review was carried out using the Pubmed database to examine the continuity of care measures validated. Results: From the narratives of 30 patients, different continuity of care’s dimensions emerged, for example the presence of a professional who knows the patient’s illness history and takes him/her from initial diagnosis to followup care, guaranteeing him/her accurate information; a multi-professional team. The same aspects result central and transversal to 5 questionnaires identified in literature. Conclusions: The analysis allows us to identify 3 central and transversal dimensions of continuity of care: informational, organizational and relational; confirming the continuity of care model produced by Haggerty et al. It follows that in order to cater to the needs of cancer patients; we need to focus simultaneously on these three dimensions along the cancer care pathway. In line with these results, we are developing the first Italian patients experience continuity of care tool.

Improving care for patients with lung cancer in the UK

The care of patients with lung cancer in the UK today has improved over the last 10 years, primarily because we are now able to measure and quantify the differences...

A provider-payor approach for determining value in the health reform era: Early reports on the mQure initiative.

255 Background: Determining value requires detailed measurement of clinical services and associated costs. In the health reform era value demonstration presents a challenge for both providers and payors: providers, unable to demonstrate value, will be unable to attract payors or patients and expand market share; payors, unable to choose the right providers, will lose opportunities to lower costs and raise quality. Methods: In July 2012, the Moffitt Cancer Center (MCC) launched the mQure (MCC – Quality Understanding Research and Evidence) Initiative to (1) measure and improve clinical performance, (2) increase compliance to evidence-based/cost conscious cancer-care pathways, and (3) demonstrate value. We introduced Clinical Performance and Value (CPV) vignettes, a value measurement tool, to measure pathway adherence, determine diagnostic accuracy and appropriate use of diagnostic tools starting with breast and lung cancer. For selected performance items identified by the CPVs, we audited medical records directly. Results: Measurement revealed high value practices, for example, diagnostic accuracy, appropriate rates of biopsy and more accurate staging compared to other groups. Value determination led to one signed plus two pending payor partnerships to implement a shared savings contract, find ways to reduce utilization and explore creating payor-led networks. The focus on individual responsibility for adherence to evidence-based practices has had an unanticipated and seemingly paradoxical benefit of shifting the group to narrow practice variation thereby shifting providers to a more self-aware culture. An external benefit is that the value signal has led to discussions to form accountable care organization (ACO) networks for cancer care. Since mQure’s inception, MCC has created partnerships with 3 hospitals. Based on the breast cancer initiative alone, financial models indicate an estimated savings of up to $2 million annually that arise from higher quality, fewer unnecessary tests and improved pathway compliance. Conclusions: In just one year, the large scale mQure project has led to expanded provider partnerships, new quality-based arrangements with payors and the formation a specialty-ACO.

Art therapy's contribution to the psychological care of adults with cancer: A survey of therapists and service users in the UK

While art therapy in cancer care has been documented for over 60 years, there remains a lack of awareness of art therapists within the UK cancer workforce. The study addressed this knowledge gap. This cross-sectional mixed-methods survey used web-based questionnaires for art therapists and service users, and semi-structured interviews with service users. The sampling frame covered England, Scotland, Wales and Northern Ireland; data collection occurred in May–July 2011. Inclusion criteria were cancer, art therapy experience and an age of at least 18 years. Art therapists had to be registered with the Health and Care Professions Council. Therapists' questionnaires used the cancer care pathway and NICE four levels model of psychological difficulties. Thirty-two art therapists and 55 service users participated. Service users found art therapy helpful (92%), agreeing that it benefited coping, aided communication, facilitated expression of feelings, provided new perspectives and assisted distraction from worries. Thematic analysis identified five themes: accessibility; mental wellbeing; creativity; support; and multiple perspectives. Art therapists are part of the UK cancer workforce, contributing their services from diagnosis to end of life. Service users confirmed the psychological importance of art therapy. The non-verbal, embodied, aesthetic aspects of art therapy provide a distinctive addition to verbal psychosocial support.

Equity in Cancer Care: Pathways, Protocols, and Guidelines

The quality of patient care varies based on numerous factors, such as health care setting, geographic location, access to medications, insurance coverage, and treatment protocols. Recently, the issue of whether use of clinical pathways can reduce costs and inappropriate variability in care has been the subject of much debate. As clinical treatment guidelines and pathways are increasingly deployed in oncology practice, they have a growing impact on the quality of treatment and how it is delivered. To fulfill the current need to discuss the use of pathways and clinical treatment guidelines in oncology and to address how patient care is impacted by their use, the National Comprehensive Cancer Network convened the NCCN Oncology Policy Summit: Equity in Cancer Care-Pathways, Protocols, and Guidelines. The summit was a forum to discuss the use and implementation of pathways, including how much flexibility pathways should allow in care, pathways' impact on public and private health insurance benefit design, what data is used to select pathway regimens and protocols, and ultimately what impact pathways may have on variation in care. The use and implementation of clinical treatment guidelines in practice was also explored from a variety of perspectives.

How many people need expert symptom assessment but are not in the last year of life?

IntroductionEarlier palliative assessment and support for symptom self management may reduce distress and health resource use in incurable illness. The end of life tariff includes assessment of unstable symptoms, even...

Relationship between Oncotype DX testing and the use of chemotherapy in high-risk patients (pts).

6098 Background: CareFirst BlueCross BlueShield (CFBCBS) insurance network partnered with Cardinal Health Specialty Solutions (CHSS) to develop a cancer care pathway for network physicians in 2008. The program included a recommendation for molecular diagnostic testing with the Oncotype DX assay for pts with early-stage estrogen receptor-positive breast cancer. Based on NCCN guidelines, the pathway suggested adjuvant chemotherapy for all pts with Oncotype DX Recurrence Scores (RS) in the high-risk category. We aimed to determine the RS risk distribution among pts who received Oncotype DX testing and assess the patterns of care that followed. Methods: Using data from CFBCBS, CHSS proprietary claims software, and Genomic Health, we retrospectively identified a cohort of women with breast cancer who were treated on the CFBCBS clinical care pathways program from 8/2008 to 6/2011 and received Oncotype DX testing. We determined the number of pts with a RS value in the low- (RS <18), intermediate- (RS 18-30), and high-risk (RS ≥31) groups along with the number of pts who subsequently received chemotherapy in each category. Results: Of 1174 women who received Oncotype DX testing, 53% of pts were in the low-, 35% in intermediate-, and 12% in the high-risk groups. Five percent of low-, 41% of intermediate-, and 74% percent of pts in the high-risk category were treated with chemotherapy. Twenty-six percent of pts in the high-risk group did not receive chemotherapy. Conclusions: The proportionate use of chemotherapy in the low and intermediate risk groups was as expected based on adjuvant chemotherapy guidelines; however, the underuse of chemotherapy in 26% of high-risk pts was an unexpected finding. Further study is needed to determine: (1) why physicians avoided chemotherapy in 26% of high-risk pts; (2) the overall number of appropriate pts who underwent Oncotype DX testing; and, (3) the tumor characteristics that may have driven the underutilization of chemotherapy in the high-risk population.

Clinical Pathways for Oncology: More Rigor Needed When Evaluating Models

To the Editor: We read with interest Dawn Holcombe's recent article in Journal of Oncology Practice/The American Journal of Managed Care joint issue, entitled “Oncology Managed Programs for Payers and Physicians: Evaluating Current Models and Diagnosing Successful Strategies for Payers and Physicians.”1 As oncologists and others in the industry increasingly turn to Journal of Oncology Practice as a source for impartial and accurate information about new approaches to cancer care, we wanted to take the opportunity to offer additional perspective on what we see as some factual inaccuracies in that article. First, the article identifies nine models for oncology management and generally paints a picture of these nine models as being separate and distinct. From our viewpoint, cancer care pathway concepts are evolving very quickly, and few of the cancer care pathways programs that are currently in operation fall neatly into any one of the nine models outlined in the article. Most of the pathways programs that we lead, for example, are a hybrid of many of the different models identified in the article. Second, as the article reviewed the approaches of various clinical pathways models, it made a number of incorrect assertions. For example, the article incorrectly stated that the pathways model used by P4 Healthcare (Dublin, OH; acquired by Cardinal Health in June 2010) “does not address any aspect of oncology care other than drugs,” “[focuses] solely on the price of drugs,” and operates “without direct medical insight into the individual patient's medical situation and disease.”1(pe46s) The article also incorrectly stated that the P4 pathways model is creating “potential for adverse/unintended consequences that affect patient care or efficacy of the drug combinations” and that “physicians are not involved in this model.”1(pe46s) Because we have both personally helped develop P4's approach to pathways development, we can confirm that each of these assertions is untrue. The P4 pathways model is, by definition, highly collaborative and intimately involves physicians. Steering committees composed of physicians within each payer network actually lead the development of the pathways they'll be expected to follow. Every one of our pathways programs also begins with a clear mandate that physicians have ultimate control of treatment decisions at the point of care. To further ensure physician control, neither P4 pathways medical directors nor payer representatives are permitted voting rights when determining pathways. Only steering committee physicians are extended that right. We believe it's impossible for 100% of patients to be cared for using a limited set of treatment protocols. That's why the P4 pathways model expressly provides room for individualized medicine and physician discretion. We set compliance goals, but in all cases, the physician has ultimate control of treatment decisions at the point of care. For example, we generally expect physicians to be pathways compliant at least 70 percent of the time in year 1 and at least 80 percent in year 2, recognizing that doctors have the direct medical insight into each patient's medical situation and need flexibility to alter treatment regimens to suit unique patient needs. To date, physician compliance in each of our pathways programs has exceeded these goals, which we view as further evidence that this approach is working for physicians and patients alike. The article also referenced a relationship between P4 pathways and one of our payer customers as an example of a payer drug cost reduction program that has shown “cracks and problems.”1(pe46s) On the contrary, the cancer care pathways program to which Ms Holcombe alluded is not only our most mature pathways program, it is also a very successful program. We presented a poster at the 2010 ASCO annual meeting2 regarding the program's success in improving both patient outcomes and reducing cancer costs, not only through reductions in drug costs, but also through patient quality improvements, such as reduced visits to the emergency room. Finally, although this article primarily characterized the P4 pathways model as a drug management model, we believe that points made earlier in this letter illustrate that our model is most closely aligned to fit within the disease management model outlined by the author. In summary, we agree that since P4 Healthcare launched the nation's first cancer care pathways program in 2008, the market has seen a number of new entrants, and new models for leveraging clinical guidelines to improve the quality and costs of cancer care are constantly evolving. As journalists, analysts, and consultants attempt to help practicing oncologists better understand cancer care pathways and the impact these programs can have on patient care, we believe it's important to conduct primary research, directly with the companies that are leading innovations in this field, to ensure that the information shared with clinical audiences is accurate and complete.

Interventions to reduce primary care delay in cancer referral: a systematic review

Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay. To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care. Systematic review in primary care. Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer. Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay. There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so.