Care Of Oncology Patients Research Articles

High-Intensity End-of-Life Care of Allogeneic Hematopoietic Cell Transplantation Recipients (HCT) — a Population-Based Study

BACKGROUNDIntensity of end-of-life care has received much attention in oncology due to concerns that high intensity care is likely expensive and may be inconsistent with patient goals. For these reasons, the National Quality Forum endorsed quality measures around intensity of end-of-life care for oncology patients and many studies have examined rates of and disparities in intensity of end-of-life care in this population treated with conventional therapy. However, little is known about intensity of end-of-life care in allogeneic HCT recipients, a population that is at very high risk for morbidity and mortality. METHODSUsing the California Office of Statewide Health Planning and Development administrative discharge database linked to death certificates, we performed a population-based analysis of allogeneic HCT recipients who died between 2000-2011 and had received their transplant within one year of death. Previously-defined and validated end-of-life care intensity indicators were used and included an intense medical intervention (CPR, intubation, ICU admission, or hemodialysis) within 30 days of death, discharge and subsequent readmission within 30 days of death, and hospital death. A patient was considered to have a given indicator if it was coded during an admission that took place entirely within 30 days of death and/or coded during a terminal admission. Multivariable logistic regression models were used to evaluate associations between clinical and sociodemographic characteristics and: i) hospital death, ii) any medically-intense intervention, iii) ≥2 intensity indicators, iv) readmission within 30 days of death. Regression analyses were done for the whole group and then stratified by age at death (pediatrics: 0-21y; adolescent and young adult [AYA]: 22-39y; adult: 40+y). Sociodemographic and clinical characteristics were considered associated with high intensity care if they were associated with an intensity indicator in at least 2 of the 4 regression analyses. Estimated costs incurred in the last year of life were calculated using each hospital's charge-to-cost ratio adjusted for 2016 dollars. RESULTSA total of 1978 patients were included in the analysis (390 pediatric, 439 AYA, and 1149 adult) with a median age at death of 40 years old; 57% were non-Hispanic white and 28% were Hispanic; 58% were male; 94% had an oncologic diagnosis (AML [38%]; ALL [22%] were most common). Eighty-four percent of the population died in the hospital, 71% of the patients had ≥2 intensity indicators and 52% had a medically-intense intervention. During their terminal admission or admission within 30 days of death, 48% of the cohort was admitted to the ICU, 44% was intubated, 21% received hemodialysis, and 8% received CPR. Entire Cohort: patient age (15-21y, 30-39y, and 40-49y; referent grp: age >60y) and presence of comorbidities at HCT were associated with a medically-intense intervention, ≥2 interventions, and hospital death. Pediatric Cohort: Presence of ≥2 comorbidities during the admission for HCT was associated with high-intensity end-of-life care (a medically-intense intervention, ≥2 interventions, and hospital death). AYA Cohort: Presence of ≥2 comorbidities during the admission for HCT was associated with high-intensity end-of-life care (a medically-intense intervention, ≥2 interventions, and hospital death). Older Adult Cohort: Patient age (40-49y; referent grp: age >60y) and presence of ≥2 comorbidities at HCT were associated with a medically-intense intervention and >2 intensity indicators. Cost of Care: HCT recipients in this study were admitted a median of 106 days during their last year of life, costing the system $558,136 in inpatient expenses per patient. CONCLUSIONSAllogeneic HCT recipients who die within a year of transplantation frequently receive a number of intensive end-of-life care interventions, as evidenced by the fact that 84% of the patients die in the hospital and 48% are admitted to the ICU at the end-of-life. Further work is needed to determine if these rates are consistent with patients' goals and whether interventions like earlier end-of-life conversations and/or palliative care consults may decrease intensity of care in this population as in non-HCT oncology patients. DisclosuresNo relevant conflicts of interest to declare.

Therapeutics for paediatric oncological emergencies.

BackgroundWith advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies.MethodsAn extensive PubMed® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years.ResultsThe general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life.ConclusionsOncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.

Clinical Efficiency and Safety Outcomes of Virtual Care for Oncology Patients During the COVID-19 Pandemic.

Telehealth has been an integral response to the COVID-19 pandemic. However, no studies to date have examined the utility and safety of telehealth for oncology patients undergoing systemic treatments. Concerns of the adequacy of virtual patient assessments for oncology patients include the risk and high acuity of illness and complications while on treatment. We assessed metrics related to clinical efficiency and treatment safety after propensity matching of newly referred patients starting systemic therapy where care was in large part replaced by telehealth between March and May 2020, and 206 newly referred patients from a similar time period in 2019 where all encounters were in-person visits. Patient-initiated telephone encounters that capture care or effort outside of visits, time to staging imaging, and time to therapy initiation were not significantly different between cohorts. Similarly, 3 month all-cause or cancer-specific emergency department presentations and hospitalizations, and treatment delays were not significantly different between cohorts. There were substantial savings in travel time with virtual care, with an average of 211.4 minutes saved per patient over a 3-month interval. Our results indicate that replacement of in-person care with virtual care in oncology does not lead to worse efficiency or outcomes. Given the increased barriers to patients seeking oncology care during the pandemic, our study indicates that telehealth efforts may be safely intensified. These findings also have implications for the continual use of virtual care in oncology beyond the pandemic.

Evaluating Nutrition Services in Outpatient Cancer Centers in New Mexico – A Pilot Study Protocol

ObjectivesNationally, 50% of all cancer patients experience malnutrition upon diagnosis or during the course of treatment. When registered dietitian nutritionists (RDNs) are involved in oncology treatment, outcomes improve, with a reduction in financial burden for the patient and health delivery system. Despite the high prevalence of outpatient treatment utilization (up to 90% of cancer patients), RDN understaffing is common in outpatient cancer treatment settings. The goal of this pilot project is to characterize and understand factors at the organizational level (e.g., policies and practices) and provider level (e.g., knowledge, attitudes, practices and needs) that affect implementation of nutrition standards of practice at outpatient oncology clinics in New Mexico (NM). Characterizing current nutrition resources in distinct regions across the state is crucial to the development of effective interventions to improve access to RDN nutrition care across NM. MethodsWe will conduct a comprehensive, 7-domain, nutrition-focused environmental scan of ∼15 treatment centers and surrounding areas. Data collected will include clinic catchment area information; patient and area census demographics; clinic screening and referral policies; clinic technical, financial, and personnel resources; and community nutrition resources. We will then conduct ∼50 semi-structured interviews of stakeholders, including administrators and medical and RDN providers, at ∼10 of these treatment facilities to contextualize the results of the environmental scan. Qualitative interviews will explore facilitators and barriers to provision of guideline concordant nutrition care. We will perform a case study analysis (both within-case and cross-case) of sites and examine the identified resources and gaps to care in each region and will note differences across settings (e.g., urban vs. rural centers). ResultsN/A. ConclusionsThis innovative, mixed-methods study will provide a context-driven inventory of nutrition processes, services, and resources at outpatient cancer treatment clinics in NM. These data will inform a tailored intervention to improve access to nutrition care for ambulatory oncology patients throughout NM. Funding SourcesAmerican Cancer Society Institutional Research Grant; NCI Cancer Center Support Grant.

Systematic review of prospective studies focused on regionalization of care in surgical oncology.

To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization.

Primary care oncology model (PCOM): Implementation of a model integrating primary and oncology care for patients taking oral anticancer agents.

TPS1587 Background: Non-adherence to oral anticancer agents (OAA) has been reported among 30% of individuals. Often, individuals with cancer are not just managing their new OAA but also medications to treat multiple chronic conditions (MCC). Multiple factors contribute to the extent patients on OAAs and MCC medications adhere to therapy. The objective of this study is to improve medication, symptom, and disease management of patients with hematological malignancies and MCC through care coordination between pharmacists. Methods: Design. This is a multi-center prospective single arm pilot study at two academic medical centers in Michigan and Tennessee. Subjects. Ninety participants will be recruited, 60 from site 1 and 30 from site 2. Inclusion criteria are: adults > 18 years, diagnosed with and initiating oral treatment for chronic myeloid leukemia, chronic lymphocytic leukemia, or multiple myeloma, diagnoses of at least 2 chronic conditions, where one is type 2 diabetes, hypertension, congestive heart failure, depression/anxiety, gastroesophageal reflux disease, hyperlipidemia, or chronic obstructive pulmonary disease, taking at least two chronic medications, and able to provide electronic consent. Exclusion criteria are: inability to speak English, and diagnosis of type 1 diabetes or HIV. Intervention. Participants will complete two Patient Reported Outcome Measures (PROMs) for their OAA that will be reviewed by the oncology pharmacist, with follow-up to the care team if needed. Participants will be scheduled for a Comprehensive Medication Review with a primary care pharmacist for up to two visits for their chronic medications. The intervention over 2 months, and the oncology and primary care pharmacists communicate via electronic health record about medications, symptoms, and disease control. Outcomes. The primary endpoints are (a) dose-adjusted adherence by proportion days covered (PDC) for the OAA and (b) PDC for chronic condition medications, assessed using 6 months of prescription claims. Data will be collected from patients using REDCap surveys and abstracted data will be entered into REDCap. Implementation by pharmacists and patient acceptability will be examined. Analysis. The association of OAA and chronic medication adherence (PDC) will be examined via correlation. Participant demographics,clinical characteristics, and the symptom experience from the PROM will be described. Using CMR results, medication problems, recommendations, and changes will be provided. Program implementation will be assessed and patient perceptions obtained from post-CMR interviews. A joint display for the quantitative and qualitative data for feasibility, appropriateness, and acceptability from pharmacists will be completed. Results: Screening and recruitment has begun. Clinical trial information: NCT04595851 and NCT04663100.

Differences in transitions of care among cancer patients with and without venous thromboembolism (VTE) events.

e18636 Background: Transitions of care are an important part of medical care, as they provide opportunities to address patient concerns, refine goals to match current needs and prevent unforeseen complications and comorbidities. One such common and prevalent comorbidity amongst cancer patients is venous thromboembolism (VTE) events. Common VTE events include the occurrence of pulmonary embolism (PE), deep vein thrombosis (DVT) or both at the time of diagnosis or any time thereafter. It is estimated that approximately 4–20% of cancer patients will experience a VTE. Cancer patients developing VTE is a serious concern as it can adversely affect the patients’ quality of life and reduce overall survival rates and prognosis. Methods: This study is designed as a case control study. The subject group consists of 87 cancer patients who had one or several VTE events after their cancer diagnosis. Patients were selected from the UVM Medical Center electronic health record database. The goal of this project was to quantify and compare the average number of transitions of care in cancer patients with and without venous thromboembolism (VTE) events. This was achieved by reviewing the patients charts three months following a VTE event and evaluating whether these patients had a greater number of transitions compared to the three months prior to their VTE event. Transitions of care in our study were defined as office visits, ED visits, and inpatient admissions related to their VTE. Results: Initial evaluation of the results showed that there were more transitions of care amongst cancer patients with a VTE than without. Preliminary data of the 87 patients shows that patients who developed a VTE event after their cancer diagnosis had on average 1.3 more transitions of care within the three months following their VTE event compared to cancer patients without a VTE event. A t test will be used to determine whether the difference between the means (number of transitions of care) of the two groups (cancer patients with VTE and those without VTE) is significant. Conclusions: The implications of having greater transitions of care amongst cancer patients with VTE events are profound. Having more transitions of care exemplifies better implementation, patient care and involvement of health care teams given a history of VTE. Furthermore, the results of this study will provide further insight on ways to improve clinical outcomes and oncology patient care given a history of VTE.

Patient care and clinical trials in gynecological oncology: Implications of the COVID-19 pandemic.

5564 Background: This is a prospective international Survey to evaluate the impact of the COVID-19 Pandemic on the management of patients with gynecological malignancies from the multidisciplinary physicians' perspective, with particular focus on clincial infrastructures, and trial participation. Methods: The anonymous online survey consisted of 53 COVID-related questions. It was sent to all healthcare professionals in gynaecological oncology centres across Europe and the Pan-Arabian region from April 2020 to October 2020. All healthcare professionals treating women with gynecological cancers were able to participate in the survey. Results: A total of 243 answers were collected from 30 different countries. The majority (73%) of participants were gynecological oncologists from university hospitals(71%) with at least an Intensive care unit with cardiopulmonary support available at their institutions. Most institutions continued to perform elective surgeries only for oncological cases (98%). Patients had to wait on average 2 weeks longer for their surgery appointments compared to previous years(range 0-12 weeks). Cases that were prioritised for surgical intervention across all tumors (Ovarian, Endometrium, Cervical) were early stage disease (74%), primary situation (61%), and good ECOG status (63%). The radicality of surgery did not change in the majority of cases (78%) across all tumor types. During the pandemic, only 38% of clinicians stated they would start a new clinical trial. 45% stated the pandemic has negatively impacted the financial structure and support for clinical trials. 79% do not routinely screen patients included in trials for SARS CoV2. Overall, approx. 20% of clinicians did not feel well informed regarding clinical pathways for COVID-19 patients throughout the pandemic. The majority preferred regular updates and training via Webinars (75%), followed by tumorboards and interdisciplinary conferences (45%). 30% of clinicians stated that they are currently experiencing difficulties in providing adequate medical care due to staff shortage. Conclusions: Despite well-established guidelines for patient care and performing clinical trials in gynecological oncology, the COVID-19 pandemic has impacted clinical research, and financial structures. Longer waiting times for operative interventions, less support for clinical trials and concerns regarding provision of adequate medical care and triaging patients are very real. This survey underlines the necessity for building robust emergency algorithms tailored to gynecological oncology patients in the future.

Oncology trainees’ perceptions and knowledge of therapeutic cannabis use.

11028 Background: Evidence shows that cancer patients are interested in learning about medicinal cannabis and frequently ask their oncologists for recommendations. To determine whether oncology training is adequately preparing physicians to address this topic, we conducted a national survey of oncology trainees to determine attitudes, practices, and knowledge about medical cannabis in cancer care. Methods: An interdisciplinary team developed an electronic questionnaire assessing trainees’ current practices regarding cannabis recommendations in cancer care and their knowledge of its effectiveness and risks compared with conventional care for cancer-related symptoms. We contacted 155 oncology training programs throughout the U.S. and asked that they distribute the survey to their trainees. Primary outcomes were: whether trainees reported discussing or recommending cannabis with/to patients and whether they felt sufficiently informed to make such recommendations. We presented data as proportions and used chi-square tests to compare proportions between groups. Results: Forty training programs from 25 states participated; of the 462 trainees in these programs, 187 completed surveys, yielding a response rate of 40%. Of the participants, 52% were female, 53% White, 33% Asian, and 5% Hispanic. One third (34%) graduated medical school before 2015, and 22% attended medical school outside the US. While 24% of trainees reported having received training regarding medical cannabis, only 12% felt sufficiently informed to make cannabis recommendations. Despite this, 91% reported having discussed cannabis with patients, and 58% reported recommending cannabis clinically to more than five patients in the prior year. Many viewed it as useful adjunctive therapy that was at least as effective as conventional treatments for: anorexia/cachexia (72%), nausea/vomiting (45%), and pain (41%). Over half (55%) believed that cannabis was beneficial to patients at the end of life; 31%, patients in active treatment; 11%, cancer survivors; 20%, the elderly with cancer and 16%, young adults with cancer. Peer-reviewed material (30%), lectures or webinars by another physician (29%), and patients and their families (22%) were the most commonly cited sources of information regarding medical cannabis. Oncologists who reported at least one area of focus as supportive/palliative care were more likely to feel sufficiently informed to make recommendations than oncologists without this focus (17% vs. 4%, P = 0.01); no other demographic or practice characteristics were associated with feeling sufficiently informed (all P > 0.10). Conclusions: Although most oncology trainees discuss cannabis use with their patients, the majority do not feel sufficiently informed about its use in cancer care. This represents an unmet need in contemporary oncology training, trainee satisfaction, and patient care.

An optimized mathematical model for cancer patient care planning in the COVID-19 era.

e18663 Background: The COVID-19 pandemic has threatened to collapse hospital and Intensive Care Unit (ICU) services, and it seems to limit the care of oncologic patients. The objective was to develop a mathematical model designed to predict the hospitalization and ICU admission demands due to COVID-19 to forecast the availability of hospital resources for the scheduling of oncological surgery and medical treatment that require hospitalitation or possible use of ICU services. Methods: We have implemented a SEIR model designed to predict the number of patients requiring hospitalization and ICU admissions for COVID-19. We evaluated the model using the number of cases registered in the hospitals of the province of Granada (Spain), that altogether cover 914,678 inhabitants. Calibration was performed using data recorded between March 15 and September 22, 2020. After that, the model was validated by comparing the predictions with data registered between September 23 and November 7, 2020. Besides, we performed a predictive analysis of scenarios regarding different possible sanitary measures. Results: Using patient registered data we developed a mathematical model that reflects the flow among the different sub-groups related to COVID-19 pandemics (Table). The best algorithm that fitted the disease dynamics was Particle Swarm Optimization, that minimized the difference between model output and real data used to calibrate the model. The validation phase showed the accuracy of the predictions, especially concerning trends in hospitalizations and ICU admissions. The different scenarios modelled on November 10, 2020 allowed us to predict the evolution of the pandemic until July 1, 2021, and to detect the peaks and valleys of disease prevalence. Conclusions: The mathematical model presented provides predictions on the evolution of COVID-19, the prevalence and hospital or ICU care demands. The predictions can be used to detect periods of greater availability of hospital resources that make it possible to schedule the oncologic surgery and intensify the care for oncologic patients. Furthermore, our model can be adapted to other population by recalibrating the model according to demographic data, the local evolution of the pandemic and the health policies. [Table: see text]

Outpatient care of oncological patients in palliative treatment situations and their relatives during the COVID-19 pandemic

HintergrundNeben Schutzmaßnahmen muss das Gesundheitssystem in der aktuellen Pandemiesituation die Fortführung der Regelversorgung sowie zusätzlich die Behandlung von Patienten mit Covid-19-Infektionen sicherstellen. Auch Praxen niedergelassener Onkologen sind betroffen.Ziel der Arbeit/FragestellungDie Arbeit untersucht Herausforderungen, Erfahrungen und Lösungsansätze in der Betreuung onkologischer Patienten in palliativer Behandlungssituation und ihrer Angehörigen durch niedergelassene Onkologen in der Pandemiesituation. Die Erkenntnisse dienen als Informationsbasis für die Strategieentwicklung in der ambulant-onkologischen Versorgung.Material und MethodenInhaltsanalytische Auswertung 13 leitfadengestützter telefonischer Interviews mit niedergelassenen Onkologen.ErgebnisseStabile lokale Netzwerke, personelle und strukturelle Anpassungen sowie Infektionsschutzmaßnahmen halfen bei der Aufrechterhaltung der Versorgungsqualität onkologischer Patienten in palliativer Behandlungssituation. Notwendige onkologische Therapien wurden fortgesetzt. Als problematisch gelten entstandene Barrieren in der Angehörigenkommunikation und das Nachholen verschobener Erst‑, Kontroll- und Nachsorgeuntersuchungen. Weitere Herausforderungen waren der Umgang mit infektionsverdächtigen Mitarbeitern und Patienten, die zeitweise mangelnde Erreichbarkeit und Information von öffentlichem Gesundheitsdienst und Kassenärztlichen Vereinigungen sowie Mehrkosten für Infektionsschutzmaterial und Personal.DiskussionDurch die entschlossene Implementierung von Infektionsschutzmaßnahmen und die strukturelle und personelle Reorganisation in Praxen konnte die ambulante Betreuung onkologischer Patienten und ihrer Angehörigen in der Pandemiesituation aufrechterhalten werden. Die Hygienekonzepte scheinen praktikabel und reaktivierbar. Eine stärkere Verwendung digitaler Lösungen (z. B. Videosprechstunden) sowie Lösungen, um dem finanziellen und personellen Mehrbedarf zu begegnen, sind dennoch notwendig. Differenzierte Konzepte zur Vermeidung von gesundheitlichen Nachteilen durch Besuchsverbote für Angehörige und körpernah arbeitende Therapeuten sind zu entwickeln.

Patient-Derived Cancer Organoids for Precision Oncology Treatment.

The emergence of three-dimensional human organoids has opened the door for the development of patient-derived cancer organoid (PDO) models, which closely recapitulate parental tumor tissue. The mainstays of preclinical cancer modeling include in vitro cell lines and patient-derived xenografts, but these models lack the cellular heterogeneity seen in human tumors. Moreover, xenograft establishment is resource and time intensive, rendering these models difficult to use to inform clinical trials and decisions. PDOs, however, can be created efficiently and retain tumor-specific properties such as cellular heterogeneity, cell–cell and cell–stroma interactions, the tumor microenvironment, and therapeutic responsiveness. PDO models and drug-screening protocols have been described for several solid tumors and, more recently, for gliomas. Since PDOs can be developed in clinically relevant time frames and share many characteristics of parent tumors, they may enhance the ability to provide precision oncologic care for patients. This review explores the current literature on cancer organoids, highlighting the history of PDO development, organoid models of glioma, and potential clinical applications of PDOs.

New Approach to the Surgical Treatment of Cardioesophageal Cancer in the Context of the COVID-19 Pandemic (Case Report)

Background. The wide and rapid spread of the new coronavirus infection, unfortunately, makes its own adjustments in clinical practice, including in the promotion of specialized care for oncological patients. Clinical case description. The authors demonstrated an example of a successful radical treatment of adenocarcinoma of the esophageal-gastric junction, complicated by dysphagia and recurrent bleeding from the tumor. Аn integrated approach, gastrostomy, adequate correction of concomitant diseases and timely vaccination against COVID-19 made it possible to carry out a full-fledged intervention in a timely manner. Conclusions. Radical treatment of patients with gastrointestinal toncological diseases in a severe viral pandemic is possible. Emergency vaccination significantly reduces the risk of developing severe respiratory and other disorders.

Role of the radiologist at HCC multidisciplinary conference and use of the LR-TR algorithm for improving workflow.

Multidisciplinary conferences (MDCs) play a major role in management and care of oncology patients. Hepatocellular carcinoma (HCC) is a complex disease benefiting from multidisciplinary discussions to determine optimal patient management. A multitude of liver-directed locoregional therapies have emerged allowing for more options for treatment of HCC. A radiologist dedicated to HCC-MDC is an important member of the team contributing to patient care in multiple ways. The radiologist plays a key role in image interpretation guiding initial therapy discussions as well as interpreting post-treatment imaging following liver-directed therapy. Standardization of image interpretation can lead to more consistent treatment received by the patient as well as accurate assessment of transplant eligibility. The radiologist can facilitate this process using structured reporting that is also supported by stakeholders involved in interdisciplinary management of liver diseases. The Liver Imaging Reporting and Data System (LI-RADS), is a living document which offers a standardized reporting algorithm for consistent communication of radiologic findings for HCC screening and characterization of liver observations in patients at risk for HCC. The LI-RADS post-treatment algorithm (LR-TR algorithm) has been developed to standardize liver observations following liver-directed locoregional therapy. This review article focuses on the role of the radiologist at HCC-MDC and implementation of the LR-TR algorithm for improving workflow.

Precision Cancer Medicine: Dynamic Learning of Cancer Biology in a Clinically Meaningful Context.

Precision medicine is revolutionizing healthcare practices, most notably in oncology. With cancer being the second leading cause of death in the USA, it is important to integrate precision oncology content in undergraduate medical education. In 2015, we launched a Clinical Cancer Medicine Integrated Science Course (ISC) for post-clerkship medical students at Vanderbilt University School of Medicine (VUSM). In this ISC, students learned cancer biology and clinical oncology concepts through a combination of classroom and patient care activities. Student feedback from mid- and end-of-course surveys and student match data were analyzed and used to develop ongoing course improvements. To date, 72 medical students have taken the Clinical Cancer Medicine ISC. Over 90% of students who completed end-of-course surveys agreed or strongly agreed that this course advanced their foundational science knowledge in clinical cancer medicine, that clinical relevance was provided during non-clinical foundational science learning activities, and that foundational science learning was embedded in course clinical experiences. Students who took this course most commonly matched in Internal Medicine, Pathology, Pediatrics, and Radiation Oncology. VUSM students who matched into Pathology and Radiation Oncology were more likely to take this ISC than students who matched in other specialties. The Clinical Cancer Medicine ISC serves as a model for incorporating precision oncology, cancer biology foundational science, and oncology patient care activities in undergraduate medical education. The course prepares students to care for oncology patients in their fields of interests during their future career in medicine.

Barriers in the Application Process for Oncological Rehabilitation: A Nationwide Expert Study

From the perspective of various expert groups involved in the care of oncological patients, barriers to the application process of oncological rehabilitation programs will be identified. The study was funded by the German Pension Insurance Association (DRV). Based on an interview study (N=61), a questionnaire instrument with 55 items describing possible barriers in the application process was designed and implemented online. Participants with more than 33% missing values were excluded from the analyses. Mean value analyses were used to identify the most significant relevance. To identify overall dimensions an explorative factor analysis was conducted . A total of 606 experts from the oncological field were included in the analyses. Among them were 249 doctors, 194 social workers, 105 nurses / medical assistants, 55 psychologists / psycho-oncologists and three other professional groups. The queried experts were on average 51 years old (SD=10.4) and had been working in the oncological field for 17 years (SD=9.8). The barriers could be assigned to the following seven factor-analytically determined content sections: coping style, application procedure, rehabilitation requirements, coordination, social responsibilities, desires of patient and the priority of rehabilitation. According to the experts statements the main obstacles to an application were the patient's desire for normality, the rigid deadline for the application and the application procedure which is difficult for patients with a migration background to understand. It was also pointed out that it is difficult to place multimorbid patients in rehabilitation facilities. The following recommendations for action to facilitate access to rehabilitation can be derived from the expert study: optimization of the coordination between different expert groups, institutions and the cost units, flexibilisation of the deadline for follow-up, simplifying the application process, providing applications/information material in additional languages, orienting rehabilitation clinics towards specific patient groups.

Can conventional clinical chemistry tests help doctors in the monitoring of oncology patients?

The use of laboratory assays in the diagnostic care of oncology patients can markedly increase the efficacy of cancer treatments. Many cancer-specific biomarker assays have been developed. However, the use of these has some limitations due to their cost. Moreover, not every diagnostic laboratory can perform a complete set of these assays. On the other hand, the smart use of conventional clinical chemistry tests could improve the management of cancer. They could be especially valuable tools in the long-term care of patients with a verified diagnosis. In this review, we discuss the utilization of the conventional clinical chemistry assays for the diagnosis, monitoring and prognosis of various oncological diseases. The use of conventional blood tests to assess the levels of chemical elements, metabolites and proteins (including enzymatic activity measurements) in the care of oncology patients is discussed. We have shown that some clinical chemistry assays could be used in the management of distinct kinds of cancer.

Use of therapeutic outcomes monitoring method for performing of pharmaceutical care in oncology patients

This study aimed to implement pharmaceutical care using the therapeutic outcome monitoring (TOM) method for pharmacotherapeutic follow-up of oncological patients. This was a prospective longitudinal study involving patients undergoing oral chemotherapy. The study environment was an outpatient pharmacy at a tertiary-level oncology hospital. Ninety patients who received oral chemotherapy were evaluated, and 27 patients were followed up in accordance with the exclusion criteria and acceptability of participation in the study. The patients were predominantly diagnosed with gynecological tumors, with a mean age of 57.56 ± 13.06. The average consumption of drugs per patient was 4.63 ± 4.85, and more than 55% of patients had undergone oral antineoplastic therapy for more than a year. The main therapeutic groups used were drugs that acted on the gastrointestinal tract and metabolism (34%). All patients had at least one drug-related problem (DRP). In total, 133 DRP were identified. Approximately 33% of patients had DRPs related to antineoplastic therapy; non-adherence, incorrect administration, and the probability of adverse events were among the frequently reported DRPs. We identified 43 negative outcomes associated with medication (NOM), with untreated health problems (47%) and non-quantitative insecurity (30%) being the most frequently reported. 81 pharmaceutical interventions were performed, and 96% were accepted. The main errors avoided with the interventions were untreated health problems, misuse, and interruptions associated with medication administration. The TOM method effectively achieved the desired results of therapy, improving the use of medicines, and thus increasing patient safety.

Integrated oral care contributes positively to the course of treatment of oncopediatric patients.

The purpose of this study was to implement a model of permanent oral health care for oncopediatric patients and to observe its effects on severe oral mucositis and subsequent treatment interruptions. We performed a quasi-experimental study in the Pediatric Department of Napoleão Laureano Hospital, in the city of João Pessoa, Brazil. A integrated oral care was implemented by a dentistry team for prevention of comorbidities, such as infections, oral pain, oral function maintenance, oral mucositis, and interventions for lesions due to severe oral mucositis. The oral comorbidities were compared before and after the implementation. The duration of severe oral mucositis (SOM) before and after the interventions and the interruptions in treatment due to SOM were the main outcome measures. Permanent oral health care reduced the duration of SOM and reduced pediatric chemotherapy interruptions due to SOM by 81.8%.Conclusion: The permanent oral health care to offer to oncopediatric patients increased surveillance regarding oral comorbidities and reduced chemotherapy interruptions due to severe oral mucositis. This care plan could be adopted anywhere around the world. What is Known: • Several studies on oral care for pediatric oncology patients, especially regarding both prevention of and treatment for oral mucositis during antineoplastic therapy, have been published. What is New: • This study describes the benefits of permanent oral care with daily oral surveillance for pediatric patients, which reduced the duration of severe oral mucositis, increased surveillance and the efficiency in diagnostic for signs of oral mucositis, enabling early intervention, and decreased chemotherapy interruptions, contributing positively to the course of treatment.

Triggers for Palliative Care Referral in Pediatric Oncology.

Simple SummaryPalliative care (PC) can improve the quality of life for pediatric cancer patients, yet these services remain underutilized, with referrals occurring late in the disease course or not at all. We previously described the patient and family characteristics that diverse pediatric oncology providers agree should be high yield triggers for PC referral in pediatric cancer patients. The current study examined how often those triggers were associated with a completed PC consult for a cohort of 931 patients. We discovered that PC referrals occur very infrequently and patients with stated triggers often do not get referred. These findings help support the need for a screening tool to standardize PC integration and improve care.Palliative care (PC) integration into the care of pediatric oncology patients is growing in acceptance and has been shown to improve the quality of life of children with cancer. Yet timing for referrals and referral practices remain inconsistent, and PC remains underutilized. We conducted a retrospective chart review of pediatric oncology patients treated at an academic institution between January 2015 to November 2018. Data collected included demographics, disease and therapy characteristics, and consultation notes, specifically documenting existence of predetermined “high yield triggers” for PC consultation. Among 931 eligible patients the prevalence of PC consultation was 5.6% while approximately 94% of patients had at least 1 trigger for PC consultation. The triggers that more often resulted in PC consultation included: symptom management needs (98%; n = 51) high-risk disease (86%; n = 45), poor prognosis (83%; n = 43), multiple lines of therapy (79%; n = 41) and a documented ICU admission (67%; n = 35). Our findings suggest that the high yield triggers for palliative care consultation that pediatric oncologists identify as important are not translating into practice; incorporating these triggers into a screening tool may be the next step to improve early PC integration.