Medical Oncology Care Research Articles

Oncology Medical Home to address challenges in breast cancer care delivery.

e16641 Background: Care fragmentation and poor coordination in oncology negatively impact patient outcomes (IOM 2001, 2005). The Patient Centered Medical Home (PCMH) promises improved coordination of primary and chronic care (IOM, 2008). We previously identified unique challenges in breast cancer care coordination (Schink JC, ARM-1162-2010). Here we explored the distinct characteristics of Oncology Medical Home (OMH) which may address these challenges. Methods: 59 semi-structured interviews with: breast cancer care providers (n=26), patients (n=9), executives (n=24) from 5 major payers. Three multi-disciplinary focus groups included a subset of interviewed individuals (n=17, n=25, n=15). Interviews and focus groups were recorded, transcribed and analyzed according to the framework approach. Results: Theme analysis identified 4 unique characteristics of OMH: 1. OMH should have a lead physician—oncologist or breast surgeon (early stage patients)—for the entire episode of cancer care, then transfer survivors to PCMH. 2. Lead physician facilitates the cross-domain care team from diagnosis through survivorship, including surgery medical oncology, radiology, supportive and primary care. 2. Care and team should be managed as a project, with key events sequenced and timed in a plan, by a care project manager (e.g. APN). 4. OMH requires a unique reimbursement model to incentivize team participation and coordination. Patients strongly encouraged the lead physician feature. Providers suggested all OMH features. Half the payers were not certain of specific OMH features, but most recognized the need for a new reimbursement model. Conclusions: Oncology has unique care coordination and reimbursement challenges. An Oncology Medical Home may address these challenges, but should incorporate features distinct to cancer care and be facilitated by redesigned provider reimbursement. Implementation of OMH may be challenging, but could revolutionize care for cancer patients. OMH pilots will inform implementation and dissemination. OMH characteristics Providers Payers Patients Oncologist or surgeon lead physician 73% 46% 89% Cross-domain care team 81% 63% 78% Care project plan 73% 38% 67% Unique reimbursement model 85% 88% 33%

The relevance of the Spanish society for medical oncology (SEOM)’s clinical oncology guidelines

In this issue of Clinical and Translational Oncology, the Spanish Society for Medical Oncology (SEOM) publishes a group of the Clinical Guidelines that are the result of an ambitious educational programme. The main objective of this programme was to periodically create and actualise a set of clinical guidelines mainly focused on the medical treatment for the majority of solid tumours and cancerrelated or therapy-related symptoms. Clinical guidelines have increasingly become a common part of clinical practice during the past decade. They are defi ned by the Institute of Medicine as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specifi c clinical circumstances” [1]. Appropriate care involves assessing the balance between the sum of the benefi ts and the sum of the risks [2]. There are several factors that have stimulated increased interest in the development of clinical guidelines. Among the most relevant reasons are the exponential increment of medical publications, rising healthcare costs, the use of more expensive technologies, variations in service delivery among providers even within the same city or geographic region and the aspiration of healthcare physicians to offer the best possible care to their cancer patients. In this scenario, clinical guidelines are considered as a tool for giving the patients the best care based on the most consistent scientifi c evidence. Therapy based on guidelines has been shown to lead to better clinical outcomes compared with locally adapted therapeutic strategies and this would also lead to improved quality of care for the patients. Several objectives can be assigned to clinical guidelines. The main aim is usually to improve the quality of the medical care. However, other important objectives to consider are to facilitate the decision-making process for the treating physician, to promote effi cient use of the health system resources and to set the basis for performing an evaluation of the quality of medical care. Clinical guidelines’ highest quality probably lies in the methodology for constructing them based on the comprehensive review of the literature and the most convincing evidence-based medicine available. Nowadays, there are many clinical guidelines in oncology, produced by different institutions, governments, scientifi c societies and cooperative groups. So why has SEOM launched a new group of clinical guidelines? This initiative is the result of the intent to adapt the best evidence-based knowledge in medical oncology to the specifi c scenario of the Spanish health care system and to actively cooperate with the health authorities in the homogenisation of medical oncology care among the different communities in Spain. For this purpose, the board of SEOM created a working group in 2008 with the aim of coordinating this project. The clinical guidelines working group established the methodology and the basis for building each guideline. They defi ned some common characteristics for each guideline with special emphasis on being clear and concise but complete at the same time, and the use of tables or algorithms for facilitating comprehension. It should be highlighted that the recommendations made by the clinical guidelines should be in accordance with the approvals obtained by the different therapies in Spain at the moment of writing the guideline. Regarding the authors, a fi rst panel of experts was nominated in order to write the fi rst draft of the guideline. Then, a second panel of experts also nomiD. Isla Casado SEOM Clinical Guidelines Coordinator Servicio de Oncologia Medica Hospital Clinico Universitario Lozano Blesa Zaragoza, Spain

Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators

An American Psychosocial Oncology Society workgroup has developed indicators of the quality of psychosocial care that can be measured through review of medical records. The present report describes the first large-scale use of these indicators to evaluate psychosocial care in outpatient medical oncology settings. Medical records of 1660 colorectal, breast and non-small cell cancer patients first seen by a medical oncologist in 2006 at 11 practice sites in Florida were reviewed for performance on indicators of the quality of psychosocial care. Assessment of emotional well-being was significantly less likely to be documented than assessment of pain (52 vs 87%, p<0.001). A problem with emotional well-being was documented in 13% of records and evidence of action taken was documented in 58% of these records. Ten of eleven practice sites performed below an 85% threshold on each indicator of psychosocial care. Variability in assessment of emotional-well being was associated (p<0.02) with practice site and patient gender and age while variability in assessment of pain was associated (p<0.001) with practice site and cancer type. Findings illustrate how use of the psychosocial care indicators permits identification of specific practice sites and processes of care that should be targeted for quality improvement efforts. Additionally, findings demonstrate the extent to which routine assessment of emotional well-being lags behind routine assessment of pain in cancer patients.

Trends in PET Scanner Ownership and Leasing by Nonradiologist Physicians

The aim of this study was to examine growth trends in ownership or leasing of private-office PET scanners by nonradiologist physicians. The Medicare Part B Physician/Supplier Procedure Summary Master Files for 2002 through 2007 were used to collect the following data for each PET-related Current Procedural Terminology((R)) code: 1) annual procedure volume, 2) places of service for the procedures, and 3) specialties of the physicians filing the claims. To determine ownership or leasing, only technical and global claims that occurred in the nonhospital, private-office setting were included in the study. Professional component-only claims were not included. Procedure volume and growth trends were compared between radiologists and other specialties. Between 2002 and 2007, radiologist-owned Medicare PET scans increased by 259%, whereas nonradiologist-owned or nonradiologist-leased scans grew by 737%. Five specialty groups accounted for 95% of all nonradiologist PET volume in 2007: internal medicine subspecialties (28,324 studies in 2007), medical oncology (14,320 studies), cardiology (13,724 studies), radiation oncology (9,563 studies), and primary care (2,398 studies). In 2002, of all Medicare PET examinations performed on units owned or leased by physicians, the share for nonradiologists was 13%; their share rose to 24% in 2007. Although a large percentage of PET scans in private offices are done by radiologists, the growth rate among nonradiologists was far higher between 2002 and 2007 (259% for the former, 737% for the latter). The disproportionately rapid growth of PET scans performed on units owned by nonradiologists raises concern about self-referral at a time when policymakers are struggling to contain costs and reduce radiation exposure.

Standardizing care in medical oncology

Medical oncology is embracing information technology to standardize care and improve patient outcomes, with a range of Web-based systems used internationally. The authors' aim was to determine the factors affecting the uptake and use of a Web-based protocol system for medical oncology in the Australian setting. The authors conducted 50 interviews and observed medical oncology physicians, nurses, and pharmacists in their treatment setting at 6 hospitals in different geographic locations. The Web-based system plays a major role in guiding oncology treatment across participating sites. However, its use varies according to hospital location, clinician roles, and experience. A range of issues impact on clinicians' attitudes toward and use of the Web-based system. Important factors are clinician-specific (eg, their need for autonomy and perceptions of lack of time) or environmental (eg, hospital policy on protocol use, endorsement of the system, and the availability of appropriate infrastructure, such as sufficient computers). The level of education received regarding the system was also found to be integral to its ongoing use. Although the provision of high-quality evidence-based resources, electronic or otherwise, is essential for standardizing care and improving patient outcomes, the authors' findings demonstrate that this alone does not ensure uptake. It is important to understand end-users, the environment in which they operate, and the basic infrastructure required to implement such a system. Implementation must also be accompanied by continuing education and endorsement to ensure both long-term sustainability and use of the system to its full potential.

Etiology of Delays in the Initiation of Adjuvant Chemotherapy and Their Impact on Outcomes for Stage II and III Rectal Cancer

This study was designed to evaluate the role of access to care and postsurgical recovery on delays in adjuvant chemotherapy for rectal cancer. Using data from the linked Surveillance, Epidemiology, and End Results-Medicare database, we analyzed patients with Stage II or III rectal cancer who received adjuvant chemotherapy after curative rectal cancer surgery between 1991 and 2002. Logistic and Cox regressions were performed to assess determinants of adjuvant chemotherapy delays and outcomes in two cohorts: patients with access to medical oncology care because of prior neoadjuvant chemotherapy (Group A) and patients without such access (Group B). Length of postoperative hospital stay served as the main proxy for postsurgical recovery. A total of 442 and 5,617 patients were included in Groups A and B, respectively. The median interval between surgery and adjuvant chemotherapy was 46 days in Group A and 42 days in Group B. Although 17 percent and 11 percent of patients in Groups A and B, respectively, waited three or more months for adjuvant chemotherapy, median overall survival was worse in this subset than in those who waited less than 3 months (54 vs. 76 months, P < 0.01). Postoperative hospital stay independently predicted for adjuvant chemotherapy delay in both groups. Disparities in delays were seen only in Group B, such that patients who were older or black had greater odds of an adjuvant chemotherapy delay (for both, P < 0.05). Advanced age and black race contribute to adjuvant chemotherapy delays and inferior outcomes, but postoperative recovery is the more important driver.

Barriers to pain and fatigue management in medical oncology

9546 Background: The relief of symptoms is a critical aspect of supportive care in medical oncology. This NCI funded study compared usual care to an educational and systems change intervention in a Comprehensive Cancer Center. This paper presents data comparing the total N=184 patients including Breast (40%), Lung (25%), Colon (20%) or Prostate (15%) cancer. Based on the NCCN Pain and Fatigue guidelines, the intervention included a four part patient education program, professional education and strategies to integrate symptom management into routine oncology practice. Methods: This trial compared symptom management in outpatient oncology patients experiencing pain and/or fatigue who received either usual care (N=83) or the intervention (N=101). Outcome measures included the Pain and Fatigue Knowledge Scales, Psychological Distress Thermometer, City of Hope QOL Tool, Karnofsky Scale and Piper Fatigue Scale. Patients were assessed at baseline and 1 and 3 months post intervention endpoints. Results: To deter...

Sex, income and age-related differences in colorectal cancer care: results from the Project for an Ontario Women's Health Evidence-based Report Card (POWER) study

6509 Background: The goal of the POWER study is to improve health and reduce inequities among women of Ontario using performance measurement. Indicators are selected to facilitate assessment of care by sex and socioeconomic status (SES). Results pertaining to colorectal cancer (CRC) are presented. Methods: An expert panel process was used to identify performance measures spanning disease spectrum from screening through follow-up care and feasible to be evaluated from administrative data. The most recently available data (2003–2005) from Ontario Cancer Registry, Registered Persons Database as well as provincial billing and hospital databases were then used to evaluate the selected measures stratified by age, sex, and income. Results: Eight indicators relevant to CRC were selected by the panel, the majority of which related to processes of care. Except for higher incidence of CRC in men as compared to women (83 v. 67/100,000) and lower rates of referral to radiation oncologist after surgery among women with rectal cancer (48.7 v. 55.8%), there were no appreciable differences in care by sex for the other 6 indicators. These indicators included 5-year survival, screening using fecal occult blood testing (FOBT), time to surgery, rates of sphincter preserving procedures, referral to medical oncology and follow-up care. In contrast, lower SES was associated with lower rates of FOBT screening (12.0 v. 17.0% in lowest [Q1] v. highest [Q5] quintiles, respectively), worse 5-year survival (46.4 v. 55.1%, Q1/Q5) and lower rates of follow-up colonoscopy within 24 months after diagnosis (77.9 v. 84.4%, Q1/Q5). Low income men appeared to be especially disadvantaged with highest incidence of CRC (92/100,000) and lowest 5-year survival (42.1%). Trends towards less care were also seen with increasing age in referral rates to medical and radiation oncology and follow-up colonoscopy but not in time to or type of surgery. Conclusions: Income and age-related rather than sex differences exist in processes of care for CRC with lower performance among low SES groups and the elderly. Further work is necessary to determine how these differences in processes of care affect outcomes and ways to facilitate access to care by disadvantaged groups. No significant financial relationships to disclose.

A study of Irish cancer specialists’ opinions regarding sexual health for cancer patients

20673 Background: Quality of life is an important aspect of cancer care. Sexual health is a feature of quality of life. Cancer patients may experience neutropenia secondary to disease or treatment. Yet, there is an absence of data on the risks to cancer patients from sexual activity when neutropenic. The aim of this study is to determine present opinion and practice by cancer specialists in Ireland regarding the sexual health care of cancer patients. Method: A cross-sectional survey using a confidential, self-administered questionnaire was performed of all ‘113’ identified consultants (75) and specialists registrars (38) in medical and paediatric oncology, haematology and palliative care attached to major cancer centres in the Republic of Ireland. Two reminders were sent. Descriptive and content analysis were performed on the quantitative and qualitative data respectively. Results: 43 (response rate of 37.5%) replies were received. While the majority of respondents 23/14 discussed to varying degrees the possible impact of cancer and treatment on fertility with patients, if applicable, only 1 ’always’ discussed the possible impact of cancer on sexual activity. Opinions regarding the risk of sexual activity in patients included: infection risk to women with neutropenia, possible infection-risk benefit of condom-associated sexual activity, bleeding secondary to related thrombocytopenia. In some cases this questionnaire provided the first opportunity to consider such issues. Concern was raised about the adequacy of medical training regarding sexual health care of patients. Conclusions: Diversity in medical advice and opinions regarding possible risks to cancer patients and specifically with neutropenia from sexual activity are evident. The sensitive nature of sexual health counselling, in this cohort of patients, together with the paucity of evidence, proved limiting factors to therapeutic dialogue. Further research is necessary with the aim of providing evidence based patient care. No significant financial relationships to disclose.

Status and perspectives of hospital mortality in a public urban Hellenic hospital, based on a five-year review.

BackgroundAnalysis of hospital mortality helps to assess the standards of health-care delivery.MethodsThis is a retrospective cohort study evaluating the causes of deaths which occurred during the years 1995–1999 in a single hospital. The causes of death were classified according to the International Statistical Classification of Diseases (ICD-10).ResultsOf the 149,896 patients who were discharged the 5836 (3.4%) died. Males constituted 55% and females 45%. The median age was 75.1 years (1 day – 100 years).The seven most common ICD-10 chapters IX, II, IV, XI, XX, X, XIV included 92% of the total 5836 deaths.The most common contributors of non-neoplasmatic causes of death were cerebrovascular diseases (I60–I69) at 15.8%, ischemic heart disease (I20–I25) at 10.3%, cardiac failure (I50.0–I50.9) at 7.9%, diseases of the digestive system (K00–K93) at 6.7%, diabetes mellitus (E10–E14) at 6.6%, external causes of morbidity and mortality (V01–Y98) at 6.2%, renal failure (N17–N19) at 4.5%, influenza and pneumonia (J10–J18) at 4.1% and certain infectious and parasitic diseases (A00–B99) at 3.2%, accounting for 65.3% of the total 5836 deaths.Neoplasms (C00–D48) caused 17.7% (n = 1027) of the total 5836 deaths, with leading forms being the malignant neoplasms of bronchus and lung (C34) at 3.5% and the malignant neoplasms of large intestine (C18–21.2) at 1.5%. The highest death rates occurred in the intensive care unit (23.3%), general medicine (10.7%), cardiology (6.5%) and nephrology (5.5%).Key problems related to certification of death were identified. Nearly half of the deaths (49.3%: n = 2879) occurred by the completion of the third day, which indicates the time limits for investigation and treatment. On the other hand, 6% (n = 356) died between the 29th and 262nd days after admission.Inadequacies of the emergency care service, infection control, medical oncology, rehabilitation, chronic and terminal care facilities, as well as lack of regional targets for reducing mortality related to diabetes, recruitment of organ donors, provision for the aging population and lack of prevention programs were substantiated.ConclusionSeveral important issues were raised. Disease specific characteristics, as well as functional and infrastructural inadequacies were identified and provided evidence for defining priorities and strategies for improving the standards of care. Effective transformation can promise better prospects.

Angiogenèse et radiothérapie : tout ce qu’un oncologue radiothérapeute doit savoir

Angiogenesis is a crucial requirement for tumorogenesis, providing oxygen and nutrient supply necessary for tumor growth and metastasis. This is a complex phenomenon regulated by many factors that can now be targeted by novel anti-cancer therapies. Antiangiogenic approaches have shown positive results in clinical trials and are now approved as standard of care in medical oncology. Many clinical trials are evaluating antiangiogenic agents in association with radiotherapy. This review aims to summarize the knowledge useful to the understanding of these novel therapies and their potential in combination with radiotherapy.

Treatment options in end-of-life care: the role of palliative chemotherapy

Advances in medical science and technology, combined with the primary goal of medical care to restore or maintain health as far as possible, often result in the transition from active to palliative care being blurred. Treatment choices are limited in advanced disease; but paradoxically, which therapy to choose is becoming an increasingly complex decision (Weissman, 2004). The role of chemotherapy in this phase remains a controversial subject, but data are emerging to show that an increasing number of patients nearing the end of life are receiving chemotherapy (Matsuyama et al, 2006), and there is a mounting body of evidence for its use in symptom palliation (Cullen, 2003; Bowcock et al, 2004; Davis, 2005). Therefore, the traditional view that medical oncology and palliative care are two distinct disciplines may need to be modified.

Palliative care for patients with advanced pancreatic and biliary cancers

Because most patients with pancreatic and biliary cancer have advanced disease, the palliation of debilitating symptoms is critically important in patient management. A multidisciplinary team consisting of representatives from surgery, medical oncology, gastroenterology, radiology, and palliative care medicine is essential for the optimal palliation of symptoms. In this article, the key issues in palliative care for patients with advanced pancreatic and biliary cancer are discussed. In particular, the prevention and amelioration of suffering due to obstructive jaundice, gastric outlet obstruction, cancer-related pain, pancreatic enzyme insufficiency, and thromboembolic disease is addressed. To this end, an algorithm for the multidisciplinary management of these challenging patients is proposed with the goal of providing clinicians with a useful framework for providing palliative care for patients with advanced pancreatic and biliary cancer.

The palliative care network as a model of continuity of care in oncologic departments

18518 Background: Although medical oncology and palliative care are often distant dimensions in the treatment of patients with cancer, it is a common notion that an integration could improve the outcome in a comprehensive assistance to the patient. Methods: To create a Palliative Care Network (PCN) in our Department, we promote the creation of a multidisciplinary team (MT) with oncologists (2), palliativists (1), psychologists (1), social workers (2) and nurses (3) with the aim of favouring the continuity of care along all the phases of the disease. The MT gathers the competences of the oncologic and palliative care units, and is coordinated by the responsible of the supportive and palliative care unit of the district. All the patients were evaluated before entering into the project and classified in three levels with different care burden. In all the patients admitted to the PCN a palliative support is planned since the early phases of metastatic disease. The palliative care project are weekly updated by the MT. The outcomes of the PCN are evaluated every six months for activity and annually for efficacy. Results: 4589 patients have been admitted in 2003–2005 period (419 in Hospice). 2441 (53.2%), 1533 (33.4%) and 615 (13.4%) patients were classified respectively in the three increasing severity levels, and an “intensive” palliative approach was needed in 2547 (55.5%) patients. The main problems referred by the patients or their families were symptoms control, pain control, the need of psychological or social support, the need of a continuity of care along the terminal phases of the disease. Preliminary data seem to suggest a positive impact of the shared approach against the symptoms of advanced or terminal disease, and an interesting level of satisfaction by patients and caregivers seems to be confirmed in a preliminary assessment. Conclusions: The continuity of care is considered an index of the quality of care and an integrated model of palliative care should be elaborated in every oncologic district; oncologic departments seem to represent the ideal dimension where favouring an integration between medical oncology and palliative care and every effort should be made to realize this kind of integration. No significant financial relationships to disclose.

Editorial Brain tumour treatment: the concept of inter- and multidisciplinary treatment

The treatment of brain tumors has improved in recent years. The principles of treatment are accurate diagnosis by imaging and neuropathology, treatment by neurosurgery, neurooncology, medical oncology, radiotherapy and optimal care and supportive strategies in a multidisciplinary setting. The development of multidisciplinary neurooncologic teams and of centers of excellence will further improve treatment quality and care. The multidisciplinary team is not confined to medical treatment alone, but needs the expertise of specially trained nurses, psychologists, occupational therapists, speech therapists and social workers to meet the needs of patients and carers.

Ethical Obligations and Counseling Challenges in Cancer Genetics

Cancer genetics is creating new practice opportunities in medical genetics, oncology, and primary care. The ethical and counseling challenges of this new area of practice are not unique but sometimes take new form in the context of genetic risk. This article uses cases to explore the issues associated with shared family risk, including competing concerns of family members, duty to warn relatives of genetic risk, and testing of children and other relatives. The ethical obligations of clinicians start with the need to maintain competence in the face of rapidly evolving science. Clinicians should be able to identify patients within their practice who are candidates for genetic testing. When genetic susceptibility to cancer is identified, patients should be offered counseling and follow-up, with referral as appropriate, to ensure delivery of care consistent with current standards. When patients experience barriers to needed health care, clinicians should advocate for their needs. Clinicians must ensure the autonomy and informed decision-making of all members of cancer-prone families. Clinicians must also provide emotional support and accurate information about cancer risks and cancer risk reduction measures, including uncertainties. Teamwork among different specialties is important in addressing these challenges.

Nursing intervention and older adults who have cancer: specific science and evidence based practice.

This review of a small and heterogeneous body of literature suggests intriguing and useful approaches to nursing interventions with older adults who have cancer and areas that clearly deserve greater attention in future research. Research such as that done by McCorkle and Goodwin,while disparate in design, clearly demonstrate the ability of interventions to achieve better continuity of care and appropriate treatment for physically and socially vulnerable older adults with cancer. Comparison across settings and studies that investigate similar clinical phenomena would illuminate further how to achieve more effective intervention with elders who have cancer. In studies addressing case management, comparison of work by McCorkle et al with that completed by Goodwin et al suggests that programs that are longer than 4-week interventions are more likely to be beneficial than are shorter programs. Goodwin et al constructed a 12-month intervention that might be extended even further to improve continuity to older adults who may lack family/social support. Continuity may be especially important as older patients move from primary or geriatric care to surgical care to medical oncology care. Such a program also may offer added benefits in care of older adults who survive an initial cancer but require vigilant follow-up for recurrence or a second primary cancer and who may face ageist assumptions about screening and early detection of those cancers. The work of Coleman, Earp, and Powe and Weinrich underscores the necessity of understanding the precise needs of rural elders in relation to cancer. These studies strongly suggest that nurses can improve screening rates and symptom management. Rural health care may have particularly poor specialty resources for cancer and aging. Increasing oncology nurses' presence in rural communities and supporting those nurses with specific content in aging may be a successful mechanism to ameliorate these deficits. Coleman's study especially found that increasing opportunities to ensure that practice is grounded in current evidence is critical to improving evidence-based practice and avoiding misconceptions about the effects of age in cancer care. The weak effects associated with the use of lay educators to improve cancer screening behaviors strongly reinforce the influence of nurses over other personnel to carry out educational interventions. In rural and urban areas alike, the credibility and professionalism of nurses was clearly of benefit. McDougall's research highlights the effects of cancer treatment on older people's cognitive status. His intervention supports the further testing of group activities led by nurses as a way to improve aspects of memory. Clinical application of this low-risk, possibly high-benefit intervention strategy, which is congruent with current work in dementia care, implies that elder care facilities might benefit from having a nurse on staff to address institutional and individual concerns related to cognitive function among older residents with cancer. A single often unstated theme throughout these studies is the impact of the nurse-patient relationship on outcome variables for older adults at risk for or living with cancer. The nurse-patient relationship, a touchstone of practice, reminds each nurse to focus on the individual elder, to look past chronological age and cancer diagnosis to understand that individual as having a life that, though it may be decades long in time, is still to be lived each day in the manner and capacity that the person can command and desires. Knowledge of that elder will aid the nurse in asking critical questions, using existing research, adapting other relevant evidence, and intervening more effectively over the course of that relationship.

Provision of oncology services in remote rural areas: a Scottish perspective.

There is a paucity of research into rural health care services. In particular little is known about the provision of specialist cancer services for patients who live in remote rural areas of the UK. This study set out to investigate current models of medical and clinical oncology care in Scotland. A national survey with key health professionals was conducted to identify rural oncology schemes currently in operation. Detailed quantitative data about the schemes together with qualitative data on how health professionals view current models of care were collected by a computer-assisted telephone survey. Schemes that currently provide outpatient and chemotherapy oncology services for remote rural patients fell into three categories: central clinics (5); shared care outreach clinics with chemotherapy provision (11); and shared care outreach clinics without chemotherapy provision (7). All radiotherapy was conducted at central clinics (5). Widely varying practices in delivery of cancer care were found across the country. The main issues for professionals about current models of care involved expertise, travelling and accessibility (for patients), communication and expansion of the rural service. Nation-wide consistency in cancer care has still to be achieved. Travelling for treatment was seen to take its toll on all patients but particularly for the very remote, elderly and poor. Most professionals believe that an expansion of rural services would be of benefit to these patients. It is clear, however, that the proper infrastructure needs to be in place in terms of local expertise, ensured quality of care, and good communication links with cancer centres before this could happen.

Medical oncology and palliative care: the intersection of end-of-life care.

Medical oncology and palliative care: the intersection of end-of-life care.

The NCI-Ireland consortium: a unique international partnership in cancer care.

The Ireland-Northern Ireland-National Cancer Institute Cancer Consortium was launched in October of 1999, at a conference in Belfast, Northern Ireland, for the development of cancer programs in Ireland and Northern Ireland, where cancer is a significant cause of mortality and morbidity. Cancer services there have undergone major restructuring as a result of several government reports. Specifically, the National Strategy Document for Cancer proposed that cancer treatment services should be centered around primary care services, regional services, and a national coordinating structure where supra-regional centers would deliver specialist surgery, medical and radiation oncology, rehabilitation, and specialist palliative care. Therefore, this was an opportune time to bring the National Cancer Institute (NCI) on board in a determined effort to redevelop and significantly improve services and outcomes for cancer patients throughout the island. During the NCI All Ireland Cancer Consortium, initial major goals were established as follows: A) To share best available technology and enhance clinical research; B) conduct joint clinical research studies involving people from all jurisdictions; C) sponsor formal training exchanges for Irish and American scholars in cancer programs in partner institutions; D) implement the use of teleconferencing, telesynergy, and other information technology capabilities to facilitate education, and E) consolidate the Cancer Registries of Ireland and Northern Ireland and learn more about cancer incidence and trends on the entire island. In the past year, significant advances have been made in all these areas. Plans are already under way for the second NCI All Ireland Cancer Conference which will be held in late 2002 and feature speakers from Ireland, Northern Ireland, the U.S., and other areas. It will be open to all oncologists, researchers, nurses, students, and other health care professionals interested in learning and enhancing cancer care and research.