Radiation Oncology Care Research Articles

Implementing Radiation Oncology Care Plans as a foundation for process improvement

AbstractBackgroundAt The Radiation Medicine Program described, the entire radiation therapy (RT) workflow was previously conducted through the use of two electronic programs. It duplicated workflow and created a situation where it was difficult to measure the RT process. Recent enhancements to the electronic medical record facilitated the consolidation of RT planning and treatment workflows into one electronic system.PurposeThis report will describe the clinical implementation of electronic Radiation Oncology (RO) Care Plans at a Regional Cancer Centre, and how they can be applied as a foundation for RT process improvements.Impact and outcomeA total of 51 Care Plans and 95 IQ Scripts were successfully implemented. The benefits of RO Care Plans include a more streamlined process, removed ambiguity, improved communication, standardised workflow and automation of tasks. In addition, multiple performance indicators can be obtained from the RO Care Plans, such as caseload reports, workflow reports and a ‘white board’.ConclusionThe implementation of RO Care Plans serves as a foundation for data-driven process improvement at a local Regional Cancer Centre.

Approval procedures for clinical trials in the field of radiation oncology

Application of ionizing radiation for the purpose of medical research in Germany needs to be approved by the national authority for radiation protection (Bundesamt für Strahlenschutz, BfS). For studies in the field of radiation oncology, differentiation between use of radiation for "medical care (Heilkunde)" versus "medical research" frequently leads to contradictions. The aim of this article is to provide principle investigators, individuals, and institutions involved in the process, as well as institutional review or ethics committees, with the necessary information for this assessment. Information on the legal frame and the approval procedures are also provided. A workshop was co-organized by the German Society for Radiation Oncology (DEGRO), the Working Party for Radiation Oncology (ARO) of the German Cancer Society (DKG), the German Society for Medical Physics (DGMP), and the German Cancer Consortium (DKTK) in October 2013. This paper summarizes the results of the workshop and the follow-up discussions between the organizers and the BfS. Differentiating between "Heilkunde" which does not need to be approved by the BfS and "medical research" is whether the specific application of radiation (beam quality, dose, schedule, target volume, etc.) is a clinically established and recognized procedure. This must be answered by the qualified physician(s) ("fachkundiger Arzt" according to German radiation protection law) in charge of the study and the treatments of the patients within the study, taking into consideration of the best available evidence from clinical studies, guidelines and consensus papers. Among the important parameters for assessment are indication, total dose, and fractionation. Radiation treatments applied outside clinical trials do not require approval by the BfS, even if they are applied within a randomized or nonrandomized clinical trial. The decision-making by the "fachkundigem Arzt" may be supported on request by an opinion given by the DEGRO Expert Committee for clinical trials. An important aim for promoting clinical research and patient care in radiation oncology is to further professionalize planning and implementation of clinical trials in this field. Correct assessment, at an early stage, whether a trial needs to be approved by the BfS may reduce unnecessary costs and reduce the time needed for the approval procedure for those trials which need to be assessed by the BfS.

Medical Student Knowledge of Oncology and Related Disciplines: a Targeted Needs Assessment.

Despite increasing numbers of cancer survivors, non-oncology physicians report discomfort and little training regarding oncologic and survivorship care. This pilot study assesses medical student comfort with medical oncology, surgical oncology, radiation oncology, hospice/palliative medicine, and survivorship care. A survey was developed with input from specialists in various fields of oncologic care at a National Cancer Institute-designated comprehensive cancer center. The survey included respondent demographics, reports of experience with oncology, comfort ratings with oncologic care, and five clinical vignettes. Responses were yes/no, multiple choice, Likert scale, or free response. The survey was distributed via email to medical students (MS1-4) at two US medical schools. The 105 respondents were 34 MS1s (32%), 15 MS2s and MD/PhDs (14%), 26 MS3s (25%), and 30 MS4s (29%). Medical oncology, surgical oncology, and hospice/palliative medicine demonstrated a significant trend for increased comfort from MS1 to MS4, but radiation oncology and survivorship care did not. MS3s and MS4s reported the least experience with survivorship care and radiation oncology. In the clinical vignettes, students performed the worst on the long-term chemotherapy toxicity and hospice/palliative medicine questions. Medical students report learning about components of oncologic care, but lack overall comfort with oncologic care. Medical students also fail to develop an increased self-assessed level of comfort with radiation oncology and survivorship care. These pilot results support development of a formalized multidisciplinary medical school oncology curriculum at these two institutions. An expanded national survey is being developed to confirm these preliminary findings.

Patients' outcomes related to person-centred nursing care in radiation oncology: A case study

PurposeThe aim of this case study is to describe patients' responses to nursing care following the implementation of a person-centred model in a radiation oncology department. MethodAn instrumental case study design utilised surveys to collect data on a range of key patient outcomes: patient satisfaction (PSS), informational issues (RSEP), quality of life (FACT_G), comfort (RTCQ), and emotional status (HADS). This occurred at the beginning of, and twelve months following, the implementation of the new model of care. ResultsThis study demonstrated that, although adverse effects of radiotherapy continue to affect patient well-being in the latter part of their course of radiation therapy, patients continue to be satisfied with nursing care. There were significant differences between groups in perceptions of the care environment and the use of the nurse as an acknowledged source of information are noteworthy, since these variables were key targets of the new model of care. The finding that nurses were seen by the post-implementation cohort as more likely to be a source of information is an important indicator that the nurses' presence was noted by patients, and they generally reported high levels of functioning despite undergoing a curative course of radiotherapy. ConclusionThe person-centred nursing approach in the radiotherapy setting has contributed to some improvements in the provision of patient care. Aspects of this study may assist in planning further nursing interventions for patients undergoing radiotherapy for cancer, and continue to enhance the contribution of the radiation oncology nurse to improved patient outcomes.

WE-B-Exhibit Hall-01: Ask the RO-ILS Experts

Have a question about RO-ILS: Radiation Oncology Incident Learning System™, or interested in learning more? Sponsored by the American Society for Radiation Oncology (ASTRO) and AAPM, RO-ILS is the only medical specialty society-sponsored incident learning system for radiation oncology. It facilitates safer and higher quality care in radiation oncology by providing a mechanism for shared learning in a secure and non-punitive environment. Please join our RO-ILS experts for a question and answer session on Wednesday, July 15th at 8:30 in the Partners in Solutions Room in Exhibit Hall C. Our experts include: Gary Ezzell, PhD, Mayo Clinic Arizona, [Brett Miller, Phillip Beron, and Derek Brown], Emily Sanscrainte from Clarity PSO and Cindy Tomlinson, MPP, ASTRO.

Changes in prostate cancer presentation for radiation oncology care after USPSTF recommendations, 2007-2013.

e16070 Background: In 2008, the US Preventive Services Task Force (USPSTF) recommended against prostate-specific-antigen based screening for prostate cancer in men age > 75, and in 2012 recommended against screening in all men. It is unknown whether these guidelines have changed the number or risk profile of patients presenting to radiation oncology care. Methods: We conducted a retrospective study of patients who presented with localized prostate cancer in 2007-2013 to a network of radiation oncology clinics in southwest Florida. In the area, the provider network (21st Century Oncology) supplies nearly all radiation oncology services. We assessed trends in total patient volume and determined the risk distribution of a random sample of patients, using risk groups defined by the National Comprehensive Cancer Network. We applied this risk distribution to the total patient volume to estimate the number of patients presenting in each risk group. Results: The number of patients presenting with prostate cancer ...

The Supportive and Palliative Radiation Oncology Service: A Dedicated Model for Palliative Radiation Oncology Care

The Supportive and Palliative Radiation Oncology Service: A Dedicated Model for Palliative Radiation Oncology Care

Supportive Care Tumor Board: Implementation and Impact for the Care of Patients with Advanced Cancer (TH340)

Objectives Recognize how to develop and implement a cancer centerewide supportive care tumor board to facilitate the concurrent management of patients with advanced cancer by oncologists and supportive care services. Recognize the ways multidisciplinary care can improve symptom management and be able to identify how specific techniques, from radiation oncology, anesthesia pain, and other interventions, can aid the medical management of pain and other symptoms. Discuss how to use a supportive care tumor board to help facilitate transitions of care across different settings, including from hospital to outpatient and from aggressive care to home hospice. Patients with incurable malignancies have high symptom burdens and complex care needs. Integrating palliative care services into the care of these patients is an important goal of AAHPM and ASCO, but it may be difficult to accomplish. In standard oncology care, tumor boards are used for treatment planning, as oncologists and other specialists review clinical data and discuss options regarding treatment options for patients with various types of cancers. However, these patients and their families often face complex challenges that cannot be resolved by disease-specific therapies alone. These include difficult-to-control symptoms (pain, nausea, fatigue, depression, and anxiety); psychosocial issues, such as poor social support and substance abuse; and end-of-life decisions. Efforts to integrate palliative care into standard oncologic approaches often meet with challenges due to institutional culture, misunderstandings regarding the nature of palliative care, and difficulties with coordinating care. As part of a Centers for Medicare and Medicaid Services (CMS) grant to improve the care of patients with advanced cancer, we implemented a weekly supportive care tumor board (SCTB) to facilitate the concurrent care of symptomatic patients with incurable cancer. This conference brings together medical, surgical, radiation oncology, and palliative care clinicians; anesthesia pain specialists; social workers; pharmacists; chaplains; and nutritionists to develop plans of care to address concerns in a timely, interprofessional, and multidisciplinary manner. This session will describe the development and implementation of an SCTB and how it changed the culture of clinical care at our institution. We will present data regarding its impact on patients, including changes in frequency and timeliness of referral to palliative and other supportive care services, effects on symptom burden, and effects on health resource utilization. We will illustrate the examples of this model with in-depth case reports of how an SCTB was used in treatment planning and care coordination for specific complex cases.

Association of lower patient ratings of physician communication with need for symptom management in lung and colorectal cancer patients.

153 Background: Symptoms are prevalent among cancer patients, but little is known about how often patients’ needs for symptom management are met or what factors are associated with unmet needs. Methods: Patients with lung and colorectal cancer from the diverse nationally-representative Cancer Care Outcomes Research and Surveillance cohort completed a survey approximately 4-6 months following diagnosis (n=5,422). We estimated the prevalence of unmet needs for symptom management during the 4 weeks prior to the survey, with unmet needs defined as patients reporting that they wanted but did not receive help for at least one symptom (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, diarrhea). Using a pre-specified conceptual model, we identified patient factors associated with unmet need using multivariable logistic regression with random effects (fixed slopes model with random intercepts for each Primary Data Collection Research site). We also tested whether clinical visits before the interview were associated with unmet need. Results: Overall, 15% (791/5,422) of patients had at least one unmet need for symptom management. Adjusting for patient sociodemographic and clinical factors, African American race, being uninsured or poor, having lung cancer versus colorectal cancer, early- vs. late-stage disease, and the presence of moderate to severe symptoms were associated with greater unmet need (all p<.05). Patients who rated their physicians communication score below 80 (on 1-100 scale) had adjusted rates of unmet need that were more than twice those of patients who rated their physicians with a perfect communication score (23.0% v. 10.0%, OR=3.05, p<0.001). Neither visits with specialty physicians (medical oncology, radiation oncology, surgery, or primary care) nor the total number of outpatient visits in the 28 days before the interview were associated with unmet need (all p>.05). Conclusions: A significant percentage of newly diagnosed lung and colorectal cancer patients report unmet needs for symptom management. Interventions to improve symptom management should consider the importance of physician communication to the experience of disease.

Reducing unwarranted variability in care in radiation oncology through clinical pathways.

171 Background: UPMC CancerCenter (UPMC) includes 37 academic and community based sites in western Pennsylvania. Consistency and quality of care are critical to such a diverse network. To meet these challenges, UPMC developed clinical pathways for medical and radiation oncology (Via Pathways). The program has served UPMC well for almost ten years and is now a key foundation for UPMC’s overall strategy to move from volume to value. Methods: Radiation treatment pathways for over 90% of cancers were developed by committees of academic and community radiation oncologists from UPMC as well as other cancer centers across the country. The committees meet semi-annually to interpret the literature and define the most efficacious and least toxic treatments for highly-specific disease presentations (e.g., oropharynx, Stage III-IV, primary chemoradiation). Guidance for simulation contouring, planning and treatment delivery are provided along with applicable citations. A web-based portal presents the pathways on a patient specific basis using the physician’s daily clinic schedule (through an interface with the EMR). The UPMC radiation oncologists also utilize a feature of the pathways that allows for peer review of Off Pathway decisions by disease experts within the UPMC Radiation Oncology department. Results: Thirty-one (31) radiation oncologists at UPMC use pathways in their daily practice. For the 12 months ended May 31, 2014, UPMC physicians confirmed a pathways status for 98% of their patient consults (n=10,178) and achieved an On-Pathway rate of 95% for their 6,239 treatment decisions. All Off-Pathway treatment decisions were approved prior to treatment by a designated peer review radiation oncologist within UPMC, typically within 24 hours of request. Reasons for going Off-Pathway were recorded as well as what alternative approach to care was chosen. Conclusions: When appropriately developed and implemented, clinical pathways are a solution to standardizing care across multiple sites and physicians with the potential to improve the quality and cost effectiveness of cancer care.

From Whole Brain to Hospice: Patterns of Care in Radiation Oncology

The development of brain metastases is a common cause of morbidity and mortality in cancer patients. Limited life expectancy is well established once a patient requires whole-brain radiotherapy (WBRT). There is emerging evidence demonstrating the value of involving palliative care services alongside traditional treatments. However, data regarding the utilization of these services in patients requiring WBRT remain unexplored. Patients with histologic or radiographic evidence of brain metastases treated with WBRT alone between July 2010 and June 2012 were reviewed retrospectively. Patient demographics, the number of hospital admissions in the last 6 months of life, survival, and referrals to palliative care services were evaluated. Ninety-eight patients were diagnosed with brain metastases and treated with WBRT alone. The median overall survival following WBRT was 80 days. Twenty-eight of the patients presented to the emergency department ≥2 times in the last 6 months of life. Sixty-eight percent of patients were referred to palliative care. Of those referrals, 57% were during an inpatient hospitalization. The median survival from palliative care referral to death was 27 days. Patients with brain metastasis requiring WBRT have a predictable dying trajectory. These patients are likely to have a high symptom burden and would benefit from palliative care. Timely palliative care referrals in this population remain inadequate and classically follow a hospital admission. Referrals continued to be late in the dying process and the recommendation for WBRT can be used as an independent marker for initiating end-of-life discussions and involving palliative care.

Development of a Comprehensive Radiation Oncology Quality and Safety Program

Radiation oncology practice is a collaborative effort that involves multiple clinical and technical specialists including physicians, medical physicists, dosimetrists, radiation therapy technologists and nurses. The safe and efficient delivery of radiation therapy was never a simple matter and is now exceedingly complex.The growing complexity of radiation oncology procedures has been identified as a significant risk factor in potentially causing patient treatment errors. National and international standards have evolved to guide the safe and effective use of ionizing radiation for treatment and have been codified by leading professional organizations into accreditation requirements that necessitate rigorous documentation of performance for each aspect of the process of care. The process of care in radiation oncology refers to a conceptual framework for guaranteeing the appropriateness, quality and safety of all patients treated with radiation for cancer and certain benign conditions.A primary objective of a Comprehensive Radiation Oncology Quality and Safety Program is the design and clinical implementation of approaches that will minimize the incidence of radiotherapy adverse events that could potentially have negative impacts on the quality of patient care.The papers in this review address multiple issues that should be considered to ensure managing the process of care with approaches that will ensure the optimal delivery of radiation therapy.

Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care

PurposeThe American Society of Clinical Oncology has recommended tailoring palliative cancer care (PCC) to the distinct and complex needs of advanced cancer patients. The Supportive and Palliative Radiation Oncology (SPRO) service was initiated July 2011 to provide dedicated palliative radiation oncology (RO) care to cancer patients. We used care providers’ ratings to assess SPRO’s impact on the quality of PCC and compared perceptions of PCC delivery among physicians practicing with and without a dedicated palliative RO service. Methods and materialsAn online survey was sent to 117 RO care providers working at 4 Boston-area academic centers. Physicians and nurses at the SPRO-affiliated center rated the impact of the SPRO service on 8 PCC quality measures (7-point scale, “very unfavorably” to “very favorably”). Physicians at all sites rated their department’s performance on 10 measures of PCC (7-point scale, “very poorly” to “very well”). ResultsAmong 102 RO care providers who responded (response rate, 89% for physicians; 83% for nurses), large majorities believed that SPRO improved the following PCC quality measures: overall quality of care (physician/nurse, 98%/92%); communication with patients and families (95%/96%); staff experience (93%/84%); time spent on technical aspects of PCC (eg, reviewing imaging) (88%/56%); appropriateness of treatment recommendations (85%/84%); appropriateness of dose/fractionation (78%/60%); and patient follow-up (64%/68%). Compared with physicians practicing in departments without a dedicated palliative RO service, physicians at the SPRO-affiliated department rated the overall quality of their department’s PCC more highly (P = .02). ConclusionsClinicians indicated that SPRO improved the quality of PCC. Physicians practicing within this dedicated service rated their department’s overall PCC quality higher than physicians practicing at academic centers without a dedicated service. These findings point to dedicated palliative RO services as a promising means of improving PCC quality.

Increasing on-treatment visit compliance for radiation therapy cancer patients.

175 Background: Weekly on-treatment-visits (OTVs) represent standard care in radiation oncology and have significant impact on the quality of patient care. Ensuring that OTVs are completed might decrease the severity of acute treatment-related side effects by facilitating timely treatment of symptoms. This study evaluates factors contributing to missed OTVs and formulates a plan to mitigate this problem. Methods: A multidisciplinary team of radiation oncology staff members reviewed clinical work flow data to determine the number of patients missing their weekly OTVs. These numbers generated benchmarks for the QIP. The team used 30 patient questionnaires and 291 electronic medical records to identify the causative factors for missing the OTVs. After analyzing these results the team generated an action plan for multiple interventions and future audit protocols. Results: On average, 5% of patients miss their weekly OTVs during radiotherapy course. The identified reasons which affected patient compliance with OTVs include: patient inconvenience waiting for the MD, parking concerns, difficulty navigating the clinic to find the exam room, failure of therapist to send the patient for OTVs, changes in MD’s schedule, lack of patient awareness about expected treatment related side effects and importance of immediate treatment of their symptoms. We developed a multidisciplinary plan to minimize patients missing OTVs which includes electronic medical record alerts, communication cues, physical triggers and improved patient education. Additionally, electronic data collection has been implemented for OTV performance metrics and auditing. Conclusions: Patients missing their weekly OTVs during radiotherapy course might be at risk for more severe treatment-related side effects. The details of this multidisciplinary QIP implementation and its impact on quality of care will be presented at the meeting.

From Whole Brain to Hospice: Patterns of Care in Radiation Oncology

Abstract Objectives: The development of brain metastases is a common cause of morbidity and mortality in cancer patients. Limited life expectancy is well established once a patient requires whole-brain radiotherapy (WBRT). There is emerging evidence demonstrating the value of involving palliative care services alongside traditional treatments. However, data regarding the utilization of these services in patients requiring WBRT remain unexplored. Methods: Patients with histologic or radiographic evidence of brain metastases treated with WBRT alone between July 2010 and June 2012 were reviewed retrospectively. Patient demographics, the number of hospital admissions in the last 6 months of life, survival, and referrals to palliative care services were evaluated. Results: Ninety-eight patients were diagnosed with brain metastases and treated with WBRT alone. The median overall survival following WBRT was 80 days. Twenty-eight of the patients presented to the emergency department ≥2 times in the last 6 months ...

The Supportive and Palliative Radiation Oncology Service: The Impact of a Dedicated Service on Palliative Cancer Care

The Supportive and Palliative Radiation Oncology Service: The Impact of a Dedicated Service on Palliative Cancer Care

Person centred nursing care in radiation oncology: A case study

PurposeThe aim of this case study is to describe clinical staff perceptions of implementing a person-centred model of nursing in an outpatient radiotherapy treatment department, using a Primary Nursing/Collaborative Practice framework. The questions are: 1) what are the nursing and radiotherapy staff perspectives of the changed model of care, 2) what factors impacted on aspects of the evolving model?, and 3) how was interdisciplinary collaboration influenced by the new model? MethodsAn instrumental case study addressed the multiple perspectives of several radiotherapy health professionals, within a qualitative approach, to assess the new model of nursing care. Interview data were obtained from thirteen clinical staff over a six month period approximately one year after the model was implemented. ResultsThe new model supports nurses to work more closely with the individual patient, with some perceived positive patient outcomes. Nurses reported increased satisfaction with their work, more autonomy and responsibility, and improved working relationships with medical staff. They also became more aware of the holistic approach to support positive patient outcomes. However, this study acknowledged that education was required for nurses to provide holistic care, especially in the context of complex interdisciplinary relationships. ConclusionsA person-centred nursing approach in radiotherapy represents a radical change to the functional approach, providing some benefits for patients. However, the challenges of providing holistic care in the context of complex interdisciplinary relationships are evident, and this study acknowledges the importance of a team approach to addressing changes in practice in the future.

Toward Evidence and Theory-Based Skin Care in Radiation Oncology

Dermatitis is a distressing symptom of radiation therapy, and current care guidelines often lack evidence. Using an evidence-based practice (EBP) model, a multidisciplinary group in an academic medical center reviewed the literature to create departmental patient education materials related to skin care that were grounded in evidence. Recommendations not supported by evidence from randomized, controlled trials were viewed within a stress-reduction framework. Until evidence related to the prevention and treatment of radiation dermatitis is more fully developed, skin care recommendations for patients with cancer who receive radiation may need to be based on evidence and theory. In addition, care for patients with radiation dermatitis should encompass strategies aimed at physical and psychosocial stressors.

TU-C-213AB-01: ACR/ASTRO Accreditation, Program an Overview of Technical Components

American College of Radiology (ACR) started the radiation oncology accreditation program in 1986 as a logical extension of the patterns of care study (PCS) and collected data from institutions that participated on the patterns of patient care among institutions. It published technical standard for various components of radiation oncology practices and evaluated the performance of centers based on practice guidelines. American Society of Radiation Oncology (ASTRO) joined ACR and formed an alliance to provide radiation oncology practice accreditation (ROPA) in 2008. ROPA provides an independent evaluation of radiation oncology center performance for a nominal fee and provides guidelines. Some states have now mandated that ROPA should be prerequisite for reimbursement as it provides a measure of quality of patient care. Accreditation process has 2 components, technical and clinical. In this talk technical components will be discussed followed by clinical component by a clinician. The technical component covers every aspect of medical physics and dosimetry for a patient care in radiation oncology. Detailed information of both components will be provided in 2 segments by a physicists and a physician. Learning Objectives: 1. History of ACR 2. Why ROPA? 3. Components of technical parameters 4. Requirements 5. Surveyors role 6. Qualifications and requirements 7. Data collection 8. Process 9. Accreditation results 10. Benefit of accreditation to institution and surveyor 11. Beyond accreditation

Radiation treatment for patients with intermediate-risk prostate cancer

Around 70% of men presenting with prostate cancer will have organ-confined disease, with the majority presenting with low- or intermediate-risk prostate cancer. This article reviews the evidence supporting the current standard of care in radiation oncology for the evaluation and management of men with intermediate-risk prostate cancer. Dose escalation, hormonal therapy, combined modality therapy, and modern techniques for the delivery of radiation therapy are reviewed.