Community-based Cancer Center Research Articles

The effect of radiation therapy in the treatment of adult soft tissue sarcomas of the extremities: a long-term community-based cancer center experience.

The aim of the study was to determine the effect of external beam radiotherapy (RT) in the treatment of extremity soft tissue sarcoma (STS) before or after limb‐sparing surgery (LSS) in a community‐based setting. Patients presenting to our institution from 1992 to 2010 and meeting eligibility criteria were stratified into low (G1) or high (G2, G3) pathologic grade and evaluated. Major complication events, including amputation, radiation‐induced sarcoma, and pathologic fracture, were assessed. Kaplan–Meier techniques and Cox proportional hazards regression models were used. One hundred and sixty‐two eligible patients underwent LSS for extremity STS (120 high grade, 42 low grade). Median time of follow‐up was 5.1 years (0.8–20.3 years). RT was administered to 111 patients. In unadjusted models, RT significantly decreased the risk of local recurrence (LR) in high‐grade STS patients (P = 0.005) and had a trend for improved recurrence‐free survival (RFS) (P = 0.069). In multivariable‐adjusted models, RT significantly improved time to LR (P = 0.001), RFS (P = 0.003), and overall survival (OS) (P = 0.003). Analysis of all patients showed those who underwent RT had a major complication rate (MCR) of 16.2%, compared to 3.9% in the no RT group (P = 0.037); however, the difference in MCR did not differ significantly when the analysis was restricted to high‐grade sarcomas. In our large experience of patients with extremity STS undergoing limb sparing surgery (LSS), RT significantly improved local recurrence (LR), RFS, and OS, in patients with high‐grade tumors. Efficacy benefits of RT should be weighed against potential complications. External beam RT should be considered in patients with resected high‐grade sarcomas.

Social Media Use for Cancer Education at a Community-Based Cancer Center in South Korea.

The main purpose of this study was to evaluate the effectiveness of the education system using social media. Eight educational video clips were developed instructing the viewer on cancer-related issues such as prevention, treatment, and survivorship. Each video was made with participation of medical professors and posted on a YouTube channel. A mobile phone application was produced containing a scheduler function, introduction of a community cancer center program, and cancer information. A medical blog was established to provide stationary materials such as images and articles. Descriptive analysis was done by Google analytics. From May of 2014 to June of 2016, 15,247 total views were recorded on the YouTube channel, and the average view duration was about 3min. The most popular video was about chemotherapy treatment; 5409 (36%) people watched this video, and 3615 (23.5%) people viewed a video on balanced dietary habits. As well as South Korea, 1,113 (7%) views were confirmed in the United States and 175 (1%) in Japan. The equipment used to watch the contents were mobile phones (59%), laptops (33%), and tablets (6%). Five hundred people installed the smartphone application from March of 2015 to July of 2016. Three hundred eighty-three medical contents were posted on the blog since March of 2015. Cancer education is necessary to address the education needs of patients with cancer and their caregivers. Education based on social media could be an effective method that reaches beyond geographical boundaries.

Clinical Chart Audits as a Potential Process Improvement Strategy Within the Radiation Therapy Department of a Community-Based Cancer Center

PurposeWithin the health care profession, many organizations rely on routine clinical chart audits to detect areas for enhancement and potential triggers for error. Effective clinician documentation within the electronic treatment record is mandatory should high-quality care be maintained. This study aimed to determine what type of information might be obtained from radiation therapy treatment chart audits. This information would help to inform areas for improvement within the department and to determine whether introducing clinical chart audits as routine would be of benefit. MethodsA chart audit tool was piloted at the host institution and subsequently finalized as a result of the pilot. Clinical chart audits of radiation treatment records (n = 196) were completed over a four-month time span. Data analysis included the calculation of proportions to examine the completeness of each of the identified tasks within the chart audit tool. ResultsAreas of excellent practice (achieving or exceeding a benchmark measurement of 90%) tend to correlate well with tasks that are currently embedded into routine quality assurance checks, such as a checklist. Areas for improvement (below set benchmark) have a commonality; they all required best practices to be followed and did not have a prompt built in to the process. ConclusionsAreas of further related research would focus on engaging radiation therapists in the successful implementation of chart audits within this radiation therapy department.

Embedding palliative care (pc) in a community-based cancer center: Benefits and barriers.

153 Background: The importance of involving PC early in the disease process of oncology patients is well documented. Decreased symptom burden, increased quality of life, and extended survival are proven outcomes; however, the provision of PC has largely been limited to the acute care setting in most institutions. Bon Secours St. Francis Health System, a community based healthcare system in Greenville, South Carolina, opened a comprehensive cancer center in late 2014. Our established inpatient PC team began seeing outpatients at the cancer center shortly after its opening. Methods: PC at the cancer center is provided in an “embedded” model of care. PC appointments were initiated at 20 hours/week and have been expanded to 28 hours/week, currently provided by NPs 24 hrs, MD 4 hrs, all of whom are certified in hospice and palliative care. Patients are seen during medical oncology, radiation oncology, or infusion appointments. In August 2015, the PC team began to participate in an interdisciplinary team meeting, reviewing new oncology patients and their expected or known needs. Results: Total visits for 2015: 559/158 new patients seen. Informal interviews from patients, oncology, and PC staff revealed the following benefits: better communication regarding treatment plans; improved symptom management; flexibility and convenience in meeting patients anywhere in the cancer center and; providing resources for staff regarding pain and symptom management and communication techniques. Barriers identified were: scheduling conflicts for patients with multiple appointments; less than full-time coverage by PC prohibits some patients from being seen during their oncology appointments; PC and oncology being separate administrative entities has required creative solutions in billing and staffing. Conclusions: Despite some barriers, the benefits of embedding a PC clinic in a community-based oncology center are clear and worthwhile. This clinic improves coordination of care between inpatient and outpatient services, which results in positive patient experiences. It is hoped that the early integration of PC in the ambulatory setting will result in a decrease in avoidable emergency room visits and hospital admissions.

Using technology to improve patient-provider communication and delivery of quality care.

76 Background: Shared decision making (SDM) is a cornerstone of patient-centered care with 85-90% of breast cancer (BC) patients preferring an active or shared role in decision-making for breast surgery. SDM has been shown to, improve patients’ understanding of treatment options, result in more conservative care choices, and lead to lower healthcare costs. However, implementation is complex as numerous misconceptions exist. Methods: We are conducting a multi-site, quality improvement (QI) project to improve SDM behaviors and adherence to quality measures through a combination of provider education and use of a novel technology platform, the Carevive Care Planning System. This platform elicits patient preferences, concerns, history, and symptoms, and presents these data with algorithm-driven recommendations as part of a treatment plan. We report results from baseline provider surveys assessing perception and knowledge of SDM. Results: Baseline surveys from 28 participants were analyzed; 43% from a university based cancer center and 57% from community based cancer centers. Survey respondents were MDs (43%), NPs (7%) and RNs (46%), all specializing in Hematology and/or Oncology. When asked, “What percentage of breast cancer patients prefers an active or shared role in decision making?”, only 29% believed 85-90% of BC patients desired an active or shared role as suggested by surgical literature; 43% believed between 55-70% of patients wanted to be engaged in decision-making. Commonly reported barriers to SDM are shown in the table below. Conclusions: Physicians may underestimate patient’s desire to participate in shared decision-making. The barriers to implementing SDM in oncology practice will likely require multi-faceted interventions to overcome. We aim to address these gaps through an intervention aimed at enhancing knowledge and patient-provider engagement through treatment summaries. [Table: see text]

Using technology to improve quality metric adherence.

257 Background: Many barriers to adherence to quality standards exist, including patient, provider, and system barriers to delivery and documentation of timely, evidence-based care. Gaps in clinician knowledge about care standards likely contribute to non-adherence. Methods: Prior to an intervention study, providers completed a questionnaire assessing their knowledge of and ability to influence institutional attainment of specific QOPI metrics. Providers’ ability to influence meeting each of 9 QOPI metrics was measured on a 1-4 scale from “not at all” to “significantly” able to influence. Providers also identified barriers to meeting each metric. Results: 28 providers completed surveys; 43% from a university based cancer center and 57% from a community based cancer center. Respondents include oncology MDs (43%), NPs (7%) and RNs (46%). Perceived ability to influence 9 quality metrics are detailed in the Table below. Providers felt the least able to influence metrics related to fertility preservation with 32% reporting no influence. 21% credited ‘lack of visibility into current data’ to be a main barrier. Providers reported limited ability to address emotional well-being with 36% reporting a ‘lack time to assess/manage’. Providers felt most able to influence physical symptoms such as pain. Conclusions: The most frequently cited barriers to meeting study-specific quality metrics included lack of a) current knowledge/latest evidence and, b) time to assess/manage. Employing methods to address these barriers may improve quality care. In part 2 of this study providers engage with the Carevive Care Planning System, designed to address these barriers by assessing patient needs at the point of care and providing evidence-based recommendations for treatment. [Table: see text]

Disease-free survival of women 70 years or older with stage I-II BC treated with BCS and RT.

e268 Background: Breast RT is the standard of care for women undergoing BCS. Recent trends suggest omitting RT for women > 70 years of age. Our retrospective study evaluated the DFS and failure pattern of women > 70 treated with BCS and RT compared with their younger cohorts. Methods: Between 2009-2011, 101 women with Stage I-II BC were treated with BCS and RT at a physician-owned, community-based cancer center. Clinical, pathologic and treatment characteristics were extracted from patients’ medical records. Results: Of the 101 patients, 71 comprised the < 70 cohort and 30 comprised the > 70 cohort. Patients in the older cohort were more likely to have Stage I tumors (80% vs 64%), but the cohorts were otherwise balanced in terms of T-size, grade, ER/PR and Her2 status. RT was typically delivered in a first course of 50.4 Gy to the whole breast followed by a 10 Gy boost. Median DFS for the older cohort was 36 months (range, 1-66) and 41 months for the younger cohort (range, 1-74). There was only one event in the older cohort, a patient who developed DM at 40 months. In the younger cohort one patient developed LR at 54 months, and 4 developed DM at 18, 33, 51 and 54 months. Conclusions: In our community-based study, women > 70 who received BCS and RT experienced excellent DFS and local control. The three-year median DFS observed in the older women in our study suggests that a long-term view should be taken when treating older patients and that biological age rather than chronological age is a better determinant of when cancer therapies should be withheld.

Safety and efficacy of radioimmunotherapy (RIT) in treatment of non-Hodgkin's lymphoma in the community setting

IntroductionRadioimmunotherapy (RIT) is a unique therapeutic modality that combines biologic and radiolytic mechanisms to induce tumor kill. RIT is underutilized in the community outpatient setting. MethodsThis is an institutional review of patients treated with RIT at St. John Hospital and Medical Center (SJH&MC) 2003–2011. RIT agents were dosed according to recommended guidelines. Response was assessed using the Revised Response Criteria for Malignant Lymphoma and toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events. The primary aim was to assess overall response rate (ORR) and overall survival (OS). The secondary aim was to assess the impact of variable host and disease factors on the ORR to RIT and OS. ResultsForty-eight patients were treated with RIT within the specified period at SJH&MC; of which 52% with follicular lymphoma (FL) and 46% with diffuse large B cell lymphoma (DLBCL). The majority of patients had relapsed or refractory disease (98%). Median duration of follow-up was 17months. The ORR was 73% with 44% complete remission (CR) rate and OS of 48months. The ORR was 79% with 58% CR rate and OS of 82months among FL patients. Among DLBCL patients, the ORR was 65% with 30% CR rate and OS of 39months. Response to last therapy before RIT was the only significant predictor of response to RIT and a significant predictor of OS in multivariate analyses. Prior exposure to EBRT did not predict response or survival in multivariate analyses. Toxicity was manageable and predominantly hematologic. ConclusionsRIT is effective and feasible for use in the community outpatient setting. Advances in knowledge and implications for patient carePatients with B-cell NHL can safely receive RIT close to home. With some coordination of effort, it is not difficult for community-based cancer centers to implement this treatment modality.

Examining patterns of multivariate, longitudinal symptom experiences among older adults with type 2 diabetes and cancer via cluster analysis

PurposeDiabetes and cancer are chronic conditions that produce symptoms, some unique to each condition and others common to both. Previous studies have reported on subgroups of patients who experience distinct combinations of symptoms in cross-sectional samples and the univariate longitudinal trajectories of individual symptoms. The literature currently lacks examples of research that take a multivariate longitudinal perspective to understanding patients' symptom experiences. The purpose of this study was to identify subgroups of patients who share distinct multivariate longitudinal profiles with respect to how symptom severity changes over time for a set of five symptoms (pain, fatigue, change in appetite, nausea, and numbness and tingling). MethodsThis exploratory study included 43 participants with pre-existing diabetes from eight community-based cancer centers who were receiving chemotherapy for a solid tumor. Using baseline and 8-week data, a model-based cluster analysis with Bayesian regularization was used to identify subgroups. ResultsTwo groups were identified. Group 1 experienced mild symptoms that changed very little at 8 weeks; group 2 experienced mild to moderate symptom severity, with small increases in fatigue, nausea, and numbness and tingling. Effect size confidence intervals suggest that level of depression, length of time with diabetes, and severity of diabetes at baseline may differ between groups. ConclusionsMore research in this area is needed to further test this model, address limitations associated with analyzing a small sample, and explore factors that may be associated with changes in the overall symptom experience for patients with diabetes and cancer.

Clinicopathologic correlation and effect of Oncotype DX Recurrence Score on treatment decisions at a community-based academic cancer center.

e11511 Background: Oncotype DX, a 21 gene recurrence score (RS) is used to predict the likelihood of benefit from systemic chemotherapy in women with node-negative, estrogen receptor (ER) positive ...

Abstract P1-15-10: Low utilization of hypofractionated radiotherapy for the treatment of early-stage breast cancer in the US

Abstract Background: Large randomized controlled trials have shown that hypofractionated whole breast irradiation (HF-WBI) is not inferior to or more toxic than conventionally fractionated whole breast irradiation (CF-WBI) for the treatment of early-stage breast cancer. Royal Marsden data were published in 2006 (10-yr), the Ontario trial was reported in 2002 (5-yr) and 2010 (10-yr), and the UK START trials were published in 2006 (5-yr) and 2013 (10-yr). We utilized the National Cancer Data Base (NCDB) to evaluate patterns of radiotherapy fractionation for early-stage, node-negative breast cancer in the U.S. We hypothesized that HF-WBI use would increase over time in response to emerging data supporting its use in this population. Methods: We conducted a retrospective, population-based cohort study of women >18 years diagnosed with T1-2N0 invasive breast carcinoma and treated with breast-conserving surgery between 2004 and 2011. Radiotherapy was categorized as accelerated partial breast irradiation (APBI; 38-40 Gy/1-10 fractions), HF-WBI (40-56 Gy/15-24 fractions) or CF-WBI (50-66 Gy/25-40 fractions). Patients treated with alternate fractionation were excluded. Patterns of breast radiotherapy fractionation were compared using the chi-square test. Multivariable logistic regression was performed for patients diagnosed in 2011, the year with the highest levels of HF-WBI utilization. Results: 217,789 patients in the NCDB met inclusion criteria. HF-WBI use increased over time, rising from 2.1% among eligible patients in 2004 to 15.1% in 2011, while APBI use remained low at <2%. Utilization of HF-WBI was significantly higher in academic centers than comprehensive community cancer centers and community-based cancer centers (p <0.0001). This pattern persisted when controlling for T-stage, hormone receptor/HER2-status, diagnosis year, and patient age >30 years. Table 1 shows frequency of HF-WBI use over time by center type. On multivariate analysis of patients diagnosed in 2011, the following factors were associated with higher use of HF-WBI: treatment at an academic center, older patient age, hormone receptor positivity, pT1 tumor size, and rural residence (Table 2). Table 1: % HF-WBI use Community Cancer CenterComprehensive Community Cancer CenterAcademic Center20040.9%1.7%3.8%20051.6%2.1%3.8%20061.2%2.0%4.6%20071.5%2.8%7.1%20082.9%5.3%10.8%20093.9%8.5%14.7%20105.8%10.7%16.4%20119.6%13.9%20.5% Table 2. Multivariate analysis, year 2011 (n=5568) OR95% CIAcademic Center vs. Community Cancer Center3.062.324.02Academic Center vs. Comprehensive Community Cancer Center1.781.532.08Patient age, 50-90 vs. 18-492.371.863.01T2 vs. T10.540.460.63HER2+ vs. Hormone Receptor +/HER2-0.750.590.97ER-/PR-/HER2- vs. Hormone Receptor +/HER2-0.660.520.84Rural vs. urban2.681.694.24 Conclusions: Utilization of HF-WBI in the US is rising, but remains low overall despite level I evidence showing its non-inferiority to CF-WBI. Given the advantages of HF-WBI in terms of patient convenience and potential healthcare system costs, further research is indicated to explore disparities in HF-WBI utilization in the US and to guide education of breast cancer providers. Citation Format: Yvonne M Mowery, Rachel A Greenup, Kevin Houck, Manisha Palta, Janet K Horton, Eun-Sil S Hwang, Julie A Sosa, Rachel C Blitzblau. Low utilization of hypofractionated radiotherapy for the treatment of early-stage breast cancer in the US [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-10.

A Clinical Prediction Model to Assess Risk for Chemotherapy-Related Hospitalization in Patients Initiating Palliative Chemotherapy.

Chemotherapy-related hospitalizations in patients with advanced cancer are common, distressing, and costly. Methods to identify patients at high risk of chemotherapy toxic effects will permit development of targeted strategies to prevent chemotherapy-related hospitalizations. To demonstrate the feasibility of using readily available clinical data to assess patient-specific risk of chemotherapy-related hospitalization. Nested case-control study conducted from January 2003 through December 2011 at the Mass General/North Shore Cancer Center, a community-based cancer center in northeastern Massachusetts. The parent cohort included 1579 consecutive patients with advanced solid-tumor cancer receiving palliative-intent chemotherapy. Case patients (n = 146) included all patients from the parent cohort who experienced a chemotherapy-related hospitalization. Controls (n = 292) were randomly selected from 1433 patients who did not experience a chemotherapy-related hospitalization. Putative risk factors for chemotherapy-related hospitalization-including patient characteristics, treatment characteristics, and pretreatment laboratory values-were abstracted from medical records. Multivariable logistic regression was used to model the patient-specific risk of chemotherapy-related hospitalization. Chemotherapy-related hospitalization, as adjudicated by the oncology clinical care team within a systematic quality-assessment program. A total of 146 (9.2%) of 1579 patients from the parent cohort experienced a chemotherapy-related hospitalization. In multivariate regression, 7 variables were significantly associated with chemotherapy-related hospitalization: age, Charlson comorbidity score, creatinine clearance, calcium level, below-normal white blood cell and/or platelet count, polychemotherapy (vs monotherapy), and receipt of camptothecin chemotherapy. The median predicted risk of chemotherapy-related hospitalization was 6.0% (interquartile range [IQR], 3.6%-11.4%) in control patients and 14.7% (IQR, 6.8%-22.5%) in case patients. The bootstrap-adjusted C statistic was 0.71 (95% CI, 0.66-0.75). At a risk threshold of 15%, the model exhibited a sensitivity of 49% (95% CI, 41%-57%) and a specificity of 85% (95% CI, 81%-89%) for predicting chemotherapy-related hospitalization. In patients initiating palliative chemotherapy for cancer, readily available clinical data were associated with the patient-specific risk of chemotherapy-related hospitalization. External validation and evaluation in the context of a clinical decision support tool are warranted.

Abstract P4-12-06: Results of next-generation sequencing panels in a large community-based hereditary cancer risk program

Abstract Background: Next-generation sequencing (NGS) allows for broader germline genetic testing for hereditary cancers. Since the Supreme Court decision of AMP v. Myriad on June 13, 2013, hereditary cancer multi-gene panels can now include BRCA1 and BRCA2, making these panels an option for first-tier testing. However, questions have been raised about the clinical utility and implications of extended panels for medical management given the inclusion of unknown to moderate penetrant genes. Methods: We reviewed all patients who underwent multi-gene panel testing from July 1, 2013 through May 23, 2014. The indications for testing included personal and/or family history of breast or ovarian cancer. The panels were ordered in a single genetic counseling clinic within a large community-based cancer center. Results: A total of 136 patients underwent panel testing via a single commercial laboratory. We identified 12 (8.8%) patients who were positive for a pathogenic or likely pathogenic mutation in a cancer susceptibility gene; 4 had prior negative BRCA1 and BRCA2 sequencing and deletion/duplication testing. These positive results included 4 BRCA2 mutations, 2 TP53 mutations, 1 CDH1 mutation, 2 ATM mutations, and 1 patient each with a CHEK2, NBN, or PALB2 mutation. Of the patients found to have a positive test result, 100% met the National Comprehensive Cancer Network (NCCN) guidelines for Hereditary Breast and Ovarian Cancer (HBOC) genetic testing. The CDH1 mutation carrier did not meet NCCN guidelines for hereditary diffuse gastric cancer testing and only one of the TP53 mutation carriers met NCCN guidelines for Li-Fraumeni syndrome. Within our cohort (136), 21 (15.4%) patients had a total of 25 variants of uncertain significance (VUS) and 103 (75.7%) patients had negative test results. Conclusion: Testing through NGS panels identified 7/12 (58%) patients with a mutation which led to changes in current medical management and 3/7 (43%) had a mutation in a gene other than BRCA1 or BRCA2. Our findings suggest that there is clinical utility of NGS panels for use in this patient population despite the inclusion of unknown to moderate penetrant genes and a higher rate of VUS than single gene testing. Citation Format: J L Blum, C A Garby, A E Simmons, S A Walker, L E Panos. Results of next-generation sequencing panels in a large community-based hereditary cancer risk program [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-12-06.

Multi-institutional registry for prostate cancer radiosurgery: An observational clinical trial.

98 Background: To report on the design, methodology and early outcome results of a multi-institutional registry study of prostate cancer radiosurgery. Methods: The Registry for Prostate Cancer Radiosurgery (RPCR) was established in 2010 to further evaluate the efficacy and toxicity of prostate radiosurgery (SBRT) for the treatment of clinically localized prostate cancer. Men with prostate cancer were asked to voluntarily participate in the Registry. Demographic, baseline medical and treatment-related data were collected and stored electronically in a HIPAA-compliant database, maintained by Advertek, Inc. Enrolled men were asked to complete short, multiple choice questionnaires regarding their bowel, bladder and sexual function. Patient-reported outcome forms were collected at baseline and at regular intervals (every 3-6 months) following treatment. Serial PSA measurements were obtained at each visit and included in the collected data. Results: From July 2010 to July 2013, nearly 2,000 men from 45 participating sites were enrolled in the registry. The majority (86%) received radiosurgery as monotherapy. At 2 years follow-up, biochemical disease free survival was 92%. No Grade 3 late urinary toxicity was reported. One patient developed Grade 3 gastrointestinal toxicity (rectal bleeding). Erectile function was preserved in 80% of men <70 yeats old. Overall compliance with data entry was 64%. Conclusions: Stereotactic radiosurgery is an alternative option to conventional radiotherapy for the treatment of organ-confined prostate cancer. The Registry for Prostate Cancer Radiosurgery represents the collective experience of multiple institutions, including community-based cancer centers, with outcome results in keeping with published, prospective trials of prostate SBRT.

Multi-institutional registry for prostate cancer radiosurgery: a prospective observational clinical trial.

Objective: To report on the design, methodology, and early outcome results of a multi-institutional registry study of prostate cancer radiosurgery.Methods: The Registry for Prostate Cancer Radiosurgery (RPCR) was established in 2010 to further evaluate the efficacy and toxicity of prostate radiosurgery (SBRT) for the treatment of clinically localized prostate cancer. Men with prostate cancer were asked to voluntarily participate in the registry. Demographic, baseline medical, and treatment-related data were collected and stored electronically in a Health Insurance Portability and Accountability Act-compliant database, maintained by Advertek, Inc. Enrolled men were asked to complete short, multiple choice questionnaires regarding their bowel, bladder, and sexual function. Patient-reported outcome forms were collected at baseline and at regular intervals (every 3–6 months) following treatment. Serial prostate-specific antigen measurements were obtained at each visit and included in the collected data.Results: From July 2010 to July 2013, nearly 2000 men from 45 participating sites were enrolled in the registry. The majority (86%) received radiosurgery as monotherapy. At 2 years follow-up, biochemical disease-free survival was 92%. No Grade 3 late urinary toxicity was reported. One patient developed Grade 3 gastrointestinal toxicity (rectal bleeding). Erectile function was preserved in 80% of men <70 years old. Overall compliance with data entry was 64%.Conclusion: Stereotactic radiosurgery is an alternative option to conventional radiotherapy for the treatment of organ-confined prostate cancer. The RPCR represents the collective experience of multiple institutions, including community-based cancer centers, with outcome results in keeping with published, prospective trials of prostate SBRT.

Barriers to clinical trial accrual in a community cancer clinic.

91 Background: The availability of and enrollment in clinical trials at an institution may be considered cancer care quality measures. Nationally, most cancer patients are initially diagnosed and treated in the community setting. Data regarding clinical trial accrual of new cancer patients from community-based cancer centers and the barriers they encounter are limited. We sought to identify potential barriers to enrollment in clinical trials at a community cancer clinic. Methods: Data on new cancer patients seen at our comprehensive community cancer clinic were prospectively collected from 2007 through 2010. Factors that potentially affected patient accrual in clinical studies were tracked. Results: During the four-year study period, a total of 662 patients were diagnosed with breast, prostate, colon, lung, gynecological, melanoma and renal cell cancers. No studies were available for 42% of the patients (n=278). Of the remaining patients, 49% (190/384) met protocol eligibility. Of the eligible study patients, 45% (85/190) enrolled, for an overall accrual rate of 13% (85/662), and 55% (105/190) declined participation. Patients declined to participate due to stress of diagnosis, refusal of treatment entirely, issues with randomization and placebo, concerns with side effects of the medications, delay of treatment while awaiting the clinical trial process, patient refusal, transportation concerns and length of treatment. Conclusions: This study demonstrates that above average clinical trial participation can be achieved in community cancer clinics in the rural setting. There are modifiable barriers to clinical trial accrual including study availability, patient eligibility and other patient factors. Improvement of patients’ perceptions and perspectives regarding the clinical trial process could be achieved through patient education. Elimination of barriers to trial accrual could be studied as a quality metric.

Experience with partial breast irradiation for treatment of breast cancer at a community-based cancer center

BackgroundMany patients after lumpectomy have barriers to whole breast radiation. Accelerated partial breast irradiation (APBI) was introduced at our institution as an alternative. MethodsRetrospective review of patients who were treated with ABPI from March 2003 to December 2011 was conducted. Results of demographics, tumor pathology, infection, and recurrence were reviewed. ResultsTwo hundred ninety-four patients received 298 treatments of APBI. The mean follow-up was 58.5 months. Using the American Society for Radiation Oncology criteria, 101 patients were suitable, 142 cautionary, and 52 patients were unsuitable. The average age was 65 with a range of 37 to 93. In our study, true local recurrence occurred in only 1.0% (n = 3). Patients recurring in the same breast elsewhere was 2% (n = 6). ConclusionsOutcomes after treatment with APBI were excellent, and breast recurrence was similar to whole breast irradiation. It may safely be offered to patients with less than suitable criteria or barriers to whole breast radiation.

Predictors of Diabetes Self-Management in Older Adults Receiving Chemotherapy

Cancer patients with diabetes have higher mortality rates and are more likely to develop infections, and be hospitalized during treatment. Hyperglycemia has been hypothesized as one of the factors associated with this increased risk. Diabetes self-management is one of the essential elements used by patients to maintain glucose levels. This exploratory study seeks to develop an understanding of the impact cancer treatment can have on overall diabetes self-management and how individual, clinical, and behavioral characteristics may influence or predict the level of diabetes self-management in adults who are undergoing chemotherapy for a solid tumor cancer. This study was conducted at 8 community-based cancer centers in Michigan and Ohio and used a written, self-administered survey at baseline and a phone survey 8 weeks later. Diabetes self-management significantly decreased (P < .001), and the level of symptom severity significantly increased (P < .001) after patients were on chemotherapy for a minimum of 8 weeks. The level of symptom severity and diabetes self-efficacy were significantly predictive of the performance of diabetes self-management activities. Chemotherapy and associated symptoms can have a negative impact on the performance of diabetes self-management activities in adults with both diabetes and cancer, increasing the risk for hyperglycemia and development of complications. Oncology nurses need to be aware of the impact cancer treatment can have on the performance of diabetes self-management activities in adults. Future research needs to test interventions that may assist patients with diabetes and cancer in managing both diseases.

Improving the Relative Dose Intensity of Systemic Chemotherapy in a Community-Based Outpatient Cancer Center

This three-phase study was performed to improve the mean relative dose intensity (RDI) of chemotherapy administered to patients in a community-based outpatient cancer center. Medical records were reviewed for patients who began receiving systemic chemotherapy for lymphoma or cancer of the breast, lung, endometrium, ovary, or colon. During phase 1, records were reviewed and the mean RDI was determined through collection of demographic, diagnostic, chemotherapy, and laboratory data. Phase 2 involved implementation of quality improvement initiatives to improve the RDI: development of a febrile neutropenia risk assessment tool, revision of our dose cancellation policy, and interdisciplinary education. Finally, after implementation of these initiatives, the mean RDI was prospectively determined in phase 3, similar to phase 1. The mean RDI was determined to be 83% during phase 1 compared with 91% during phase 3 (P=.0087). For adjuvant chemotherapy, the mean RDI was 85% and 95% for phases 1 and 3, respectively (P=.0035). Likewise, for metastatic disease, the mean RDI was 76% and 82% for phases 1 and 3, respectively (P=.3935). The proportion of regimens that met or exceeded the recommended minimum goal RDI of 85% was 54% for phase 1 and 80% for phase 3. Granulocyte colony-stimulating factor use increased from 69% preintervention to 81% postintervention. The mean overall RDI improved above the threshold goal of 85%, with the RDI for adjuvant chemotherapy reaching 95%, after implementation of three quality-improvement initiatives. With continued education and following policies already in place, further improvements in RDI could be demonstrated.

Translating SBRT From Academic to Community Practice

Purpose/Objective(s): Similar to stereotactic radiosurgery (SRS) used for decades in treatment of intra-cranial metastasis, stereotactic body radiation therapy (SBRT) is becoming an established, efficient, and effective means in achieving high rates of local tumor control. The institution is one of the largest cancer care delivery systems in the United States, In 2008 and 2009, it expanded its radiosurgical practice to two of its large communitybased practices. Materials/Methods: We adapted the practice of SRS and SBRT utilizing LINAC-based radiosurgical techniques that include cone-based, 3D conformal, IMRT/IMRS, VMAT, and gated-VMAT techniques employing the clinical and research foundation established at our academic hub. With centralized training, clinical guidance, and routine oversight, the two clinical programs were established separately. Centralized treatment planning and review was essential in establishing treatment guidelines. Results: Two hundred thirty patients treated from May 2008 and Dec 2011 were analyzed, most with metastatic or recurrent neoplasms. Separate data bases were established to document and summarize: (1) various treatment sites, (2) dose-fractionation schemes, (3) response, (4) toxicity, (5) survival, (6) demographics, and several other endpoints. A collaborative effort was established to combine the databases. An additional and more in depth analysis of patients with oligometastases, lung cancer, and the special population of the elderly were performed and will be summarized in separate manuscripts. The well-described efficacy and toxicity profiles have been replicated in this setting as well as achieving a high rate of local control, palliation and, in some settings, improved survival. Acute side effects are relatively minor and significantly less compared to standard fractionated radiation therapy. Conclusions: Utilizing a team-based approach and following standardized guidelines for dose-fractionation and normal tissue protection, SBRT can become a standard part of practice of an experienced comprehensive community-based cancer center. Special attention to appropriate imaging, target delineation, patient immobilization, quality assurance and patient safety may allow this modality to become the next major improvement in treatment options demonstrating better disease control and less toxicity for many situations. Our analysis validates previous observations of a potential cost savings for our healthcare system, greater access to treatment secondary to increased patient convenience, fewer treatments, and increased quality of life for patients. Author Disclosure: R.B. Wynn: None. A. Mihai: None. P. Thiron: None. J. Westrup: None. M. Krebs: None. J. Armstrong: None. L.A. Rock: None. G. Fagan: None. R. Bhatnagar: None. D.E. Heron: None.