Comprehensive Oncology Care Research Articles

Cancer rehabilitation and palliative care: critical components in the delivery of high-quality oncology services.

Palliative care and rehabilitation practitioners are important collaborative referral sources for each other who can work together to improve the lives of cancer patients, survivors, and caregivers by improving both quality of care and quality of life. Cancer rehabilitation and palliative care involve the delivery of important but underutilized medical services to oncology patients by interdisciplinary teams. These subspecialties are similar in many respects, including their focus on improving cancer-related symptoms or cancer treatment-related side effects, improving health-related quality of life, lessening caregiver burden, and valuing patient-centered care and shared decision-making. They also aim to improve healthcare efficiencies and minimize costs by means such as reducing hospital lengths of stay and unanticipated readmissions. Although their goals are often aligned, different specialized skills and approaches are used in the delivery of care. For example, while each specialty prioritizes goal-concordant care through identification of patient and family preferences and values, palliative care teams typically focus extensively on using patient and family communication to determine their goals of care, while also tending to comfort issues such as symptom management and spiritual concerns. Rehabilitation clinicians may tend to focus more specifically on functional issues such as identifying and treating deficits in physical, psychological, or cognitive impairments and any resulting disability and negative impact on quality of life. Additionally, although palliative care and rehabilitation practitioners are trained to diagnose and treat medically complex patients, rehabilitation clinicians also treat many patients with a single impairment and a low symptom burden. In these cases, the goal is often cure of the underlying neurologic or musculoskeletal condition. This report defines and describes cancer rehabilitation and palliative care, delineates their respective roles in comprehensive oncology care, and highlights how these services can contribute complementary components of essential quality care. An understanding of how cancer rehabilitation and palliative care are aligned in goal setting, but distinct in approach may help facilitate earlier integration of both into the oncology care continuum-supporting efforts to improve physical, psychological, cognitive, functional, and quality of life outcomes in patients and survivors.

Microsatellite Instability Testing in Colorectal Carcinoma: A Practical Guide

In this month’s “Road Ahead” article, we continue last month’s theme that focused on the role of pathology in the care of our GI patients. Many gastroenterologists have successfully incorporated pathology into their core practices either within a business infrastructure or as part of a larger health care system. Dr Gibson and her colleagues at Yale University School of Medicine have helped inform us about a particularly difficult management problem: how to handle the genetically high-risk patients we see frequently in our hospitals and endoscopy units. New comprehensive practice guidelines concerning management of hereditary colon cancer syndromes are in development, but this short article provides a clear and concise guide for the practicing gastroenterologist.

Patient retention and costs associated with a pancreatic multidisciplinary clinic.

96 Background: Multidisciplinary clinics (MDC) are a burgeoning method of administering timely and comprehensive oncologic care. The continuity of care achievable with MDCs, in addition to their costs, are not well-described. We compared retention rates and charges for MDC patients to patients with individual referrals at the same academic center. Methods: The geographic origins of 482 MDC patients and 3,766 non-MDC patients, all referred for pancreatic cancer treatment between 2008-2010, were defined as “local,” “adjacent states,” and “non-adjacent states.” Proportions of patients in each group who presented initially and subsequently returned were compared using chi-squared tests. Multivariate adjustment was performed for disease stage and other clinical risk factors. Gross charges per patient were determined using billing data. Results: Overall, the MDC retained a higher percentage of patients for subsequent treatment than the non-MDC group (60.8% vs. 53.6%; p=0.003), as well as all three individual regions. Multivariate adjustment results are not yet available, but will be at the time of the meeting. Mean charges per patient were 11% higher for the non-MDC group. Conclusions: The MDC achieved higher patient retention, suggesting improved continuity of care. Total charges were higher for the non-MDC group, suggesting that MDCs may be more cost-effective. [Table: see text] [Table: see text]

My choices, my wishes: Advance care planning advocacy in the adult oncology population.

6 Background: Working through end-of-life care (EOL) issues with our patients is one of the most challenging aspects of cancer care. Although studies of EOL care interventions that are patient-focused and result in high-quality EOL experiences are increasing, most still do not achieve an EOL experience consistent with preferences. We aimed to provide an intervention for standardized advanced care planning (ACP) documentation and education to improve quality of life (QOL) for patients (pts) with terminal cancer (TC). Methods: Pts with TC (for this study defined as stage IV cancer or metastatic disease) were evaluated retrospectively through our EHR IKnowMed (IKM) before and after an ACP documentation and an education intervention. Descriptive statistics were used to identify and measure utilization of ACP introduction and charting as well as completion of advance directive documentation. Within IKM there are discrete fields for EOL data including ACP discussion, ACP facilitation, documentation of ADs. Education on tool documentation occurred in early 2012. Our ACP program was launched in March 2012. This included an ACP office visit conducted by a practitioner with ACP training, standardized education literature on EOL and ACP, launch of a website with EOL and ACP educational material, recording of ACP documents and documentation of hospice utilization and ACP preferences within our EHR. Results: Baseline characteristics and improvements in ACP introduction, charting, and AD documentation that occurred during our documentation and intervention process can be seen in the Table. Conclusions: Implementation of a standardized ACP program improves utilization and documentation of ACP planning, and documentation of ADs. These interventions improve QOL and health literacy for patients with TC. By incorporating these strategies with definable metrics, strategic intervention can be measured and reported. Further study of the relationships between ACP documentation and patient outcomes is necessary for comprehensive oncology care. [Table: see text]

Advanced care planning metrics for stage IV cancers and strategies for improved utilisation in oncology-settings

To define Advanced Care Planning (ACP) Metrics within an oncology-specific electronic health record (EHR) in order to develop strategies to increase awareness and utilisation of Advanced Directives documentation. Descriptive statistics...

Utility of Abdominal Computed Tomography in Head and Neck Cancer Patients

Objective: Assess the role of abdominal computed tomography (CT) imaging in the staging and surveillance of patients with head and neck squamous cell cancer (HNSCC) for distant metastatic disease (DMD) and second primary tumors (SPT). Method: Retrospective review of 172 HNSCC patients treated at an academic center who underwent abdominal CT imaging from 2003 to 2007. These scans were categorized as suspicious, positive, or negative for DMD or SPT. Charts of patients with suspicious or positive results were reviewed to determine resultant work-up and outcomes. Results: After consideration of exclusion criteria, 165 patients were included in this retrospective study. Normal abdominal CT scans were seen in 139 patients while the remaining 27 patients had abnormal abdominal CT findings. Of these 27, 16 patients (9.7%) were determined to have malignancy. Twelve patients had DMD, and 4 were diagnosed with SPT. Conclusion: Abdominal CT imaging identified DMD or SPT in 9.7% of patients resulting in significant alteration in their comprehensive oncologic care. This rate is not inconsequential and might justify the use of abdominal CT in managing HNSCC patients. Prospective trials might help determine the impact of abdominal CT findings on survival.

Surgical education and training program development for gynecologic oncology: American perspective

The purpose of this paper is to provide information about gynecologic oncology fellowship training and guidance in program development. The characteristics necessary for a physician to develop into a successful gynecologic oncologist include an extensive fund of knowledge related to the subspecialty, strong interpersonal skills, the ability to practice within the complex systems required for management of gynecologic cancer patients, surgical expertise, and the clinical ability to provide comprehensive oncologic care for these women. In order for a trainee to acquire these skills, a gynecologic oncology training program must accept only highly qualified individuals as fellows, have a dedicated core faculty, practice in a supportive environment that has appropriate facilities, and provide adequate clinical material. The gynecologic oncology training program must be organized with an emphasis on education of the fellows. Part of the educational program is formal (lectures, assigned reading, basic skill sets, etc.). Training in clinical and surgical skills is a day-to-day process that occurs during the course of patient care. One requirement of The American Board of Obstetrics and Gynecology (ABOG) is that the fellow spends 12 months of protected time doing research. Fellows are also required to take 2 courses, one in biostatistics and one in cancer biology. A thesis of publishable quality is also required. All programs must perform ongoing quality assurance and reassessment of potential areas for improvement. ABOG is responsible for the accreditation and ongoing monitoring of the fellowship programs.

Selecting and implementing support groups for bereaved adults.

This paper offers a rationale for initiating bereavement support groups in sites providing cancer care and delineates models to implement them. Skills needed to lead a bereavement support group are identified, with emphasis on adding to staff members' competency that has already been developed by facilitating groups for oncology patients and their families. Bereavement support groups are essential elements in the provision of comprehensive oncology care, though they are seldom offered by staff in the traditional hospital setting. It is important that the bereaved feel that there is a place in which they have the time and understanding required to work through the normal grieving process. Special requirements for facilitators include self-awareness of the impact of loss in their own lives and ability to tolerate both the emotions expressed in the grieving process and the often extended time period required for members' personal healing. Several bereavement support models, including the time-limited, ongoing, monthly, and self-help groups, are documented. Bereavement support is an essential element in the provision of comprehensive oncology care. Predictive models to identify individuals who are at higher risk for psychological distress could be used in oncology clinics to facilitate early referral or greater psychological support for family members. Staff members wishing to introduce this service can build on skills already developed leading traditional oncology support groups, and can utilize cofacilitation with a mental health professional to ease the anxiety of assuming a new role and obtain mentoring. Recruitment for a group might be achieved by inviting family members of patients who have died within a specific time frame or by issuing press releases to local papers and church bulletins. Offering bereavement support in the oncology setting is especially helpful to family members who might otherwise be unaware of such a service and who now have the opportunity to attend.