Integrated Cancer Programs Research Articles

Treatment facility: Effects on stage IV osteosarcoma survival.

e23501 Background: Osteosarcoma is a malignant, bone-forming tumor that makes up approximately 20% of bone cancers. Osteosarcoma has an overall 5-year survival of 68%, so to see significant changes in survival, this study looks only at Stage IV osteosarcoma. Osteosarcoma is most commonly treated with a combination of chemotherapy and surgery, but no studies have been conducted to investigate the facility type at which treatment is received and its effect on survival outcomes. The goal of this study is to investigate the survival of patients with stage IV osteosarcoma based on treatment facility type. Methods: There were 1,634 patients with stage IV osteosarcoma identified in the National Cancer Database (NCDB), with 657 including data on facility type. SPSS version 27 was used to generate both descriptive statistics regarding demographics and Kaplan-Meier curves to determine the impact treatment facility type has on overall survival. Results: Stage IV osteosarcoma was more common in males (59.5%) and white race (77%) with 55.4% receiving treatment at academic centers, 22.5% at comprehensive community programs, 16.9% at integrated cancer programs, and 5.2% at community cancer programs. Patients on Medicare also demonstrated a decreased overall survival when compared to all other insurance types (p < 0.001). In stage IV osteosarcoma patients, there were statistically significant differences in survival outcomes when comparing each facility type to each other (with p values all < 0.05), except for the comparison between comprehensive community cancer programs and integrated network cancer programs. Patients who received treatment at academic/research programs demonstrated the best overall survival with a median of 7.29 months when compared to community center programs, comprehensive community cancer programs, and integrated network programs (with p values of < 0.001, 0.046, and 0.03, respectively). Patients treated at academic research programs were more likely to be white males with private insurance or Medicare. Conclusions: Patients treated at academic centers for stage IV osteosarcoma had better survival outcomes compared to those treated at nonacademic facilities. These patients were more likely to be white, insured individuals. African Americans and Medicare patients were associated with increased risk of mortality from stage IV osteosarcoma. Future studies can be done with multivariate analyses to determine other variables that may affect outcomes in this patient population.[Table: see text]

The Radiation Incident Safety Committee: Supporting Cancer Programs in the Delivery of High Quality Radiation Treatment

Purpose: The Radiation Treatment Program (RTP) at Ontario Health, Cancer Care Ontario, established the Radiation Incident Safety Committee (RISC) responsible for promoting incident learning, safety and quality improvement. The committee uses a provincial approach, discussing regularly reported safety events, to operationalize quality improvement initiatives intended to support integrated cancer programs (ICP)s. A retrospective review of actual incident event types reported identified variation in the number of submitted incidents within a portion of ICPs. In response to this observed variation, RISC sought to identify areas of success and opportunities for improvement in supporting ICPs in effective incident reporting and learning. Methods: RISC distributed a three-part survey to ascertain the current state of the quality and incident reporting practices across the province. The survey explored program quality and incident reporting practices across the following three domains. 1. Compliance with the Canadian Partnership for Quality Radiotherapy's (CPQR) “Quality Assurance Guidelines for Canadian Radiation Treatment Programs” guidance document (specifically exploring the document's key quality indicators relevant to incident reporting). 2. Local incident reporting culture and practices, and 3. The programmatic impact of RISC initiatives. Results: Seventy-three per cent of programs (n=15) identified that they regularly review compliance to the CPQR indicators, with 67% of programs reviewing compliance within the last year. One hundred per cent of programs had procedures to identify critical radiation treatment incidents and report incidents as per requirements of local, provincial, and/or national organizations, as per CPQR guidance. 87% of responding programs identified that they had local written policies and procedures regarding the reporting, investigation, action, documentation, and monitoring of treatment. Finally, with respect to incident learning processes, 80% of programs perform root cause analyses for severe events or those at risk for programmatic impact. Relating to RISC Initiatives, responding ICPs described they had established mechanisms to share RISC deliverables and incident alerts with the inter-professional team and radiation department. Programs also identified that RISC initiatives had a positive impact, providing guidance and improving reporting consistency. Lastly, ICPs identified that there were opportunities for further support, specifically in the interpretation of dosimetric impact and the classification of complex events. Conclusion: The RISC survey identified a number of successes and opportunities for improvement. Programs have implemented policies and procedures surrounding incident reporting and learning, however, there are opportunities to improve aspects of incident reporting at a local and provincial level. RISC plans to establish novel solutions to support programmatic learning as the committee continues to expand its mandate, improving the quality and safety of radiation treatment in Ontario.

Factors associated with palliative care (PC) utilization in advanced and metastatic renal cell carcinoma (RCC).

297 Background: Palliative care (PC) offers various benefits for patient with cancer that include, but are not limited to, decrease in disease-specific symptoms and improvement in functional status. Several oncological guidelines have adopted early integration of PC into oncologic care to improve quality of life among patients with advanced malignancies. However, PC utilization patterns and factors associated with its use in advanced renal cell carcinoma (RCC) remain poorly understood. Methods: Using the National Cancer Database (NCDB), we abstracted patients with stage III and IV RCC from 2004-2014 and evaluated PC utilization amongst this cohort. Socioeconomic and clinical factors were compared for patient receiving and not receiving PC for advanced RCC. Multivariable logistic regression identified factors that were associated with receipt of PC. Results: We identified 20,122 and 42,014 patients with stage III and IV RCC, respectively. Among this cohort, 329 and 9,317 patients received PC for stage III and IV RCC, respectively. From 2004 to 2014, PC utilization has been stable at ~1% for stage III RCC and has significantly increased from 17% to 20% for stage IV RCC. Multivariable analysis demonstrated that Blacks, income >$48,000, regions outside of Northeast, stage III RCC, and patients that received surgery were less likely to receive PC. Patients that were female, with more comorbidities, uninsured or with government insurance, lower educational status, treated at academic or integrated cancer program, with sarcomatoid histology, receiving systemic therapy were more likely to receive PC. Conclusions: While PC utilization has significantly increased for stage IV RCC, there are several demographic, socioeconomic, and clinical factors that predict PC usage among patients with advanced RCC. Taken together, this suggests the need for more equitable and systematic use of PC among patients with advanced RCC.

Immunotherapy in metastatic melanoma: A sociodemographic analysis of the National Cancer Database.

87 Background: Metastatic melanoma carries poor prognosis and traditional chemotherapy has limited efficacy, but immune checkpoint inhibitors (ICIs) have drastically improved disease outcomes since first approved in 2011. Access to these costly agents in the real-world setting can be challenging. We aimed to assess the demographic and socioeconomic factors associated with receipt of immunotherapy in Stage IV melanoma using National Cancer Database (NCDB). Methods: NCDB first classified ICIs as immunotherapy agents in 2013, hence we queried the database to identify patients with Stage IV melanoma from 2013 to 2016. Patients were divided into receipt of immunotherapy or no receipt of immunotherapy; those without documentation of either were excluded. Factors compared between the two groups included age, sex, diagnosis year, Charlson-Deyo score, insurance and state Medicaid expansion status, income, treatment region, and facility type. Survival analyses were performed by Kaplan-Meier method. Logistic Regression was used to examine factors associated with immunotherapy receipt. Results: 9512 Stage IV melanoma patients had documented immunotherapy status during 2013 to 2016. 36.0% of patients received immunotherapy. Median overall survival (mOS) for all-comers was 10.1 months with improved survival for those who received immunotherapy compared to those who did not (mOS 18.4 v 7.4 months; p<0.01). Regression analysis revealed increased receipt of immunotherapy was associated with diagnosis in states with Medicaid expansion (OR: 1.16, 95% CI:1.002-0.1.340) compared to non-expansion; west north central (OR:1.433; 95%CI:1.139-1.804) and mountain (OR:1.433; 95%CI:1.132-1.813) regions when compared to pacific; academic/research program (OR:1.923; 95%CI:1.592-2.323) and integrated cancer programs (OR:1.362; 95%CI:1.094-1.695) compared to community program. Charlson-Deyo Scores of 1-3, lower Income, increased age, and less high school graduation were associated with decreased immunotherapy receipt. Conclusions: Improved survival is realized in those who receive immunotherapy for stage IV melanoma. Socio-demographic factors show discrepant receipt of immunotherapy.

Implementing survivorship care planning in a large integrated cancer program.

69 Background: Aurora Health Care is comprised of 15 hospitals and 22 oncology clinics. Aurora Cancer Care (ACC), a Commission on Cancer (CoC) accredited program, diagnoses and treats 7,000 adult cancer patients annually, more than any other healthcare system in Wisconsin. The CoC’s Survivorship Standard 3.3 requires accredited cancer programs to provide cancer patients with survivorship counseling and a written care plan. ACC was challenged to develop a consistent model of survivorship care that can work at multiple sites across the system. Methods: Workflow planning and education began at all oncology clinics in fourth quarter of 2014. Thirteen disease specific survivorship care plan templates were built into the EMR with some-auto population functionality. A system wide delivery plan was launched in first quarter of 2015 with the goal of targeting 10% of eligible patients. Initial focus was on breast cancer patients with some sites also including other cancers. The model of survivorship care is an “embedded consultation” in medical or surgical oncology with an advanced practice provider (APP) completing the care plan and meeting with the patient at the end of first line treatment. Results: Initial required volumes were estimated based on 2013 registry data with a goal of completing approximately 700 care plans in 2015 to meet the 10% CoC standard. During Q1 & Q2 of 2015, 444 care plans were generated and given to patients, mostly for breast cancer survivors. The most significant barrier surrounded retrieving data from the EMR. Conclusions: Data from the first half of 2015 demonstrates success with the approach. Aurora Cancer Care will exceed the benchmark of 700 care plans. There has been a high level of engagement with the APPs who have taken ownership of survivorship care planning, contributing to the success of the program thus far. Because of difficulty retrieving data from the EMR, manual tracking was still required. Future modifications will address this and other barriers.

A Framework for the Organization and Delivery of Systemic Treatment

Increasing systemic treatment and shortages of oncology professionals in Canada require innovative approaches to the safe and effective delivery of intravenous (IV) cancer treatment. We conducted a systematic review of the clinical and scientific literature, and an environmental scan of models in Canada, the United Kingdom, Australia, and New Zealand. We then developed a framework for the organization and delivery of IV systemic treatment. The systematic review covered the medline, embase, cinahl, and HealthStar databases. The environmental scan retrieved published and unpublished sources, coupled with a free key word search using the Google search engine. The Systemic Treatment Working Group reviewed the evidence and developed a draft framework using evidence-based analysis, existing recommendations from various jurisdictions, and expert opinion based on experience and consensus. The draft was assessed by Ontario stakeholders and reviewed and approved by Cancer Care Ontario. The poor quantity and quality of the evidence necessitated a consensus-derived model. That model comprises four levels of care determined by a regional systemic treatment program and three integrated structures (integrated cancer programs, affiliate institutions, and satellite institutions), each with a defined scope of practice and a specific organizational framework. New models of care are urgently required beyond large centres, particularly in geographically remote or rural areas. Despite limited applicable evidence, the development and successful implementation of this framework is intended to create sustainable, accessible, quality care and to measurably improve patient outcomes.

Trends in trastuzumab utilization in Ontario: A single payer system

11534 Background: Ontario, a province of 13 million, has a single payer system for new IV cancer drugs, the New Drug Funding Program (NDFP) of Cancer Care Ontario. Trastuzumab (T) is an NDFP drug with funding for both adjuvant (adj) and metastatic (met) breast cancer. Each patient (pt) is registered as adj, or met with line of treatment (tx). Adj T is funded for pts who receive adj chemotherapy (chemo) for node+ disease or node-, >1cm. Methods: Pts who received T were identified in the NDFP from 1999–2007. Funding for met disease was from 1999 onwards and for adj tx from 7/2005 (tx allowed for those whose adj chemo ended after 10/2004). For adj T, records of further chemo were identified for pts treated in Integrated Cancer Programs, for whom complete tx information is available, 50% of all adj pts. Results: About 5,300 cases of breast cancer are diagnosed annually in ON. 1,799 patients have received met T since 1999. Initially met tx was 1st, 2nd and 3rd line, including single agent T. Since 2005 tx is more likely to be 1st line with a taxane or vinorelbine. Median duration of tx with docetaxel (D) is 7 mos, range <1 mo –28.2 mos. Since 2005, 2,217 pts have received adj T. Of these, 866 pts have complete records available and completed adj T by the end of 10/2007. Only 19 have received further chemo for mets. At most 50% of relapses would receive either no tx or hormonal tx, so we estimate that 38/886 or 4.3% of pts have relapsed after adj T. Currently, 100 pts/mo are enrolled in the NDPF, 80 for adj T and 20 for met T. Conclusions: In Ontario 960/5,300 or 18% of pts receive adj T and chemo annually. Relapses have been very infrequent (<5%) after adj T to date. In the met setting most T is given in combination with D, with a median duration of use of 7 mos. No significant financial relationships to disclose.

Regional models of care for systemic therapy: Standards for organization and delivery

17057 Background: Rapidly expanding indications for cancer systemic therapy combined with human resource and facility constraints require innovative approaches to deliver safe, patient-centred, and evidence-based care across Ontario, a province covering 1 million sq km, organized into 14 regions, each with about 1 million inhabitants. A systemic therapy project team recommended the best way to organize the delivery of ambulatory systemic therapy in Ontario. Methods: A core multidisciplinary panel reviewed the evidence and developed standards. The panel used evidence-based analysis of relevant publications, an environmental scan of other existing recommendations and expert opinion based on experience and consensus to formulate a standards document to guide treatment delivery. This was reviewed and amended by the full project team. The document was circulated to oncologists, family practitioners, internists, pharmacists, nurses and administrators who work in or have responsibility for systemic therapy in the regions for practitioner feedback. Results: A Regional Systemic Therapy Program (STP) Model was developed in which Integrated Cancer programs (ICPs) provide comprehensive cancer services, leadership of quality and overall organisation/coordination for the region. STPs include ICPs directly linked to satellite centres and also affiliated to centres with their own systemic therapy programs to provide appropriate systemic therapy services for all regions under a common set of standards. Five levels of care are recommended, with complexity and availability of services differentiating the levels. For each level, standards were established for; 1-Providers and their roles, 2-Education for providers, 3-Service type and complexity, 4-Service volumes, 5- Quality assurance and safety, 6-Facility requirements, 7-Administrative and organizational responsibilities. The intent is to provide the same standard of care in the most appropriate setting within the appropriate time frame. STPs will implement, monitor and evaluate quality indicators. Conclusions: A detailed review of the document including results of practitioner feedback as well as survey results from the 14 STPs to determine whether standards are being currently met will be presented. No significant financial relationships to disclose.

Cancer Care Ontario and integrated cancer programs

A performance management system has been implemented by Cancer Care Ontario (CCO). This system allows for the monitoring and management of 11 integrated cancer programs (ICPs) across the Province of Ontario. The system comprises of four elements: reporting frequency, reporting requirements, review meetings and accountability and continuous improvement activities. CCO and the ICPs have recently completed quarterly performance review exercises for the last two quarters of the fiscal year 2004-2005. The purpose of this paper is to address some of the key lessons learned. The paper provides an outline of the CCO performance management system. These lessons included: data must be valid and reliable; performance management requires commitments from both parties in the performance review exercises; streamlining performance reporting is beneficial; technology infrastructure which allows for cohesive management of data is vital for a sustainable performance management system; performance indicators need to stand up to scrutiny by both parties; and providing comparative data across the province is valuable. Critical success factors which would help to ensure a successful performance management system include: corporate engagement from various parts of an organization in the review exercises; desire to focus on performance improvement and avoidance of blaming; and strong data management systems. The performance management system is a practical and sustainable system that allows for performance improvement of cancer care services. It can be a vital tool to enhance accountability within the health care system. The paper demonstrates that the performance management system supports accountability in the cancer care system for Ontario, and reflects the principles of the provincial governments commitment to continuous improvement of healthcare.

Reconstructing Cancer Services in Ontario

This paper draws upon experience gained in the recent restructuring of cancer services in Ontario that can provide insights for broader regionalization efforts. Although Ontario is the only province in Canada not to regionalize its healthcare system, the Ontario cancer services system, like most others in Canada, is based on a regionalized system. However, the growing burden of cancer and predictable crises in cancer services in Ontario necessitated a rethinking of how the cancer system should be structured and how services should be delivered. Based on recommendations by the Cancer Services Implementation Committee in 2001, Ontario's cancer services system has recently gone through major restructuring, which has established new institutional arrangements for the Ministry of Health and Long-Term Care, Cancer Care Ontario (CCO) (the provincial cancer agency) , a new Quality Council and 11 new regionally based Integrated Cancer Programs (ICPs). This restructuring has created several levers for promoting regional change and motivating performance improvement, including (1) public reporting on performance with a new quality mandate, (2) fiscal and performance-based agreements between CCO and the ICPs, (3) leading and coordinating communities of practice and (4) direct ministerial access. While institutional relationships are still developing, these experiences may provide important insights for regionalization efforts in other jurisdictions and sectors in Canada.