Interdisciplinary Oncology Research Articles

The role of Advanced Practice Providers in interdisciplinary oncology care in the United States.

Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs), generally referred to as Advanced Practice Providers (APPs), are fundamental to interdisciplinary oncology care. As the projected demand for oncology services is anticipated to outpace the supply of oncologists, APPs will become increasingly vital in the delivery of oncology care and services. The training, education, and scope of practice for APPs gives the interdisciplinary care team professionals that deliver high-quality clinical services and provide valuable contributions and leadership to health care quality improvement initiatives. Optimizing the integration of APPs in oncology care offers immense advantages towards improvement of clinical outcomes.

Diagnosis and treatment of dermatofibrosarcoma protuberans. European consensus-based interdisciplinary guideline

Dermatofibrosarcoma protuberans (DFSP) is a skin fibroblastic tumour that is locally aggressive, with a tendency for local recurrence, but rarely metastasizes. A unique collaboration of multi-disciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on DFSP diagnosis and treatment, based on systematic literature reviews and the experts’ experience. Diagnosis is suspected clinically and confirmed by pathology. Analysis by fluorescence in situ hybridisation (FISH) or multiplex reverse transcriptase-polymerase chain reaction (RT-PCR) to detect specific chromosomal translocations and fusion gene transcripts is useful to confirm a difficult DFSP diagnosis. Treatment is mainly surgical, with the aim to achieve complete resection of the tumour. In order to reduce the recurrence rate, the treatment of choice of DFSP seems to be Mohs’ micrographic surgery (MMS) and related variants. In hospitals where only standard histopathological procedures are available, standard excision with lateral safety margin of 3cm is advisable. Imatinib (Glivec®) is approved in Europe for the treatment of inoperable primary tumours, locally inoperable recurrent disease, and metastatic DFSP. Imatinib has also been given to patients with extensive, difficult-to-operate tumours for preoperative reduction of tumour size, but the usefulness of this attitude should be confirmed by clinical trials. Therapeutic decisions for patients with fibrosarcomatous DFSP should be primarily made by an interdisciplinary oncology team (‘tumour board’).

Beyond clinical trials in advanced soft tissue sarcoma: what to expect from trabectedin treatment? Foreword.

*Department of Interdisciplinary Oncology, HELIOS Klinikum Berlin-Buch, Berlin, Germany; Tel.: +49 30 9401 54801; peter.reichardt@helios-kliniken.de Trabectedin has mechanisms of action that differentiate it from conventional cytotoxic agents used in the treatment of advanced soft tissue sarcoma; the possibility that these multiple mechanisms of action have different roles in different tumors [1] provides opportunity to refine and perhaps even individualize its use. Since trabectedin first became available for clinical investigation in 1995, much has been learned about its unique clinical profile. Some distinguishing characteristics of trabectedin include prolonged tumor control, activity in almost all histological subtypes, positive outcomes in translocation-related sarcoma, maintenance of response, ability to rechallenge after treatment interruption and lack of cumulative toxicity [2]. In this Supplement, evidence for trabectedin is reviewed with the intent of finding answers to some relevant questions regarding its use in clinical practice: Who to treat? When to treat? How to treat? In addition, three clinical case studies provide practical examples of how the characteristics of trabectedin lend themselves to application in diverse settings of advanced soft tissue sarcoma.

Interdisciplinary community oncology clinic intervention to improve pain control for all patients.

63 Background: In rural Yuma, AZ there are too few palliative care specialists to meet the needs of the population. This report presents a unique approach to interdisciplinary care for pain management beginning early in cancer care. To address this need a palliative care specialist collaborated with the entire clinical staff of the community cancer center, including physicians, nurses, social worker, pharmacist, and medical assistants, to initiate a new distress screening tool and develop an interdisciplinary collaborative practice model for pain management. Methods: Data was analyzed from 274 consecutive patients using a review of systems form which was modified 3/2014 to include more information regarding pain, depression/anxiety, communication about illness, spiritual needs, and educational needs, and from 55 patients admitted to home hospice. All clinical staff reviewed the data together and mapped clinical processes. A pain assessment protocol was developed for nurses and medical assistants, who gave the assessment summary to the physician seeing the patient. Further training for nurses taught an algorithm to collaborate with physicians for pain medication orders driven by the assessment findings. Results: About 1/3 of patients had significant concerns about pain. End-of-life data showed that 31% of 55 patients admitted from the cancer center to a local hospice had moderate to severe pain (pain score 4-10) at the time of hospice admission. 88% of these patients’ pain was controlled within 48 hours of admission to home hospice, with pain score 0-3. Data for 274 consecutive clinic patients showed that 30% of patients had concerns about pain, 30% about advanced care planning and communication, and 32% about anxiety, depression, and coping. Of the 162 patients who reported distress, 57% reported distress in 2 or more domains. Conclusions: Hospice data showed that nearly all cancer patients with moderate to severe pain could have pain control within 48 hours. Patients undergoing treatment should be able to have similar results, but were not. Follow-up data collection to assess effect of the collaborative practice model intervention is planned for August 2014.

Interdisciplinary oncology education: A survey of trainees and program directors in the United States.

e17617 Background: High quality cancer treatment requires optimal coordination of multidisciplinary care. Therefore, oncologists must have a strong understanding of collaborating specialties. This ...

Epigenetics in esophageal cancers.

Esophageal cancers are a challenging upper gastrointestinal tract tumor entity for interdisciplinary oncology. For the two main histotypes, namely esophageal squamous cell carcinomas and Barrett's adenocarcinomas, several genetic aberrations have been shown to contribute to carcinogenesis and progression as well as to represent potential novel targets for therapeutic intervention. This is paralleled by growing insight into epigenetic alterations of esophageal cancers. Studies involving the analyses of human tissue specimens predominantly describe altered patterns of miRNA expression, DNA methylation patterns, and histone marks levels. This review provides a critical update on this increasing knowledge of epigenetic alteration in esophageal cancers by specifically focusing on the translational aspects of epigenetic analyses from human tissue specimens.

The multiple oral presentations of multiple myeloma

The purpose of this case series is to show the varied oral presentations of multiple myeloma, illustrating the importance of carefully surveying the oral cavity for suspicious lesions that could be indicative of palpable disease and/or recurrence. The diagnostic criteria and prognostic features for multiple myeloma were also reviewed. This report focuses on five patients with myeloma manifestations involving the oral cavity, in which the oral presentation of multiple myeloma was an early indication of disease relapse. Although the clinical presentation may be variable, the majority of patients will develop lytic bone lesions and less commonly, extramedullary involvement during the course of their disease. The presentation of myeloma can be varied and the oral presentation, although rare, may be the sole manifestation or part of a group of signs of disease progression. Clinical presentations of patients with myelomatous lesions can mimic common dental pathologies, which then, in turn, can lead to delays in diagnosis and treatment. As members of an interdisciplinary oncology team, it is essential to be familiar with oral manifestations of multiple myeloma and proper diagnostic/biopsy techniques in order to avoid misdiagnosis and treatment delays.

Intraoperative radiation therapy opportunities for clinical practice normalization: Data recording and innovative development

BackgroundIntraoperative radiotherapy (IORT) refers to the delivery of a high dose of radiation at the time of surgery. AimTo analyze clinical and research-oriented innovative activities developed in a 17-year period using intraoperative electron-radiation therapy (IOeRT) as a component of treatment in a multidisciplinary approach for cancer management. Materials and methodsFrom 01/1995 to 03/2012 IOeRT procedures were registered in a specific Hospital-based database. Research and developments in imaging and recording for treatment planning implementation are active since 2006. Results1004 patients were treated and 1036 IORT procedures completed. Median age of patients was 61 (range 5 months to 94 years). Gender distribution was male in 54% of cases and female in 46%. Disease status at the time of IORT was 796 (77%) primary and 240 (23%) recurrent. Cancer type distribution included: 62% gastrointestinal, 18% sarcoma, 5% pancreas, 2% paediatric, 3% breast, 77 7% oligotopic recurrences, 2% other. IORT technical characteristics were: Applicator size 5cm 22%, 6cm 21%, 7cm 21%, 8cm 15%, 9cm 6%, 10cm 7% 12cm 5% 15cm 3%. Electron energies: 6MeV 19%, 8MeV 15%, 10MeV 15%, 12MeV 23%, 15MeV 19%, 18MeV 6%, other 3%. Multiple fields: 108 (11%). Dose: 7.5Gy 3%, 10Gy 35%, 12Gy 3%, 12.5Gy 49%, 15Gy 5%, other 5%. ConclusionAn IORT programme developed in an Academic Hospital based on practice-oriented medical decisions is an attractive interdisciplinary oncology initiative proven to be able to generate an intensive clinical activity for cancer patient quality care and a competitive source of scientific patient-oriented research, development and innovation.

Complete remission of extensive cutaneous metastatic melanoma on the scalp under topical mono-immunotherapy with diphenylcyclopropenone

ejd.2013.2066 Auteur(s) : Torsten Hinz1 torsten.hinz@ukb.uni-bonn.de, Lin-Kristin Ehler1, Thomas Bieber1, Monika-H Schmid-Wendtner2 1 Department of Dermatology, Allergy University of Bonn Sigmund-Freud-Str 25 53105 Bonn Germany 2 Interdisciplinary Oncology Center (IOZ) Munich, Munich, Germany The management of disseminated cutaneous metastases without systemic spreading in melanoma patients is challenging and may lead to frustrating results. Various treatment regimens like radiotherapy, isolated [...]

P-198 SPARC and TNF-α contribute significantly to erythroid failure in MDS with 5q deletion and influence considerably the efficacy of lenalidomide

G. Buesche1, A. Giagounidis2, O. Bock3, H. Teoman3, G. Gohring4, B. Schlegelberger4, S. Dieck3, A. Ganser5, A. List6, J.M. Bennett7, C. Aul8, H.H. Kreipe3. 1Department of Pathology, Hannover Medical School, Hannover, Germany; 2Department of Oncology Hematology and Palliative Treatment, Marienhospital, Dusseldorf, Germany; 3Department of Pathology, Hannover Medical School, Hannover, Germany; 4Institute of Cell and Molecular Pathology, Hannover Medical School, Hannover, Germany; 5Department of Hematology Hemostasis Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany; 6Department of Interdisciplinary Oncology, University of South Florida, Tampa FL, USA; 7Cancer Center, University of Rochester, Rochester NY, USA; 8Department 2 Oncology and Hematology, St. Johannes Clinic, Duisburg, Germany

Multiple malignancies in a single patient

We report on an 83-year-old woman who suffered from seven manifestations of at least five different nonmetastasizing malignancies during a period spanning more than three decades. Although suspected, an inherited genetic tumor syndrome could not be detected. This patient history exemplifies the development of interdisciplinary oncology and specifies the success but also the risks of intensified locoregional treatments. In particular, radiation oncologists routinely have to perform a risk-benefit analysis, rendering their work both challenging and fascinating.

Diagnosis and treatment of melanoma. European consensus-based interdisciplinary guideline – Update 2012

Cutaneous melanoma (CM) is potentially the most dangerous form of skin tumour and causes 90% of skin cancer mortality. A unique collaboration of multi-disciplinary experts from the European Dermatology Forum (EDF), the European Association of Dermato-Oncology (EADO) and the European Organization of Research and Treatment of Cancer (EORTC) was formed to make recommendations on CM diagnosis and treatment, based on systematic literature reviews and the experts’ experience. Diagnosis is made clinically and staging is based upon the AJCC system. CMs are excised with one to two centimetre safety margins. Sentinel lymph node dissection (SLND) is routinely offered as a staging procedure in patients with tumours more than 1mm in thickness, although there is as yet no clear survival benefit for this approach. Interferon-α treatment may be offered to patients with stage II and III melanoma as an adjuvant therapy, as this treatment increases at least the disease-free survival (DFS) and less clear the overall survival (OS) time. The treatment is however associated with significant toxicity. In distant metastasis, all options of surgical therapy have to be considered thoroughly. In the absence of surgical options, systemic treatment is indicated. BRAF inhibitors like vemurafenib for BRAF mutated patients as well as the CTLA-4 antibody ipilimumab offer new therapeutic opportunities apart from conventional chemotherapy. Therapeutic decisions in stage IV patients should be primarily made by an interdisciplinary oncology team (‘tumour board’).

The role of chaplains within oncology interdisciplinary teams

The role of chaplains/spiritual care professionals and the importance of addressing spiritual needs within interdisciplinary oncology teams are in need of systematic review and critical appraisal. This review focuses on four key areas: basic concepts of spirituality within the healthcare domain; the relevance of spirituality within cancer care; the role of spiritual care within interdisciplinary cancer teams; and the current status of spiritual care professionals in interdisciplinary cancer teams. Addressing cancer patient's spiritual issues is recognized as a component of comprehensive cancer care. Spirituality has a positive effect on subjective and emotional aspects of cancer patient's health, including quality of life, wellbeing and distress. Failing to address cancer patients spiritual needs impacts patient wellbeing, satisfaction with care, perceived quality of care and is associated with higher healthcare costs. Although a variety of disciplines address spiritual issues, spiritual care professionals are recognized by patients, clinicians, researchers and within best practice guidelines of national health councils as specialists within this domain. Spiritual care professionals are increasingly recognized as integral members of interdisciplinary oncology teams. However, the full integration of spiritual care professionals within the standard practice of oncology interdisciplinary teams is lacking, as spiritual care services continue to be treated as ancillary services within cancer care organizations.

Role of R classification in the interdisciplinary oncology

The R classification describes the tumor status after therapy. Many clinicians and pathologists use the definition in a misunderstood or wrong way, and sometimes, despite many recommendations this definition is not used in the daily routine, at all. The R status means not only the tumorous infiltration of the surgical margins but also includes the lymph node status and the metastases. It represents the whole tumorous process giving the most reliable prognostic marker. It is important for colleagues working in the same therapeutic group that the R status defined by pathologists has to mean the same consequences. This article shows how the R classification can be used in the daily routine and how someone can solve the misunderstandings in different R categories.

Development and implementation of an interdisciplinary oncology program in a community hospital

The development and implementation of an interdisciplinary oncology program in a community hospital are described. Before the program was established, clinical pharmacists responsible for order entry and verification did not have a defined structure and resource to effectively communicate with medical oncologists and nurses on patient care issues and oncology drug information. The practice model did not meet practice needs, departmental safety, quality, or cost-saving goals. An interdisciplinary team was established to determine where current processes and procedures were needed to decrease errors and improve efficiency associated with chemotherapy services. Three stages of practice development were planned, and an interdisciplinary oncology program involving nursing and pharmacy team members and medical oncologists was established. Standardized order forms, various pharmacy collaborative agreements, protocols, improved oncology nursing and pharmacy processes, and established standards in order writing, dispensing, administration, and monitoring were developed. An oncology pharmacist specialist position was requested, and this pharmacist played an essential role in helping the hospital realize significant cost savings and improve the quality of care provided to patients receiving chemotherapy services. Data were collected for 96 chemotherapy orders before program implementation and for 75 orders after program implementation, and a 45% reduction in total error related to chemotherapy drugs was observed (p < 0.0625). The most common cause of errors was missing information, typically an omitted duration or frequency, dose, route, or premedication (63% of all errors documented). The development and implementation of an interdisciplinary oncology program resulted in decreased medication-error rates, expanded pharmacy services, and cost savings.

University of South Florida College of Medicine

University of South Florida College of Medicine

Effects of a computer-supported interactive tailored patient assessment tool on patient care, symptom distress, and patients' need for symptom management support: a randomized clinical trial

To examine the effects of a computer-assisted, interactive tailored patient assessment (ITPA) tool in oncology practice on: documented patient care, symptom distress, and patients' need for symptom management support during treatment and rehabilitation. For this repeated measures clinical trial at a university hospital in Norway, 145 patients starting treatment for leukemia or lymphoma were randomly assigned to either an intervention (n=75) or control group (n=70). Both groups used the ITPA for symptom assessments prior to inpatient and outpatient visits for up to one year. The assessment summary, which displayed patients' self-reported symptoms, problems, and distress in rank-order of the patient's need for support, was provided to physicians and nurses in the intervention group only but not in the control group. Significantly more symptoms were addressed in the intervention group patient charts versus those of the control group. Symptom distress in the intervention group decreased significantly over time in 11 (58%) of 19 symptom/problem categories versus 2 (10%) for the control group. Need for symptom management support over time also decreased significantly more for the intervention group than the control group in 13 (68%) symptom categories. This is the first study to show that an ITPA used in an interdisciplinary oncology practice can significantly improve patient-centered care and patient outcomes, including reduced symptom distress and reduced need for symptom management support.

539 The early integration of palliative care for breast cancer patients in the SOP breast cancer at the Cologne Bonn CIO (Center of interdisciplinary oncology)

539 The early integration of palliative care for breast cancer patients in the SOP breast cancer at the Cologne Bonn CIO (Center of interdisciplinary oncology)

Seltene Kopf-Hals-Tumoren II

Approximately 20% of skin tumors occur in the head and neck region. The therapeutic procedure is laid down in the current interdisciplinary guidelines of the EBM on skin tumors (squamous epithelial carcinoma, melanoma, Merkel cell carcinoma and basal cell carcinoma). For mucous membrane tumors primary R0 surgery is recommended. Approximately 57% of Merkel cell carcinomas occur in the head and neck region. Bilateral selective neck dissection and adjuvant radiation therapy is recommended for every stage. Operative therapy with histological confirmation is the standard procedure for treatment of basal cell carcinoma. The therapeutic procedure for squamous epithelial carcinoma depends on the extent and the histological subtype of the tumor. Complete surgical excision with topographically assigned histopathological control of the incision edges is the first choice treatment as long as this is medically acceptable. Malignant growths in the region of the nasal and paranasal cavities form approximately 4% of head and neck tumors. The general therapeutic principles depend on the possibility of complete resection of the tumor. Postoperative radiation and chemotherapy should be carried out depending on experience with other head and neck tumors in a pT3/4 situation. A dilemma with rare soft tissue sarcomas with many histological subtypes is that at present there is no appropriate classification for this group of tumors. In addition there are no guidelines or evidence with respect to indications for resection of residues after primary chemotherapy of pediatric rhabdomyosarcoma-like tumors. It is therefore recommended that these tumors should be treated in interdisciplinary oncology centers. Small cell carcinomas are highly malignant and rapidly form metastases. The therapy of small cell carcinomas in the head and neck region depend on the localization, tumor spread, lymph node status and the presence of distant metastases.

The Sound and the Fury: Financial Conflicts of Interest in Oncology

Benjamin Djulbegovic, H. Lee Moffitt Cancer Center & Research Institute and the Department of Interdisciplinary Oncology, University of South Florida, Tampa, FL Cara Angelotta and Kjersti E. Knox, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL Charles L. Bennett, Division of Hematology/Oncology, Department of Medicine, Northwestern University University Feinberg School of Medicine; Robert H. Lurie Comprehensive Cancer Center; Jesse Brown Veterans Affairs Medical Center; and the Veterans Affairs Center for Management of Complex Chronic Care, Chicago, IL