Oncology Outreach Research Articles

The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach.

Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies. We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and >60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and >60-day adjuvant delay. We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25). Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.

Characterizing the Traveling Oncology Workforce and Its Influence on Patient Travel Burden: A Claims-Based Approach.

Oncology outreach is a common strategy for extending cancer care to rural patients. However, a nationwide characterization of the traveling workforce that enables this outreach is lacking, and the extent to which outreach reduces travel burden for rural patients is unknown. This cross-sectional study analyzed a rural (nonurban) subset of a 100% fee-for-service sample of 355,139 Medicare beneficiaries with incident breast, colorectal, and lung cancers. Surgical, medical, and radiation oncologists were linked to patients using Part B claims, and traveling oncologists were identified by observing hospital service area (HSA) transition patterns. We defined oncology outreach as the provision of cancer care by a traveling oncologist outside of their primary HSA. We used hierarchical gamma regression models to examine the separate associations between patient receipt of oncology outreach and one-way patient travel times to chemotherapy, radiotherapy, and surgery. On average, 9,935 of 39,960 oncologists conducted annual outreach, where 57.8% traveled with low frequency (0-1 outreach visits/mo), 21.1% with medium frequency (1-3 outreach visits/mo), and 21.1% with high frequency (>3 outreach visits/mo). Oncologists provided surgery, radiotherapy, and chemotherapy to 51,715, 27,120, and 5,874 rural beneficiaries, respectively, of whom 2.5%, 6.9%, and 3.6% received oncology outreach. Rural patients who received oncology outreach traveled 16% (95% CI, 11 to 21) and 11% (95% CI, 9 to 13) less minutes to chemotherapy and radiotherapy than those who did not receive oncology outreach, corresponding to expected one-way savings of 15.9 (95% CI, 15.5 to 16.4) and 11.9 (95% CI, 11.7 to 12.2) minutes, respectively. Our study introduces a novel claims-based approach for tracking the nationwide traveling oncology workforce and supports oncology outreach as an effective means for improving rural access to cancer care.

Characterization of the nationwide traveling oncology workforce and assessment of its influence on patient travel burden for access to cancer care: A claims-based approach.

147 Background: Oncology outreach is a common strategy for extending cancer care to rural patient populations. Several rural states consistently rely on oncology outreach arrangements and maintain specialized cancer registries to monitor physician travel. However, the nationwide characterization of the traveling oncology workforce is currently lacking, and the extent to which their outreach provides access and minimizes travel burden for rural patients remains unclear. Methods: A 100% fee-for-service sample of Medicare beneficiaries with incident breast, colorectal, and lung cancer from 2016-2018 was used in this cross-sectional study. Oncologists were linked to the patient cohort using Part B professional claims. Traveling oncologists were identified annually by observing hospital service area (HSA) transition patterns and partitioned into travel frequency bins. Encounters associated with a traveling oncologist were considered as “outreach” if they occurred outside of the oncologist’s primary HSA. Hierarchical models were used to examine the separate associations between outreach encounters and log-transformed travel time to first chemotherapy, radiotherapy, and surgery for rural patients. Results: On average, 4,333 of 30,069 oncologists engaged in annual outreach. Of this workforce, 49.5% traveled across HSA borders 1-3 times per year (low), 26.9% 4-12 times per year (medium), and 23.6% >12 times per year (high). The low travel workforce consisted of 52.3% surgeons, 34.2% medical oncologists, and 13.5% radiation oncologists, whereas the high travel workforce consisted of 15.0% surgeons, 52.0% medical oncologists, and 33.0% radiation oncologists. Collectively, traveling oncologists administered 6,677 counts of first radiotherapy, 4,681 counts of first surgery, and 1,623 counts of first chemotherapy for rural patients, of which 22.5%, 16.8%, and 15.0% were completed at outreach locations. In adjusted models, oncology outreach was associated with a 14% reduction (95% CI: 0.82-0.89) in travel time to first radiotherapy and a 13% reduction (95% CI: 0.79-0.95) in travel time to first chemotherapy for rural patients. Conclusions: Our study uses a novel claims-based approach for characterizing the nationwide traveling oncology workforce and supports oncology outreach as an effective means for improving rural access to care. These results provide conservative estimates of the influence of oncology outreach on rural access to care, as our analysis is limited to Medicare beneficiaries and does not consider patients who bypass available outreach services.

Implementation of the Avera/Sema4 oncology and analytics protocol (ASAP).

TPS6605 Background: Precision medicine represents a new era in oncology and population health. Comprehensive molecular profiling and hereditary cancer testing are increasingly important in the routine management of many malignancies, yet may not be widely adopted in many practices and leads to patients not consistently receiving care recommended by current national guidelines such as NCCN and ASCO. In addition, available targeted DNA sequencing panels may be limited to only defined drivers and lack detection in precancerous conditions. Whole exome sequencing (WES) combined with whole transcriptome sequencing (WTS) represent an expanded testing approach that identifies additional genetic changes beyond standard commercial panel tests. Current evidence suggests that WES/WTS is feasible to carry out in routine clinical practice, with improved detection of somatic alterations compared to smaller panels, and the promise to enhance access to targeted therapies and clinical trials. The primary purpose of the ASAP study is to understand the breadth of molecular characteristics present in participants cared for in a large integrated community-based health system, by linking comprehensive molecular profiles with clinical data extracted and curated from the electronic medical record. Methods: Avera Health is a large, Midwestern, predominantly rural vertically integrated health system with six regional cancer centers and over 40 oncology outreach sites across South Dakota and surrounding states. The ASAP study was initiated in November 2021 in GYN and as of February, the study is enrolling in the Otolaryngology clinic and expected to open in medical oncology and hematology in March/April 2022. The study will expand to include additional cancer centers outside of Sioux Falls later in 2022 and is anticipated to be open for accrual for 5 years. Enrolled participants are expected to receive WES/WTS and proteomics on their primary tumor and metastatic sites were feasible as well as hereditary testing, pharmacogenomics (PGx) and microbiome profiling. Liquid biopsies will be performed every 3 months while on treatment or when treatment is changed, in follow up to coincide with scheduled radiographic testing, and as part of annual routine surveillance. For participants not diagnosed with cancer, each participant will receive hereditary testing, PGx, microbiome, and a liquid biopsy at least annually. Participants also consent to sharing their electronic health information. Future stages of this work will employ natural language processing (NLP) methods to develop algorithms to help identify opportunities to improve patient outcomes. Projected enrollment is 1000 participants in year 1, 1500 participants in year 2, and up to 3000 annually thereafter. Approximately 50 patients have consented as of February 1 2022. Clinical trial information: NCT05142033.

Parents’ Perceptions of the Psychosocial Impact of a Nurse-Led Paediatric Haematology Oncology Outreach Service for Children in Their Own Homes

Parents’ Perceptions of the Psychosocial Impact of a Nurse-Led Paediatric Haematology Oncology Outreach Service for Children in Their Own Homes

Framework for Improving Governance and Quality of Rural Oncology Outreach Services.

Rural outreach is a common method for delivering oncology services closer to rural residents; however, there is no clear service framework for supporting its quality and governance. This work aimed to develop an agreed framework for improving the governance and quality of a rural oncology outreach service. A Six Sigma and participatory action approach was used. Key clinicians and managers identified project goals and scope, participated in several rounds of interviews and medical record audits, and discussed findings to reach consensus about a framework for quality outreach service delivery from one regional cancer center supporting two rural hospital sites (5-chair nurse-led oncology units). Themes included strong investment by stakeholders in maintaining the outreach service for its importance for rural populations. The referral, treatment, and clinical governance processes were implicitly understood between stakeholders but not well documented. Medical record audits of treated patients identified important gaps in clinical information at rural sites. Through reflection and discussion, consensus was reached about a framework for quality service delivery. The participatory action planning cycle involving sites in regular discussions fostered information sharing, strong engagement, and uptake of the final framework. The framework was applied to a memorandum of understanding for planning, governance, and outcomes monitoring and provides a basis for developing new and benchmarking existing oncology outreach services.

Ophthalmic Oncology Outreach: Harnessing the Power of Social Media.

IntroductionSocial media refers to a collection of internet-based applications that facilitate content creation and sharing between individuals and groups. What differentiates social media from traditional media is that the content is user generated as opposed to centrally generated, such as newspap

Pediatric oncology outreach clinic: First step to care

Pediatric oncology outreach clinic: First step to care

Do radiation oncology outreach clinics affect the use of radiotherapy?

Background and purposeThe scope and effect of radiation oncology (RO) outreach activities within centralized radiotherapy (RT) systems is poorly defined. The purpose of this study was to describe the outreach activities of Ontario’s regional cancer centres, and to explore the relationship between radiation oncology (RO) outreach clinics and rates of radiotherapy (RT) utilization at hospitals without RT on site (HWOS-RT). Materials and methodsOntario RO centres’ outreach activities were identified by semi-structured interview. A multivariate analysis determined the association between on-site RT facilities, or presence of RO clinic at HWOS-RT, and RT utilization within one year of diagnosis (RT1Y), for all patients diagnosed with cancer in Ontario in 2011–2012. ResultsRO outreach varied widely by region. Of the largest 58 diagnosing hospitals, 14 had RT on-site, 19 had no RT but RO outreach clinic(s) and 25 had no RT or RO clinic. RT was used more frequently for patients diagnosed at hospitals with on-site RT compared to those at HWOS-RT (RT1Y = 35% vs. 29%, RR = 1.32 [95% CI 1.27–1.38]). For HWOS-RT, RT was used more frequently if there was an RO clinic (RT1Y = 31% vs. 29%, RR = 1.06 [95% CI 1.02–1.10]). ConclusionsRO outreach clinics were associated with a small but significant increase in RT utilization. There is opportunity to improve access to RT by optimizing the effectiveness of RO outreach.

Development and validation of an individualized survivorship care plan (ISCP) for women with endometrial cancer during the transition of the end of active treatment to the cancer survivorship.

The after-treatment phase is a distinct phase that is still neglected in the oncological continuum of care. It is the transition between two phases in the care trajectory-treatment and survivorship-that gives rise to many challenges for survivors, care providers and the healthcare system alike. Aiming to facilitate the transition between the end of active treatment and the cancer survivorship phases, we pursued two objectives: 1) Develop an individualized follow-up care plan (IFCP) based on both the literature and the perspective of WEC, healthcare professionals involved with the target clientele and oncology outreach managers, and 2) Have this IFCP validated by an interdisciplinary team. For the first objective, WEC-related needs at the end of active treatment (immediate end, three months and six months), as well as the perceptions of health professionals and oncology outreach managers were gathered by interview and group discussion on the benefit of an IFCP, its content and desired format. A content analysis of the interview data was performed using the Miles and Huberman approach (2003). For the second objective, an iterative consultation process with health professionals allowed for validation by consensus. These two objectives are the first qualitative phase of a mixed-methods sequential exploratory design that will make the development of an IFCP possible. In the second phase, we conducted a feasibility study of the implementation of the IFCP during the end of active treatment transition to cancer survivorship transition. This will be the subject of a second article. The interviews (n=47) revealed WECs' lack of preparation for the transition from the end of active treatment to the cancer survivorship. The following needs were specified: information (80%), emotional support, particularly to overcome their fear of recurrence (75%), the management of physical symptoms (45%), and support for adapting to change (45%). The data gathered from healthcare professionals and outreach managers support the utility of an IFCP in meeting these needs. The iterative validation process by the interdisciplinary team made consensus on the format and content possible. The final version of the IFCP is seen as a tool for information and communication in the survivorship phase. Some obstacles to its transfer to clinical practice are reported. This study presents the entire process that led to the development of an IFCP that integrates both the needs of endometrial cancer survivors and the opinions of healthcare professionals and the oncology outreach managers organizing this care. Indications on how the IFCP could be implemented within this organization are also formulated.

The Impact of Radiation Oncology Outreach Activities on the Utilization of Radiation Therapy

The Impact of Radiation Oncology Outreach Activities on the Utilization of Radiation Therapy

Abstract A27: Addressing cancer disparities through use of a novel community-based oncology program

Abstract Purpose: This study evaluates a novel approach to address cancer disparities by incorporating a comprehensive clinical oncology outreach facility within the context of a primary care setting in Boston. We hypothesize that this unique oncology program will improve access to care for underserved populations, and may serve as a model system for other health disparity initiatives. Methods: The Whittier Street Health Clinic (WSHC) is a Federally Qualified Health Center, that provides comprehensive primary health care and support services for vulnerable communities. In 2012, the Dana-Farber Cancer Institute's Cancer Care Equity Program partnered with WSHC to develop an initiative aimed at streamlining cancer care and services to address cancer disparities in the underserved population Whittier serves. A retrospective chart review was performed to evaluate the impact of the program on patient outcomes, specifically timeliness of care/time to resolution and time to initiation of treatment. We have identified a cohort of patients (N = 50) who have been provided cancer-related services through this initiative from December 2012 to July 2013. All patients were ≥ 18 years old. Timeliness of care/time to resolution is defined as the amount of time elapsed between patient presentation until their reason for visit to the oncology facility has been resolved. Time to initiation of treatment was measured only for patients with newly diagnosed cancer; it is defined as the amount of time elapsed between patient presentation at the oncology facility to the start of treatment. T-tests and one-way ANOVA were carried out to determine if there were any statistically significant differences in the timeliness of care/time to resolution for different demographic subgroups. Results: In this cohort, 48% of patients self-identify as Black/African-American, 48% Hispanic, and 2% other. Forty-eight percent are men; 52% are women. Although the majority of patients are English-speaking (58%), a large proportion (38%) speaks Spanish. The average time to resolution for subjects was 29 days and 19 days for imaging and clinical evaluation respectively. This presents an overall reduction compared to baseline data (N = 38) from WSHC, which had an average of 67.7 days for time to resolution, which was mainly diagnostic resolution. A similar trend was also observed in time to initiation of treatment (52.5 days vs. baseline of 67.6 days). There is no statistically significant difference in the timeliness of care/time to resolution between different demographic subgroups served by the oncology program (e.g. English speakers vs. Spanish speakers, p = 0.336). Conclusion: The data supports our hypothesis that employing the use of a comprehensive oncology program within the context of an established community center improves access to specialized oncologic care for vulnerable populations. This unique model improves timeliness of care by reducing time to diagnostic resolution, which may ultimately help improve cancer outcomes. Citation Format: Ann Oluloro, Ann Oluloro, Karen M. Winkfield, Ludmila Svoboda, Laura Tesler Waldman, Christopher S. Lathan. Addressing cancer disparities through use of a novel community-based oncology program. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A27. doi:10.1158/1538-7755.DISP13-A27

Trends in Medical Oncology Outreach Clinics in Rural Areas

To examine the long-term trends in medical oncology outreach in Iowa, a state with a high proportion of rural residents, and to assess the involvement of the 2011 Iowa oncology workforce in visiting consultant clinics using a unique data source. Outreach locations and clinic frequencies are tracked annually in the Visiting Medical Consultant Database (Carver College of Medicine) along with the physicians' primary practice locations. Growth in the number of cities served and number of clinic days from 1989 to 2011 was analyzed using joinpoint analysis. Data from 2011 were used to estimate the trip length for participating oncologists. The number of rural cities served by medical oncology outreach increased significantly between 1989 and 1996. Clinic days grew significantly in two periods: 1989 to 1998 and 2003 to 2005. In 2011, more than 2,100 clinic days were provided in 66 sites (95% of clinic days in rural areas). Almost half of all Iowa-based oncologists regularly participate in outreach. Oncologists staffing visiting consultant clinics in Iowa drive an estimated 21,000 miles per month. For more than 20 years, visiting medical oncologists have brought cancer care to rural patients in Iowa. Access to cancer care in rural Iowa (ie, clinic days) increased significantly in the post-Medicare Modernization Act period (after 2005). High participation rates and travel burdens may influence oncologist training and retention strategies. Because the Affordable Care Act seeks to expand access for vulnerable populations (eg, rural elderly), it is critical to better understand the existing system of rural cancer care delivery.

Evaluation of Place of Care at Time of Death at One United Kingdom Principal Treatment Centre for Children with Cancer

We review the success of a specialist Children and Young People's Oncology Outreach and Symptom Care Nursing Service (CYPOONS) in determining place of death for children with cancer treated at one United Kingdom Principal Treatment Centre (PTC). The service includes proactive provision of individualised symptom guidelines, blood product support and an emergency box in the home and coordination of local services.

Evaluating a palliative care services: our experience of the role of “a professional users” survey” as an evaluating tool

Evaluating our paediatric palliative oncology outreach service to improve clinical effectiveness and facilitate changes, in line with standards set, is challenging. The authors utilised the tool of a “professional users9 survey”. Aims To compare our paediatric oncology palliative care practice against the standards set by the “Improving outcomes in children with cancer, NICE, 2005” (IOG). Methods The authors devised a professional users9 survey. It consisted of thirty-eight questions directly taken from the standards stated in the paediatric palliative care section of the IOG. The questionnaire was divided into sections containing “yes/no” answers with comment boxes at the end of each section. The sections were: information and communication, end of life care, outreach visits, general practitioner (GP) meetings, symptom support and advice, out of hour9s advice, symptom boxes, voluntary sector, allied health professionals, education and training and demographics regarding the respondent (including professional role and time in post). The postal questionnaire and cover letter were sent out to 24 community and paediatric oncology shared care hospitals (POSCU) teams (including shared care consultant, ward link nurses or clinical nurse specialist) and four children9s hospices. The anonymous questionnaires were returned to our centre9s audit department (an independent source) for collation of the results. Results Our percentage response rate was: 50% hospice, 48% community nursing team and 43% POCSU (35% consultants, 20% nurses). The overall POSCU response calculation was based on whether at least one member of the team replied from a specific centre. Overall, the response was very positive. There were areas identified as needing improvement including communication to POSCUs, in particular providing regular written updates, and regular local training days including education around reasons for GP involvement. Conclusion There are challenges in evaluating a service through a professional users9 survey, including respondent apathy. Though when engaged, the professional users of a service provide valuable feedback into how to improve and enhance services effectively. This also enables them to feel they have buy-in into the changes that can be made as a result of the survey. From our view, it enables us to objectively direct improvements in our service.

Factors to consider when starting up a videoconference medical oncology outreach clinic

Cancer patients from small regional and rural towns often travel long distances for short consultations with specialists, for investigations and for chemotherapy. Low numbers of patients in each location mean specialist visits to the towns are not an effective method of service delivery, and many specialists are reluctant to supervise chemotherapy via telephone. Medical oncologists at The Townsville Hospital have demonstrated that using videoconferencing for their clinics can be a successful alternative. They have been conducting clinics and supervising chemotherapy effectively for Mt Isa cancer patients using this technology for over three years.

Place and Provision of Palliative Care for Children With Progressive Cancer: A Study by the Paediatric Oncology Nurses’ Forum/United Kingdom Children's Cancer Study Group Palliative Care Working Group

The purpose of this study was to describe and show effectiveness of the outreach team model of palliative care (PC) in allowing home death for children with incurable cancer. Over 7 months, 185 children from 22 United Kingdom oncology centers were recruited to a prospective questionnaire survey. One hundred sixty-four children from 22 centers died (median age, 8.7 years; 88 boys, 76 girls). One hundred twenty-six families completed two or more questionnaires. One hundred twenty (77%) of 155 with complete data died at home. Preference for home death was recorded in 90 (68%) of 164 and 132 (80%) 164 at study entry and last month of life, respectively. Death occurred in preferred place for 84 (80%) of 105 with recorded preference at entry. Forty-one (25%) of 164 and 68 (41.5%) of 164 needed no outpatient or inpatient hospital visits, respectively. A named individual provided on-call PC advice by phone or home visit in 22 (100%) and 18 (82%) of 22 oncology centers, respectively. As PC progressed, involvement of oncologist and social worker appeared less, whereas pediatric oncology outreach nurse specialists (POONSs) remained prominent. Preference for home death expressed by families in our study is similar to others, but the proportion of children actually able to die there is higher. Home death is facilitated by this model. Key components are POONSs, pediatric palliative and/or oncology specialist, and general practitioner. Professional roles change during PC and after death. An ongoing role for the oncology team in bereavement support is highlighted.

Survey of psychosocial support provided by UK paediatric oncology centres

Aim: To obtain a comprehensive overview of current patterns of psychosocial support provided by National Health Service (NHS) paediatric oncology treatment centres across the UK. Methods: A postal questionnaire was...

Oncology outreach: history in the making

Elspeth Brewis describes the background to the first paediatric oncology outreach nursing service established in Glasgow in 1978

Use of a Depression Screening Tool and a Fluoxetine-Based Algorithm to Improve the Recognition and Treatment of Depression in Cancer Patients: A Demonstration Project

Helping oncologists to identify and treat depression is an important step in improving the overall care of people with cancer. In previous work performed in our community-based, ambulatory oncology outreach network, we validated a depression screening tool, put into place depression screening programs, and taught oncologists how to follow up on screening with brief, reliable clinical interviews. Subsequently, we provided these oncologists with a fluoxetine-based antidepressant algorithm to follow for the treatment of their depressed patients. In this article, we report on the initial experience identifying and treating 35 ambulatory oncology patients who were screened with the Zung Self-rating Depression Scale (ZSDS). Structured follow-up interviews by their oncologist determined whether the patients qualified for a diagnosis of a major depressive episode. These patients then received 1 of 4 treatments based on the algorithm (no treatment, fluoxetine alone, fluoxetine plus bedtime doxepin, or fluoxetine plus methylphenidate). Patients were matched by their oncologist to a prototype patient for each treatment arm based on their symptomatic presentation (i.e., patients requiring a side effect minimization approach were to be placed on fluoxetine alone; patients who had significant insomnia, weight loss, or neuropathic pain were placed on the fluoxetine plus doxepin regimen; those with prominent fatigue were to receive fluoxetine plus methylphenidate). Patients were followed weekly for one month, and then every two weeks for two more months, with telephone assessments of their depression, associated symptoms and overall quality of life. Results suggested that oncologists most often chose the simplest regimen (fluoxetine alone) but that patients uniformly benefited in terms of improved mood and overall quality of life throughout the 12 weeks of follow-up. Our initial experience suggests that oncologists can be empowered to recognize and treat depression in their patients with a screen-and-intervene approach. Such an approach may benefit patients, and, if kept simple, can be incorporated into day-to-day care of people with cancer.