Oncology Practice Research Articles

Implementation of a palliative care service in a tertiary hospital in a developing country: Methods, strategies and results.

e24056 Background: In Rio de Janeiro, only 11 palliative care facilities exist, creating challenges in meeting the complex needs of patients with metastatic cancer. Our study aims to implement a palliative care service within an existing oncology practice. This approach holds promise as a model that could guide similar practices in low- and middle-income countries, offering a blueprint for the implementation of palliative care services on a broader scale. Methods: This descriptive study spans from February to December 2023, involving the monitoring of 176 patients. Eligible patients met criteria such as a FAST scale for dementia syndrome ≥ 7A, stage IV disease, ranking 5 stroke, terminal organic failure, uncontrolled symptoms, or requiring end-of-life care. The PC team, denoted as “Continued Care”, comprises a medical leader, 3 routine doctors, and 1 nurse. Activities undertaken by the team encompass consults requested by internal medicine and intensive care unit (ICU) teams, outpatient care, continuous education, and daily monitoring of patients with advance care plan (ACP). Results: Among 176 patients initially enrolled, outcomes were completed for 171 patients. Remarkably, 80% of those receiving PC assistance had an ACP in place, with 78% opting for exclusive non-invasive support. The overall death rate was 38%. Notably, among patients enrolled in the PC program, the ICU death rate was 31%. Conclusions: Institutional PC policies associated with the integration of a dedicated team into the hospital's routine, and investments in disseminating knowledge about irreversible illness processes and comfort strategies, emerge as a pivotal component in establishing a comprehensive and integrated model of PC services. This approach appears to surpass the effectiveness of traditional consult or sectorized model, emphasizing the importance of an institutionalized and holistic framework for delivering quality PC.

Implementing large language model-based artificial intelligence (AI) technology in proposing effective treatment plans in patients with cancer.

e13660 Background: Language Learning Models (LLM), are programs that can respond to queries without previous exposure to the input. This is because the programs are actually generative mathematical models trained on hundreds of terabytes of textual data. The output is thus a statistical assessment of the corpus of human generated text likely indicating the correct answer. ChatGPT is an example of an LLM that can understand questions and synthesize responses based on probability. However Chat GPT’s potential to accurately assist physicians with a diagnosis, remains yet to be determined. The goal of this study is to elucidate AI’s potential in proposing both feasible and accurate treatment plans specifically for patients with cancer. Methods: Fifty patients at a medical oncology practice were recruited for this study. For each patient, the physician’s shorthand notes were recorded and organized. ChatGPT was then asked to come up with a potential treatment plan using these notes according to a predetermined set workflow for each individual. The responses were then reviewed by a medical oncologist for accuracy and feasibility via a qualtrics survey. Results: ChatGPT correctly proposed a treatment plan in agreement with the physician for a total of 18 cancer patients allowing for the agreement rate to be 36%. For the rest of the 32 patients, the physician disagreed with the proposed ChatGPT treatment plan on the basis of lack of personalization, inhibitive cost, incorrect recommendation, and greater alternative options. Thirteen patients fell into the ‘Lack of Personalization in Treatment' category, twelve in the ‘Incorrect Recommendation’ category, four in ‘Inhibitive Cost' category, and three in the ‘Greater Alternative Options’ category. Most patients however fell in the category of personalization, suggesting ChatGPT’s unfamiliarity with the subject of generating personal treatment plans. Conclusions: In the current study, ChatGPT was expected to create a treatment plan with only the clinician’s abridged shorthand notes and without any familiarity with the physician’s personal preferences for treatment. This knowledge gap can account for an agreement rate less than 50%. Despite its flaws, ChatGPT was, however, able to generate an adjusted and corrected version of the treatment plan when prompted further outside the set workflow. This highlights the invaluable role of clinical experience in synthesizing an accurate treatment plan. With its encroachment into the medical field, ChatGPT has shown potential in proposing feasible and accurate treatment plans, especially in the oncology clinical setting. Despite the low agreement rate obtained from this study, ChatGPT has shown promise in developing an agreeable treatment plan with the oversight of the attending physician.

Characterization of cancer clinical trials in the community setting.

e13506 Background: Extending clinical trials to community oncology sites is an imperative to meet accrual goals, ensure generalizable results, and facilitate optimal and equitable clinical care. The types of trials attractive to and successful in the community, however, are likely different from those run primarily at academic centers. We analyzed the characteristics of clinical trials open at a network of community oncology practices across the United States in the last 2 years, in order to inform both sponsors and sites about the studies most well-suited for a community setting. Methods: We analyzed characteristics from every clinical trial entered in OncoTrials, a clinical trial screening and tracking tool utilized exclusively by US community oncology practices, between 9/1/2021 through 10/09/2023 via knowledge of the trial NCT number and data available through API from clinicaltrials.gov. Descriptive statistics, including median and range for continuous variables and percentages for categorical variables are reported. Results: 1,310 clinical trials were open across 64 community oncology practices. Sponsors were classified as 80% industry (n=1,054), 15% NIH (n=195), 1% network (n=13) and 5% other (n=48). 93% of studies were interventional, 5% observational, 1% registry and 1% expanded access. Types of interventional studies (n=1,215) and the number of sites that ran them are shown (Table). The median target enrollment across all studies was 235 patients. Individual trials were open at a median of 2 community practices in our cohort (range 1-22 practices); 521 clinical trials (40%) were open at only one practice and 34 trials (2.6%) were open at more than 10 practices. The mean number of unique trials open at a practice during our 2 year observation period was 54 (median 35, range 1-264). Among these trials, the most commonly associated tumor types were lung (15%), pan-solid tumors (14%), breast (11%), lymphoma (6%), colorectal (6%), prostate (5%), gynecologic (4%), bladder (4%), head and neck (4%) and melanoma (4%). Conclusions: Community oncology practices supported a robust portfolio of clinical trials, most commonly focused on treatment of solid tumors. The vast majority were interventional (phase 2-3) and industry-sponsored. Half of sites ran Phase I trials, and Phase IV trials were uncommon but had broad participation across sites. Notably, a large proportion of studies were only open at one single site in a cohort of 64 community oncology practices. This highlights the opportunity for sponsors to leverage networks, consortia, and further research to ensure that appropriate studies are accessible among a broader range of community research sites. [Table: see text]

Impact of preparation and execution of strategy to mitigate the platinum shortage within a network of community oncology practices.

e13572 Background: The US Oncology Network (USON) is made up of over 600 sites of care and treats 1,400,000 patients annually. Drug shortages have a massive impact on patient outcomes, particularly with limited source oncology medications. Proactive mitigation strategies by the national USON Pharmacy & Therapeutics (P&T) committee are examined to assess impact on cisplatin and carboplatin (cis/carbo) shortages, where a phased approach extended supply for patients. Methods: P&T began implementing gradual reductions in cis/carbo allocations in mid-April 2023. This included stewardship to reserve use in patients with limited alternatives, dose rounding, reducing dose/cycle, and extending cycle interval, when clinically appropriate. As supply depletion became imminent, P&T implemented a novel drug ordering process that restricted cis/carbo use criteria to curative intent without alternative treatment options, requiring case-by-case approval. Comprehensive clinical guidance was developed to provide recommendations for alternative therapies. Alternative regimen templates were built into the centrally managed EHR. To evaluate the impact, drug utilization patterns were tracked during the 6-month shortage (April - September 2023) and compared to historical data. Results: Pronounced impacts were seen during acute supply constraints: cisplatin administrations (admins) and mg decreased to 53% and 48% of baseline, carboplatin admins and mg decreased to 84% and 78%. Compared to the prior 6 months, patients receiving cis/carbo was similar pre-shortage (15,368) vs. during (15,296).Mitigation strategies resulted in preservation of cis/carbo admins for diseases with limited alternatives (NSCLC, head & neck, ovarian/uterine); other cancers with alternatives had a decrease in admins (see table). Dose conservation guidance led to a decrease in average mg administered by 5.1% for cisplatin (72.2 vs. 68.5), and 6.2% for carboplatin (385.5 vs. 361.7). New admins of oxaliplatin increased by 11% (4,230 vs 4,714), primarily in GI malignancies. Conclusions: The rigors of stewardship with a phased approach allowed USON to sustain new patients while conserving cis/carbo for those with limited alternatives. Frequent communication about supply status and conservation guidance was critical for transition to alternative treatment strategies. This experience tested USON organizational readiness for future shortages. [Table: see text]

Impact of the integration of remote clinical oncology pharmacists into routine precision medicine workflows on biomarker testing rates within The US Oncology Network community-based practices.

e13813 Background: The US Oncology Network implemented a centralized, remote clinical oncology pharmacist review program (ClinReview) into select community-based practices. Initially, pharmacists were integrated into a precision medicine workflow process to increase biomarker testing rates among patients receiving adjuvant treatment for non-small cell lung cancer, with recommendations achieving a 100% acceptance rate. Following this success, metastatic prostate cancer patients were incorporated into the established workflow, following updated guideline recommendations for both germline and somatic testing and the 2023 approvals of PARP inhibitors in the first-line treatment setting. With previously reported testing rates only reaching 60%, we sought to evaluate the impact of the pharmacist integration into the precision medicine workflow on biomarker testing in metastatic prostate patients. Methods: Over a 4-month period, ClinReview remotely identified patients with metastatic prostate cancer during normal order review. The EMR was reviewed to assess germline and somatic testing status. If testing was not ordered, the pharmacist sent a recommendation to the treating provider. Initial testing rates for germline and somatic testing, BRCA+ status and provider acceptance rates for testing recommendations were collected. Additional data was collected utilizing a de-identified database. While additional data collection is ongoing, descriptive statistics were utilized to analyze data and the impact of the pharmacists’ interventions. Results: Across 9 practices, 142 patients were initiated on treatment for metastatic prostate cancer. At the time of initial assessment, germline and somatic testing was not ordered in 50% and 37% of patients, respectively. Pharmacists recommended additional testing in 61 patients (43%) with a 73% provider acceptance rate. Findings showed equitable testing rates across racial demographics. Pharmacist workflow integration enhanced combined germline and somatic testing rates, demonstrating an improvement from a baseline of 57% up to 77% currently. Conclusions: Community oncology practices seek to provide high-value care, including offering the most current evidence-based precision medicine testing. These findings highlight the continued need for improved somatic and germline testing in metastatic prostate cancer. However, the implemented precision medicine pharmacist workflow demonstrates the positive impact a clinical pharmacist can have on both testing rates and the potential to improve therapeutic offerings within this growing treatment space. [Table: see text]

The role of shared decision-making in cancer pain management: Insights from a systematic review.

e24078 Background: Effective pain management in cancer care is crucial for patient quality of life. Shared decision-making (SDM) interventions are increasingly recognized for their potential to improve patient outcomes by facilitating patient engagement in care decisions. This systematic review synthesizes evidence on the impact of SDM interventions in cancer pain management. Methods: This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted a comprehensive search across multiple databases, including PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, and the Cochrane Library. The search also extended to grey literature sources such as conference proceedings, dissertations, and unpublished reports to ensure a thorough coverage of the subject matter. Our search strategy employed a combination of MeSH terms and keywords related to 'decision making,' 'patient participation,' 'pain management,' and 'cancer.' This strategy was tailored to each database's unique syntax and search operators. Results: Ten studies, including six pilot and feasibility studies and four randomized controlled trials (RCTs) and Preintervention-Postintervention studies, were systematically reviewed. The interventions implemented diverse SDM strategies ranging from digital tools and personalized education to clinical decision support systems, targeting key aspects of pain management and patient-provider communication. Frequent intervention components included patient-reported outcome dashboards, symptom management support, and educational resources for pain management. The Tailored Education and Coaching (TEC) intervention notably increased pain-specific patient communication by 31%, while the PAINRelieveIt intervention did not significantly impact analgesic adherence but effectively reduced pain misconceptions among caregivers. Some interventions, like the Carevive CPS, showed high patient involvement in SDM (94.1%) and compliance with quality oncology practice initiative metrics (98%). However, the effectiveness of these interventions varied, with some showing no significant impact on primary pain outcomes. The variability in measured outcomes such as pain intensity, analgesic adherence, and patient satisfaction indicates a context-dependent effectiveness of SDM interventions, highlighting the importance of personalized approaches and the role of implementation strategies in influencing patient engagement and intervention success. Conclusions: SDM interventions in cancer pain management are diverse in structure and impact. Some interventions show promise in improving communication and reducing misconceptions, but their direct effect on pain outcomes varies.

PENTAGON (Predicting Clinical Trials in Gynecologic Oncology): A retrospective study assessing study design factors that affect enrollment in gynecologic cancer trials.

e13647 Background: Obstacles to attaining a diverse clinical trial population contribute to poor representation in medicine, increasing health disparities by limiting generalizability and applicability of findings. Our objective is to evaluate trial enrollment trends according to patient and trial demographics for those who have sought care at our multi-center, mixed-setting Gynecologic Oncology practice. Additionally, we aim to determine specific trial criteria that promote or impede enrollment for patients and physicians. Methods: An IRB-approved, retrospective cohort study evaluating all patients who screened positive for a clinical trial through the Gyn Onc practice’s manual screening process was performed. Screening events were new neoplasms, recurrences or progressions, and changes in treatment. Data was collected from July 2022 to December 2023. Demographic information, trials for which each patient was considered, trials patients enrolled on, and trial characteristics were recorded. Results: After adjustment, there were no significant differences between patient factors (age, marital status, race, ethnicity, and number of screening events) and enrollment status. Of trials available, 9% require biopsy and 94.7% are in person. Most studies are interventional (78.9%) and pharmaceutical trials (73.7%). There was a drastic unadjusted estimated increase in enrollment for Medicaid patients compared to other insurances (55.2% vs 32%, p=.031). There was also an increase in enrollment for cervical cancer patients (18.4%, p=.106) compared to other cancer sites (56.5% vs 32.8%, p=.036). There was a positive relationship between distance traveled to the treatment site and clinical trial enrollment. Patients who lived within 20 miles of the clinical trial site had an enrollment percentage of 30.1% (n=93), compared to 46.55% enrollment for those who lived further (n=58). There was a significant increase in enrollment likelihood without an exclusion criterion of previous history of other cancer (50% vs 33.3%, p=.046). Trials that required no history of chemotherapy had an enrollment of 27.3% (compared to 44.1%). Conclusions: Unlike prior reports, we did not demonstrate differences in trial enrollment by race, socioeconomic or insurance status. This suggests that our objective manual screening process enhances equitable clinical trial offerings. It is possible that this objective manual screening process attenuates provider bias and offers clinical trials to historically marginalized and underrepresented groups.

Impact of Exigent Research Network’s partnership with the Tempus AI TIME Program on the screening and matching of patients for clinical trials.

e13599 Background: Exigent Research is comprised of independent community oncology practices with a central patient data repository to support clinical research. The Tempus AI TIME program provides clinical trials solutions including a diverse trial portfolio, TApp an AI powered patient matching platform, patient tracking LINK portal, and a rapid trial activation process. This partnership facilitated Tempus AI to continuously search the data repository and enabled Exigent to increase trial enrollment. Methods: TApp is a clinical trial matching platform that utilizes patient data, trial eligibility criteria, and NLP models to execute AI powered matching of subjects to trials. TApp searches the entire patient population for TIME trial matches. New patient clinical information or changes to trial eligibility criteria triggers a new TApp search and matches are reviewed by Tempus AI nurses. Trials were opened in an accelerated “just in time” manner if a subject was ready immediately or prospectively prior to a first patient being identified. Data collected included trial activations, number of patients, available studies, patient and trial updates, TApp searches, nursing effort, matches, and consents. Interventional Phase I to III trials and observational studies were included. Results: From 2022 - 2023, there were 16 Exigent sites in the TIME network. The patient population screened was 244,986 matched to 189 clinical trials. There were 3,179,079 changes to individual patient records and 2,152 trial updates. This triggered 216,712,093 unique TApp searches and 33,083 matches reviewed by nurses. In total, 1,312 patients matched to observational studies and 6,040 patients for interventional trials. Cumulatively, nurses spent 6,617 hours on patient screening resulting in a $330,830 cost. There were 71 trial activations resulting in 312 patient consents (169 observational, 143 interventional). The average duration for study activation was 12.3 days for a just in time activation and 33.8 days for a prospective activation. Conclusions: Exigent Research leveraged a central data repository with the Tempus AI TIME program to continuously screen a large patient population for 185+ trials. During a two-year period, 215M+ unique TApp searches occurred which resulted in over 310 patient consents with rapid activation times. Future clinical trial strategies should partner AI screening technologies with robust trial infrastructure solutions to maximize enrollment success. [Table: see text]

Quantification of the environmental impact of radiotherapy and associated secondary human health effects: a multi-institutional retrospective analysis and simulation

The health-care industry is a substantial contributor to global greenhouse gas emissions, yet the specific environmental impact of radiotherapy, a cornerstone of cancer treatment, remains under-explored. We aimed to quantify the emissions associated with the delivery of radiotherapy in the USA and propose a framework for reducing the environmental impact of oncology care. In this multi-institutional retrospective analysis and simulation study, we conducted a lifecycle assessment of external beam radiotherapy (EBRT) for ten anatomical disease sites, adhering to the International Organization for Standardization's standards ISO 14040 and ISO 14044. We analysed retrospective data from Jan 1, 2017, to Oct 1, 2023, encompassing patient and staff travel, medical supplies, and equipment and building energy use associated with the use of EBRT at four academic institutions in the USA. The primary objective was to measure the environmental impacts across ten categories: greenhouse gases (expressed as kg of carbon dioxide equivalents [CO2e]), ozone depletion, smog formation, acidification, eutrophication, carcinogenic and non-carcinogenic potential, respiratory effects, fossil fuel depletion, and ecotoxicity. Human health effects secondary to these environmental impacts were also estimated as disability-adjusted life years. We also assessed the potential benefits of hypofractionated regimens for breast and genitourinary (ie, prostate and bladder) cancers on US greenhouse gas emissions using an analytic model based on the 2014 US National Cancer Database for fractionation patterns and patient commute distances. We estimated that the mean greenhouse gas emissions associated with a standard 25-fraction EBRT course were 4310 kg CO2e (SD 2910), which corresponded to 0·0035 disability-adjusted life years per treatment course. Transit and building energy usage accounted for 25·73% (1110 kg CO2e) and 73·95% of (3190 kg CO2e) of total greenhouse gas emissions, respectively, whereas supplies contributed only 0·32% (14 kg CO2e). Across the other environmental impact categories, most of the environmental impact also stemmed from patient transit and energy use within facilities, with little environmental impact contributed by supplies used. Hypofractionated treatment simulations suggested a substantial reduction in greenhouse gas emissions-by up to 42% for breast and 77% for genitourinary cancer-and environmental impacts more broadly. This comprehensive lifecycle assessment of EBRT delineates the environmental and secondary health impacts of radiotherapy, and underscores the urgent need for sustainable practices in oncology. The findings serve as a reference for future decarbonisation efforts in cancer care and show the potential environmental benefits of modifying treatment protocols (when clinical equipoise exists). They also highlight strategic opportunities to mitigate the ecological footprint in an era of escalating climate change and increasing cancer prevalence. Mount Zion Health Fund.

Ambulatory care hematology/oncology pharmacy services: A comprehensive review by the Saudi Oncology Pharmacy Assembly

AbstractSaudi Vision 2030 has driven significant changes in ambulatory care pharmacy services in the Kingdom of Saudi Arabia (KSA), transitioning pharmaceutical care from inpatient to outpatient settings. With a growing need to address non‐communicable diseases, particularly cancer, ambulatory care oncology pharmacy services are of paramount importance. This study aims to evaluate the potential benefits and challenges of establishing such services in the KSA and offers recommendations for clinical pharmacists. A comprehensive literature search was conducted using PubMed, MEDLINE, EMBASE, and Google Scholar, encompassing research from inception to September 2023. The search focused on English language studies related to ambulatory care oncology/hematology pharmacy services. Among the 1351 studies found, those assessing the impact of clinical pharmacists on patient outcomes in outpatient oncology clinics were included. The review of the literature highlights the substantial impact of clinical pharmacists in outpatient hematology/oncology settings. A selection of several studies revealed their role in improving patient care, reducing health care costs, and enhancing treatment outcomes. Notable findings include a high acceptance rate of pharmacist interventions with significant cost savings, increased pharmacist involvement in patient encounters, and reduced emergency department visits and inpatient admissions due to pharmacist interventions. These results showed the valuable contributions of clinical pharmacists in the international outpatient oncology setting. Establishing ambulatory care hematology/oncology pharmacy services in Saudi Arabia is critical, considering the rising cancer burden. The value of specialized oncology clinical pharmacists in the outpatient setting is emphasized by various studies conducted in the United States. This review proposes a framework for patient‐centered oncology practices, serving as a valuable resource for the strategic development of ambulatory care oncology pharmacy services in Saudi Arabia. These efforts align with Saudi Vision 2030's broader goals of enhancing health care quality and patient care.

Cancer Treatment Before and After Physician-Pharmacy Integration

Integration of pharmacies with physician practices, also known as medically integrated dispensing, is increasing in oncology. However, little is known about how this integration affects drug use, expenditures, medication adherence, or time to treatment initiation. To examine the association of physician-pharmacy integration with oral oncology drug expenditures, use, and patient-centered measures. This cohort study used claims data from a large commercial insurer in the US to analyze changes in outcome measures among patients treated by pharmacy-integrating vs nonintegrating community oncologists in 14 states between January 1, 2011, and December 31, 2019. Commercially insured patients were aged 18 to 64 years with 1 of the following advanced-stage diagnoses: breast cancer, colorectal cancer, kidney cancer, lung cancer, melanoma, or prostate cancer. Data analysis was conducted from May 2023 to March 2024. Treatment by a pharmacy-integrating oncologist, ascertained by the presence of an on-site pharmacy or nonpharmacy dispensing site. Oral, intravenous (IV), total, and out-of-pocket drug expenditures for a 6-month episode of care; share of patients prescribed oral drugs; days' supply of oral drugs; medication adherence measured by proportion of days covered; and time to treatment initiation. The association between an oncologist's pharmacy integration and each outcome of interest was estimated using the difference-in-differences estimator. Between 2012 and 2019, 3159 oncologists (745 females [27.1%], 2002 males [72.9%]) treated 23 968 patients (66.4% female; 53.4% aged 55-64 years). Of the 3159 oncologists, 578 (18.3%) worked in practices that integrated with pharmacies (with a low rate in 2011 of 0% and a high rate in 2019 of 31.5%). In the full sample (including all cancer sites), after physician-pharmacy integration, no significant changes were found in oral drug expenditures, IV drug expenditures, or total drug expenditures. There was, however, an increase in days' supply of oral drugs (5.96 days; 95% CI, 0.64-11.28 days; P = .001). There were no significant changes in out-of-pocket expenditures, medication adherence, or time to treatment initiation of oral drugs. In the breast cancer sample, there was an increase in oral drug expenditures ($244; 95% CI, $41-$446; P = .02) and a decrease in IV drug expenditures (-$4187; 95% CI, -$8293 to -$80; P = .05). Results of this cohort study indicated that the integration of oncology practices with pharmacies was not associated with significant changes in expenditures or clear patient-centered benefits.

The impact of the new ESTRO-ACROP target volume delineation guidelines for postmastectomy radiotherapy after implant-based breast reconstruction on breast complications

The European Society for Radiotherapy and Oncology–Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed to evaluate the impact on breast complications with the new guideline compared to the conventional guidelines. In total, 308 patients who underwent PMRT after tissue expander or permanent implant insertion from 2016 to 2021 were included; 184 received PMRT by the new ESTRO-ACROP target delineation (ESTRO-T), and 124 by conventional target delineation (CONV-T). The endpoints were major breast complications (infection, necrosis, dehiscence, capsular contracture, animation deformity, and rupture) requiring re-operation or re-hospitalization and any grade ≥2 breast complications. With a median follow-up of 36.4 months, the cumulative incidence rates of major breast complications at 1, 2, and 3 years were 6.6%, 10.3%, and 12.6% in the ESTRO-T group, and 9.7%, 15.4%, and 16.3% in the CONV-T group; it did not show a significant difference between the groups (p = 0.56). In multivariable analyses, target delineation is not associated with the major complications (sHR = 0.87; p = 0.77). There was no significant difference in any breast complications (3-year incidence, 18.9% vs. 23.3%, respectively; p = 0.56). Symptomatic RT-induced pneumonitis was developed in six (3.2%) and three (2.4%) patients, respectively. One local recurrence occurred in the ESTRO-T group, which was within the ESTRO-target volume. The new ESTRO-ACROP target volume guideline did not demonstrate significant differences in major or any breast complications, although it showed a tendency of reduced complication risks. As the dosimetric benefits of normal organs and comparable oncologic outcomes have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.

Breaking bad news in oncology practice: experience and challenges of oncology health professionals in Ethiopia – an exploratory qualitative study

ObjectiveTo explore the experience and challenges health professionals face during breaking bad news (BBN) to patients with cancer in the oncology centre of Black Lion Specialized Hospital (BLSH), Addis Ababa,...

ANTEGRADE METHODS OF BILIARY DECOMPRESSION IN TUMOR OBSTRUCTION OF THE BILIARY TRACT

Percutaneous transhepatic endoscopic ultrasound-guided intervention is a crucial method for addressing mechanical jaundice. This technique for restoring bile outflow enables the resolution of several medical and diagnostic issues with minimal invasiveness and fewer complications compared to traditional open surgical treatments. Most often, antegrade cholangiostomy is used in oncological practice, where the variety of clinical situations determines the indications for performing this intervention in different variants and with different goals. According to the world literature, at the moment, sufficient experience of transdermal technologies has been accumulated, their application in clinical practice has been worked out, which allows to recognize them, to a certain extent, as routine. The purpose of this work is to optimize biliary decompression in patients with tumor obstruction of the biliary tract, to improve the prevention of complications, to enhance the immediate results of treatment and the quality of life for this group of population. The study analyzed the examination and surgical treatment outcomes of 64 patients with tumor-related mechanical jaundice treated in surgical hospitals from 2017 to 2023. All patients underwent antegrade biliary drainage procedures, specifically percutaneous transhepatic cholangiostomy and bile duct stenting under ultrasound guidance, to achieve biliary decompression. Percutaneous transhepatic endoscopic interventions have become the primary method for biliary decompression in cases of bile duct obstruction due to tumors. These procedures, particularly for malignant tumors, are associated with relatively few complications and low mortality rates.

Problems of late radiation injuries of the skin and possibilities of their treatment

Currently there is a problem of insufficient effectiveness of treatment of late radiation skin lesions. Possibilities of application of combined schemes of treatment of malignant neoplasms, including radiation therapy, show both good immediate and distant results, life expectancy of patients has increased. However, the issue of such remote local radiation lesions as radiation ulcers also remains relevant. Such lesions in the practice of clinical oncologists usually occur from 1-1,5 months and more after the end of the course of close-focus X-ray therapy for skin cancer. The peculiarity of radiation ulcers is that they heal extremely poorly even by secondary tension. In the pathogenesis of late radiation ulcers, along with disruption of microcirculation, the main role is played by the direct damaging effect of radiation on stem cells and, consequently, suppression of reparative processes. For this reason, such ulcerous defects are characterized by torpidity to drug and surgical treatment. The analysis of modern scientific and practical literature does not fully reveal the peculiarities of the pathogenesis of post-radiation skin lesions leading to the development of radiation ulcers. Researchers have set a goal to search for new modern methods of effective treatment of this pathology. The main purpose of the literature review was to theoretically substantiate the possibilities of including enzyme antioxidants and epidermal growth factor preparations into the complex of pathogenetic treatment of radiation skin ulcers. Superoxide dismutase (SOD) is an active enzyme-antioxidant, it neutralizes excessive free oxygen radicals, and also has a pronounced anti-inflammatory effect by means of oxidative post-radiation stress of skin tissues. Epidermal growth factor promotes cell growth and differentiation of stem cells (SC) involved in ulcer defect regeneration. Pathogenetically justified stepwise application of these drugs will improve the effectiveness of treatment of post-radiation skin ulcers. This paper presents the current information about the pathogenesis of late radiation skin ulcers, the mechanism of action of SOD, epidermal growth factor preparations, as well as the importance of the microenvironment and the homing effect in controlling the links of the pathogenesis of radiation ulcers and the possibility of their reparative regeneration.

Telemedicine: Does it have a place in surgical oncology practice?

Telemedicine has gained traction in surgical subspecialties, particularly since the COVID-19 pandemic. This study aims to identify whether telemedicine can be appropriately integrated within surgical oncology practice. This retrospective study evaluated patients who received either telemedicine or office follow-up after undergoing surgical oncology operations between 2016 and 2021. The telemedicine group (TG) and office group (OG) received a 15-question survey regarding their satisfaction with their care. Patient outcomes and responses were analyzed utilizing propensity-score matching in 1:1 fashion. Telemedicine group and OG each had 21 patients. Length of stay, complication frequency, follow-up frequency, and readmissions frequency within 90-days were comparable between groups. Telemedicine group expressed comparable satisfaction with postoperative care relative to OG (95.2% vs. 85.7%, p = 0.61). All telemedicine patients said they would utilize telemedicine again in the future and would recommend its use to others. Patient satisfaction with postoperative telemedicine follow-up is comparable to those with in-person follow-up.

Anthracycline-induced cardiotoxicity – primary preventive options. An overview

Anthracycline-induced cardiotoxicity (AIC) has been known since the 1970s but remains relevant, mainly due to the widespread use of anthracyclines in oncological practice. Currently, AIC is viewed as a prolonged and continuous process that starts with the initial dose at molecular and cellular levels and advances, ultimately resulting in cardiomyopathy and heart failure. Many contemporary studies aim to discover methods for early detection of anthracycline-related myocardial injury. Additionally, ongoing research focuses on agents for primary prevention of AIC, examining their effectiveness, place, and timing of administration. This review aims to present the available preventive options, interconnecting them with their mechanisms of action and the mechanisms of AIC. According to current recommendations, primary prevention is indicated for high- and very high-risk patients and includes general measures to lower cardiovascular risk, neurohormonal therapy, and statins. Regular cardiology assessments are a crucial component of heart damage prevention. Evidence of mild myocardial injury (deteriorated Global Longitudinal Strain and troponin release) justifi es cardioprotective measures. Some aspects remain unanswered, including whether early cardioprotection is required, as well as the role and effi cacy of sacubitril/valsartan and sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors) for AIC prevention. Physical activity is a promising method to reduce the cardiac damaging effects of anthracyclines. 

Panel Interview of ONcology practices with Emergent Experience of teclistamab in the Real world: the TecPIONEER Study

Objective To understand clinicians’ current teclistamab step-up dosing (SUD) model and how they envision future administration models, as well as perceived barriers and facilitators to these models in day-to-day clinical practice. Methods Interviews of clinicians with RW experience administering teclistamab, with a subsequent roundtable discussion to discuss interview findings. Topics of interest included managing adverse events (AE), and handling logistics of SUD and transition of care (ToC). Results 20 clinicians representing 19 practices participated. Of 14 practices administering inpatient teclistamab SUD, 12 (86%) utilized a single admission. A day 1-3-5 dosing schedule with a 7-day length of stay was planned in 10/14 (71%). The remaining 5 practices employed outpatient or hybrid SUD. SUD models depended on cellular therapy experience, patient volume, and monitoring capabilities. Clinicians desired to administer SUD outpatient for convenience and reduced healthcare resource use. 11% of practices reported using tocilizumab for cytokine release syndrome (CRS) prophylaxis, whilst it was uniformly used to treat grade 2+ CRS. Corticosteroids were the preferred treatment for neurotoxicity. Infection prophylaxis with intravenous immunoglobulin was reported by 89% of practices. Patient- and institution-level factors affected decision-making of transitioning patients back to referring sites after SUD. Conclusion The results consolidated practice-based experiences and indicated diverse RW SUD models and patient management strategies in practices with familiarity with teclistamab AE management and ToC protocols. Inpatient SUD is common, with expectations that approaches will evolve toward outpatient or community-based administration. Further research is needed to investigate outcomes of different care models and AE management strategies.

Spending Analysis of Machine Learning-Based Communication Nudges in Oncology.

Serious illness conversations (SICs) in the outpatient setting may improve mood and quality of life among patients with cancer and decrease aggressive end-of-life care. Interventions informed by behavioral economics may increase rates of SICs between oncology clinicians and patients, but the impact of these interventions on end-of-life spending is unknown. This study is a secondary analysis of a stepped-wedge cluster randomized, controlled trial that involved nine medical oncology practices and their high-risk patients at a large academic institution between June 2019 and April 2020. The study included 1187 patients who were identified by a machine-learning algorithm as high risk of 180-day mortality and who died by December 2020. The patients were randomly assigned to standard of care (controls) or to a behavioral intervention designed to increase clinician-initiated SICs. We abstracted spending - defined as inflation-adjusted costs for acute care (inpatient plus emergency room), office/outpatient care, intravenous systemic therapy, other therapy (e.g., radiation), long-term care, and hospice - from the institution's accounting system, and we captured spending at inpatient, outpatient, and pharmacy settings. To evaluate intervention impacts on spending, we used a two-part model, first using logistic regression to model zero versus nonzero spending and second using generalized linear mixed models with gamma distribution and log-link function to model daily mean spending in the last 180days of life. Models were adjusted for clinic and wedge fixed effects, and they were clustered at the oncologist level. For all patients with at least one SIC within 6 months of death, we also calculated their mean daily spending before and after SIC. Median age at death was 68years (interquartile range, 15.5), 317 patients (27%) were Black or of ethnicities other than white, and 448 patients (38%) had an SIC. The intervention was associated with lower unadjusted mean daily spending in the last 6 months of life for the intervention group versus controls ($377.96 vs. $449.92; adjusted mean difference, -$75.33; 95% confidence interval, -$136.42 to -$14.23; P=0.02), translating to $13,747 total adjusted savings per decedent and $13 million in cumulative savings across all decedents in the intervention group. Compared with controls, patients in the intervention group incurred lower mean daily spending for systemic therapy (adjusted difference, -$44.59; P=0.001), office/outpatient care (-$9.62; P=0.001), and other therapy (-$8.65; P=0.04). The intervention was not associated with differences in end-of-life spending for acute care, long-term care, or hospice. Results were consistent for spending in the last 1 and 3 months of life and after adjusting for age, race, and ethnicity. For patients with SICs, mean daily spending decreased by $37.92 following the first SIC ($329.87 vs. $291.95). A machine learning-based, behaviorally informed intervention to prompt SICs led to end-of-life savings among patients with cancer, driven by decreased systemic therapy and outpatient spending. (Funded by the Penn Center for Precision Medicine and the National Institutes of Health; ClinicalTrials.gov number, NCT03984773.).

Modern approaches to the treatment of anemia of malignant neoplasms

Anemia in patients with cancer is a common concomitant condition. The development of anemia in cancer has a multifactorial pathogenesis, including inflammation, metastasis of solid tumors to the bone marrow and displacement of normal hematopoiesis sprouts in the bone marrow by tumor cells in hemoblastosis, myelosuppression against the background of chemo/radiation therapy, nutritional insufficiency due to anorexia, etc. Anemia in cancer patients reduces the quality of life, the response to antitumor therapy, increases the risk of tumor progression and is an independent factor negatively affecting survival. The article discusses the tactics of managing patients with anemia in accordance with the Clinical recommendations of the Ministry of Health of the Russian Federation “Anemia in malignant neoplasms” and “Management of CancerAssociated Anemia With Erythropoiesis-Stimulating Agents: ASCO/ASH Clinical Practice Guideline Update”. The results of clinical studies are presented, which indicate the effectiveness of the use of erythropoiesis-stimulating drugs (including epoetin alpha) in oncological practice, which reduce the need for hemotransfusions and increase hemoglobin levels in patients with anemia against the background of antitumor chemotherapy.