Primary Oncology Research Articles

In-person prospective audit and feedback on an oncology ward: development of an immunocompromised antimicrobial stewardship program.

To describe clinical syndromes, opportunities for antimicrobial optimization, and acceptance of recommendations made by an immunocompromised antimicrobial stewardship program performing in-person prospective audit and feedback (IPPAF) on inpatient oncology services. Retrospective cohort study. Three inpatient oncology services including patients with solid tumor malignancies in an academic cancer center. Hospitalized adults with oncologic malignancies receive antimicrobials for any indication. We reviewed all patients receiving antimicrobials on inpatient oncology services who were included in IPPAF and prospectively documented clinical syndromes represented, most common recommendations, and acceptance rate. We also examined the standardized antimicrobial administration ratio (SAAR) for oncology units over the study period. Over 34 weeks, we performed 154 interventions for 138 patients. Metastatic malignancy was common (52%) and 90-day mortality was high (43%). Diagnostic uncertainty was common (33/154, 21%), as were cases of intra-abdominal pathology (30/154, 19%), pneumonia (25/154, 16%), and urinary tract infection (12/154, 8%). The most common recommendations were changes in duration (63/154, 41%) and stopping antimicrobials for syndromes determined to be noninfectious (29/154, 19%). Acceptance of interventions was high (77% overall) and several SAARs on the primary oncology unit significantly decreased after starting IPPAF. We identified numerous opportunities for antimicrobial optimization among solid tumor malignancy patients. Most clinical syndromes were ones also encountered frequently in non-oncology populations, but several were unique and represented opportunities for targeted education.

Multiple myeloma: a paradigm for blending community and academic care.

The care of the multiple myeloma (MM) patient is complex, with most patients requiring multiple lines of therapy over a span of many years to decades. Since the days when autologous stem cell transplantation became the standard of care for a large subset of patients, it was imperative that community practices and specialized academic centers work together to optimize the initial care of patients. Now, with the unprecedented number of treatment options and the introduction of chimeric antigen receptor T-cell therapies and bispecific T-cell engagers, that collaboration has become even more important and stretches from the upfront treatment to the relapsed and refractory disease setting. I will discuss the unique safety profile and logistical aspects that pose challenges and opportunities for the safe and successful delivery of these therapies. Close interaction, communication, and established partnerships between the primary oncologist, the myeloma specialist, and the transplant or immune effector cell provider will be required to provide the optimal care longitudinally for each patient. This multidisciplinary approach to treating MM can serve as a paradigm for blending community and academic care.

Factors influencing implementation of a care coordination intervention for cancer survivors with multiple comorbidities in a safety-net system: an application of the Implementation Research Logic Model

BackgroundUnder- and uninsured cancer survivors have significant medical, social, and economic complexity. For these survivors, effective care coordination between oncology and primary care teams is critical for high-quality, comprehensive care. While evidence-based interventions exist to improve coordination between healthcare teams, testing implementation of these interventions for cancer survivors seen in real-world safety-net settings has been limited. This study aimed to (1) identify factors influencing implementation of a multicomponent care coordination intervention (nurse coordinator plus patient registry) focused on cancer survivors with multiple comorbidities in an integrated safety-net system and (2) identify mechanisms through which the factors impacted implementation outcomes.MethodsWe conducted semi-structured interviews (patients, providers, and system leaders), structured observations of primary care and oncology operations, and document analysis during intervention implementation between 2016 and 2020. The practice change model (PCM) guided data collection to identify barriers and facilitators of implementation; the PCM, Consolidated Framework for Implementation Research, and Implementation Research Logic Model guided four immersion/crystallization data analysis and synthesis cycles to identify mechanisms and assess outcomes. Implementation outcomes included appropriateness, acceptability, adoption, and penetration.ResultsThe intervention was appropriate and acceptable to primary care and oncology teams based on reported patient needs and resources and the strength of the evidence supporting intervention components. Active and sustained partnership with system leaders facilitated these outcomes. There was limited adoption and penetration early in implementation because the study was narrowly focused on just breast and colorectal cancer patients. This created barriers to real-world practice where patients with all cancer types receive care. Over time, flexibility intentionally designed into intervention implementation facilitated adoption and penetration. Regular feedback from system partners and rapid cycles of implementation and evaluation led to real-time adaptations increasing adoption and penetration.DiscussionEvidence-based interventions to coordinate care for underserved cancer survivors across oncology and primary care teams can be implemented successfully when system leaders are actively engaged and with flexibility in implementation embedded intentionally to continuously facilitate adoption and penetration across the health system.

Examining provider perceptions and practices for comprehensive geriatric assessment among cancer survivors: a qualitative study with an implementation science focus.

Introduction: Cancer rates increase with age, and older cancer survivors have unique medical care needs, making assessment of health status and identification of appropriate supportive resources key to delivery of optimal cancer care. Comprehensive geriatric assessments (CGAs) help determine an older person's functional capabilities as cancer care providers plan treatment and follow-up care. Despite its proven utility, research on implementation of CGA is lacking. Methods: Guided by a qualitative description approach and through interviews with primary care providers and oncologists, our goal was to better understand barriers and facilitators of CGA use and identify training and support needs for implementation. Participants were identified through Cancer Prevention and Control Research Network partner listservs and a national cancer and aging organization. Potential interviewees, contacted via email, were provided with a description of the study purpose. Eight semi-structured interviews were conducted via Zoom, recorded, and transcribed verbatim by a professional transcription service. The interview guide explored providers' knowledge and use of CGAs. For codebook development, three representative transcripts were independently reviewed and coded by four team members. The interpretive process involved reflecting, transcribing, coding, and searching for and identifying themes. Results: Providers shared that, while it would be ideal to administer CGAs with all new patients, they were not always able to do this. Instead, they used brief screening tools or portions of CGAs, or both. There was variability in how CGA domains were assessed; however, all considered CGAs useful and they communicated with patients about their benefits. Identified facilitators of implementation included having clinic champions, an interdisciplinary care team to assist with implementation and referrals for intervention, and institutional resources and buy-in. Barriers noted included limited staff capacity and competing demands on time, provider inexperience, and misaligned institutional priorities. Discussion: Findings can guide solutions for improving the broader and more systematic use of CGAs in the care of older cancer patients. Uptake of processes like CGA to better identify those at risk of poor outcomes and intervening early to modify treatments are critical to maximize the health of the growing population of older cancer survivors living through and beyond their disease.

Development of a Real-Time Dashboard Characterizing Acute Leukemia Clinical Trial Enrollment Diversity at the Practice, Investigator, and Individual Clinician Level

Introduction Adult acute leukemia clinical trials in the United States under-enroll persons from historically marginalized groups. Practices, investigators, and individual clinicians have identified the lack of multidimensional, real-time enrollment data as a barrier to remediating participation inequities. We sought to overcome this by developing a visual data interface (“dashboard”) for assessing enrollment diversity across an institution in real-time. Methods Real-time dashboard data sources were the electronic health record (EPIC) and the trial registration system (OnCore); Tableau software was used for data visualization. The primary objective was to create an integrated data source that accurately assigned individuals as patients of the correct clinical group, primary oncologist, and research protocol(s). The primary endpoint was an accurate assignment algorithm, defined as an area under the receiver operator curve (AUROC) of >=0.90, as compared to manual review. Trial enrollment was assigned via OnCore and was itself the reference standard, so algorithm classification was considered accurate if individuals were assigned correctly to the clinical group and primary oncologist. The AUROC of a basic assignment algorithm was 0.78, requiring a sample size of 528 to show improvement to 0.90 or above. Interim testing was performed to assess potential improvements in logic accuracy. Exploratory objectives were to assess associations between exposures (e.g., age, race, ethnicity, sex) and outcomes (treatment trial and biobank enrollment) among a one-year cohort of patients followed by the clinical group, as determined by the final algorithm. Due to small numbers in some race and ethnicity categories, a People of Color aggregate variable was generated and included those listed as Hispanic Black, Other, Unknown, White, and Non-Hispanic Asian, Black, and Other. Associations were determined using parametric or non-parametric bivariate tests, as appropriate; multiplicity was not considered. Results Interim testing was used to revise diagnostic criteria assignment and inpatient encounter algorithms. This improved classification AUROCs to 0.80 and then 0.85, after which the physician assignment algorithm was further revised and finalized. Final testing of 528 patients seen on randomly chosen dates resulted in an AUROC of 0.98 for the assignment algorithm against manual classification. Real-time data visualizations were then developed to display multidimensional enrollment diversity data grouped by patient panels for individual clinicians (Figure 1) and by trial for primary investigators, with additional views showing trends over time and enrollment process metrics (i.e., who is consented, eligible, on study). From 6/22/2022-6/21/2023 there were 432 unique patients followed by the clinical group, of which 124 (28.7%) participated in a treatment trial and 287 (66.4%) in a biobanking study. Patient characteristics and bivariate comparisons of participation by study type are shown in Table 1. Characteristics associated with treatment trial participation included lower Social Deprivation Index score (20 vs 27, p=0.05), residing outside Massachusetts (36.2% vs 25.5%, p=0.03), and having ALL (33.8% vs 25.8%, p=0.02). Characteristics associated with biobank study participation included lower Social Deprivation Index score (21 vs 25, p=0.01) and having ALL (33.8% vs 25.8%, p=0.02). While Persons of Color participated in treatment trials (22.4% vs 29.7%) and biobanks (62.1% vs 66.7%) numerically less than NHW, but differences were not significant (p>0.05). Conclusions An enrollment diversity dashboard can accurately provide real-time data on acute leukemia clinical research participation at a large referral center. In this cohort, enrollment rates were relatively high and associated with socioeconomic status, place of residence, and disease type but not race-ethnicity. The dashboard is now being revised to incorporate trial eligibility metrics and will be piloted as performance feedback for practices, investigators, and individual clinicians.

SURG-15. RIGHT FRONTAL-PARIETAL PILOCYTIC ASTROCYTOMA WHO GRADE I ASSOCIATED WITH HEMORRHAGIC COMPONENT AND ESSENTIAL HYPERTENSION IN AN ADULT

Abstract Pilocytic astrocytoma (PA) is a primary glial neoplasm and low-grade tumor. After total resection, the prognosis is very good. A poor prognosis results from leptomeningeal spreading and bleeding, both of which are extremely uncommon in Pilocytic Astrocytoma patients. Case presentation We report the case of a 43-year-old male that presented with a 4 days’ history of right sided frontal headache, non-radiating and mostly felt in the morning. Not associated with vomiting and fever. In addition, there was a sudden decline in level of consciousness with no associated stool or urine incontinence. The patient also developed three episodes of tonic clonic convulsions, lasting less than 3 minutes associated with urine incontinence and frothing from the mouth. Two days later, there was a sudden onset of left sided weakness involving upper and lower limbs. However, there is no history of trauma or hypertension. He was identified as having a hemorrhagic right frontal-parietal PA evidence on MRI associated with essential hypertension. The patient had an intervention combination of medical treatment and craniotomy via fronto-temporal approach plus excision of lesion. Histopathological examination of specimen determined that it was PA WHO grade I. He was treated with oral anti-epileptic therapy (Phenytoin 300 mg once a day), folic acid supplementation (400 mcg once a day), anti-hypertensive therapy (Amlodipine 10 mg and Losartan 50 mg once daily) and he showed marked improvement and was discharged home after 1 month and followed up by primary neurosurgeon, oncologist and physician. CONCLUSION: This case report raises awareness of Pilocytic Astrocytoma among adults and emphasizes the value of early diagnosis and management of patients with Pilocytic Astrocytoma associated with essential hypertension can prevent complications, reduce morbidity and mortality.

Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study

BackgroundAdvances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery.MethodsThis protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation.DiscussionStudy findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites.Trial registrationRegistered with ClinicalTrials.gov on June 2, 2022: NCT05400941.

Clinical characteristics and therapeutic behavior of breast cancer patients using mistletoe therapy consulting a clinic offering integrative oncology: a registry data analysis

MotivationCancer patients often use complementary and/or alternative medicine, such as mistletoe therapy, alongside conventional cancer therapies. In Switzerland, so far not much is known about treatment patterns of breast cancer patients using integrative oncology. Solid knowledge on complementary care utilization may help to enhance integrative oncology care in Switzerland.MethodsIn this exploratory, descriptive database study, we investigated the treatment pathways of a cohort of breast cancer patients who received mistletoe therapy and were documented in the cancer registry of an anthroposophic Swiss hospital offering integrative oncology treatments.ResultsPatients treated with mistletoe in this cohort are in median 10 years younger than Swiss breast cancer patients as a whole. Only 5.8% of these patients were treated with mistletoe alone, while 60.5% of them supplemented chemotherapy and/or hormone therapy and/or surgery and/or radiation with mistletoe therapy. Nearly 80% of patients started conventional therapy followed by additional mistletoe therapy or started mono mistletoe therapy after completion of conventional therapies. The median time from initial diagnosis to hospital admission (inpatient and/or outpatient) was less than one year. Almost ¾ of the patients were treated in an outpatient setting only.ConclusionFrom our data, it appears that younger breast cancer patients are more likely to use mistletoe therapy simultaneously with or following their conventional medical therapies. The extent to which these patients discuss their mistletoe therapy and eventually other complementary and/or alternative therapies with their primary oncologists is not clear from the data. We therefore recommend that (Swiss) oncologists should openly discuss the desire for integrative oncology therapies, especially with their younger breast cancer patients, in order to find the best holistic care pattern for these patients.

Quality metrics at scale: Deriving time to first cancer treatment from electronic health records.

580 Background: Measurements of cancer care quality are critical for internal administration and participation in value-based care programs, towards the goal of improving patient outcomes. Data from electronic health records (EHRs) have the potential to allow for automatic computation of quality measures at a larger scale than manual chart review. This requires the creation of algorithms that process data and apply custom logic to define a clinically meaningful measurement. In this work, we describe the development and performance of an algorithm for deriving time from first primary oncologist visit to first cancer treatment using EHR data. Methods: This EHR-derived measure of time to first treatment (TTT) was implemented at an academic medical center for all patients who had a visit since 01/01/2011 and a cancer-related diagnosis code. We defined a patient’s primary oncologist as the first medical oncologist who they visited at least 5 times. These criteria were chosen to find the first provider at the site who the patient likely established care with and received treatment from. Then the patient’s TTT is computed as the number of days between their first visit date with this oncologist and the date of their first antineoplastic drug administration. Data on other treatment modalities, such as surgery and radiation therapy, were not available at the time of algorithm development. We allow for patients to receive their first treatment up to 60 days before their first visit to account for inpatient treatments before a primary outpatient oncologist is established. This algorithm’s performance was assessed through manual chart review among a sample of 38 patients. Results: Our algorithm correctly assigned 37 out of 38 patients (97.4%) to their primary oncologist, and computed the correct TTT for 28 out of 38 patients (73.4%). Incorrect TTT computations were mostly due to missingness of systemic therapy administrations in the structured EHR data; these were primarily for oral therapies. Conclusions: This work demonstrates the feasibility of measuring a patient’s TTT from structured EHR data alone. In particular, a patient’s initial visit with their primary oncologist can be derived with high accuracy. From this index date, the accuracy of the metric is dependent on the availability of structured treatment data. To further improve the EHR-derived metric, future work should incorporate other treatment modalities through structured data sources such as billing codes, and improve completeness of systemic therapy data in a scalable way, such as from natural language processing techniques.[Table: see text]

Circulating cell-free HPV DNA is a strong marker for disease severity in cervical cancer.

For cervical cancer (CC), circulating cell-free HPV DNA (ccfHPV) may establish disease severity. Furthermore, HPV integration has been correlated to viral load and survival. In this study, pre-treatment plasma from 139 CC cases (50 primary surgery patients, 22 primary surgery + adjuvant oncological therapy patients, and 67 primary oncological therapy patients) was collected (2018-2020). Furthermore, plasma from 25 cervical intraepithelial neoplasia grade 3 patients and 15 healthy women (negative controls) were collected. Two next-generation sequencing (NGS) panels were used to establish ccfHPV presence and human papillomavirus type 16 (HPV16) integration status. ccfHPV was detected in four primary surgery (8.0%), eight primary surgery + adjuvant oncology (36.4%), and 54 primary oncology (80.6%) patients. For primary oncology patients with HPV16-related cancer (n = 37), more ccfHPVneg than ccfHPVpos patients had HPV16 integration (P = 0.04), and in patients with HPV16 integration (n = 13), ccfHPVpos patients had higher disease stages than ccfHPVneg patients (P = 0.05). In summary, ccfHPV presence is related to disease severity and may add to the debated Sedlis criteria used for identifying patients for adjuvant oncological therapy. However, ccfHPV detection is influenced by HPV integration status and disease stage, and these factors need to be considered in ccfHPVneg patients.

Virtual inpatient continuity visit to reduce readmissions, establish goals of care and engage palliative care: A feasibility pilot.

421 Background: Patients with solid tumors readmitted within 30 days (d) have a median overall survival of less than 90d. Decisions regarding goals of care (GOC), engagement with Palliative Care (PC) and further therapy are often deferred to the outpatient team leading to future readmissions. Methods: A pilot virtual continuity visit (VCV) program was developed using a video platform to arrange meetings with outpatient oncologists, inpatient teams, patients, families and PC providers during a hospital readmission within 30d. The intervention occurred on a single solid tumor oncology service at an academic medical center. Patients were included if discharged from the same hospital within 30d and not readmitted from hospice or SNF. Exclusion criteria included admission for scheduled therapy, curative-intent treatment, or acute side effects of new therapy. Orders were placed at the discretion of the inpatient team. Visits were scheduled only on weekdays. A structured discussion tool was used for prognostic awareness, GOC and availability of PC services. Results: From April 1, 2022 through March 31, 2023, 96 unique patients were eligible for VCVs. This represented 6% admissions to this floor. 15 VCV were completed, 23 were scheduled but not completed, 58 were not scheduled. Reason scheduled visits not completed included: in-person family meeting (7 ), physician unavailable (9), transfer off floor (1), conversation deferred to outpatient visit (4), not clinically necessary (2). Reason visits not scheduled: unable to schedule prior to D/C (37), deferred to outpatient (2) hospice D/C (3), not appropriate (5), in person visit (1). Of the 15 patients who completed VCV, 0% were readmitted within 30d, 100% had documented GOC discussion and 100% had PC engaged in the VCV. Of the 7 patients who had in person visits, 3 of 7 were readmitted, 1 of 7 in person visits had a documented GOC discussion. No PC engagement was present for the in-person meetings. 51/58 patients without scheduled VCV were readmitted, 22 within 30d. Conclusions: VCV are feasible via a video platform with the patient, primary oncologist, inpatient team and PC. The structured discussion provided clear documentation of prognostic awareness, GOC and engagement with PC. No patient who completed a VCV was readmitted.

Characteristics of patients utilizing general inpatient (GIP) hospice.

236 Background: GIP hospice acute care is an inpatient designation for patients (pts) with terminal illness and clinical need to manage uncontrolled symptoms that cannot be managed in other settings. We recently revised hospital workflows to streamline GIP enrollment when appropriate. This study investigates the GIP utilization patterns and characteristics of pts with cancer on GIP. Methods: In December 2022, in collaboration with a consulting hospice program, we revised hospital workflows to improve access to and increase provider and pt awareness about GIP hospice for eligible pts at our academic cancer center. In this study, we review the use of GIP services in hospitalized pts with cancer since the revised workflow. We investigate pt demographics, care utilization (chemotherapy use, hospital readmission) and advanced care planning (ACP) documentation. All data presented are descriptive. Results: A total of 44 pts with cancer enrolled in GIP hospice between 12/2022 and 5/2023 after workflow optimization. This rose from 9 pts in the preceding 6 months prior to revised workflow. Median age was 67 years (range 29-90); 57% were male; 41% were White, 34% were Asian, 5% were Black, and 18% were Other Race; 18% had a hematologic malignancy, and all other pts (82%) had metastatic solid tumors (gastrointestinal, genitourinary, and thoracic diseases most prevalent). 82% listed English as the primary language, and 11% needed an interpreter. 48% had Medicare, 16% had Medicaid, and 36% had private insurance. 98% of the pts had uncontrolled pain as the predominant symptom necessitating inpatient hospice. Among enrolled pts, 98% died on GIP, with a median length of stay preceding GIP of 11.5 days and 2 days on GIP. 39% of pts transitioned to GIP during their first hospitalization within 90 days of death, while 52% had hospital readmissions with a median of 2 admissions in the 90 days prior to death. 18% (8/44) received chemotherapy within 30 days of death (38% [n=3] with curative intent). Notably, the median length of time pts had been followed by their outpatient oncologist was 22 months, and only 18% had fewer than 3 months history at our cancer center. 48% utilized outpatient palliative care prior to death. ACP documentation was completed for 61% of pts (45% with documented prognosis), though only 27% had any documentation by their primary oncologist. Conclusions: Our pilot to identify pts eligible for GIP who could benefit from this care at end of life was successful in increasing utilization of this service. Most pts dying in the hospital on GIP had metastatic solid tumors, with two hospitalizations in the months prior to death. Most pts also had a well-established relationship in the oncology clinic but still had no prior utilization of hospice and only benefitted from a median of 2 days on GIP hospice prior to death. Additional data is needed to understand perspectives and barriers to utilization of outpatient hospice and palliative care resources.

V CAN intervention: Quality improvement initiative to increase and sustain vaccination rates among adult patients with cancer.

400 Background: ASCO, NCCN, and CDC recommend vaccination of patients who are immunocompromised as a result of receiving cancer therapy. Nonetheless, the uptake for vaccination utilization among cancer patients is poor. We explored patient perceptions of vaccination to develop an implementable plan to improve vaccination uptake. Methods: Perception Questionnaire and (ii) interviews to explore patients’ vaccination experience. Based on the results of the situation analysis, we developed a theory-driven complex-based intervention called V CAN (Vaccination among adult CANcer patients) to increase vaccination uptake. Results: For the situation analysis, a total of 60 patients completed the assessments. Median age was 59 (range, 26-94) years, and were 28% men. Thirty-eight patients conducted the survey while on cancer treatment and 22 during survivorship. The most common vaccine that patients had received was the COVID vaccine (83%), with a median 2 doses. Only 52% of patients had received the influenza vaccine, and only 43% patients had received it yearly. Most patients agree that it is important to get up to date with vaccines (73%), but only 58% reported a willingness to take a vaccine if offered to them. There were 32% patients who mentioned that they were never told the importance of vaccination, and 41.6% patients reported a problem understanding their cancer diagnosis and care. Qualitative analysis found that at the initial diagnosis of cancer, most patients were not aware of the importance of vaccination. Patients were more psychologically affected by cancer diagnosis. Patients also expressed that they were not educated by the oncologist about the importance of vaccination. Most patients reported a willingness to get vaccinated and adhere to the vaccination schedule. From these results, our V CAN intervention was developed based on the theory of the planned behavior and health belief models. The theory of planned behavior is a well-defined psychological model that connects one's beliefs and behavior. The health belief model is a psychological health-behavior change model that is used to explain and predict health-related behavior, particularly the uptake of preventive healthcare. In this intervention, various measures will be taken, including educating healthcare providers on our results and their role in emphasizing the importance of vaccination to patients, evidence-based knowledge assessments, initiation of training, and education events (e.g., vaccination schedule display in clinic, training, and biannual lectures). Conclusions: Most cancer patients have a poor perception of vaccination. Health awareness about vaccination remained poor, with a lack of education and reinforcement from primary care providers and oncologists. Psychological support and education via the V CAN intervention is needed to increase vaccination rates among cancer patients.

Pilot study of remote electronic patient-reported outcomes (ePRO) symptom monitoring of palliative care needs among outpatients with advanced solid cancers.

250 Background: Early specialty palliative care for patients with advanced cancer is an evidence-based practice that improves health outcomes, yet patients do not receive timely referrals. ePRO symptom monitoring provides a ready care delivery platform to monitor patients for unmet palliative care needs and direct palliative care referral based on patient report. This study sought to obtain feasibility data for ePRO symptom monitoring of palliative care needs. Methods: We conducted a single-arm pilot study of longitudinal ePRO symptom monitoring of multidimensional palliative care needs among outpatients with advanced breast, gastrointestinal, and gynecologic cancers at an academic oncology practice. Adult patients on active treatment with a prognosis > 6 months were approached consecutively. Patients completed baseline measures and enrolled on a third-party symptom monitoring platform for 12 weeks. Patients received weekly monitoring of 14 common symptoms using the National Cancer Institute's PRO version of the common terminology criteria for adverse events (PRO-CTCAEs). Patients received monthly monitoring of palliative needs using 11 PRO items from validated measures and a clinician-developed item for patient request for palliative care. Weekly symptom alerts and monthly palliative care PRO assessments were reported to the primary oncology team for interdisciplinary clinical management. Acceptability and appropriateness of the intervention were assessed using the Acceptability of Intervention Measure (AIM) and Intervention Appropriateness Measure (IAM). Results: From May 2022 to April 2023, 29 of 37 eligible patients (78%) consented to the study, of which 25 completed baseline measures and enrolled on the platform (68% enrollment rate; most common reason for refusal was not enough time). Median age was 53 years (range 29-77), 18 (72%) female, 12 (48%) non-Hispanic White, 32% reported an ECOG-PRO score 2-3. 96% of patients met pre-defined ePRO adherence thresholds and 92% completed study end measures (1 patient censored for death). Completion of the palliative PRO items was > 94% for 9 of 11 items. Two PRO items for spiritual distress screening were skipped most often. 80% of patients reported a severe score for at least one palliative PRO symptom during the study period. Mean AIM and IAM scores were 3.92 and 4.26, respectively (range 3.25 – 5; best possible total score 5). Conclusions: Expanding evidence-based ePRO symptom monitoring to include monthly palliative care needs assessment is highly feasible, acceptable, and appropriate to patients. Adherence to PRO items was high, and most patients had at least one area of need. Future work will refine the ePRO palliative assessment with attention to spiritual distress screening and determine severity thresholds to develop a PRO-directed referral system to specialty palliative care.

GLIOMA-13 RIGHT FRONTO-PARIETAL PILOCYTIC ASTROCYTOMA WHO GRADE I ASSOCIATED WITH HEMORRHAGIC COMPONENT AND ESSENTIAL HYPERTENSION IN AN ADULT: A CASE REPORT

Abstract Pilocytic astrocytoma (PA) is a primary glial neoplasm and low-grade tumor. After total resection, the prognosis is very good. A poor prognosis results from leptomeningeal spreading and bleeding, both of which are extremely uncommon in Pilocytic Astrocytoma patients. CASE PRESENTATION: We report the case of a 43-year-old male that presented with a 4 days’ history of right sided frontal headache, non-radiating and mostly felt in the morning. Not associated with vomiting and fever. In addition, there was a sudden decline in level of consciousness with no associated stool or urine incontinence. The patient also developed three episodes of tonic clonic convulsions, lasting less than 3 minutes associated with urine incontinence and frothing from the mouth. Two days later, there was a sudden onset of left sided weakness involving upper and lower limbs. However, there is no history of trauma or hypertension. He was identified as having a hemorrhagic right fronto-parietal PA evidence on MRI associated with essential hypertension. The patient had an intervention combination of medical treatment and craniotomy via fronto-temporal approach plus excision of lesion. Histopathological examination of specimen determined that it was PA WHO grade I. He was treated with oral anti-epileptic therapy (Phenytoin 300 mg once a day), folic acid supplementation (400 mcg once a day), anti-hypertensive therapy (Amlodipine 10 mg and Losartan 50 mg once daily) and he showed marked improvement and was discharged home after 1 month and followed up by primary neurosurgeon, oncologist and physician. CONCLUSION: This case report raises awareness of Pilocytic Astrocytoma among adults and emphasizes the value of early diagnosis and management of patients with Pilocytic Astrocytoma associated with essential hypertension can prevent complications, reduce morbidity and mortality.

An Opportunity to Study Mechanisms of Palliative Care by Integrating into Management of The Treatment of Renal Cancer Carcinoma

Achieving patient-centered care requires helping patients understand their illness, eliciting patient values, and developing a collaborative care plan with input from patient and physician. Combining existing models in communication skills and shared decision making provides a road map for accomplishing these tasks in delivering patient-centered care. In this article, we highlight the importance of patient understanding of their prognosis as a key step in delivering patient-centered care. We then review literature suggesting that both patient and patient’s physicians’ emotions play an inhibitory role in accurate formulation and communication of prognosis by physicians and accurate incorporation of this information by patients. We postulate that the finding of benefit of early integration of palliative care (PC) in improving patient-centered outcomes may be addressing these inhibitory factors. Key skills of empathic communication by a PC team that is focused on addressing patient emotions may facilitate better understanding of prognosis and thus improved patient-centered decision leading to improved patient centered outcomes. Finally, we propose advances treatment of renal cell carcinoma makes it an ideal disease that can inform this hypothesis of how integration of PC works. Specifically, we propose that the curability potential in metastatic RCC, amplifies challenges associated with patient prognostic understanding and decision making. Studying which discipline – primary oncology team or palliative care team – can help patients achieve more accurate prognostic understanding leading to more patient centered choices and improved patient-centered care.

Effects of Comprehensive Geriatric Assessment (CGA) Guided Care vs. Usual Care on Overall Survival (OS) and Health-Related Quality of Life (HRQL) for Older Adults with Cancer: A Systematic Review of Randomized Trials (RCTs)

There is evidence from RCTs demonstrating that our current models of CGA guided care can reduce treatment related toxicity effectively. However, it is unclear if CGA guided care can improve OS and HRQL. We aimed to determine the effect of CGA guided care compared with usual care on OS and HRQL. We searched MEDLINE, EMBASE, CENTRAL and CINAHL from date of inception to October 2022 for RCTs comparing CGA guided care with usual care for patients with cancer who were 60 years old and greater on OS and HRQL. We assessed the risk of bias using Cochrane ROB 2 tool. We performed the meta-analysis using random-effects models. The I2 statistic was adopted to assess heterogeneity between studies. We adopted the Synthesis without meta-analysis approach for data not amenable for meta-analysis. The certainty of evidence was rated using the GRADE approach. This study is registered with Cochrane Database of Systematic Reviews. We found 15 eligible RCTs including 3507 participants. There are variations in types of CGA used with 4 trials using CGA to recommend oncology treatment regimen and 10 trials making no recommendation on oncology treatment. The implementation of CGA recommendations were carried out by a geriatrician in 14 trials, but by the primary oncologist in 1 trial. Six, five and four RCTs were judged to have low, unclear and high risk of bias respectively. Eleven and six RCTs reported OS and HRQL outcomes respectively. There was no significant difference between CGA guided and usual care for OS (Hazard Ratio 1.02, 95% CI (0.90 to 1.15), I2 = 0%; moderate certainty). There was significant variation in the measurement of HRQL in terms of instruments, summary measures and time points. EORTC QLQ C30 and ELD 14 were used in 3 RCTs. The effects of CGA guided care on HRQL were inconsistent. Two trials using FACT-G or Elderly Functional Index (ELFI) reported significant improvement in HRQL at 3 and 6 months post randomization. Meta-analysis of the mean difference in the change of the EORTC QLQ C30 and E14 HRQL scores relative to baseline at 6 months post randomization demonstrated no significant difference between CGA guided and usual care for HRQL across various domains (moderate certainty evidence). The current models of CGA guided care did not improve OS and had variable effects on HRQL when compared to usual care in older patients with cancer. The inconsistent effects of CGA guided care on HRQL suggest that CGA guided care may have more significant effects on the social and functional outcomes domains, aspects of HRQL that is predominantly measured in FACT-G and ELFI score respectively. There is also heterogeneity in how CGAs are performed and implemented. Future research should focus on developing new models of CGA guided care to improve OS and HRQL.

A Checklist for Radiation Therapy Planning: Update 2023

We developed a checklist to help navigate the radiation simulation and setup process. We distilled the tasks to be performed into an easily memorizable acronym P-P-I-I-I-T (Patient Prescription, Patient Position, Immobilization, Imaging, Image Guided Radiotherapy, and Treatment Technique). This checklist ensures coverage of all the key elements and improves patient safety and treatment planning quality. Since our initial publication, we applied the checklist on 600 patients and are now presenting an update. We updated the checklist to ensure inclusion of the American College of Radiology (ACR) recommendations for radiation planning and incorporated feedback we received from allied radiation oncology professionals. The inspiration behind the easily memorizable acronym, P-P-I-I-I-T, came from a similar published checklist for systematically evaluating of a radiotherapy treatment plan, CB-CHOP, which stands for Contours, Beam Arrangement, Coverage, Heterogeneity/Hot Spots, Organs at Risk and Prescription (Dean et al. 2017), The checklist provides a simplified and standardized approach to treatment plan evaluation. Similarly, P-P-I-I-I-T checklist was put into usage as aid for both learners and staff radiation oncologists, and applied to radiation planning for 600 patients treated in Iowa between 2019 to 2022. During each session another radiation oncologist, two dosimetrists, two radiation nurses, and one physicist were present. The other radiation oncologist acted as observer to ensure the checklist was being applied appropriately by the primary radiation oncologist. The rest of the treatment team provided feedback which was relevant to their professional domains. The feedback from all members was collected and incorporated to make revisions to an updated checklist which was put into use as of January 2023. The components of the revised list are as follows: The following are the components of the revised 2023 checklist: P - Patient Prescription: Confirms the proposed dose, fractionation, and scheduling (such as concurrent chemotherapy). P - Patient Position: Describes optimal position including head, shoulder, arms and legs, alternative positions, and changes due to unexpected issues. I - Immobilization: Considers type of device, 4D set-up, gating, and custom immobilization. I - Imaging: Chooses imaging modality, slice thickness, and contrast agent, as well as fusions for SBRT and SRS. Discusses image guidance incorporating ACR recommendations and reference points. T - Treatment Technique: Includes proposed technique such as 3D, VMAT, electrons, and bolus and energy to be used. Standardization of practical guidelines and safety checklists are increasingly common in medicine. P-P-I-I-I-T (P²I³T) continues to be a simple acronym that can be used by radiation oncology residents and attendings as a checklist to ensure a complete and accurate patient setup and simulation.

Evaluation of Peer Review Practice in Radiation Oncology Treatment Planning: Single Institution Experience

Pretreatment Peer review meeting at our radiation oncology department is a weekly meeting, where the initial radiation treatment (RT) planning process for every patient is discussed including: Computed Tomography (CT) simulation and treatment planning. In this study, we are aiming to evaluate our peer review process and to report the compliance to the suggested modifications. All RT plans for all patients indicated for radiotherapy accepted by the primary radiation oncology team then presented in our weekly peer review meeting for final approval. A minimum of two radiation oncologists reviewed each plan and their suggestions documented then suggested modifications are classified as changes in: field arrangement, clinical target volume (CTV), dose and fractionation. Compliance to suggested modification also recorded as: applied and not applied with or without documented justification. Atotal of 1779 radiation treatment plans were discussed in our regular weekly peer review meetings for a period of 3 years. 67.5% of them were treated with radical intent while 32.5% treated with palliative intent. The most common technique used was three-dimensional conformal (3DCRT) followed by intensity modulated RT (IMRT) (70.6% and 29.4%, respectively). The most frequently reviewed sites were: breast (38%), Gastrointestinal (11.9%) and head and neck (9.3%).1592 plans (89.48%) were labeled as: approved, 162 (9.1%) labeled as: modified and only 25 (1.4%) plans labeled as: hold. The frequency of modifications was significantly greater in breast (39.5%) than Gastrointestinal (17.9%) followed by gynecological cancers (14.2%) (P value <0.001). Modifications were more predominant with radical plans (64.2%) than palliative ones (35.8%) (P value <0.001) and statistically greater using 3DCRT (64.2%) than IMRT (35.8%) (P value <0.001). CTV recorded as the most frequent variable suggested for modifications (34.6%), followed by dose and fractionation (24.7%) (P value = 0.035). 72.2% of recommended modifications were applied by the consultant of primary team and 22.2% of non-applied modifications were justified and documented. There was 100% compliance rate to all plans labeled as hold. The practiceof peer review in radiation oncology specialty is very challenging. Its role in quality assurance of the radiotherapy process is highly accepted by radiation oncologists at our radiation oncology department. It is reflected in their high compliance rate to the suggested modifications. We recommend its implementation routinely at any radiation oncology department to enhance the quality of RT plans.

A grounded theory of interdependence between specialist and generalist palliative care teams across healthcare settings

Background: Individuals with palliative care needs face increased risk of discontinuity of care as they navigate between healthcare settings, locations and practitioners which can result in poor outcomes. Little is known about interactions that occur between specialist and generalist palliative care teams as patients are transition from hospital to community-based care after hospitalisation. Aim: To understand what happens between inpatient specialist palliative care teams and the generalist teams who provide post-discharge palliative care for shared patients. Design: A constructivist grounded theory approach, using semi-structured interviews and constant comparative analysis, including coding, memo-writing and diagram construction. Settings/participants: Interviews (n = 21) with specialist palliative care clinicians and clinicians in other specialties providing generalist palliative care. Specialists had training in palliative care and worked in specialty palliative care practices; other clinicians worked in primary care or oncology and did not have specialised palliative care training. Results: A grounded theory of interdependence between specialist and generalist palliative care teams across healthcare settings was constructed. Two states of inter-team functioning were found which related to how teams perceived themselves: separate teams or one cross-boundary team. Three conditions influenced these two states of inter-team functioning: knowing the other team; communicating intentionally; and acknowledging and valuing the role of the other team. Conclusions: Teams need to explicitly consider and agree their mode of functioning, and enact changes to enhance knowledge of the team, intentional communication and valuing other teams’ contributions. Future research is needed to test or expand this theory across a range of cultures and contexts.