Quality Oncology Research Articles

Managing motion in conventionally fractionated lung cancer radiation therapy: Collaborative quality improvement from a statewide consortium of academic and community practices

The Michigan Radiation Oncology Quality Consortium (MROQC), funded by Blue Cross and Blue Shield of Michigan and Blue Care Network, was founded in 2011 as a collaborative effort between academic and community practice radiation oncology centers in the state of Michigan to assess the utilization of and need for advanced planning and delivery techniques in the treatment of breast and lung cancer patients. The consortium currently includes 22 active institutions. As part of the group’s efforts, several quality improvement projects have been initiated, such as the promotion of accelerated whole breast fractionation in eligible patients. 1 Jagsi R. Griffith K.A. Heimburger D. Walker E.M. Grills I.S. Boike T. et al. Choosing wisely? Patterns and correlates of the use of hypofractionated whole-breast radiation therapy in the state of Michigan. Int J Radiat Oncol Biol Phys. 2014; 90: 1010-1016 Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar In late 2014, a project was initiated to increase utilization of respiratory motion assessment for definitive, conventionally fractionated patients with lung cancer. Although national recommendations suggest motion assessment for patients in whom respiratory motion is expected to have a potential effect on treatment, 2 ASTRO A ACR–ASTRO practice parameter for image-guided radiation therapy (IGRT). 2014 Google Scholar , 3 Keall PJ Mageras GS Balter JM et al. The management of respiratory motion in radiation oncology report of AAPM Task Group 76. Med Phys. 2006; 33: 3874-3900 Crossref PubMed Scopus (1657) Google Scholar our data showed a consortium utilization rate of only 56%, with some institutions much lower than that. It can be difficult to predict which tumors may benefit from motion management techniques during treatment planning and/or delivery, 3 Keall PJ Mageras GS Balter JM et al. The management of respiratory motion in radiation oncology report of AAPM Task Group 76. Med Phys. 2006; 33: 3874-3900 Crossref PubMed Scopus (1657) Google Scholar , 4 Liu HH Balter P Tutt T et al. Assessing respiration-induced tumor motion and internal target volume using four-dimensional computed tomography for radiotherapy of lung cancer. Int J Radiat Oncol Biol Phys. 2007; 68: 531-540 Abstract Full Text Full Text PDF PubMed Scopus (275) Google Scholar , 5 Seppenwoolde Y Shirato H Kitamura K et al. Precise and real-time measurement of 3D tumor motion in lung due to breathing and heartbeat, measured during radiotherapy. Int J Radiat Oncol Biol Phys. 2002; 53: 822-834 Abstract Full Text Full Text PDF PubMed Scopus (1149) Google Scholar although the extent of motion, on average, is increased in nonattached and lower lobe tumors.

Raising all boats in supportive oncology: Initial impact of the Coleman Supportive Oncology Collaborative (CSOC).

150 Background: The Institute of Medicine (IOM) and Commission on Cancer (CoC) recommend systematic delivery of supportive oncology and survivorship care to all cancer patients. CSOC aims to improve the quality of supportive care across Chicago-area providers. Methods: 35 CSOC participating institutions (cancer centers, support centers, hospice) formed care delivery design teams - Distress, Survivorship and Palliative. Teams collaboratively developed solutions to supportive oncology gaps: patient screening tools, care delivery processes, provider training, and quality metrics to assess supportive oncology quality and the CSOC impact. Six implementation centers (2 safety-net, 3 academic & 1 public) reviewed charts at baseline (2014 diagnoses) and after the initial implementation period (2015 diagnoses), compared by frequencies and Fisher’s exact test. Results: Eight metrics contained patient data at 2 time points; improvements were seen in 7/8 metrics. (See Table). Conclusions: CSOC developed supportive oncology screening, and care processes aligned with IOM and CoC standards. Significant improvements were shown after implementation across diverse settings. Ongoing work will further evaluate the impact of CSOC efforts on patient care. [Table: see text]

Improving advanced care planning in patients with metastatic cancer.

6 Background: Our group as a member of the Michigan Oncology quality Consortium (MOQC) participates in ongoing quality metric evaluations every spring and fall. Through this exercise we found we were performing low on the advance care planning (ACP) metrics. To address this we first realized we did not had a consistent place in the HER to document this. We created an ACP note and then worked on identifying a patient advocate and starting the ACP process. Methods: We first assessed our standard practice prior to joining MOQC and found we were entirely dependent upon the physician to initiate the discussion and often this was being done by the physician only at the time of disease progression. We then garnered the healthcare team to help with the process. The medical assistants (MA) would give the patient the DPOA/ACP forms with a brief explanation of the forms. This would be reiterated by the provider. On subsequent visits, the MA would ask the patient about the status of the form and if it had been filled out, and if not the nurse was flagged to call the patients . The physician assistant starting discussing the DPOA/ACP form in the chemo teach sessions. We then audited the charts of 100 patients’ after implementing the changes and compared them to our historic data from MOQC. Results: By implementing these changes we were able to increase our hospice enrollment from 47% to 66%; and our documented discussion of ACP went from 27% to 83%. However 25% of our patients still died in the hospital and we were consulted on only 50% of the hospitalized patients. Conclusions: Although we were able to improve referrals to hospice and increase discussion of ACP, there is still much work to be done. Despite the improvements we saw in the documentation of end of life discussions there was still a significant number of patietns who were admitted to the hospital at the end of life and who died in the hospital. One of the reasons could be the lack of communication with admitting providers as we were consulted in only 50% of those patients.

Does site-of-care for oncology infusion therapy influence treatment patterns, cost, and quality in the United States?

Background: The increase in hospital acquisition of community oncology clinics in the US has led to a shift in the site-of-care (SOC) for infusion therapy from the physician office (PO) to the hospital outpatient (HO) setting.Objective: To investigate differences by SOC in treatment patterns, quality, and cost among patients with cancer undergoing first-line infusion therapy.Research design and methods: This retrospective analysis identified adult patients from Humana medical claims who initiated infusion therapy from 2008–2012 for five common cancer types in which infusion therapy is likely, including early stage breast cancer; metastatic breast, lung, and colorectal cancers; and non-Hodgkin’s lymphoma or chronic lymphocytic leukemia. Differences by SOC in first-line treatment patterns and quality of care at end-of-life, defined as infusions or hospitalizations 30 days prior to death, were evaluated using Wilcoxon-Rank Sum and Chi-square tests where appropriate. Differences in cost by SOC were evaluated using risk-adjusted generalized linear models.Main outcome measures: Treatment patterns, quality of care at end of life, healthcare costs.Results: There were differences in duration of therapy and number of infusions for some therapy regimens by SOC, in which patients in the HO had shorter duration of therapy and fewer infusions. There were no differences in quality of care at end-of-life by SOC. Total healthcare costs were 15% higher among patients in HO ($55,965) compared with PO ($48,439), p < .0001.Limitations: Analyses was restricted to a claims-based population of cancer patients within a health plan.Conclusion: This study, in an older, predominantly Medicare Advantage oncology cohort, found differences by SOC in treatment patterns and cost, but not quality. Where differences were found, patients receiving care in the HO had shorter duration of therapy and fewer infusions for specific treatment regimens, but higher healthcare costs than those treated in a PO.

Improving the quality of radiation oncology: 10 years’ experience of QUATRO audits in the IAEA Europe Region

Background and purposeThe IAEA has developed a methodology for comprehensive quality audits of radiotherapy practices called Quality Assurance Team for Radiation Oncology (QUATRO). This study explores the factors that impacted quality of care among QUATRO audited centres in the IAEA Europe Region. Materials and methodsThe 31 QUATRO reports collected over 10years include extensive data describing the quality of radiotherapy at the audited centres. A coding key was developed to aggregate and review these data in terms of recommendations for improvement and positive findings (commendations). ResultsOverall 759 recommendations and 600 commendations were given. Eight centres recognized as centres of competence differed from other centres mostly because they operated complete quality management systems and were adequately staffed. Other centres had excessive staff workloads and many gaps in the process of care. Insufficient equipment levels were prevalent. Patient centredness, communication, dosimetry, quality control and radiation protection were frequently commended by QUATRO. ConclusionsThis analysis points to barriers to quality care such as insufficient staffing, education/training, equipment and lack of quality management. It highlights the correlation between the human resources availability and quality of care. It has also identified common action items for enhancing quality of radiotherapy programmes in the Region.

Dosimetric predictors for acute esophagitis during radiation therapy for lung cancer: Results of a large statewide observational study

PurposeThe purpose of this study is to identify dosimetric variables that best predict for acute esophagitis in patients treated for locally advanced non–small cell lung cancer in a prospectively accrued statewide consortium. Methods and materialsPatients receiving definitive radiation therapy for stage II-III non–small cell lung cancer within the Michigan Radiation Oncology Quality Consortium were included in the analysis. Dose-volume histogram data were analyzed to determine absolute volumes (cc) receiving doses from 10 to 60 Gy (V10, V20, V30, V40, V50, and V60), as well as maximum dose to 2 cc (D2cc), mean dose (MD), and generalized equivalent uniform dose (gEUD). Logistic regression models were used to characterize the risk of toxicity as a function of dose and other covariates. The ability of each variable to predict esophagitis, individually or in a multivariate model, was quantified by receiver operating characteristic analysis. ResultsThere were 533 patients who met study criteria and were included; 437 (81.9%) developed any grade of esophagitis. Significant variables on univariate analysis for grade ≥2 esophagitis were concurrent chemotherapy, V20, V30, V40, V50, V60, MD, D2cc, and gEUD. For grade ≥3 esophagitis, the predictive variables were: V30, V40, V50, V60, MD, D2cc, and gEUD. In multivariable modeling, gEUD was the most significant predictor of both grade ≥2 and grade ≥3 esophagitis. When gEUD was excluded from the model, D2cc was selected as the most predictive variable for grade ≥3 esophagitis. For an estimated risk of grade ≥3 esophagitis of 5%, the threshold values for gEUD and D2cc were 59.3 Gy and 68 Gy, respectively. ConclusionsIn this study, we report the novel finding that gEUD and D2cc, rather than MD, were the most predictive dose metrics for severe esophagitis. To limit the estimated risk of grade ≥3 esophagitis to <5%, thresholds of 59.3 Gy and 68 Gy were identified for gEUD and D2cc, respectively.

Are we making an impact with incident learning systems? Analysis of quality improvement interventions using total body irradiation as a model system

PurposeDespite increasing interest in incident learning systems (ILS) to improve safety and quality in radiation oncology, little is known about interventions developed in response to safety data. We used total body irradiation (TBI) as a model system to study the effectiveness of interventions from our institutional ILS. Methods and materialsNear-miss event reports specific to TBI were identified from a departmental ILS from March 2012 to December 2015. The near-miss risk index was rated at multidisciplinary review from 0 (no potential harm) to 4 (critical potential harm). Interventions were analyzed for effectiveness with a schema adapted from The Joint Commission and other agencies: “most reliable” (eg, forcing functions, automation), “somewhat reliable” (eg, checklists, standardization), and “least reliable” (eg, training, rules, procedures). Causal factors of each event were drawn from the casual factor schema used in radiation oncology ILS. ResultsOf 4007 safety-related reports, 266 reports pertained to TBI. TBI reports had a somewhat higher proportion of high-risk events (near-miss risk index 3-4) compared with non-TBI reports (25% vs 17%, P = .0045). A total of 117 interventions were implemented. The reliability indicators for the interventions were: most reliable (11% of interventions), somewhat reliable (17%), and least reliable (72%). Interventions were more likely to be applied to high-risk events (54% vs 41%, P = .03). There was a pattern of high-reliability interventions with increased risk score of events. Events involving human error (eg, slips) and equipment/information technology lent themselves more often to high-reliability interventions. Events related to communication, standardization, and training were associated with low-reliability interventions. ConclusionsOver a 3.5-year period, 117 quality improvement strategies were developed for TBI based on ILS. Interventions were more likely to be applied to high-risk events and high-risk events were more likely to be associated with high-quality interventions. These results may be useful to institutions seeking to develop interventions based on ILS data.

Raising all boats in supportive oncology: Initial impact of the Coleman Supportive Oncology Collaborative (CSOC).

e18205 Background: The Institute of Medicine (IOM) and Commission on Cancer (CoC) recommend systematic delivery of supportive oncology and survivorship care to all cancer patients. CSOC aims to improve the quality of supportive care across Chicago-area providers. Methods: 35 CSOC participating institutions (cancer centers, support centers, hospice) formed care delivery design teams Distress, Survivorship &amp; Palliative. Teams collaboratively developed solutions to supportive oncology gaps: patient screening tools, care delivery processes, provider training, and quality metrics to assess supportive oncology quality and the CSOC impact. Six implementation centers (2 safety-net, 3 academic &amp; 1 public) reviewed charts at baseline (2014 diagnoses) and after the initial implementation period (2015 diagnoses), compared by frequencies and Fisher’s exact test. Results: Eight metrics contained patient data at 2 time points; improvements were seen in 7/8 metrics. Conclusions: CSOC developed supportive oncology screening, and care processes aligned with IOM and CoC standards. Significant improvements were shown after implementation across diverse settings. Ongoing work will further evaluate the impact of CSOC efforts on patient care. [Table: see text]

Variation in the use of advanced imaging at the time of breast cancer diagnosis in a statewide registry.

Although national guidelines do not recommend extent of disease imaging for patients with newly diagnosed early stage breast cancer given that the harm outweighs the benefits, high rates of testing have been documented. The 2012 Choosing Wisely guidelines specifically addressed this issue. We examined the change over time in imaging use across a statewide collaborative, as well as the reasons for performing imaging and the impact on cost of care. Clinicopathologic data and use of advanced imaging tests (positron emission tomography, computed tomography, and bone scan) were abstracted from the medical records of patients treated at 25 participating sites in the Michigan Breast Oncology Quality Initiative (MiBOQI). For patients diagnosed in 2014 and 2015, reasons for testing were abstracted from the medical record. Of the 34,078 patients diagnosed with stage 0-II breast cancer between 2008 and 2015 in MiBOQI, 6853 (20.1%) underwent testing with at least 1 imaging modality in the 90 days after diagnosis. There was considerable variability in rates of testing across the 25 sites for all stages of disease. Between 2008 and 2015, testing decreased over time for patients with stage 0-IIA disease (all P < .001) and remained stable for stage IIB disease (P = .10). This decrease in testing over time resulted in a cost savings, especially for patients with stage I disease. Use of advanced imaging at the time of diagnosis decreased over time in a large statewide collaborative. Additional interventions are warranted to further reduce rates of unnecessary imaging to improve quality of care for patients with breast cancer. Cancer 2017;123:2975-83. © 2017 American Cancer Society.

Oncology pharmacist opportunities: Closing the gap in quality care.

174 Background: The quality of care provided to oncology patients is beginning to be linked to hospital and practice payment models. Oncology pharmacy specialists are well trained to deliver high-quality oncology care, with a focus on the appropriate utilization and monitoring of medication therapy, patient education and collaboration with other healthcare team members. The extent to which the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) metrics identify specific areas in which pharmacists may enhance care is not known. These findings are important because Centers for Medicare and Medicaid Services designate QOPI as a Qualified Clinical Data Registry (QCDR) and over 1000 US-based oncology practices submit quality data to it. Methods: We reviewed all QOPI measures for potential oncology pharmacist involvement. We utilized a summary of services provided by board-certified oncology pharmacists to identify which services would best fit the care described by the selected QOPI measures. Three individuals identified the areas where pharmacists could contribute and consensus was reached. Metrics were only scored positively for pharmacist impact if they could be obtained via the pharmacist as the primary team member responsible for meeting the measure. Results: Two hundred QOPI quality measures from Fall 2016 were reviewed and 177 were analyzed. Potential areas of pharmacist impact were identified in 67 (38%) of the included metrics. These measures fell within 11 of the 13 possible categories of the service summary. A total of 147 services were identified for the 67 actionable metrics. Patient counseling and education (28%), symptom management and supportive care (23%), chemotherapy adjustment (10%), and participation in protocol-based care (10%) comprised services that most commonly contributed to the ASCO QOPI measure performance. Conclusions: Multiple opportunities exist for pharmacists to directly impact the quality metrics that are measured by the service summary. Focusing new services and patient care activities to address validated quality metrics is a natural next step in the care that oncology clinical pharmacists provide to patients.

The relationships between patient volume per oncologist, social worker presence, and capacity to provide psychosocial care.

156 Background: The purpose of this study was to investigate the relationships between new patient volume per oncologist, the availability of a social worker, and the capacity to provide psychosocial care. Methods: Community practices within Michigan Oncology Quality Consortium (MOQC), a statewide quality collaborative, completed NCI’s 10-item Cancer Psychosocial Care Matrix (CPCM). The CPCM speaks to communication, assessment, coordination, training, and outcomes and quality, each on a separate Likert scale. Analyses describe the ability to meet psychosocial care and the availability of a social worker, new patients/full time oncologist, payer mix, and percent minorities. Results: To date,15 of 47 practices (32%) completed the CPCM. We report on 4 measures with sizeable variation between practices. Scores were the highest on the ability to communicate the importance of psychosocial care and implementing a plan (scale of 1 – 3; mean of 2.36, standard deviation, SD 0.72; mean of 1.79, SD 0.89). The lowest scores were related to linking patients with services and offering provider education (scale of 1 – 5: mean of 2.18, SD 1.08; mean of 2.20, SD 0.94). Linear regression showed an association with number of patients/oncologist and the ability to provide staff training of effective patient/provider communication and monitoring this activity’s impact. For every 100-person increase in the number of patients/oncologist, there was a -0.16 (p = 0.046) rating difference in staff training and a -0.25 (p = 0.006) rating difference to monitor the communication’s effect. A dedicated social worker was present in 3 practices. Regression analysis showed a relationship between a social worker and recognizing (p=0.02) and addressing psychosocial care (p&lt;0.001). There was wide variation in payer mix and percent minorities but no association between the dependent variables and these characteristics. Conclusions: Community practices with a larger volume of new patients/oncologist/year are less likely to provide staff training and monitoring on psychosocial communication. In this sample, payer mix and racial composition are not associated with a practice’s ability to deliver psychosocial care.

Challenges, barriers, and keys to success for sustainable quality improvement in oncology: A focus group of oncology quality leaders.

78 Background: A sustainable, standardized approach for quality assessment and improvement is increasingly expected in oncology. This requires oncology leaders to identify processes and infrastructure to facilitate sustainable initiatives for practice refinement. To date, few summative reports of lessons learned, key success factors, and barriers to regular quality improvement have been reported. Methods: After IRB protocol approval, a focus group of 11 diverse physician oncology leaders was conducted, using a guide developed through multiple discussions by investigators. The physicians represented diverse organizations with community-based, private practice and academic settings. Data analysis of interview transcripts was performed iteratively, with a grounded theory approach with a method called “constant comparisons”, with related open and axial coding techniques. Transcripts were coded independently by two or three coders, and the resulting code lists integrated prior to final analysis. Differences in coding were resolved by consensus. Results: Overall, physician quality leaders discussed needs and barriers in 5 major domains: coordination of care, communication, finances, value, and quality improvement. Two major themes emerged: rapid change cycles in a dynamic landscape of practice--changing business models and care delivery, new expensive drugs, oral chemotherapy--and their respective unintended consequences on quality of care, e.g. financial toxicity for patients, misalignment of financial incentives and a quality agenda. Participants discussed responding to these changes and key factors in harnessing the practice model to deliver quality care. Conclusions: Cancer care delivery is rapidly evolving and undergoing intrinsic cycles of quality improvement. This project helps to inform systemic quality improvement efforts targeted towards oncology practices by identifying areas of concern and highlighting key factors to be addressed to achieve value, alignment and quality of care. Institutional culture and infrastructure including resources and incentives for quality improvement/measurement were identified as critical success factors.

Feasibility of capturing radiation oncology quality metrics in a large integrated oncology practice.

83 Background: Metrics to assess quality are important to improve processes of care. While such capture and reporting are common in medical oncology practices, it is less common with radiation oncology. As part of a large integrated oncology practice with more than 400 physicians and 57 radiation oncologists, we explored the feasibility of capturing and reporting a bundle of metrics at each of 52 radiation oncology practice sites. Methods: At the beginning of each quarter, the first 20 charts were sampled at each rad onc site of service to capture the following metrics: performance status at the start of radiation therapy, pain level at the start of XRT for patient with bone metastasis, cancer staging documented, dose limits to normal tissue tissues established and clearly documented for IMRT cases, and adherence to the 2015 US Oncology Breast Cancer XRT Pathways. Pathways adherence was captured via physician attestation. Beginning in the second quarter, Breast Cancer Pathways concordance with the final delivered plan was reported. Beginning in the 3rdquarter, additional pathways were captured (but not reported) for NSCLC, Prostate, Rectal Cancer, and Bone Metastasis sites. Results: See table. Conclusions: Availability of metrics data and compliance was greater than 80% in all 52 radiation oncology practice sites. Documentation of dose limits was seen as an opportunity for improvement via standardization of workflows, as there were multiple workflows within the record and verify system. Concordance rate between attestation of pathways compliance and the delivered plan was high. Breast cancer pathways compliance fell in the third quarter when additional pathways were added, suggesting that increasing complexity of metrics requirements may decrease performance. [Table: see text]

Leveraging technology to facilitate distress screening.

195 Background: Research has shown cancer patients are at increased risk for distress during their cancer treatment. Distress screening is required for cancer programs seeking accreditation from the American College of Surgeons, Commission on Cancer and certification from the American Society of Clinical Oncology Quality Oncology Practice Initiative. Developing a successful distress screening program is essential for cancer programs. Methods: The purpose of this project was to create a comprehensive distress screening program utilizing the electronic health record (EHR) to identify patients requiring screening and document interventions. A multidisciplinary team was established to develop a distress screening process for our cancer program. The team developed a screening tool based on the National Comprehensive Cancer Network Distress Thermometer. The distress screening tool was built into the EHR. An alert was created to notify staff at visit check-in to provide the distress screening tool. Once completed, the score and any areas of distress indicated by the patient are entered into the EHR by the medical assistant. When a score is documented, the nurse case manager (CM) receives a “Distress Score” alert when accessing the patient’s chart, indicating the need for nursing review. The CM reviews the score, assesses patient needs and documents any needed interventions or referrals. A specific score does not require a specific intervention, rather the CM is required to determine the needs of the individual patient and take appropriate action. Results: In 2015, 8069 patients were offered distress screening with 13,527 distress screenings completed. This resulted in 629 referrals to social work. 803 distress screens had a score of seven or greater (6%). Conclusions: The multidisciplinary team continues to evaluate the process and make changes. Auditing reveals compliance with documenting a distress score of 95% or greater across all oncology areas and review by the CM of at least 93% on a consistent basis. In many instances, the physician and/or the CM address distress related to the patient’s disease or symptom management. Use of the EHR has facilitated the workflow and allowed information to be visible to the care team.

Site variation in assessment of biomarkers on biopsy specimens in patients with metastatic disease.

224 Background: Clinical practice guidelines in patients with metastatic breast cancer recommend assessment of biomarkers—estrogen receptors (ER), progesterone receptors (PR), and HER2—on metastatic lesions. The purpose of this study was to identify factors associated with assessment of these biomarkers in patients who had undergone confirmatory biopsies. We were particularly interested in variation between treatment sites. Methods: Eligible patients were those diagnosed with metastatic breast cancer who had undergone a confirmatory biopsy and who were part of the Michigan Breast Oncology Quality Initiative (MiBOQI) registry, a statewide registry of 25 health systems. Analyses investigated associations between assessment of ER, PR, HER2 and treating center, disease, clinical and non-clinical factors. Results: Between 2006 and 2015, 805 patients had a confirmatory biopsy. Of these, 66% had ER, 63% had PR, 62% had HER2, and 57% had all three assessed on the biopsy specimen. In bivariate analysis, characteristics associated with assessment of biomarkers were earlier stage and hormone receptor-positive primary tumors, private or military insurance, white race, longer time since initial diagnosis, and bone only, liver only, lung only, chest wall, skin, and lymph nodes, and multiple sites of metastases. Younger age was positively associated with assessment of HER2. Biomarker assessment also varied significantly between treatment sites and increased over time. In multivariate analyses, time since diagnosis of the primary (p &lt; 0.001) and treatment site (p &lt; 0.001) remained significant. With the exception of ER (p = 0.09), performance of biomarkers increased significantly over time. Conclusions: Across 25 health systems in a quality improvement collaborative, the proportion of patients with metastatic disease who underwent a confirmatory biopsy increased over time. Nonetheless, treatment site continued to be independently associated with the odds of having biomarkers assessed on biopsy specimens. Our findings suggest that there are opportunities for improvement to provide guideline-concordant care in patients treated in diverse settings.

Clinical and nonclinical factors associated with confirmatory biopsy in metastatic breast cancer.

249 Background: In patients with metastatic breast cancer, clinical practice guidelines include obtaining histologic confirmation of metastases when possible. The purpose of this study was to investigate patterns and correlates of receipt of a confirmatory biopsy. Methods: Data were abstracted from the records of patients diagnosed with metastatic breast cancer in the Michigan Breast Oncology Quality Initiative (MiBOQI), a statewide registry of 25 health systems. Patients with Stage IV disease at diagnosis were excluded. Analyses investigated associations between receipt of a confirmatory biopsy and disease, clinical and non-clinical factors, and treating health system. Results: Data were available for 1,231 (96%) of eligible patients between 2006 and 2015. Of these, 66% had a confirmatory biopsy; the proportion of patients having a biopsy varied between the 25 sites from 41% to 100% (p = 0.03). In bivariate analyses, younger age (p = 0.02), lower comorbidity (p = 0.007), longer time between the primary and recurrence (p &lt; 0.001), more recent year of recurrence (p = 0.01), having liver, skin, soft tissue, or multiple metastases (p &lt; 0.001), and private or government insurance (p = 0.002) were associated with biopsy. In multivariate analyses, longer time since the primary diagnosis (p &lt; 0.001), more recent year of recurrence (p = 0.03), initial site(s) of recurrence (p &lt; 0.001), and private or government insurance (p = 0.004) remained significant predictors of biopsy. Treatment site was no longer significant (p = 0.14). Minority status, obesity status, and disease characteristics (stage, estrogen receptor, progesterone receptor, HER2, grade) of the primary were not significant in either bivariate or multivariate analyses. Analyses were repeated without insurance with no change in the other findings. Conclusions: In a statewide collaborative, the proportion of patients having a confirmatory biopsy increased over the study period and was associated with several clinical factors. Insurance was an independent and significant predictor of receipt of what is considered standard care.

Abstract P1-10-08: Factors affecting the administration of post-mastectomy radiation therapy (PMRT) in Michigan

Abstract Background: Evidence-based guidelines for locoregional therapy of invasive breast cancer treated with mastectomy include adjuvant PMRT for: ≥4 positive axillary lymph nodes (LN); T3 or above; or a positive surgical margin. We assessed PMRT uptake using data from the Michigan Breast Oncology Quality Initiative (MiBOQI), a Blue Cross Blue Shield of Michigan/Blue Care Network-sponsored collaborative quality initiative, and identified factors influencing its use in Michigan. Methods: We prospectively collected clinical data on all patients with stage I-III breast cancer in 25 health systems belonging to MiBOQI and identified patients who underwent mastectomy from 2008 to 2013. Patients with previous cancer, bilateral disease, or treated with neoadjuvant chemotherapy were excluded. Univariate and multivariate analyses were performed to identify independent factors associated with the use of PMRT in patients with 0, 1-3, and 4+ positive LNs. Covariates included age, hormone receptor status, HER2 status, surgical margin, T category, Charlson comorbidity index, and immediate reconstruction. Two-tailed p-values &amp;lt;0.05 were considered significant. Analyses were carried out using SAS software, version 9.4 (SAS Institute, Cary, NC). Results: We identified 6,596 patients with stage I-III invasive breast cancer. Of these, 4,455 had no positive axillary LNs; 1,481, 1-3 positive LNs; and 660, ≥4 positive LNs. There was wide variation in PMRT use across MiBOQI sites, from 13% to 63.% in patients with 1-3 positive LNs (overall 42%) and from 35% to 91% in patients with 4+ positive LNs (overall 69%). In multivariate analyses stratified by nodal status (0, 1-3, 4+), age ≥ 70 yrs was negatively associated with PMRT. We also noted lower PMRT use in women aged 51-69 with 0 and 1-3 positive LNs (Table 1). Table 1. Multivariate analysis: PMRT and age (+)LNs = 0(+)LNs = 1-3(+)LNs ≥ 4AgeOdds ratiop-valueOdds ratiop-valueOdds ratiop-value≤50 y (reference)1.0 1.0 1.0 51-69 y0.70 (0.49 - 0.98)0.030.69 (0.54 - 0.88)&amp;lt;0.00011.03 (0.63 - 1.65)&amp;lt;0.0001≥70 y0.60 (0.37 - 0.96) 0.26 (0.18 - 0.37) 0.31 (0.18 - 0.54) In the 0 and 1-3 positive node groups, PMRT use was strongly associated with T category and close or positive margin status (Table 2). Table 2: Surgical characteristics and PMRT uptake (+)LNs = 0(+)LNs = 1-3(+)LNs ≥4VARIABLEOdds ratiop-valueOdds ratiop-valueOdds ratiop-valueMargin status Negative (reference)1.0 1.0 1.0 Positive16.7 (10.5 - 26.7)&amp;lt;0.00012.27 (1.32 - 3.90)0.0010.69 (0.32 - 1.47)0.90Close (&amp;lt;1 mm)4.63 (3.03 - 7.10) 1.90 (1.29 - 2.80) 0.97 (0.55 - 1.69) T category T0 to T2 (reference)1.0 1.0 1.0 T3 to T426.2 (16.4 - 41.8)&amp;lt;0.00013.24 (2.19 - 4.78)&amp;lt;0.00010.86 (0.57 - 1.28)0.45 Finally, there was no association between PMRT use and hormone receptor status, HER2 status, Charlson comorbidity index, or reconstructive surgery at the time of mastectomy. Conclusions: PMRT use across Michigan was lower than the American College of Surgeons Commission on Cancer target of 90% in patients with 4 or more positive LNs. Contrary to common belief, immediate reconstructive surgery was not independently associated with decreased PMRT uptake. Understanding reasons for nonuse of PMRT may lead to interventions to increase its use by MiBOQI member institutions in patients for whom it is indicated. Citation Format: Gorski DH, Braun T, Munir K, Griggs JJ, Breslin TM, Henry NL. Factors affecting the administration of post-mastectomy radiation therapy (PMRT) in Michigan [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-08.

Improving Oncology Quality Measurement in Accountable Care: Filling Gaps with Cross-Cutting Measures.

Funding for this project was provided by the National Pharmaceutical Council (NPC). Westrich and Dubois are employees of the NPC. Valuck is a partner with Discern Health. Blaisdell and Dugan are employed by Discern Health. McClellan reports fees for serving on the Johnson & Johnson Board of Directors. Dugan reports consulting fees from the National Committee for Quality Assurance and Pharmacy Quality Alliance. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Blaisdell, Valuck, Dugan, and Westrich. Blaisdell took the lead in data collection, along with Valuck and Dugan, and data interpretation was performed by Valuck, Blaisdell, Westrich, and Dubois. The manuscript was written by Blaisdell, along with Valuck and Dugan, and revised by Valuck, Westrich, Miller, and McClellan.

Lower Incidence of Esophagitis in the Elderly Undergoing Definitive Radiation Therapy for Lung Cancer

IntroductionMost patients with lung cancer are elderly and poorly represented in randomized clinical trials. They are often undertreated because of concerns about their ability to tolerate aggressive treatment. We tested the hypothesis that elderly patients undergoing definitive lung radiation might tolerate treatment differently than younger patients. MethodsA total of 125 patients who underwent definitive lung radiotherapy were identified from a prospective institutional database (University of Michigan cohort). Logistic regression modeling was performed to assess the impact of age on esophagitis grade 2 or higher or grade 2 or higher and pneumonitis grade 3 or higher or grade 2 or higher, with adjustment for esophageal and lung dose, respectively, as well as for chemotherapy utilization, smoking status, and performance status. The analysis was validated in a large cohort of 691 patients from the Michigan Radiation Oncology Quality Consortium registry, an independent statewide prospective database. ResultsIn the University of Michigan cohort, multivariable regression models revealed a significant inverse correlation between age and rate of esophagitis for both toxicity levels, (adjusted OR = 0.93 for both models and 95% confidence intervals of 0.88–0.98 and 0.87–0.99), with areas under the curve of 0.747 and 0.721, respectively, demonstrating good fit. This same association was noted in the Michigan Radiation Oncology Quality Consortium cohort. There was no significant association between age and pneumonitis. ConclusionsThere is a lower incidence of esophagitis with increasing age even after adjustment for use of chemotherapy. This is a novel finding in thoracic oncology. No age dependence was noted for pulmonary toxicity. The elderly are able to tolerate definitive thoracic radiation well and should be offered this option when clinically warranted.

The relationship between patient activation, confidence to self-manage side effects, and adherence to oral oncolytics: a pilot study with Michigan oncology practices.

The Michigan Oncology Quality Consortium (MOQC) is a continuous quality improvement collaborative seeking to improve oncology care in Michigan, including for patients taking oral chemotherapy. The aim of this study was to assess the relationship between patient activation, confidence to self-manage side effects, and adherence to oral oncolytics to inform future oncology care. A multicenter cross-sectional observational study was conducted using an online survey to examine patient activation (patient activation measure, PAM), health literacy, symptom burden (Edmonton Symptom Assessment System, ESAS), confidence to self-manage side effects (fatigue, nausea, and diarrhea), and adherence to oral oncolytics. Inclusion criteria were patients taking an oral oncolytic for at least 1month. Bivariate analyses and logistic regression were performed to evaluate relationships between the variables. A total of 125 respondents, mean (SD) age 66.2 (13.6), 57.7% female, and 95.1% Caucasian completed the survey. The mean (SD) PAM score was 65.0 (18.0). Confidence to manage fatigue, nausea, and diarrhea was associated with higher activation, and confidence to self-manage fatigue and diarrhea were associated with higher health literacy. About 30% of participants reported some level of non-adherence to oral oncolytics, and those who experienced side effects (Fisher's exact test p=0.033) and with shorter length of therapy (t test p=0.027) were significantly more likely to be non-adherent. These findings show that there is room for improvement across practices involved with MOQC with regard to supporting patients taking oral oncolytics. Patients will need to improve their activation levels, and oncology clinics will need to create new workflows in order to enhance self-care management ability for patients taking oral oncolytics.