Quality Of Care In Oncology Research Articles

INNOVATIVE MODEL OF COUNSELLING AND GUIDANCE FOR CANCER PATIENTS AND PERSONS AT RISK, IN ORDER TO IMPROVE THE QUALITY OF ONCOLOGICAL SERVICES

The continuous preoccupation at the international level to improve the quality of oncologic care has led to the development of models of good practice with proven efficacy, such as navigator. Given the current situation in Romania, in terms of morbidity and mortality through cancer, it is necessary the adoption and introduction of such innovative practice models, of great benefit to patients with cancer, but also for the health system. National School of Public Health, Management and Professional Development and Romanian Nursing Association meet this aim through the project Innovative Strategy for Bridging Cancer Care in by elaboration of aninnovativemodel for oncology services in Romania. This modelstartsfrom the knowledge of the current situation regarding the barriers in the system, the needs of patients and medical staff and proposes the integration of the positive experiences in United States regarding the improving of early detection of the disease, improving the quality of patients' care and patient s’ satisfaction. The model of nurse navigator adapted, adequate for Romania is one of guidance, counselling, information and support for patients with oncological diseases, but at the same time, of education and prevention among the general population and population groups at higher risk for cancer. Keywords: cancer, quality of services, innovative models, Romania, nurse navigator

INFECTION RELATED TO CENTRAL VENOUS CATHETER: INDICATOR OF QUALITY OF CARE IN ONCOLOGY

Objetivo: Fundamentar “infecção relacionada a cateter venoso central de longa-permanência” como indicador de qualidade da assistência de enfermagem em oncologia e identificar indicadores de processo correlacionados. Métodos: Levantamento exploratório em uma unidade de internação clínica oncológica, sendo investigadas variáveis clínicas, terapêuticas e relativas aos cateteres e cuidados de enfermagem. Através do cálculo da razão de prevalências foram analisados elementos intervenientes no desempenho do indicador de resultado avaliado. Resultados: Processos associados ao risco de infecção foram: periodicidade da renovação de curativos, manutenção da permeabilidade do cateter, manutenção do sistema de infusão fechado e atenção a sinais flogísticos. Conclusão: Ações de prevenção de infecção estiveram contidas no espectro de ações do enfermeiro, corroborando-se o uso do indicador infecção relacionada a cateter venoso central de longa-permanência, como importante medida a ser gerenciada em unidades de internação oncológica. Descritores: Indicadores de Qualidade em Assistência a Saúde, Enfermagem Oncológica, Cateterismo Venoso Central, Infecção.

Patients’ and professionals’ evaluations of quality of care in oncology outpatient clinics

The purpose of this study is to compare patients' and professionals' evaluations of the quality of care in oncology outpatient clinics. The data were drawn from a 2011 survey of 1,379 patients and 155 professionals conducted in 15 % of oncology outpatient clinics in Quebec, Canada. Respondents completed self-administered questionnaires that addressed the aspects of timeliness (TIM), patient-centred care (PCC), communication (COM), quality of the physical environment (QPE), and continuity (CONT). Patients' and professionals' mean scores (maximum = 4) for each aspect were compared using mixed model analysis. Patients' and professionals' perceptions of quality of care were largely positive, with mean scores for all items of 3.66 and 3.37, respectively. However, for the majority of aspects of quality, the professionals' scores were lower than those of patients. The aspects rated most positively by both groups were PCC, COM and CONT. Timeliness was the least positively evaluated, with mean scores of 3.34 for patients and 3.16 for professionals. In many respects, cancer patients and professionals share relatively common views about the most and least positive aspects of the quality of care, although professionals tend to be more critical. Aspects evaluated less favourably by both groups and those on which opinions differ are good candidates for improvements. Some ideas for solutions are proposed. Positive patient feedback is especially important in cancer care, where attraction and retention of professionals is a key concern.

Identifying Tools and Strategies to Provide Quality Oncology Care

This session of the ASCO Quality Symposium provided an opportunity to examine a variety of research and quality improvement strategies aimed at improving the quality of cancer care along the continuum.

Patient Income Level and Cancer Clinical Trial Participation

Studies have shown an association between socioeconomic status (SES) and quality of oncology care, but less is known about the impact of patient SES on clinical trial participation. We assessed clinical trial participation patterns according to important SES (income, education) and demographic factors in a large sample of patients surveyed via an Internet-based treatment decision tool. Logistic regression, conditioning on type of cancer, was used. Attitudes toward clinical trials were assessed using prespecified items about treatment, treatment tolerability, convenience, and cost. From 2007 to 2011, 5,499 patients were successfully surveyed. Forty percent discussed clinical trials with their physician, 45% of discussions led to physician offers of clinical trial participation, and 51% of offers led to clinical trial participation. The overall clinical trial participation rate was 9%. In univariate models, older patients (P = .002) and patients with lower income (P = .001) and education (P = .02) were less likely to participate in clinical trials. In a multivariable model, income remained a statistically significant predictor of clinical trial participation (odds ratio, 0.73; 95% CI, 0.57 to 0.94; P = .01). Even in patients age ≥ 65 years, who have universal access to Medicare, lower income predicted lower trial participation. Cost concerns were much more evident among lower-income patients (P < .001). Lower-income patients were less likely to participate in clinical trials, even when considering age group. A better understanding of why income is a barrier may help identify ways to make clinical trials better available to all patients and would increase the generalizability of clinical trial results across all income levels.

Quality improvement research in oncology: A bibliometric analysis.

159 Background: As part of the Affordable Care Act of 2010, the U.S. government has established a “National Strategy for Quality Improvement in Health Care,” with the goal of implementing evidence-based research into practice. The quantity of oncology research devoted to quality improvement is uncertain. We use the percentage of quality improvement articles in the oncology literature as a proxy metric to gauge the importance given to quality improvement in oncology. Methods: A MEDLINE literature search was performed on July 14, 2012. We approximated the number of articles published in the field of oncology using a PubMed search with the MeSH (Medical Subject Headings) term “neoplasm” or keywords “neoplasm,” “cancer,” or “oncology.” Results were limited to English language and publication dates between July 2010 and June 2012. From this data, the number of articles concerning quality improvement was approximated using the MeSH term “quality improvement” or keywords “quality improvement.” Results: Of approximately 246,000 English language, oncology-related articles published in the last two years, 314 focused on “quality improvement.” The topic of quality improvement comprised only 0.1% of the oncology literature over this period. Conclusions: Using bibliometric analysis, it appears that research on quality improvement in oncology is infrequent. Quality improvement research has been found effective in other fields and requires increased emphasis by the oncology research community. To improve the quality of care in oncology, evidence-based research in the field of quality improvement should increase.

The association between the transfer of emergency department boarders to inpatient hallways or off-service beds and the quality of oncology care.

113 Background: Emergency department (ED) crowding is an important issue in the delivery of high-quality medical care. At our quaternary care hospital a policy was implemented to ease ED crowding by moving suitable admitted patients into inpatient hallway beds or off-service beds. This study assesses the impact of off service and hallway bed admissions on patient care and satisfaction. Methods: Retrospective and prospective data were collected from Jan 1 to Dec 31, 2011, on admissions to the oncology service via the ED. Patient care data was collected as follows: chest/abdominal exams performed at first MD visit, number of MD visits within 48 hours, time to antibiotic administration, time to complete vitals, and mean time spent in the ED. Satisfaction surveys were also given to all patients. Results: One hundred and eighteen patients were admitted to a hallway bed (HALL). A random sample of 90 patients were used for comparison in the on service (ON) and off service (OFF) groups. Among HALL patients, 4% percent discharged themselves against medical advice (0% of OFF and ON patients). MD visits within 48 hours were the same among all groups (mean=6). Forty-two percent of hallway patients had a chest/abdominal exam during the first MD visit (32% and 33% for OFF and ON patients, respectively). Time to first completion of vitals was 1:05 (hh:mm) for HALL patients (1:21 and 00:34 for OFF and ON patients, respectively). Time to antibiotic administration was 15:34 for hallway patients (23:59 and 12:35 for OFF and ON patients, respectively). More HALL patients expressed dissatisfaction with their hospital stay (16.7%) compared to OFF (0%) and ON patients (0%). Mean time for admitted patients in the ED awaiting their HALL bed was 9:14, considerably longer than for OFF patients (3:08) and ON patients (4:19). Conclusions: Admission of oncology patients in hallway or in off-service beds did not appear to compromise the timeliness or frequency of medical assessments. However, delays in nursing care (completion of vital signs and drug administration) were noted and patient satisfaction was decreased. Moreover, the policy did not meet its intent to reduce patient time spent in the ED.

Antiemetic guideline consistency and incidence of chemotherapy-induced nausea and vomiting (CINV) in U.S. community oncology practice: INSPIRE study.

167 Background: Electronic Health Records (EHRs) are a valuable source to evaluate the quality of oncology care, particularly when combined with patient outcomes data. Our objective was to evaluate the impact of guideline consistent/inconsistent chemotherapy prophylaxis (GCCP, GICP) on the incidence of no CINV after cycle 1 of highly or moderately emetogenic chemotherapy (HEC or MEC). Methods: INSPIRE (Impact of NCCN Antiemesis Guideline Usage on Patient Reported Emesis) was a prospective observational, multicenter study that enrolled chemotherapy-naive adults initiating single-day HEC or MEC. Results from the MASCC Antiemesis Tool, administered 5 to 8 days after HEC/MEC, were merged with EHR data. The primary endpoint, no CINV (no emesis and no clinically significant nausea), was compared between groups using logistic regression. Results: 1,295 patients (mean age=59.3, 30.0% male, 35.5% HEC) were enrolled from Georgia Cancer Specialists (53.0%), Tennessee Oncology (38.1%), Florida Cancer Specialists (5.7%), and Cancer Specialists of N. Florida (3.2%). The prevalence of GCCP was 57.3% (28.7% HEC; 73.1% MEC). If corticosteroids were prescribed to all HEC patients on days 2-4, GCCP for HEC would increase from 28.7% to 89.8%. If NK1-receptor antagonists (NK1-RA) were prescribed to all MEC patients, GCCP for MEC would increase from 73.1% to 97.8%. GCCP and GICP-treated patients differed by age, (p=0.010), HEC/MEC (p&lt;0.0001), primary cancer site (p&lt;0.0001), practice site (p&lt;0.0001). The percent with no CINV, no emesis, and no clinically significant nausea was significantly higher for GCCP patients. Conclusions: Increased GCCP could significantly reduce CINV after HEC or MEC. The main reasons for guideline inconsisteny were lack of corticosteroids in the delayed phase for HEC and lack of NK1-RA for MEC. There remains room for improvement in nausea control. [Table: see text]

Development of a collaborative improvement network by a state affiliate of the American Society of Clinical Oncology.

79 Background: Participation in the Quality Oncology Practice Initiative (QOPI) by members of the Northern New England Oncology Society (NNECOS) has been historically low (two practices consistently participating). A survey of members identified a lack of resources (time, personnel, financial) as the principal obstacles. In alignment with NNECOS’ mission “To assure the availability of and access to high quality oncology care in our region,” NNECOS sought to determine if it could establish a Collaborative Improvement Network (CIN) in which 1) experienced practices mentor inexperienced practices in QOPI, and 2) practices benchmark results against each other, sharing best practices. Methods: Six practices from the NNECOS member states of Maine, New Hampshire, and Vermont agreed to join the CIN and participate in the fall 2010 and spring 2011 QOPI data collection. Meetings were held following each QOPI data collection and blinded results were compared. High achievers on individual metrics shared their processes/tools with all the participants in the CIN. Results: To develop consistency in data collection, a joint training program for abstractors was developed. There was rapid agreement to eliminate the blinding of results, allowing candid discussions about the barriers to success and strategies for overcoming those barriers. The following tools that successful practices had used were shared: a “one page chemotherapy treatment summary,” chemotherapy consent forms, an oral chemotherapy procedure, and a “chair-side smoking cessation program.” Interventions piloted included a “hardwired chemotherapy treatment summary” and a “hardwired intervention for emotional distress.” Improvement was seen in “plan of care for severe pain” (72% to 85%), “signed consent for chemotherapy” (59% to 81%), and “infertility risk discussions” (14% to 35%). The CIN continues to operate, with 8 of the 17 practices in the three states participating. It is currently engaged in a project to implement specific performance improvement processes for end-of-life care. Conclusions: We have shown that it is possible for an ASCO State Affiliate to sponsor and develop a CIN.

Utilization of intensive care resources due to better communication of end-of-life issues.

1 Background: Advanced life support resources are required for optimal care of patients undergoing curative therapy, but their use in patients with terminal disease does not improve patient outcomes. In 2007, our cancer center established the Duffey Pain and Palliative Care team, and one important goal was to help our physicians improve at discussing end-of-life issues with patients. We hypothesized that if this effort was effective, it would result in less utilization of intensive care unit (ICU) management among patients who die in the center. Methods: All inpatient deaths were systematically tabulated and code status displayed at the multidisciplinary Morbidity and Mortality review twice per quarter, beginning in July 2006. Utilization of ICU care, defined as ventilator or dialysis support, was identified from billing data and confirmed by chart review. Survival to discharge among patients who received ICU care was monitored as a component of our patient safety dashboard. Results: From 2008 through 2011, 525 oncology patients died while hospitalized in the cancer center. During this period, among patients who died, there was a gradual increase in no-code status, election of comfort care, or withdrawal of ICU support, from 81% to 95% (OR 1.14 per quarter, p&lt;0.0001). Although the proportion of patients who received any ICU care during their terminal hospitalization did not change, the duration of such care decreased: the proportion with mechanical ventilation for over 14 days decreased from 10% to 5% (OR 0.93 per quarter, p&lt;0.05). There was no decrease in the survival-to-discharge of patients who received ICU care. Conclusions: A multidisciplinary team approach to improve discussion of end-of-life issues, combined with regular feedback to cancer center staff regarding code status at death, resulted in significant changes in patient and family decisions about management at the end of life over a four-year interval. These changes have reduced utilization of ICU care during terminal hospitalizations with no reduction in the survival-to-discharge of all patients who receive ICU care. We propose appropriate establishment of code status and survival-to-discharge of ICU patients as measures of quality oncology care.

Implementing a breast cancer registry and treatment plan/summary program in clinical practice: A pilot program

There is a need to better measure and improve the quality of oncology care and improve communication with patients and other providers. The American Society of Clinical Oncology Breast Cancer Registry (BCR) pilot evaluated the feasibility and acceptability of prospective data collection for quality assessment in daily clinical practice. Data were used to create and share treatment plans/summaries (TPSs) at the point of care. Using a web-based tool, 20 diverse practices entered clinical data on each new early-stage breast cancer patient into the BCR for 14 months (September 2009 through November 2010). The tool created individual TPSs that were shared with patients. Practices received practice-specific and aggregate BCR quality measures data, participated in a survey, and received a participation stipend. Twenty practices entered 2014 patients into the BCR, collecting demographic, clinical, and treatment information. Fifty-two percent of practice participants replied to an end-of-pilot survey: 73% were satisfied with the BCR and web-based tool, 31% expressed concern regarding time and effort, and 52% reported additional practice costs during the pilot. Among those who created or shared the TPSs, 90% thought the documents improved oncologist-patient communication, and 95% favored using BCR data for practice quality improvement. Prospective data collection for quality assessment is feasible and allows sharing of TPSs with patients at the point of care. Future efforts should focus on decreasing implementation burden to practices, broadening participation, examining costs, and, most importantly, assessing its effects on patient outcomes.

JS2-6 - Current Status and Future Direction of Communication Skill Training Program

ABSTRACT Current communication skill training utilizes role-playing with ‘bad news telling’ protocol, and significant improvement in clinician's self-efficacy has been reported. Recent randomized trial clearly demonstrated that early palliative care integrated with standard oncologic care improves the outcomes of patients with metastatic non-small-cell lung cancer compared with standard oncologic care alone (Temel et al. N Engl J Med 2010; 363: 733–742). In the study, the palliative care team paid specific attention to assessing physical and psychosocial symptoms control, establishing goals of care, assisting with decision-making regarding treatment, and coordinating care on the basis of the individual needs of the patient. As a result, more patients assigned to early palliative care had an accurate assessment of their prognosis over time. Patients receiving early palliative care who reported an accurate perception of their prognosis were less likely to receive intravenous chemotherapy near the end of life. These findings are strong evidence that quality of oncologic care depend on patients' perception of the disease and prognosis, physical, and psychosocial symptoms control. Because several options are available in the current oncologic care, optimum decision-making is critically important. Future communication skill training challenges include discussing prognosis, assisting with decision-making and working as a multidisciplinary team. More medical oncologists should participate as facilitator in communication skill training program.

Patterns of decision making about cancer clinical trial participation among the online cancer treatment community: A collaboration between SWOG and NexCura.

CRA6009 Background: Studies have shown an association between socioeconomic status (SES) and quality of oncology care, but less is known about the impact of SES on decision-making about CT participation. Methods: We assessed patterns of CT treatment decision-making according to important SES and demographic factors (age, sex, race, income, education) in a large sample of patients surveyed via a web-based treatment decision tool (NexCura, The Woodlands, TX). Eligible patients had a new diagnosis of breast, lung, colorectal, or prostate cancer, and were &gt;18. Logistic regression (conditioning on type of cancer) was used. Reasons for non-participation in CTs were assessed using pre-specified items about treatment, family, cost, and logistics. All data were self-reported. Results: 5,499 patients were surveyed from 2007-2011. 40% discussed CTs with their physician; this differed by age (42% &lt;65 v. 29% &gt;65), income (42% &gt;$50k/yr v. 36% &lt;$50k/yr), and education (42% &gt;college degree (CD) v. 37% &lt;CD). 45% of discussions led to offers of CT participation, and 51% of offers led to CT participation. The overall CT participation rate was 9%, differing by age, income, and education (see table below). In a multivariate model including all SES and demographic factors (plus covariates comorbidity status and “distance to clinic”, a surrogate for convenience), income remained a predictor of CT participation (OR 0.73, 95% CI, 0.57-0.94, p=.01). Even in patients &gt;65, who are nearly universally covered by Medicare, lower income predicted reduced CT participation (age by income interaction test, p&gt;.05). Cost concerns were much more evident among lower income patients (p=.0001). Conclusions: Lower income patients were less likely to participate in CTs, even when considering age group.A better understanding of why income is a barrier may help identify ways to make CTs better available to all patients, and would increase the generalizability of CT study results across all levels of SES. [Table: see text]

Patient-related predictors of poor-quality pain care in advanced lung cancer patients.

6062 Background: Unrelieved pain remains a major problem for all patients, including those with cancer, despite national standards for pain management. Screening and addressing pain is an integral part of oncology visits and an ASCO QOPI indicator of quality oncology care. The goal of this study was to assess associations between patient-related factors, particularly patient distress, and meeting ASCO quality metrics for appropriate management of pain in patients with advanced lung cancers. Identification of patient related factors could lead to targeted quality improvement efforts. Methods: From 8/07 to 9/10, we recruited consecutive new patients in a multidisciplinary thoracic oncology clinic to participate in a research database for which patients completed self-report instruments for distress, depression (PHQ-9) and anxiety (GAD-7), at their first oncology visit. We then performed a QOPI chart audit for patients with advanced lung cancer who received care at our institution. A composite measure of appropriate pain management was calculated. Components of the composite measure included 1) documentation of pain assessment, and 2) for patients with moderate-severe pain (≥4 on 10 point scale) plan of care documentation. Results: 253 patients completed baseline assessments and had follow up. Pain was assessed in 252 (99%) patients. Over a third (88/253) of newly diagnosed advanced lung cancer patients had at least moderate pain on their first visit to the medical oncologist. Almost half of patients with moderate-severe pain were depressed (40/88). Of the patients with moderate-severe pain, 54/88 (63%) had a plan of care related to pain documented in the oncologist’s note. In total, 219 (87%) patients received appropriate pain assessment and care. In a multivariate model including age, sex, histology, ECOG PS, provider, depression, and anxiety, only depression independently predicted inadequate pain care. Depressed patients were 3 times more likely to receive poor quality pain care (OR 2.75, 95% CI 1.04-7.25, p=0.04). Conclusions: At initial oncology visit, pain is present in over a third of patients with advanced lung cancer. Depression is highly co-morbid with pain and appears to be a risk factor for inadequate pain care.

Follow-Up of Breast Cancer Survivors

important study of the follow-up preferences of breast cancer survivors. However, I was struck by the marked disconnect between the study’s findings and the authors’ conclusions. In this survey of the self-perceived impact of follow-up by different types of providers, the 218 breast cancer survivors who completed the questionnaire overwhelmingly preferred follow-up with a medical oncologist to follow-up with a primary care physician (PCP) or nurse practitioner (NP). The odds ratios for the belief that medical oncologist follow-up relative to PCP follow-up would decrease breast cancer worry, and increase the chance of surviving cancer, were 36 (95% CI, 21 to 62) and 42 (95% CI, 24 to 74), respectively. Confidence in follow-up by an NP was nonsignificantly lower than that for a PCP. Nevertheless, the authors concluded that “Breast cancer survivors are comfortable with both PCPs and NPs providing follow-up care . . . the NP-led survivorship clinic model, with increased guidance for PCPs, offers a promising route for improving quality of and satisfaction with survivor care.” 1(p158) Breast cancer worry and fear of recurrence are high among breast cancer survivors, and often correlate poorly with objective prognosis. For example, in one study of 136 patients treated with curative intent, more than 50% had moderate to high levels of fear of recurrence. 2 It is inconceivable that a follow-up model that would exacerbate such fears would improve patient satisfaction. Shifting follow-up care from the oncologist to a PCP or NP could have more subtle detrimental effects on patient care, particularly for future medical oncology graduates, who would see far fewer follow-up patients during their training, and would never acquire the experience of monitoring large numbers of patients treated with adjuvant systemic therapy over several years. How will they be able to have balanced discussions with patients for whom the indication for chemotherapy is borderline if they have never seen the 40-year-old ICU nurse who can no longer work because of “chemo brain,” or the mother of six children who develops a cardiomyopathyrelated stroke? Nor will their perspective be balanced if they are asked to see only the patients with complications in the NP-led follow-up clinic next door. Even if patient care could somehow be unaffected, medical oncologists would have much to lose in terms of job satisfaction if we handed most, if not all, of our patients over to other health care professionals for follow-up. Undoubtedly most of us would prefer to see another patient responding to neoadjuvant chemotherapy than a whining but otherwise well survivor. But, more important, a clinic with several women in their thirties dying of metastatic disease is only bearable if, in the same clinic, there is also a patient, expected to have died 15 years ago of locally advanced disease, proudly showing pictures of her son’s wedding or daughter’s graduation. Referring patients with breast cancer who have completed active treatment to their PCP or a NP for follow-up is appropriate and optimal in many cases. Most patients, who greatly prefer medical oncologist follow-up initially, will gladly “graduate” back to their PCP after several years. However, the decision and timing should be made jointly by the patient and medical oncologist, taking into account factors such as patient preference and tumor prognosis. A health care system that allows both traditional and alternative follow-up models will maximize patient satisfaction, maintain the quality of oncology care, and avoid oncologist burn-out.

Business and Science: Lessons From the 2011 Cancer Center Business Summit

This issue of Journal of Oncology Practice presents a special series, including abstracts and two primary articles, derived from the fifth annual Cancer Center Business Summit convened in Chicago in October 2011.1 The theme of the meeting was achieving accountable cancer care. The meeting is co-operatively hosted by three organizations: the health care section of the law firm Foley & Lardner, LLP; Altos Solutions, through their Oncology Metrics division; and the Cancer Center Business Development Group. Over the past 2 years, ASCO has been an active participant in the planning group for the meeting. What is striking about the meeting is the eclectic membership of the planning committee and the audience the meeting serves. Represented are large and small oncology practices, financial firms, a host of consultancies, academic medical centers, community health systems, analytic firms, health information technology firms, and more. Attendees include oncologists of all stripes, nurse managers, administrators and service line managers, pharmacists, and an array of business representatives. On reflection, this diversity of attendees is understandable. To coordinate and run an oncology practice—whether institutional or community, privately owned or hospital employed—requires more than a “village” of support, and many transactions. The astute oncology practice will ask for help and tap into professional advisors and knowledgeable colleagues frequently. No longer can a practitioner look forward to a career served in a single, stable practice model. One has to re-evaluate the market place regularly and embrace change. How does this affect our profession and our professional organization? What role can clinicians play in these business conversations? At the end of the day, oncology practice is about patient care: the interaction of an oncologist with a given patient. We know that this interaction requires skill on the part of oncologists, as well as a supportive clinical team to provide and implement a coordinated treatment plan. Our profession's strengths over the years (and ASCO's strengths) are its focus on the interactions between the care team and patient and advocating for quality oncology care. ASCO provides a wealth of educational offerings to support the development of clinical decisions, to educate oncologists on how to communicate effectively with the patient, and to define what quality means in oncology. However, as the delivery of oncology care becomes ever more complex, oncologists who wish to effectively advocate for access to quality oncology care will require a deeper understanding and working knowledge of the myriad business and transactional forces that shape our practice structures. These include all of the business and commercial entities and skills that are represented in the attendees and planners of the Cancer Center Business Summit. ASCO's involvement in the Business Summit has a virtuous motivation. The multiple business-oriented folk that support our practices must develop an understanding about how oncologists think, how clinical decisions are made, and the complexity of the patient-doctor relationship. Indeed, the entirety of how oncologists process information and assess its validity is based on our science, yet often business information and data do not conform to the rules or rigor that we apply to a scientific experiment. Conflicting data and information are common in the marketplace, but oncologists are not familiar with the available methods that can provide a framework to resolve such conflicts. Might the transparent methodologies of our science have something to offer the business communities that support us? It was in this spirit that before the 2011 Business Summit, the planning group decided to approach a portion of this business-oriented meeting in a similar fashion to how we approach a scientific meeting. A call for abstracts was developed, and businesses, practices, and institutions were invited to submit work that described new methods for dealing with problems or best practices that were working in their settings. Clearly, this set a new tone for the meeting. In this issue of JOP, we present nine accepted abstracts from the 2011 Business Summit. The topics are diverse, ranging from an approach using telemedicine to cover under-served rural areas, to a quantitative analytic for dealing with operating room inventory management, to a framework for practices that might enable them to survive in reimbursement models in which there is no margin on drugs. In addition, two of the meeting organizers present articles that were derived from talks at the Business Summit. Barkley presents survey results gathered from high-performing systems, divining attitudes and plans concerning the development of new payment models for care. Blau provides a legal analysis and assessment of oncology professional service agreements as tools to preserve practice autonomy in affiliation with institutions. This process will be repeated in the 2012 Business Summit. The organizers hope that the meeting will blend the diverse business-related information needed to support a practice with the scientific spirit of open communication and critical assessment.

Alessandro Liberati

Alessandro Liberati

Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care. Summary of an Institute of Medicine Workshop

The Institute of Medicine's National Cancer Policy Forum recently convened a workshop on patient-centered cancer treatment planning, with the aim of raising awareness about this important but often overlooked aspect of cancer treatment. A primary goal of patient-centered treatment planning is to engage patients and their families in meaningful, thorough interactions with their health care providers to develop an accurate, well-conceived treatment plan, using all available medical information appropriately while also considering the medical, social, and cultural needs and desires of the patient and family. A cancer treatment plan can be shared among the patient, family, and care team in order to facilitate care coordination and provide a roadmap to help patients navigate the path of cancer treatment. There are numerous obstacles to achieving patient-centered cancer treatment planning in practice. Some of these challenges stem from the patient and include patients' lack of assertiveness, health literacy, and numeracy, and their emotional state and concurrent illnesses. Others are a result of physician limitations, such as a lack of time to explain complex information and a lack of tools to facilitate treatment planning, as well as insensitivity to patients' informational, cultural, and emotional needs. Potential solutions to address these obstacles include better training of health care providers and patients in optimal communication and shared decision making, and greater use of support services and tools such as patient navigation and electronic health records. Other options include greater use of quality metrics and reimbursement for the time it takes to develop, discuss, and document a treatment plan.

Predictive biomarkers: a paradigm shift towards personalized cancer medicine

Advances in our understanding of the intricate molecular mechanisms for transformation of a normal cell to a cancer cell, and the aberrant control of complementary pathways, have presented a much more complex set of challenges for the diagnostic and therapeutic disciplines than originally appreciated. The oncology field has entered an era of personalized medicine where treatment selection for each cancer patient is becoming individualized or customized. This advance reflects the molecular and genetic composition of the tumors and progress in biomarker technology, which allow us to align the most appropriate treatment according to the patient's disease. There is a worldwide acceptance that advances in our ability to identify predictive biomarkers and provide them as companion diagnostics for stratifying and subgrouping patients represents the next leap forward in improving the quality of clinical care in oncology. As such, we are progressing from a population-based empirical 'one drug fits all' treatment model, to a focused personalized approach where rational companion diagnostic tests support the drug's clinical utility by identifying the most responsive patient subgroup.

Intervention model for cancer control in a low-income African area.

e16539 Background: Cancer outcome is an emergency in low-income areas (LIAs) such as Tanzania, where incidence is 84 and 91 per 100,000 males and females, respectively. Prior to 2008, an Oncology Department (OD) did not exist at Bugando Medical Center (BMC), Mwanza, Tanzania (catchment area of 14 million people). Methods: Thanks to an agreement between BMC, Association Tison, IRST, and Istituto Oncologico Romagnolo, a Pathology Laboratory and an OD were instituted in 2000 and 2008, respectively. The oncology team comprises a multidisciplinary staff of 13, including 1 physician and 3 nurses who received cancer training at IRST. Volunteer Italian oncologists provide support for the Tanzanian team each month. Results: Between Jan 2009 and Dec 2010, 1610 patients were admitted to BMC OD, of whom 511 were children and 1099 adults (670, 61% females; 429, 39% males). The majority of children (70%) had Burkitt’s lymphoma, 20% retinoblastoma and the remaining, acute leukemias, Wilm’s and brain tumors.The highest rate of cancer in adults was cervical cancer in females (32%) and hepatocarcinoma (HCC) in males (30%). Out of 562 women screened for breast and cervical cancer, only 3% had stage I breast cancer, treated with curative intent. Among patients screened for cervical cancer, 18% showed alterations at colposcopy, and biopsy confirmed cancer. One third of these were inoperable locally advanced cervical tumors. Conclusions: Cancer epidemiological patterns in Tanzania differ from those of high-income areas (HIAs) due to the high prevalence of infection-related cancers. Several challenges exist: inadequate or poorly accessible diagnostics; drug availability and cost; patients lost to follow up; lack of palliative care culture; and bureaucracy. This transnational collaboration aims to improve the quality of oncology care and to foster no-profit trials on tumors with a low incidence in HIAs, but with greater relevance in LIAs. Number of patients (%) admitted to the BMC OD. Cervix HCC Breast Kaposi’s sarcoma Esophagus Hodgkin lymphoma Prostate Ovary Others Total Males – 129 (30) – 64 (15) 77 (18) 38 (9) 73 (17) – 48 (11) 429 (39) Females 214 (32) – 141 (21) 47 (7) 34 (5) 67 (10) – 20 (3) 147 (22) 670 (61) All adults 214 (32) 129 (30) 141 (21) 111 (10) 111 (10) 105 (9) 73 (7) 20 (2) 195 (18) 1099