A Unique Partnership Between the University of Hawai'i Cancer Center and the University of Guam: Fifteen Years of Addressing Cancer Health Disparities in Pacific Islanders in Hawai'i and Guam

This manuscript describes the efforts in research, education, and outreach of a unique partnership between the University of Hawai'i Cancer Center and the University of Guam in addressing cancer health disparities faced by Pacific Islanders in Hawai'i, Guam, and other parts of Micronesia. Significant accomplishments of this 15-year collaboration in research, training Micronesian students, and impact on the local communities are highlighted.

Characteristics and Outcomes of Ethics Consultations on a Comprehensive Cancer Center's Gastrointestinal Medical Oncology Service

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database (which includes categorization of the primary issues, contextual ethical issues, and other case characteristics) of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 patients were identified. The most common primary ethical issue was the DNR order (39%), followed by medical futility (28%). The most common contextual issues were dispute/conflict between staff and family (48%), dispute/conflict intra-family (16%), and cultural/ethnic/religious issues (16%). The majority of ethical issues leading to consultation were resolved (84%); i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning.

Hospital cancer pain management by electronic health record-based automatic screening

OBJECTIVES

A cancer pain clinic (CPC) service is a thorough, comprehensive consultation service for patients with uncontrolled cancer pain. The aim of this study was to determine the success of a new CPC service with enrollment via electronic health record-based automatic screening at 1 cancer center in Korea.

STUDY DESIGN

A case-control study and a satisfaction survey.

METHODS

The intervention group (n = 158) was enrolled in the CPC service, whereas the control group (n = 158), which was matched using propensity scores, did not participate in the service. The pain scores of participants were compared using an independent t test. Thirty-nine patients and 20 physicians completed a self-administered survey on instructions for pain-relief medications, effective usage of long-acting and short-acting opioids, perceptions of or barriers to CPC services, knowledge of opioid use, and overall satisfaction.

RESULTS

Although the baseline pain score of the intervention group was significantly higher than that of the control group (P = .013), the difference in the decrease of pain between the groups was significant at days 1 (P = .001) and 2 (P = .039). Although the difference in pain scores disappeared on day 3, total pain score was significantly lower in the intervention group than in the control group (P = .012). When comparing pain relief events (<4 points on a 0-10 numeric rating scale that measured pain daily), the intervention group experienced more relief events than did controls (P = .017). Patients were satisfied with their physicians giving clear instructions and considering their opinions about pain-relief medications. The oncology residents expressed satisfaction with the management of patients with opioid-naïve or intractable pain.

CONCLUSIONS

The new CPC service seems to provide effective pain relief and users seem to be highly satisfied with it. These results support the importance of an integrated and specialized approach to cancer-related pain management.

A prospective comparison of cancer clinical trial availability and enrollment among adolescents/young adults treated at an adult cancer hospital or affiliated children's hospital

BACKGROUND

Low cancer clinical trial (CCT) enrollment may contribute to survival disparities affecting adolescents and young adults (AYAs) (ages 15-39 years). The objective of this study was to evaluate whether differences in CCT availability related to treatment site could explain the low CCT enrollment.

METHODS

This prospective, observational cohort study was conducted at an academic children's hospital and its affiliated but geographically separated adult cancer hospital within a National Cancer Institute-designated Comprehensive Cancer Center. For consecutive, newly diagnosed AYA patients, it was determined whether an appropriate CCT existed nationally, was available at the treatment site, and was used for enrollment. Proportions of AYAs in these categories were compared between sites using the chi-square test.

RESULTS

One hundred fifty-two consecutive AYA patients were included from the children's hospital (n = 68; ages 15-20 years) and the adult cancer hospital (n = 84; ages 18-39 years). Although there was no difference in CCT existence for individual AYA patients by site (children's hospital [36 of 68 patients; 52.9%] vs adult cancer hospital [45 of 84 patients; 53.6%]; P = .938), CCT availability was significantly lower at the adult cancer hospital (14 of 84 patients [16.7%] vs 30 of 68 [44.1%] at the children's hospital; P < .001). The proportion of AYAs enrolled was low at both sites (8 of 68 patients [11.8%] vs 6 of 84 patients [7.1%], respectively; P = .327). Fewer existing CCTs were available at the adult cancer hospital (4 of 27 patients [14.8%] vs 8 of 14 patients [57.1%], respectively), and those were directed toward solid tumors and new agents.

CONCLUSIONS

Efforts to improve low CCT enrollment among AYAs should be differentiated by treatment site. In the adult setting, these efforts should be aimed at improving CCT availability by overcoming site-level barriers to opening existing CCTs.

Searching for Survivor-Specific Services at NCI-Designated Comprehensive Cancer Centers: A Qualitative Assessment

Background: Cancer survivorship presents unique medical, psychosocial, and logistical challenges for survivors, their caregivers, and clinicians. NCI-designated Comprehensive Cancer Centers (CCCs) serve a unique role in the delivery of cancer care because they not only provide care but also serve as a model for community oncologists and clinics through the development and dissemination of standards of care. Survivors, their caregivers, and clinicians look to CCCs to provide information about how to navigate the transition from active to posttreatment care. However, there is wide variability in the types of resources CCCs make available on their websites. The goal of our assessment was to understand the types of posttreatment survivor-specific resources CCCs are providing on their website. Methods: We analyzed the websites of the 47 CCCs to evaluate survivor-specific resources around the 4 components of survivorship care described by the Institute of Medicine guidelines for survivorship care plans: surveillance, prevention, intervention, and coordination. Results: Of the 47 CCCs, 74.5% (n=35) had discoverable survivor-specific services on their websites. Despite our inclusive approach to coding, few websites contained extensive information targeted at survivors, their caregivers, or clinicians. Only the coordination and intervention elements were discussed by at least half of the CCCs. From the vantage point of cancer survivors, their lay caregivers, loved ones, or clinicians, there is limited information about survivor-specific services on the websites of the 47 CCCs. This dearth of information translates into substantial work for these groups to find the resources they may need. Conclusions: The CCCs have an opportunity to serve as information hubs and to lessen the amount of work associated with survivorship. As models of cancer care delivery, the CCCs can also set the standard for community oncologists and clinics for delivery of care that improves the quality of life for survivors.

Pediatric Palliative Care in Iran: Applying Regionalization of Health Care Systems

Background: Establishing palliative care services is a priority in the health system of Iran. Considering the necessity of integrating these services into the health system, this study aimed to explore the stakeholders’ perceptions about the provision of a conceptual framework for palliative care services for children with cancer according to the health system in of Iran. Methods: The present qualitative study was conducted through in-depth semi-structured interviews held with 29 participants including palliative care specialists, policy-makers, health care providers, the parents of children with cancer selected through purposive sampling, between August 2016 and February 2017. Interviews continued until saturation of data. All interviews were recorded, transcribed and analyzed using MAXQDA10 software. Results: The codes extracted from interviews produced the main theme “ classes of palliative care services” with the two main categories “comprehensive care” including, strengthening family shelter, maintaining the child in a familiar environment, achieving stability and “establishing social justice” including, easy access to services, financial relief and quality care. Conclusion: Presenting a framework based on level of palliative care services, the findings of this study paves the way for integrating these services into Iranian health system.

Oncologic emergencies in a cancer center emergency department and in general emergency departments countywide and nationwide

Background

Although cancer patients (CPs) are increasingly likely to visit emergency department (ED), no population-based study has compared the characteristics of CPs and non-cancer patients (NCPs) who visit the ED and examined factors associated with hospitalization via the ED. In this study, we (1) compared characteristics and diagnoses between CPs and NCPs who visited the ED in a cancer center or general hospital; (2) compared characteristics and diagnoses between CPs and NCPs who were hospitalized via the ED in a cancer center or general hospital; and (3) investigated important factors associated with such hospitalization.

Methods and findings

We analyzed patient characteristic and diagnosis [based on International Classification of Diseases-9 (ICD-9) codes] data from the ED of a comprehensive cancer center (MDACC), 24 general EDs in Harris County, Texas (HCED), and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1/1/2007–12/31/2009. Approximately 3.4 million ED visits were analyzed: 47,245, 3,248,973, and 104,566 visits for MDACC, HCED, and NHAMCS, respectively, of which 44,143 (93.4%), 44,583 (1.4%), and 632 (0.6%) were CP visits. CPs were older than NCPs and stayed longer in EDs. Lung, gastrointestinal (excluding colorectal), and genitourinary (excluding prostate) cancers were the three most common diagnoses related to ED visits at general EDs. CPs visiting MDACC were more likely than CPs visiting HCED to be privately insured. CPs were more likely than NCPs to be hospitalized. Pneumonia and influenza, fluid and electrolyte disorders, and fever were important predictive factors for CP hospitalization; coronary artery disease, cerebrovascular disease, and heart failure were important factors for NCP hospitalization.

Conclusions

CPs consumed more ED resources than NCPs and had a higher hospitalization rate. Given the differences in characteristics and diagnoses between CPs and NCPs, ED physicians must pay special attention to CPs and be familiar with their unique set of oncologic emergencies.

The 'lost tribe' reconsidered: Teenagers and young adults treated for cancer in adult settings in the UK

PURPOSE

Although the UK has pioneered the development of specialist adolescent cancer units, the majority of teenagers and young adults (TYAs) continue to be treated at their local hospital or at a cancer centre alongside adults of all ages. This study aimed to elicit young people's views on this experience of having cancer treatment in an adult setting.

METHODS

Seventeen participants who had been treated for cancer in an adult hospital between the ages of 15 and 24 were recruited via cancer charities and social media. Telephone interviews were conducted with the participants and the resulting data were analysed using thematic analysis.

RESULTS

Already feeling out of sync as a TYA with cancer, participants felt out of place in the adult setting. Four factors contributed to this negative experience: a lack of affinity with older patients; the challenging issues in the adult setting; the absence of empathy towards TYAs by staff; and the unsuitability of the environment for adolescents.

CONCLUSION

Staff working with TYAs with cancer in the adult setting should be aware of the potentially detrimental impact of this environment on this cohort of patients, and consider ways of adapting and modifying their approach.

Development of a tailored survey to evaluate a patient-centered initiative

OBJECTIVES

Patient-centered care initiatives have proliferated, but assessing their effectiveness requires measures tailored to their likely effects. In this article, we describe the development and pilot testing of patient surveys used to assess change in patients' cancer care experiences over time in response to a patient-centered care initiative.

STUDY DESIGN

Prospective case series.

METHODS

Domains of patient-centered care were informed by the goals of the initiative and a review of existing tools. Items were selected and modified from 6 domains of validated or semivalidated instruments. Items were piloted with patients with cancer in waiting room settings to further assess the relevance and clarity of items, whether important concepts were missing, and acceptability regarding place and timing of the surveys and to estimate baseline top box scores (percentage of patients scoring an item the highest quality level) to minimize likely ceiling effects. The instrument was then administered to a consecutive sample of Stanford Cancer Center patients. Baseline item responses, Cronbach's alpha, and response bias were estimated.

RESULTS

Items were modified based on patient feedback, top box scores, and reassessment of the domains. Over 6 months, 11,273 patients were surveyed, with a 49.7% response rate. Baseline top box scores ranged from 41.7% to 75.0% for any given item. Reliability and internal consistency were high for all domains (Cronbach's alpha ≥0.80) except for the access domain.

CONCLUSIONS

We developed reliable instruments to evaluate the essential elements of a patient-centered care initiative at an academic medical center, which minimized patient burden and maximized the response rate.

[Observational study of outpatient unit duration of stay depending on the route of administration (intravenous vs subcutaneous) for a targeted therapy]

New routes of administration available for some targeted therapies, especially subcutaneous injections, have an impact not only on the patients' daycare experience, but also on the unit's organization. This observational study conducted on 48 voluntary patients at the Institut universitaire du cancer Toulouse-Oncopole shows that the mean duration of the outpatient unit stay is diminished by one hour when a subcutaneous injection is used instead of an intravenous route. This duration decrease is mainly caused by an 82% average reduction in treatment duration. However, the waiting times before and after the treatment itself are not significantly impacted. Organizational methods related to the treatment prescription and preparation remain indeed the same. Anticipated prescription is not noticeably impacted either. This reduction of the duration of stay will truly be obtained if the whole unit's organization is adapted.

Are we prepared to implement a Lean philosophy within cancer-care service in Oman?

Lean, as it applies to business, has come to signify simplicity, swift response, and efficiency. The concept is to do more with less; namely, to use resources in the most productive way possible through the elimination of all types of waste. The Lean approach can be applied to any field, including healthcare, in which the exponential growth of costs is widespread. Hospitals began experimenting with Lean healthcare in 1990s. Equal accessibility to healthcare is consistent with the tenets of social justice and a society’s duty to ensure basic healthcare to everyone. However, the gap between a state’s constitutional responsibility and resource availability is widening, creating a need for an evolution in healthcare provision based on relevance, objectivity, and impartiality. Health-services providers must juggle limited resources to ensure even-handed healthcare availability to all in the era of cost explosion.

Biobanks and Comprehensive Cancer Center Finland (FICAN) as institutions enabling clinical drug testing

Clinical trials aiming at developing targeted drug therapies require the identification of appropriate patient groups, utilizing both clinical information and the biological profile of the disease. The Finnish healthcare system provides exceptional possibilities for utilizing health data in identifying patient groups, planning of clinical sample studies and recruiting patients. Biobanks established at university hospitals together with the regional cancer centers play a central role in collecting biological specimens and attaching health data to the specimens. Combined with longitudinal health data, the collections of tissue specimens obtained in connection with the diagnosis offer versatile possibilities for the development of companion diagnostics of targeted drugs. Specimens collected on the basis of informed consent in connection with diagnosis and treatment enable the identification of patients suitable for drug trials, and a contact according to the consent. In the development of new functions, national collaboration - both geographical and between research infrastuctures - becomes of paramount importance. Combining the resources of biobanks, the genome strategy and the Comprehensive Cancer Center, an enabling legislation and, above all, patients with a positive attitude towards examinations, offer excellent possibilities for Finland to become the model country of individualized treatment.

[Sarcoma centres : a necessary tool in the management of patients and for research.]

Sarcomas are rare diseases, the treatment of which requires an appropriate technical plateform and a broad spectrum of multidisciplinary specialists. Many are initially treated by unplanned excision, and then referred to specialized centres. Secondary treatments may lead to higher complication rates and local recurrence, with lower functional outcome, life quality and possibly overall survival. In order to improve the accessibility for referral to a specialist centre, the coordination of clinical and research activities, and the quality of the management of sarcomas in general, Lausanne University Hospital (CHUV) has opened a Sarcoma centre on October 1st 2016. The objective of the present paper is to illustrate the concept and provide useful clinical recommendations.

Quality assessments for cancer centers in the European Union

BACKGROUND

Cancer centers are pressured to deliver high-quality services that can be measured and improved, which has led to an increase of assessments in many countries. A critical area of quality improvement is to improve patient outcome. An overview of existing assessments can help stakeholders (e.g., healthcare professionals, managers and policy makers) improve the quality of cancer research and care and lead to patient benefits. This paper presents key aspects of assessments undertaken by European cancer centers, such as: are assessments mandatory or voluntary? Do they focus on evaluating research, care or both? And are they international or national?

METHODS

A survey was sent to 33 cancer centers in 28 European Union member states. Participants were asked to score the specifics for each assessment that they listed.

RESULTS

Based on the responses from 19 cancer centers from 18 member states, we found 109 assessments. The numbers have steadily increased from 1990's till 2015. Although, a majority of assessments are on patient-care aspects (n = 45), it is unclear how many of those include assessing patient benefits. Only few assessments cover basic research. There is an increasing trend towards mixed assessments (i.e., combining research and patient-care aspects)

CONCLUSIONS

The need for assessments in cancer centers is increasing. To improve efforts in the quality of research and patient care and to prevent new assessments that "reinvent the wheel", it is advised to start comparative research into the assessments that are likely to bring patient benefits and improve patient outcome. Do assessments provide consistent and reliable information that create added value for all key stakeholders?

The business of palliative medicine—Part 3: The development of a palliative medicine program in an academic medical center

Palliative medicine is the total continuing care of patients with cancer. Most resources for cancer care focus on curative attempts while often ignoring the symptoms created by the disease and its treatment. Attempts at curative treatment of the malignancy must be coupled with pain and symptom relief, psychosocial and spiritual care, and support for the patient and family extending from the time of diagnosis through the bereavement period. To accomplish this important goal, we must establish comprehensive palliative medicine programs in cancer centers throughout the world. These programs must include education, research, and patient care and must work through an interdisciplinary team. The Cleveland Clinic Foundation palliative medicine program (PMP) is composed of a primary inpatient service, consult service, outpatient clinic, hospice homecare, and cancer homecare services. In this article, we describe the structure and development of the program and suggest future avenues for growth.

Procedural Impact of a Dedicated Interventional Oncology Service Line in a National Cancer Institute Comprehensive Cancer Center

PURPOSE

We tested the hypothesis that establishing a dedicated interventional oncology (IO) clinical service line would increase clinic visits and procedural volumes at a single quaternary care academic medical center.

METHODS

Two time periods were defined: July 2012 to June 2013 (pre-IO clinic) and July 2013 to June 2014 (first year of dedicated IO service). Staff was recruited, and clinic space was provided in the institution's comprehensive cancer center. Clinic visits and procedure numbers were documented using the institution's electronic medical record and billing forms. IO procedures included were transarterial chemoembolization, Y-90 radioembolization, perfusion mapping for Y-90, portal vein embolization, and bland embolization. We compared changes in clinic visit and procedure numbers using paired t tests. Changes after IO initiation were compared to 1-year changes in the Medicare 5% Limited Data Set by cross-referencing Current Procedure Terminology and International Classification of Diseases codes in 2012 and 2013.

RESULTS

Clinic visits increased from 9 to 204 (P = .003, t = 8.89, df = 3). Procedures increased from 60 to 239 (P = .018, t = 3.85, df = 4). Procedural volumes increased at least 150% for each subtype. The volumes in the 5% Limited Data Set did not change significantly over the 2-year period (443 to 385, P > .05).

CONCLUSIONS

The establishment of a dedicated IO service significantly increased clinic visits and procedural volumes. National trends were unchanged, suggesting that the impact of our program was not part of a sudden increase of IO procedures.

Insights From Building a New National Cancer Institute Community Oncology Research Program Site

BACKGROUND

The new National Cancer Institute (NCI) Community Oncology Research Program (NCORP) went live August 1, 2014; 34 sites were selected for the program, including 7 new sites that previously did not have a research grant from the NCI. This report describes the first year of a new program site.

METHODS

Accrual, investigator and site participation, and number of open studies by the program over the first 12 months of the grant were compared to performance at our institution over the prior 12 months.

RESULTS

During the pre-NCORP period, 84 patients were accrued to NCI-sponsored trials and 106 patients to non–NCI-sponsored trials. In year 1 of the new program, 140 were accrued to NCI-sponsored trials—a 66% improvement, and 109 patients to non–NCI-sponsored trials (P = 0.013 when comparing corresponding increases for NCI vs non-NCI trials). Success of the NCI-sponsored trials was associated with increased accrual to both treatment trials (P = 0.03) and Alliance for Clinical Trials in Oncology-sponsored trials (P = 0.0001).

CONCLUSIONS

NCORP implementation was associated with a significant (P = 0.013) improvement in accrual to NCI-sponsored trials that was immediate (1 year) and large (a 66% increase in accrual). In year 2, the intention is to increase cancer control studies; foster inclusion of radiation, surgical, gynecologic, and neurologic oncologists; and focus on minority outreach. Studies that accrue poorly will be assessed, and those accruing poorly on a national basis will be considered for closure. Studies accruing well nationally will be evaluated for barriers to local accrual.

A pilot videoconference group stress management program in cancer survivors: lessons learned

CONTEXT

Cancer is a challenging experience and there is evidence that psychosocial interventions are effective at improving adjustment following treatment. At our cancer center, 14 cancer survivors (breast, prostate and blood cancers) completed a four-session cognitive-behavioral stress program. The first session was delivered at the survivor's local cancer center, where they were provided with a loaner tablet. The three subsequent sessions were delivered through group-based videoconference on the tablet. Session content was supplemented with a tailored ebook, designed specifically for this program. Participants provided feedback about the program as well as a standardized measure of perceived stress.

ISSUES

Despite evidence that psychosocial programs are effective, there are significant barriers to dissemination, particularly for those residing in rural areas who do not live near academic medical centers where such programming is more readily available. Our experiences delivering a group-based videoconference program in cancer survivors are described, including positives and challenges associated with its design and implementation.

LESSONS LEARNED

Study participants enrolled from across four different US states, and the majority reported at least a 30-minute commute to their cancer center. This travel burden played a meaningful role in their desire to participate in our videoconference-based program. Although participants reported that session content was well suited to addressing stress management concerns, and session facilitators were able to effectively teach program techniques (eg progressive muscle relaxation, cognitive-reframing) and that the program was helpful overall, only modest improvements in perceived stress were seen. Participants noted challenges of the delivery including feeling disconnected from others, difficulty focusing, technical problems, and a desire for a longer program. Thus, although the novel delivery of a group-based, psychosocial program using tablet videoconference is feasible in a survivorship program, and desired by cancer survivors, key improvements must be made in future efforts. Our enthusiasm about the potential of telehealth must be tempered with the reality that such delivery can present challenges that interfere with the intervention implementation and efficacy. Facilitators must proactively address both the technological and interpersonal challenges associated with the use of group-based videoconference in order to improve its ability to positively impact cancer survivors. Many of these issues can be resolved prior to program launch, and require foresight and planning on the part of the program team.

Reference centres for adults with rare and complex cancers - Policy recommendations to improve the organisation of care in Belgium

BACKGROUND

Rare and/or complex cancers call for a very specific expertise and adequate infrastructure. In Belgium, every hospital with a programme in oncology can deliver care for adults with rare and/or complex cancer types, without having demonstrated a specific know-how to adequately manage these patients. Therefore, the Minister of Health ordered a scenario for the organisation of care for adults with rare and/or complex cancers, taking into account the current Belgian situation and relevant foreign experience.

METHODS

Combined methods were used in this study: a literature review, the consultation of stakeholders, in depth discussions in 14 multidisciplinary groups leading to concrete proposals for several rare/complex cancers and the consultation of a panel of expert pathologists.

RESULTS

The core recommendation is the set-up of shared care networks around reference centres, with multidisciplinary teams of recognised expertise in specific rare/complex cancers. The definition of minimum caseloads for hospitals and medical specialists, the evaluation of the quality of care, a model of diagnostic confirmation and the set-up of a national portal website which provides information on rare and/or complex cancers and reference centres are highly recommended.

CONCLUSION

It is no longer practicable, efficient or ethical that every hospital or every practitioner continues to offer care for every rare/complex cancer. Improving the quality of rare/complex cancer care requires to concentrate expertise and sophisticated infrastructure in reference centres. Furthermore, the formation of networks between reference centres and peripheral centres will allow a delivery of care combining expertise and proximity. The next step is the translation of the recommendations into policy decisions. It is very well realised that this will take some courage and that a certain degree of resistance will have to be surmounted, but eventually, the best interest of the patient should prevail.