Clinical challenges in the implementation of a tomotherapy service for head and neck cancer patients in a regional UK radiotherapy centre

OBJECTIVE

Intensity-modulated radiotherapy (IMRT) is increasingly being used to treat head and neck cancer cases.

METHODS

We discuss the clinical challenges associated with the setting up of an image guided intensity modulated radiotherapy service for a subset of head and neck cancer patients, using a recently commissioned helical tomotherapy (HT) Hi Art (Tomotherapy Inc, WI) machine in this article. We also discuss the clinical aspects of the tomotherapy planning process, treatment and image guidance experiences for the first 10 head and neck cancer cases. The concepts of geographical miss along with tomotherapy-specific effects, including that of field width and megavoltage CT (MVCT) imaging strategy, have been highlighted using the first 10 head and neck cases treated.

RESULTS

There is a need for effective streamlining of all aspects of the service to ensure compliance with cancer waiting time targets. We discuss how patient toxicity audits are crucial to guide refinement of the newly set-up planning dose constraints.

CONCLUSION

This article highlights the important clinical issues one must consider when setting up a head and neck IMRT, image-guided radiotherapy service. It shares some of the clinical challenges we have faced during the setting up of a tomotherapy service. Implementation of a clinical tomotherapy service requires a multidisciplinary team approach and relies heavily on good team working and effective communication between different staff groups.

[Introduction of a clinical protocol for extravasation at the National Institute of Oncology, Budapest, Hungary]

Extravasation of cytostatics occurs when an infusion containing a cytotoxic drug leaks into the surrounding perivascular and subcutaneous tissues. Incidence of cytostatic extravasation is found to be 0.1-6% according to the literature. Depending on the severity of complications, pain, loss of function in the extremities, or in extreme cases tissue necrosis necessitating an amputation may develop, drawing consequences like delay or interruption of the chemotherapy. Extent of complications is greatly influenced by the type of medication administered, general condition of the patient, and professional preparedness of staff providing the oncological health service. The protocol recently implemented in the National Institute of Oncology is a short, compact guidance for physicians and nurses providing oncological care, so by quick and adequate management of extravasation cases, severe complications could be prevented. More complex practical guidelines including algorithms could be created as a result of a wider collaboration, with the help of which oncological health professionals could easily cope with this rare problem. The authors describe in their review the implementation of the use of dry warm and cold packs, dymethylsulfoxide and hyaluronidase and their function within the algorithm of extravasation treatment.

Pediatric neuro-oncology in small centers--quality control of network support: the HIT-GBM experience

BACKGROUND

The quality of care for children with brain tumors might be higher in large medical centers; however, it may be possible to improve the quality of care received in smaller centers if they join an effective network.

AIM

This study used the HIT-GBM® database to compare the quality of care provided to pediatric high-grade glioma and diffuse intrinsic pontine glioma patients among various medical centers of differing sizes.

PATIENTS AND METHODS

Overall survival was used as a defining parameter. Indirect measures were the time intervals between the first clinical signs of cancer, initial diagnostic imaging, surgery, or chemotherapy and radiation.

RESULTS

From 1995 to 2003, 310 children (137 girls and 173 boys, aged 3 to 18 years old) were registered from 72 medical centers in Europe. Center sizes differed from 1 to 17 registered patients. Center size did not affect survival, nor any of the time intervals studied.

CONCLUSION

There was no evidence that the quality of care differed between smaller and larger centers.

Utilizing the Canadian Emergency Department Triage and Acuity Scale (CTAS) in an oncology urgent care clinic: the university health network experience

The Canadian Triage Acuity Score (CTAS) is a validated triage method used in Canadian emergency departments (ED) that groups patients according to severity of presenting illness (CIHI, 2005). According to Tanabe, Gimbel, Yarnold and Adams (2004), five-level triage systems can be utilized in order to benchmark with similar programs. CTAS, a five-level triage system, can also be used as an instrument to determine triage quality and to predict admission rates, hospital length of stay and diagnostic utilization (Jiminez et al., 2003). In June 2009, Princess Margaret Hospital launched REACH (Reducing Emergent and Acute Care Hospitalization), an oncology-specific urgent care clinic. In order to appropriately utilize resources, assist patients in a timely manner according to acuity, and compare and contrast data to that which is traditionally reported from our area EDs, we implemented the use of a validated triage methodology, CTAS, in this urgent care clinic. The following paper describes the University Health Network experience with utilizing CTAS in an oncology population.

Follow-up policies at Canadian head and neck cancer treatment centres

OBJECTIVE

to demonstrate the extent of the variation in follow-up policies in Canadian head and neck cancer treatment centres.

METHOD

telephone survey of head and neck surgeons.

RESULTS

there is a wide variation in both follow-up policies and beliefs about follow-up. The majority of centres saw patients every 2 to 3 months for the first 2 years, every 3 to 4 months in year 3, and every 6 months in years 4 and 5.

CONCLUSIONS

research is required to determine effective follow-up policies to maximize both patient outcomes and resource management as the numbers of patients in follow-up increase.

The quest for a "winning" breast center

This article focuses on the initiatives and first hand experiences in the establishment of a women's breast center at a not-for-profit, 305 bed, community hospital located in the highly affluent area of southern Connecticut. According to the National Consortium of Breast Centers (NCBC), a breast center organizes the screening, diagnosis, and treatment of breast services in a multidisciplinary approach. The services can be under one roof or at different locations, but the key is they must be under one unified leadership. Making a commitment to establish and maintain a viable breast center can be financially advantageous, as well as an outstanding service dedicated to women's breast health.

Improvement in the care of multiple endocrine neoplasia type 1 through a regional multidisciplinary clinic

BACKGROUND

Multiple endocrine neoplasia type 1 (MEN1) is associated with significant morbidity and mortality. Timely detection of MEN1 kindred, together with treatment of associated tumours, results in an improved outcome. We describe how the development of a dedicated multidisciplinary MEN clinic has improved the diagnosis and treatment of MEN1-associated endocrinopathies.

DESIGN AND PATIENTS

A dedicated MEN clinic was developed at Aintree University Hospital, Liverpool in 2002 for patients living in Merseyside, Cheshire and North Wales. The multidisciplinary approach adopted, aimed to improve communication and continuity of care. Patients see all clinicians involved in their care (Consultant Endocrinologist, Paediatrician, Clinical Geneticist and Endocrine Surgeon) simultaneously, allowing for a unified, clear approach and a reduction in unnecessary attendances. The clinicians adopt a proactive approach to tracing the relatives of patients, with the aim of identifying kindred with previously asymptomatic disease.

RESULTS

In 2002, 16 patients from 5 families were diagnosed clinically with MEN1. Twenty MEN1-associated endocrinopathies had been diagnosed and 21 surgical procedures had been performed. By the end of 2008, 45 patients from 15 families had been identified, with 83 endocrinopathies diagnosed and 50 surgical procedures performed. Ninety-four known relatives are awaiting screening for MEN1.

CONCLUSION

The successful identification of patients with MEN1 has resulted in an exponential increase in the number of patients attending the clinic. As relatives undergo screening, the diagnosis of MEN is likely to increase. The ever increasing numbers of patients requiring screening, surveillance and treatment has implications in the planning of future service provision.

Environment critical to teenagers' recovery

The Teenage Cancer Trust (TCT), the charity devoted to improving the lives of teenager cancer sufferers, has released the initial results of an independent study which it says prove that a high quality built environment, of the calibre seen in its 13 existing U.K. teenage cancer units, not only boosts patient morale by giving sick youngsters a feeling of control, but also encourages young cancer sufferers to complete their treatment, significantly impacting the number of positive outcomes. Jonathan Baillie reports on the study's London launch.

Patient-centred care: more than the sum of its parts--Planetree's patient-centred hospital designation programme

When a nurse at the Celilo Cancer Center at the Mid-Columbia Medical Center in The Dalles, Oregon, found out that his patient was scheduled to receive chemotherapy on her wedding anniversary, he asked the woman and her husband what song they'd first danced to on their wedding day. It was "Save the Last Dance For Me," and the next day, when the couple rose from their chairs after the patient's six-hour infusion, the song began playing. Right there in the infusion area, with their arms around each other, they danced. This story illustrates the kind of care that has become the norm at the 10 hospitals in North America recognized since 2007 as patient-centred hospitals by Planetree's Patient-Centred Hospital Designation Program. At these hospitals "patient-centred care" is more than a buzzword. Rather, it's reflected in their mission statements, strategic plans, models of nursing care, and day-to-day operations. While many organizations, including the Institute of Medicine, the Institute for Healthcare Improvement, and Planetree, have endeavored to define patient-centred care, no definition conveys its essence as well as the patients at these hospitals can. "This place has a special character," one patient said in a focus group. Others have said, "You can tell the nurses here care about you as a person," "They are a special breed of people here," and "I don't think it's just a job for them; they're here for a reason." Over the past year, this series, Putting Patients First, has explored several aspects of the patient-centered approach--encouraging patients to review their medical records, lifting restrictions on family involvement in care, and lowering noise levels in hospitals, among others. We believe they show that, ultimately, patient-centered care is more than the sum of its parts.

[Improvement in diagnosis and therapy of breast cancer in physician-organized service]

Our program has facilitated access to medical aid making earlier treatment of breast cancer possible. The morbidity rates in a city district being 1.5 times those of the metropolitan area, with 52-62% of early cancers among them, organ-saving operations rose from 3-5% to 16-17%. As a result, the 12-month mortality rate was 7.2%, while overall and relapse-free survival - 70.6 and 68.7%, respectively, which was comparable with results reported from advanced onco-centers.

Analysis of the standardization and centralization for cancer treatment in Nagasaki prefecture

In medical care systems for cancer, it is important to consider the issues of standardization and centralization. In this study, we employed the Nagasaki Cancer Registry, which has a high registry rate, to investigate standardization and centralization for five major cancers, in addition to childhood malignancies (which are often rare types). Subjects were patients diagnosed with cancer and registered in the Nagasaki Cancer Registry between 1985 and 2004. For standardization, we calculated a Preference Index and five-year survival rate, and for centralization we investigated Pareto curves and Gini coefficients as well as the annual average number of cases per hospital. Results suggested that patients migrate to medical service areas different from where they reside in order to receive treatment at facilities thought to have a better record of treatment. In addition, while the number of patients and treatment facilities for childhood cancer was decreasing due to a decline in the number of children, the centralized tendency differed for the 12 diagnoses assessed. By conducting analyses based on population-based cancer registries using the evaluation methods employed in this study, it should be possible to investigate patients' migrant patterns, as well as to develop systems for providing medical care in secondary medical service areas.

Interprofessional collaboration with service users in the development of cancer services: The Cancer Partnership Project

Patient and Public Involvement (PPI) is a cornerstone of UK National Health Service (NHS) policy. The Cancer Partnership Project (CPP) is the leading national PPI initiative in cancer care. The CPP espouses a "partnership" model, with a "Partnership Group" - collaborative service improvement groups formed of NHS staff and service users - in each of 34 cancer networks in England. These groups aim to enable service users to influence local cancer service development and thereby improve the effectiveness of services. We interviewed 59 cancer service users and NHS staff in a reflective evaluation of CPP. Groups were active and visible in 30 networks, their main activities being: providing an accessible source of consumer opinion; prolific networking and representation; patient information and communication projects; and lobbying for service improvements. The groups exhibited some significant tensions. The motivations of professional staff varied markedly, and "obligatory" involvement as part of a person's job was counter-productive when not coupled with a "personal" belief in the value of PPI. Other controversial areas were the disclosure by patients' of personal health and treatment experiences, and emotional attachment to the group. It was concluded that partnership groups represent a useful PPI model, but more attention generally should be paid to the complexities of PPI and timescales required for meaningful cultural change.

Evaluation of formative development in the neighborhood cancer care cooperative

The Radiation Oncology Community Outreach Group (ROCOG) and Neighborhood Cancer Care Cooperative (NCCC) were funded by the National Cancer Institute Radiation Research Program Cancer Disparities Research Partnership program in September 2003. ROCOG/NCCC provides customized, community hospital-based initiatives intended to help close the cancer disparities gap. In our two preceding articles in this issue, we have explored contextual and organizational development, described infrastructure and component programs, and outlined early evaluation strategies. This article will conclude the series of publications describing our early development by evaluating the formative implementation phase of the project. Our first 12 months were initially evaluated through a survey designed to assess staff and key stakeholders' perception of progress. An assessment of the level of completion of key project tasks was conducted 6 months after the survey. This combination has allowed ROCOG/NCCC to determine areas of success and also illustrate those in need of improvement. Our evaluation strategy can also serve as an efficient and inexpensive model for other similar community-based start-up programs to replicate.

Creation of community-based research capabilities in the neighborhood cancer care cooperative: administrative infrastructure, program initiatives, and evaluation priorities

The Radiation Oncology Community Outreach Group (ROCOG) and the Neighborhood Cancer Care Cooperative (NCCC) were developed to address oncology-related health disparities utilizing a community-based, collaborative organizational design. Funded in 2003 by the National Cancer Institute's Cancer Disparities Research Partnership program, ROCOG/NCCC has focused on reducing barriers to care and enhancing the health care system's responsiveness to minority and indigent populations within Southwestern Pennsylvania. This article will describe the component programs that have been developed under this umbrella, as well as the evolved administrative, governance, and evaluation infrastructure that supports these initiatives.