Surgeons' knowledge and practices regarding the role of radiation therapy in breast cancer management

Radiation Oncologists' Views on Adjuvant Radiotherapy for Early-Stage Breast Cancer in the Elderly: Comparisons between Japan and the United States

PURPOSE

To understand perspective on breast cancer using a survey.

MATERIALS & METHODS

Questionnaire was distributed to 304 Japanese radiation oncologists (RadOncs) (response rate: 64.1%). Result was compared with a similar US survey.

RESULTS

In a scenario with an 81-year-old patient with comorbidities, while most US RadOncs chose to tell that radiation might not be necessary, 2% of Japanese chose it. In a scenario with a healthy 65-year-old breast cancer patient with lumpectomy, while most US RadOncs chose to discuss omission of radiation, 24.5% of Japanese chose it.

CONCLUSIONS

Differences were observed on radiotherapy for older early-stage breast cancer.

Travel, Treatment Choice, and Survival Among Breast Cancer Patients: A Population-Based Analysis

Background: Travel distance to care facilities may shape urban-rural cancer survival disparities by creating barriers to specific treatments. Guideline-supported treatment options for women with early stage breast cancer involves considerations of breast conservation and travel burden: Mastectomy requires travel for surgery, whereas breast-conserving surgery (BCS) with adjuvant radiation therapy (RT) requires travel for both surgery and RT. This provides a unique opportunity to evaluate the impact of travel distance on surgical decisions and receipt of guideline-concordant treatment. Materials and Methods: We included 61,169 women diagnosed with early stage breast cancer between 2004 and 2013 from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Driving distances to the nearest radiation facility were calculated by using Google Maps. We used multivariable regression to model treatment choice as a function of distance to radiation and Cox regression to model survival. Results: Women living farthest from radiation facilities (>50 miles vs. <10 miles) were more likely to undergo mastectomy versus BCS (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.22-1.79). Among only those who underwent BCS, women living farther from radiation facilities were less likely to receive guideline-concordant RT (OR: 1.72, 95% CI: 1.32-2.23). These guideline-discordant women had worse overall (hazards ratio [HR]: 1.50, 95% CI: 1.42-1.57) and breast-cancer specific survival (HR: 1.44, 95% CI: 1.29-1.60). Conclusions: We report two breast cancer treatments with different clinical and travel implications to show the association between travel distance, treatment decisions, and receipt of guideline-concordant treatment. Differential access to guideline-concordant treatment resulting from excess travel burden among rural patients may contribute to rural-urban survival disparities among cancer patients.

Development of Residents' Self-Efficacy in Multidisciplinary Management of Breast Cancer Survey

BACKGROUND

Treating patients with breast cancer is multidisciplinary; however, it is unclear whether surgery residency programs provide sufficient training in multidisciplinary care. Self-efficacy is one way of measuring the adequacy of training. Our goal was to develop a method of assessing self-efficacy in multidisciplinary breast cancer care.

METHODS

Based on a literature review and subject-matter expert input, we developed a 30-item self-efficacy survey to measure six domains of breast cancer care (genetics, surgery, medical oncology, radiation oncology, pathology, and radiology). We constructed and validated the survey using a seven-step survey development framework. The survey was administered to general surgery residents at a single academic surgical residency.

RESULTS

Response rate was 66% (n = 31). Internal consistency was strong (Cronbach alpha = 0.92). Self-efficacy was moderate (mean = 3.05) and tended to increase with training (postgraduate year [PGY] 1: mean= 2.37 versus PGY 5: mean= 3.54; P < 0.001), providing evidence for construct validity. Self-efficacy was highest in the surgery (3.56) compared with others (genetics 2.67, medical oncology 3, radiation oncology 2.67, pathology 2.67, and radiology 3.33). This trend was similar across all PGY groups, except for interns, whose self-efficacy in surgery was low.

CONCLUSIONS

We created a survey to assess self-efficacy in multidisciplinary breast cancer care and provided initial evidence of survey validity. Although self-efficacy in surgery improved with years in training, medical and radiation oncology self-efficacy remained low. As modern breast cancer treatment is highly multidisciplinary, an expanded education program is needed to help trainees incorporate multidisciplinary clinical perspectives.

A Modified Communication and Optimal Resolution Program for Intersystem Medical Error Discovery: Protocol for an Implementation Study

Background

Preventable medical errors represent a major public health problem. To prevent future errors, improve disclosure, and mitigate malpractice risks, organizations have adopted strategies for transparent communication and emphasized quality improvement through peer review. These principles are incorporated into the Agency for Healthcare Research and Quality (AHRQ) Communication and Optimal Resolution (CANDOR) Toolkit, which facilitates (1) transparent communication, (2) error prevention, and (3) achieving optimal resolution with patients and families; however, how medical errors should be addressed when they are discovered between systems—intersystem medical error discovery (IMED)—remains unclear. Without mechanisms for disclosure and feedback on the part of the discovering provider, uncertainty remains as to the extent to which IMED is communicated with patients or responsible providers. Furthermore, known barriers to disclosure and reporting one’s own error may not be relevant or may be replaced by other unknown barriers when considering scenarios of IMED.

Objective

This study aims to develop and test implementation of a modified CANDOR process for application to IMED scenarios.

Methods

We plan a series of studies following an implementation framework. First, we plan a participatory, consensus-building stakeholder panel process to develop the modified CANDOR process. We will then conduct a robust preimplementation analysis to identify determinants of implementation of the modified process. Using the Consolidated Framework for Implementation Research as a theoretical framework, we will assess organizational readiness by key informant interviews and individual-level behaviors by a survey. Findings from this analysis will inform the implementation toolkit that will be developed and pilot-tested at 2 cancer centers, sites where IMED is hypothesized to occur more frequently than other settings. We will measure 5 implementation outcomes (acceptability, appropriateness, reach, adoption, and feasibility) using a combination of key informant interviews and surveys over the pre- and postimplementation phases.

Results

This protocol was funded in August 2018 with support from the AHRQ. The University of Michigan Medical School Institutional Review Board has reviewed and approved the scope of activities described. As of April 2019, step 1 of aim 1 is underway, and aim 1 is projected to be completed by April 2020. Data collection is projected to begin in January 2020 for aim 2 and in August 2020 for aim 3.

Conclusions

Providing a communication and resolution strategy applicable to IMED scenarios will help address the current blind spot in the patient safety movement. This work will provide important insights into the potential utility of an implementation toolkit to improve transparent communication and optimal resolution of IMED scenarios. The natural progression of this work will be to test the toolkit more broadly, understand the feasibility and barriers of implementation on a broader scale, and pilot the implementation in new organizations.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13396

Impact of Peer Review on Use of Hypofractionated Regimens for Early-Stage Breast Cancer for Patients at a Tertiary Care Academic Medical Center and Its Community-Based Affiliates

PURPOSE

Data have demonstrated that hypofractionated radiation therapy (HFRT) and conventionally fractionated radiation therapy regimens are equivalent with respect to outcomes. Efforts to increase HFRT use have had mixed success. We implemented a prospective peer review chart rounds integrating all practice sites and reviewed the use of HFRT in an attempt to identify potential predictors of use.

MATERIALS AND METHODS

Patients treated with whole-breast radiation therapy within our cancer care network from January 2016 to June 2017 were evaluated. Radiation courses with a dose per fraction of greater than 2 Gy were considered HFRT, whereas those with a dose per fraction of less than or equal to 2 Gy were considered as conventionally fractionated radiation therapy. Patient, provider, and tumor characteristics were categorized by use of HFRT and compared between groups using a χ² test or two-tailed t test.

RESULTS

A total of 349 consecutive patients were identified. All 120 patients treated at the main academic site received HFRT. There was significant variation in use of HFRT among community-based providers (28% to 100%; P < .001). There was increased use of HFRT after implementation of institution-wide prospective peer review (66% v 81% before and after implementation, respectively; P = .001). Age, tumor grade, chemotherapy receipt, surgeon type (academic v community), and treatment after implementation of peer review all correlated with HFRT use. On multivariable analysis, treatment after implementation of peer review ( P < .001) remained a significant predictor of HFRT use, as did age ( P = .005), tumor grade ( P = .013), and surgeon type ( P < .001).

CONCLUSION

Significant variation persists in the use of HFRT among providers. Increased awareness and oversight through prospective peer review may be useful in improving compliance to HFRT. Expanding these efforts to include education of referring surgeons may be helpful.

Comparative Analysis of the Views of Oncologic Subspecialists and Palliative/Supportive Care Physicians Regarding Advanced Care Planning and End-of-Life Care

BACKGROUND

Early palliative/supportive care (PSC) consultation and advance care planning (ACP) improve outcomes for patients with incurable cancer. However, PSC is underutilized in the United States.

OBJECTIVE

To examine philosophical differences among PSC, radiation oncology (RO), and medical oncology (MO) physicians in order to understand barriers to early PSC referral.

DESIGN

An electronic survey collected views of a nationwide cohort of health-care professionals regarding ACP and end-of-life care. Setting/Participants/Measurements: A subgroup analysis compared the responses from all 51 PSC, 178 RO, and 81 MO physician participants (12% response rate), using Pearson χ² and Mann-Whitney U tests for categorical and ordinal data, respectively.

RESULTS

More statistically significant differences were observed between RO-PSC (12 questions) and MO-PSC (12 questions) than RO-MO (4 questions). Both RO and MO were more likely than PSC physicians to believe doctors adequately care for emotional ( P < .001) and physical ( P < .001) needs of patients with an incurable illness. Both RO and MO were also less likely to believe that PSC physicians were helpful at addressing these needs ( P = .002 and <.001, respectively) or that patients' awareness of their life expectancy leads to better medical ( P = .007 and .002, respectively) and personal ( P = .001 for each) decisions. Palliative/supportive care physicians felt that doctors are generally less successful at explaining/clarifying advanced life-sustaining treatments than RO ( P < .001) or MO ( P = .004). MO favored later initiation of ACP than either RO ( P = .006) or PSC physicians ( P = .004).

CONCLUSIONS

Differences in perception of appropriate end-of-life care exist between oncologists and PSC physicians, suggesting a need for improved education and communication between these groups.

Out of the Basement and Into the Classroom: Pathways for Expanding the Role of Radiation Oncologists in Medical Student Education

PURPOSE

To characterize radiation oncologist involvement in undergraduate medical education at US academic medical centers and to incorporate these findings into practical pathways for greater and broader integration of radiation oncology (RO) into medical curricula.

METHODS

Chairpersons and residency program directors at RO departments directly affiliated with a medical school were asked to describe all the ways in which radiation oncologists in their department are involved in medical student education, excluding their elective clerkship.

RESULTS

Of 75 eligible departments, 49 responded (response rate 65.3%). Twenty departments (40.8%) reported that at least one faculty member participates in a curricular educational session on an oncology-related topic. Twelve (24.5%) of these sessions were focused specifically on RO. Twenty-one departments (42.9%) had faculty involved with organized clinical shadowing or preceptorship programs for first- and second-year medical students. Twelve departments (24.5%) described no involvement in the formal curricula at their local or affiliated medical school. Thirteen departments (44.8%) described participation in a medical school-organized residency fair, and 12 departments (41.4%) sponsor an RO interest group. Reported novel approaches to teaching included development of multidisciplinary clerkships or educational sessions that include RO concepts, guest lectures on RO during a required clerkship, organized extracurricular experiences such as an oncology seminar series, participation in special medical student enrichment programs, and sponsorship or initiation of an RO interest group.

CONCLUSION

The minority of RO departments are involved in formal teaching of the medical student body at large. The approaches described herein should facilitate more robust involvement of radiation oncologists in all areas of undergraduate medical education.

Prognostic value of the lymph node ratio for lymph-node-positive breast cancer- is it just a denominator problem?

Purpose

To examine the prognostic value of lymph node ratio (LNR) for patients with node-positive breast cancer with varying numbers of minimum nodes removed (>5, > 10 and > 15 total node count).

Methods

This study examined the original histopathological reports of 332 node-positive patients treated in the state of New South Wales (NSW), Australia between 1 April 1995 and 30 September 1995. The LNR was defined as the number of positive lymph nodes (LNs) over the total number of LNs removed. The LNR cutoffs were defined as low-risk, 0.01–0.20; intermediate-risk, 0.21– 0.65; and high-risk, LNR >0.65.

Results

The median follow-up was 10.3 years. In multivariate analysis, LNR was an independent predictor of 10-year breast cancer specific survival when > 5 nodes were removed. However, LNR was not an independent predictor when > 15 nodes were removed. In a multivariate analysis the relative risk of death (RR) decreased from 2.20 to 1.05 for intermediate-risk LNR and from 3.07 to 2.64 for high-risk while P values increased from 0.027 to 0.957 for intermediate-risk LNR and 0.018 to 0.322 for high-risk with the number of nodes removed increasing from > 5 to > 15.

Conclusions

Although LNR is important for patients with low node denominators, for patients with macroscopic nodal metastases in several nodes following an axillary dissection who have more than 15 nodes dissected, the oncologist can be satisfied that prognosis, selection of adjuvant chemotherapy and radiotherapy fields can be based on the numerator of the positive nodes.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-015-0865-2) contains supplementary material, which is available to authorized users.

How can we best respect patient autonomy in breast cancer treatment decisions?

Helping patients to maximize their autonomy in breast cancer decision-making is an important aspect of patient-centered care. Shared decision-making is a strategy that aims to maximize patient autonomy by integrating the values and preferences of the patient with the biomedical expertise of the physician. Application of this approach in breast cancer decision-making has not been uniform across cancer-specific interventions (e.g., surgery, chemotherapy), and in some circumstances may present challenges to evidence-based care delivery. Increasingly precise estimates of individual patients' risk of recurrence and commensurate predicted benefit from certain therapies hold significant promise in helping patients exercise autonomous decision-making for their breast cancer care, yet will also likely complicate decision-making for certain subgroups of patients.