Current Practice Patterns in Locally Advanced Rectal Cancer at Academic Institutions: A National Survey Among Radiation Oncologists, Medical Oncologists, and Colorectal Surgeons.

PURPOSE: To assess the current treatment patterns in locally advanced rectal cancer (LARC) among radiation oncologists (RO), medical oncologists (MO), and colorectal surgeons (SR) specializing in gastrointestinal (GI) malignancies at academic institutions. MATERIALS AND METHODS: An online survey consisting of 7 LARC clinical vignettes was distributed to GI specialists practicing at ACGME accredited academic institutions. Treatment paradigms consisted of long-course chemoradiation (LC-CRT) and short-course (SCRT) radiotherapy, chemotherapy (CHT), and surgery. The survey was open from January to April 2021. RESULTS: Thirty-six RO, 14 MO and 21 SR (71/508 physicians) replied resulting in a response rate of 14.0%. For low rectal node positive tumors, 88.7% of primary recommendations incorporated TNT (73.1% LC-CRT, 26.9% SCRT). NOM was preferred by 41.3% if a clinical complete response (cCR) was achieved. The presence of high-risk features led 95.8% of physicians to employ TNT (79.4% LC-CRT, 20.6% SCRT). For a cT3N1-2 mid-rectal tumor without high-risk features, 85.9% would primarily recommend TNT (56.6% LC-CRT, 43.4% SCRT). For a cT4bN2a mid-rectal tumor without high-risk features, 97.2% of primary recommendations included TNT (76.9% LC-CRT, 23.1% SCRT). CONCLUSION: Among academic RO, MO, and SR, the traditional regimen of LC-CRT, surgery, and adjuvant CHT is now infrequently recommended for LARC. TNT has been widely adopted for locally advanced node positive rectal tumors with variable patterns of care with respect to sequencing of CHT and RT. Fractionation with LC-CRT remained the majority. Non-operative management after a cCR in low rectal tumors has gained traction transforming LARC from a once classically perceived surgical disease.

Impact of a Palliative Care Nurse Practitioner in an Oncology Clinic: A Quality Improvement Effort.

PURPOSE: Guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether outcomes can be improved by modifying health care delivery in a real-world setting. METHODS: We report our 6-year experience of embedding a nurse practitioner in an oncology clinic (March 2014-March 2020) to integrate early, concurrent advance care planning and PC. RESULTS: Compared with patients with advanced cancer not enrolled in the palliative care nurse practitioner program, in March 2020, patients who are enrolled are more likely to have higher quality of PC (eg, goals of care note documentation [82% v 15%; P < .01], referral to the psychosocial oncology program [67% v 37%; P < .01], and referral to hospice [61% v 34%; P < .01]) and less inpatient utilization in the last 6 months of life (eg, hospital days [12 v 18; P < .01] and intensive care unit days [1.2 v 2.3; P < .01]). The program expanded over time with the support of faculty skills training for advance care planning and PC, supporting a shared mental model of PC delivery within the oncology clinic. CONCLUSION: Embedding a trained palliative care nurse practitioner in oncology clinics to deliver early integrated PC can lead to improved quality of care for patients with advanced cancer.

Cost-Health Literacy as an Educational Objective in Fellowship Training.

Physicians are encouraged to communicate with their patients about financial concerns, but are infrequently taught skills necessary to do so. This study describes a curriculum for oncology fellows aimed to improve skills of cost-health literacy, and provides assessment of the curriculum impact on self-perceived cost communication practices. Oncology fellows at a large academic program in 2019 participated in a cost-health literacy curriculum over 3 months. The curriculum consisted of a didactic on financial toxicity (45 min), a problem-based learning case highlighting financial toxicity risk factors and areas for intervention (30 min), and a group discussion (30 min) to review and consolidate strategies to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Of 19 participants, 16 completed both the pre-survey and post-survey and were included in the analysis. After the intervention, participants were more likely to report comfort discussing out-of-pocket costs (50% vs. 19%, p = 0.002) and to feel they could help a patient experiencing financial toxicity (62% vs. 6%, p = 0.005). There was no improvement in the subjective assessment of patient financial distress (57% v 50%, p = 0.759). Oncology fellows can improve self-reported cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and if it objectively impacts cost communication practices.

Characterizing the relationships between tertiary and community cancer providers: Results from a survey of medical oncologists in Southern California.

BACKGROUND: Tertiary cancer centers offer clinical expertise and multi-modal approaches to treatment alongside the integration of research protocols. Nevertheless, most patients receive their cancer care at community practices. A better understanding of the relationships between tertiary and community practice environments may enhance collaborations and advance patient care. METHODS: A 31-item survey was distributed to community and tertiary oncologists in Southern California using REDCap. Survey questions assessed the following attributes: demographics and features of clinical practice, referral patterns, availability and knowledge of clinical trials and precision medicine, strategies for knowledge acquisition, and integration of community and tertiary practices. RESULTS: The survey was distributed to 98 oncologists, 85 (87%) of whom completed it. In total, 52 (61%) respondents were community practitioners and 33 (38%) were tertiary oncologists. A majority (56%) of community oncologists defined themselves as general oncologists, whereas almost all (97%) tertiary oncologists reported a subspecialty. Clinical trial availability was the most common reason for patient referrals to tertiary centers (73%). The most frequent barrier to tertiary referral was financial considerations (59%). Clinical trials were offered by 97% of tertiary practitioners compared to 67% of community oncologists (p = 0.001). Most oncologists (82%) reported only a minimal-to-moderate understanding of clinical trials available at regional tertiary centers. CONCLUSIONS: Community oncologists refer patients to tertiary centers primarily with the intent of clinical trial enrollment; however, significant gaps exist in their knowledge of trial availability. Our results identify the need for enhanced communication and collaboration between community and tertiary providers to expand patients' access to clinical trials.

Unsolicited patient complaints among radiation, medical, and surgical oncologists.

BACKGROUND: Unsolicited patient complaints (UPCs) about physician practices are nonrandomly associated with malpractice claims and clinical quality. The authors evaluated the distributions and types of UPCs associated with oncologists by specialty and assessed oncologist characteristics associated with UPCs. METHODS: This retrospective study reviewed UPCs associated with US radiation oncologists (ROs), medical oncologists (MOs), and surgical oncologists (SOs) from 35 health care systems from 2015 to 2018. Average total UPCs were compared by specialty in addition to sex, medical school graduation year, degree, medical school location, residency location, practice setting, and practice region. For continuous variables, linear regression was used to test for an association with total complaints. RESULTS: The study included 1576 physicians: 318 ROs, 1020 MOs, and 238 SOs. The average number of UPCs per physician was different and depended on the oncologic specialty: ROs had significantly fewer complaints (1.28; 95% confidence interval [CI], 1.02-1.54) than MOs (3.81; 95% CI, 3.52-4.10) and SOs (6.89; 95% CI, 5.99-7.79; P < .0001). In a multivariable analysis, oncologic specialty, recency of graduation, and academic practice were predictive of higher total UPCs (P < .05). UPCs described concerns with care and treatment (42.8%), communication (26.4%), accessibility (17.5%), concern for patient (10.3%), and billing (2.9%). CONCLUSIONS: ROs had significantly fewer complaints than MOs and SOs and may have a lower risk of malpractice claims as a group. In addition to oncologic specialty, a more recent year of medical school graduation and working at an academic center were independent risk factors for UPCs. Further research is needed to clarify the reasons underlying these associations and to identify interventions that decrease UPCs and associated risks. LAY SUMMARY: This study of 1576 oncologists found that radiation oncologists had significantly fewer complaints than medical oncologists, who in turn had significantly fewer complaints than surgical oncologists. Other characteristics associated with more patient complaints included recency of medical school graduation and practice in an academic setting. Oncologists' patient complaints provide information that may have practical applications for patient safety and risk management. Understanding and addressing the characteristics that increase the risk for complaints could improve patients' experiences and outcomes.

Workup of anemia in cancer.

Anemia is a common diagnosis in patients with cancer that may affect both quality of life and survival. Anemia in this patient population is often multifactorial, caused by direct effects of the malignancy, products secondary to the malignancy, the effects of treatment, or other factors. Therefore, a systematic approach is required to determine the true cause or causes of anemia. An appropriate workup of anemia in patients with cancer can lead to treatment with the potential to reduce transfusion needs and improve quality of life. The clinical benefit of these interventions for specific patients must be weighed against possible risk.

Establishing a Denominator for Palliative Care Quality Metrics for Patients with Advanced Cancer.

Background: Measurement and monitoring of palliative care quality metrics for patients with advanced cancer promote early integration of palliative care within the oncology clinic. Accurately identifying the subset of advanced cancer patients within a population of cancer patients who would most benefit from palliative care is critical to the development of palliative care-relevant quality improvement activities. Methods: We evaluated two automated approaches to identifying patients with solid tumors sufficiently advanced to warrant discussions of palliative care and advanced care planning. These approaches included (1) pattern matching of words indicating an advanced cancer in oncology notes, radiology imaging, and active problem lists and (2) International Classification of Diseases (ICD-10) codes. We randomly selected 586 charts of patients with active cancer who are patients in our health system to establish a gold standard for advanced cancer through expert chart review. We evaluated the sensitivity and specificity of these automated approaches to identify advanced cancer patients compared with the gold standard. Results: We found that the highest performing pattern matching method had a specificity of 76% and a sensitivity of 81%. Using our final ICD-10 algorithm, we achieved a specificity of 92% and a sensitivity of 68%. We improved our sensitivity to 76% while maintaining our specificity at 91% when we excluded patients assigned to oncologists who predominantly see hematological malignancies. Conclusions: We achieved high specificity and reasonable sensitivity for an advanced cancer quality metric denominator using an ICD-10 algorithm within an academic oncology practice. This concrete definition will help inform quality improvement efforts locally and beyond.

A Case of Cutaneous Plasmablastic Lymphoma in HIV/AIDS with Disseminated Cryptococcus.

We present a case of a patient with HIV/AIDS who presented with a tender left lower extremity cutaneous mass over a site of previous cryptococcal infection and was found to have plasmablastic lymphoma (PBL). The incidence of PBL is estimated to account for less than 5% of all cases of non-Hodgkin lymphoma (NHL) in HIV-positive individuals. In fact, there were only two reports of extraoral PBL at the time of a 2003 review. PBL in HIV-positive individuals is an aggressive malignancy that tends to occur in middle-aged males with low CD4 counts, high viral loads, and chronic HIV infection. The definitive diagnosis can be made with biopsy which typically shows malignant lymphoid cells that stain positive for plasma cell markers and negative for B-cell markers. The most common treatment is chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP-like regimens, but the overall survival rate is poor despite its relative responsiveness to chemotherapy. This case highlights the challenges that remain in improving clinical outcomes, the importance of antiretroviral therapy and HIV disease control, and a potential association between a chronic inflammatory state caused by disseminated Cryptococcus and tumorigenesis in individuals with PBL.