What are survivorship care plans failing to tell men after prostate cancer treatment?

BACKGROUND: Survivorship care plans contain important information for patients and primary care physicians regarding appropriate care for cancer survivors after treatment. We describe the completeness of prostate cancer survivorship care plans and evaluate the concordance of follow-up recommendations with guidelines. METHODS: We analyzed 119 prostate cancer survivorship care plans from one academic and one community cancer center, abstracting demographics, cancer/treatment details, and follow-up recommendations. Follow-up recommendations were compared with the American Cancer Society (ACS), American Society of Clinical Oncology (ASCO), and National Comprehensive Cancer Network (NCCN) guidelines. RESULTS: Content in >90% of plans included cancer TNM stage; prostate-specific antigen (PSA) at diagnosis; radiation treatment details (98% of men received radiation); and PSA monitoring recommendations. Potential treatment-specific side effects were listed for 82% of men who had surgery, 86% who received androgen deprivation therapy (ADT), and 97% who underwent radiation. The presence of posttreatment symptoms was noted in 71% of plans. Regarding surveillance follow-up, all guidelines recommend an annual digital rectal exam (DRE). No plans specified DRE. However, all 71 plans at the community site recommended at least annual follow-up visits with urology, radiation oncology, and primary care. Only 2/48 plans at the academic site specified follow-up visits. All guidelines recommend PSA testing every 6-12 months for 5 years, then annually. For the first 5 years, 90% of plans were guideline-concordant, 8% suggested oversurveillance, and 2% were incomplete. In men receiving ADT, ACS and ASCO recommend bone density imaging and NCCN recommends testosterone levels. Of 77 men on ADT, 1% were recommended bone density imaging and 16% testosterone level testing. CONCLUSIONS: While care plan content is more complete for demographic and treatment summary information, both sites had gaps in reporting posttreatment symptoms and ADT-related testing recommendations. These findings highlight the need to improve the quality of information in care plans, which are important in communicating appropriate follow-up recommendations to patients and primary care physicians.

Assessment of Radiation Oncology Nurse Education in the United States.

PURPOSE: Nurses in the radiation oncology (RO) clinic have a critical role in the management of patients receiving radiation therapy. However, limited data exist regarding the exposure of nurses to RO during training and the current educational needs of practicing RO nurses. This study assesses nurses' prior RO education, participation in national training efforts, and perceived educational needs. METHODS AND MATERIALS: A web-based survey using a 5-point Likert-type scale was distributed to RO nurses at 3 academic medical centers. Questions focused on prior education experiences, clinical areas of strength/weakness, and perceived value of future educational interventions. Likert-type scores are reported as median (interquartile range), and a Kruskal-Wallis test was conducted to assess for significant differences in responses. RESULTS: The survey response rate was 39 of 54 (72%). Respondents were 90% female and trained at 30 nursing schools in 17 states. Only 5% of nurses reported a curriculum in nursing school with RO content, and nearly all (97%) received their RO education on the job. Forty-one percent of nurses completed the Oncology Nursing Society radiation therapy certificate course, and only 5% completed the American Society for Radiation Oncology nursing module. Nurses felt most confident in the overall management of patients with breast (4 [3-4]), prostate (4 [3-5]), and central nervous system (4 [3-4]) cancers and least confident for lymphoma (3 [2-4]), gynecologic (3 [2-4]), and head and neck cancers (3 [2-4]; P < .01). Nurses rated didactic lectures from physicians (5 [3-5]), shadowing RO residents (4 [3-5]), and working with simulation therapists (4 [3-5]) as valuable components to include in a training curriculum (P = .08). CONCLUSIONS: Nursing school exposure to RO is limited, and only a minority of RO nurses complete RO-specific training or certification available from national organizations. This study identifies several areas of perceived clinical nursing strengths and weaknesses that can be used to inform the design of future RO nursing educational programs.

Substance Use Screening Protocol: Implementation of a System for Patients With Cancer.

BACKGROUND: Substance use by patients with a cancer diagnosis may have a detrimental effect on short- and long-term outcomes. Screening, brief intervention, and referral to treatment (SBIRT) has been recommended for all patients in primary care and emergency medicine. OBJECTIVES: The purpose of this quality improvement project was to train clinical providers and to implement an effective SBIRT program in a radiation oncology clinic in a comprehensive cancer center. METHODS: An interprofessional task force developed a staff training protocol that incorporated oncology-specific content. The team then piloted an SBIRT program in the outpatient clinic. FINDINGS: Staff training results were mixed, with only a few evaluation items showing significant improvement. Despite these results, staff training and the implementation of an SBIRT may be valuable in improving substance use screening in this vulnerable population.

Adoption of an incident learning system in a regionally expanding academic radiation oncology department.

AIM AND BACKGROUND: We describe a successful implementation of a departmental incident learning system (ILS) across a regionally expanding academic radiation oncology department, dovetailing with a structured integration of the safety and quality program across clinical sites. MATERIALS AND METHODS M: Over 6 years between 2011 and 2017, a long-standing departmental ILS was deployed to 4 clinical locations beyond the primary clinical location where it had been established. We queried all events reported to the ILS during this period and analyzed trends in reporting by clinical site. The chi-square test was used to determine whether differences over time in the rate of reporting were statistically significant. We describe a synchronous development of a common safety and quality program over the same period. RESULTS: There was an overall increase in the number of event reports from each location over the time period from 2011 to 2017. The percentage increase in reported events from the first year of implementation to 2017 was 457% in site 1, 166.7% in site 2, 194.3% in site 3, 1025% in site 4, and 633.3% in site 5, with an overall increase of 677.7%. A statistically significant increase in the rate of reporting was seen from the first year of implementation to 2017 (p < 0.001 for all sites). CONCLUSIONS: We observed significant increases in event reporting over a 6-year period across 5 regional sites within a large academic radiation oncology department, during which time we expanded and enhanced our safety and quality program, including regional integration. Implementing an ILS and structuring a safety and quality program together result in the successful integration of the ILS into existing departmental infrastructure.

Patterns of Incident Reporting Across Clinical Sites in a Regionally Expanding Academic Radiation Oncology Department.

PURPOSE: We evaluated patterns of event reporting across five clinical locations within an academic radiation oncology department, with the goal of better understanding variability across sites. METHODS AND MATERIALS: We analyzed 1,351 events reported to a departmental incident learning system over 1 calendar year across the five locations with respect to volume of events, event type, process map location of origin and detection, and event reporter. RESULTS: We found marked variability in reporting patterns, including reporting rate, event type, event severity, event location of origin and detection within the departmental process map, and discipline of event reporters. These differences relate both to variability in process and workflow (reflected by frequency of specific workflow events at each site) and in reporting culture (reflected by volume or rate of event reporting, and discipline of event reporter). CONCLUSIONS: These data highlight the variability in reporting culture even within a single department, and therefore the need to tailor and individualize safety and quality programs to the unique clinical site, with the long-term goal of achieving a common culture of safety while supporting unique processes at individual locations. This work also raises concern about extrapolating single-institution incident learning system results without understanding the unique workflow and culture of clinical sites.

The Needs and Benefits of Continuous Model Updates on the Accuracy of RT-Induced Toxicity Prediction Models Within a Learning Health System.

PURPOSE: Clinical data collection and development of outcome prediction models by machine learning can form the foundation for a learning health system offering precision radiation therapy. However, changes in clinical practice over time can affect the measures and patient outcomes and, hence, the collected data. We hypothesize that regular prediction model updates and continuous prospective data collection are important to prevent the degradation of a model's predication accuracy. METHODS AND MATERIALS: Clinical and dosimetric data from head and neck patients receiving intensity modulated radiation therapy from 2008 to 2015 were prospectively collected as a routine clinical workflow and anonymized for this analysis. Prediction models for grade ≥2 xerostomia at 3 to 6 months of follow-up were developed by bivariate logistic regression using the dose-volume histogram of parotid and submandibular glands. A baseline prediction model was developed with a training data set from 2008 to 2009. The selected predictor variables and coefficients were updated by 4 different model updating methods. (A) The prediction model was updated by using only recent 2-year data and applied to patients in the following test year. (B) The model was updated by increasing the training data set yearly. (C) The model was updated by increasing the training data set on the condition that the area under the curve (AUC) of the recent test year was less than 0.6. (D) The model was not updated. The AUC of the test data set was compared among the 4 model updating methods. RESULTS: Dose to parotid and submandibular glands and grade of xerostomia showed decreasing trends over the years (2008-2015, 297 patients; P < .001). The AUC of predicting grade ≥2 xerostomia for the initial training data set (2008-2009, 41 patients) was 0.6196. The AUC for the test data set (2010-2015, 256 patients) decreased to 0.5284 when the initial model was not updated (D). However, the AUC was significantly improved by model updates (A: 0.6164; B: 0.6084; P < .05). When the model was conditionally updated, the AUC was 0.6072 (C). CONCLUSIONS: Our preliminary results demonstrate that updating prediction models with prospective data collection is effective for maintaining the performance of xerostomia prediction. This suggests that a machine learning framework can handle the dynamic changes in a radiation oncology clinical practice and may be an important component for the construction of a learning health system.

Evaluation of classification and regression tree (CART) model in weight loss prediction following head and neck cancer radiation therapy.

OBJECTIVE: We explore whether a knowledge-discovery approach building a Classification and Regression Tree (CART) prediction model for weight loss (WL) in head and neck cancer (HNC) patients treated with radiation therapy (RT) is feasible. METHODS AND MATERIALS: HNC patients from 2007 to 2015 were identified from a prospectively collected database Oncospace. Two prediction models at different time points were developed to predict weight loss ≥5 kg at 3 months post-RT by CART algorithm: (1) during RT planning using patient demographic, delineated dose data, planning target volume-organs at risk shape relationships data and (2) at the end of treatment (EOT) using additional on-treatment toxicities and quality of life data. RESULTS: Among 391 patients identified, WL predictors during RT planning were International Classification of Diseases diagnosis; dose to masticatory and superior constrictor muscles, larynx, and parotid; and age. At EOT, patient-reported oral intake, diagnosis, N stage, nausea, pain, dose to larynx, parotid, and low-dose planning target volume-larynx distance were significant predictive factors. The area under the curve during RT and EOT was 0.773 and 0.821, respectively. CONCLUSIONS: We demonstrate the feasibility and potential value of an informatics infrastructure that has facilitated insight into the prediction of WL using the CART algorithm. The prediction accuracy significantly improved with the inclusion of additional treatment-related data and has the potential to be leveraged as a strategy to develop a learning health system.

Prospective evaluation of patient reported swallow function with the Functional Assessment of Cancer Therapy (FACT), MD Anderson Dysphagia Inventory (MDADI) and the Sydney Swallow Questionnaire (SSQ) in head and neck cancer patients.

OBJECTIVES: The Functional Assessment of Cancer Therapy (FACT) instrument is comprised of a group of related and overlapping quality of life (QoL) questionnaires including a core general form, head and neck cancer (HNC)-specific items, and an expert-selected index (FACT-HNSI). Understanding how these relate to more HNC-specific instruments such as the MD Anderson Dysphagia Inventory (MDADI) and Sydney Swallow Questionnaire (SSQ) is vital for guiding their use in clinical trials. MATERIALS AND METHODS: HNC patients concurrently completed MDADI, SSQ, and FACT questionnaires at radiation oncology clinic visits (2015-2016). Spearman correlation coefficients were calculated between each FACT instrument and MDADI or SSQ. Unsupervised k-means cluster analyses were performed to identify clusters of similar QoL responses. Principal component analysis (PCA) identified the degree of variability explained by each instrument. RESULTS: We identified 631 instances (363 patients) where the questionnaires were completed concurrently. Correlations between the various FACT measures and SSQ or MDADI were all significant (p < 0.001), but FACT HNC-specific subscale and FACT-HNSI showed the strongest correlation with MDADI and SSQ. Clustering identified 3 distinct groups of responses when combining instruments either pairwise or three-way. PCA revealed that MDADI and FACT HNC-specific subscale provide similar and likely redundant information. CONCLUSION: FACT HNC-subscale and FACT-HNSI may be preferable over other FACT measures for use in clinical trials where patient-reported swallow function is evaluated. MDADI and FACT provide similar insights into HNC patient QoL while SSQ provides additional, complementary information which could serve to better stratify patients into groups with high, medium, and low QoL outcomes.

Real-time management of incident learning reports in a radiation oncology department.

PURPOSE: The optimal approach to managing incident learning system (ILS) reports remains unclear. Here, we describe our experience with prospective coding of events reported to the ILS with comparisons of risk scores on the basis of event type and process map location. METHODS AND MATERIALS: Reported events were coded by type, origin, and method of discovery. Events were given a risk priority number (RPN) and near-miss risk index (NMRI) score. We compared workflow versus near-miss events with respect to origin and detection in the process map and by risk scores. A χ2 test was used to compare the differences between workflow and near-miss events. A comparison of RPN scores was done by independent t test. RESULTS: During 2016, 1351 events were reported. Of these events, 1300 (96.2%) were workflow and 51 (3.8%) near-miss events. Workflow events were more likely to both originate (1041 of 1300 events; 81.2%) compared with near-miss events (31 of 51 events; 62.7%; P = .005) and be detected in pre-treatment (997 of 1300 events; 76.7%) compared with near-miss events (24 of 51 events; 47%; P < .001). Average occurrence (scale: 1-10) was 6.14 for workflow versus 3.33 for near-miss events (P < .001), average severity was 2.94 versus 7.35 (P < .001), and average detectability was 1.33 versus 4.67 (P < .001). Mean overall RPN was 22.4 for workflow versus 108.4 for near-miss events (P = .07) and mean NMRI was 1.16 versus 3.19, respectively. Events that originated and were detected in treatment delivery had the greatest mean overall RPN (38.2 and 32.1, respectively) and NMRI scores (1.62 and 1.6, respectively). CONCLUSIONS: Our experience demonstrates that workflow event reports are far more common than near-misses and that near-miss events are more likely to both originate and be discovered in later treatment phases. The frequency of workflow reports highlights the imperative need for safety and operational teams to work collaboratively to maximize the benefit of ILS. We suggest a potential utility of the RPN system to guide mitigation strategies for future near-miss events.

Using a real-time location system to measure patient flow in a radiation oncology outpatient clinic.

PURPOSE: Common performance metrics for outpatient clinics define the time between patient arrival and entry into an examination room as "waiting time." Time spent in the room is considered processing time. This characterization systematically ignores time spent in the examination room waiting for service. If these definitions are used, performance will consistently understate total waiting times and overstate processing times. Correcting such errors will provide a better understanding of system behavior. METHODS AND MATERIALS: In a radiation oncology service in an urban academic clinic, we collected data from a patient management system for 84 patients with 4 distinct types of visits: consultations, follow-ups, on-treatment visits, and nurse visits. Examination room entry and exit times were collected with a real-time location system for relevant care team members. Novel metrics of clinic performance were created, including the ratio of face time (ie, time during which the patient is with a practitioner) to total cycle time, which we label face-time efficiency. Attending physician interruptions occurred when the attending is called out of the room during a patient visit, and coordination-related delays are defined as waits for another team member. RESULTS: Face-time efficiency levels for consults, follow-ups, on-treatment visits, and nurse visits were 30.1%, 22.9%, 33.0%, and 25.6%, respectively. Attending physician interruptions averaged 6.7 minutes per patient. If these interruptions were eliminated, face-time efficiencies would rise to 33.2%, 29.2%, 34.4%, and 25.6%, respectively. Eliminating all coordination-related delays would increase these values to 41.3%, 38.9%, 54.7%, and 38.7%, respectively. CONCLUSIONS: A real-time location system can be used to augment a patient management system and automate data collection to provide improved descriptions of clinic performance.

Interventional Radiation Oncology (IRO): Transition of a magnetic resonance simulator to a brachytherapy suite.

PURPOSE: As a core component of a new gynecologic cancer radiation program, we envisioned, structured, and implemented a novel Interventional Radiation Oncology (IRO) unit and magnetic resonance (MR)-brachytherapy environment in an existing MR simulator. METHODS AND MATERIALS: We describe the external and internal processes required over a 6-8 month time frame to develop a clinical and research program for gynecologic brachytherapy and to successfully convert an MR simulator into an IRO unit. RESULTS: Support of the institution and department resulted in conversion of an MR simulator to a procedural suite. Development of the MR gynecologic brachytherapy program required novel equipment, staffing, infrastructural development, and cooperative team development with anesthetists, nurses, therapists, physicists, and physicians to ensure a safe and functional environment. Creation of a separate IRO unit permitted a novel billing structure. CONCLUSIONS: The creation of an MR-brachytherapy environment in an MR simulator is feasible. Developing infrastructure includes several collaborative elements. Unique to the field of radiation oncology, formalizing the space as an Interventional Radiation Oncology unit permits a sustainable financial structure.

Quantitative Evaluation of Head and Neck Cancer Treatment-Related Dysphagia in the Development of a Personalized Treatment Deintensification Paradigm.

PURPOSE: To test the hypothesis that quantifying swallow function with multiple patient-reported outcome (PRO) instruments is an important strategy to yield insights in the development of personalized deintensified therapies seeking to reduce the risk of head and neck cancer (HNC) treatment-related dysphagia (HNCTD). METHODS AND MATERIALS: Irradiated HNC subjects seen in follow-up care (April 2015 to December 2015) who prospectively completed the Sydney Swallow Questionnaire (SSQ) and the MD Anderson Dysphagia Inventory (MDADI) concurrently on the web interface to our Oncospace database were evaluated. A correlation matrix quantified the relationship between the SSQ and MDADI. Machine-learning unsupervised cluster analysis using the elbow criterion and CLUSPLOT analysis to establish its validity was performed. RESULTS: We identified 89 subjects. The MDADI and SSQ scores were moderately but significantly correlated (correlation coefficient -0.69). K-means cluster analysis demonstrated that 3 unique statistical cohorts (elbow criterion) could be identified with CLUSPLOT analysis, confirming that 100% of variances were accounted for. Correlation coefficients between the individual items in the SSQ and the MDADI demonstrated weak to moderate negative correlation, except for SSQ17 (quality of life question). CONCLUSIONS: Pilot analysis demonstrates that the MDADI and SSQ are complementary. Three unique clusters of patients can be defined, suggesting that a unique dysphagia signature for HNCTD may be definable. Longitudinal studies relying on only a single PRO, such as MDADI, may be inadequate for classifying HNCTD.

Pelvic Radiation and Normal Tissue Toxicity.

Radiation is a component of treatment for many pelvic malignancies, most often originating in the gynecologic, gastrointestinal, and genitourinary systems. Therefore, the management of acute and long-term side effects is an important part of practice as a radiation oncologist, and limiting morbidity is a primary goal. Toxicities vary and are dependent on treatment techniques. Advances in radiation delivery, imaging, and knowledge of underlying biologic determinants of radiation-induced normal tissue toxicity can guide treatment of acute and long-term side effects from pelvic radiation.

Development of Pediatric Emergency Protocols and Communication Plans in Pediatric Radiation Oncology: Multidisciplinary Core Competencies.

Radiation therapy is an essential component of treatment for many pediatric cancers, yet the cost of maintaining a radiation facility at a dedicated pediatric center is often prohibitive. As a result, adult facilities treat pediatric patients where preparation for a pediatric emergency may be inadequate. The purpose of this quality improvement project was to develop a multidisciplinary emergency preparedness plan for a collaborative pediatric radiation oncology program at an adult community hospital with its partnering academic children's hospital. Using a cyclical process involving multidisciplinary collaboration that combines policy development, preparation, and team-building, the authors created the protocols and processes that would support the stabilization of a pediatric emergency and facilitate transfer to the partnering children's hospital. Further development of a communication plan outlines the flow of patient information through the multidisciplinary team during these transitions of care. Areas for future work include quantitative outcome measures to determine the effectiveness of the policies and procedures developed to prepare staff for pediatric emergencies.

Prevalence of Substance Use in Patients With Cancer Receiving Radiation Therapy.

BACKGROUND: Individuals with cancer and risky alcohol and illicit substance use (AISU) are more likely to suffer diminished quality of life and subpar treatment outcomes. The prevalence of AISU in patients with cancer is poorly understood. OBJECTIVES: This article reports on the results of a needs assessment to quantify AISU in individuals with cancer seeking care in the radiation oncology department of a large, academic medical center. METHODS: Medical records were reviewed for all patients seen in the radiation oncology department in a one-week (five-day) period in the fall of 2014 (N = 397). Demographic and prevalence data were analyzed. FINDINGS: The prevalence rates of AISU in this sample were slightly lower than estimates for the general population and inconsistency was noted in the documentation of relevant information. Despite the limitations, data analyses suggested that a significant percentage of patients receiving radiation therapy for cancer diagnoses exhibited substance use patterns that placed them at increased risk for negative short- and long-term outcomes. The findings support the need for systematic substance use screening, assessment, and risk-based interventions as an essential component of comprehensive cancer care.

A data-mining framework for large scale analysis of dose-outcome relationships in a database of irradiated head and neck cancer patients.

PURPOSE: To develop a hypothesis-generating framework for automatic extraction of dose-outcome relationships from an in-house, analytic oncology database. METHODS: Dose-volume histograms (DVH) and clinical outcomes have been routinely stored to the authors' database for 684 head and neck cancer patients treated from 2007 to 2014. Database queries were developed to extract outcomes that had been assessed for at least 100 patients, as well as DVH curves for organs-at-risk (OAR) that were contoured for at least 100 patients. DVH curves for paired OAR (e.g., left and right parotids) were automatically combined and included as additional structures for analysis. For each OAR-outcome combination, only patients with both OAR and outcome records were analyzed. DVH dose points, DVt, at a given normalized volume threshold Vt were stratified into two groups based on severity of toxicity outcomes after treatment completion. The probability of an outcome was modeled at each Vt = [0%, 1%, …, 100%] by logistic regression. Notable OAR-outcome combinations were defined as having statistically significant regression parameters (p < 0.05) and an odds ratio of at least 1.05 (5% increase in odds per Gy). RESULTS: A total of 57 individual and combined structures and 97 outcomes were queried from the database. Of all possible OAR-outcome combinations, 17% resulted in significant logistic regression fits (p < 0.05) having an odds ratio of at least 1.05. Further manual inspection revealed a number of reasonable models based on either reported literature or proximity between neighboring OARs. The data-mining algorithm confirmed the following well-known OAR-dose/outcome relationships: dysphagia/larynx, voice changes/larynx, esophagitis/esophagus, xerostomia/parotid glands, and mucositis/oral mucosa. Several surrogate relationships, defined as OAR not directly attributed to an outcome, were also observed, including esophagitis/larynx, mucositis/mandible, and xerostomia/mandible. CONCLUSIONS: Prospective collection of clinical data has enabled large-scale analysis of dose-outcome relationships. The current data-mining framework revealed both known and novel dosimetric and clinical relationships, underscoring the potential utility of this analytic approach in hypothesis generation. Multivariate models and advanced, 3D dosimetric features may be necessary to further evaluate the complex relationship between neighboring OAR and observed outcomes.

Evaluation of chemotherapy-induced peripheral neuropathy using current perception threshold and clinical evaluations.

PURPOSE: Chemotherapy-induced peripheral neuropathy (CIPN) is increasing with introduction of new and combination cancer pharmacotherapies. This study evaluated associations between clinical and self-report measurements and current perception threshold (CPT), a neuroselective measure of sensory nerve function that may detect asymptomatic CIPN damage. METHODS: Data for this secondary analysis were from a prospective, observational study using CPT to evaluate CIPN. Bivariate mixed models, accounting for the intraclass correlation between repeated patient assessments, were used to assess the relationship between CPT at each frequency (5, 250, and 2,000 Hz) and each subjective measure (Neuropathic Pain Scale, FACT-GOGntx) and objective measurement (quantitative sensory testing, deep tendon reflexes, and grip strength). RESULTS: A total of 29 chemotherapy-naïve subjects with various cancer types had a mean age of 56.7 (SD 10.4); nine subjects developed CIPN grade >1 using NCI CTC-AE criteria. Cold detection thresholds were inversely associated with CPT 5 [b(95 % CI) = -2.5(-4.5, -0.5)] and CPT 2,000 [-7.5(-11.8, -3.3)] frequencies. FACT GOG-ntx quality of life (QoL) scale and neurotoxicity and function subscales were inversely associated with CPT 2,000 [-1.8 (-3.5, -0.05), -2.2 (-4.2, -0.2), and -5.4 (-9.8, -0.9), respectively], indicating worsening QoL, impairment, and function as hypoesthesia increases. CONCLUSIONS: CPT 2,000 may identify impending worsening of patient-reported outcomes such as QoL.