Enhanced PAtient Clinical Streamlining (EPACS): Quality Initiative to Improve Healthcare for New Surgical Outpatient Visits.

PURPOSE: For patients who select a specialty hospital for cancer treatment, the wait time until the initial consultation leaves patients anxious and delays treatment. To improve quality of care, we implemented an enhanced patient clinical streamlining (EPACS) process that establishes an early connection and coordinates care before the first surgical outpatient visit at our specialty cancer center. METHODS: During a pre-visit EPACS phone call to new patients, an advanced practice provider (APP) collected medical history and ordered work-up tests or consultations if feasible. First visit cancellation rate, number of patients who started treatment, time to start of treatment, and satisfaction by the care team and patient were compared between patients treated with versus without EPACS. RESULTS: Among 5062 consecutive new patients, 720 (14%) received an EPACS call and 4342 did not (86%); work-up was ordered pre-visit in 34% and 16%, respectively. Fewer EPACS patients cancelled the first visit (4.6% vs. 12%, p < 0.001), more started treatment (55% vs. 50%, p = 0.037), and their time to treatment was shorter, but not significantly (median 17 vs. 19 days, p = 0.086). Patient interaction was considered to be improved by EPACS by 17 of 17 APPs and 14 of 16 surgeons, and outpatient clinic efficiency by 14 of 17 APPs and 13 of 16 surgeons. EPACS reduced anxiety and increased preparedness for the first visit in 29 of 31 patients. CONCLUSIONS: EPACS improved effectiveness, timeliness, and physician and patient satisfaction with health care at our cancer center.

Prevalence of patient-reported gastrointestinal symptoms and agreement with clinician toxicity assessments in radiation therapy for anal cancer.

PURPOSE: Gastrointestinal (GI) symptoms pose a significant burden to patients receiving chemoradiation therapy (CRT) for anal cancer; however, the impact of symptoms from the patient perspective has not been quantified. This retrospective study examined and compared patient and clinician reports of acute GI toxicity during CRT. MATERIALS AND METHODS: Patients treated with definitive RT using intensity-modulated radiation therapy for anal cancer between 9/09 and 11/12 were reviewed. Median RT dose was 56 Gy (range 45-56), and 76 patients (97%) received concurrent 5-fluorouracil-based chemotherapy. During RT, patients completed the 7-item Bowel Problem Scale (BPS) weekly. Clinicians assessed toxicity separately using CTCAE v. 3.0. Scores of BPS ≥ 3 and CTCAE ≥ 1 were considered to be clinically meaningful. Agreement of the two assessments was evaluated by Cohen's kappa coefficient. RESULTS: Seventy-eight patients completed at least one BPS and had a corresponding clinician assessment. Patients reporting scores of ≥3 was highest at week 5 (n = 68) for diarrhea (44.1%), proctitis (57.4%), and mucus (48.4%), while urgency (47.6%), tenesmus (31.7%), and cramping (27%) were highest at week 4 (n = 63). Baseline bleeding scores (26.7%; score ≥3) improved during treatment (13.4% at week 5). "Poor" agreement was observed between patient- and clinician-reported proctitis (Cohen's k = 0.11; n = 58); however, there was "good" agreement for diarrhea (Cohen's k = 0.68; n = 58). CONCLUSIONS: Acute GI toxicity during definitive CRT for anal cancer was most significant during weeks 4-5, while rectal bleeding improved during treatment. Discrepancies in patient- and clinician-reported symptoms demonstrate the potential for patient-reported outcomes to be useful tools for anal cancer clinical assessments.

Prospective study of vaginal dilator use adherence and efficacy following radiotherapy.

BACKGROUND AND PURPOSE: Vaginal stenosis (VS) after pelvic radiotherapy (RT) can impair long-term quality of life. We prospectively assessed adherence and efficacy of vaginal dilator (VD) use in women after pelvic RT. MATERIAL AND METHODS: Women with gastrointestinal (n=63) and gynecologic (n=46) cancers self-reported use and VD size in monthly diaries for 12months after radiotherapy. Adherence was measured as actual VD use out of recommended times over 12months (3×/week×52weeks=156). RESULTS: Among 109 participants, aged 28-81years (median, 58years), mean percent adherence over 12months was 42% (95% confidence interval [CI], 36-48%). Adherence was highest in the first quarter (56%), but fell to 25% by the fourth. Disease type, treatment sequence, and chemotherapy were predictors of adherence (all P<.05). Eighty-two percent maintained pre-RT VD size at 12months; of 49% with a decrease in VD size at 1month post-RT, 71% returned to pre-RT VD size at 12months. Disease type, younger age, and increased adherence at 6months were associated with maintaining or returning to pre-RT size at 12months (all P⩽.05). CONCLUSION: VD use is effective in minimizing VS, but adherence at 12months was poor. Studies evaluating methods of improving adherence and determining the optimal frequency and duration of use are needed.

Dosimetric Predictors of Radiation-Induced Vaginal Stenosis After Pelvic Radiation Therapy for Rectal and Anal Cancer.

PURPOSE: Although vaginal stenosis (VS) is a recognized toxicity in women who receive pelvic radiation therapy (RT), the relationship between RT dose and the volume and extent of toxicity has not been analyzed. We modeled this relationship to identify predictors of VS. METHODS AND MATERIALS: We evaluated 54 women, aged 29 to 78 years, who underwent pelvic RT for rectal or anal cancer during 2008 to 2011 and were enrolled in a prospective study evaluating vaginal dilator use. Maximum dilator size was measured before RT (baseline) and 1 month and 12 months after RT. Dilator use was initiated at 1 month. The difference (D) in dilator size before and after RT was recorded. Those with D ≤-1 were classified as having VS (n=35); those with D ≥0 were classified as having no VS (n=19 at 1 month). Dose-volume parameters were extracted, and the generalized equivalent uniform dose (gEUD) was used to build a predictive model. RESULTS: The mean vaginal doses were 50.0 Gy and 36.8 Gy for anal and rectal cancer patients, respectively. One month after RT, a gEUD model using a wide range of a values suggests that sparing of vaginal volume to a low dose may be important. When gEUD (a = -1) was <35 Gy and the mean vaginal dose was <43 Gy, severe VS was reduced (P=.02). A 1-year analysis suggests increasingly negative D values with increasing mean dose. However, patients with compliance <40% were more likely to have toxicity. CONCLUSIONS: Vaginal stenosis is influenced by multiple RT dose-volume characteristics. Mean dose and gEUD constraints together may reduce the risk of severe VS. Patients receiving higher mean vaginal doses should have greater compliance with dilator therapy to minimize risk of toxicity. Further validation with independent datasets is needed.

Patient-Reported Outcomes vs. Clinician Symptom Reporting During Chemoradiation for Rectal Cancer.

BACKGROUND: Pelvic radiotherapy with concurrent 5-fluorouracil-based chemotherapy is a component of standard therapy for patients with T3/T4 or node-positive rectal cancer and may be associated with acute gastrointestinal toxicity. In this retrospective study, we sought to compare patient-reported outcomes (PROs) with clinician reports of acute symptoms experienced by rectal cancer patients receiving chemoradiation. PATIENTS AND METHODS: Charts of 199 patients with rectal cancer who received chemoradiation at some point from November 2006 through February 2011 were reviewed. Clinicians assessed toxicity weekly using Common Terminology for Clinical Adverse Events version 3.0, and, beginning in September 2009, the patients reported symptoms weekly, using the 7-item Bowel Problems Scale. One hundred ninety-seven patients with at least 1 clinician or patient assessment were eligible for the study. We used descriptive statistics to compare patient and clinician assessments in a subgroup of 65 patients (paired group) who had at least 1 patient and clinician assessment on the same day. Cohen's κ coefficient was used to evaluate agreement between the patients and the clinicians. RESULTS: The patients reported diarrhea and proctitis more often than clinicians reported them throughout treatment. Uncorrected agreement for diarrhea and proctitis was 82% and 72%, respectively. Cohen's κ was .64 for diarrhea, indicating moderate agreement, and .22 for proctitis, indicating only slight agreement. CONCLUSIONS: Our findings suggest a discrepancy between clinician and PRO reports. Further study may discern potential benefits of collecting PROs in prospective studies and in clinical practice.

Nursing management of patients receiving stereotactic radiosurgery.

Stereotactic radiosurgery (SRS) is a minimally invasive procedure that delivers high-dose radiation in a single fraction to a precisely targeted lesion in the brain. When SRS is provided using a modified linear accelerator that produces x-ray beams, a stereotactic head ring is used for localization of the target area and immobilization during treatment. Radiation oncology nurses have a unique role in caring for patients receiving SRS. Prior to the procedure, a radiation oncology nurse assesses the patient, educates the patient and family about the procedure, and collaborates in the details of planning. On the day of treatment, the radiation oncology nurse assists with head ring placement, provides care and monitoring throughout the day, and provides discharge instructions. This article describes the SRS procedure, reviews possible side effects, and discusses the radiation oncology nursing role.