Reducing time to treatment and patient costs with breast cancer: the impact of patient visits.

BACKGROUND: The purpose of this study was to evaluate the impact of processes aimed at reducing time to treatment initiation (TTI) on minimizing the days spent to complete pretreatment visits and the associated costs for patients with nonmetastatic breast cancer. METHODS: System-wide initiatives were implemented in 2014 to minimize TTI, by incorporating multiple strategies (eg, creation of teams, patient liaisons, process mapping) and enhanced communication to increase coordinated visits. Average number of days spent to complete visits, TTI, and associated patient costs including driving expenses, parking, food, childcare, and lost wages were calculated and compared between the years 2015 and 2018. RESULTS: In 2015, the median TTI was 43.5 days and the average number of separate days spent to attend multidisciplinary visits prior to first treatment was 1.86. These were reduced to 29 days and 1.52 visits, respectively, in 2018 (p < 0.0001 for both). When evaluating treatment visits by surgical procedure, the average number of visits was reduced regardless of surgical procedure. The average number of visits was highest for patients undergoing mastectomy with reconstruction (2.34 in 2015, reduced to 1.65 in 2018, p < 0.0001). A single visit to complete treatment planning was associated with patient costs of $249 as compared with multiple trips costing $491 for 2 visits and up to $1,226 for 5 visits. CONCLUSIONS: In breast cancer patients, implementing processes to reduce time to treatment was associated with fewer visits required prior to treatment initiation, resulting in lower patient costs.

Machine Learning-Based Risk Assessment for Cancer Therapy-Related Cardiac Dysfunction in 4300 Longitudinal Oncology Patients.

Background The growing awareness of cardiovascular toxicity from cancer therapies has led to the emerging field of cardio-oncology, which centers on preventing, detecting, and treating patients with cardiac dysfunction before, during, or after cancer treatment. Early detection and prevention of cancer therapy-related cardiac dysfunction (CTRCD) play important roles in precision cardio-oncology. Methods and Results This retrospective study included 4309 cancer patients between 1997 and 2018 whose laboratory tests and cardiovascular echocardiographic variables were collected from the Cleveland Clinic institutional electronic medical record database (Epic Systems). Among these patients, 1560 (36%) were diagnosed with at least 1 type of CTRCD, and 838 (19%) developed CTRCD after cancer therapy (de novo). We posited that machine learning algorithms can be implemented to predict CTRCDs in cancer patients according to clinically relevant variables. Classification models were trained and evaluated for 6 types of cardiovascular outcomes, including coronary artery disease (area under the receiver operating characteristic curve [AUROC], 0.821; 95% CI, 0.815-0.826), atrial fibrillation (AUROC, 0.787; 95% CI, 0.782-0.792), heart failure (AUROC, 0.882; 95% CI, 0.878-0.887), stroke (AUROC, 0.660; 95% CI, 0.650-0.670), myocardial infarction (AUROC, 0.807; 95% CI, 0.799-0.816), and de novo CTRCD (AUROC, 0.802; 95% CI, 0.797-0.807). Model generalizability was further confirmed using time-split data. Model inspection revealed several clinically relevant variables significantly associated with CTRCDs, including age, hypertension, glucose levels, left ventricular ejection fraction, creatinine, and aspartate aminotransferase levels. Conclusions This study suggests that machine learning approaches offer powerful tools for cardiac risk stratification in oncology patients by utilizing large-scale, longitudinal patient data from healthcare systems.

Palliative Care Training during Fellowship: A National Survey of U.S. Hematology and Oncology Fellows.

BACKGROUND: Despite requirements for palliative care training during fellowship, there is a paucity of recent data regarding the attitudes, knowledge, and skills of hematology/ oncology fellows in palliative care. OBJECTIVE: Our aim was to assess fellows' attitudes toward and quality of training in palliative care during fellowship and perceived preparedness to care for patients at the end of life (EOL). METHODS: In May 2013 a cross-sectional survey of hematology/oncology fellows was conducted. RESULTS: Fellows from 93 of 138 fellowship programs responded (67.4%). Of the 347 fellows e-mailed, 176 participated. Nearly all fellows (99%) indicated that physicians have a responsibility to help patients at EOL. Fellows felt their overall training in fellowship was superior to training in EOL care (4.24±0.78 versus 3.53±0.99 on a 5-5 scale where 1=poor and 5=excellent, p<0.0001). Fellows who had a rotation in palliative care during fellowship (44.9%) reported better teaching on managing a patient at EOL than those who did not (3.91±1.0 versus 3.21±0.87, p<0.0001). Fellows reporting better teaching in EOL care felt better prepared to care for patients at EOL (r=0.52, p<0.0001). More than 25% reported not being explicitly taught how to assess prognosis, when to refer a patient to hospice, or how to conduct a family meeting to discuss treatment options. CONCLUSION: Many recent oncology fellows are still inadequately prepared to provide palliative care to their patients. There is significant room for improvement with regards to the quality of palliative care training in U.S. hematology/oncology fellowship programs.

Developing oncology biosimilars: an essential approach for the future.

The treatment of many diseases, particularly cancer, has been profoundly impacted by the introduction of biologic therapies (biologics), which are incorporated into the treatment algorithms of most oncology clinical practice guidelines. Biologics are large molecular weight, structurally complex proteins that are produced via complex manufacturing processes. With the patents of key biologics, including many widely used in oncology, set to expire in the near future, a number of pharmaceutical companies have focused on developing biosimilars. While the goal of development is to demonstrate that the biosimilar product is highly similar to the reference biologic product, biosimilars should not be viewed as "generic" biologics. Generic drugs are small chemical moieties that are identical to the patent-expired "reference" small-molecule drugs. It is not possible to produce an identical copy of a biologic, so the term "biosimilar" was chosen to define an appropriately similar biologic product. Improving patient access to cancer therapies such as biologics and reducing healthcare costs are key initiatives of the US Government; the integration of approved biosimilars into clinical practice will be instrumental in accomplishing these goals.

Building a statewide clinical trials network for cancer care in West Virginia.

In the United States, mortality rates have been declining for certain tumors, For the majority of advanced stage cancer types, cure is unattainable but treatment is still evolving. Advances in the treatment of cancer can be achieved by enrolling patients in cancer clinical trials. Presently, less than 3% of adult cancer patients participate on clinical trials in the United States. Providing cancer care and access to clinical trials are a challenge in a rural state, with a dispersed population base, such as West Virginia. Building upon recognition of barriers to clinical trials awareness and access, oncology leaders in the state are in the formative stages of developing a statewide cancer clinical trials network. Realization of this network will have an enormous impact on cancer care in our state and perhaps can serve as a model for other community and physician teams for other diseases.

Breast and ovarian cancer genetics and prevention.

Inherited breast and ovarian cancers account for 10% of all breast and ovarian cancers. Relative to sporadic breast and ovarian cancers, these cancers tend to occur at an earlier age and grow more aggressively. Women with BRCA1 and BRCA2 mutations (BRCA1/2 mutation) have a 65% to 85% cumulative lifetime risk of developing invasive breast cancer and a 15% to 65% cumulative lifetime risk of developing invasive ovarian cancer. Identification of patients with the mutation is therefore crucial, because preventive measures such as prophylactic bilateral mastectomy, prophylactic bilateral salpingpo-oophorectomy and chemoprevention with Tamoxifen can prevent breast and ovarian cancer. Likewise, genetic counseling prior to testing is important, considering the major impact of the test results on an individual's life.