Real time patient-reported outcome measures in patients with cancer: Early experience within an integrated health system.

BACKGROUND: While patient-reported outcome measures (PROMs) have benefit in cancer clinical trials, real-world applications are lacking. This study describes the method of implementation of a cancer enterprise-wide PROMs platform. METHODS: After establishing a multispecialty stakeholder group within a large integrated health system, domain-specific instruments were selected from the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (pain interference, fatigue, physical function, and depression) and were administered at varying frequencies throughout each patient's cancer journey. All cancer patients with an oncologic visit were eligible to complete the PROMs prior to the visit using a patient portal, or at the time of the visit using a tablet. PROMs were integrated into clinical workflow. Clinical partnerships were essential for successful implementation. Descriptive preliminary data were compared using multivariable logistic regression to determine the factors associated with method of PROMs completion. RESULTS: From September 16, 2020 to July 23, 2021, 23 of 38 clinical units (60.5%) implemented PROMs over 2392 encounters and 1666 patients. Approximately one third of patients (n = 629, 37.8%) used the patient portal. Black patients (aOR 0.70; 95% CI: 0.51-0.97) and patients residing in zip codes with higher percentage of unemployment (aOR: 0.07, 95% CI: 0.01-0.41) were among the least likely to complete PROMs using the patient portal. CONCLUSIONS: Successful system-wide implementation of PROMs among cancer patients requires engagement from multispecialty stakeholders and investment from clinical partners. Attention to the method of PROMs collection is required in order to reduce the potential for disparities, such as Black populations and those residing in areas with high levels of unemployment.

Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Quality Measures Initiative.

PURPOSE: Ensuring high quality, evidence-based radiation therapy for patients is of the upmost importance. As a part of the largest integrated health system in America, the Department of Veterans Affairs National Radiation Oncology Program (VA-NROP) established a quality surveillance initiative to address the challenge and necessity of providing the highest quality of care for veterans treated for cancer. METHODS AND MATERIALS: As part of this initiative, the VA-NROP contracted with the American Society for Radiation Oncology to commission 5 Blue Ribbon Panels for lung, prostate, rectal, breast, and head and neck cancers experts. This group worked collaboratively with the VA-NROP to develop consensus quality measures. In addition to the site-specific measures, an additional Blue Ribbon Panel comprised of the chairs and other members of the disease sites was formed to create 18 harmonized quality measures for all 5 sites (13 quality, 4 surveillance, and 1 aspirational). CONCLUSIONS: The VA-NROP and American Society for Radiation Oncology collaboration have created quality measures spanning 5 disease sites to help improve patient outcomes. These will be used for the ongoing quality surveillance of veterans receiving radiation therapy through the VA and its community partners.

Phase II trial of preoperative chemoradiation with a hyperfractionated radiation boost in locally advanced rectal cancer.

PURPOSE: The purpose of this phase II study was to prospectively determine the efficacy of preoperative chemoradiation with a hyperfractionated (Hfx) RT boost to 61.8 Gy in locally advanced rectal cancer. METHODS: Eligibility stipulated that the primary lesion had to be either T4; or T3 and >4 cm or 40% of the bowel circumference. Radiation (RT) consisted of 45 Gy to the pelvis (1.8 Gy per fraction) followed by 1.2 Gy twice daily (to the gross tumor volume) to a total RT dose of 61.8 Gy. There was 5-FU infused at 1 g/m2/24 hours for 4 days during the 1st and 6th weeks of RT (concurrent with the Hfx boost). Surgical resection was planned 4 to 6 weeks later. Adjuvant chemotherapy (bolus 5-FU/leucovorin) was scheduled for 4 cycles at 28-day intervals. RESULTS: There were 22 patients, ages 22 to 81 years (median, 64) enrolled in the study. Of the 20 patients evaluable for response, 10 (50%) had evidence of clinical downstaging and 5 patients (25%) had > or =90% fibrosis in the resected specimen. With a median f/u of 40 months (7-158), the 4 years actuarial rate for all patients (n = 22) of OS was 64%, of DFS 62%, and of LC 84%. 3/21 patients (14%) had positive margins, all of whom developed a local failure (P < 0.001). CONCLUSION: This regimen of high dose preoperative chemoRT with a Hfx RT boost (to 61.8 Gy) in patients with bulky, locally advanced rectal cancer results in clinical downstaging in half of the patients with significant fibrosis in the operative specimen.

Comparing cancer patients who enroll in a smoking cessation program at a comprehensive cancer center with those who decline enrollment.

BACKGROUND: Despite the availability of smoking interventions for cancer patients, many eligible patients decline enrollment into such programs. We examined reasons patients provide for declining smoking treatment and compared treatment decliners to enrollees. METHODS: Eligible cancer patients (N = 231) were offered smoking cessation treatment. During recruitment, demographic, medical (eg, cancer stage), and smoking-related behavioral (eg, readiness to quit) data were collected, and decliners stated a reason for refusal. Patients who enrolled in the cessation program (N = 109) were compared with those who declined (N = 122) in terms of recruitment data, and reasons for declining were compiled. RESULTS: Decliners were significantly more likely to: (1) have head and neck cancer (vs lung cancer); (2) exhibit fewer physical symptoms (eg, shortness of breath); (3) report a lower readiness to quit smoking; (4) indicate no intention to quit smoking; and (5) smoke fewer cigarettes. A preference to quit without professional assistance was the most common reason for declining treatment. CONCLUSIONS: Our findings highlight important differences between patients who enroll in a smoking cessation program and those who decline and underscore the need for motivational interventions to facilitate enrollment into smoking interventions for cancer patients.

Mindless or mindful? Radiation oncologists' perspectives on the evolution of prostate cancer treatment.

The evolution of radiation therapy treatment for prostate cancer has been striking over the last 10 years. Advances in brachytherapy (BT), external beam radiotherapy (EBRT), and the combination of EBRT + BT have led to improved biochemical and clinical results. This article describes these advances in the context of the treatment decision process. Key to this process is the assignment of patient risk, which is based on the results of conventional radiation dose and techniques. Using the 1992 AJCC palpation staging system, Gleason score, and pretreatment prostate-specific antigen, two different risk assessment algorithms were compared. Both gave comparable approximations of risk, although the single factor high-risk model was superior in differentiating those patients with the highest probability of failing treatment after radiotherapy. Such criteria are the foundation for treatment selection. Objective findings support BT alone or EBRT alone for low-risk patients, high-dose EBRT or EBRT + BT for intermediate-risk patients, and EBRT + androgen deprivation for high-risk patients. In summary, advances in radiation oncology have led to significant gains in prostate cancer control. Clinical prognostic factor-based patient selection is central to the optimization of outcome.

Processes of change related to smoking behavior among cancer patients.

PURPOSE: The purpose of this study was to examine the degree to which transtheoretical model processes of change (methods and strategies for cessation) were associated with smoking status and quitting behavior (ie, intentions and attempts to quit) among patients with head and neck or lung cancer. The relationship between medical variables and processes of change was also explored. DESCRIPTION OF STUDY: Twenty-nine smokers and 45 abstainers who were recruited from treatment clinics within a comprehensive cancer center completed a brief survey. Multivariate analysis of variance and Pearson correlation procedures were used to evaluate hypothesized relationships. RESULTS: As hypothesized, quitters used behavioral processes such as counter-conditioning and reinforcement management significantly more than smokers and used self-reevaluation, an experiential process, significantly less than smokers. Contrary to the hypothesis, however, quit attempts and intentions were associated with both experiential (ie, consciousness raising and self-reevaluation) and behavioral (ie, reinforcement management and self-liberation) processes of change. Use of the processes of change was not influenced by medical variables, including cancer type, illness phase, disease stage, type of current medical treatment, and duration of illness. CLINICAL IMPLICATIONS: These findings suggest that behavioral counseling to promote smoking cessation for patients with cancer should involve assisting the patient to do the following: develop an awareness of the health risks related to continued smoking; devise and use alternative behaviors; implement the use of reinforcement strategies for cessation successes; and develop a sense of confidence and commitment about quitting as well as healthy lifestyle values. These strategies are discussed within the context of models and guidelines for smoking cessation in clinical practice.