Impact of an Interactive On-line Tool on Therapeutic Decision-Making for Patients with Advanced Non-Small-Cell Lung Cancer.

BACKGROUND: Treatment guidelines provide recommendations but cannot account for the wide variability in patient-tumor characteristics in individual patients. We developed an on-line interactive decision tool to provide expert recommendations for specific patient scenarios in the first-line and maintenance settings for advanced non-small-cell lung cancer. We sought to determine how providing expert feedback would influence clinical decision-making. METHOD: Five lung cancer experts selected treatment for 96 different patient cases based on patient and/or tumor-specific features. These data were used to develop an on-line decision tool. Participant physicians entered variables for their patient scenario with treatment choices, and then received expert treatment recommendations for that scenario. To determine the impact on decision-making, users were asked whether the expert feedback impacted their original plan. RESULTS: A total of 442 individual physicians, of which 88% were from outside the United States, entered 653 cases, with report on impact in 389 cases. Expert feedback affected treatment choice in 73% of cases (23% changed and 50% confirmed decisions). For cases with epidermal growth factor receptor (EGFR) mutation or anaplastic lymphoma kinase (ALK) fusion, all experts selected targeted therapy whereas 51% and 58% of participants did not. Greater variability was seen between experts and participants for cases involving EGFR or ALK wild-type tumors. Participants were 2.5-fold more likely to change to expert recommended therapy for ALK fusions than for EGFR mutations (p = 0.017). CONCLUSION: This online tool for treatment decision-making resulted in a positive influence on clinician's decisions. This approach offers opportunities for improving quality of care and meets an educational need in application of new therapeutic paradigms.

Practice challenges affecting optimal care as identifed by US medical oncologists who treat renal cell carcinomas.

BACKGROUND: Approval of new agents provides alternative treatment options for medical oncologists and their patients with renal cell carcinoma (RCC). Treatment decisions remain challenging in the absence of clear evidence supporting optimal selection and sequencing of treatment for different patient or tumor characteristics. OBJECTIVE: To assess the clinical practice gaps of medical oncologists treating patients with RCC. METHODS: Medical oncologists practicing in the United States with a case load of 1 or more RCC patient(s) a year were recruited to participate in either an online case-based survey followed by a 45-minute interview (phase 1) or a 15-minute online survey with case vignettes (phase 2). Respondents' answers were compared with treatment guidelines and faculty experts' recommendations. RESULTS: Qualitative interviews (n = 27) and quantitative surveys (n = 142) were compiled. Clinical performance gaps demonstrating oncologists' diffculties to optimally adjust their treatment plan were identifed. When presented with an RCC patient with treatment-related hypertension, 34% of respondents did not select an expert-recommended option. In a scenario focused on recognizing clinical signs and symptoms as an important component of treatment decision-making, 40% of respondents agreed with the expert-recommended approach. For a progressive patient with chronic obstructive pulmonary disease, 78% of respondents were misaligned with evidence-based treatment options. LIMITATIONS: Self-selection and respondent bias may have occurred. Sample size may have limited the statistical power. CONCLUSIONS: This study identifed clinically relevant performance gaps among US oncologists treating RCC patients. Education to assure familiarity with the most recent changes is needed. FUNDING/SPONSORSHIP: Pfzer Medical Education Group provided fnancial support through an educational research grant.

Practice gaps and barriers to optimal care of hematologic malignancies in the United States.

BACKGROUND: Treating patients with hematologic malignancies can be challenging for physicians because of the rapidly evolving standards of care and relatively low incidence of these diseases. OBJECTIVE: To identify clinical challenges among hematologists and medical oncologists regarding the provision of care to patients with chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL), or B-cell lymphomas. Methods Hematologists and medical oncologists in active practice in the United States and who have a case load of ≥ 1 patient a year with CML, ALL, or B-cell lymphoma were recruited. The initial qualitative phase consisted of an online case-based survey followed by an interview exploring the contextual and behavioral factors that influence treatment decisions (n = 27). The analysis of qualitative data then informed a quantitative phase, in which 121 participants completed an online survey composed of case vignettes, multiple choice, and semantic differential rating scale questions. The respondents' answers were compared with recommendations from treatment guidelines and faculty experts. RESULTS: A higher frequency of bone marrow biopsies was reported compared with expert faculty recommendations by 74% of oncologists. Many respondents failed to recognize the clinical relevance of BCR-ABL mutations other than T315I. Respondents reported perceiving difficulties in individualizing treatment and interpreting response to treatment in patients with ALL and B-cell lymphomas. Fewer than 30% of respondents recognized the mechanisms of action of 5 of the 9 promising investigational agents presented. LIMITATIONS: Participant self-selection bias is a possibility because participation was voluntary. Practice gaps are not based on clinical data, but hypothetical case situations and self-report. CONCLUSIONS: Findings from this study can guide education to address the identified challenges in caring for patients with hematologic malignancies and improving patient care. FUNDING: This needs assessment was financially supported with an educational research grant from Pfizer Medical Education Group to the Annenberg Center for Health Sciences at Eisenhower.