Clinicians' Experiences and Perspectives about a New Lung Cancer Referral Pathway in a Regional Health Service.

Introduction: Development and implementation of the Townsville Lung Cancer Referral Pathway [TLCRP] aims to reduce delays and improve referral patterns of people with suspected lung cancer in north Queensland, Australia. Reported in this paper is the experiences and perspectives of general practitioners [GPs] and specialists of the TLCRP. Methods: This was a descriptive qualitative study nested within a larger project evaluating TLCRP, utilising a broader implementation science framework. In-depth, semi-structured interviews with GPs and specialists were conducted. An iterative, inductive thematic analysis of interview transcripts was used to derive key codes, then grouped into themes regarding participant experiences and perceptions. Results: Data analysis identified two major themes and several sub-themes. The major themes were variation in the uptake of TLCRP and enhancing coordinated care and communication. Discussion: Several enablers and barriers to implementing TLCRP were identified. Barriers to adaptation of TLCRP included lack of clinical time, resistance to changing referral patterns, lack of familiarity or experience with HealthPathways and technology issues. Conclusion: Emerging themes from this study may be used to reduce the barriers and improve uptake of TLCRP and other health care pathways in the local health service and may have wider relevance in other settings.

Patient and carer experiences of lung cancer referral pathway in a regional health service: a qualitative study.

BACKGROUND: Lung cancer referral pathways aim to reduce delays and improve referral patterns of people with suspected lung cancer. AIM: As part of implementing a lung cancer referral pathway at a regional Australian hospital, this study aimed to explore the experiences and perceptions of people with lung cancer and their carers. METHODS: In-depth interviews were used to elicit data for thematic analysis in this cross-sectional descriptive qualitative study. Patients with newly diagnosed lung cancer and their carers at a regional academic cancer centre were invited to participate in interviews. Five interviews were conducted face-to-face, and 14 interviews were conducted by telephone (as per interviewee preference). Interviews were audiorecorded, transcribed and qualitatively analysed. Descriptive phrases were used to generate initial inductive codes and themes. RESULTS: Nineteen participants approached agreed to take part in the study. Factors that positively impacted the care experience were good communication, timeliness and patient advocacy and support. Improper communication, long waiting times for investigations and appointments, uncertainty about the process and inconsistent advice from providers negatively impacted the care experience. Participants preferred face-to-face or video-linked consultations over telephone consultations. CONCLUSIONS: Understanding the experiences of rural and regional patients and carers with the lung cancer referral pathway is important to improve quality of care. Implementing changes to the referral pathway to improve patient and carer experiences needs to be an ongoing quality improvement exercise.

Optimal Care Pathways for People with Lung Cancer- a Scoping Review of the Literature.

INTRODUCTION: Much of the existing work around implementation of cancer optimal care pathways (OCP) has either focused exclusively on the clinical elements of care or has targeted individual stages in the cancer trajectory, rather than using a patient-centred or service delivery lens to inform the integration of care across the continuum. This review aimed to identify and summarise the available literature on lung cancer OCP. METHODS: A scoping review was conducted, with literature across multiple databases and grey literature searched. Articles were included if the OCP was being used to manage adult patients with lung cancer and reported on either the development process and outcomes and/or barriers and facilitators associated with optimal care pathway development and/or uptake. RESULTS: Of the 381 references screened, 32 articles were included. The lung cancer pathways reviewed varied significantly. A number of themes were identified including the development and implementation of the OCP; the use of quality indicators to audit the OCP; and studies on outcomes of the OCP incorporating timeliness of care delivery, patient experiences and health care utilisation and costs. CONCLUSIONS: The limited number of relevant articles found in this review may suggest that an OCP for lung cancer is still in its preliminary stages across the broader health systems.

Enhancing Chemotherapy Capabilities in Rural Hospitals: Implementation of a Telechemotherapy Model (QReCS) in North Queensland, Australia.

INTRODUCTION: The Queensland Remote Chemotherapy Supervision (QReCS) model enables rural nurses to administer chemotherapy in smaller rural towns under supervision by health professionals from larger centers using telehealth. Its implementation began in North Queensland, Australia (population, 650,000), in 2014 between two regional cancer centers (Townsville and Cairns as primary sites) and six rural sites (125 to 1,000 kilometers from primary sites). Our study examined the implementation processes, feasibility, and safety of this model. METHODS: Details of implementation and patients' clinical details for the period of 2014 to 2016 for descriptive analysis were extracted from telechemotherapy project notes and oncology information systems of North Queensland, respectively. RESULTS: After a successful pilot study in Townsville Cancer Centre, statewide rural and cancer networks of Queensland Health, in collaboration with clinicians and managers across the state of Queensland, developed the QReCS model and a guide for operationalizing it. QReCS was implemented at six sites from 2014 to 2016. Main enablers across North Queensland included collaboration among clinicians and managers, availability of common electronic medical records, funding from Queensland Health, and installation of telehealth infrastructure by statewide telehealth services. Main barriers included turnover of senior management and nursing staff at two rural towns. Sixty-two patients received 327 cycles of low- to medium-risk chemotherapy agents. Rates of treatment delays, adverse events, and hospital admissions were similar to those in face-to-face care. CONCLUSION: Implementation of the QReCS model across a large geographic region is feasible with acceptable safety profiles. Leadership by and collaboration among clinicians and managers, adequacy of resources and common governance are key enablers.

Delays in lung cancer management pathways between rural and urban patients in North Queensland: a mixed methods study.

BACKGROUND: Despite advances in medical therapies, disparity in outcome between rural and urban patients remain in Australia and many Western countries. AIMS: To examine time delays in lung cancer referral pathways in North Queensland (NQ), Australia, and explore patients' perspective of factors causing these delays. METHODS: Prospective study of patients attending three cancer centres in Townsville, Cairns and Mackay in NQ from 2009 to 2012. Times along referral pathway were divided as follows: Onset of symptoms to treatment (T1), symptoms to general practitioner (GP) (T2), GP to specialist (T3) and Specialist to treatment (T4). Quantitative and qualitative methods were used for analysis. RESULTS: In total, 252 patients were participated. T1 was influenced by remoteness (125 days in Townsville vs 170 days for remote, P = 0.01), T2 by level of education (91 days for primary education vs 61 days for secondary vs 23 days for tertiary/Technical and Further Education (TAFE), P = 0.006), and age group (14 days for 31-50 years, 61 days for 51-70 years, 45 days for >71 years, P = 0.026), T3 by remoteness (15 days for Townville and 29.5 days for remote, P = 0.02) and T4 by stage of disease (21 days for Stage I, 11 days for Stage II, 34 days for Stage III 18 days for Stage IV, P = 0.041). Competing priorities of family and work and cost and inconvenience of travel were perceived as rural barriers. CONCLUSION: Remoteness, age and level of education were related to delays in various time lines in lung cancer referral pathways in NQ. Provision of specialist services closer to home may decrease delays by alleviating burden of cost and inconvenience of travel.

Ipilimumab-induced autoimmune hypophysitis: a differential for sellar mass lesions.

UNLABELLED: Autoimmune hypophysitis (AH) has been previously described in a typical demographic population, primarily women in the reproductive age group and perinatal period. The era of immune modulation using anti-cytotoxic T-lymphocyte-associated antigen 4 biological therapy (ipilimumab) against advanced cancers like metastatic melanomas has now resulted in a new form of hypophysitis being increasingly recognised under a spectrum of immune-related adverse events. Drug-related AH often presents with subtle symptoms and a pituitary mass, with the potential for fatality necessitating wide awareness and a high index of clinical suspicion given that it is usually treatable. We describe below two cases of AH within the last three months at our centre, which were treated with different regimens and produced good endocrine outcomes. LEARNING POINTS: AH is a new and defined clinical entity occurring as a side effect of ipilimumab, which enhances immune-mediated destruction of metastatic melanoma.It can present insidiously and have life-threatening complications related to hypocortisolism, hence a high index of clinical suspicion must be exerted by treating physicians, and seems to result in resolution of pituitary masses and variable improvements of pituitary function.Clinical improvement, radiological resolution of pituitary masses and variable normalisation of pituitary function are possible with early treatment with high-dose oral or i.v. steroids and hormone replacement therapy, although duration and dosing protocols are unclear at this stage.Ipilimumab should continue to be prescribed as treatment for metastatic melanoma; however, close clinical observation of patient's progress must be maintained while they are on this drug.Predictive factors for onset of AH remain unclear and it is imperative that AH is distinguished from pituitary metastases.Further studies are required to determine the safety of continuing therapy with ipilimumab in patients who have developed AH while on treatment.

Non-Hodgkin's lymphoma in a patient on treatment with temozolomide.

A 68-year-old man was diagnosed with glioblastoma multiforme of the right basal ganglia in March 2010. He was treated with radiotherapy and concurrent chemotherapy with daily temozolomide for over 6 weeks. During the maintenance phase of treatment with temozolomide, he developed a swelling in the left cheek; a biopsy of which proved to be non-Hodgkin's lymphoma. The temozolomide was stopped and the lymphoma was successfully treated with chemotherapy.

Efficacy and tolerability of weekly low-dose cisplatin concurrent with radiotherapy in head and neck cancer patients.

AIMS: In this retrospective analysis, we describe the efficacy and tolerability of weekly cisplatin 40 mg/m(2) used in concurrent chemoradiation of head and neck cancer at the Townsville Cancer Centre. METHODS: Review of medical records of patients who received radical chemoradiotherapy for head and neck cancer at Townsville Cancer Centre from 2003 to 2009. RESULTS: In all 102 patients were analysed, 62 of whom had definitive chemoradiation and the remainder adjuvant chemoradiotherapy. Median follow up was 20.1 months (range 5-86 months). Overall 68.6% of patients received 5 weeks or more of planned chemotherapy. Radiotherapy interruptions occurred in four (6.4%) patients. The rate of grade 3-4 adverse events was 51% including neutropenia (18.6%), mucositis (21.8%) and dysphagia (12.9%) and 30.7% of patients needed hospital admission to manage toxicities. For definitive and adjuvant groups, estimated 3-year survival was 64.5 and 71.5%, respectively, and estimated 3-year disease-specific survival rates were 70.3 and 81.6%, respectively. The 3-year overall survival for patients who received five or more cycles of chemotherapy was 75.2%, compared to 52.6% for those receiving fewer than five cycles (P = 0.018). CONCLUSION: Despite this is being a small retrospective study, survival figures and toxicity profiles of low dose weekly cisplatin are comparable to historical controls using high-dose regimens, hence justifying our approach. In addition, radiotherapy interruptions are minimized and cisplatin is easy to administer in outpatient settings. Future three-arm studies could include this regimen as the basis of treatment combined with targeted therapies.

Attitudes, knowledge and barriers to participation in cancer clinical trials among rural and remote patients.

AIM: To assess the knowledge of randomized clinical trials and willingness and barriers to participation among rural, remote and regional cancer patients of North Queensland. METHODS: A survey was conducted in medical oncology outpatient clinics at the Townsville and Mt Isa hospitals on patients, following their informed consent, using questionnaires. Rurality was defined according to the rural remote and metropolitan area classification. RESULTS: Of the 180 patients approached, 178 participated. The median distance to the regional trial center for rural participants was 180 km (range 80-1300 km). 45.4% lived in rural or remote areas and the rest lived in Townsville, a regional metropolitan center. Their overall knowledge was low, with a median knowledge score of 3 (inter-quartile ranges n=2.5). For randomized controlled trials there were no significant relationships between willingness to participate and rurality or education level (P=0.981). Cost of travel (41.1% rural or remote; 23.5% regional; P<0.001) and the need for family or friends to accompany them (38.9% rural or remote; 24.1% regional, P=0.021) were more important for rural/remote than regional patients as factors affecting participation. CONCLUSION: Rural and remote patients are as interested in participating in randomized clinical trials as regional patients. Their knowledge of trials is poor and education earlier in the consultations is needed. Since cost of travel and the need for family members to accompany them are important for rural patients trial budgets should include the cost of travel to encourage participation.