A study in patient satisfaction regarding telemedicine consultations in radiation oncology.

INTRODUCTION: Telemedicine consultations can be a cost-effective and convenient method of communication, particularly with patients living in remote areas. Given the dearth of patient-reported satisfaction data with this form of consultation in Radiation Oncology, we surveyed patients to assess this in our department. METHODS: The study recruited patients who had experienced both a Telemedicine consultation and an in-person consultation with the same radiation oncologist at our tertiary centre in South Australia. Eligible patients were identified from the Royal Adelaide Hospital oncology information system. The patient satisfaction questionnaire was sent via registered post with a reply-paid envelope. The questionnaire consisted of 38 questions divided into four major categories, focusing on communication, medical care, privacy/confidentiality and convenience. Results of the survey were tabulated in an excel spreadsheet. RESULTS: Between 1 January 2018 and 1 January 2019, 130 eligible patients were identified. One hundred and nine patients were alive and contactable of whom 37 responded (34%). Two surveys were returned incomplete resulting in 35 patient responses available for analysis. The median age was 70 years (range 35-87); 74% were male. There was no statistically significant difference between the satisfaction scores for Telemedicine and in-person consultations with regards to communication, privacy/confidentiality or overall satisfaction. The respondent felt it was more important to be examined when the consultation was conducted in-person and found Telemedicine consultations more convenient in terms of cost and time. CONCLUSION: Telemedicine used in Radiation Oncology is an effective form of consultation that is convenient, provides a similar level of patient satisfaction and maintains patient confidentiality. Telemedicine consultations should therefore be considered for all rural and remote cancer patients where feasible.

Application of stereotactic body radiotherapy in advanced pancreatic cancers in Australia.

INTRODUCTION: The majority of pancreatic cancers present locally advanced and carry a high mortality rate. Treatment is challenging, with mixed data suggesting use of chemotherapy alone or in combination with radiotherapy. The use of radiotherapy has previously been limited due to lack of ability to deliver radiation to the tumour mass without causing significant toxicity to surrounding organs. Stereotactic body radiotherapy (SBRT) allows delivery of higher biologically equivalent dose in a shorter treatment duration. We sought to investigate the safety and application of this technique in our centre. METHOD: We enrolled 27 patients from 2015, identified as locally advanced unresectable with histologically confirmed, non-metastatic, pancreatic adenocarcinoma. All patients had endoscopically inserted fiducial markers and where possible concurrent chemotherapy was administered. Dose schedules ranged from 25 to 42 Gy in 5 or 3 fractions. RESULTS: With an overall median follow up of 9 months (range, 3-32.7), the median survival was 11.6 months. Of those alive at 1 year, the local control rate was 67%. Six patients had Grade 3 toxicity, and other six had Grade 2 toxicity. None had Grade 4 or above toxicity. The most common symptom recorded was fatigue. CONCLUSION: SBRT for locally advanced pancreatic cancer is technically complex but feasible in a high volume centre. SBRT is unique, allowing safe delivery of high radiation dose resulting in good local control and decreases treatment time making it an attractive option for patients with unresectable pancreatic cancer.

Stereotactic body radiation therapy for early hepatocellular carcinoma: a retrospective analysis of the South Australian experience.

BACKGROUND: Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumours unsuitable for established curative treatment such as ablation or surgery. The aim of the study is to evaluate the efficacy and safety of SBRT in the treatment of small hepatocellular carcinoma (HCC) in South Australia. METHODS: From 2014 to 2018, 13 HCC patients were treated with SBRT. Eligibility criteria for SBRT included: unsuitable for standard curative therapies (resection or percutaneous ablation), lack of complete response to prior transarterial chemoembolization, Child-Pugh classification ≤B7, tumours ≤5 cm and minimum of up to 6 months follow-up post-SBRT. The prescribed radiation dose was determined by liver function with doses ranging from 40 to 45 Gy in three or five fractions. Records for all patients were reviewed, and treatment response was scored according to the modified response evaluation criteria in solid tumours. Toxicity was graded according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS: The median follow-up time was 22.7 months, and the median tumour size was 40 mm. The 1 year local control was 92.3%, recurrence-free survival was 67.7% and overall survival was 86.4% at end of study. Three patients underwent liver transplant. No grade ≥3 non-haematological toxicities were observed. One patient experienced acute grade ≥3 haematological toxicity. CONCLUSION: SBRT is a safe, effective and non-invasive alternative treatment option for patients with small HCCs, unsuitable for standard, evidence-based therapies and lacking complete response to transarterial chemoembolization. Randomized controlled trials are required to further investigate the role of SBRT in HCC.

Human Universal Energy Improved Health-related Quality of Life Outcomes 1 Month After External Beam Radiotherapy for Early-stage Breast Cancer.

BACKGROUND: The demand for the use of human universal energy (HUE) as a form of complementary alternative medicine (CAM) for cancer treatment is increasing, but scientific evidence of its efficacy is lacking. AIMS: The aims of this first randomized study of external beam radiotherapy (EBRT) + HUE versus EBRT + sham HUE in subjects with early breast cancer were to (1) document the changes in health related quality of life (HRQoL) during EBRT and immediately 1 mo after completion of radiation treatment within each subject group and to (2) compare the differences in HRQoL between the 2 groups of subjects. METHOD: Eligible subjects were randomized to either HUE (n = 16) or sham-HUE (n = 16). HRQoL measurements were taken in each patient group before starting treatment, during week 3 of EBRT, immediately after completing treatment, as well as 1 mo after EBRT. These results were evaluated using the validated functional assessment of cancer therapy-breast cancer (FACT-B) HRQoL instrument consisting of the FACT-G and breast cancer specific subscales and trial outcome index (TOI) summary scores. Changes in the scores relevant to both groups were compared using a Mann-Whitney U test. The effect of the HUE treatment was quantified by analysis of covariance (ANCOVA) models. All statistical analysis was done at a 95% confidence interval and the differences were considered significant if P ≤ .05. RESULTS: The tests associated with FACT-G, social wellbeing, and emotional well-being scores returned insignificant P value > .05. The test associated with physical well-being and FWB returned significant P value ≤ .05, but the (adjusted) quantified influence of the HUE treatment on these scores was less than the clinically significant threshold of 5 points, and the FWB clinically significant threshold of greater than 2.9 points. The test associated with FACT-B, breast cancer specific (BCS), and TOI scores returned significant or close to significant P value, α ≤ .05, and the (adjusted) quantified influence of HUE treatment on these scores is more than the accepted thresholds (5 points for BCS and 10 points for FACT-B and TOI) for clinical difference. CONCLUSION: Although some results, such as P values for Mann-Whitney U tests and coefficients of HUE treatment in initial ANCOVA models showed promising and positive effects of HUE treatment on the subject, further research with a larger sample size is necessary to confidently conclude whether HUE treatment has significant positive influence on subject HRQoL.

Comparative study between 68 Ga-prostate-specific membrane antigen positron emission tomography and conventional imaging in the initial staging of prostate cancer.

INTRODUCTION: The management of prostate cancer has undergone significant advances since the introduction of 68 Ga-prostate-specific membrane antigen (68 Ga-PSMA) positron emission tomography (PET) scans. Data on the use of 68 Ga-PSMA PET scans in the setting of biochemical recurrence is widely available. Data on the use of 68 Ga-PSMA PET as an initial staging modality, however, is limited. The aim of this retrospective study was to compare the staging of patients with newly diagnosed prostate cancer between 68 Ga-PSMA PET and current conventional imaging modalities. The potential impact of any change in stage will be analysed. METHODS: Details of all patients who underwent 68 Ga-PSMA PET in South Australia between March 2016 and March 2017 were obtained. One hundred and thirty-one patients with newly diagnosed prostate cancer who had 68 Ga-PSMA PET prior to consideration of definitive treatment were included in this study. The stage pre-68 Ga-PSMA PET (based on conventional imaging) and post-68 Ga-PSMA PET was recorded. The stage was classified as A - localised disease, B - presence of regional lymphadenopathy, C - oligometastatic disease (up to three metastases) and D - widespread metastases. Management plans were recorded. RESULTS: This study showed that the use of 68 Ga-PSMA PET resulted in a change of stage in 37 (28%) patients with an upstage in 17 (13%) patients and a downstage in 20 (15%) patients (P < 0.001). 68 Ga-PSMA PET excluded oligometastatic disease in 11 (8%) patients who had suspicious oligometastatic disease based on a single conventional imaging modality. These 68 Ga-PSMA PET findings impacted on management in at least 24 (18%) patients. CONCLUSION: The use of 68 Ga-PSMA PET scans in initial staging can have a significant impact on staging and management when compared to current conventional imaging modalities.

Developing high-specificity anti-hypertensive alerts by therapeutic state analysis of electronic prescribing records.

OBJECTIVE: This paper presents a model for analysis of chronic disease prescribing action over time in terms of transitions in status of therapy as indicated in electronic prescribing records. The quality of alerts derived from these therapeutic state transitions is assessed in the context of antihypertensive prescribing. DESIGN: A set of alert criteria is developed based on analysis of state-transition in past antihypertensive prescribing of a rural Australian General Practice. Thirty active patients coded as hypertensive with alerts on six months of previously un-reviewed prescribing, and 30 hypertensive patients without alerts, are randomly sampled and independently reviewed by the practice's two main general practice physicians (GPs), each GP reviewing 20 alert and 20 non-alert cases (providing 10 alert and 10 non-alert cases for agreement assessment). MEASUREMENTS: GPs provide blind assessment of quality of hypertension management and retrospective assessment of alert relevance. RESULTS: Alerts were found on 66 of 611 cases with coded hypertension with 37 alerts on the 30 sampled alert cases. GPs assessed alerting sensitivity as 74% (CI 52% - 89%) and specificity as 61% (CI 45% - 74%) for the sample, which is estimated as 26% sensitivity and 93% specificity for the antihypertensive population. Agreement between the GPs on assessment of alert relevance was fair (kappa = 0.37). CONCLUSIONS: Data-driven development of alerts from electronic prescribing records using analysis of therapeutic state transition shows promise for derivation of high-specificity alerts to improve the quality of chronic disease management activities.

Understanding caseload and practice through analysis of therapeutic state transitions.

Increasing uptake of electronic medical records (EMRs) offers opportunities for analysis and quality assurance of clinical practice; but making appropriate inferences about chronic disease management is non-trivial. We propose a state-transition model for analysis of chronic disease therapy by community practices based on clinical practice guidelines. We abstract guideline recommendations to key therapeutic states, and map electronic prescribing data into a series of states and transitions, which can then be interpreted with respect to the recommendations of the guideline. By applying our approach to a patient cohort diagnosed with both hypertension and diabetes mellitus, we demonstrate that the method identifies cases at risk of suboptimal care, deserving further review by General Practitioners (GPs).