Electronic Medical Records and Quality of Cancer Care

The implementation of electronic medical records (EMR) systems was mandated by the U.S. federal government in large part due to research indicating that difficulty accessing clinical data was one of the most common causes of preventable deaths. Several assumptions were implicit in this mandate, including the assumption that the implementation of EMR would indeed improve clinicians’ access to clinical data, that implementation of EMR would pose little to no risk to patients, and that the clinical benefit of improved access to clinical data would outweigh any risks that might arise. As detailed in this review, both formal research and extensive experiential observation have called all three assumptions into question. Specifically, as detailed below, there is clear evidence that EMR systems are associated with multiple specific risks to patients, whereas few, if any, scientifically rigorous outcomes-based studies have demonstrated that the potential benefits of EMR outweigh the known risks. In addition, there is currently little to no scientifically rigorous evidence that EMR systems constitute a cost-effective methodology for improving patient outcomes.     

Incorporation of Prognostic and Predictive Factors Into Glioma Clinical Trials

Treatment of brain tumors is increasingly informed by biomarkers that predict patient prognosis and response to therapy. While this progress represents a great opportunity for the field of neuro-oncology, it also presents significant challenges. Biomarkers are not straightforward to identify, and previously used clinical trial paradigms are poorly suited to the task of identifying treatments effective only in selected subsets of patients. Unless investigators adapt new tools and procedures that better account for the biological diversity of gliomas, future clinical trials run the dual risk of missing important treatment effects and exposing patients to interventions destined to prove ineffective for their tumors. In this article, we will review the progress made in the past decade with respect to biomarkers in neuro-oncology, address barriers to ongoing progress, and discuss clinical trial designs that may prove useful in moving neuro-oncology fully into the era of personalized medicine.     

Impact of Disease Progression,Line of Therapy,and Response on Health-Related Quality of Life in Multiple Myeloma: A Systematic Literature Review

This systematic literature review (SLR) was conducted to better understand the impact of disease progression, line of therapy, and clinical response on health-related quality of life (HRQoL) in patients with multiple myeloma (MM). Multiple databases were searched to identify records relating to HRQoL in adult patients with MM. Titles and abstracts were independently screened by 2 reviewers for inclusion based on pre-defined criteria. Records flagged for inclusion had full texts subsequently screened using the same method. A third round of screening was then conducted to identify studies that assessed the relationship of HRQoL to disease progression, line of therapy, or clinical response. Quality assessment was conducted on utility studies using the National Institute for Health and Care Excellence Quality Assessment Checklist for Health State Utility Values. After all rounds of screening were complete, 44 records (representing 41 studies) were included in the SLR. Thirty records reported data relating HRQoL to disease progression, 5 reported data relating HRQoL to line of therapy, and 19 reported data relating HRQoL to response. Despite a lack of homogeneity and small number of studies, the data show overall that progressive disease and increasing lines of therapy were associated with worsened patient HRQoL and increasing depth of response was associated with improved patient HRQoL. The findings from this SLR support that desirable treatment outcomes such as delayed progression, fewer lines of therapy, and achieving the deepest possible clinical response result in improved HRQoL in patients with MM.     

Advanced Practice Providers in Radiation Oncology

PurposeThe report highlights utilization of advanced practice providers (APPs) in an academic radiation oncology center and how their role benefits patient care and departmental workflow.Methods and MaterialsA self-reported workflow analysis of department APPs was conducted across 5 disease sites. A review of electronic medical records was performed to determine the percent of APP follow-ups completed independently versus in a shared capacity with the radiation oncologist. A review of the APP’s didactic and clinical training program was performed.ResultsAcross all disease sites, approximately 40% of the APP’s time was spent on direct patient care, predominantly composed of independent follow-up visits (9%-35%) and telehealth (2%-30%). The breast malignancies group was an outlier with a higher focus on consults or shared visits (25%). Indirect patient care accounts for 30% to 50% of workflow with the focus on visit preparation or care coordination (13%-35%) and dictation (8%-13%). Administrative responsibilities including process improvement, research, education, and leadership account for the remainder (5%-26%) and are varied across disease sites. The central nervous system malignancies group and genitourinary malignancies group reported a greater percentage of their time (23%-26%) on administration compared with other groups (5%-9%). On average APPs see most of their visits independently from the physicians (86.41%) with 13.59% of visits being seen in a shared capacity.ConclusionsAPPs can positively affect the field of radiation oncology by augmenting clinical capacity, optimizing workflow and increasing department efficiency via both direct and indirect patient care and through involvement in administrative and leadership duties. By implementing an independent-to practice model, simultaneous APP and physician clinics run parallel to each other, limiting shared visits for complex cases. This promotes APP job satisfaction and provides greater access to patient care without compromising quality. This article highlights a model for the utilization of APPs, which can be implemented by other radiation oncology departments or practices.     

Endoscopic electronic record: A new approach for improving management of colorectal cancer prevention

Digestive endoscopy is currently the main diagnostic procedure for investigation of the digestive tract when a digestive disease is suspected.The use of computers and electronic medical records for the management of endoscopic data are an important key to improving endoscopy unit efficiency and productivity.This technology supports optimal program operation,monitoring and evaluation colorectal cancer screening.This article is a comprehensive survey of endoscopic electronic medical records and information systems.Computerized clinical records have the capability of identifying patients due for screening and to calculate baseline rates of colorectal cancer screening by patient characteristics and by primary care physician and practice group.This paper describes data flow in the endoscopy unit,the minimum data set of colorectal cancer and key features of endoscopic electronic medical record.In addition,the researchers state standards in different aspects,especially terminology standards and interoperability standards for image and text.     

To treat or not to treat: Patient exclusion in immune oncology clinical trials due to preexisting autoimmune disease

Newly developed immune checkpoint inhibitors (ICIs) demonstrate impressive clinical activity. However, they can also cause life-threatening side effects. The efficacy and toxicity associated with ICIs both derive from unregulated, enhanced immune activation. Health care providers have been hesitant to prescribe these medications to patients who have preexisting autoimmune disease (AD) because of concerns that this may exacerbate their underlying immune condition. These patients have also been excluded from ongoing ICI clinical trials. However, new data suggest that the potential benefits of ICI treatment may outweigh the potential risks for this patient group as long as physicians also provide sufficient monitoring for AD exacerbations or other side effects. Therefore, it may be appropriate to include patients with advanced malignancies and preexisting AD in ICI clinical trials when no other effective cancer treatment options exist. Overall, physicians should avoid excluding patients from ICI therapy unnecessarily when the potential benefits outweigh the potential risks.     

Recommendations to improve the clinical adoption of NGS‐based cancer diagnostics in Singapore

Next‐generation sequencing (NGS)‐based diagnostics have demonstrated clinical utility in predicting improved survival benefits with targeted treatment in certain cancer types, and positive cost–benefit in several healthcare systems. However, clinical adoption in Singapore remains low despite commercial availability of these diagnostics. This expert opinion review examines the key challenges to the clinical adoption of NGS‐based diagnostics in Singapore, provides recommendations on impactful initiatives to improve adoption, and also offers practical guidance on specific cancer types in which NGS‐based diagnostics are appropriate for use in Singapore. Limited patient affordability is one major challenge to clinical adoption of NGS‐based diagnostics, which could be improved by enabling patient access to more funds for specific cancer types with clear benefits. Expert opinion based on current evidence and clinical experience supports the upfront use of hotspot panels in advanced non–small cell lung cancer (NSCLC), metastatic colorectal cancer, advanced and recurrent ovarian cancer, and acute myeloid leukemia. Comprehensive genomic profiling could be considered for upfront use in select patients with NSCLC and ovarian cancer, or in refractory patients with the four cancer types. Wider adoption of NGS‐based diagnostics will improve the delivery of cancer care in Singapore and Asia‐Pacific, and thus lead to better patient outcomes.     

Evaluation of a patient-held record for patients with cancer

The objective of this study was to evaluate a patient-held record (PHR) for patients with cancer. A randomized controlled trial (RCT) was conducted of a PHR to be used by patients newly diagnosed with lung or colorectal cancer (hospital), patients with cancer at any stage (community) and professionals involved in their care, together with surveys of health professionals to gauge views on PHR. Main outcome measures were patient satisfaction with information and communication, and patient and healthcare professionals' views of PHR. The only significant difference was 86% of control compared with 58% of intervention patients were very satisfied with information received at the end of treatment (odds ratio 4.4, 95% confidence interval 1.2–15.6, P < 0.05). Fifty-three per cent of intervention respondents found the PHR helpful (63% hospital vs. 38% community patients), and 69% felt that it would be useful to them in the future. Primary healthcare (PHC) professionals found the PHR of more benefit than those working in hospitals ( P < 0.05). The PHR did not improve measures of patient satisfaction with information or communication. Despite its limited use by many health professionals, the PHR was well received by recently diagnosed patients, and those who did not receive negative responses to it from staff involved in their care. It was also positively valued by staff in PHC. An evaluation of a customized record provided at the time of diagnosis is warranted.     

End of life issues in brain tumor patients

Despite aggressive antitumor treatment, the prognosis of brain tumor (BT) patients remains poor. In the last stage of disease, BT patients present severe symptoms due to the growing tumor or to treatment side-effects, which require adequate palliative management and supportive therapy. However, studies specifically addressing palliative care and end-of-life (EoL) issues in BT patients are lacking. This study explores symptoms experienced by BT patients in the last weeks of disease and EoL issues observed in a population of brain tumor patients followed at home until death by a neuro-oncological home care palliative unit set up in our Institution in 2000. From October 2000 to December 2005, 324 patients affected by brain tumor and discharged from our Institution were enrolled in a comprehensive program of neuro-oncological home care supported by the Regional Health System. Out of 324 patients enrolled in the home care program, 260 patients died of which 169 (65%) were assisted at home until the end of life and have been included in this study. Clinical symptoms, palliative treatments and EoL treatment decisions were collected from home clinical records. Among the 169 patients assisted at home until death, the most frequent symptoms observed in the last four weeks of life were: epilepsy 30%, headache 36%, drowsiness 85%, dysphagia 85%, death rattle 12%, agitation and delirium 15%. Palliative management of brain tumor patients requires a multidisciplinary approach performed by a well trained neuro-oncology team. Development of home care models of assistance may represent an alternative to in-hospital care for the management of patients dying of brain tumor and may improve the quality of end-of-life care. An erratum to this article can be found at     

Clinical trial participation among patients enrolled in the Glioma Outcomes Project

BACKGROUND: Patient participation in well-designed and conducted clinical trials enables researchers to test new therapies. An understanding of the variables that possibly influence patient enrollment may help in patient recruitment for future trials. The authors evaluated factors that influenced patient enrollment in clinical trials using a prospective, large, multi-institutional registry of patients with malignant glioma. METHODS: Data were examined from 708 patients who underwent first or second surgery for a malignant glioma who were enrolled in the Glioma Outcomes Project, which is a prospective observational data base that captures clinical practice patterns. The frequency of clinical trial participation and the variables that may have been associated with trial participation were evaluated. These variables included age, gender, race, household income, educational level, first versus second craniotomy, histology, and whether the patient was treated at an academic institution. RESULTS: One hundred fifty-one of 708 patients (21.3%) participated in a clinical trial, which was higher than the participation reported typically for patients with other types of primary malignancies. In univariate analysis, race, histology, and first craniotomy were significant between the two groups, with Caucasian patients and patients with glioblastoma histology showing higher participation rates. In a multivariate logistic regression model, significant predictors included young age and glioblastoma multiforme histology. CONCLUSIONS: The authors present information on factors that may influence clinical trial participation among patients with malignant glioma and compare their data with information described previously on patients with other types of malignant disease. The percent of participation among the patients in the current study was greater than among patients with other primary tumor sites. Strategies should be implemented to improve recruitment to neuro-oncology trials, especially in elderly and minority populations.     

A Structured Intervention to Support Early Palliative Care Conversations for Oncology Patients – A Qualitative Feasibility Study

AimsFor patients with advanced cancer, early access to palliative care can have numerous psychosocial and disease management benefits. However, it can be difficult for clinicians to initiate these initial conversations about palliative care. The aim of the present study was to beta test an intervention to facilitate timely conversations about palliative care between patients and clinicians.Materials and methodsThe study reported forms one stage of a complex intervention development study following Medical Research Council guidance for developing complex interventions. Feasibility was explored from patient and clinician perspectives in an oncology outpatient setting.ResultsSixteen patients and 18 clinicians participated. Three phases of the intervention were assessed through patient and clinician interviews. The analysis produced three themes in each phase: (i) Preparation (patient preparedness; healthcare professionals' perspectives on palliative care; administration, data and communication); (ii) STEP consultation (defining perspectives on palliative care; how palliative care fits with the current treatment plan; permission to explore future care); (iii) Outcomes (changes in perspective and approaches to coping; opening the door to future conversations; referrals and involvement of palliative services).ConclusionsThe STEP intervention generated important early conversations about end-of-life care that may otherwise not have occurred. No patients regretted having the STEP consultation, which resulted in palliative care referrals for some. Others felt better informed about the support services available and better able to have further conversations. Participating clinicians found the structured conversation guide useful, as it acted as a prompt for areas to cover, as well as providing an explicit way to open discussion about difficult topics.     

Neurologic complications of melanoma

Neurologic complications are common in patients with melanoma and are often associated with a poor prognosis. In an era with new, effective treatments, patients are living longer, and this has resulted in an increase in complications of both the disease and the therapy. A multidisciplinary approach to neurologic complications in patients with melanoma, with involvement from medical oncology, neuro-oncology, radiation oncology, and often neurosurgery, is necessary. In this review, neurologic complications of melanoma, including clinical implications and treatment strategies, are described.     

Predictors of heterogeneity in the first-line treatment of patients with advanced/metastatic gastric cancer in the U.S.

Background

Patients with metastatic gastric cancer have a poor prognosis (5-year survival of less than 10%). This study was designed to describe the treatment patterns of patients with gastric cancer and to understand the factors associated with treatment choices to inform evidence-based care.

Methods

A retrospective observational study was conducted using two real-world databases to describe treatment trends and to quantify variability in treatment patterns of patients diagnosed with advanced/metastatic gastric cancer between 1/1/2007 and 9/30/2014 in the U.S. Heterogeneity was measured by the Herfindahl–Hirschman Index (HHI). Predictors (baseline clinical, treatment, and demographic variables) of treatment regimen choice were evaluated using logistic regression.

Results

A total of 5772 patients with advanced/metastatic gastric cancer were included in this study [5044 from claims data and 728 from electronic medical records (EMR)]. Of the 5044 from claims data, 2457 had evidence of metastatic disease at diagnosis. Only the fluorouracil + oxaliplatin regimen exceeded 10% utilization in the first-line setting [claims metastatic (12.1%), claims advanced (8.2%), and EMR metastatic (16.6%) cohorts]. The HHI demonstrated extreme heterogeneity (0.14 for first-line therapy and 0.13 for second-line therapy). Patient age and geographic region of residence were significantly associated with treatment choice across all three cohorts in the first-line setting (p < 0.05).

Conclusion

Treatment of patients with gastric cancer was highly variable. Despite the availability of treatment guidelines, there is a lack of consistent treatment patterns. There is a need to improve evidence-based care for patients with gastric cancer.

     

Big Data Solutions for Controversies in Breast Cancer Treatment

The digital world of data is expanding with an annual growth rate of 40%, and health care is among the fastest growing sector of the digital world with an annual growth rate of 48%. Rapid growth in technology has augmented data generation; for example, electronic health records produce huge amounts of patient-level data, whereas national registries capture information on numerous factors affecting health care delivery and patient outcomes. This big data can be utilized to improve health care outcomes. This review discusses relevant applications in breast cancer treatment.     

Comparison of the JCAHO Scoring System and the ESAS Scoring System in Determining the Palliative Care Needs of Gynecological Cancer Patients Treated at Hasan Sadikin Hospital

Objective: The purpose of this study was to analyze the relationship between quality of life with the JCAHO and the ESAS scoring system, and to compare the JCAHO and the ESAS scoring system in determining the palliative care needs of gynecological cancer patients treated at RSHS. Method: The subjects of this study were all gynecological cancer patients who were treated at RSHS in May-August 2020. This study was an analytic study with a cross sectional design. The data of this study were obtained from interviews, questionnaires and patient medical records, the study was analyzed bivariate using chi square with α = 0.05. Results: The results showed that the quality of life of patients with gynecological cancer was associated with the JCAHO palliative score (p <0.05), the better the patient’s quality of life, the better the JCAHO palliative score. The quality of life of gynecological cancer patients was related to ESAS (p <0.05), the better the patient’s quality of life, the better the ESAS. There was difference between the JCAHO palliative score and the ESAS in determining the palliative care needs of gynecological cancer patients (p< 0.05). Conclusion: Quality of life has correlation with palliative scores, the lower the palliative score, the better the quality of life. This study showed significant difference between the JCAHO palliative score and the ESAS in determining the palliative care needs of gynecological cancer patients. The JCAHO palliative score measures objectively how the patient is on admission for treatment, this score not only measures the intensity of symptoms but measures the underlying disease, comorbid disease, functional status of the patient and other criteria for the patient.  ESAS assesses the intensity of symptoms, the assessment of palliative care needed can change rapidly if the intensity of symptoms in patients changes.     

Surgical standards in the management of ovarian cancer

Surgery is the cornerstone of management of epithelial ovarian cancer and has broad applications throughout the clinical course of disease, from initial diagnosis to palliative care. Comprehensive surgical staging is essential for precise prognostic determination and treatment planning for patients with apparent early-stage ovarian cancer. Although randomized trials are lacking, the survival advantage associated with optimal primary cytoreduction has been consistent and reproducible. With increasing radicality of cytoreductive surgical techniques and sophistication of postoperative care, it appears that an "optimal" surgical procedure is that which leaves the patient with no visible residual disease. The survival benefits of cytoreductive surgery are also applicable to women with stage IV ovarian cancer, although the rate of success is somewhat attenuated compared with patients with stage III disease. Recent data also indicate that with appropriate surgical selection criteria, secondary cytoreduction is associated with a significant prolongation of survival for patients with recurrent ovarian cancer. Unfortunately, several recent publications illustrate how the decentralization of health care may have significant ramifications on the ability of women with known or suspected ovarian cancer to avail themselves of the surgical standard of care.     

An association between parameters of liver blood flow and percentage hepatic replacement with tumour

The extent of hepatic replacement with tumour is a significant prognostic factor in patients with liver metastases. Measuring the percentage hepatic replacement (PHR) accurately is difficult, but is important for both patient management and clinical trial evaluation. This study correlates haemodynamic indices obtained by dynamic liver scintigraphy (DLS) with estimates of PHR made from isotope scan, ultrasound, CT scan and laparotomy in 45 patients with established colorectal liver metastases and 21 controls who also underwent DLS. There was a significant reduction in the mesenteric fraction (MF) in the group of patients with metastases compared to the controls (P less than 0.001), and also a significant trend for progressive reduction in the MF with increasing PHR. A significant rise in an index of total hepatic arterial blood flow was also demonstrated with increasing PHR. These results are important with current interest in regional hepatic arterial therapy, and may prove of clinical value for prediction or monitoring of response to therapy.     

Alternative approaches to paying for cancer care

By their very nature, electronic health records (EHRs) facilitate appropriate documentation and make it possible to read and understand submitted records in terms of their appropriate comprehensive nature. Other potential EHR benefits include the ability to enhance communication, measure and improve the quality of care, increase clinical trial participation, mine data, participate in e-prescribing, and improve billing processes.     

The evolution of oncology electronic health records

Health information technology will transform health care delivery over the coming years. The central element of this will be the electronic health record, maintained by health professionals and linked to other health care providers, patients, and research and population health databases. Support of oncology functionality will necessitate special attention to how electronic health records are constructed, cancer-related data represented within, and clinical decision support tools designed to best support the objectives of quality care and cost-effectiveness. Standardization of functions and software will permit data exchange, leading to enhanced interoperability of systems. The present efforts at establishing oncology-related standards for electronic health records are reviewed.     

Is There a Role for Clinical Practice Guidelines in Multidisciplinary Tumor Board Meetings? A Descriptive Study of Knowledge Transfer Between Research and Practice

The aim of this study was to characterize practice patterns and decision-making processes of healthcare providers attending weekly neuro-oncology tumor board meetings, and to assess their familiarity with clinical practice guidelines (CPGs) in neuro-oncology. Members of the Neuro-Oncology Tumor Team at two tertiary cancer centers completed a web-based questionnaire assessing characteristics of weekly tumor board meetings and perceptions of CPGs. Twenty-three (66%) tumor team members responded. Diagnostic imaging results and interpretation, medical, surgical, and/or radiation treatment planning, and pathology results and interpretation were the most commonly identified aspects of patient care discussed at tumor board meetings, and almost all respondents indicated that these meetings were “very beneficial” to their own practice. When deciding on a treatment plan, respondents rely most on the clinical expertise of colleagues, medical literature, personal experience, active clinical trial protocols, and published CPGs. Opinions of the local CPGs varied considerably, and while 56% of respondents supported regular discussion of them during meetings, only 32% indicated that they were routinely reviewed. Updating the literature more frequently, implementing a formal grading system for the evidence, and incorporating clinical care pathways were the most frequently cited methods to improve the CPGs. Tumor board meetings are beneficial to the treatment planning process for neuro-oncology patients.