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Bulen BJ, Khazanov NA, Hovelson DH, Lamb LE, Matrana M, Burkard ME, Yang ESH, Edenfield WJ, Claire Dees E, Onitilo AA, Buchschacher GL, Miller AM, Parsons BM, Wassenaar TR, Suga JM, Siegel RD, Irvin W, Nair S, Slim JN, Misleh J, Khatri J, Masters GA, Thomas S, Safa MM, Anderson DM, Mowers J, Dusenbery AC, Drewery S, Plouffe K, Reeder T, Vakil H, Patrias L, Falzetta A, Hamilton R, Kwiatkowski K, Johnson DB, Rhodes DR, Tomlins SA. Validation of Immunotherapy Response Score as Predictive of Pan-solid Tumor Anti-PD-1/PD-L1 Benefit. Cancer Res Commun 2023; 3:1335-1349. [PMID: 37497337 PMCID: PMC10367935 DOI: 10.1158/2767-9764.crc-23-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/16/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
Immunotherapy response score (IRS) integrates tumor mutation burden (TMB) and quantitative expression biomarkers to predict anti-PD-1/PD-L1 [PD-(L)1] monotherapy benefit. Here, we evaluated IRS in additional cohorts. Patients from an observational trial (NCT03061305) treated with anti-PD-(L)1 monotherapy were included and assigned to IRS-High (-H) versus -Low (-L) groups. Associations with real-world progression-free survival (rwPFS) and overall survival (OS) were determined by Cox proportional hazards (CPH) modeling. Those with available PD-L1 IHC treated with anti-PD-(L)1 with or without chemotherapy were separately assessed. Patients treated with PD-(L)1 and/or chemotherapy (five relevant tumor types) were assigned to three IRS groups [IRS-L divided into IRS-Ultra-Low (-UL) and Intermediate-Low (-IL), and similarly assessed]. In the 352 patient anti-PD-(L)1 monotherapy validation cohort (31 tumor types), IRS-H versus IRS-L patients had significantly longer rwPFS and OS. IRS significantly improved CPH associations with rwPFS and OS beyond microsatellite instability (MSI)/TMB alone. In a 189 patient (10 tumor types) PD-L1 IHC comparison cohort, IRS, but not PD-L1 IHC nor TMB, was significantly associated with anti-PD-L1 rwPFS. In a 1,103-patient cohort (from five relevant tumor types), rwPFS did not significantly differ in IRS-UL patients treated with chemotherapy versus chemotherapy plus anti-PD-(L)1, nor in IRS-H patients treated with anti-PD-(L)1 versus anti-PD-(L)1 + chemotherapy. IRS associations were consistent across subgroups, including both Europeans and non-Europeans. These results confirm the utility of IRS utility for predicting pan-solid tumor PD-(L)1 monotherapy benefit beyond available biomarkers and demonstrate utility for informing on anti-PD-(L)1 and/or chemotherapy treatment. Significance This study confirms the utility of the integrative IRS biomarker for predicting anti-PD-L1/PD-1 benefit. IRS significantly improved upon currently available biomarkers, including PD-L1 IHC, TMB, and MSI status. Additional utility for informing on chemotherapy, anti-PD-L1/PD-1, and anti-PD-L1/PD-1 plus chemotherapy treatments decisions is shown.
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Affiliation(s)
| | | | | | | | - Marc Matrana
- Ochsner Cancer Institute, New Orleans, Louisiana
| | - Mark E. Burkard
- University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Eddy Shih-Hsin Yang
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | | | | | - Adedayo A. Onitilo
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | | | | | | | | | | | | | | | - Suresh Nair
- Lehigh Valley Topper Cancer Institute, Allentown, Pennsylvania
| | | | | | - Jamil Khatri
- ChristianaCare Oncology Hematology, Newark, Delaware
| | - Gregory A. Masters
- Medical Oncology Hematology Consultants, Helen F Graham Cancer Center and Research Institute, Newark, Delaware
| | - Sachdev Thomas
- Kaiser Permanente Northern California, Oakland, California
| | | | - Daniel M. Anderson
- Metro-Minnesota Community Oncology Research Consortium, St. Louis Park, Minnesota
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Blinder VS, Garrett-Mayer E, Jacobsen PB, Kozlik MM, Markham MJ, Siegel RD, Kamal AH, Crist STS, Rosenthal J, Chiang AC. Oral Chemotherapy Metric Performance in Quality Oncology Practice Initiative Practices: Updated Trends and Analysis. J Natl Compr Canc Netw 2022; 20:1099-1106.e2. [PMID: 36240846 DOI: 10.6004/jnccn.2022.7024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Oral chemotherapy performance measures were first introduced into ASCO's Quality Oncology Practice Initiative (QOPI) in 2013. This study examined performance on these measures among QOPI-participating practices and evaluated whether it differed among practices based on meeting QOPI Certification Program standards. METHODS A total of 192 QOPI-participating practices (certified, n=50 [26%]; not certified, n=142 [74%]) reported performance on oral chemotherapy measures in 2017 and 2018. Inclusion was limited to practices reporting on ≥3 charts for ≥1 oral chemotherapy measure. Performance was defined as the percentage of charts examined that adhered to the measure. Descriptive analyses were used to characterize performance within and across practices, and mixed-effects logistic regression models were conducted to compare performance based on certification status. RESULTS Median performance across practices for the 9 oral chemotherapy measures examined ranged from 44% (education before the start of treatment addressing missed doses, toxicities, and clinical contact instructions [composite measure]) to 100% (documented dose, documented plan, and education about toxicities). Certified practices were more likely to provide education about clinic contact instructions than noncertified practices (odds ratio, 4.87; 95% CI, 1.00-24.0). Performance on all other measures was not significantly associated with certification status. CONCLUSIONS There is wide variability in quality related to performance on oral chemotherapy measures across all QOPI-participating practices, and several areas were identified in which administration of oral chemotherapy could be improved. Our findings highlight the need for the development and implementation of appropriate standards that apply to oral chemotherapy and address the complexities that set it apart from parenteral treatment.
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Affiliation(s)
| | | | - Paul B Jacobsen
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | | | - Merry Jennifer Markham
- University of Florida College of Medicine, UF Health Cancer Center, Gainesville, Florida
| | - Robert D Siegel
- Bon Secours St. Francis Cancer Center, Greenville, South Carolina
| | - Arif H Kamal
- Duke Cancer Institute, Durham, North Carolina; and
| | | | - Jon Rosenthal
- American Society of Clinical Oncology, Alexandria, Virginia
| | - Anne C Chiang
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut
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3
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Siegel RD, Garrett-Mayer E, Lipner RS, Kozlik MMP, Vandergrift JL, Crist STS, Chen RC, Chiang AC, Kamal AH. Relationship Between Participation in ASCO's Quality Oncology Practice Initiative Program and American Board of Internal Medicine's Maintenance of Certification Program. JCO Oncol Pract 2022; 18:e1350-e1356. [PMID: 35363501 DOI: 10.1200/op.21.00777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Medical oncologists have a variety of options for demonstrating proficiency in providing high-quality patient care. Perhaps, the best-known opportunity for demonstrating individual expertise and lifelong learning is the American Board of Internal Medicine (ABIM) maintenance of certification (MOC) program. At the practice level, ASCO has offered the Quality Oncology Practice Initiative (QOPI) as a means of optimizing cancer care delivery. In this study, we assess the association between active involvement in MOC on an individual basis and whether that individual's practice is involved with the QOPI program. METHODS We evaluated 13,600 US medical oncologists initially certified by the ABIM and divided them into those initially certified before 1990 (the year in which ABIM started to require periodic recertification), those from 1990 to 2007, and those from 2008 to 2016. It was then determined which of these had let their certificates expire by 2020. These data were then compared with practices that participated in QOPI from 2017 to 2019, resulting in the matching of 97% of physicians. RESULTS Of individuals initially certified before 1990 (and technically with lifelong certification), 22% were in QOPI practices. Among those who did not have lifelong certification, there was an association between QOPI participation and maintenance of ABIM certification. For those initially certified between 1990 and 2007, 35% of oncologists with up-to-date ABIM certification were in QOPI practices, whereas only 11% with expired ABIM certification were QOPI participants (P < .0001). For those in the 2008-2016 category, the numbers were 36% v 16%, respectively (P < .0001). CONCLUSION Our analysis identifies a relationship between participation in these ABIM and ASCO proficiency programs. The reasons for this are likely complex and based on a variety of institutional, professional, monetary, and personal factors.
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Affiliation(s)
| | | | | | | | | | | | | | - Anne C Chiang
- Yale Cancer Center, Yale University School of Medicine, New Haven, CT
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Krop IE, Jegede OA, Grilley-Olson JE, Lauring JD, Mitchell EP, Zwiebel JA, Gray RJ, Wang V, McShane LM, Rubinstein LV, Patton D, Williams PM, Hamilton SR, Kono SA, Ford JM, Garcia AA, Sui XD, Siegel RD, Slomovitz BM, Conley BA, Arteaga CL, Harris LN, O'Dwyer PJ, Chen AP, Flaherty KT. Phase II Study of Taselisib in PIK3CA-Mutated Solid Tumors Other Than Breast and Squamous Lung Cancer: Results From the NCI-MATCH ECOG-ACRIN Trial (EAY131) Subprotocol I. JCO Precis Oncol 2022; 6:e2100424. [PMID: 35138919 PMCID: PMC8865530 DOI: 10.1200/po.21.00424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/12/2021] [Accepted: 01/05/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE PIK3CA mutations frequently contribute to oncogenesis in solid tumors. Taselisib, a potent and selective inhibitor of phosphoinositide 3-kinase, has demonstrated clinical activity in PIK3CA-mutant breast cancer. Whether PIK3CA mutations predict sensitivity to taselisib in other cancer types is unknown. National Cancer Institute-Molecular Analysis for Therapy Choice Arm EAY131-I is a single-arm, phase II study of the safety and efficacy of taselisib in patients with advanced cancers. METHODS Eligible patients had tumors with an activating PIK3CA mutation. Patients with breast or squamous cell lung carcinoma, or whose cancer had KRAS or PTEN mutations, were excluded. Patients received taselisib 4 mg, orally once daily continuously, until disease progression or unacceptable toxicity. The primary end point was objective response rate. Secondary end points included progression-free survival (PFS), 6-month PFS, overall survival (OS), and identification of predictive biomarkers. RESULTS Seventy patients were enrolled, and 61 were eligible and initiated protocol therapy. Types of PIK3CA mutations included helical 41 of 61 (67%), kinase 11 of 61 (18%), and other 9 of 61 (15%). With a median follow-up of 35.7 months, there were no complete or partial responses. Six-month PFS was 19.9% (90% CI, 12.0 to 29.3) and median PFS was 3.1 months (90% CI, 1.8 to 3.7). Six-month OS was 60.7% (90% CI, 49.6 to 70.0) and median OS was 7.2 months (90% CI, 5.9 to 10.0). Individual comutations were too heterogeneous to correlate with clinical outcome. Fatigue, diarrhea, nausea, and hyperglycemia were the most common toxicities, and most were grade 1 and 2. CONCLUSION In this study, taselisib monotherapy had very limited activity in a heterogeneous cohort of heavily pretreated cancer patients with PIK3CA-mutated tumors; the presence of a PIK3CA mutation alone does not appear to be a sufficient predictor of taselisib activity.
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Affiliation(s)
- Ian E. Krop
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Opeyemi A. Jegede
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA
| | | | | | | | | | - Robert J. Gray
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA
| | - Victoria Wang
- Dana-Farber Cancer Institute, ECOG-ACRIN Biostatistics Center, Boston, MA
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5
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Wolpin BM, Richards DA, Cohn AL, Chen X, Bredno J, Kurtzman KN, Yecies J, Shaknovich R, Zhang N, Tummala MK, Spigel DR, Cosgrove D, Wilks S, Siegel RD, Fung ET, Jamshidi A, Aravanis A, Hartman AR, Liu MC, Klein EA. Performance of a blood-based test for the detection of multiple cancer types. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
283 Background: Cancers of the esophagus, stomach, pancreas, gallbladder, liver, bile duct, colon and rectum will account for 17% of incident cancer diagnoses and 26% of cancer-related deaths in the US in 2019. We developed a methylation-based cfDNA early multi-cancer detection test that also can predict the tissue of origin (TOO) of these and other cancers types; performance of this test for gastrointestinal (GI) tract cancers is reported here. Methods: The Circulating Cell-free Genome Atlas (CCGA; NCT02889978) study is a prospective, multi-center, observational, case-control study with longitudinal follow-up, enrolling individuals with cancer ( > 20 cancers, all stages, newly diagnosed) and without cancer. Plasma cfDNA was subjected to a cross-validated targeted methylation (TM) sequencing assay. Methylation fragments were combined across targeted genomic regions and assigned a probability of cancer and a predicted TOO. GI cancer classes were upper GI (esophagus/stomach, n = 67), pancreas/gallbladder/extrahepatic bile duct (n = 95), liver/intrahepatic bile duct (n = 29), and colon/rectum (n = 121). Results: Detection across all GI cancers was 82% (95% CI 77-86) at a > 99% pre-set specificity. Overall predicted TOO accuracy was 92% (88-95) among the samples for which TOO was predicted (6/255 had indeterminate predicted TOO). The table shows performance by GI cancer type. Conclusions: Simultaneous detection at high specificity ( > 99%) of multiple cancer types, including GI cancers across stages at high sensitivity (82%), was shown using TM analysis of cfDNA. Accurate (92%) localization of cancers to specific regions of the GI tract was also achieved. Detection of multiple GI cancers from a single noninvasive blood test could be a practical method for detecting GI and other cancers, and may facilitate diagnostic work-ups. Clinical trial information: NCT02889978. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - David R. Spigel
- Sarah Cannon Research Institute and Tennessee Oncology, Nashville, TN
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Conry A, Peters M, Fried DB, Adams A, Campbell AW, Bearden JD, Siegel RD, Crosswell HE. Complete Response to Dual Immunotherapy in a Young Adult with Metastatic Alveolar Soft Part Sarcoma Enabled by a Drug Recovery Program in a Community Practice. J Adolesc Young Adult Oncol 2019; 9:449-452. [PMID: 31855495 DOI: 10.1089/jayao.2019.0113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Alveolar soft part sarcoma (ASPS) is an extremely rare tumor that frequently occurs in adolescent and young adults (AYA). Survival is poor for patients with metastatic and/or relapsed disease not amenable to local control, and limited therapeutic options are available. A major barrier to cancer care in the United States AYA population is lack of access to coordinated care and appropriate therapies for those who lack insurance or who are underinsured. We report a 25-year-old unemployed, uninsured, single mother who presented with a 12.8 × 21 cm soft tissue thigh mass with heterogeneous avidity, max standardized uptake value of 9, with metastatic disease to the ipsilateral inguinal lymph nodes and to the bilateral lungs. After local control of the primary mass was obtained, a recently developed, comprehensive drug replacement program (DRP) was used to gain access to nivolumab, and after frank progression was noted, ipilimumab was added every 6 weeks. No biomarkers associated with response to immunotherapy were identified. After four cycles, a complete response was observed and patient remains disease free 36 months after beginning dual immunotherapy treatment. We obtained immunotherapy agents through a DRP and describe the development and the utility of this program in the community setting. Our report highlights both first documented sustained complete response to sequenced immunotherapy in an AYA with ASPS as well as a comprehensive DRP, which enabled access to therapy for our patient.
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Affiliation(s)
- Alexandra Conry
- Bon Secours St. Francis Health System, St. Francis Cancer Center, Greenville, South Carolina, USA
| | - Melissa Peters
- Spartanburg Regional Health System, Gibbs Cancer Center & Research Institute, Spartanburg, South Carolina, USA
| | - Daniel B Fried
- Spartanburg Regional Health System, Gibbs Cancer Center & Research Institute, Spartanburg, South Carolina, USA
| | - Amy Adams
- Bon Secours St. Francis Health System, St. Francis Cancer Center, Greenville, South Carolina, USA
| | - Alfred W Campbell
- Spartanburg Regional Health System, Gibbs Cancer Center & Research Institute, Spartanburg, South Carolina, USA
| | - James D Bearden
- Spartanburg Regional Health System, Gibbs Cancer Center & Research Institute, Spartanburg, South Carolina, USA
| | - Robert D Siegel
- Bon Secours St. Francis Health System, St. Francis Cancer Center, Greenville, South Carolina, USA
| | - Howland E Crosswell
- Bon Secours St. Francis Health System, St. Francis Cancer Center, Greenville, South Carolina, USA
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Siegel RD, Slough RG, Crosswell HE, Standifer TM, Borron ME, Pringle DL, Hancock KK, Widener LH, Hill EB, Spann TF, Stoeppler-Biege KM. Drug Recovery and Copay Assistance Program in a Community Cancer Center: Charity and Challenges. J Oncol Pract 2019; 15:e628-e635. [PMID: 31162998 DOI: 10.1200/jop.19.00016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The cost of cancer care is escalating dramatically, in part because of the rising expense of systemic cancer therapy. This creates financial dilemmas for patients and insurers and potential economic disruption for institutions attempting to provide cancer care to the underserved. Our institution initiated a drug recovery and copay assistance program (DRCAP) to mitigate the impact of the rising cost of parenteral medications. METHODS We performed a 3-year review of our strategies to mitigate financial burden of parenteral therapeutics and supportive care medicines. Financial metrics were established and analyzed before and after implementing DRCAP. Medication encounters and associated costs were stratified by adolescents and young adults (15 to 39 years of age), and adults 40 years of age and older and were annualized from 2016 to 2018. RESULTS The DRCAP resulted in a total of nearly $3.5 million worth of drugs replaced or copay assistance yearly in 2017 and 2018. This accounted for approximately 10% of our pharmacy budget for parenteral medications in each of these years. The vast majority was received in the form of drug replacement. The DRCAP resulted in assistance to 173 and 256 patients in 2017 and 2018, respectively. CONCLUSION A DRCAP increased availability of otherwise unaffordable parenteral oncolytics and resulted in cost savings for our institution. Adolescents and young adults were disproportionately represented because of inadequate or no insurance. Despite the salutary benefits, such programs likely inflate the overall cost of cancer care. Cancer care providers participating in a DRCAP will remain in this conundrum until market forces can affect the cost of oncology therapeutics.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Erin B Hill
- 1 Bon Secours St Francis Cancer Center, Greenville, SC
| | - Terra F Spann
- 1 Bon Secours St Francis Cancer Center, Greenville, SC
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Siegel RD, Standifer T, Spann T, Borron M, Slough R, Pringle D, Helms B, Stoeppler-Biege K. Impact of a comprehensive copay assistance and drug recovery system in a community cancer center. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
121 Background: The cost of oncology drugs has escalated rapidly while rollbacks in health care coverage and the emergence of high deductible and limited policies have made these drugs unaffordable for many. Many pharmaceutical companies offer drug replacement for those uninsured or for whom coverage is inadequate. Previously Bon Secours St. Francis Cancer Center (BSSFCC) had contracted with a third-party to recover replacement drug from these pharmaceutical programs. In 2017, we opted to suspend that third-party contract and take the process internally. Methods: BSSFCC is located in Greenville, SC. Nearly1500 new cases of cancer were diagnosed in 2016, of which, 3.5% are uninsured. We hired 2.5 FTE's to manage our drug recovery program. After clearance with legal and compliance officers, limited power of attorney was obtained to pursue these efforts on the patients’ behalf. Patients who had no drug coverage, inadequate coverage, or off-label denials were identified at the time of chemotherapy education, pre-authorization, or by after-the-fact processing of claims. Our efforts at drug recovery are noted below. Results: We recovered drug for 71 patients during fiscal 2017. The total cost of those recovered drugs was $3.25 million. This compared with $389,000 recovered by our third-party vendor (pre-commission) in FY 2016. $842,000 of drug replacement were for off-label use in insured patients, while $587,000 represented use in the uninsured. The remainder represented replacement drug for those with inadequate drug coverage and an ipilimumab replacement program for adjuvant therapy for melanoma. Conclusions: Embedding a process within a community cancer center to manage drug recovery for the un- and underinsured proved to have a substantial return on investment. The drug expenses which had to be written off were decreased substantially but most importantly, our ability to replace drug with some reliability allowed many of our patients to receive effective therapy that otherwise would have been cost prohibitive. Although the ability to recover drugs in this fashion is both helpful and appreciated, our program does nothing to rein in the unsustainable rise in the cost of cancer care.
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Affiliation(s)
| | | | - Terra Spann
- Bon Secours St. Francis Health System, Greenville, SC
| | | | | | | | - Bonnie Helms
- Bon Secours St. Francis Health System, Greenville, SC
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9
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Siegel RD, Sandifer T, Spann T, Borron M, Slough R, Pringle D, Helms B, Stoeppler-Biege K. Impact of a comprehensive drug recovery system in a community cancer center. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e18642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Terra Spann
- Bon Secours St. Francis Health System, Greenville, SC
| | | | | | | | - Bonnie Helms
- Bon Secours St. Francis Health System, Greenville, SC
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10
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Pant S, Spira AI, Cho BC, Goel S, Hoimes CJ, Alva AS, Balaraman R, Bauer TM, Lowry PA, Ramaekers RC, Siegel RD, Werner TL, Tannir NM, Faltaos D, Potvin D, Neuteboom ST, Christensen J, Chao RC, Kyriakopoulos C. Evaluation of the spectrum selective RTK inhibitor sitravatinib in clear cell renal cell carcinoma (ccRCC) refractory to anti-angiogenic therapy (AAT). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.4568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Shubham Pant
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Sanjay Goel
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Christopher J. Hoimes
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | | | | | | | | | | | | | | | - Nizar M. Tannir
- The University of Texas MD Anderson Cancer Center, Houston, TX
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11
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Crosswell HE, Kilburn J, Peters M, Sandifer T, Bearden JD, Siegel RD. Targeting tumors and financial toxicity in AYAs: Exceptional response to dual immunotherapy in an uninsured young adult with soft tissue sarcoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e23530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Ashley J, Bayne JH, Weems J, Spann T, Stinnett L, Strobel M, Hegedus P, Siegel RD. Palliative care in the ambulatory setting: Bon Secours St. Francis Hospital (BSSFH). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.31_suppl.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
109 Background: Palliative care is integral to holistic cancer therapy. Early integration of palliative principles results in improvements in quality of life and survival. Despite the evident value of specialized palliative services, the conventional delivery paradigm, particularly in community centers, has remained episodic, crisis driven, and principally provided in the acute care setting. BSSFH opened its cancer center in October 2014. We chose to embed palliative services in the ambulatory setting to introduce patients early in their cancer journey to an integrated program of symptom management. Methods: The BSSFH Cancer Center is a 65,000 sq ft facility located in Greenville, SC. The analytic caseload for 2016 was approximately 1250. One palliative care practitioner per day sees patients both independently and concurrently with medical, gynecological and radiation oncology colleagues. These individuals also participate in Lean projects optimizing care in a variety of disease states. Mandatory referrals at presentation were initially codified for patients with stage 4 lung , and subsequently for pancreatic and all patients receiving multimodality therapy for head and neck carcinomas. Additional patients are referred from our weekly Interdisciplinary Care Rounds or otherwise at the discretion of their attendings. Results: The program showed ongoing growth through 2016, shortly following its inception. Total outpatient encounters in 2015 were 559 while in 2016 were 928. Total new referrals were 158 in 2015 and 190 in 2016 implying that the increase in total visits had less to do with new patient referrals and were more a result of visit-to-visit management of complex circumstances. Conclusions: Palliative medicine is optimally provided with consistency and not episodically. This is best accomplished when such care occurs in both the acute and ambulatory settings through an ongoing therapeutic relationship. BSSFH has created a model in which such care is feasible in the community setting. We are now trying to assess what impact this intervention has had on quality of life, simplifying transitions of care, and on the economics of health care within our system.
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Affiliation(s)
| | | | - John Weems
- Bon Secours St. Francis Health System, Greenville, SC
| | - Terra Spann
- St. Francis Cancer Center, Bon Secours St. Francis Health System, Greenville, SC
| | | | | | - Patricia Hegedus
- St. Francis Cancer Center, Bon Secours St. Francis Health System, Greenville, SC
| | - Robert D. Siegel
- St. Francis Cancer Center, Bon Secours St. Francis Health System, Greenville, SC
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13
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Crosswell HE, Bomar KN, Vickery N, Stoeppler-Biege K, Spann TD, Siegel RD. Trials and Tribulations for Adolescents and Young Adults with Cancer: Measuring the Impact of a Community-Based Program. J Natl Compr Canc Netw 2017; 15:1171-1176. [PMID: 28874601 DOI: 10.6004/jnccn.2017.0153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bayne J, Weems J, Siegel RD, Bowen TN, Stinnett L, Ashley J. Embedding palliative care (pc) in a community-based cancer center: Benefits and barriers. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.26_suppl.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
153 Background: The importance of involving PC early in the disease process of oncology patients is well documented. Decreased symptom burden, increased quality of life, and extended survival are proven outcomes; however, the provision of PC has largely been limited to the acute care setting in most institutions. Bon Secours St. Francis Health System, a community based healthcare system in Greenville, South Carolina, opened a comprehensive cancer center in late 2014. Our established inpatient PC team began seeing outpatients at the cancer center shortly after its opening. Methods: PC at the cancer center is provided in an “embedded” model of care. PC appointments were initiated at 20 hours/week and have been expanded to 28 hours/week, currently provided by NPs 24 hrs, MD 4 hrs, all of whom are certified in hospice and palliative care. Patients are seen during medical oncology, radiation oncology, or infusion appointments. In August 2015, the PC team began to participate in an interdisciplinary team meeting, reviewing new oncology patients and their expected or known needs. Results: Total visits for 2015: 559/158 new patients seen. Informal interviews from patients, oncology, and PC staff revealed the following benefits: better communication regarding treatment plans; improved symptom management; flexibility and convenience in meeting patients anywhere in the cancer center and; providing resources for staff regarding pain and symptom management and communication techniques. Barriers identified were: scheduling conflicts for patients with multiple appointments; less than full-time coverage by PC prohibits some patients from being seen during their oncology appointments; PC and oncology being separate administrative entities has required creative solutions in billing and staffing. Conclusions: Despite some barriers, the benefits of embedding a PC clinic in a community-based oncology center are clear and worthwhile. This clinic improves coordination of care between inpatient and outpatient services, which results in positive patient experiences. It is hoped that the early integration of PC in the ambulatory setting will result in a decrease in avoidable emergency room visits and hospital admissions.
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Affiliation(s)
| | - John Weems
- Bon Secours St. Francis Health System, Greenville, SC
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Abstract
Thrombocytopenia is a commonly encountered labora tory abnormality in the intensive care unit setting. Al though moderate degrees of thrombocytopenia may be dismissed as clinically trivial, severe thrombocytopenia can have catastrophic consequences. This review di vides the potential pathogenesis of thrombocytopenia into three pathophysiological categories: (1) produc tive, (2) consumptive, and (3) distributional. The im portant etiologies and appropriate therapies for throm bocytopenia in each of these categories are discussed. We have attempted to emphasize the underlying patho genic mechanisms as well as highlight the diagnostic dilemmas likely to be faced by intensive care unit physi cians. Although this review stresses those thrombocyto penic disorders most likely to be encountered in the intensive care unit, chronic etiologies of thrombocy topenia are also discussed because preexistent throm bocytopenia will further complicate the care of any acutely ill intensive care unit patient.
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Affiliation(s)
- Edward G. Wittels
- Department of Medicine, The Miriam Hospital, and Brown University, Providence, RI
| | - Robert D. Siegel
- Department of Medicine, The Miriam Hospital, and Brown University, Providence, RI
| | - Eric M. Mazur
- Department of Medicine, The Miriam Hospital, and Brown University, Providence, RI
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Siegel RD. ASCO Quality Care Symposium 2016 Exemplars in Quality and Identifying High-Quality Practice: Delivering Quality in the Community Setting (Bon Secours St Francis Cancer Center). J Oncol Pract 2016; 12:898-901. [PMID: 27302081 DOI: 10.1200/jop.2016.012336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Bauer TM, Adkins D, Schwartz GK, Werner TL, Alva AS, Hong DS, Carvajal RD, Saleh MN, Bazhenova L, Goel S, Eaton KD, Siegel RD, Wang D, Lauer RC, Neuteboom ST, Faltaos D, Chen I, Christensen J, Chao RC, Heist RS. A first in human phase I study of receptor tyrosine kinase (RTK) inhibitor MGCD516 in patients with advanced solid tumors. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.2575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Todd Michael Bauer
- Sarah Cannon Research Institute, and Tennessee Oncology, PLLC., Nashville, TN
| | | | | | | | | | - David S. Hong
- Department of Investigational Cancer Therapeutics (Phase 1 Program), The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Sanjay Goel
- Montefiore Einstein Center for Cancer Care, Bronx, NY
| | | | | | - Ding Wang
- Henry Ford Health Systems, Detroit, MI
| | - Richard C. Lauer
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | | | - Isan Chen
- Mirati Therapeutics Inc., San Diego, CA
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18
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Dueck AC, Mendoza TR, Mitchell SA, Reeve BB, Castro KM, Rogak LJ, Atkinson TM, Bennett AV, Denicoff AM, O'Mara AM, Li Y, Clauser SB, Bryant DM, Bearden JD, Gillis TA, Harness JK, Siegel RD, Paul DB, Cleeland CS, Schrag D, Sloan JA, Abernethy AP, Bruner DW, Minasian LM, Basch E. Validity and Reliability of the US National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). JAMA Oncol 2016; 1:1051-9. [PMID: 26270597 DOI: 10.1001/jamaoncol.2015.2639] [Citation(s) in RCA: 511] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE To integrate the patient perspective into adverse event reporting, the National Cancer Institute developed a patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). OBJECTIVE To assess the construct validity, test-retest reliability, and responsiveness of PRO-CTCAE items. DESIGN, SETTING, AND PARTICIPANTS A total of 975 adults with cancer undergoing outpatient chemotherapy and/or radiation therapy enrolled in this questionnaire-based study between January 2011 and February 2012. Eligible participants could read English and had no clinically significant cognitive impairment. They completed PRO-CTCAE items on tablet computers in clinic waiting rooms at 9 US cancer centers and community oncology practices at 2 visits 1 to 6 weeks apart. A subset completed PRO-CTCAE items during an additional visit 1 business day after the first visit. MAIN OUTCOMES AND MEASURES Primary comparators were clinician-reported Eastern Cooperative Oncology Group Performance Status (ECOG PS) and the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30). RESULTS A total of 940 of 975 (96.4%) and 852 of 940 (90.6%) participants completed PRO-CTCAE items at visits 1 and 2, respectively. At least 1 symptom was reported by 938 of 940 (99.8%) participants. Participants' median age was 59 years; 57.3% were female, 32.4% had a high school education or less, and 17.1% had an ECOG PS of 2 to 4. All PRO-CTCAE items had at least 1 correlation in the expected direction with a QLQ-C30 scale (111 of 124, P<.05 for all). Stronger correlations were seen between PRO-CTCAE items and conceptually related QLQ-C30 domains. Scores for 94 of 124 PRO-CTCAE items were higher in the ECOG PS 2 to 4 vs 0 to 1 group (58 of 124, P<.05 for all). Overall, 119 of 124 items met at least 1 construct validity criterion. Test-retest reliability was 0.7 or greater for 36 of 49 prespecified items (median [range] intraclass correlation coefficient, 0.76 [0.53-.96]). Correlations between PRO-CTCAE item changes and corresponding QLQ-C30 scale changes were statistically significant for 27 prespecified items (median [range] r=0.43 [0.10-.56]; all P≤.006). CONCLUSIONS AND RELEVANCE Evidence demonstrates favorable validity, reliability, and responsiveness of PRO-CTCAE in a large, heterogeneous US sample of patients undergoing cancer treatment. Studies evaluating other measurement properties of PRO-CTCAE are under way to inform further development of PRO-CTCAE and its inclusion in cancer trials.
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Affiliation(s)
- Amylou C Dueck
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | - Tito R Mendoza
- Department of Symptom Research, University of Texas MD Anderson Cancer Center, Houston
| | - Sandra A Mitchell
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Bryce B Reeve
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Kathleen M Castro
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Lauren J Rogak
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas M Atkinson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Antonia V Bennett
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Andrea M Denicoff
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| | - Ann M O'Mara
- Division of Cancer Prevention, National Cancer Institute, Rockville, Maryland
| | - Yuelin Li
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steven B Clauser
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Donna M Bryant
- Department of Clinical Research, Cancer Program of Our Lady of the Lake and Mary Bird Perkins, Baton Rouge, Louisiana
| | - James D Bearden
- Gibbs Cancer Center and Research Institute, Spartanburg, South Carolina
| | - Theresa A Gillis
- Helen F. Graham Cancer Center and Research Institute, Christiana Care Health System, Newark, Delaware
| | - Jay K Harness
- Center for Cancer Prevention and Treatment, St. Joseph Hospital of Orange, Orange, California
| | - Robert D Siegel
- Helen and Harry Gray Cancer Center, Hartford Hospital, Hartford, Connecticut
| | - Diane B Paul
- patient advocate and cancer survivor, Brooklyn, New York
| | - Charles S Cleeland
- Department of Symptom Research, University of Texas MD Anderson Cancer Center, Houston
| | - Deborah Schrag
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeff A Sloan
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Amy P Abernethy
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Deborah W Bruner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Lori M Minasian
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill5Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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Siegel RD, Crosswell HE, Dillard T, Bayne J, Redenz T, Duggan K, Belew A. Interdisciplinary care rounds in the community: Changing the paradigm of supportive service involvement in cancer care. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.7_suppl.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
83 Background: Although cancer centers have focused on optimizing seamless Multidisciplinary Care (MDC) at tumor boards and/or clinics, there has been little published on effective ways to involve supportive services into the management of cancer patients. Historically, supportive services have been initiated when there is an active need rather than in anticipation of that need. As an alternative to pursuing such "crisis management" in our patients, Bon Secours St. Francis Cancer Center (BSSF) initiated Interdisciplinary Care (IDC) Rounds in an effort to anticipate patient needs, enhance quality of life (QoL), and potentially limit avoidable emergency room and hospital admissions. Methods: We initiated IDC Rounds with participants from the following disciplines: medical oncology, navigation, clinic nursing, palliative medicine, financial counseling, psychology, nutrition, clinical research, adolescent and young adult, and oncology rehabilitation/survivorship (ORS). A database was created to track new patients with malignancies within three weeks of presentation and the subsequent recommendations made by the IDC team. Those recommendations are then forwarded to the primary medical oncologist who has the ability to agree to those recommendations in full or in part before they are actuated. Results: BSSF is a non-academic, community-based cancer program and receives over 1,300 referrals annually from a referral population of 1.32 million in 10 counties. Short term metrics demonstrate a 57% and 100% increase in referrals to ORS and palliative care, respectively. Successes and challenges including sustainability, cost and measurable impact will be discussed. Conclusions: We have shown that it is feasible in the community setting to create a process that will allow early integration of supportive services into the full service care of cancer patients. Results demonstrate an increase in short-term metrics such as referrals to supportive services. Our ultimate goal is that formalized IDC results not only in earlier involvement by needed services but enhanced QoL for our patients with fewer emergency room and hospital admissions. Those data will be compiled as the program matures.
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Affiliation(s)
| | | | - Terra Dillard
- Bon Secours St. Francis Cancer Center, Greenville, SC
| | | | - Tina Redenz
- Bon Secours St. Francis Cancer Center, Greenville, SC
| | - Kyle Duggan
- Bon Secours St. Francis Cancer Center, Greenville, SC
| | - Angela Belew
- Bon Secours St. Francis Cancer Center, Greenville, SC
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Bennett AV, Dueck AC, Mitchell SA, Mendoza TR, Reeve BB, Atkinson TM, Castro KM, Denicoff A, Rogak LJ, Harness JK, Bearden JD, Bryant D, Siegel RD, Schrag D, Basch E. Mode equivalence and acceptability of tablet computer-, interactive voice response system-, and paper-based administration of the U.S. National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Health Qual Life Outcomes 2016. [PMID: 26892667 DOI: 10.1186/s12955-016-0426-6.pubmedpmid:26892667;pubmedcentralpmcid:pmcpmc4759776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND PRO-CTCAE is a library of items that measure cancer treatment-related symptomatic adverse events (NCI Contracts: HHSN261201000043C and HHSN 261201000063C). The objective of this study is to examine the equivalence and acceptability of the three data collection modes (Web-enabled touchscreen tablet computer, Interactive voice response system [IVRS], and paper) available within the US National Cancer Institute (NCI) Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) measurement system. METHODS Participants (n = 112; median age 56.5; 24 % high school or less) receiving treatment for cancer at seven US sites completed 28 PRO-CTCAE items (scoring range 0-4) by three modes (order randomized) at a single study visit. Subjects completed one page (approx. 15 items) of the EORTC QLQ-C30 between each mode as a distractor. Item scores by mode were compared using intraclass correlation coefficients (ICC); differences in scores within the 3-mode crossover design were evaluated with mixed-effects models. Difficulties with each mode experienced by participants were also assessed. RESULTS 103 (92 %) completed questionnaires by all three modes. The median ICC comparing tablet vs IVRS was 0.78 (range 0.55-0.90); tablet vs paper: 0.81 (0.62-0.96); IVRS vs paper: 0.78 (0.60-0.91); 89 % of ICCs were ≥0.70. Item-level mean differences by mode were small (medians [ranges] for tablet vs. IVRS = -0.04 [-0.16-0.22]; tablet vs paper = -0.02 [-0.11-0.14]; IVRS vs paper = 0.02 [-0.07-0.19]), and 57/81 (70 %) items had bootstrapped 95 % CI around the effect sizes within +/-0.20. The median time to complete the questionnaire by tablet was 3.4 min; IVRS: 5.8; paper: 4.0. The proportion of participants by mode who reported "no problems" responding to the questionnaire was 86 % tablet, 72 % IVRS, and 98 % paper. CONCLUSIONS Mode equivalence of items was moderate to high, and comparable to test-retest reliability (median ICC = 0.80). Each mode was acceptable to a majority of respondents. Although the study was powered to detect moderate or larger discrepancies between modes, the observed ICCs and very small mean differences between modes provide evidence to support study designs that are responsive to patient or investigator preference for mode of administration, and justify comparison of results and pooled analyses across studies that employ different PRO-CTCAE modes of administration. TRIAL REGISTRATION NCT Clinicaltrials.gov identifier: NCT02158637.
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Affiliation(s)
- Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Campus Box 7411, Chapel Hill, NC, 27599, USA.
| | - Amylou C Dueck
- Division of Health Sciences Research, College of Medicine, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Sandra A Mitchell
- Division of Cancer Control and Population Sciences, Outcomes Research Branch, National Cancer Institute, 9609 Medical Center Drive, East Tower, Suite 3-448, Rockville, MD, 20850, USA.
| | - Tito R Mendoza
- Department of Symptom Research, The University of Texas M. D. Anderson Cancer Center, 1400 Pressler Street, Unit 1450, Houston, TX, 77030, USA.
| | - Bryce B Reeve
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Campus Box 7411, Chapel Hill, NC, 27599, USA.
| | - Thomas M Atkinson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA.
| | - Kathleen M Castro
- Division of Cancer Control and Population Sciences, Outcomes Research Branch, National Cancer Institute, 9609 Medical Center Drive, East Tower, Suite 3-448, Rockville, MD, 20850, USA.
| | - Andrea Denicoff
- Cancer Therapy Evaluation Program, National Cancer Institute, 9609 Medical Center Drive, MSC 9737, Bethesda, MD, 20892, USA.
| | - Lauren J Rogak
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2nd Floor, New York, NY, 10017, USA.
| | - Jay K Harness
- The Center for Cancer Prevention and Treatment, St. Joseph Hospital of Orange, 1100 West Stewart Drive, Orange, CA, 92868, USA.
| | - James D Bearden
- Gibbs Cancer Center and Research Institute, Spartanburg Regional Healthcare System, 101 East Wood Street, Spartanburg, SC, 29303, USA.
| | - Donna Bryant
- The Cancer Program of Our Lady of the Lake and Mary Bird Perkins, 1950 Essen Lane, Baton Rouge, LA, 70809, USA.
| | - Robert D Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, 85 Retreat Avenue, Hartford, CT, 06106, USA.
| | - Deborah Schrag
- Dana Farber Cancer Institute, 450 Brookline Ave, D-1008, Boston, MA, 02215, USA.
| | - Ethan Basch
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2nd Floor, New York, NY, 10017, USA.
- Department of Medicine, University of North Carolina at Chapel Hill, Campus Box 7305, Chapel Hill, NC, 27599, USA.
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Bennett AV, Dueck AC, Mitchell SA, Mendoza TR, Reeve BB, Atkinson TM, Castro KM, Denicoff A, Rogak LJ, Harness JK, Bearden JD, Bryant D, Siegel RD, Schrag D, Basch E. Mode equivalence and acceptability of tablet computer-, interactive voice response system-, and paper-based administration of the U.S. National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Health Qual Life Outcomes 2016; 14:24. [PMID: 26892667 PMCID: PMC4759776 DOI: 10.1186/s12955-016-0426-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 02/10/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND PRO-CTCAE is a library of items that measure cancer treatment-related symptomatic adverse events (NCI Contracts: HHSN261201000043C and HHSN 261201000063C). The objective of this study is to examine the equivalence and acceptability of the three data collection modes (Web-enabled touchscreen tablet computer, Interactive voice response system [IVRS], and paper) available within the US National Cancer Institute (NCI) Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) measurement system. METHODS Participants (n = 112; median age 56.5; 24 % high school or less) receiving treatment for cancer at seven US sites completed 28 PRO-CTCAE items (scoring range 0-4) by three modes (order randomized) at a single study visit. Subjects completed one page (approx. 15 items) of the EORTC QLQ-C30 between each mode as a distractor. Item scores by mode were compared using intraclass correlation coefficients (ICC); differences in scores within the 3-mode crossover design were evaluated with mixed-effects models. Difficulties with each mode experienced by participants were also assessed. RESULTS 103 (92 %) completed questionnaires by all three modes. The median ICC comparing tablet vs IVRS was 0.78 (range 0.55-0.90); tablet vs paper: 0.81 (0.62-0.96); IVRS vs paper: 0.78 (0.60-0.91); 89 % of ICCs were ≥0.70. Item-level mean differences by mode were small (medians [ranges] for tablet vs. IVRS = -0.04 [-0.16-0.22]; tablet vs paper = -0.02 [-0.11-0.14]; IVRS vs paper = 0.02 [-0.07-0.19]), and 57/81 (70 %) items had bootstrapped 95 % CI around the effect sizes within +/-0.20. The median time to complete the questionnaire by tablet was 3.4 min; IVRS: 5.8; paper: 4.0. The proportion of participants by mode who reported "no problems" responding to the questionnaire was 86 % tablet, 72 % IVRS, and 98 % paper. CONCLUSIONS Mode equivalence of items was moderate to high, and comparable to test-retest reliability (median ICC = 0.80). Each mode was acceptable to a majority of respondents. Although the study was powered to detect moderate or larger discrepancies between modes, the observed ICCs and very small mean differences between modes provide evidence to support study designs that are responsive to patient or investigator preference for mode of administration, and justify comparison of results and pooled analyses across studies that employ different PRO-CTCAE modes of administration. TRIAL REGISTRATION NCT Clinicaltrials.gov identifier: NCT02158637.
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Affiliation(s)
- Antonia V Bennett
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Campus Box 7411, Chapel Hill, NC, 27599, USA.
| | - Amylou C Dueck
- Division of Health Sciences Research, College of Medicine, Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Sandra A Mitchell
- Division of Cancer Control and Population Sciences, Outcomes Research Branch, National Cancer Institute, 9609 Medical Center Drive, East Tower, Suite 3-448, Rockville, MD, 20850, USA.
| | - Tito R Mendoza
- Department of Symptom Research, The University of Texas M. D. Anderson Cancer Center, 1400 Pressler Street, Unit 1450, Houston, TX, 77030, USA.
| | - Bryce B Reeve
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Campus Box 7411, Chapel Hill, NC, 27599, USA.
| | - Thomas M Atkinson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th Floor, New York, NY, 10022, USA.
| | - Kathleen M Castro
- Division of Cancer Control and Population Sciences, Outcomes Research Branch, National Cancer Institute, 9609 Medical Center Drive, East Tower, Suite 3-448, Rockville, MD, 20850, USA.
| | - Andrea Denicoff
- Cancer Therapy Evaluation Program, National Cancer Institute, 9609 Medical Center Drive, MSC 9737, Bethesda, MD, 20892, USA.
| | - Lauren J Rogak
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2nd Floor, New York, NY, 10017, USA.
| | - Jay K Harness
- The Center for Cancer Prevention and Treatment, St. Joseph Hospital of Orange, 1100 West Stewart Drive, Orange, CA, 92868, USA.
| | - James D Bearden
- Gibbs Cancer Center and Research Institute, Spartanburg Regional Healthcare System, 101 East Wood Street, Spartanburg, SC, 29303, USA.
| | - Donna Bryant
- The Cancer Program of Our Lady of the Lake and Mary Bird Perkins, 1950 Essen Lane, Baton Rouge, LA, 70809, USA.
| | - Robert D Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, 85 Retreat Avenue, Hartford, CT, 06106, USA.
| | - Deborah Schrag
- Dana Farber Cancer Institute, 450 Brookline Ave, D-1008, Boston, MA, 02215, USA.
| | - Ethan Basch
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2nd Floor, New York, NY, 10017, USA. .,Department of Medicine, University of North Carolina at Chapel Hill, Campus Box 7305, Chapel Hill, NC, 27599, USA.
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Bomar K, Vickery N, Duggan M, Redenz T, Lukker T, Jensen K, Paciarelli E, Dillard T, Siegel RD, Crosswell HE. The Bon Secours St. Francis Cancer Survivorship Program: A model for community-based multidisciplinary survivorship care. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.3_suppl.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
45 Background: In 1974, Giulio D' Angio,MD, stated “Cure Is Not Enough” and the concept of Survivorship was ignited. Multidisciplinary survivorship clinics have since become a mainstay of many pediatric cancer programs; few such clinics exist in adult cancer programs, especially in community practice. We report on the development of a survivorship care plan and a community-based clinic designed to provide guideline-driven after care for cancer survivors. Methods: An overview of the vision and mission of the Bone Secours St. Francis Cancer Center Survivorship Program is provided. Descriptive analysis of the components and metrics of success are provided, in the context of accrediting organizations requirements for current and future goals for survivorship care. Results: BSSF, which is a non-academic, community-based cancer program, and receives over 1300 referrals annually from a referral population of 1.32 million in 10 counties. St. Francis , accredited by both the Commission on Cancer and National Accreditation Program for Breast Centers, has been providing cancer‐related services to the Upstate South Carolina region for a decade. The survivorship program at St. Francis is a STAR‐certified program and is a patient‐centered service provided in a comprehensive and coordinated multidisciplinary team approach, including integrated psychologic care. A custom survivorship care plan was developed and efforts, including successes and barriers, to implementation of plans for all cancer survivors in accordance with CoC and NAPBC goals are addressed. Conclusions: The BSSF Cancer Center Survivorship Program has developed a practical, yet comprehensive SCP, which is risk-adapted and guideline-driven in order to provide customized survivorship education and monitoring. The MDC provides comprehensive evaluations and recommendations in order to maximize health and well-being of patients navigating life after cancer diagnosis and treatment. Our efforts have demonstrated that survivorship clinics of this nature can be established and successful in a non-academic community setting.
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Affiliation(s)
| | | | | | - Tina Redenz
- Bon Secours St. Francis Cancer Center, Greenville, SC
| | | | | | | | - Terra Dillard
- Bon Secours St. Francis Cancer Center, Greenville, SC
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Siegel RD, Castro KM, Eisenstein J, Stallings H, Hegedus PD, Bryant DM, Kadlubek PJ, Clauser SB. Quality improvement in the national cancer institute community cancer centers program: the quality oncology practice initiative experience. J Oncol Pract 2014; 11:e247-54. [PMID: 25538082 DOI: 10.1200/jop.2014.000703] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) began in 2007; it is a network of community-based hospitals funded by the NCI. Quality of care is an NCCCP priority, with participation in the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) playing a fundamental role in quality assessment and quality improvement (QI) projects. Using QOPI methodology, performance on quality measures was analyzed two times per year over a 3-year period to enhance our implementation of quality standards at NCCCP hospitals. METHODS A data-sharing agreement allowed individual-practice QOPI data to be electronically sent to the NCI. Aggregated data with the other NCCCP QOPI participants were presented to the network via Webinars. The NCCCP Quality of Care Subcommittee selected areas in which to focus subsequent QI efforts, and high-performing practices shared voluntarily their QI best practices with the network. RESULTS QOPI results were compiled semiannually between fall 2010 and fall 2013. The network concentrated on measures with a quality score of ≤ 0.75 and planned voluntary group-wide QI interventions. We identified 13 measures in which the NCCCP fell at or below the designated quality score in fall 2010. After implementing a variety of QI initiatives, the network registered improvements in all parameters except one (use of treatment summaries). CONCLUSION Using the NCCCP as a paradigm, QOPI metrics provide a useful platform for group-wide measurement of quality performance. In addition, these measurements can be used to assess the effectiveness of QI initiatives.
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Affiliation(s)
- Robert D Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Kathleen M Castro
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Jana Eisenstein
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Holley Stallings
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Patricia D Hegedus
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Donna M Bryant
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Pam J Kadlubek
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
| | - Steven B Clauser
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT; National Cancer Institute, Bethesda, MD; Norton Cancer Institute, Louisville, KY; Gibbs Cancer Center-Spartanburg Healthcare System, Spartanburg, SC; Mary Bird Perkins-Our Lady of the Lake Cancer Center, Baton Rouge, LA; and American Society of Clinical Oncology, Alexandria, VA
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Noyes AM, Lonial K, Siegel RD. Tumor lysis syndrome in a nonsmall cell lung cancer. Conn Med 2014; 78:421-423. [PMID: 25195308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Tumor lysis syndrome (TLS) is an oncologic emergency caused by intense tumor cell destruction resulting in profound electrolyte abnormalities. It is generally recognized as a consequence of cytotoxic therapy in particularly chemotherapy-sensitive tumors such as hematologic cancers. Despite having been primarily recognized in hematologic malignancies, TLS has been reported in solid tumors as well. We present a case of a 72-year-old female who developed TLS after receiving etoposide and carboplatin for a poorly-differentiated carcinoma with areas of small-cell differentiation metastatic to her liver. She had previously undergone a thoracotomy and resection for a poorly differentiated squamous cell cancer of the lung.
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Castro KM, Spain P, Teixeira-Poit S, Prabhu Das I, Adjei BA, Siegel RD, Clauser S, Halpern MT. Sustaining quality cancer care in the NCI Community Cancer Centers Program (NCCCP). J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.6536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathleen M. Castro
- National Cancer Institute of the National Institutes of Health, Rockville, MD
| | | | | | - Irene Prabhu Das
- Division of Cancer Control and Population Science, National Cancer Institute of the National Institutes of Health, Rockville, MD
| | | | - Robert D. Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT
| | - Steven Clauser
- Patient Centered Outcomes Research Institute, Washington, DC
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Siegel RD. American Society of Clinical Oncology Quality Care Symposium 2012: re-engineering your practice to deliver quality and value. J Oncol Pract 2014; 9:160-1. [PMID: 23942499 DOI: 10.1200/jop.2013.000925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This session highlighted the steps in creating a reliable system-based health care delivery system—one that is team based, is continually evolving, and provides the highest quality and efficient care for our patients.
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Affiliation(s)
- Robert D Siegel
- Cancer Clinical Research Office, Hartford Hospital, Hartford, CT 06106, USA.
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Castro KM, Friedman EL, Mack N, Siegel RD, Eisenstein J, Prabhu Das I, Clauser S. Improving quality of care within the NCI Community Cancer Centers Program (NCCCP) network. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
178 Background: The National Cancer Institute (NCI) Community Cancer Centers Program (NCCCP) was initiated to expand cancer research and deliver quality cancer care in communities. A program goal was support of quality care initiatives. Twenty-one community sites in 16 states participated in the network providing care to approximately 40,000 cancer patients/year. We describe strategies for implementation of a structured quality program within our network. Methods: Four components served as the foundation for quality efforts: 1) increasing multidisciplinary care (MDC) programs; 2) ASCO QOPI participation; 3) Commission on Cancer Rapid Quality Reporting System (RQRS) participation; and 4) expansion of genetic counseling/services. A Quality of Care subcommittee formed to guide quality efforts within the network. Clinicians from the network served as subcommittee leadership and each site designated a quality of care lead. The subcommittee met by teleconference monthly, developed goals, shared best practices, developed processes to accomplish goals and documented improvements in priority areas. Results: Strategies employed to improve quality included: assessment tool development, participation in national quality reporting initiatives, review and monitoring of network data, and network performance improvement projects. Conclusions: The NCCCP identified areas of needed quality improvement. In addition, the network developed implementation strategies and created benchmarks that measure program quality. Participants benefitted from the opportunity to interface with one another and set network goals, while adopting strategies to best fit their own practices and community sites. [Table: see text]
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Affiliation(s)
- Kathleen M. Castro
- National Cancer Institute of the National Institutes of Health, Rockville, MD
| | | | - Nadesa Mack
- Lehigh Valley Hospital and Health Network, Allentown, PA
| | - Robert D. Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT
| | - Jana Eisenstein
- National Cancer Institute of the National Institutes of Health, Bethesda, MD
| | - Irene Prabhu Das
- Division of Cancer Control and Population Science, National Cancer Institute of the National Institutes of Health, Rockville, MD
| | - Steven Clauser
- National Cancer Institute of the National Institues of Health, Rockville, MD
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Siegel RD, Stallings H, Bryant DM, Kadlubek P, Borowski L, Castro KM, Clauser SB. Utilizing QOPI in the quality improvement efforts of the NCI Community Cancer Centers Program (NCCCP). J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.34_suppl.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
208 Background: The NCCCP is a network of community based institutions from New England to Hawaii funded by the NCI. Quality of care is a priority of the NCCCP with participation in ASCO’s Quality Oncology Practice Initiative (QOPI) playing a fundamental role. QOPI provides a process for quality assessment but we have also used it as a measure of quality improvement (QI) network-wide. Using QOPI methodology, we have analyzed our performance twice a year in an effort to enhance our implementation of quality indicators relevant to program aims. Methods: A data sharing agreement allows individual practice QOPI data to be electronically sent to the NCI where it is aggregated with the other NCCCP QOPI participants. Data are presented via webinar within the network using a variety of QI strategies. For example, blinded site performance distributions are benchmarked against NCCCP national averages on specific indicators. High performing practices voluntarily present their QI initiatives and best practices to the network. The NCCCP Quality of Care Subcommittee then selects QI projects and areas to focus quality improvement efforts. Results: In Spring 2012, 44 practices affiliated with 25 NCCCP sites participated in QOPI, a consistent pattern since Fall 2010. The table below describes the percent compliance with certain QOPI measures for the NCCCP aggregate over time. Selected measures were perceived as having had suboptimal compliance in Fall 2010. Conclusions: QOPI is an effective tool for assessing quality within a network and for measuring quality improvement efforts. Best practices from within the network can be leveraged and disseminated to enhance the quality of cancer care. This methodology facilitates quality initiatives despite the logistical challenges of working with practices across the country. [Table: see text]
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Affiliation(s)
- Robert D. Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT
| | | | - Donna M. Bryant
- The Cancer Program of Our Lady of the Lake and Mary Bird Perkins, Baton Rouge, LA
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Jacobsen PB, Wells KJ, Meade CD, Quinn GP, Lee JH, Fulp WJ, Gray JE, Baz RC, Springett GM, Levine RM, Markham MJ, Schreiber FJ, Cartwright TH, Burke JM, Siegel RD, Malafa MP, Sullivan D. Effects of a brief multimedia psychoeducational intervention on the attitudes and interest of patients with cancer regarding clinical trial participation: a multicenter randomized controlled trial. J Clin Oncol 2012; 30:2516-21. [PMID: 22614993 DOI: 10.1200/jco.2011.39.5186] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE The negative attitudes of patients with cancer regarding clinical trials are an important contributor to low participation rates. This study evaluated whether a brief psychoeducational intervention was effective in improving patients' attitudes as well as their knowledge, self-efficacy for decision making, receptivity to receiving more information, and general willingness to participate in clinical trials. PATIENTS AND METHODS A total of 472 adults with cancer who had not been asked previously to participate in a clinical trial were randomly assigned to receive printed educational information about clinical trials or a psychoeducational intervention that provided similar information and also addressed misperceptions and concerns about clinical trials. The primary (attitudes) and secondary outcomes (knowledge, self-efficacy, receptivity, and willingness) were assessed via patient self-report before random assignment and 7 to 28 days later. RESULTS Patients who received the psychoeducational intervention showed more positive attitudes toward clinical trials (P = .016) and greater willingness to participate (P = .011) at follow-up than patients who received printed educational information. Evidence of an indirect effect of intervention assignment on willingness to participate (estimated at 0.168; 95% CI, 0.088 to 0.248) suggested that the benefits of psychoeducation on willingness to participate were explained by the positive impact of psychoeducation on attitudes toward clinical trials. CONCLUSION A brief psychoeducational intervention can improve the attitudes of patients with cancer toward clinical trials and thereby increase their willingness to participate in clinical trials. Findings support conducting additional research to evaluate effects of this intervention on quality of decision making and rates of participation among patients asked to enroll onto therapeutic clinical trials.
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Affiliation(s)
- Paul B Jacobsen
- Moffitt Cancer Centerand University of South Florida, Tampa, FL, USA.
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Siegel RD, Bryant DM, Stallings H, Kadlubek P, Borowski L, Castro KM, Clauser SB. Fertility preservation: Utilizing QOPI metrics in the quality improvement efforts of the NCI Community Cancer Centers Program (NCCCP). J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.e16532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e16532 Background: The NCCCP is a consortium of 30 community based institutions funded by the NCI. Quality of care has been a priority of the NCCCP with participation in the Quality Oncology Practice Initiative (QOPI) serving as a fundamental element in those efforts. QOPI provides both a metric for baseline assessment and a means for measuring improvement across the network. Participation in QOPI became required with expansion of the NCCCP in 2010. Utilizing QOPI methodology, we describe our efforts to optimize adherence to fertility preservation standards of care. NCI Contract No. HHSN261200800001E Methods: A data sharing agreement allows individual practice performance to be electronically forwarded to the NCI twice a year where it is aggregated with the other NCCCP QOPI participants. This allows for ongoing evaluation of group statistics as well as comparisons between participating institutions. Those practices scoring highest on individual parameters are queried for best practices. Results: In Spring 2011, 38 practices/23 NCCCP sites participated resulting in 2653 chart reviews. 258 charts were applicable to fertile individuals as defined by QOPI. 46 charts were in compliance with suggested standards (17.8%) compared with the national rate of 26.1%. Four practices performed well above the national average and became the NCCCP's leaders for establishing best practices. The NCCCP then embarked upon a process of defining barriers to compliance with the fertility preservation recommendations, created an assessment tool by which each practice could identify the degree it integrated fertility preservation into their care models, and began the process of integrating nationally available educational materials and speakers. QOPI metrics will be used to measure the impact of these interventions. Conclusions: QOPI is a useful tool for measuring quality within a network, identifying barriers to compliance with ASCO fertility preservation recommendations and assessing quality improvement efforts. This methodology has allowed us to proceed with quality initiatives despite the logistical challenges of working with institutions and physicians from Maine to Hawaii.
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Affiliation(s)
- Robert D. Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT
| | - Donna M. Bryant
- The Cancer Program of Our Lady of the Lake and Mary Bird Perkins, Baton Rouge, LA
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Dueck AC, Mendoza TR, Mitchell SA, Reeve BB, Castro KM, Denicoff A, O'Mara AM, Rogak LJ, Clauser SB, Bryant DM, Gillis TA, Bearden JD, Siegel RD, Harness JK, Paul DB, Cleeland CS, Sloan JA, Schrag D, Minasian LM, Basch EM. Validity and reliability of the patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE). J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.9047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9047 Background: Symptomatic adverse events (AE) in cancer trials are reported by clinicians using the National Cancer Institute's (NCI) Common Terminology Criteria for Adverse Events (CTCAE). To integrate the patient perspective into AE reporting, NCI contracted (HHSN261201000043C) to create a patient-reported outcomes companion tool (PRO-CTCAE). We report the validity and reliability of PRO-CTCAE’s 124 items reflecting 78 symptomatic AEs. Methods: English-speaking subjects (n=869; 44% male; median [mdn] age 59; 32% racial/ethnic minority; 34% high school or less; 17% ECOG Performance Status [PS] 2-4) receiving treatment for a range of cancers at 4 NCI-designated cancer centers and 5 sites in NCI's Community Cancer Centers Program completed a web-based survey in clinic including PRO-CTCAE and EORTC QLQ-C30. Pearson correlations were computed between PRO-CTCAE items and QLQ-C30 scales. Differences in PRO-CTCAE item scores between clinician-reported ECOG PS (0-1 vs 2-4) groups were computed. Test-retest reliability of 48 prespecified items was evaluated in a subset (n=79). Results: Correlations in the expected direction were observed for 116/124 PRO-CTCAE items with the QLQ-C30 global health scale (mdn r=-.21; range .08 to -.57). Stronger correlations were seen for PRO-CTCAE items with conceptually related QLQ-C30 domains: fatigue with physical, role and social functioning (-.54 to -.66); anxiety and depression with emotional functioning (-.54 to -.70); and concentration and memory problems with cognitive functioning (-.62 to -.72) [all p <0.001]. Fatigue, nausea, vomiting, pain, dyspnea, insomnia, appetite loss, constipation and diarrhea items strongly correlated with corresponding QLQ-C30 symptom scales (.69 to .79, all p <0.001). Scores for 98/124 PRO-CTCAE items were higher in the ECOG PS 2-4 vs 0-1 group (mdn effect size .3). Test-retest reliability was observed across all tested items (mdn intraclass correlation coeff .77; range .53 to .96). Conclusions: Results demonstrate favorable validity and reliability of PRO-CTCAE in a large, heterogeneous sample of patients undergoing cancer treatment. Further testing in multicenter treatment trials is underway.
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Affiliation(s)
| | - Tito R. Mendoza
- University of Texas M. D. Anderson Cancer Center, Houston, TX
| | | | - Bryce B. Reeve
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | - Donna M. Bryant
- The Cancer Program of Our Lady of the Lake and Mary Bird Perkins, Baton Rouge, LA
| | - Theresa A. Gillis
- Helen F. Graham Cancer Center at Christiana Care Health System, Newark, DE
| | | | - Robert D. Siegel
- Hartford Hospital-Helen and Harry Gray Cancer Center, Hartford, CT
| | - Jay K. Harness
- The Center for Cancer Prevention and Treatment, St. Joseph Hospital of Orange, Orange, CA
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Talcott JA, Yeap BY, Clark JA, Siegel RD, Loggers ET, Lu C, Godley PA. Safety of early discharge for low-risk patients with febrile neutropenia: a multicenter randomized controlled trial. J Clin Oncol 2011; 29:3977-83. [PMID: 21931024 DOI: 10.1200/jco.2011.35.0884] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Febrile neutropenia commonly complicates cancer chemotherapy. Outpatient treatment may reduce costs and improve patient comfort but risk progression of undetected medical problems. PATIENTS AND METHODS By using our validated algorithm, we identified medically stable inpatients admitted for febrile neutropenia (neutrophils < 500/μL) after chemotherapy and randomly assigned them to continued inpatient antibiotic therapy or early discharge to receive identical antibiotic treatment at home. Our primary outcome was the occurrence of any serious medical complication, defined as evidence of medical instability requiring urgent medical attention. RESULTS We enrolled 117 patients with 121 febrile neutropenia episodes before study termination for poor accrual. We excluded five episodes as ineligible and three because of inadequate documentation of the study outcome. Treatment groups were clinically similar, but sociodemographic imbalances occurred because of block randomization. The median presenting absolute neutrophil count was 100/μL. Hematopoietic growth factors were used in 38% of episodes. The median neutropenia duration was 4 days (range, 1 to 15 days). Five outpatients were readmitted to the hospital. Major medical complications occurred in five episodes (8%) in the hospital arm and four (9%) in the home arm (95% CI for the difference, -10% to 13%; P = .56). No study patient died. Patient-reported quality of life was similar on both arms. CONCLUSION We found no evidence of adverse medical consequences from home care, despite a protocol designed to detect evidence of clinical deterioration. These results should reassure clinicians who elect to treat rigorously characterized low-risk patients with febrile neutropenia in suitable outpatient settings with appropriate surveillance for unexpected clinical deterioration.
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Affiliation(s)
- James A Talcott
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Rustagi T, Siegel RD. Zollinger-ellison syndrome with subsequent association of insulinoma. JOP 2010; 11:486-488. [PMID: 20818125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Siegel RD, Clauser SB, Lynn JM. National Collaborative to Improve Oncology Practice: The National Cancer Institute Community Cancer Centers Program Quality Oncology Practice Initiative Experience. J Oncol Pract 2009; 5:276-281. [PMID: 19949445 DOI: 10.1200/jop.091050] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2009] [Indexed: 11/20/2022] Open
Abstract
Collaboration between QOPI and the NCCCP sites represents an evolution in the QOPI process, in which QOPI provides a metric for measuring quality and serves as a springboard for comprehensive quality improvement across independent but mutually committed practices.
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Affiliation(s)
- Robert D Siegel
- Helen and Harry Gray Cancer Center, Hartford Hospital, Hartford, CT; Division of Cancer Control and Population Sciences; and Coordinating Center for Clinical Trials, National Cancer Institute, Bethesda, MD
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Wang XW, Staff I, Siegel RD. Survival and patterns of relapse following treatment of small-cell lung cancer at a community cancer center. Conn Med 2001; 65:259-63. [PMID: 11402468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Although data from previously published trials have suggested an incremental improvement in response rate and survival in patients with small-cell lung cancer, few of these trials originate from private practice/community cancer center settings. The outcomes of patients with small-cell lung cancer treated in such a practice setting are reviewed and compared to prior studies with particular attention to the potential role of prophylactic cranial irradiation (PCI). METHODS One hundred eighty patients treated between 1988 and 1998 comprise the basis of this analysis. In each individual, the specifics of therapy were recorded as well as the best response, sites of relapse, and survival. RESULTS The disease was limited in extent (LD) in 99 patients (55%) and extensive (ED) in 81 (45%). The overall/complete response rates for LD patients and ED patients respectively were 90.9%/72.7% and 61.7%/18.5%. Median survivals for LD and ED patients were 20.2 and 9.59 months respectively. The one-year, two-year, and five-year actual survival rates for the entire group were 59.1%, 22.2%, and 8.7%. Central nervous system relapses occurred in 42.9% of this largely nonprophylactic cranial irradiation treated patient population. The central nervous system was the only site of relapse in 13.6%. CONCLUSIONS The outcomes of patients treated in this private practice/community cancer center setting are similar to those previously published from single university and multi-institutional studies. Although these data support the use of cranial irradiation in patients who achieve a complete response, the impact of such an intervention will remain relatively insignificant until there is an improvement in systemic therapy.
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Affiliation(s)
- X W Wang
- Division of Medical Oncology-Helen and Harry Gray Cancer Center, Hartford Hospital, Hartford, USA
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Abstract
Solitary toxic adenoma and toxic multinodular goiter are very common forms of thyrotoxicosis around the world. Advances in molecular biology and genetics have led to new insights into the pathogenesis of these disorders. Current theories on autonomy in the thyroid are discussed in this article. The therapeutic roles of surgery, radioiodine ablation, and percutaneous ethanol administration also are reviewed.
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Affiliation(s)
- R D Siegel
- Division of Endocrinology, Diabetes, Metabolism and Molecular Medicine, New England Medical Center, Boston, Massachusetts, USA
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Abstract
Diabetes mellitus has been shown to be associated with lipid abnormalities. Prior studies have indicated that women with diabetes have a risk of coronary heart disease similar to that of men. We compared lipid parameters in diabetic and nondiabetic participants in cycle 3 of the Framingham Offspring Study. Values for plasma total cholesterol (TC), triglyceride, lipoprotein, cholesterol, apolipoprotein (apo) A1, B, apo and lipoprotein(a) [Lp(a)] and low-density lipoprotein (LDL) particle size were analyzed in 174 diabetic and 3,757 nondiabetic subjects. Data from a total of 2,025 men and 2,042 women participating in the third examination (1983 to 1987) of the Framingham Offspring Study were subjected to statistical analysis. Male and female diabetics showed lower high-density lipoprotein (HDL) cholesterol, higher triglycerides, higher very-low-density lipoprotein (VLDL) cholesterol, lower apo A1, and higher LDL particle scores, indicating smaller size, than nondiabetics. Female diabetics also showed significantly higher TC and apo B values than nondiabetics. The results remained statistically significant after controlling for obesity and menopausal status. The presence of small dense LDL particles (pattern B) was highly associated with diabetes and hypertriglyceridemia in both sexes, and the relative odds for pattern B remained significant in women but not in men after adjustment for age and hypertriglyceridemia. No differences in apo E isoform distribution were found for diabetics and nondiabetics. Diabetes was not associated with elevated LDL cholesterol levels. In conclusion, diabetics have lower HDL cholesterol and higher triglyceride levels and are more likely to have small dense LDL particles. Diabetes is not a secondary cause of elevated LDL cholesterol. Lipid screening of diabetics should include full quantification of lipids for proper assessment of potential atherosclerotic risk.
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Affiliation(s)
- R D Siegel
- Division of Endocrinology, Diabetes, Metabolism, and Molecular Medicine, New England Medical Center, Boston, MA 02111, USA
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Abstract
The case described confirms the status of chronic fatigue among the most common--and most frustrating--of all the symptoms physicians are called on to evaluate. New theories regarding the causes of the complaint implicate not only neuroendocrine interactions but the immune system and its cytokines as well.
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Affiliation(s)
- R D Siegel
- New England Medical Center, Tufts University School of Medicine, Boston
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Talcott JA, Siegel RD, Finberg R, Goldman L. Risk assessment in cancer patients with fever and neutropenia: a prospective, two-center validation of a prediction rule. J Clin Oncol 1992; 10:316-22. [PMID: 1732432 DOI: 10.1200/jco.1992.10.2.316] [Citation(s) in RCA: 391] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE The study was undertaken to validate a clinical model for predicting the medical risk of cancer patients with fever and neutropenia. PATIENTS AND METHODS A consecutive sample of 444 cancer patients with fever and neutropenia (granulocyte count less than 500/microL) at two hospitals, a specialized cancer referral center and a university-affiliated general medical hospital, was studied to identify clinical characteristics in the first 24 hours that predict subsequent serious medical complications during the hospital stay. To control for bias, major risk factors and complications were subject to blinded review. RESULTS Serious medical complications occurred in 34% of patients with risk factors identified in a prior study, including prior inpatient status (group I), outpatients with a serious independent comorbidity (group II), or uncontrolled cancer (group III), compared with 5% of the remaining patients (group IV) (P less than .000001). Two of the complications in group IV patients were transient asymptomatic hypotension, and the remaining three complications occurred after at least 1 week of progressive medical deterioration. These risk groups were independently significant in stepwise logistic regression analysis. Multiple complications (17%) and death (10%) were common among patients in groups I through III but did not occur in group IV patients. CONCLUSIONS This risk assessment model accurately stratified the medical risk of these patients using only clinical information available on the first day of their course. Low-risk patients are an appropriate population in which to study less intensive treatment strategies.
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Affiliation(s)
- J A Talcott
- Dana-Farber Cancer Institute, Boston, MA 02115
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Sikov WM, Siegel RD. Recent developments in medical oncology. R I Med J (1976) 1990; 73:451-5. [PMID: 2263841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- W M Sikov
- Department of Medicine, Miriam Hospital, Providence, Rhode Island
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Abstract
Bleomycin administered intrapleurally has been demonstrated to be an effective sclerosing agent. The lack of morbidity associated with its use has made it an attractive alternative to other available agents. Pharmacologic data indicate that (1) intracavitary bleomycin is systemically absorbed, and (2) the plasma half-life of bleomycin increases exponentially with renal failure. We report the findings in a patient with renal failure who experienced alopecia and significant mucositis following sclerotherapy. We suspect this systemic toxicity resulted from intrapleural bleomycin and suggest that this treatment be used with caution in patients with renal dysfunction.
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Siegel RD, Ryan LM, Antman KH. Osteosarcoma in adults. One institution's experience. Clin Orthop Relat Res 1989:261-9. [PMID: 2917442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Twenty-six patients were referred to the adult sarcoma clinic of the authors' institution between 1979 and 1986. The diagnosis was not confirmed in four patients. The median age of the 22 confirmed patients was 37. Twelve patients had central skeletal primaries; of these 12, seven had metastatic or unresectable disease. Six patients were treated with complete resection of tumor followed by adjuvant chemotherapy; of these six, four remained continuously disease-free at 25+, 29+, 72+, and 75+ months. Eight patients received no adjuvant chemotherapy following complete resection. Four have remained disease-free for more than two years (31, 33, 44, 44+ months); however, only one remains continuously disease-free. Adults tolerated chemotherapy well and should be considered appropriate candidates for adjuvant trials. Many, however, will have advanced-stage, poor-prognosis lesions and require alternative approaches for treatment.
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Affiliation(s)
- R D Siegel
- Division of Medicine, Dana Farber Cancer Institute, Harvard Medical School
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Siegel RD, Ryan LM, Antman KH. Adults with Ewing's sarcoma. An analysis of 16 patients at the Dana-Farber Cancer Institute. Am J Clin Oncol 1988; 11:614-7. [PMID: 3189226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Between 1975 and 1985, 16 patients with Ewing's sarcoma were treated in the Adult Sarcoma Clinic at the Dana-Farber Cancer Institute. Of 10 patients with extraskeletal or pelvic primaries, 2 (1 pelvic, 1 extraskeletal) are surviving disease-free at 77 and 103 months from diagnosis. Of the six remaining patients, 5 are alive from 38 to 125 months from diagnosis. No relapses were documented after 18 months of disease-free survival. Adults with localized skeletal Ewing's sarcoma outside the pelvis respond well to multimodality therapy. However, pelvic and extraskeletal disease occur in a disproportionately large segment of this older population and are associated with a poor prognosis.
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Affiliation(s)
- R D Siegel
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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Bernal SD, Cualing HM, Elias AD, Siegel RD. Chapter 18 Stability and shedding of small cell carcinoma membrane antigens: Applications to detection of antigens in marrow and serum. Lung Cancer 1988. [DOI: 10.1016/s0169-5002(88)80020-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Histologic conversion within the non-Hodgkin's lymphomas is a well-described phenomenon. Conversion from an indolent to that of a more aggressive histologic pattern is the most frequently noted form of this variability. We describe two patients in whom relapse with an indolent nodular lymphoma was noted after combination chemotherapy for diffuse disease. Implications for diagnostic evaluation and therapy as well as the pathogenesis of this unique form of conversion are discussed.
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Mills AJ, Walker JH, Siegel RD, Samela D. Alcohol fuels from biomass. Environ Sci Technol 1983; 17:394A. [PMID: 22656921 DOI: 10.1021/es00115a704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Bamrah VS, Keelan MH, Soin JS, Llaurado JG, Siegel RD, Tresch DD, Tristani FE, Brooks HL. Thallium-201 scintigraphy for detection of multivessel disease in patients with prior inferior myocardial infarction. Chest 1982; 82:581-9. [PMID: 7128225 DOI: 10.1378/chest.82.5.581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Siegel RD, Morgenstern P. Control of particulate emissions from stationary fuel burning sources in the core area of the Metropolitan Boston air quality control region. Am Ind Hyg Assoc J 1976; 37:109-16. [PMID: 1251798 DOI: 10.1080/0002889768507420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Strategies to control emissions were investigated to develop a plan to meet secondary ambient particulate standards in Metropolitan Boston. Each strategy was evaluated for emission reduction potential, cost, and feasibility. The strategy selected by the State, a periodic inspection and maintenance plan for combustion sources, meets the goal of clean air at minimum cost.
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Siegel RD. Measurement of aircraft engine pollutant emissions. A review of instrumentation, test, and sampling procedures. J Air Pollut Control Assoc 1972; 22:845-53. [PMID: 5085288 DOI: 10.1080/00022470.1972.10469720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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