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J.M. Luna
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ED 04 - How to Set up a Multidisciplinary Lung Cancer Program Within a Community Care Environment and Provide Everyone with the Best Care for Lung Cancer (ID 4)
- Event: WCLC 2015
- Type: Education Session
- Track: Community Practice
- Presentations: 6
- Moderators:J.M. Luna, S.E. Witta
- Coordinates: 9/07/2015, 14:15 - 15:45, Mile High Ballroom 2a-3b
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ED04.01 - How Can Multi-Disciplinary Care Be Executed at the Private Practice Level? (ID 1782)
14:20 - 14:33 | Author(s): E. Edell
- Abstract
- Presentation
Abstract not provided
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ED04.02 - How Can We Strengthen MD Care in Large Hospital Systems? (ID 1783)
14:33 - 14:46 | Author(s): K. Mileham
- Abstract
- Presentation
Abstract:
Lung cancer remains the leading cause of cancer-related mortality in men and women. Since about 85% of all lung cancer care in the United States is provided in the community setting (1), it is imperative to optimize the delivery of accessible, high-quality lung cancer care in this environment. Implementation of a multidisciplinary clinic is not enough to strengthen physician care across large hospital systems. Many systems have an established weekly tumor board to review patient cases. These multidisciplinary conferences are a venue for involved specialties including thoracic surgery, medical oncology, pulmonary medicine, radiology, radiation oncology, and pathology to provide an opinion regarding the management of each presented case. This forum for open dialogue results in reinforced recommendations and streamlines patient care (2). It can be challenging for physicians in a community setting who are managing multiple tumor types to remain abreast of evolving information regarding each subgroup. Expanding multidisciplinary care beyond the case conference provides a more robust collaboration for physicians managing these patients. For physicians, journal club, continuing medical education programs, and standardized guidelines provide direction regarding the latest advances in diagnosis and management. Specifically in lung cancer, launching a screening program builds partnerships with radiologists pursuing early detection and expands relationships with other practitioners monitoring abnormal chest imaging. For patients, access to smoking cessation directives, chemotherapy teaching, palliative medicine, and survivorship programs enhances the care delivered in community lung cancer programs. A nurse navigator is an invaluable resource providing the patient and family support and education to improve the cancer experience. The navigator also serves as a liaison to ensure interdisciplinary coordination of cancer management. Clinical trials, genetic counselors, interpreters and geriatric oncologists should supplement well-integrated lung cancer networks. Even when all of these components are implemented into a community lung cancer program with the goal to provide the best care, if the core physician care is not strengthened as a part of this process, in a large hospital system, the program will fall short. Thus it is just not what should be executed but how. In large hospital systems, clinicians can become engaged through regional councils, designed to establish the aims of a cohesive lung cancer program and to create a model that will service these recommendations (3). Allowing system-wide participation in customizing the organizational structure of a lung cancer program will result in team development. If team is defined as “a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable” (4), then it seems that strengthened care is inevitable. In a large health system, physician teams need to have shared goals and values, need to understand and recognize the competencies of other team members, and need to learn from other disciplines and respect their different views and perspectives. Individual team members may need to reassess exclusive claims to specialist knowledge and authority in order to form effective multidisciplinary teams which can provide the best care. By establishing a one-tiered system, physicians of various expertise find a comfortable niche that is not rewarded by self-promotion. Some physicians may maintain a more traditional generalized oncology clinic. Other physicians may adopt a more academic practice with subspecialty care, clinical trial participation, and literature publications. Collegiate collaborations between these two models strengthen physician care because the gap between private practice and academics is bridged within the same system. Because tumor boards provide multidisciplinary meetings but not necessarily multidisciplinary care, tumor boards may validate physician care but not necessarily strengthen it. A physical multidisciplinary clinic is not required to achieve this success. Instead, a solid team of engaged members focused on a specific disease will enrich the program. Routine meetings of a disease-specific section open to all interested provide a forum to review comprehensive needs for lung cancer patients. When a consistent message is issued from the group, physician care is strengthened. Telephone, video, and internet access to all disease-specific section meetings encourage participation. Communication facilitated by technology is the backbone to the success of this linked enterprise. The format of routine section meetings provides the venue to shift the “what” into the “how.” Announcements for lung cancer events are widely distributed. Consensus-driven standard algorithms of care are reviewed and updated. Finally, research options are reassessed. Integration of clinical trials in the community setting is necessary to strengthen care even in larger systems that may otherwise feel that care is already comprehensive. The best academic programs are often built on a reputation of offering research and clinical trial opportunities. Because the majority of patients with lung cancer are never seen in major academic centers, it is imperative that community programs become involved in clinical trials. Common protocol review (again maximizing participation with technology access) broadens interest. A centralized trials unit blends the team with appropriate system-wide delegation of resources. Utilization of a common internal review board allows for trials to open efficiently as well as simultaneously at multiple sites within the larger system. Local access obviates the need for travel, enhances program visibility, and provides ongoing relationships with the larger worldwide research community. Ultimately, a larger hospital system will benefit from restructuring the community. Physician care can be effectively strengthened not under the traditional hub-and-spoke model but instead as a cancer institute “without walls” (5). Regional councils, subspecialty sections, and multi-site clinical trial options under common review are all successful when system-wide participation is encouraged and when access is easily provided via advanced technology. Consider the large hospital organization as a system not a center. Aim to decentralize cancer care facilities by providing as many of the programs of a tertiary referral center throughout the region, limiting patient travel and lost time while still maintaining balanced quality (6). In order strengthen physician care in large hospital systems, growth measured as patient encounters is not as productive as reorganizing the care team. You can have “many” but still be “One.” 1. American College of Surgeons: Commission on cancer national cancer data base. Benchmark Reports v1.1 2. Fischel RJ, Dillman RO: Developing an effective lung cancer program in a community hospital setting. Clin Lung Cancer 10: 239-243, 2009 3. Dahele M, Ung Y, Meharchand J, et al: Integrating regional and community lung cancer services to improve patient care. Curr Oncol 14: 234-237, 2007 4. Carrier JM, Kendall I: Professionalism and interprofessionalism in health and community care; some theoretical issues. Interprofessional Issues in Community and Primary Health Care, 1995 5. Goldberg P: The Raghavan experiment. The Cancer Letter 39: 1-9, 2013 6. Raghavan D: Costs of cancer care: rhetoric, value, and steps forward. Semin in Oncol 40: 659-661, 2013
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ED04.03 - Treating Diverse Communities (ID 1784)
14:46 - 14:59 | Author(s): L. Carr
- Abstract
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Minority populations often suffer disproportionately from lung cancer due to 1) lower levels of education 2) jobs with higher occupational hazards 3) housing in areas with higher environmental hazards and 4) economic disadvantage. Lower socioeconomic status leads to higher rates of uninsured or underinsured populations living in neighborhoods with less access to quality health care. The recently published “Neighborhood Deprivation Study of Lung Cancer”, demonstrated living in a social-economic depressed environment, defined as high rates of low education status (< 10 years formal education), low income (less than 50% of individual median income), high unemployment and high rates of social welfare assistance, leads to higher incidence and mortality from lung cancer[1]. The lung cancer mortality was 13 per 1000 in high deprivation neighborhoods vs 8 per 1000 (OR 1.6) in low deprivation neighborhoods. Minority communities also have more barriers to effective cancer care. Barriers include differences in culturally related health beliefs, (values and preferences that are not understood by health care providers and lead to decreased compliance with medical recommendations), language discordance, provider stereotypes that lead to health care disparities, limited clinic hours of service that do not account for community work patterns, etc. Health care disparities in lung cancer have been studied in treatment decisions for early-stage disease. Bach et al. studied the differences in survival of Medicare beneficiaries with stage I or II NSCLC based on race[2]. The five year survival of black patients was significantly less than white patients, 26 % vs. 34.1% (p < 0.001). The difference in survival could be accounted for by the lower number of black patients treated with surgery, 64.0 % vs. 76.7 % for white patients. Although the difference in treatment had an impact on survival, the authors could not determine if this was due to patient held health beliefs regarding surgery and/or black patients being offered surgical resection less often. A similar outcome was seen by Koshy et al. when examining the National Cancer Database for differences in radiation treatment modalities offered for early stage disease[3]. Socioeconomic factors, including insurance type and race/ ethnicity, were significant variables in determining if a patient received no radiation therapy, conventional radiation therapy or stereotactic body radiation therapy. Each of these barriers is important to study and overcome as efforts to improve the treatment of diverse patient populations will increase the lung cancer cure rate. Applying cultural competence to cancer care delivery will improve adherence to screening and prevention measures, improve compliance to medical treatment and necessary follow-up, and reduce health care disparities. Effectively treating diverse populations of lung cancer patients requires change on multiple levels within healthcare delivery. On an organizational level, the leadership and workforce must allow for greater minority representation, to remain connected to the communities they serve. For minority patients, racial concordance between patient and physician is associated with greater patient satisfaction and higher self-reported quality of care. Specific quality measures for diverse patient populations must be developed. For example, patient-reported health care quality surveys can be adapted to better evaluate culturally diverse populations. Ultimately, health care organizations benefit from establishing ongoing links for consultation with representatives from diverse communities. On a structural level, work-processes can be adapted to aid diverse patient populations. Often the intake process is difficult or cumbersome for minority patients to navigate. Lack of interpreter services or inappropriate health care education materials can limit the effectiveness of the clinic visit. Ngo-Metzger et al. studied the effects of language discordance between patient and provider within a Chinese and Vietnamese population in the US. Patients with language discordant providers reported receiving less health education compared to those with language concordant providers. This effect was mitigated with the use of a clinic interpreter[4]. This language barrier includes key signage and patient information documents. The Joint Commission has published guidance in establishing effective communication, both written and verbal, for diverse patient populations[5]. Finally the clinical (patient- provider encounter) level must be addressed. When cultural differences between provider and patient are not fully understood it becomes a barrier to effective care. Diverse patient populations have specific health beliefs; such as use of home remedies, attitude toward medical care and medical practices, level of trust in doctors and the health system. Each of these differences, if not understood, can interfere with effective care. The Witness Program is an example of a successful, culturally competent approach to health care delivery[6]. Although African-American (AA) women have high rates of breast cancer, screening with mammography was low in this population. To better understand the cultural barriers associated with breast cancer screening among this group, investigators performed multiple focus groups. By directly interviewing AA women in the community barriers to breast cancer screening were identified. The Witness Program® turned cultural barriers into culturally based interventions. Key to this project are Witness Role Models – African American breast and cervical cancer survivors who talk about their experiences with other AA women in a community setting. This approach has led to improved rates of breast cancer screening among the women who participated in this educational program. Training of medical providers in cultural competency is necessary to effectively treat diverse patient communities. Efforts to improve the care of diverse patient populations will increase the lung cancer cure rate. This begins by having a clear understanding of the community that is served, including health care values and beliefs, predominate language used, and any barriers to health care that are present. Training for staff in cultural competency and the ability to evaluate the perceived quality of health care of diverse populations is needed to provide the best care. References 1. Li et al. Journal of Thoracic Oncology, 2015; 10:256-263. 2. Bach PB et al. N Engl J Med. 1999; 341:1198-1205. 3. Koshy et al. Journal of Thoracic Oncology. 2015; 10:264-271. 4. Ngo-Metzger et al. J Gen Intern Med. 22(suppl 2):324-30. 5. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010. 6. Bailey et al. J Natl Med Assoc. 2000; 92:136-142.
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ED04.04 - Differences in Rural/Urban Care (ID 1785)
14:59 - 15:12 | Author(s): C.H. Reynolds
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The rapid changes in lung cancer treatment,with the development of new treatment modalities such as immunotherapy, coupled with the emergence of low-dose CT screening for lung cancer have made mutli-modality thoracic oncology programs even more vital than previously. Howerver, almost all of these programs are in urban areas, despite a great need in rural communities. Epidemiologic studies show that rural areas have higher lung cancer and all cancer mortality than urban areas (Singh et al J Ca Epidemiol 2011) with even greater disparity in minority and socio-economically disadvantaged rural populations. An analysis of the SEER database found that rural residence had no impact on stage-specific lung cancer survival with the exception of Stage I (Atkins et al, Am J Crit Care Med 191:2015;A3595). Tobacco use is more prevalent in rural communities and may account for much of the higher lung cancer mortality seen in these communities (ALS monograph, Cutting Tobacco's Rural Roots: Tobacco Use in Rural Communities, 2014). It does appear that rural residents are more likely to be diagnosed with an advanced stage of lung cancer than their urban peers (Wen et al, Ann Pub Health and Res 2015 2:1011 ; Johnson et al, Lung Cancer 2014 83:401-7). Survival was lower in rural areas with greater poverty and less educated residents. In addition, rural residents were less likely to receive radiotherapy and chemotherapy, and those in less educated areas were less likely to undergo surgery or chemotherapy (Johnson et al). Another study found poorer outcomes in Stage I lung cancer in rural areas, perhaps due to less access to surgical care (Atkins, op cit). Kim et al compared barriers to clinical trial participation in rural and urban areas of South Carolina (Kim et al, J Comm Health 2013). They found no significant difference between rural and urban residents in willingness to participate in clinical trials but found that rural residents perceived less access to less access to, and awareness and knowledge of, clinical trials. A study funded by the Rand Corporation found that physicians who participated in tumor boards weekly were more likely to enroll lung cancer patients in clinical trials (Kiehl et al, J Onc Practice 2015 11:E267-78). This suggests that rural thoracic oncology programs are likely to improve clinical trial participation by rural residents by improving access and physician particiapation. It is not just access to therapeutic modalities in lung cancer that differs between rural and urban areas; supportive/ palliative care is also different. An analysis of the SEER database found disparities in end of life care as well. Medicare beneficiaries in rural areas had more ER visits in the last 90 days of life than urban residents. Urban residents had more ICU days in the last 90 days of life and were more likely to be enrolled in hospice programs. Minority and lower socioeconomic patients were less likely to use hospice and had more ICU days, inpatient days, and ER visits in the last 90 days of life (Nayar et al, J Comm Health 2014 39:1012-9). These disparities are of particular note since several studies have shown that early palliative care improves survival in lung and other cancers. Greater prevalence of rural thoracic oncology programs may improve access to potentially curative modalities, particularly for early stage disease. Given the higher prevalence of tobacco use in rural populations, these programs should ideally include smoking cessation efforts. Since rural residents are more likely to be diagnosed with advanced lung cancer, the implementation of low-dose CT screening is likely to be particularly beneficial in these communities. It seems likely that rural areas with thoracic oncology programs will have better rates of clinical trial access and participation. Incorparation of early effective palliative care into these programs may improve outcomes and help reduce the disparities seen in end of life care and survival in rural areas. However, resources are often limited in small rural hospitals, so it may be difficult to provide all of these services.
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ED04.05 - The Use of Pathways to Guide Consistency (ID 1786)
15:12 - 15:25 | Author(s): E.S. Kim
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Introduction and Rationale: Assessment and treatment of the cancer patient continues to increase in complexity. Some oncologists have subspecialized in their disease discipline, allowing for a greater depth of knowledge in that particular cancer but not having the breadth of expertise over numerous cancers. The majority of cancer treatment is delivered in the community-based setting where most oncologists practice general oncology. This has created a need for treatment guidelines which help oncologists manage patients in a standard approach. The evolution of treatment guidelines or pathways has several purposes. There has been much research in justifying the implementation of treatment pathways as they lead to consistent care, tend to lower healthcare costs overall, and influence outcomes of care[1-3]. However, each individual system, hospital, or physician will have their own purpose for utilizing pathways, ranging from education of assessment and treatment recommendations to providing evidence to payers for treatment. The development of clinical pathways requires a predetermined strategy. Reports have stressed the need for transparency, inclusiveness, disclosure and frequency of meetings[4][,][5]. This then requires a team to translate the results of these meetings into disseminated information for the clinical teams. The Institute of Medicine published recommendations in 2011 on how to develop these clinical pathways[4]. Various other organizations have published guidelines, such as the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), Cancer Care Ontario, Cancer Council Australia, and Via Oncology. National Comprehensive Cancer Network (http://www.nccn.org/about/default.aspx) Clinical Practice Guidelines in Oncology The NCCN is the most comprehensive set of guidelines in the United States, covering 97% of all cancers. Guidelines cover the entire cancer spectrum, from prevention to survivorship issues, and are evidence-based and continually updated. Guideline content is consensus based and developed by one of 47 panels consisting of multidisciplinary and disease-specific oncologists and researchers. Within the guidelines, a variety of content can be utilized, including algorithms or decision pathways and discussion text summarizing historical and current data. American Society of Clinical Oncology (http://www.instituteforquality.org/practice-guidelines) Clinical Practice Guidelines ASCO currently has 11 topic areas in which clinical practice guidelines are available for both solid and hematologic malignancies (e.g. use of diagnostic testing and predictive assays, disease-specific treatment, supportive care and survivorship). Each year, ASCO solicits guideline proposals from its members. Expert panels, consisting of oncologists, nurses, pharmacists, and practice managers approve proposal topics and develop the guidelines. Anyone has the opportunity to comment on or provide new evidence for use in the guidelines through the ASCO Guideline Wiki page (https://pilotguidelines.atlassian.net/wiki/display/GW/ASCO+Guidelines). European Society of Medical Oncology (http://www.esmo.org/Guidelines) Clinical Practice Guidelines The ESMO Clinical Practice Guidelines consist of 60 guidelines on cancers of the breast, lung, gastrointestinal tract, head and neck, and more, as well as supportive care and bone health. The ESMO Guidelines Committee is comprised of a Subject Editor and other leading experts and they are charged with authoring, publishing, and disseminating the full clinical practices guidelines and Pocket Guides. Cancer Care Ontario (https://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=7582) Program in Evidence-Based Care (PEBC) The Cancer Care Ontario’s PEBC is a program of the Ontario provincial cancer system, with support from the Ontario Ministry of Health and Long Term Care. Guidelines focus on all stages of cancer, including prevention, screening, diagnostic assessment, treatment, palliative care and survivorship. The PEBC consists of multidiscipline panels (disease-specific and modality-specific guideline development groups) consisting of 200+ physicians, other healthcare providers, and methodologists. Cancer Council Australia (http://www.cancer.org.au/health-professionals/clinical-guidelines/) Clinical Guidelines Network Cancer Council Australia (CCA) is Australia’s national non-government cancer organizations. CCA has published full and condensed guidelines on cancer screening and treatment of lung, esophageal, endometrial, sarcoma, and prostate cancers. The CCA is currently working to transform these guidelines in to a web-based format Via Oncology, LLC (http://viaoncology.com/) Via Oncology Pathways Via Oncology is affiliated with the University of Pittsburgh Medical Center (UPMC) and University of Pittsburgh Cancer Institute (UPCI). The Via Oncology Pathways were developed in 2005 to ensure high quality and standardized care in medical and radiation oncology across UPMC/UPCI facilities and now has grown to include practices from 20 states. Disease committees, consisting of physicians from all participating practices, have developed guidelines covering more than 90% of cancers to demonstrate value to patients, payers and referring physicians. Guidelines are available to participating providers only. Overcoming Barriers and Resistance Many reasons for why physicians do not follow guidelines have been noted in the literature, including: lack of clarity; length of guidelines; guideline format; lack of awareness; lack of familiarity; lack of agreement with the evidence; lack of outcome expectancy; lack of self-efficacy; inertia of previous practice; organizational constraints; excessive frequency of revision; and external barriers[5-8]. Kaster et al recently published data on key domains (stakeholder involvement, evidence synthesis, considered judgment, implementation feasibility, message, and format) related to positive implementation of pathways[5]. These domains largely are nested within two, broad categories: content creation and communication of content[5]. Clinical Trials One aspect that is not as inclusive in all clinical pathways is access or information to clinical trials. This content is an entirely different aspect to clinical pathways as different groups value clinical trials access differently. National accrual rates to clinical trials are low[9][,][10]. Barriers to clinical trial participation are noted on the patient, physician and system level. Clinical pathways that incorporate clinical trials may benefit the patient by increasing physician knowledge of available trials and may benefit the overall clinical trial by increasing accrual rates. EAPathways, Levine Cancer Institute, Carolinas HealthCare System We have developed in-house clinical pathways which include not only treatment pathways to assist clinicians, but also have a number of additional features. These include access to documents, educational resources, clinical trials information and communication to colleagues. The pathways on this proprietary system are developed by our disease-specific sections and housed on our system intranet. Conclusions Clinical pathways are an integral part of patient management. Their utilization is increasing and additional groups are developing these. Functionality and adaptability will be key, especially in the oncology realm, as changes in molecular testing and treatment options are occurring at a faster than ever rate. Educating our practitioners and empowering their ability to accurately assess and treat patients with cancer will enable consistent and efficient care. References 1. Hall SF, Irish JC, Gregg RW, Groome PA, Rohland S. Adherence to and uptake of clinical practice guidelines: lessons learned from a clinical practice guideline on chemotherapy concomitant with radiotherapy in head-and-neck cancer. Current oncology (Toronto, Ont.). Apr 2015;22(2):e61-68. 2. Sullivan WJ. Demystifying pathways in oncology. Managed care (Langhorne, Pa.). Jun 2012;21(6):34-38. 3. Gesme DH, Wiseman M. Strategic use of clinical pathways. Journal of oncology practice / American Society of Clinical Oncology. Jan 2011;7(1):54-56. 4. Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, eds. Clinical Practice Guidelines We Can Trust. Washington DC: 2011 by the National Academy of Sciences; 2011. 5. Kastner M, Bhattacharyya O, Hayden L, et al. Guideline uptake is influenced by six implementability domains for creating and communicating guidelines: a realist review. Journal of clinical epidemiology. May 2015;68(5):498-509. 6. Kastner M, Estey E, Bhattacharyya O. Better guidelines for better care: enhancing the implementability of clinical practice guidelines. Expert review of pharmacoeconomics & outcomes research. Jun 2011;11(3):315-324. 7. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. Jama. Oct 20 1999;282(15):1458-1465. 8. Collins IM, Breathnach O, Felle P. Electronic clinical decision support systems attitudes and barriers to use in the oncology setting. Irish journal of medical science. Dec 2012;181(4):521-525. 9. Go RS, Frisby KA, Lee JA, et al. Clinical trial accrual among new cancer patients at a community-based cancer center. Cancer. Jan 15 2006;106(2):426-433. 10. Comis RL, Miller JD, Colaizzi DD, Kimmel LG. Physician-related factors involved in patient decisions to enroll onto cancer clinical trials. Journal of oncology practice / American Society of Clinical Oncology. Mar 2009;5(2):50-56.
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ED04.06 - Evaluating Quality of Care Outcomes from Screening to Treatment in Community Based Settings (ID 1787)
15:25 - 15:38 | Author(s): R. Booton
- Abstract
- Presentation
Abstract not provided
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