Geoff Porter

Completeness of dictated operative reports in breast cancer—the case for synoptic reporting

Currently, the dictated operative report forms the cornerstone of documenting breast cancer surgery. Synoptic electronic reporting using a standardized template has been proposed for breast cancer operative notes to improve documentation. The goal of this study was to determine the current completeness of dictated operative reports for breast cancer surgery.

National adoption of sentinel node biopsy for breast cancer: lessons learned from the Canadian experience.

Abstract:u2002 Sentinel lymph node biopsy (SLNB) in breast cancer has not been readily adopted into Canadian surgical practice in comparison with the United States. We sought to evaluate current national practice patterns and explore barriers to direct efforts to improve the adoption of SLNB in Canada. All active (nu2003=u20031413) general surgeons in Canada were surveyed by mail. Surgeon demographics, practice patterns, skill acquisition and attitudes towards SLNB were assessed. The response rate was 63% (nu2003=u2003889). Of the 506 (57%) surgeons who treated breast cancer, half were community based with breast surgery comprising <25% of their practices. Most (70%) performed ≤5 breast surgeries/month. Almost all (96%) believed SLNB was standard of care or an acceptable alternative to axillary lymph node dissection (ALND). Of these, 306 (61%) performed SLNB. Predictors of performing SLNB were breast/oncology fellowship (pu2003=u20030.03) or greater percentage of practice dedicated to breast (pu2003=u20030.02) but not region, type of practice (community versus academic), gender or year of residency completion. Reasons for performing SLNB were decreased morbidity (85%) and enhanced staging (59%) as opposed to competitive pressure (13%). The majority (75%) performed SLNB as a stand‐alone procedure for T1/T2 cancers and high‐risk ductal carcinoma in situ (70%). Almost half (46%) abandoned back up ALND after 30 or fewer cases even though the majority (75%) acknowledged the false‐negative rate should be <5%. Most (76%) learned SLNB through mentoring or a formal course/residency. Of the 197 (39%) not performing SLNB, 53% felt that inadequate access to nuclear medicine and gamma probe equipment was the predominant barrier. SLNB has been adopted into Canadian surgical practice. The majority of surgeons believe that SLNB is an acceptable alternative to ALND, with 61% now performing SLNB compared to 27% in 2001. Barriers to implementation appear to be related to inadequate resources as opposed to lack of belief in the procedure.

Adherence to Clinical Practice Guidelines for Adjuvant Chemotherapy for Colorectal Cancer in a Canadian Province: A Population-Based Analysis

PURPOSEnClinical practice guidelines (CPGs) recommend adjuvant chemotherapy after curative-intent surgery for colorectal cancer (CRC). Studies have shown variable rates of adherence to adjuvant therapy CPGs. This study sought to determine the proportion of patients in Nova Scotia receiving CPG-concordant adjuvant chemotherapy within 12 weeks of surgery for CRC in 2001 to 2005, and to identify factors associated with chemotherapy receipt beyond 12 weeks from surgery or chemotherapy nonreceipt.nnnMETHODSnPatients with stages IIB or III colon or stages II or III rectal cancer who underwent curative-intent surgery in Nova Scotia were identified through the provincial cancer registry and anonymously linked to 14 administrative health databases. Chart review was conducted to obtain chemotherapy data and reasons for chemotherapy nonreceipt. Logistic regression was used to identify factors independently associated with receipt of chemotherapy and meeting the 12-week benchmark (P < .05).nnnRESULTSnA total of 1,151 patients were identified, of whom 59% received chemotherapy. Factors predicting chemotherapy receipt were male sex, age < 75 years, no hospital readmission within 30 days of surgery, stage III disease, no prior cancer diagnosis, and rectal cancer. Of the 679 patients who received chemotherapy, 479 (72%) met the 12-week benchmark, with male sex, urban residence, less social deprivation, colon cancer and increased length of hospital stay as significant factors. Of the 472 patients who did not receive chemotherapy, the most common reason for nonreceipt was no consultation with a medical oncologist (53%).nnnCONCLUSIONnA number of factors influence adherence to adjuvant chemotherapy CPGs for CRC and should be incorporated in future work as novel regimens enter clinical practice.

Timely access and quality of care in colorectal cancer: are they related?

OBJECTIVEnColorectal cancer patients want both timely access and high-quality care. The objective of this study was to explore relationships between quality indicators and access time intervals specific to colorectal cancer patients.nnnDESIGNnProspective consecutive cohort study.nnnSETTINGnSingle health district.nnnPARTICIPANTSnBetween February 2002 and February 2004, all patients undergoing non-emergent surgery for primary colorectal cancer were enrolled.nnnINTERVENTIONnA standardized method was used to collect clinicodemographic, diagnostic and treatment event data.nnnMAIN OUTCOME MEASURESnAssociations between accepted colorectal cancer-specific quality indicators and benchmarked access time intervals for diagnosis, surgery and adjuvant therapy were examined using multivariate logistic regression, controlling for clinicodemographic factors.nnnRESULTSnAmong the 392 patients in the study cohort, 9.9% were diagnosed on screening examination, 53.1% underwent preoperative staging imaging and 74.5% underwent full preoperative colonic examination. On multivariate logistic regression, patients presenting via screening were more likely to move from presentation to diagnosis within the 4-week benchmark for this access time interval, compared with symptomatic patients (RR 8.1, P < 0.001). The absence of preoperative staging imaging was associated with achievement of the 4-week benchmark for the access time interval from diagnosis to surgery (RR 2.5, P < 0.001). Similarly, an absence of complete preoperative colonic examination was associated with achievement of the 8-week benchmark for the access time interval from surgery to adjuvant therapy (RR 6.6, P = 0.008).nnnCONCLUSIONSnAlthough several associations between quality indicators and benchmarked access time intervals for colorectal cancer patients were identified, the relationship between quality and access is complex and far from universal. It is therefore clear that quality care and timely access are not synonymous, and that both must be studied to improve colorectal cancer care.

Investigations for patients with early-stage breast cancer: oversetting the stage

See also page [E387][1] and [www.cmaj.ca/lookup/doi/10.1503/cmaj.150003][2]nnA systematic review of staging for early breast cancer by Cancer Care Ontario, published in 2001, showed that, for asymptomatic patients, no tests had a detection rate greater than 0.5% for stage I disease and only bone

Electronic operative reports to support quality improvement and patient-centered care.

95 Background: Operative reports (OP) for cancer surgery are usually narrated, although they provide inconsistent and incomplete information for patient care. National standards for cancer OP were unavailable until 2007. Over 10 years, surgeons in four Canadian provinces have transitioned from narrative to electronic synoptic reporting (ESP) for specific cancers. The electronic OP are now considered a patient medical record and integral to subsequent patient care. Surgeons are using electronic reports for quality assurance, billing, medical-legal conflict resolution and research.nnnMETHODSnDisease-site expert panels were formed to bring together surgeons to discuss, identify, develop and form consensus on a core set of elements for breast, colorectal, ovary, endometrial, lung, prostate, and thyroid cancer surgeries and 64 quality indicators to set practice standards to consistently and comprehensively record pre-operative, operative procedures, intra-operative observations and pathology, clinical stage findings, complications and outcomes. These standards were implemented using ESP in four provinces and a mixed methods evaluation was carried out.nnnRESULTSn245 surgeons in academic and community hospitals piloted and implemented pan-Canadian standards and generated 2000 synoptic reports and 729 discharge summaries over six months. In comparison to narrative reports, surgeons reported that the electronic synoptic reports: Capture complete and essential content (89% - 96%), 50% more; Contain 25 - 50 items vs. 2000 narrated words; Faster completion and turnaround time (5- 15 minutes) vs. 5 days; Rapid transmission to patient charts (91% in 1 hour and 97% within 24 hours) vs. 30 - 90 days; Result in cost savings

Using Canadian administrative data to evaluate primary and oncology care of breast cancer patients post-treatment: Subset of the CanIMPACT Study.

90/case; Enable performance measurement of surgical care to assess quality and outcome of surgery (e.g., residual disease and survival in patients) and length of aggressive vs. non-aggressive surgery and hospital stay (5.49 hours and 8.39 days vs. 3.06 hours and 6.83 days).nnnCONCLUSIONSnSurgeons are building partnerships with key players to strategize best approaches to enable a system-wide adoption and implementation of synoptic operative reporting and quality of care measurement across Canada.

Prostate cancer care in Canada: Informed decision-making, patterns of care, and treatment trends.

5 Background: CanIMPACT is a multi-provincial Canadian research team funded to identify and address key issues faced by cancer patients and providers at the intersection of primary and specialist oncology care. Canada has national healthcare standards, but provincial/territorial healthcare delivery systems. One facet will use administrative data from the population-based, publicly-funded healthcare system to evaluate issues during pre-diagnosis, treatment, and post-treatment survivorship for breast cancer patients. For the survivorship phase, we aim to conduct the following analyses and compare across provinces: 1) Utilization of physician services overall and by specialty, including oncologists, non-oncology specialists, and primary care; 2) Assessment of adherence to ASCO and Canadian follow-up guideline for breast cancer care, use of surveillance breast imaging, and metastatic investigations; 3) Assessment of adherence to recommended care of chronic illness and preventive care; 4) Quantification of the cost of follow-up overall and by specialty; 5) Comparison of inter- and intra-provincial variation for all outcomes by health administrative region and for vulnerable groups (age ≥ 75 at diagnosis, northern/rural/remote, low income, immigrants), and examine the effect of continuity of primary care and chronic disease on post-treatment care.nnnMETHODSnPatients will be identified from provincial cancer registries and linked to data extracted from: outpatient physician service claims, hospital inpatient and outpatient data, and cancer facility medical records.nnnRESULTSnParticipating provinces have finalized the core questions and detailed protocols, and assessed data comparability. They are in the process of obtaining the required ethics and data access approvals, and data acquisition for processing and analysis.nnnCONCLUSIONSnResults will address existing information gaps that can be used to improve transition and care across the cancer care trajectory. Importantly, results will be combined with those of a CanIMPACT qualitative study to inform design of a pragmatic randomized trial focused on improving coordination and quality of care.

Variations in Medical Oncology Utilization for Pancreatic Cancer Patients in Nova Scotia

289 Background: Because treatment options for localized prostate cancer (PCa) have similar survival outcomes but varying side effects, it is important that patients are meaningfully involved in the decision-making process to ensure the chosen treatment aligns with their needs, wants and preferences. Here, we describe PCa patients experience with informed decision-making as well as treatment patterns and trends over time.nnnMETHODSnFocus groups were conducted with 47 men treated for PCa across Canada to understand their cancer journey experience. Thematic analysis was conducted. A subset of this data on informed decision-making is described. Men (≥ 35 years) diagnosed with localized, low-risk PCa from 2011-2013 were identified using data from six provincial cancer registries. Treatment data were identified by linking hospital/cancer centre data with registry data. Descriptive statistics were generated to describe treatment patterns and trends.nnnRESULTSnFocus group participants expressed a desire to be involved in the treatment decision-making process. While many participants felt completely informed about the treatment choices available to them, others felt they had not been properly engaged in the treatment decision-making process. Some participants felt they had opted for surgery or radiation therapy (RT) without full knowledge of the trade-offs between potential benefits and side effects. Others felt they may have made different decisions about their care had they been more informed. From registry data, in 2013 surgery was the most common primary treatment for men with low-risk PCa ranging from 12.0% in New Brunswick to 41.7% in Nova Scotia. RT was the second most common ranging from 6.4% in New Brunswick to 18.3% in Saskatchewan. Varying majorities of men had no record of surgical or radiation treatment, a proxy for active surveillance. Treatment trends over time suggest an increase in the use of non-active treatment approaches from 60.7% in 2011 to 69.9% in 2013.nnnCONCLUSIONSnSystem performance indicators yield useful information about oncology practice patterns and trends. This information is enhanced when combined with patient level information on how men felt about decision-making around their PCa care.