Katya Losk

Variation in the use of granulocyte-colony stimulating factor for dose dense paclitaxel: A single institution retrospective study

INTRODUCTION The necessity of using granulocyte-colony stimulating factor (G-CSF) during dose-dense (DD) paclitaxel (T) after doxorubicin and cyclophosphamide (AC) is unclear. METHODS This was a retrospective cohort study including patients with stage I-III breast cancer treated at Dana-Farber Cancer Institute with adjuvant DD-ACT between January 2011 and December 2013. Descriptive analyses evaluating patterns of G-CSF utilization during T were performed. RESULTS Overall, 156 patients were treated with DD-ACT by 26 providers. The majority of patients (135, 87%) received at least one dose of G-CSF during T (group 1), 17% of these patients received it in only one cycle and 48% received it in all four cycles. Reasons for omitting G-CSF included high baseline absolute neutrophil count and pain. Twenty-one (13%) patients did not receive any G-CSF during T (group 2). Respectively, 94% and 90% of patients completed the treatment in groups 1 and 2. There were no cases of treatment cessation due to neutropenia. Six percent of patients in group 1 had at least one treatment delay. There were no treatment delays reported in group 2. Variation in the use of G-CSF by provider and by patient was found, with 11 providers choosing not to use G-CSF in at least one patient. CONCLUSIONS We identified substantial variation in the use of G-CSF within the practice. However, omission of G-CSF was not associated with treatment delays or adverse events. Prospective studies are warranted to formally test whether routine G-CSF is necessary during dose-dense T therapy.

Implementation of Surgeon-Initiated Gene Expression Profile Testing (Oncotype DX) Among Patients With Early-Stage Breast Cancer to Reduce Delays in Chemotherapy Initiation

PURPOSE Delays to adjuvant chemotherapy initiation in breast cancer may adversely affect clinical outcomes and patient satisfaction. We previously identified an association between genomic testing (Onco type DX) and delayed chemotherapy initiation. We sought to reduce the interval between surgery and adjuvant chemotherapy initiation by developing standardized criteria and workflows for Onco type DX testing. METHODS Criteria for surgeon-initiated reflex Onco type DX testing, workflows for communication between surgeons and medical oncologists, and a streamlined process for receiving and processing Onco type DX requests in pathology were established by multidisciplinary consensus. Criteria for surgeon-initiated testing included patients ≤ 65 years old with T1cN0 (grade 2 or 3), T2N0 (grade 1 or 2), or T1/T2N1 (grade 1 or 2) breast cancer on final surgical pathology. Medical oncologists could elect to initiate Onco type testing for cases falling outside the criteria. We then examined 720 consecutive patients with breast cancer who underwent Onco type DX testing postoperatively between January 1, 2014 and November 28, 2016 and measured intervals between date of surgery, Onco type DX order date, result received date, and chemotherapy initiation date (if applicable) before and after intervention implementation. RESULTS The introduction of standardized criteria and workflows reduced time between surgery and Onco type DX ordering, and time from surgery to receipt of result, by 7.3 days ( P < .001) and 6.3 days ( P < .001), respectively. The mean number of days between surgery and initiation of chemotherapy was also reduced by 6.4 days ( P = .004). CONCLUSION Developing consensus on Onco type DX testing criteria and implementing streamlined workflows has led to clinically significant reductions in wait times to chemotherapy decision making and initiation.

Implementation of a Breast/Reconstruction Surgery Coordinator to Reduce Preoperative Delays for Patients Undergoing Mastectomy With Immediate Reconstruction

PURPOSE Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays. METHODS A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014. RESULTS A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed. CONCLUSION A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows.

Abstract P1-12-08: Factors associated with delays in chemotherapy initiation among patients with breast cancer

Background: National guidelines endorse time-dependent quality metrics for breast cancer care. We examined factors associated with delays in chemotherapy initiation at an NCI designated comprehensive cancer center. Methods: We identified 523 patients who received post-operative adjuvant chemotherapy between January 2011 and December 2013 at our center. We defined 28 days from last definitive surgery (LDS) to chemotherapy as the target timeframe, and unacceptable delay in chemotherapy initiation (UCD) as more than 42 days from LDS. Multivariate regression models were used to identify factors associated with UCD and the impact of Oncotype testing in HR+ patients. Results: Median days between LDS and chemotherapy initiation was 34 (IQR 15), with 30% of patients starting within 28 days of LDS and 23% having UCD (Table 1). Tumor characteristics such as subtype and stage affected UCD; patients with HR+ or HER2+ tumors were more likely to be delayed compared to those with TNBC. Patients with stage I disease were more likely to be delayed as well as patients undergoing mastectomy or mastectomy with reconstruction. Patients whose pathology sign-out was more than 10 days post-operatively were more likely to be delayed. A higher proportion of UCD was found in HR+ patients (31%) who received an Oncotype recurrence score compared to those who did not (20%). Conclusions: This study provides insight into populations that may be at risk to experience delays in chemotherapy initiation, directing interventions to improve the timeliness of care. Citation Format: Losk K, Vaz Duarte Luis I, Camuso K, Lloyd M, Kadish S, Hirshfield-Bartek J, Cutone L, Golshan M, Lin N, Bunnell C. Factors associated with delays in chemotherapy initiation among patients with breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-12-08.

Abstract P2-13-12: Implementation of a breast/reconstructive surgery coordinator to reduce preoperative delays for patients undergoing mastectomy with immediate reconstruction

Background The scheduling of mastectomy with immediate reconstruction (M-IR) procedures requires coordination between breast and plastic surgical teams that can contribute to delays in breast cancer treatment and subsequently impact patient outcomes and satisfaction. The breast center leadership at our comprehensive cancer center established a time-to-treatment target of 28 days from initial consultation with a breast surgical oncologist to M-IR. We sought to determine if a centralized breast surgical coordinator (BC) could reduce preoperative delays. Methods We initiated a 60-day pilot program to evaluate the impact of a BC on the workflow, efficiency, and timeliness for patients seen at our breast center. All reconstructive surgery candidates were referred to the BC, who had access to the clinic and operating room schedules of the breast and plastic surgeons. The BC worked with patients and both surgical services to identify the earliest consult and surgery dates and facilitated case booking. Interval days between initial surgical consult and M-IR were calculated. The median time to M-IR and the proportion of M-IR cases that met the time-to-treatment goal was determined. These results were compared to a reference cohort of breast cancer patients undergoing M-IR during the same time period (January-March) in 2013 and 2014, who had their consults and surgeries scheduled independently by breast surgery administrative staff. Patients who received neoadjuvant therapy or did not have a definitive cancer diagnosis at initial consultation were excluded from the time-to-treatment calculation. Results A total of 99 patients were referred to the BC (62% cancer, 21% neoadjuvant, and 17% prophylactic) during the pilot period. Focusing exclusively on patients with a definitive breast cancer diagnosis at initial consultation, an 18.5% increase in the percentage of cases that met the target (p=0.04), and a 7 day decrease in the median number of days to M-IR (p=0.02) was observed with the implementation of the BC (Table 1). Conclusion The coordination of care between breast surgical and reconstructive services presents timeliness challenges which may be partially alleviated through the implementation of a BC role. Establishing a centralized position to coordinate co-surgeon cases has improved time-to-treatment for M-IR at our cancer center. Further research is warranted to validate these preliminary findings, and determine the impact the BC has on operational efficiency and workflows. Citation Format: Losk K, Mallory M, Caterson S, Camuso K, Cutone L, Roberts P, Lin N, Bunnell C, Golshan M. Implementation of a breast/reconstructive surgery coordinator to reduce preoperative delays for patients undergoing mastectomy with immediate reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-12.

Standardizing coordination between surgical oncology and reconstructive surgery for breast cancer patients undergoing mastectomy with immediate reconstruction.

110 Background: Timely diagnosis and treatment of breast cancer, endorsed by organizations such as ASCO and NCCN, are essential to ensure optimal clinical outcomes and patient satisfaction. Inefficient care coordination may adversely affect care quality. At our cancer center, 75% of patients who undergo mastectomy seek a reconstructive surgery consult and over 60% elect mastectomy with immediate reconstruction. We sought to evaluate and reduce the time to reconstructive surgery consult and first definitive surgery (FDS) by streamlining coordination between services. METHODS We studied 330 patients who underwent mastectomy with immediate reconstruction between January 2011 and April 2013. Time intervals between initial surgical consult, reconstruction consult, and FDS were calculated. After examining existing best practices in patient referral and scheduling, we established targets of 7 days from initial consult to reconstruction consult and 28 days from initial consult to FDS. To achieve these targets, facilitated sessions were held with administrative and clinical experts to create a standard referral and scheduling process, including a referral template and establishing surgical teams based on clinic and operating room alignment. The interventions were implemented over a 6-month period. RESULTS Mean days from initial consult to reconstructive surgery consult decreased, with significant improvement in reaching the 7 day target. No significant changes from time of initial consult to FDS were observed. CONCLUSIONS Standardizing coordination has led to timelier reconstructive surgery consults for patients undergoing mastectomy with immediate reconstruction. Other factors, such as operating room availability, pre-operative testing and patient preference should be explored to reduce the time to FDS. [Table: see text].