Nicole J. Look Hong

Multidisciplinary Cancer Conferences: Exploring Obstacles and Facilitators to Their Implementation

PURPOSEnMultidisciplinary cancer conferences (MCCs) provide an opportunity for health professionals to discuss diagnosis and treatment options to optimize patient management. The purpose of this study was to explore the barriers and facilitators in implementing MCCs in Canada.nnnMETHODSnThis exploratory study used qualitative interviews and observation to explore the experiences of implementing MCCs in four hospitals in Ontario, Canada. Interviews were transcribed verbatim and analyzed using standard qualitative research methodology guided by grounded theory principles.nnnRESULTSnThirty-seven MCCs for gastrointestinal cancer were observed across three hospital sites, and 48 interviews were conducted among a range of clinical specialists and administrators. The dominant theme suggested that MCCs can most effectively be implemented if administrators and health professionals see value in MCCs, despite the time and effort required. A number of factors (eg, provincial policy, hospital administrative and clinician support, and an efficient MCC process) influenced whether MCCs were valued.nnnCONCLUSIONnVariation exists in the enthusiasm of health professionals and the administrative capacity of institutions regarding routine implementation of MCCs. A systematic implementation plan for MCCs is needed involving both cancer care providers and administrators.

Multidisciplinary cancer conferences: Exploring the attitudes of cancer care providers and administrators

The multidisciplinary cancer conference (MCC) provides an outlet for contributors in cancer care collectively to evaluate diagnosis and treatment options and to provide optimal patient care. The prevalence and perceived benefits of MCCs in Canada have not previously been described. Between February and March 2007, the Cancer Services Integration Survey, including four key statements concerning MCCs, was administered to cancer care providers and administrators in Ontario, Canada. A total of 1,769 responses were received with a response rate of 33%. Overall, 74% of respondents were aware of MCCs within their region, but only 58% were either regular MCC participants, or acknowledged participation of cancer providers in their institutions. Using multilevel modeling, physicians (OR 2.69, p-valueu2009<u20090.01, 95% CI 1.62–4.57) and surgeons (OR 3.00, p-valueu2009<u20090.01, 95% CI 1.52–6.20) both perceived greater benefit of MCCs for coordinating and improving patient plans than administrators. Although MCCs appear to positively influence patient care and interprofessional interactions, variability exists among cancer providers and administrators concerning their acceptance and perceived benefits. Further research should concentrate on further probing these trends, and exploring explanations and solutions for the inconsistent acceptance of MCCs into routine cancer care.

Cost-effectiveness analysis of staging strategies in patients with regionally metastatic melanoma.

Variability exists regarding optimal staging for node‐positive melanoma. Options include combinations of physical examination (PE), radiography, computed tomography (CT), and positron emission tomography (PET). Cost‐effectiveness of regimens has never been investigated.

In Search of a Gold Standard Scoring System for the Subjective Evaluation of Cosmetic Outcomes Following Breast-Conserving Therapy.

The absence of a widely accepted method for aesthetic evaluation following breast‐conserving surgery for breast cancer limits the ability to evaluate cosmetic outcomes. In this study, two different panel scoring approaches were compared in an attempt to identify a gold standard scoring system for subjectively assessing cosmetic outcomes following breast‐conserving therapy. Standardized photographs of each participant were evaluated independently by twelve health care professionals involved in breast cancer diagnosis and treatment using the Danoff four‐point scale. Individual Danoff scores were combined using two methods, a random sample “three‐panel” score and an iterative “Delphi‐panel” score, in order to create a final cosmetic score for each patient. Agreement between these two aggregative approaches was assessed with a weighted kappa (wk) statistic. Patient and professional recruitment occurred at two separate tertiary care multi‐disciplinary breast health centers. Women with unilateral breast cancer who underwent breast‐conserving therapy (segmental mastectomy or lumpectomy and radiotherapy) and were at least 2 years after radiotherapy were asked to participate. Ninety‐seven women were evaluated. The Delphi approach required three rounds of evaluation to obtain greater than 50% agreement in all photographs. The wk statistic between scores generated from the “three‐panel” and “Delphi‐panel” approaches was 0.80 (95% CI: 0.71–0.89), thus demonstrating substantial agreement. Evaluation of cosmetic outcomes following breast‐conserving therapy using a “three‐panel” and “Delphi‐panel” score provide similar results, confirming the reliability of either approach for subjective evaluation. Simplicity of use and interpretation favors the “three‐panel” score. Future work should concentrate on the integration of the three‐panel score with objective and patient‐reported scales to generate a comprehensive cosmetic evaluation platform.

Topical immunotherapy with diphencyprone (DPCP) for in-transit and unresectable cutaneous melanoma lesions: an inaugural Canadian series

ABSTRACT Background: Diphencycprone (DPCP) is an immune contact sensitizer applied to melanoma lesions. Early studies show favorable efficacy. We present the first North-American series of patients treated with DPCP. Methods: A single center retrospective study of patients with in-transit or unresectable melanoma lesions treated with DPCP from December 1,2014 to December 31,2015 was completed. Primary objectives were response rate and toxicity. Secondary objective was health-related quality of life assessment with the Functional Assessment of Cancer Therapy-Melanoma (FACT-M) questionnaire. Results: Fifteen consecutive patients were identified with median age of 78 (range 43–92). 73% of patients had prior treatment. Two patients (13%) had a complete response after 25 and 32 weeks, respectively. Four patients (27%) had a partial response with a mean treatment time of 30 weeks (range 6–51 weeks). Six (40%) had stable disease. Six patients stopped DPCP – three from systemic progression and three from toxicity. The most common toxicity was blisters; one patient had significant skin ulceration that resolved on stopping DPCP. Median FACT-M score was 142.95 (possible total 172). Mean overall follow-up time was 22.7 weeks. Conclusion: DPCP is a feasible option for in-transit and other melanoma cutaneous lesions ineligible/refractory to surgery and may delay need for systemic therapy.

Patient and provider experiences with active surveillance: A scoping review

Objective Active surveillance (AS) represents a fundamental shift in managing select cancer patients that initiates treatment only upon disease progression to avoid overtreatment. Given uncertain outcomes, patient engagement could support decision-making about AS. Little is known about how to optimize patient engagement for AS decision-making. This scoping review aimed to characterize research on patient and provider communication about AS, and associated determinants and outcomes. Methods MEDLINE, EMBASE, CINAHL, and The Cochrane Library were searched from 2006 to October 2016. English language studies that evaluated cancer patient or provider AS views, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings. Results A total of 2,078 studies were identified, 1,587 were unique, and 1,243 were excluded based on titles/abstracts. Among 344 full-text articles, 73 studies were eligible: 2 ductal carcinoma in situ (DCIS), 4 chronic lymphocytic leukemia (CLL), 6 renal cell carcinoma (RCC) and 61 prostate cancer. The most influential determinant of initiating AS was physician recommendation. Others included higher socioeconomic status, smaller tumor size, comorbid disease, older age, and preference to avoid adverse treatment effects. AS patients desired more information about AS and reassurance about future treatment options, involvement in decision-making and assessment of illness uncertainty and supportive care needs during follow-up. Only three studies of prostate cancer evaluated interventions to improve AS communication or experience. Conclusions This study revealed a paucity of research on AS communication for DCIS, RCC and CLL, but generated insight on how to optimize AS discussions in the context of routine care or clinical trials from research on AS for prostate cancer. Further research is needed on AS for patients with DCIS, RCC and CLL, and to evaluate interventions aimed at patients and/or providers to improve AS communication, experience and associated outcomes.

Melanoma patterns of care in Ontario: A call for a strategic alignment of multidisciplinary care

Variability in melanoma management has prompted concerns about equitable and timely treatment. We investigated patterns of melanoma diagnosis and treatment using population‐level data.

Melanoma patterns of care in Ontario: A call for a strategic alignment of multidisciplinary care-Response to letter

REPLY TO “MELANOMA PATTERNS OF CARE IN ONTARIO: A CALL FOR STRATEGIC ALIGNMENT OF MULTIDISCIPLINARY CARE)” LETTER TO EDITOR (JSO-2018-0028) Michele Maruccia MD, Rossella Elia MD, Eleonora Nacchiero MD, Michelangelo Vestita MD, Giuseppe Giudice MD Dear Dr. Maruccia and colleagues. Many thanks for your topical and timely reply to our recent manuscript examining patterns of melanoma care in Ontario. As you point out, the most startling association to adequate care that we discovered was exposure to a specialist—surgeon and/or dermatologist. This clearly emphasizes the need to establish functioning multidisciplinary networks. Your work in Italy though the Italian Melanoma Intergroup, the National Registry, and your website consultations are certainly laudable efforts to link knowledgeable specialists together, encourage timely collection of patient data, and inspire the development of quality metrics for cancer care. In Canada, we are pursuing similar opportunities. Administration of cancer care is done primarily on the provincial level. As such, the Canadian Melanoma Research Network (CMRN) attempts to create a national platform to bring together data from provinces across the country to look at clinical outcomes (https://www. wwmrn.org/) and join clinicians and researchers together into a unified repository. This network has expanded to a Global Melanoma Research Network (GMRN), “dedicated to bringing together health professionals worldwide for the purpose of advancement in melanoma research.” We hope that this data platform can be useful in tracking items such as lymphedema, which is traditionally difficult to identify with accuracy in administrative data sources such as those used in our study. The next challenge that we face as responsible melanoma practitioners is the integration of clinical patient outcomes and policy decision-making. Controversial and lively debate exists at multiple administrative andgovernment levels about the appropriate alignmentof quality metrics in the determination of regional funding decisions. Furthermore, the assimilation of quality and value remains a challenge, particularly when quality metrics are used for value-based pricing decisions of drugs or services. Treatment of early melanomas is largely surgical, and guidelines for adequate surgical care are less complex than those used for regionally advanced andmetastatic disease. For the latter, animated discussion balancing emerging exciting clinical data, the achievement of quality assurance metrics, and budgetary sustainability are likely to dominate melanoma-related agendas for years to come.

Interventions are needed to support patient–provider decision-making for DCIS: a scoping review

PurposePrognostic and treatment uncertainty make ductal carcinoma in situ (DCIS) complex to manage. The purpose of this study was to describe research that evaluated DCIS communication experiences, needs and interventions among DCIS patients or physicians.MethodsMEDLINE, EMBASE, CINAHL and The Cochrane Library were searched from inception to February 2017. English language studies that evaluated patient or physician DCIS needs, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings.ResultsA total of 51 studies published from 1997 to 2016 were eligible for review, with a peak of 8 articles in year 2010. Women with DCIS lacked knowledge about the condition and its prognosis, although care partners were more informed, desired more information and experienced decisional conflict. Many chose mastectomy or prophylactic mastectomy, often based on physician’s recommendation. Following treatment, women had anxiety and depression, often at levels similar to those with invasive breast cancer. Disparities were identified by education level, socioeconomic status, ethnicity and literacy. Physicians said that they had difficulty explaining DCIS and many referred to DCIS as cancer. Despite the challenges reported by patients and physicians, only two studies developed interventions designed to improve patient–physician discussion and decision-making.ConclusionsAs most women with DCIS undergo extensive treatment, and many experience treatment-related complications, the paucity of research on PE to improve and support informed decision-making for DCIS is profound. Research is needed to improve patient and provider discussions and decision-making for DCIS management.