Yvette DeJesus

Incidence and Prevention of Venous Thromboembolism in Patients Undergoing Breast Cancer Surgery and Treated According to Clinical Pathways

Objective:To minimize treatment variations, we have implemented clinical pathways for all breast cancer patients undergoing surgery. We sought to determine the incidence of postoperative venous thromboembolism (VTE) in patients treated on these pathways. Summary Background Data:Cancer patients have an increased risk of VTE because of a hypercoagulable state. The risk of VTE following breast cancer surgery is not well established. Methods:We retrospectively reviewed prospectively collected data for all patients who underwent breast cancer surgery and were treated on the clinical pathways with mechanical antiembolism devices and early ambulation in the postoperative period between January 2000 and September 2003. Results:During the study period, 3898 patients underwent 4416 surgical procedures. Seven patients with postoperative VTE within 60 days were identified, for a rate of 0.16% per procedure. Six patients presented with only a deep venous thrombosis or a pulmonary embolism; 1 patient had both. The median time from surgery to diagnosis of VTE was 14 days (range, 2–60 days; mean, 22 days). No relationship was identified between stage of breast cancer or type of breast surgery and development of VTE. Two (29%) of the 7 patients with VTE had received neoadjuvant chemotherapy. VTE treatment consisted of subcutaneous low-molecular-weight heparin (n = 5) or intravenous heparin (n = 2) followed by warfarin. There were no deaths. Conclusions:VTE following breast cancer surgery is rare in patients who are treated on clinical pathways with mechanical antiembolism devices and early ambulation in the postoperative period. We conclude that systemic VTE prophylaxis is not indicated in this group of patients.

An outcomes management program in gynecologic oncology

OBJECTIVE To evaluate the effectiveness of an outcomes-management program designed to provide high-quality patient care, generate data for outcomes research, and decrease costs in a managed-care environment. METHODS An outcomes-management program was launched in June 1994, based on the elimination of wasteful or ineffective therapies through the systematic development of practice guidelines and collaborative care paths, with concomitant definition of desired outcomes. Over 3 months, care paths were developed for our most common surgical procedures. A matched control outcomes study was undertaken for the most commonly performed gynecologic oncology procedure: total abdominal hysterectomy and oophorectomy with pelvic and para-aortic node sampling for endometrial cancer. Thirty consecutive women treated on the care path were compared with 29 matched controls accrued during the period of care-path planning and with 73 controls from the period preceding care-path planning. Patient satisfaction with care-path treatment was assessed by a survey sent 2 weeks after discharge. RESULTS Median length of hospital stay decreased significantly, from 6 days before care-path planning to 4 days after care-path implementation (P < .001). Median laboratory costs decreased by 74% (P < .001), medication costs by 35% (P < .001), room costs by 29% (P < .001), and total hospital costs by 20% (P < .002). Incremental improvements were observed during care-path planning. There were no readmissions for complications in the care-path group. According to the survey results, patient satisfaction with care was very high among care-path patients. CONCLUSIONS A physician-driven outcomes-management program in an academic setting permits the delivery of high-quality care and supports outcomes research while decreasing costs.

Infusion site soft‐tissue injury after paclitaxel administration

Background. Paclitaxel is a diterpenic plant product that has significant activity in several solid tumors, including epithelial ovarian cancer. After promising results in Phase I and II studies, its use has increased dramatically. With this increased use, isolated reports of local tissue reactions to paclitaxel have been described. The purpose of this study was to characterize further the presentation and clinical course of this toxic effect.

The role of nursing in cervical cancer prevention and treatment

Nurses today assume multiple roles, such as patient advocate, care provider, and research investigator. At the Second International Conference on Cervical Cancer (April 11–14, 2002, Houston, TX), nurses presented original research describing these roles in the context of cervical cancer screening, prevention, and detection in the United States and Sweden; outlined the uses of practice guidelines; and suggested future directions for nursing research. In the 20th century, nurses expanded their patient care responsibilities and promoted cancer control by expanding their skills. Some sought to broaden the spectrum of care by investigating cervical cancer screening disparities, behavioral aspects of screening, and differences between the stated purposes of screening programs and those of the nurse‐midwives operating them. In the 21st century, nurses interested in cervical cancer control expect to broaden the scope of their care and their research roles further by continuing to improve training, advocating screening (and increased education about screening), and helping to establish new sources of funding for research. Cancer 2003;98(9 Suppl):2070–2074.

Usage of erythropoiesis-stimulating agents in cancer patients at an academic cancer center and experience with specific care management tools for anemia†

In 2007, the US Food and Drug Administration (FDA) issued regulatory alerts for use of erythropoiesis‐stimulating agents (ESAs) in cancer patients with anemia after clinical trials and meta‐analysis data found that high ESA doses were associated with adverse outcomes in patients. In response to these findings, specific patient management tools for anemia (consisting in an algorithm and prescribing order set) were developed by a multidisciplinary team at The University of Texas MD Anderson Cancer Center.

Factors related to end-of-life (EOL) chemotherapy in solid tumor (ST) patients.

92 Background: Quality performance measures for cancer care, including use of chemotherapy in the last two-weeks of life, will be required for reporting. In this study, we evaluated the use of chemotherapy in ST patients (pts) within 14 days of EOL relative to several factors that may influence this practice. METHODS Adult pts (≥18 years) treated for ST at our institution, deceased December 01, 2010 through May 31, 2012, were retrospectively studied. Data on demographics, chemotherapy (excluded: hormones) within 14 days EOL, comorbidities, and cancer diagnoses were from administrative databases. Logistic regression analysis was performed for association of EOL chemotherapy with age, gender, ethnicity, comorbidities, cancer types, and metastatic status. RESULTS 5,607 pts met study criteria: median age 64 years; 48% female; 76% metastatic disease. EOL chemotherapy frequency was 3.9% overall, 4.6% in metastatic disease versus 1.7% in non-metastatic disease (p<0.01). Of 23 patients who received chemotherapy and had non-metastatic disease, the major tumor sites were: brain/other nerve system (34.8%) and lung/bronchus (21.7%).The top 10 frequencies in chemotherapy use by tumour sites were: melanoma (6.7%), female breast (5.5%), lung and bronchus (4.9%), pancreas (4.2%), brain/other never system (3.9%), head and neck (3.8%), female genital system, excluding ovary (3.4%), ovary (3.2%), liver/intrahepatic bile duct (3.0%), colon and rectum (2.6%). By regression analysis, the factor statistically significantly associated with receiving chemotherapy was metastatic disease (odds ratio [OR], 3.29; 95% CI,1.96-5.54), while factors associated with significantly less treatment were age ≥ 65 (OR, 0.66; 95% CI, 0.49-0.90); and any comorbid conditions (≥1 versus 0) (OR, 0.58; 95% CI, 0.38-0.89). CONCLUSIONS A small portion of ST patients who died received EOL chemotherapy (3.9%). However, metastatic disease and diagnosis category influenced treatment. Melanoma and breast cancer patients had higher frequency of EOL treatment. Older age and comorbidities were associated with less treatment. Variation in EOL treatment of ST patients is thus influenced by several clinical factors, but did not seem influenced by gender or ethnicity factors.

Chemotherapy use during the last 30 days of life in patients with cancer.

231 Background: Treatment options are increasingly available to patients with advanced cancer. Appropriately timed cession of chemotherapy is a quality-of-care measure in the Quality Oncology Practice Initiative of the American Society of Clinical Oncology. To gain insight into whether communication about end-of-life (EOL) issues might need to be improved, we analyzed chemotherapy use during the 30 days at the EOL (EOLCx) among patients at large cancer center. We also analyzed the presence of electronic DNR (eDNR) orders at the time of death in hospital as a surrogate indicator of EOL discussions. METHODS We reviewed the records of cancer patients (age≥18 years) who received their care at The University of Texas MD Anderson Cancer Center and died between December 2010 and May 2012. Logistic regression was used to measure associations of EOLCx and age, gender, ethnicity, comorbidities, cancer type, and cancer progression. RESULTS A total of 7,399 patients met the inclusion criteria. The median age was 64 years; 46% were female and 18% had hematologic malignancies (HM). 996 patients (14%) received EOLCx, and of these, 554 died in the hospital (7%, 554/7,399). Of those who died in the hospital, 93% had eDNR orders (no difference between solid tumors [ST] and HM). The EOLCx was higher for patients who died in the hospital than for those who died elsewhere (44% vs 7%) and higher for patients with HM than for those with ST (38% vs 8%). EOLCx was more common in patients with ST with metastases, HM without relapse, and HM with relapse than in those with ST without metastases [odds ratios (ORs), 3.3, 13.9, and 32.8, respectively; all p<0.05]. EOLCx was less common in older patients (≥65 years) than younger patients (OR, 0.6; p<0.05) and was more common in patients with comorbidities than in those without (OR, 1.3; p<0.05) and in patients who were not black or Hispanic than in white patients (OR, 1.6; p<0.05). No difference of EOLCx between genders was found. CONCLUSIONS EOLCx was more common in patients with HM with or without relapse than in patients with ST. Most patients had eDNR orders at the time of death in hospital. The results suggest that communication about prognosis and advanced planning about the goals of medical care is becoming critical part in overall oncologic care plan.

Compliance with established pneumonia core measures at MD Anderson Cancer Center in the emergency center.

189 Background: Pneumonia is the major cause of death due to infectious diseases in the United States. In the cancer patient, pneumonia is the overall leading infectious cause of death. Pneumonia Core Measures (PCM) and Clinical Pathways are frequently used by healthcare organizations to ensure the delivery of high-quality care and pathogen-directed therapy. A multidisciplinary team was organized at the University of Texas MD Anderson Cancer Center (MDACC) Emergency Center (EC) into a Pneumonia Team to optimize care and to enhance compliance with current PCM. METHODS A retrospective review of EC patients during pneumonia season was completed. RESULTS Three areas for improvement in the EC were identified. The areas include lack of EC staffs knowledge on PCM, lack of standardized order-sets for pathogen-directed treatment, and cancer patients presenting with pneumonia syndromes that fall outside established Community-Acquired Pneumonia (CAP) guidelines. The identified problems were addressed through three strategies: Intense EC staff education initially and yearly prior to pneumonia season (September-March). Microbiologic analysis of the pathogens responsible for the pneumonias in our unique cancer population at MDACC. Development and implementation of an institutional pneumonia algorithm and an order-set. The Pneumonia Team also identified a gap between our patient population and the current PCM. Pneumonia patients at MDACC EC are divided into two distinct groups, solid tumor and hematologic cancers. The microbiology analyzed in both groups is consistent with Healthcare-Associated Pneumonia (HCAP) and not CAP. Microbiology analysis identified gram positive, gram negative, fungal, viral and multi-drug resistant organisms. The initial analysis demonstrated that 87% of our patients met criteria for HCAP and only 12% met CAP. Based on this percentage, antibiotic selection for our CAP patients comprises a small portion of our total population. CONCLUSIONS Our current algorithm and order-set optimize care and minimize variation to match our patient population. These findings provide important considerations for policy makers in regard to pneumonia measurements in a cancer setting.