Enhancing Cancer care of rural dwellers through telehealth and engagement (ENCORE): protocol to evaluate effectiveness of a multi-level telehealth-based intervention to improve rural cancer care delivery

Abstract Background Despite lower cancer incidence rates, cancer mortality is higher among rural compared to urban dwellers. Patient, provider, and institutional level factors contribute to these disparities. The overarching objective of this study is to leverage the multidisciplinary, multispecialty oncology team from an academic cancer center in order to provide comprehensive cancer care at both the patient and provider levels in rural healthcare centers. Our specific aims are to: 1) evaluate the clinical effectiveness of a multi-level telehealth-based intervention consisting of provider access to molecular tumor board expertise along with patient access to a supportive care intervention to improve cancer care delivery; and 2) identify the facilitators and barriers to future larger scale dissemination and implementation of the multi-level intervention. Methods Coordinated by a National Cancer Institute-designated comprehensive cancer center, this study will include providers and patients across several clinics in two large healthcare systems serving rural communities. Using a telehealth-based molecular tumor board, sequencing results are reviewed, predictive and prognostic markers are discussed, and treatment plans are formulated between expert oncologists and rural providers. Simultaneously, the rural patients will be randomized to receive an evidence-based 6-week self-management supportive care program, Cancer Thriving and Surviving, versus an education attention control. Primary outcomes will be provider uptake of the molecular tumor board recommendation and patient treatment adherence. A mixed methods approach guided by the Consolidated Framework for Implementation Research that combines qualitative key informant interviews and quantitative surveys will be collected from both the patient and provider in order to identify facilitators and barriers to implementing the multi-level intervention. Discussion The proposed study will leverage information technology-enabled, team-based care delivery models in order to deliver comprehensive, coordinated, and high-quality cancer care to rural and/or underserved populations. Simultaneous attention to institutional, provider, and patient level barriers to quality care will afford the opportunity for us to broadly share oncology expertise and develop dissemination and implementation strategies that will enhance the cancer care delivered to patients residing within underserved rural communities. Trial registration Clinicaltrials.gov, NCT04758338. Registered 17 February 2021 – Retrospectively registered, http://www.clinicaltrials.gov/

Download Full-text

Using a tele-oncology service provides a direct benefit to patients and caregivers in rural communities in the Intermountain West.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e14153 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e14153-e14153

Author(s):

Derrick S. Haslem ◽

Zachary Reese ◽

Kimberlee Emfield ◽

David Michael Gill ◽

Ryan Eldredge Wilcox ◽

...

Keyword(s):

Rural Communities ◽

Cancer Care ◽

Treatment Strategies ◽

Cancer Center ◽

Oncology Service ◽

Nurse Navigator ◽

Local Facility ◽

Ancillary Staff ◽

Increasing Demand ◽

Intermountain Healthcare

e14153 Background: Cancer treatment is becoming more complex, necessitating subspecialty expertise and multidisciplinary approaches to treatment planning. Simultaneously, there is increasing demand to provide care as close to home as possible. Oncology services are in high demand with a geographical mismatch between where oncologists work and where patients live. Traditionally, patients have been required to travel long distances to seek care outside of their communities resulting in increased financial expense and emotional distress caused by leaving the comforts of their support system. Leveraging existing technologies, most of modern cancer care, including infusions can be delivered through a coordinated effort from consulting/ordering oncologists, onsite administrators, physicians, nurses and ancillary staff. Methods: Using a secure video-conferencing platform, Intermountain Healthcare has implemented 5 tele-oncology clinics (Site A- Sevier, UT; B- Cassia, ID; C- Teton, ID; D- Uintah Basin, UT, E- Star Valley, WY) in rural communities of Utah, Idaho and Wyoming. Patients are referred to the clinic by local providers. With the assistance of a nurse navigator, oncologists meet with patients via video conference for initial consults, follow-up, supportive care, survivorship care and systemic treatment including chemotherapy, immunotherapy, and targeted therapy. Standard NCCN/ASCO guidelines are followed in the treatment strategies for these patients. Care is taken to ensure any treatment that can safely be delivered in the local facility/community is coordinated to take place there. Based on distances from the rural facility to nearest tertiary cancer center, we calculated the mileage avoided and hours traveled avoided by using tele-oncology. Results: Since 2017, the tele-oncology service has managed 269 unique patients (A- 200; B- 21, C- 22, D- 18, E- 8) with 1,237 total tele-oncology visits (A- 1,068; B- 69; C- 39; D- 32; E- 29). In total, there were 397,326 driving miles avoided (A- 326,808; B- 26,358; C- 22,932; D- 9,280; E- 11,948). Travel hours avoided in total were 6,062 hours (A- 4,989; B- 380; C- 341; D- 155; E- 197). Conclusions: Intermountain Healthcare’s tele-oncology program benefits patients and communities by easing travel burden and improving quality of life by making cancer care more convenient and providing the care closer to home. Work is ongoing to prospectively evaluate the effects on the communities in addition to cancer related outcomes.

Download Full-text

Outpatient Care

10.1007/978-3-030-82052-7_4 ◽

2021 ◽

pp. 21-33

Author(s):

Ian Qianhuang Wu ◽

Francesca Lorraine Wei Inng Lim ◽

Liang Piu Koh

Keyword(s):

T Cell ◽

Cancer Care ◽

Hospital Admissions ◽

Care Delivery ◽

Cost Effective ◽

Outpatient Setting ◽

Cancer Center ◽

T Cell Therapy ◽

Car T Cell Therapy ◽

Near Future

AbstractManagement of haematology-oncology patients has historically been largely inpatient-based. With advances in the understanding of disease and improvements in supportive care, patients are increasingly being managed in the outpatient setting. This is especially evident in autologous stem cell transplantation, which is now routinely done as an outpatient procedure at various centres. As clinicians gain more experience in novel therapies such as chimeric antigen receptor (CAR)-T cell therapy and bispecific T cell engager (BiTE) therapy, these may potentially be administered in the outpatient setting in the near future with the adoption of a risk-stratified approach. Such a paradigm shift in the practice of haematology-oncology is inevitable and has been driven by several factors, including pressure from the institution/hospital to avoid unnecessary hospital admissions and for optimal use of inpatient resources to be more cost-effective and efficient. With favourable local regulations and funding, outpatient cancer care can be economically beneficial. The success of an outpatient cancer center is heavily dependent on planning the facility to be equipped with the appropriate infrastructure, together with the trained medical and supportive personnel in place. This, coupled with the utilization of emerging technology such as telemedicine, has the potential to revolutionize cancer care delivery in the outpatient setting.

Download Full-text

Individualized Molecular Profiling for Allocation to Clinical Trials Singapore Study—An Asian Tertiary Cancer Center Experience

JCO Precision Oncology ◽

10.1200/po.20.00261 ◽

2021 ◽

pp. 859-875

Author(s):

Amanda O. L. Seet ◽

Aaron C. Tan ◽

Tira J. Tan ◽

Matthew C. H. Ng ◽

David W. M. Tai ◽

...

Keyword(s):

Clinical Trial ◽

Clinical Trials ◽

Tumor Tissue ◽

Molecular Profiling ◽

Tumor Board ◽

Cancer Center ◽

Precision Oncology ◽

Molecular Tumor Board ◽

Tumor Types ◽

Tertiary Cancer Center

PURPOSE Precision oncology has transformed the management of advanced cancers through implementation of advanced molecular profiling technologies to identify increasingly defined subsets of patients and match them to appropriate therapy. We report outcomes of a prospective molecular profiling study in a high-volume Asian tertiary cancer center. PATIENTS AND METHODS Patients with advanced cancer were enrolled onto a prospective protocol for genomic profiling, the Individualized Molecular Profiling for Allocation to Clinical Trials Singapore study, at the National Cancer Center Singapore. Primary objective was to identify molecular biomarkers in patient's tumors for allocation to clinical trials. The study commenced in February 2012 and is ongoing, with the results of all patients who underwent multiplex next-generation sequencing (NGS) testing until December 2018 presented here. The results were discussed at a molecular tumor board where recommendations for allocation to biomarker-directed trials or targeted therapies were made. RESULTS One thousand fifteen patients were enrolled with a median age of 58 years (range 20-83 years). Most common tumor types were lung adenocarcinoma (26%), colorectal cancer (15%), and breast cancer (12%). A total of 1,064 NGS assays were performed, on fresh tumor tissue for 369 (35%) and archival tumor tissue for 687 (65%) assays. TP53 (39%) alterations were most common, followed by EGFR (21%), KRAS (14%), and PIK3CA (10%). Of 405 NGS assays with potentially actionable alterations, 111 (27%) were allocated to a clinical trial after molecular tumor board and 20 (4.9%) were enrolled on a molecularly matched clinical trial. Gene fusions were detected in 23 of 311 (7%) patients tested, including rare fusions in new tumor types and known fusions in rare tumors. CONCLUSION Individualized Molecular Profiling for Allocation to Clinical Trials Singapore demonstrates the feasibility of a prospective broad molecular profiling program in an Asian tertiary cancer center, with the ability to develop and adapt to a dynamic landscape of precision oncology.

Download Full-text

Integrating Diversity, Equity, and Inclusion Approaches Into Treatment of Commercial Tobacco Use for Optimal Cancer Care Delivery

Journal of the National Comprehensive Cancer Network ◽

10.6004/jnccn.2021.7091 ◽

2021 ◽

Vol 19 (Suppl_1) ◽

pp. S4-S7

Author(s):

_ _

Keyword(s):

Tobacco Use ◽

Cancer Care ◽

Community Organization ◽

Care Delivery ◽

Cancer Control ◽

Population Level ◽

Cancer Center ◽

Tobacco Treatment ◽

Incidence And Mortality ◽

Equity And Inclusion

Tobacco-related cancer incidence and mortality and commercial tobacco use have decreased steadily in recent decades, but improvements have not been equitably experienced across population subgroups. A complex interaction across socioecological domains of individual, interpersonal, community/organization, and societal/policy factors influence disparities in tobacco use, treatment, and related health outcomes. NCI’s Cancer Center Cessation Initiative (C3I) provides an ideal platform to examine and intervene on multilevel influences across the cancer control continuum to reduce any disproportionate tobacco-related burden and eliminate tobacco-related disparities. The C3I Diversity, Equity, and Inclusion (DEI) Working Group encourages cancer centers to develop, evaluate, and adopt evidence-based practices regarding DEI for prevention and treatment of commercial tobacco use across the cancer control continuum. This paper highlights how 3 C3I sites intervene to address socioecological influences on tobacco use among racially, ethnically, socioeconomically, and geographically diverse patient subgroups. It then outlines ways in which DEI considerations could be integrated into research with patients with cancer who use tobacco and practices related to standards of cancer care. Incorporating DEI considerations in the pursuit of optimal tobacco treatment could facilitate elimination of inequities in population-level cancer outcomes, spanning the full continuum of cancer care from prevention to survivorship.

Download Full-text

45. Molecular tumor board efforts at Vanderbilt-Ingram Cancer Center

Cancer Genetics ◽

10.1016/j.cancergen.2019.04.051 ◽

2019 ◽

Vol 233-234 ◽

pp. S18

Author(s):

Neha Jain ◽

Christine Micheel ◽

Justin Balko ◽

Christine Lovly ◽

Ben Park

Keyword(s):

Tumor Board ◽

Cancer Center ◽

Molecular Tumor Board

Download Full-text

Systematic identification of metastatic population subsets for advance care planning (ACP) discussions: A scalable approach using electronic health record (EHR) technology.

Journal of Clinical Oncology ◽

10.1200/jco.2013.31.31_suppl.243 ◽

2013 ◽

Vol 31 (31_suppl) ◽

pp. 243-243

Author(s):

Cynthia Taniguchi ◽

Kevin Donald Olson ◽

Deb Harrison ◽

J. Russell Hoverman ◽

Aimee Ginsburg Arlen ◽

...

Keyword(s):

Clinical Data ◽

Cancer Care ◽

Care Delivery ◽

Data Extraction ◽

Disease Status ◽

Extraction Process ◽

Cancer Center ◽

Patient Identification ◽

Clinical Criteria ◽

Data Elements

243 Background: Comprehensive cancer care embraces the concept of having timely discussions with patients about end of life care preferences regarding treatment interventions. Physicians and healthcare teams are frequently challenged with identifying patients who are clinically appropriate for these discussions and subsequent management of ACP work within the context of clinic resource capacity. A data extraction process is needed to systematically identify cancer population subsets for ACP based on clinical data elements maintained within an EHR database. Methods: Seven cancer center sites of service participated in a 90-day pilot study for delivering ACP services to discrete patient populations who it was believed would most benefit from ACP. Electronic methodology was developed and tested through the pilot process to systematically identify those patients having documented evidence of designated clinical criteria, including metastatic disease status. Metastatic status was determined using five clinical data elements. EHR technology enabled further targeting by cancer diagnoses and allowed this program to be scalable to individual practice capacity. Additional filtering capability was incorporated to exclude non-applicable patient records. Results: On a weekly basis, each pilot site received a report of eligible patients based on clinical criteria and practice-specific diagnoses. During the 90-day pilot period, sites collectively identified an average of 871 patients per week who met clinically-based selection criteria. Once a patient was identified, physicians were able to determine if the patient was appropriate for ACP introduction. The systematic patient identification process allowed ACP to be easily integrated into mainstream practice workflow. Conclusions: EHR technology is invaluable for strategically identifying cancer patient population subsets for clinically appropriate delivery of ACP services. Automated notification of eligible patients and the ability to filter the population enabled practices to engage the ACP process wholly within the scope of comprehensive cancer care delivery.

Download Full-text

A virtual tumor board-driven synaptic knowledge network.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.8_suppl.89 ◽

2017 ◽

Vol 35 (8_suppl) ◽

pp. 89-89

Author(s):

Laurence J. Heifetz ◽

Ahrin B. Koppel ◽

Elaine Melissa Kaime ◽

Daphne Palmer ◽

Thomas John Semrad ◽

...

Keyword(s):

Clinical Trial ◽

Rural Areas ◽

Cancer Care ◽

Knowledge Network ◽

Tumor Board ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Hospital District ◽

Number Of Patients ◽

Tumor Boards

89 Background: In 2006, Tahoe Forest Hospital District—a 25-bed hospital in Truckee, CA, a mountain resort community one hour from regional and two hours from academic cancer services—designed and implemented an oncology program utilizing effective telecommunications with a committed academic partner, the UC Davis Comprehensive Cancer Center in Sacramento. Methods: The UC Davis Cancer Care Network was established with four remote cancer programs, enabling participation in daily virtual tumor boards, clinical trial enrollment, and quality assurance assistance. (Richard J. Bold, et. al., Virtual tumor boards: community-university collaboration to improve quality of care. Community Oncol 10(11):310-315, November 2013.; Laurence J. Heifetz, MD, et. al., A Model for Rural Oncology. J Oncol Pract, 7:168-171, May 2011.). An increasing number of patients were observed to in-migrate to Truckee from even more remote rural areas in the mountains. In 2013, the now Gene Upshaw Memorial Tahoe Forest Cancer Center developed four remote telemedicine clinics to allow even more physically distant patients the capacity to be followed locally. Results: Since we opened the remote telemedicine clinics, our Sullivan-Luallin patient satisfaction scores have averaged 4.82/5.00 for “overall satisfaction with the practice” and 4.90/5.00 for “recommending your provider to others”; our in-migration rate of patients from outside our primary catchment area increased from 43% to 52%: and clinical trial accrual rate averaged 10%. Conclusions: Reducing cancer health disparities is an ASCO mission. (cover, ASCO Connection, July 2014; Laurence J. Heifetz, MD. Country Docs with City Technology Can Address Rural Cancer Care Disparities. Oncol, 29(9):641-644, September 2015.). We believe this synaptic knowledge network effectively addresses that mission for rural communities. This model can be scaled in many configurations to address the inherent degradation of quality care as a function of physical distance to an academic center that rural doctors and patients deal with on a daily basis. The key is to insist on a cultural shift – Do something smart at lunch every day. Attend a virtual tumor board.

Download Full-text

Understanding practices and gaps in multidisciplinary hepatocellular carcinoma (HCC) care within the community oncology setting.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.4_suppl.390 ◽

2019 ◽

Vol 37 (4_suppl) ◽

pp. 390-390

Author(s):

Lorna Lucas ◽

Philip Agop Philip ◽

Marianne Gandee ◽

Amanda Kramar

Keyword(s):

Clinical Trials ◽

Community Care ◽

Care Delivery ◽

Delayed Diagnosis ◽

Multidisciplinary Care ◽

Tumor Board ◽

Cancer Center ◽

Multidisciplinary Teams ◽

Nccn Guidelines ◽

Psychosocial Services

390 Background: HCC incidence continues to rise and presents a myriad of complex challenges involving multi disciplines to screen, diagnose, and provide personalized therapy. Recent advances in diagnostics and therapies necessitate a well-coordinated multidisciplinary approach in managing HCC patients, signaling a need to understand care within community care. The study aimed to understand how multidisciplinary cancer programs were structured to manage HCC care and to identify challenges and practices for management of HCC, a cancer less commonly seen in community care settings. Methods: The Association of Community Cancer Centers (ACCC) developed a survey to identify factors associated with delivery and coordination of care for HCC patients. The survey deployed electronically in July 2018 to multidisciplinary providers, representing 17 oncology professions. Of responses (n = 31), 69% identified their care setting as a “non-teaching community hospital, freestanding cancer center, private practice or other.” Results: 61% of respondents indicated their cancer programs do not have specialized hepatobiliary multidisciplinary team. Among those who have hepatobiliary multidisciplinary teams the composition and degree of specialization varied. 85% of respondents that do not have a specialized hepatobiliary team indicated that HCC patients are managed in consultation with a general tumor board. 52% indicated their program discussed participation in clinical trials with all HCC patients, and 55% of cancer programs conducted HCC clinical trials. 52% indicated their program had a formal pathway that outlines adherence to the NCCN guidelines for HCC management, 5% were in the process of developing and 43% were not in the process of developing such a pathway. Of respondents that reported barriers their program faces (n = 13) 31% indicated lack of psychosocial services, lack of screening and no/limited access to clinical trials. 23% responded delayed treatment and 15% responded delayed diagnosis as challenges. Conclusions: Review of multidisciplinary care delivery for HCC patients revealed unique protocols and challenges within primarily community-based settings.

Download Full-text

The cancer care network clinical trials program: Rising from the camp fire ashes.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.27_suppl.168 ◽

2019 ◽

Vol 37 (27_suppl) ◽

pp. 168-168

Author(s):

Ofilio Ramon Vigil ◽

Dana Ann Little ◽

Kristin J. Mensonides ◽

Richard J. Bold

Keyword(s):

Clinical Trial ◽

Clinical Trials ◽

Rural Communities ◽

Cancer Care ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Trial Participation ◽

Care Network ◽

Research Oversight ◽

The City

168 Background: The UC Davis Health Cancer Care Network (CCN) in Sacramento improves quality through partnerships with community cancer centers and the UC Davis Comprehensive Cancer Center (UCDCCC). The UCDCCC, as an NCI Lead Academic Participating Site (LAPS) grant recipient, lists Adventist Health Rideout Cancer Center (RCC) in Marysville (42 miles north of Sacramento) as a component. The Adventist Health Feather River Cancer Center (FRCC) and the town of Paradise were devastated by the 2018 Camp Fire, forcing FRCC’s relocation to the city of Chico (49 miles north of Marysville). FRCC was forced to disband its local IRB and unable to continue clinical trials research operations during the aftermath of this natural disaster. The CCN established an affiliation with the FRCC in April 2019. Future plans include establishing an IRB agreement and adding FRCC as a LAPS component. The CCN identified strategies to facilitate the participation of FRCC patients in clinical trials. Methods: The CCN identified 13 NCTN clinical trials with 34 enrolled patients that were in need of appropriate research oversight. Four of these trials were previously never activated at the UCDCCC or its affiliates. CCN staff engaged leaders at the various institutions involved: Quality Assurance (QA) Managers at each NCTN research base, the CIRB, the local IRB, the CTSU, and other leaders within UC Davis and Adventist Health. Results: Stakeholders acknowledged the unusual and urgent nature of our requests and questions, while contributing to the development of a plan allowing patients to continue clinical trial participation. QA managers approved a plan transferring patients to the RCC, allowing research staff to collect and submit data while patients continue receiving care closer to home. Together we developed a notification letter to inform patients of this plan. Conclusions: The relocation of facilities and patients brought rare challenges while conducting clinical research in rural communities. We learned that the cooperation and flexibility of all parties involved was crucial in supporting the continued care for FRCC's clinical trial patients and research contributions.

Download Full-text