2015 Innovations in Cancer Treatment and Care Conference

Griffith is a multicultural city in south-western NSW, with a population of 16,972, with a greater population living in the surrounding rural and remote areas. Palliative Care & End of Life [EOL] Services, were being provided by a wide range of service providers, in both acute and community sectors. Despite Strategic Planning and Model of Care directives, variation in the integration of services and a lack of resources meant that patients and carers were subject to variations in methods of service delivery.

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Palliative Patient Journeys—providing services in a regional and rural setting

Author

Ms Annie Williams

Aims

To ensure equity of access and service delivery to palliative care patients, and their families and carers, that is tailored to meet their needs and provide for, and meet, the challenges of their geographic locations.

Method

Using Redesign Methodology, this initiative has worked extensively to obtain patient, carer and stakeholder perspective as a key diagnostic and planning tool to assess the effectiveness of current service delivery models, and to identify and prioritise opportunities to improve services and streamline the patient journey.

Results

Development of local solutions to ensure:

• Agreement of a shared vision for palliative and EOL services within the wider Griffith community and referral areas
• Patients and Carers actively involved in future service planning to ensure that efficient and effective service delivery models to meet the needs and expectations of persons with complex healthcare needs.
• Implementation of collaborative multi sector partnerships to drive process and service improvements in patient focussed delivery of Palliative and End of Life [EOL) services within Griffith and its rural referral communities.

Implications

• Patients and Carers have the opportunity to directly contribute to process improvement initiatives under the Redesign framework
• Adaptation of Palliative Care Services Models of Care to be readily transferrable to regional and rural settings
• Extrapolation of lessons learnt to other "hub and spoke" models of clinical service delivery.

Review by a Multidisciplinary Team (MDT) has been shown to lead to increased rates of surgical resection, radiotherapy, chemotherapy and timeliness of care. Most recently, the Victorian lung cancer patterns of care study have found that MDT review is an independent predictor of lung cancer survival.

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Predictors of MDT review and the impact on lung cancer survival for HNELHD residents treated in the public sector from Cancer Institute NSW

Authors

Tracey E, Gupta S, Kaminski D, Troke P, Proietto A

Aims

1. To examine predictors of lung cancer MDT review in the HNELHD after adjusting for patient, tumour, treatment and system factors
2. To determine whether MDT review is an independent predictor of survival 

Method

Hunter New England residents diagnosed with lung cancer between January 1^st 2009 and June 30^th2013 obtained from the Clinical Cancer Registry were linked to HNE Lung Cancer MDT surveys obtained from ARIA. Exclusions: Private patients reviewed by the MDT that had not also been treated in the public sector and patients who were treated outside the LHD. Logistic regression was used to estimate predictors of MDT review and proportional hazards regression modelling was used to analyse survival.

Results

Of the 2,167 individuals with lung cancer 411 or 20% were reviewed at the MDT. The odds of MDT review were higher for stage 2 patients; if cytological or histologically verified; four times more likely if treated at Calvary Mater or John Hunter; if undergoing radiotherapy treatment and if seen by a specialist nurse. A Lower odds of MDT review was observed for patients with stages III and IV, unknown or unstaged; those referred to Palliative Care and those who died within a month of diagnosis. MDT review was found to be an independent predictor of survival with a 21% lower hazard of death (HR 0.79 95% CI 0.20–to0.90). After adjustment for sex, age, aboriginal status, TNM stage, histological subtype, surgery, chemotherapy, radiotherapy, palliative care and hospital of treatment. Further stratification by stage and after adjustment for other covariates showed that stage III patients had the most marked survival advantage HR (0.59 95%CI 0.45–to0.77).

Implications

Current guidelines recommend that all lung cancer patients be reviewed at an MDT given that this is not feasible targeting stage III patients would appear to confer a significant survival advantage.

Hepatocellular cancer (HCC) is among the top 10 causes of cancer death in Australia, with ~80% of cases attributable to chronic viral hepatitis. Although 60–to80% of HCCs are preventable by antiviral therapies, multiple barriers exist in the diagnostic and treatment continuum. Chronic hepatitis B (CHB) is the main cause for rising HCC rates in Western Sydney, where the greatest burden of disease is among people born in hepatitis B endemic countries.

Primary content

Hepatocellular cancer (HCC) is among the top 10 causes of cancer death in Australia, with ~80% of cases attributable to chronic viral hepatitis. Although 60–to80% of HCCs are preventable by antiviral therapies, multiple barriers exist in the diagnostic and treatment continuum. Chronic hepatitis B (CHB) is the main cause for rising HCC rates in Western Sydney, where the greatest burden of disease is among people born in hepatitis B endemic countries.

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Implementing a shared care model to prevent liver cancer and improve chronic hepatitis B outcomes in a high disease prevalence area from Cancer Institute NSW

Authors

Kristen Stone, Monica Robotin, Mamta Porwal, Jacob George

Aims

To provide a high quality, effective and supportive service to General Practitioners and the local community in order to increase the level of understanding surrounding the relationship between chronic hepatitis B and liver cancer, and through this increase the uptake of antiviral therapy and decrease the overall burden of end stage liver disease and liver cancer. 

Method

A shared care model of CHB management was developed to support local general practitioners to deliver optimal care for their CHB patients. The model ensures GPs are supported by a clinical nurse specialist in triaging patients with CHB and referral to local liver specialists (as necessitated) according to current management guidelines.

Results          

Since program inception in March 2015, 120 patients have been enrolled across two general practices at Blacktown and Auburn in the Western Sydney local government area. All patients have been triaged into an appropriate pathway of ongoing monitoring and care, including a recommended surveillance interval for early detection of HCC.  Ten patients commenced antiviral treatment and were effectively transitioned back to their general practitioner.

Implications

Piloting a shared care model of CHB management led to timely referral, monitoring and surveillance of patients, thereby assisting in the prevention of HCC in the populations at risk. Implementing a system to allow for the tracking of patient results and HCC surveillance requirements means patients are engaged in a program that ensures cancer screening is correctly implemented. This model also empowers GP’s in the process of caring for their patients with CHB in an environment in which the patients feel comfortable.

The commonly understood model of shift to shift nursing handover does not apply to most ambulatory day treatment units. Nonetheless, ‘handover’ of patient clinical information remains quintessential to safe clinical practice. Of considerable interest is how EMR may aid the transfer of patient clinical information in these circumstances and address the question: does this facilitate improved patient care?

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Optimising the Model of Care for Patient Management at The Tweed Cancer Care and Haematology Unit – Handover utilising MOSAIQ EMR. from Cancer Institute NSW

Authors

Brendan Esposito

Aims

To demonstrate the effectiveness of morning handover utilising MOSAIQ EMR within Cancer Care and Haematology at The Tweed Hospital and its’ impact on patient care delivery.

Method

The methods used in this project to establish the impact of the handover utilising EMR on patient care delivery included the following:

• A Comparison of Handover utilising MOSAIQ to current local and national standards
• Benchmarking local Handover Practices
• Comparative Essentials of Care Observations and Staff Satisfaction Surveys
• Examination of Incidence Reports
• Interrogative EMR Patient Chart Audits

Results

• Handover utilising MOSAIQ EMR meets local and national standards with limited exceptions
• Handover practices vary widely locally
• EOC observations and staff satisfaction surveys indicate that handover using MOSIAQ is valued by staff and has resulted in greater staff satisfaction and a perception of safer and better coordinated patient care. A reduction in staff sick leave has also been observed in the period after the implementation of handover utilising MOSIAQ.
• Examination of incident reports suggest an improvement in patient safety and an improvement in inter-disciplinary communication.
• Interrogative chart audit: an increase was seen in the nursing assessments of patient blood results and the number of patients receiving chemotherapy education, prior to the patient receiving chemotherapy. The handover process has also resulted in an increase in the number of medical instructions being actioned by nursing staff. A similar increase is shown in the number of nursing plans being actioned by nursing staff.

Implications

It can be concluded that the dedicated, formalised, embedded and sequenced process of patient handover utilising MOSIAQ EMR to review patients, has positively impacted on the safety and care of patients and lead to improvements in staff satisfaction and feeling of collegiality. Handover is considered essential and valuable to the nursing practice within our service. This process meets National and local standards and is readily applicable to the local circumstances within our unit and may prove applicable in other ambulatory settings utilising EMR systems.

The Sydney West Translational Cancer Research Centre is a five year program grant funded by the Cancer Institute NSW aimed at improving patient outcomes through translational research. Multidisciplinary teams (MDTs) are key to the delivery of cancer care in Australia. There is a lack of knowledge and research into how these MDT teams can best be engaged in translational research from basic science through to implementation science and quality improvement.

Primary content

The Sydney West Translational Cancer Research Centre is a five year program grant funded by the Cancer Institute NSW aimed at improving patient outcomes through translational research. Multidisciplinary teams (MDTs) are key to the delivery of cancer care in Australia. There is a lack of knowledge and research into how these MDT teams can best be engaged in translational research from basic science through to implementation science and quality improvement.

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Engaging multidisciplinary teams in translational research and quality improvement fromCancer Institute NSW

Authors

Shaw, TJ.  T. Janssen, A. Museth, K. Robinson,   Harnett, P

Methods

The study used mixed methods to identify organizational systems and structures that support MDTs to engage in translational research and quality improvement. Structured observations were made of 43 MDT meetings across 8 tumour streams to determine how these teams engaged with translational research. Eighteen semi structured interviews were conducted with MDT leaders and champions to collect information about how teams interact with and generate research and implementation initiatives. From observations and interviews a series of interventions was described to support the engagement of MDTs in translational research. These interventions were presented at 2 focus groups at which a prioritization process was applied to determine which interventions were most acceptable and likely to have impact.

Results

A small number of MDT teams were active in basic research and clinical trials but few teams, if any, engaged with implementation science or quality improvement. Four interventions were prioritized as likely to have a significant impact on a team’s ability to engage in translational research and quality improvement. These included: access to high quality data around individual and team performance; research active team leaders; having experts such as basic scientists or implementation scientists embedded into teams on a regular basis; and having dedicated research or quality improvement-focused meetings.

Implications

This is the first project to systematically investigate and describe a series of interventions that can be applied to increase the engagement of MDTs in translational research and quality improvement. The current lack of engagement represents a considerable missed opportunity to engage clinical teams in research and quality improvement which is universally acknowledged as a key challenge. The authors are currently piloting the interventions across a number of tumour streams.

Over 50% of patients undergoing allogeneic BMT can now be expected to become long-term survivors. Unfortunately many survivors experience an increased risk of secondary cancers, infections and chronic diseases.

Primary content

Over 50% of patients undergoing allogeneic BMT can now be expected to become long-term survivors. Unfortunately many survivors experience an increased risk of secondary cancers, infections and chronic diseases.

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Secondary Cancers, Health Behaviour and Cancer Screening Adherence in survivors of Allogeneic Blood and Marrow Transplant (BMT) in NSW. from Cancer Institute NSW

Authors

Gemma Dyer, Stephen Larsen, Nicky Gilroy, Louisa Brown, Megan Hogg, Lisa Brice, Masura Kabir, Matt Greenwood, John Moore, Mark Hertzberg, John Kwan, Gillian Huang, Jeff Tan, Christopher Ward & Ian Kerridge.

Aims

Using a cross-sectional descriptive survey, we sought to identify the incidence of secondary cancers and adherence with recommended cancer screening and preventative practices in BMT survivors. 

Method

BMT survivors aged over 18 and transplanted between 2000–to2012 in NSW were eligible to participate.  Survivors completed the Sydney Post BMT Study survey, the FACT-BMT (V4), the Chronic GvHD Activity Assessment Self Report, the Lee Chronic GvHD Symptom Scale, DASS21, the Post Traumatic Growth Inventory and the Fear of Recurrence Scale. 

Results

583 survivors were contacted and 443 (78%) responded.  Median age was 54 years (range 19–to79 yrs). Median duration post transplantation was 5 yrs (range: 1–to22 yrs). One hundred and seven (24.1%) reported a diagnosis of at least one cancer following BMT: 7 (1.6%) reported mouth cancer; 94 (21.2%) skin cancers and 17 (3.8%) another malignancy type, unrelated to their pre-transplant cancer diagnosis.

High risk health behaviours such as smoking, drinking (more than 14 standard drinks/per week) and not being ‘sun smart’ were reported by 7.5%, 7.7% and 22.9% survivors respectively. Thirty-two percent were overweight, and 16% obese.  Regular exercise (at least 3 times per week) was reported by 200 (45.1%) of survey respondents.

Uptake of cancer screening was poor post transplant in particular for bowel (32.3%) and in males, prostate checks (36%).

Implications

This study identifies gaps in screening and preventative practices in an Australian cohort of BMT survivors, and identifies the burden of secondary malignancies. Education and counselling with regard to health promotion, high risk health behaviour, and secondary cancers is vital both pre and post transplant.  The development and implementation of a long term model of care that incorporates the BMT team and the survivor’s GP, and utilises current free Australian cancer screening programs at a minimum, are needed to prevent morbidity and mortality in long term BMT survivors.

Illawarra Shoalhaven Cancer and Haematology Network (ISCaHN) has been using an oncology information system (OIS) as a complete electronic record for over 4 years. There has been both considerable and valuable treatment data generated at the point of care. Are we able to rapidly assess the outcomes of our own treatment data, and use this outcome data to help inform the delivery of care to our patients?

Primary content

Illawarra Shoalhaven Cancer and Haematology Network (ISCaHN) has been using an oncology information system (OIS) as a complete electronic record for over 4 years. There has been both considerable and valuable treatment data generated at the point of care. Are we able to rapidly assess the outcomes of our own treatment data, and use this outcome data to help inform the delivery of care to our patients?

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ISCaHN Treatment Dashboard: Providing clinician decision support with data generated at the point of care from Cancer Institute NSW

Authors

Graeme Bell and Dr Chee Fon Chang

Aims

The aim of the dashboard is to present data extracted in real time from the OIS that is accessible and actionable for clinicians. The aim of the dashboard is to provide clinicians with a clinical decision tool, informed by their own treatment data.

Method

A reporting connection to the operation database (MOSAIQ) allows for real-time data retrieval. The report was built with specific data points defined. The data was then displayed in several pivot tables, which are built to display the pre-determined treatment outcomes, toxicity and demographic data.

These dashboard elements have built-in capabilities to add filters and drill downs, hence allowing the displayed data to be disseminated further. This gives the clinicians control to dissect the data further and additional insights for decision making. 

Results

Outcomes reported in the dashboard include treatment timeliness, cessation rates, deceased on treatment rates, discontinued treatment rates, and a select number of reported toxicities. These outcomes may then be filtered on a number of patient demographic data including stage of disease, age, gender and ECOG status.

The dashboard also provides an ability to compare outcomes between specific care plans. This paper will discuss a specific example of this in action. Treatment data from the prescription of Nivolumab will be compared with that of Ipilimumab treatment data. This treatment data displays high toxicity, cessation of treatment and disease progression from Ipilimumab, particularly when compared with Nivolumab treatment outcomes.

Implications

The dashboard provides ISCaHN clinicians with the data to ensure that our care is safe, appropriate, and effective with efficacious results. Data displayed in the dashboard, combined with evidence-based medicine and proven treatments, will ensure high quality patient treatment outcomes.

Current clinical electronic health record systems do not provide accessible information for quality assurance and research purposes. Furthermore, data entry is limited due to inappropriate and/or insufficient fields.

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A Real-Time Prostate Cancer Radiotherapy Research Database from Cancer Institute NSW

Authors

A/Prof Thomas Eade, A/Prof Andrew Kneebone, Lesley Guo, Dr Thilo Schuler, Mary-Anne Brancato

Aims

To collect and store real-time clinico-pathological data on prostate cancer patients referred to radiotherapy at Royal North Shore Hospital’s Northern Sydney Cancer Centre (NSCC).

Method

In 2007 specific prostate cancer tables and data fields were established by NSCC clinicians to create an ethically-approved in-house electronic relational database in Microsoft Access. This database was implemented for use during standard care, designed and used by the clinicians. Ongoing improvements were made to the database to accommodate clinical requirements and encourage clinician use. This ensured a high proportion of completed data. For this abstract we have perfomed a systematic analysis of the database and its data quality, peer reviewed publications and clinical audits facilitated. We reviewed all patients in the database, excluding patients who were not treated at the NSCC.

Results

Since 2007 there have been 1660 patients added into the database with key baseline demographics and medical history collected on more than 90% of these patients. Radiation therapy treatment at NSCC was given to 1292 (78%) patients and follow-up occurred on 1160 patients; with follow-up data completed (≥24 months) in 469 patients. Phone folow-up commenced in 2014 and 801 patients have agreed to this option. From this data, five clinical audits have been conducted on various prostate cancer outcomes. Additionally, 24 peer-reviewed publications and 26 published abstracts have been produced.

Implications

Real time data collection by clinicians which can be used to aid clinical decision making, for audit and research is possible in the NSCC environment. Limitations of an Access platform need to be overcome to increase the utility of real time data collection.

Computed tomography ventilation imaging (CTVI) is an exciting new functional lung imaging modality enabling functionally adaptive lung cancer radiotherapy treatments. In 2015, this became clinical reality with the first patient treatment performed in the US. Unfortunately the development of new CTVI workflows in the clinic can be challenging, due to the requisite advanced four-dimensional (4D) image processing. To overcome this, we have developed VESPIR (VEntilation via Scripted Pulmonary Image Registration), a user-friendly software toolkit to help streamline the end-to-end validation of CTVI workflows in the clinic.

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Introducing VESPIR: a new open-source software to investigate CT ventilation imaging in lung cancer radiotherapy from Cancer Institute NSW

Authors

John Kipritidis, Henry C. Woodruff, Paul J. Keall

Aims

In this CINSW supported work, we present a number of examples demonstrating the power of VESPIR to generate and validate CTVIs against nuclear medicine ventilation images of lung cancer patients acquired at Australian institutions.

Method

VESPIR is a collection of modular software functions allowing the user to easily script the major steps of CTVI generation and validation based on routine 4DCT lung scans. This includes: (i) lung segmentation, (ii) deformable image registration (DIR) between exhale/inhale images, (iii) ventilation quantification in terms of breathing-induced lung density and/or volume change, and optional evaluation of (iv) DIR accuracy in terms of anatomic feature matching, and (v) CTVI accuracy in terms of voxel-wise agreement with ground truth clinical ventilation imaging. VESPIR is being made available as an open-source MATLAB toolkit and a standalone executable, and supports a number of different clinical CT image types (4DCT, breath-hold CT and on-line cone beam CT).

Results

Compared to nuclear medicine ventilation imaging, CTVI typically yields voxel-wise Spearman correlations in the range 0.4–to0.6 indicating moderate or better accuracy of CTVI versus ground truth ventilation. The accuracy of CTVIs can vary with DIR parameters (accuracy) and the choice of ventilation quantification metric.

Implications

VESPIR puts CTVI into the hands of clinicians and provides the first convenient means of investigating CTVI accuracy across different algorithm parameters and clinical settings. We invite all interested users to provide feedback on this tool.

We examined the possible utility of using Cancer Institute NSW Clinical Cancer Registry data by examining one contentious issue in radiation oncology as an example. Increasing evidence has been published about the safety and efficacy of hypofractionated radiotherapy, in comparison with standard fractionation, in early, node-negative breast cancer.

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One example of how Clinical Cancer Registry level data can review practice variation - assessment of the variations in use of hypofractionation in NSW 2007–to2012 for early, node-negative breast cancer. 

Authors

G. Delaney^1–to2'³, S. Gandhidasan^l, F.Terlich⁴, D. Baker'', R.Walton⁴, D.Currow⁴ 

Aims

The study aim was to investigate the hypofractionation regimen variations in NSW public radiation oncology facilities.

Method

Data from the NSW Clinical Cancer Registry were extracted. Inclusion criteria included node negative breast cancer (TNM stage I or IIA), diagnosis date 2007–to2012 and year of radiotherapy treatment 2008–to2012. Data extracted included dose, fractionation type, patient age, distance from treatment facility, year of diagnosis, year of treatment, laterality of treatment and treatment department. Standard fractionation was defined as dose per fraction of 1.8 –to 2,4 Gy per fraction and hypofractionation as >2.4 Gy per fraction. Variations in practice were analysed. Logistic regression was performed to examine possible reasons for variation in practice.

Results

Of the 6124 patients fulfilling study criteria, 3986 patients (65.1%) had standard fractionation and 2138 patients (34.9%) hypofractionation in 14 NSW public radiotherapy centres. There was a spread of fractionation used across departments ranging from 6% to 92%. Hypofractionation use exceeded 50% in 4 departments. Logistic regression modelling showed that increasing age, right sided lesions, increasing distance from a treating facility and later year of treatment all predicted a greater likelihood of receiving hypofraction (p<0.01 for all factors). However, the model fit was poor and the likelihood of being treated was much more influenced by the facility in which patients received their therapy and the specific treating radiation oncologist.

Implications

While hypofractionation is becoming more common, there remain a substantial proportion of patients for whom hypofractionation would be considered appropriate who are not receiving hypofractionation. Understanding factors that predict treatment variations assist in developing strategies to address the issue. Hypofractionation for early breast cancer being adopted more widely would lead to greater patient convenience, better resource efficiencies and perhaps increase the use of post-lumpectomy radiotherapy, as some patients might currently forego radiotherapy due to perceived inconvenience of standardly fractionated radiotherapy.

Organisations

¹Cancer Therapy Centre, Liverpool Hospital;

²UNSW Australia

³Ingham Institute of Applied Medical Research

⁴Cancer Institute NSW

Routine electronic storage of medical records and imaging is becoming standard practice in radiotherapy. There is immense potential to utilise this increasingly diverse data resource as an evidence base for decision support systems for cancer prognosis and subsequent personalised treatment decisions. A distributed learning infrastructure has been established that links prediction models across NSW radiotherapy clinics. Patient data remains at all times within its clinic of origin while model parameters and statistics are shared between clinics to allow decisions based on broader sources of evidence whilst still protecting privacy.

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A distributed data mining network infrastructure for Australian radiotherapy decision support from Cancer Institute NSW

Authors

Matthew Field, University of Sydney; Mohamed Samir Barakat, University of Sydney; Michael Bailey, Illawarra Cancer Care Centre; Martin Carolan, Illawarra Cancer Care Centre; Andre Dekker, MAASTRO Clinic; Geoff Delaney, Liverpool Hospital; Gary Goozee, Liverpool Hospital; Lois Holloway, Liverpool Hospital; Joerg Lehmann, University of Sydney; Tim Lustberg, MAASTRO Clinic; Johan van Soest, MAASTRO Clinic; Jonathan Sykes, Westmead Cancer Therapy Centre; Sean Walsh, MAASTRO Clinic; David Thwaites, University of Sydney.

Aims

To facilitate the improvement of radiotherapy decision support systems by combining routinely-available information from multiple NSW cancer centres in a data-protected manner. To use bioinformatics tools for data-mining and modelling that provides meaningful decision support systems (DSS) integrating both radiomics (imaging-based) and clinical patient features. 

Method

The computer assisted theragnostics (CAT) system, as developed by our international collaborators at MAASTRO clinic, was used for compiling a standardized and de-identified clinical and imaging databases [1]. An Australian research cloud computing server was used to host a distribution program written as a Java web service. This service was designed to send a compiled support vector machine classifier to each clinic and allow the algorithm to then send and receive parameters between each clinic to construct a consensus prediction model.

Results

The CAT system for lung cancer diagnosis was installed in three clinics, Liverpool, Illawarra and Westmead Cancer Care Centre with an unfiltered cohort of 4650, 2004, 1453 patients respectively. The distribution infrastructure was then tested with simulated data points. The result was confirmed by repeating the algorithm when centralising this simulated data. The accuracy of prediction on a withheld test data set was higher when using the consensus prediction model versus each localised model.

Implications

It is feasible to train prediction models based on large cohorts of patients across multiple clinics while satisfying the data privacy rights of the patients. Using this system we intend to construct clinical decision support systems that stratify patients into treatment regimens such as curative or palliative radiotherapy dosages.

References

[1] Dekker, Andre, Shalini Vinod, Lois Holloway, Cary Oberije, Armia George, Gary Goozee, Geoff P. Delaney, Philippe Lambin, and David Thwaites. “Rapid Learning in Practice: A Lung Cancer Survival Decision Support System in Routine Patient Care Data.” Radiotherapy and Oncology 113, no. 1 (October 2014): 47–to53. doi:10.1016/j.radonc.2014.08.013.

Curative lung radiotherapy has historically been hampered by inadequate imaging techniques. Conventional CT provides poor information regarding tumour shape, size and motion throughout the patient’s breathing cycle. Consequently lung radiotherapy techniques have been characterised by excessively large targets to ensure the actual tumour receives the intended treatment.

Primary content

Curative lung radiotherapy has historically been hampered by inadequate imaging techniques. Conventional CT provides poor information regarding tumour shape, size and motion throughout the patient’s breathing cycle. Consequently lung radiotherapy techniques have been characterised by excessively large targets to ensure the actual tumour receives the intended treatment.

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4DCT driving improved lung radiotherapy outcomes at NCCI from Cancer Institute NSW

Authors

Lisa Connors, Vanessa Connors, Amara Fonseca, Pat Dwyer, Andrew Last and Gareth Livingston.

Aims

NCCI implemented new (4DCT) technology in 2012 to overcome limitations inherent in lung radiotherapy. The information and precision afforded by 4DCT will provide the framework to drive improved radiotherapy treatments for both early and late stage diseases.

Method

4DCT allows the target to be viewed in each phase of the breathing cycle. This patient specific information overcomes the need for excessive margins at the planning stage, whilst identification of the average tumour position (within the breathing cycle) allows for more accurate positioning of the patient/target prior to treatment commencing. For patients diagnosed with:

• Early Stage disease: increased precision in viewing the moving target may allow for ablative doses to be accurately delivered to small targets in as little as 3–to5 SABR treatments therefore improving local control rates.
• Later Stage disease: smaller margins are required to successfully treat larger tumours with curative doses, subsequently reducing the amount of healthy tissue receiving radiation and lowering rates of treatment related side effects.

Results

Analysis of the first 20 4DCT patients showed:

• A 9% (28cc) mean decrease in target size for 60% of patients
• Inadequate tumour coverage for 5% of patients using Conventional CT methods.
• Follow-up of a separate 30 patients treated with IMRT and 4DCT showed only 3% grade 3 oesophagitis and 0% grade 3 pulmonary toxicity (literature: 10–to20%)
• More than 25 patients have succeeded in having stereotactic ablative doses.

Implications

Implementation of SABR is likely to significantly improve disease control for suitable candidates whilst the shorter treatment regimen decreases pressure on waiting lists and reduces overall costs on the health system.

For patients receiving conventional dose regimens, low rates of grade 3 toxicities (characterised by hospital admission) mean both improvement in patients’ quality of life and a decrease in health costs.

4DCT = 4 Dimensional Computerized Tomography

IMRT = Intensity Modulated Radiotherapy

SABR = Stereotactic Ablative Radiotherapy

The implementation of image-guided technology and progressively conformal techniques in modern radiotherapy for the treatment of cancer, ensure the planned distribution of dose is well matched to the clinician-defined target volume. However, this precision relies on the target volume including all malignant tissue, with delineation uncertainty resulting in potential normal tissue toxicities and insufficient dose to the cancer. Methods need to be implemented to minimise delineation uncertainty, and subsequently improve local control and patient outcomes.

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Defining and assessing a delineation uncertainty margin for modern radiotherapy fromCancer Institute NSW

Authors

L R Bell; E M Pogson; P Metcalfe; L Holloway

Aims

To define and assess a target volume expansion margin to account for delineation uncertainty in modern radiotherapy.

Method

A whole breast radiotherapy cohort (n=21) with eight independent observer target volumes was utilised as a proof of concept. The cohort was divided into categories based on volume and laterality. The margin was defined as twice the standard deviation in target volumes, averaged for each category across all patients. The margin was defined at angular increments to account for the anisotropic nature of delineation uncertainty. Both cylindrical and spherical coordinates were investigated, with the delineation margin applied to the smallest, largest and consensus target volume on each patient. The overlap with each target volume was determined and an estimate of the amount of excess normal tissue included and missed tissue was made (Fig la). Cylindrical and spherical approaches were statistically compared. 

Results

Margin encompassment was high with >93% average overlap of observer target volumes. Spherically defined margins have significantly greater overlap than cylindrically (p<0.05). Average extra tissue (Fig lb) was <20% of the union of target volumes in all cases. There was no missed tissue. No significant differences (p<0.05) for extra and missed tissue between spherical and cylindrical approaches were observed.

Implications

This delineation margin for whole breast radiotherapy has >94% CTV encompassment, includes <20% extra tissue and misses no tissue when defined in both cylindrical and spherical coordinates. Spherically defined margins are more appropriate with superior CTV encompassment with no differences in extra tissue and missed tissue compared to cylindrical. Analysis should be performed to determine the dosimetric impact of this margin.

One in five women who survive breast cancer will develop lymphoedema of the upper body at some point in their life. Following breast surgery, women are recommended to follow strategies to minimise their lymphoedema risk (e.g., limiting exposure of the at-risk arm to trauma). Adherence to these strategies is typically less than optimal.

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Factors underlying adherence to lymphoedema risk reduction from Cancer Institute NSW

Authors

Sherman, K.A., Kilby, CJ., & Ridner, S.H.

Aims

Guided by psychological theory (i.e., the Cognitive-Social Health Information Processing and Common Sense models), this international comparative study aimed to identify individual and psychological factors associated with evidence-based lymphoedema risk reduction strategies (i.e., seeking medical advice at the first signs of lymphoedema, avoiding extreme temperatures such as experienced in a sauna, and avoiding trauma to the affected arm) in Australian and US breast cancer survivors.

Method

Respondents (N=597) completed measures of demographics and medical history, FACT-B Quality of Life physical subscale, Illness perception questionnaire (IPQ), lymphoedema perceived risk, lymphoedema knowledge, and beliefs about effectiveness of risk minimisation strategies (i.e., response efficacy), self-efficacy, and self-regulation of negative emotions regarding lymphoedema risk. Participants also reported their adherence to i) seeking medical advice at the first sign of lymphoedema, ii) avoiding extreme heat, and iii) avoiding trauma to the affected arm.

Results

Logistic regression analyses indicated that adherence to seeking medical advice was associated with greater response efficacy, illness coherence and emotional representation from the IPQ, women from the US, and women who had an axillary lymph node dissection (ALND). Avoiding extreme heat was associated with greater perceived risk, self-efficacy, illness coherence, emotional representation, a lower level of education, women who had undergone ALND, radiotherapy, and older women. Avoiding trauma was associated with greater perceived risk, self-regulation, illness coherence and emotional representation, perceived chronicity and cycling of lymphoedema from the IPQ, and women who were older and underwent ALND.

Implications

These findings highlight the importance of both individual and psychological factors in understanding adherence to lymphoedema risk minimisation strategies. Health professionals should strive to ensure at-risk women have a coherent understanding of psychological and physiological risks of lymphoedema, and self-efficacy, or confidence, in the effectiveness of proposed risk reduction strategies and their ability to enact these strategies.

The need for real-time access to outcomes data is well-recognized. However, providers, payers, and patients lack access to timely and relevant outcomes data to support informed decision-making and comparisons across providers and over time. To help address these gaps, MD Anderson initiated a project to develop patient-centered outcome measures and to integrate data collection within the electronic health record (EHR) in 2014.

Primary content

The need for real-time access to outcomes data is well-recognized. However, providers, payers, and patients lack access to timely and relevant outcomes data to support informed decision-making and comparisons across providers and over time. To help address these gaps, MD Anderson initiated a project to develop patient-centered outcome measures and to integrate data collection within the electronic health record (EHR) in 2014.

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Expedited patient-centered outcome measurement development for cancer care fromCancer Institute NSW

Authors

Tracy E. Spinks, Tinisha L. Mayo, Seohyun Lee, Thomas W. Feeley, MD

Aims

This project aims to: 1) apply an expedited, patient-centered approach to create disease-specific outcome measure sets for cancer care; and, 2) establish routine outcomes data collection, including patient-reported outcomes (PRO), within the EHR.

Method

Clinical, quality, and data experts collaborated to define cancer-specific outcome measure sets. A three-tiered outcomes hierarchy developed by Michael Porter of Harvard Business School was used to define the outcomes: 1) health status achieved/retained; 2) recovery process; and, 3) health sustainability.^1[i] Using an expedited approach, groups identified and prioritized measure concepts to create a focused measure set. Patient feedback from prior focus groups was used to ensure that important outcomes for patients were included. Measure specifications (numerator, denominator, etc.) were defined, validated PRO instruments were selected, and benchmarks were established, where possible. Workflows were defined to support data collecting via MD Anderson's new EHR, EPIC. In some cases, early implementation was achieved using simple IT solutions.

Results

6 outcome sets were developed across 9 disease sites within 4–to6 months. Most will be integrated into MD Anderson's new EHR, EPIC, in March 2016 at "go live." 14 additional outcome sets will be added in late–to2016. Overall, 20 outcome sets across 23 disease sites are planned. Common measures (e.g., survival) and condition-specific measures (e.g., speaking for head and neck cancer) are included.

Implications

This project showed that an expedited timeframe can be used to implement patient-centered outcome measurement. It can be applied to other health conditions and across providers to expedite outcomes measurement and to give providers and patients timely access to the outcomes that matter most.

[i] ¹ Porter, M.E. (2010). What is value in health care? N Engl Med, 363(26), 2477–to2481. doi: 10.1056/1\ISMp1011024[i]

The demand on Australian EDs has increased by an average of 4.2% each year while the cancer incidence rate has doubled since 1991. Many patients with cancer present to EDs but may be better managed using alternative healthcare models.

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Cancer patients’ experiences in one tertiary referral emergency department (ED): could ED bypass for cancer patients relieve ED congestion and improve care? from Cancer Institute NSW

Authors

Meredith Oatley, Stephen Clarke, Margaret Fry, Lesley Mullen 

Aims

The aim of the study was to explore the characteristics of cancer patients presenting to one tertiary referral ED at Royal North Shore Hospital.

Method

A 12-month audit was conducted of adult ED cancer patient presentations. A random sample (n=286) was then analysed of admitted patients.

Results          

1110 cancer patients presented to ED in 12 months (2.4% of total). For the random sample, the average age was 65.3 years while gender was evenly split (146 females: 50.3%). The three most common symptoms at presentation were: fever (n = 54: 18.6%); abdominal pain (n = 34: 11.7%) and shortness of breath (n = 32: 11.0%)(Table 2). Patients also presented due to abnormal test findings (n = 29: 10%). A majority of patients (n = 231: 79.7%) presented between Monday and Friday and during business hours (0800–to1700; n = 173: 59.7%). Most were allocated Triage Categories 2 (n = 94: 32.4%) or 3 (131: 45.2%). There was no statistical variation in triage code allocation with time of day (P = .282), weekday vs weekend presentation or gender (P = .931). Over 12 months 162 patients (56%) presented on multiple occasions (average 3.4 times).  271 pts (94%) were admitted. The median time to administration of antibiotics was 119.8 minutes. 112 patients (36%) died with 12 months of presentation.

Implications

Cancer patients while only a small percentage of total ED presentations are usually allocated high triage codes, present with significant symptoms, have high admission rates and a high 12-month mortality rate. Appropriate management, including antibiotics can be delayed. Timely and appropriate emergency and palliative care is required to optimise outcomes and reduce morbidity and mortality rates. New cancer treatments with different side-effects will further impact on knowledge deficits in EDs.

Community based symptom management care models to support cancer patients requiring urgent care and medical assessment need to be established to reduce ED presentation rates.

St Vincent’s Head and Neck Clinic is a well-established, multidisciplinary clinic which has provided a co-ordinated team approach to the head and neck patient’s complex needs for over three decades. With the development of a new, purpose-built cancer facility, a clinical redesign project was undertaken, with the aim to further enhancing the patient experience and improving the quality of care for patients attending the weekly Multidisciplinary Head and Neck Clinic.

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Enhancing the patient experience in a new purpose-build MDT meeting room with adjoining procedure and sterilizing room for head and neck cancer patients from Cancer Institute NSW

Authors

Stephanie Scarf, Helen Brake and Colette Dolan

Aims

The aims of the clinical redesign project were to identify issues impacting on patient care in the old facility, to address these in the design of the new facility, with a specific focus on the patient experience and delivering a patient-centred model of care. 

Method

The Centre for Healthcare Redesign Methodology (ACI NSW Agency for Clinical Innovation) was used to guide the stages of the project.  A project team was established.

The diagnostic stage included process mapping, consultation with staff and patients, identification and prioritisation of issues.

Solution design involved reviewing the Ministry of Health Policies and Procedures to ensure infection control compliance was met.  Building design, clinical processes, equipment and technological solutions were identified.

Results

The project resulted in:

• Improved patient experience
• State-of-the-art technology for medical assessment and diagnostics
• Improved infection control processes through the building design
• Improved communication between members of the multidisciplinary team resulting in improved patient management
• The development and implementation of policies and procedures for the new procedure room for patients having a nasopharyngeal procedure

Implications

• A new model of patient-centric care incorporating the mission and values of the hospital (compassion, justice, integrity and excellence) has improved the patient experience
• The environment has improved the staff experience and enhanced communication
• There has been a cost benefit from improved equipment management
• The organisation has met the ACI Patient-centred dimensions of care
• Ongoing engagement with consumers to continue to improve the health service

Patients with Squamous cell carcinoma (SCC) of the Head and Neck (H&N) are often treated with curative intent using treatment protocols placing them at high risk of nutritional decline. Recently released COSA guidelines recommend that prophylactic enteral feeding should be considered for T4 upper aerodigestive tract tumours undergoing concurrent chemoradiotherapy. Evidence is yet to identify optimal method of nutrition intervention and timing across all tumour stages in this population.

Primary content

Patients with Squamous cell carcinoma (SCC) of the Head and Neck (H&N) are often treated with curative intent using treatment protocols placing them at high risk of nutritional decline. Recently released COSA guidelines recommend that prophylactic enteral feeding should be considered for T4 upper aerodigestive tract tumours undergoing concurrent chemoradiotherapy. Evidence is yet to identify optimal method of nutrition intervention and timing across all tumour stages in this population.

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Weight loss among patients with Head and Neck Cancer at St Vincent's Hospital (SVH): Preliminary findings. from Cancer Institute NSW

Authors

Amanda Duffy, Vicki Flood, Mark Halaki, Stephen Cooper, Alan Spigelman, Richard Gallagher.

Aims

To investigate the efficacy of nutrition interventions on the health outcomes of patients receiving curative intent therapy for SCC of the H&N. The aim of this preliminary medical record is to provide information about reported weight loss of patients at diagnosis and during treatment.

Method

A retrospective audit of medical records of patients, diagnosed with pathological SCC of the H&N and treated with curative intent between 2012–to2014 at SVH has been undertaken. Data collected includes information about: medical diagnosis, treatment modality, nutrition intervention received (oral nutrition support, nasogastric tube, gastrostomy tube, parenteral nutrition or any combination of these), weight loss, socio-demographic variables, smoking and alcohol use. Preliminary analyses will provide descriptive information of the mean and distribution of % weight loss among patients during treatment.

Results

To date, in this preliminary audit, 48 patients with SCC of H&N have been investigated, 76% men, mean age=59 (SD=11). Among these people, 30% provided self-reported history of weight loss, 80% current/past smokers and 50% heavy alcohol use at first presentation. Heterogeneous treatment modalities were pursued with curative intent. Preliminary data of weight change from first presentation to end of treatment for 29 of these patients indicated a mean weight loss of 8%; (range: +7% gain to –to 24% loss).

Implications

These preliminary results indicate considerable variation in weight changes at presentation to conclusion of treatment. These results will be further extended to include additional records, and investigations will include% weight change, patient survival and hospital admissions for different nutrition interventions received, adjusted for a range of confounding variables. Ultimately, we plan to use this information to further inform decisions for practice and appropriate nutrition support among patients attending SVH.

Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.

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Do we need a new system to price oncology pharmaceuticals? from Cancer Institute NSW

Authors

Philip Haywood

Background

The high cost of these treatments requires government subsidy for most people to be able to achieve access. In Australia, subsidisation occurs via the Pharmaceutical Benefits Schedule. To be listed on the PBS, the economic evidence is considered alongside the clinical evidence supporting treatment. In particular, the economic framework requires consideration of the costs and outcomes of the new treatment compared with current treatment. The increasing number of treatment options makes this more complicated and is a challenge for frameworks considering the clinical and economic evidence.

New therapies may replace existing therapies, they may be added to existing therapies or they may displace older therapies from their current position in the treatment pathway.

Aim

To assess the importance of displacement in economic evaluations

Method

Randomised Controlled Trials of anti-cancer therapies were synthesized via a meta-analysis. Specifically, the effects of treatment being displaced from one line of therapy to the next line of therapy have been assessed in terms of overall survival, progression-free survival and toxicity.

The results of the meta-analysis were included in a decision-analytic model and the cost-effectiveness of treatment, taking displacement into account, calculated.

Results

Overall, displacing a treatment from one line of therapy to the next increases toxicity and decreases effectiveness. The displacement results in a reduction in the cost-effectiveness of the therapy. The net economic loss associated with the reduction in the cost-effectiveness is highly variable. Drivers include the mechanism of reimbursement, the initial price for subsidising the therapy and the number of people expected to take the therapy.

Implications

The cost-effectiveness of treatment is dependent on the line of therapy it is used in. Without pricing changes, the cost-effectiveness worsens as a treatment is displaced from one line of therapy to the next. However, the size of the opportunity cost of the health forgone from the worsening cost-effectiveness is highly variable. Price discounts as high as 90⁰Io may be required to restore acceptable cost-effectiveness in some circumstances.

The Royal Prince Alfred Hospital lung MDT was established in 1984. Historically, information about MDT decision making was captured as free text in the electronic medical record, including patient investigation and staging. This information was accessible to clinical staff; however, it was not routinely distributed to GPs involved in the patient's care. We identified a potential gap in the current reporting and communication processes.

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The Lung Cancer Demonstration Project: Implementation and evaluation of a lung cancer multidisciplinary team (MDT) communication tool for general practitioners (GPs) fromCancer Institute NSW

Authors

Gemma Collett, Nicole Rankin, Clare Brown, Shiraz Abdulla, Merran Findlay, Philip Beale, Brian McCaughan, Tim Shaw, David Barnes 

Aims

This project aimed to develop, implement and evaluate a new lung MDT reporting form to GPs in order to improve the communication flow about lung cancer cases following MDT discussion and making treatment recommendations. We sought to evaluate the timeliness, acceptability and appropriateness of the form by gaining feedback from GPs.

Method

The form was revised by the MDT clinicians prior to implementation. Registrars completed the form for all patients presented during the MDT. The form was sent to each patient's GP within 1–to2 days. A brief telephone survey was developed by the team. We conducted the survey with consenting GPs within 2 weeks of receipt. Data were collated from the completed GP surveys.

Results

To date, 13 GPs have completed phone surveys; 62% were female; 62% were from regional and 38% metropolitan settings. Nearly all participants (92%) reported that the information provided in the form was useful, relevant and will be used for communicating to patients about the treatment pathway and coordination of their treatment plan. Most (85%) reported receiving the form in a timely manner, found it easy to interpret and used it in communication with the patient.

Implications

The evaluation has confirmed that GPs found the form to be delivered in a manner that was timely, acceptable and appropriate. It is anticipated that it will benefit GPs in communicating the outcomes of MDT treatment recommendations to their patients.

The experience of membership of multidisciplinary collaborative cancer research networks is largely unreported. Sydney Catalyst Translational Cancer Research Centre (TCRC) is a multi-disciplinary and multi-institutional virtual consortium of researchers and clinicians from institutions in metropolitan Sydney and regional New South Wales. Following the Westfall model of translational research, we support multi-disciplinary collaborative cancer research focused on T1112 bench to bedside research and T2/3 translation of evidence into practice.

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Member experiences in an Australian Translational Cancer Research Centre and their understanding of translational research. from Cancer Institute NSW

Authors

Adam Walczak, Nicole Rankin, Michelle Lai, Phyllis Butow, Danielle Miller, Sonia Yip.

Background

The experience of membership of multidisciplinary collaborative cancer research networks is largely unreported. Sydney Catalyst Translational Cancer Research Centre (TCRC) is a multi-disciplinary and multi-institutional virtual consortium of researchers and clinicians from institutions in metropolitan Sydney and regional New South Wales. Following the Westfall model of translational research, we support multi-disciplinary collaborative cancer research focused on T1112 bench to bedside research and T2/3 translation of evidence into practice.

Aims

The aim of this research was to qualitatively explore the experiences of members of Sydney Catalyst to identify members' understanding and perceptions of translational research, benefits of membership and impact on research, key successes during the first three and a half years of operation.

Method

Members of Sydney Catalyst TCRC completed audio-recorded, individual, semi-structured interviews. Recorded interviews were transcribed verbatim and analysed using thematic text analysis with an inductive, data-driven approach.

Results

Twenty-two members from across T1–to3 research participated, including healthcare professionals, post-graduate students and academic researchers drawn from multiple biomedical and clinical disciplines and representing approximately 5% of the membership. Seven superordinate themes were identified during analysis; I) exposure to and experience of translational research, ii) collaboration and networking fostered by translational research network Membership, iii) benefits and successes arising through membership iii) sought and unexpected opportunities available through membership iv) the impact of level of active participation on the benefits of a TCRC, v) the role and identity of a TCRC, vi) the impact of the TCRC on collaboration and challenges experienced in this area and vii) feedback on the education offered by the TCRC. We will report on these themes.

Implications

By qualitatively exploring the experiences of members of a TCRC that encompass metropolitan and regional members, our study provides a unique and rich insight into how members understand and experience translational research that all research networks can learn from to inform initiatives and practices to enhance their members' experience.

Lung cancer remains the leading cause of cancer death in developed countries. There is growing evidence that earlier diagnosis of lung cancer is an important factor in improving outcomes. Despite this, there is surprisingly little qualitative research that documents lung cancer patients' diagnostic pathway and beyond.

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Mapping lung cancer diagnostic pathways: a qualitative study of interviews with lung cancer patients and their caregivers from Cancer Institute NSW

Authors

S York, N Rankin, M Lai, P Butow, D Barnes, R Zielinski, E Stone, T Shaw.

Aims

This study aimed to describe and document lung cancer diagnostic and treatment pathways based on lung cancer patient and carer narratives. This study is one component of a lung cancer implementation research program in the Australian setting.

Method

We developed a semi structured qualitative interview schedule to conduct with patients and their caregivers. We recruited participants via treating clinician (respiratory physician or medical oncologist) by sending a personal invitation letter. All patients were at least 6 months post diagnosis at the time of first invitation and interviews were conducted by telephone or face-to-face, according to participant preference. Interviews were recorded, transcribed and coded using a coding framework developed by four members of the investigator team. Detailed patient pathway maps were drawn, documenting the key points as discussed by participants. We conducted a content analysis and developed qualitative themes to interpret patient journeys.

Results

Eighteen lung cancer patients participated in the qualitative interviews across two metropolitan and one rural site. The patient journey maps provided rich data to understand the complexity of pathways that patients experience in the lead up to their lung cancer diagnosis and subsequent treatment. We examined all the maps to identify common elements and areas of greatest variability. In particular we will highlight the variations between the metropolitan and rural sites and the apparent barriers and facilitators to timely diagnosis.

Implications

The patient journey through lung cancer diagnosis is complex. The maps illustrate the heterogeneity in the pathways of lung cancer patients. These data will inform lung cancer implementation research projects to address the diagnostic pathway and improve patient care.

Given the prevalence and adverse effects of psychological distress on treatment outcomes, particularly the influence of depression on nutritional outcomes, evidence based clinical practice guidelines recommend dietitian screening and referral of head and neck cancer patients for psychosocial distress. However, research suggests that the provision of this care is sub-optimal.

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A clinical practice change intervention from Cancer Institute NSW

Authors

Kristen McCarter, Luke Wolfenden, Amanda Baker, Ben Britton, Alison Beck, Gregory Carter, Judy Bauer, Chris Wratten, Patrick McElduff, Sean Halpin

Aims

This study describes a clinical practice change intervention that aims to improve the routine provision of depression screening and referral by dietitians in head and neck cancer patients undergoing radiotherapy. 

Method

The study employs a multi-site, stepped-wedge randomised controlled trial design. The intervention will be implemented across four Australian radiotherapy departments who provide care to patients with head and neck cancer. The intervention to facilitate depression screening and referral will include the following evidence based clinical practice change strategies: executive support, staff training, academic detailing, systems and prompts, performance audit and feedback and provision of tools and resources. The primary outcome is the increase in routine depression screening and referral to appropriate psychosocial support by dietitians in head and neck cancer patients at initial session, which will be assessed via audiotape of dietitian clinical consultation with patients and medical record audits. Dietitian ratings of how helpful the intervention components are will also be evaluated.

Results

Preliminary results indicate that 0% (n=162) of control (pre-intervention) patients were screened for distress by dietitians. The intervention has been implemented at all four sites. Results of the post-training rate of depression screening and referral are expected in February 2016. The intervention components, including staff visits, feedback reports, resources and supervision have been well received and rated positively by the participating dietitians.

Implications

This study is the first to implement a multi-component clinical practice change intervention in increasing the provision of dietitian depression screening and referral in head and neck cancer patients. If effective, the intervention could serve as a model for improving the implementation of guidelines in other outpatient clinics in Australia and internationally. Such an outcome has the potential to improve the clinical management and health outcomes of thousands of HNC patients each year.

Adverse events are a significant quality and safety issue in the hospital setting due to their direct impact on patients. Additionally, such events are often handled by junior doctors due to their direct involvement with patients. As such, it is important for health care organisations to prioritise education and training for junior doctors on identifying adverse events and handling them when they occur. How we make this education relevant and engaging remains a key challenge.

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The cancer cup challenge—running an international program in safety and quality in oncology from Cancer Institute NSW

Authors

Anna Janssen, Tim Shaw, Lauren Bradbury, Tania Moujaber, Anne Mette Nørrelykke, Jessica Zerillo, Tracy Robinson, Paul Harnett

Aims

To develop and evaluate a quality improvement and adverse event awareness program for junior oncology doctors across three international sites. 

Method

A mixed methodology was used to develop and evaluate the program. The Qstream spaced learning platform was used to disseminate information to participants, as it has been demonstrated to impact on both knowledge and behaviour. Eight short case based scenarios with expert feedback were developed by a multidisciplinary advisory committee containing representatives from the international sites. The program used a gamification element where registrars across the three sites competed in a friendly competition. At the conclusion of the course impact on participant knowledge was evaluated using analysis of the metrics collected by the Qstream platform. Additionally, an online survey and semi-structured interviews were used to evaluate engagement and perceived value by participants.

Results

A total of 35 junior doctors registered to undertake the Qstream program, with 31 (88.57 %) successfully completing it. Analysis of the Qstream metrics revealed 76.57% of cases were answered correctly on first attempt. The post-program survey received 17 responses, with 76.47% indicating cases for the course were interesting and 82.35% feeling cases were relevant. Finally, 14 participants consented to participate in semi-structured interviews about the program, with feedback towards the course being generally very positive.

Implications

Developing effective,engaging and sustainable training for doctors is important to ensure positive patient outcomes are aintained in the hospital setting. This is of particular importance with junior doctors as they work closely with patients, and they are learning skills and behaviours which will influence their practice throughout their careers.

The full rollout of the National Bowel Cancer Screening Program (NBCSP), offering free biennial screening using immunochemical Fecal Occult Blood Test (iFOBT) for 50–to74 years is targeted for 2020. In 2013–to14, the overall participation rate among Australians who were invited to participate was 36%.

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The impact of National Bowel Cancer Screening Program in Australia from Cancer Institute NSW

Authors

Jie-Bin Lew, James St John, Dayna Cenin, Xiang-Ming Xu, Veerle Coupe, Marjolein Greuter, Michael Caruana, Emily He, Karen Canfell

Aims

To perform a comprehensive, updated estimate of the cost, health outcomes and resource utilisation associated with full rollout of the NBCSP.

Method

The ASCCA model, which models the development of colorectal cancer (CRC) via both the adenoma-carcinoma and serrated pathway and is based on Dutch trial data, was used for the evaluation. ASCCA was adapted to the Australian setting and expanded to perform detailed modelling of CRC screening, including the gradual rollout of NBCSP from 2006 to 2020. Base-case screening participation and compliance rates for colonoscopy follow-up were derived from NBCSP data. Alternative scenarios assuming an increase in screening participation rate and colonoscopy follow-up compliance rates were modelled. 

Results

In the base case scenario, the CRC incidence and mortality rates were estimated to decrease after 2020 after full rollout of biennial screening. However, the number of incident cancer cases and cancer deaths were predicted to increase over time due to population growth and ageing. On average, the biennial program was estimated to involve an average ~1.6 million individuals screened p.a. and would prevent ~2,000 deaths; involving ~140,000 colonoscopy examinations p.a. in 2020–to2035, equivalent to a number needed-to-screen of 780 FOBT per CRC death prevented, and 67 colonoscopies per CRC death prevented. The program was estimated to be highly cost-effective. Increases in screening participation would save more lives.

Implications

Biennial FOBT screening in Australia will save lives but involve more colonoscopy examinations per year. Increasing participation across the population increases costs and resource utilisation; however, it would have a beneficial impact on population health outcomes. The current evaluation has involved the development of a comprehensive model of the NBCSP in Australia, which provides a platform to assess further developments in CRC screening in Australia.

Prof Phyllis Butow (BA(Hons), MPH, MClinPsych, PhD) is Professor, and NHMRC Senior Principal Research Fellow in the School of Psychology at the University of Sydney. She is Chair of the Australian Psycho-Oncology Co-operative Research Group (PoCoG) and a co-director of the Centre for Medical Psychology and Evidence-based Decision-making (CeMPED). Prof Butow has worked for over 20 years in the areas of doctor-patient communication and Psycho-Oncology. She has won many awards, including the International Psycho-Oncology Society Bernard Fox award for outstanding contribution to Psycho-Oncology research in 2009 and the Clinical Oncological Society of Australia Tom Reeve award for outstanding contribution to cancer care in 2011, and was named NSW Cancer Researcher of the year in 2012. Prof Butow has conducted a large body of research on patient and family support, patient involvement in cancer consultations and decision-making, and disparities in outcomes and needs of immigrants with cancer.

Executive Director Organisational Effectiveness, WSLHD

Carrie was appointed as the Executive Director for Organisational Effectiveness in December 2013. She has had a long and varied career in the public and private sector.  A nurse by background, after qualifying, she spent time in oncology and palliative care before moving to adult education. Following a post as Education Officer at St. Columbas Hospice in Edinburgh she was appointed as an Officer to the Royal College of Nursing.  A secondment to the Scottish Executive Health Department to focus on partnership working was followed by appointments as a Management Consultant, and latterly Fellow for the Office for Public Management.  From there, she moved to NHS Tayside, where she established the Tayside Centre for Organisational Effectiveness (TCOE) which still acts as an Innovation Hub, supporting and enabling innovation and improvement across public service and local communities. 

Her current post as Executive Director for Organisational Effectiveness at Western Sydney Local Health District has responsibility for supporting the healthcare system to create the necessary internal capability and capacity to improve.

Carrie is passionate about quality improvement and enabling high performance in healthcare systems.

Adam Elshaug, M.P.H., Ph.D., is an internationally recognized researcher and policy advisor specializing in reducing waste and optimizing value in health care. He is Associate Professor of Health Care Policy, HCF Research Foundation Principal Research Fellow, and Director of the Value in Health Care Division in the Menzies Centre for Health Policy at The University of Sydney. He is also Senior Fellow with the Lown Institute in Boston, a ministerial appointee to the (Australian) Medicare Benefits Schedule (MBS) Reviews Taskforce, a member of the Choosing Wisely Australia advisory group, and the ACSQHC's Atlas of Healthcare Variation Advisory Group. Associate Professor Elshaug was a 2010–to11 Commonwealth Fund Harkness Fellow based at the US Agency for Healthcare Research and Quality (AHRQ). From mid–to2011 to mid–to2013, he then served as NHMRC Sidney Sax Fellow in Harvard Medical School’s Department of Health Care Policy. In parallel, he became The Commonwealth Fund's Inaugural Visiting Fellow for 2012–to13 in New York City.

A/Prof Shakespeare is a Fellow of the Royal Australian and New Zealand College of Radiologists and is the Director and Senior Consultant Radiation Oncologist at the North Coast Cancer Institute Port Macquarie. He is also the Director of Cancer Services for the Northern NSW and Mid-North Coast Local Health Districts. He is a Conjoint Associate Professor at the University of NSW. He was the clinical lead in building, staffing and operating the $60 million public integrated North Coast Cancer Institute within 3 public hospitals and 500km of coastline. NCCI has six linear accelerators and approx 120 FTE radiotherapy staff. He received NSW Premier's Gold Public Service Award for NCCI project. He is the prior Director of Oncology Services, Tan Tock Seng Hospital, Singapore. He has a focus on quality, having designed the RANZCR Peer Review audit instrument and being a member of the Faculty Quality Improvement Committee. He is also the radiation oncology reviewer for the Australian Council on Healthcare Standards (ACHS) Clinical Indicators. He has a special interest in breast, prostate, and lung cancer. A/Prof Shakespeare was the inaugural chair of NSW Cancer Institute National Radiation Oncology Practice Guidelines (eviQ.org.au) and was on the steering committee for Cancer Council Localised Prostate Cancer booklet. He has over 60 publications focusing on prostate cancer and clinical and patient decision-making, and is undertaking a PhD in prostate cancer outcomes.

Professor Sanchia Aranda was appointed CEO of Cancer Council Australia in August 2015.

Professor Aranda has more than 30 years’ experience in cancer control as a clinician, researcher, educator and senior healthcare administrator.

From her early career as a Registered Nurse in New Zealand she specialised in cancer and palliative care, completing a Bachelor of Applied Science, a Master of Nursing and a doctoral thesis exploring nurse-patient relationships in cancer and palliative care. She has extensive experience in health-system administration and most recently was Director of Cancer Services and Information and Deputy CEO at the Cancer Institute NSW.

Professor Aranda is President-elect of the Union for International Cancer Control (the world’s peak member-based cancer organisation) and a former President of the International Society of Nurses in Cancer Care.

As well as being a research fellow at the Peter MacCallum Cancer Centre, she holds academic appointments at the School of Health Sciences, University of Melbourne, and the Faculty of Nursing, University of Sydney.

Widely published in Australian and international health literature, Professor Aranda has also conducted research reviews for the National Health and Medical Research Council, Australian Research Council, Cancer Councils, state nursing boards and private sector research funding bodies.

As CEO of Australia’s peak non-government cancer control organisation, Professor Aranda is a strong independent voice on evidence-based cancer control. She is engaged in all fields of cancer from primary prevention through to survivorship and advanced care, and has a particular professional interest in improved ways to care for and support cancer patients.

She is a regular commentator on cancer issues in Australia media.

Professor Aranda’s role in cancer control has been recognised nationally and internationally, and in 2013 she was named the 4th Peter MacCallum Cancer Centre Distinguished Fellow for her contributions to cancer nursing.

Professor David Currow is the Chief Cancer Officer, NSW and Chief Executive Officer, Cancer Institute NSW, the NSW Government’s cancer control agency.

He was appointed to the position in March 2010.  Before that he was the foundation Chief Executive Officer of Cancer Australia, the Commonwealth’s cancer control agency.

He leads a team of 200 people whose expertise and remit include prevention (tobacco control, ultraviolet light protection), screening (BreastScreen, Cervical Screening and Bowel Screening), service performance and development (including the population based cancer registry, Australia’s only population-based clinical cancer registry, eviQ – the world’s major evidence-based protocol website in oncology, and Canrefer, linking general practitioners and consumers with multidisciplinary teams in two clicks of a button), and strategic research and investment.  The role of the Cancer Institute NSW is to decrease the incidence of cancer, increase the survival for people who are diagnosed with cancer and improve the quality of care for people with cancer.

Julie McCrossin gets people talking and she is renowned for her warmth, humour, intelligence and commitment to social justice.

After 20 years as a broadcaster with ABC Radio National, ABC TV and Network Ten, she is now a freelance journalist and facilitator. She presented the radio show Life Matters on ABC Radio National for 5 years, covering countless health, welfare and educational topics with a frequent rural focus. Julie was also a team leader on the media quiz show “Good News Week” for 5 years on Network Ten and ABC TV.

Currently Julie writes for the NSW Law Society Journal and facilitates conferences and seminars nationally. Julie offers a range of interactive formats that stimulate audience discussion while keeping people on topic and on time. Julie is especially known for her capacity to guide forums on sensitive topics, such as suicide prevention, mental health, child protection and family law.

Julie has qualifications in the arts, education and law. She is an Ambassador for the Fred Hollows Foundation, Red Cross Australia, Adult Learning Australia, and FRANS Inc (Making Things Happen for People with Disabilities), and is Patron of Wagga Women’s Health Centre.www.juliemccrossin.com