Breast Intraoperative Radiation Therapy (IORT): New Intraoperative Treatment for Early-Stage Breast Cancer Eliminating Weeks of External Beam Radiation
Gregory M. Graves, MD; Joyce A. Eaker, MD; Nitin Rohatgi, MD; Jeannine Graves, RN, MPA, CNOR, OCN
Objectives: To introduce a technological advance in the outpatient setting for early-stage breast cancer. This treatment approach is timely in terms of access to comprehensive breast care that is affordable, timely, and decreases exposure to healthy tissue and organs. Successful patient navigation with this treatment option results in a shorter acute care treatment phase with surgery, radiation, and chemotherapy/hormonal therapy transit shortened by several weeks.
Methods: Sutter Medical Center, Sacramento, treats 300 new patients with invasive breast cancer and 85 with ductal carcinoma in situ annually. In November 2011, we developed a multidisciplinary breast team that launched our IntraBeam Breast IORT program. Our goal was to treat 50 patients the first year. We treated 57 in the first 14 months. All patients were treated on an outpatient basis. We followed the Targit-A criteria for patient selection. The retrospective patient analysis follows.
Results: Patient range: 51-93 years; mean, 68 years (8 patients >80 years of age); tumor size: 6 mm-27 mm; (mean, 14 mm); wound complications: infection: 1, hematomas: 2, uncomplicated seromas: 10; operating room time: 90-130 minutes per procedure; positive lymph nodes: 3/57 (5%); patients receiving breast irradiation after Breast IORT: 6/57 (10.5%); cosmetic results: good-excellent: >90% (based on verbal patient reporting); cost-savings per case: $7000; contribution margin: $150,000. We are in the process of entering our patients in the Targit-R Rad Cap retrospective registry trial for outcome analysis of all Breast IORT cases in the United States.
Conclusions: Breast IORT using the IntraBeam unit provides a safe and cost-effective method for the treatment of early-stage breast cancer. Critical to program outreach and success has been the role of the RN Navigator. The navigator provides patient education; referring physician education; care coordination between surgery, radiology, radiation oncology and medical oncology; and follow-up data collection and analysis. Evaluative measures include time reduction from one intervention point to the next, improved patient care for long-term survival, improved patient satisfaction, improved cost-savings per case, and qualification for use as an accountable care organization treatment approach. Clinical pathway guidance is a hallmark of oncology navigation. Providing an accelerated process from suspicion to diagnosis and treatment via nurse navigation eliminates fragmentation of care that is common for patients with breast cancer. Inclusion in this treatment option provides patients with supportive care starting with diagnosis through and including survivorship.
The Advocacy Connector: Bridging the Knowledge Gap
Joanne Vanak, RN, MSN1; Ellen Ivey, BS2; John Kerrane, MS, RPh3; Susan King, RN, MS, OCN4
1Janssen Services, LLC; 2Johnson & Johnson Healthcare Systems, Inc.; 3Janssen Services, LLC; 4Pharmacyclics, Inc.
Background: There is a knowledge gap between the capabilities of advocacy groups and healthcare providers (HCPs) and patients. The need to create awareness about valuable resources, available through not-for-profit organizations, for HCPs, patients, and caregivers led to the creation of our project titled “Advocacy Connector” (www.advocacy connector.com). Advocacy Connector is a web-based resource that links patients and HCPs to a variety of advocacy groups that will serve to address a host of patient needs (eg, emotional and educational needs and financial support). Initially, this resource will focus on the area of oncology.
Objective: To help connect oncology patients with relevant advocacy group resources, either on their own or with the assistance of their HCPs.
Methods: Not-for-profit state and national level advocacy groups focusing on services directed toward oncology patients across the United States were given a survey to complete. Information regarding state-level advocacy groups was gleaned from the 12 states with the highest incidence rates of cancer (California, Florida, Texas, New York, Pennsylvania, Ohio, Illinois, Michigan, North Carolina, New Jersey, Georgia, and Virginia). The groups were asked if they would participate in an online resource that would highlight the capabilities of their respective organizations. The advocacy groups identified their key services, the results of which were then reviewed and validated by an independent vendor.
Results: The Advocacy Connector is a compilation of information from both state- and national-level advocacy groups, specifically focused on the following cancer-related diseases: prostate, ovarian, breast, colorectal, and lung, as well as leukemia, lymphomas, and myelomas. Advocacy Connector is organized so that patients and HCPs can easily access information about each advocacy group according to the type of services they provide for each type of cancer. Available information includes: help lines, alternative and complementary therapies, research, caregiver support, clinical trial information, counseling, end-of-life care, financial assistance, legal/insurance assistance, men’s health, pain management and palliative care, screening and early detection, spiritual support, survivorship, travel services, veteran services, wellness, nutrition and exercise, women’s health, and young adult cancer support. Materials may be printed for home use by patients and caregivers. Telephone numbers for the resources are included in the printed information for those who have no access to computers. Information is also available in non-English languages (eg, Spanish).
Conclusions: We believe the Advocacy Connector will help bridge the knowledge gap by increasing awareness of the extent of services offered by oncology advocacy groups and thereby increase patient knowledge, access to services, and overall satisfaction.
Implementation of a Lung Computer Tomography Cancer Screening Program at Frederick Memorial Hospital
Margaret Siebeneichen, BA, BSN, RN; Paul Chomiak, MD; Mark Soberman, MD, MBA, FACS
Frederick Memorial Hospital
Background: Lung cancer is the third most common cancer and the leading cause of cancer death in the United States.1 Smoking is the most important risk factor for lung cancer, resulting in approximately 85% of all lung cancer cases in the United States.2 Approximately 37% of US adults are current or former smokers.2 The incidence of lung cancer increases with age, occurring most commonly in patients aged 55 years or older. Lung cancer has a poor prognosis, and an estimated 160,340 Americans were expected to die from lung cancer in 2012 accounting for approximately 28% of all cancer deaths.3 The majority of lung cancer cases are non–small-cell lung cancer (NSCLC),2 and most screening programs focus on the detection and treatment of early-stage NSCLC. Screening for lung cancer in a high-risk patient population would identify earlier-stage tumors and may improve lung cancer–specific survival.4 The National Lung Screening Trial (NLST) provided the first definitive evidence that screening for lung cancer with low-dose computed tomography (LDCT) decreases lung cancer mortality in certain high-risk groups.5
Methods: Frederick Memorial Hospital created a process for screening high-risk patient populations using an LDCT. Patients can self-refer to the program; no physician order is necessary. Patients are screened for eligibility as per the NLST criteria (recently modified to be in concordance with the Prostate, Lung, Colorectal and Ovarian Screening Trial data) by a nurse navigator. If appropriate, the navigator sets up the screening appointment. Computed tomography (CT) scans are read by a radiologist and a thoracic surgeon. The nurse navigator contacts the patient and informs him or her of the results. Written copies of results, with a letter explaining the findings, are also mailed to the patient and the primary care physician. Depending on the findings, the patient is given recommendations for follow-up. The following data points were collected: total number of inquiries, total number of patients screened, patient demographics of the screened population, total time spent from initial inquiry to date of screening, total time of scan to recommendations, screening study results, and outcomes.
Results: From December 2012 to June 2013, there were 103 inquiries about the lung cancer screening program; 64 patients qualified for the program and were screened using LDCT, 50% of patients were female, 47% were active smokers, 53% were former smokers, and 94% had been exposed to secondhand smoke. The total time from intake to performance of the screening CT scan for Q1 2013 was 5.7 days and Q2 2013 was 3.8 days. The total time from CT scan to recommendations offered in Q1 2013 was 3.3 days; in Q2 2013, it was 2.4 days. Thirty-one percent of patients had a benign/normal scan, 42% were identified with an indeterminate pulmonary nodule, 7% of patients were identified with a finding worrisome for lung cancer, and 10% were identified with “other” abnormal CT scan findings. Thirty-one percent of patients received a recommendation to continue annual CT screening, 42% were referred to either a pulmonologist or thoracic surgeon for longitudinal radiographic surveillance as per American College of Chest Physicians guidelines, 17% were referred to thoracic surgery for evaluation and intervention, 6% were referred to thoracic surgery for evaluation and intervention, and 6% were referred to a specialist or primary care physician for evaluation of abnormal “other” findings.
Conclusions: Individuals at an increased risk for lung cancer have been shown to benefit from LDCT screenings, although some uncertainty remains about the potential harms of screening. In fact, the US Preventive Services Task Force has very recently endorsed CT screening for lung cancer. The involvement of a multidisciplinary team that includes a thoracic surgeon is essential in order to minimize unnecessary surgical procedures and procedure-related morbidity, and to determine the best surgical technique for resection.4 The involvement of a nurse navigator decreases the time for inquiry to completed screen and also eliminates the performance of inappropriate screens. The nurse navigator is the touch point for these patients, and maintains a database to ensure the findings and recommendations are communicated and acted upon, so that patients do not “fall through the cracks” of the healthcare system.
1. American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013. http://www.cancer.org/research/cancerfacts figures/cancerfactsfigures/cancer-facts-figures-2013. Accessed, July 15, 2013.
2. Humphrey L, Deffebach M, Pappas M, et al. Screening for lung cancer: systematic review to update the U.S. Preventive Screening Task Force Recommendation Statement. Evidence Synthesis No. 105. AHRQ Publication No. 13-05196-EF-1. Rockville, MD: Agency for Healthcare Research and Quality, 2013.
3. American Lung Association. Lung Cancer Fact Sheet. Washington, DC: American Lung Association. http://www.lung.org/lung-disease/lung-cancer/resources/fact-figures/lung-cancer-fact-sheet.html. Accessed August 13, 2013.
4. Jones D, Minor G, Internal communications. CT Screening for Lung Cancer.
5. Rocco G, Allen M, Altorki N; STS Task force on CT screening. Clinical statement on the role of the surgeon and surgical issues related to CT screening programs for lung cancer. Ann Thorac Surg. 2013;96:357-360, et al.