Developing and maintaining the resilience of interdisciplinary cancer care teams: an interventional study.

BACKGROUND: Providing care to cancer patients is associated with a substantial psychological and emotional load on oncology workers. The purpose of this project is to co-construct, implement and assess multidimensional intervention continuums that contribute to developing the resilience of interdisciplinary cancer care teams and thereby reduce the burden associated with mental health problems. The project is based on resources theories and theories of empowerment. METHODS: The study will involve cancer care teams at four institutions and will use a mixed-model design. It will be organized into three components: (1) Intervention development. Rather than impose a single way of doing things, the project will take a participatory approach involving a variety of mechanisms (workshops, discussion forums, surveys, observations) to develop interventions that take into account the specific contexts of each of the four participating institutions. (2) Intervention implementation and assessment. The purpose of this component is to implement the four interventions developed in the preceding component, assess their effects and whether they are cost effective. A longitudinal quasi-experimental design will be used. Intervention monitoring will extend over 12 months. The effects will be assessed by means of generalized estimating equation regressions. A cost-benefit analysis will be performed to assess the cost-effectiveness of the interventions, taking an institutional perspective (costs and benefits associated with the intervention). (3) Analysis of co-construction and implementation process. The purpose of this component is to (1) describe and assess the approaches used to engage stakeholders in the co-construction and implementation process; (2) identify the factors that have fostered or impeded the co-construction, implementation and long-term sustainability of the interventions. The proposed design is a longitudinal multiple case study. DISCUSSION: In the four participating institutions, the project will provide an opportunity to develop new abilities that will strengthen team resilience and create more suitable work environments. Beyond these institutions, the project will generate a variety of resources (e.g.: work situation analysis tools; method of operationalizing the intervention co-development process; communications tools; assessment tools) that other oncology teams will be able to adapt and deploy elsewhere.

Benefits of improving processes in cancer care with a care pathway-based electronic medical record.

PURPOSE: We analyzed the intermediate and longer term changes in patients' waiting times following the implementation of an electronic medical record (EMR) dedicated to ambulatory treatment in both medical and radiation oncology. METHODS AND MATERIALS: A pre-post study design was developed to assess improvements in patients' waiting times, defined as the number of days between key steps in patient management preceding the first treatment. The postperiod began 1 year after the EMR go-live to allow for a preliminary period of adjustment to the new EMR. The EMR under study was closely integrated into the clinicians' workflow, being designed as a care pathway information system to provide real-time support to the coordination of the entirety of care processes involving all the care personnel. RESULTS: The large majority of the waiting-time indicators decreased over time, with decreases ranging from 2 to 28 days. However, an important time lag was necessary to see an improvement, to the extent that better access was only observed in the final months of the postperiod. CONCLUSION: The study highlights the potential to design EMR applications that capitalize on tight workflow integration, both in medical and radiation oncology, to deal with the fundamentally collaborative nature of cancer care delivery.

Online stochastic optimization of radiotherapy patient scheduling.

The effective management of a cancer treatment facility for radiation therapy depends mainly on optimizing the use of the linear accelerators. In this project, we schedule patients on these machines taking into account their priority for treatment, the maximum waiting time before the first treatment, and the treatment duration. We collaborate with the Centre Intégré de Cancérologie de Laval to determine the best scheduling policy. Furthermore, we integrate the uncertainty related to the arrival of patients at the center. We develop a hybrid method combining stochastic optimization and online optimization to better meet the needs of central planning. We use information on the future arrivals of patients to provide an accurate picture of the expected utilization of resources. Results based on real data show that our method outperforms the policies typically used in treatment centers.

Chemosensitized radiosurgery for recurrent brain metastases.

Temozolomide is known to penetrate the blood-brain barrier and sensitize brain tumors to radiation and has been used clinically to sensitize fractionated external beam radiotherapy. However, there are limited prospective clinical data available on the safety of temozolomide as a chemosensitizing agent administered with stereotactic radiosurgery. This is a phase I trial of previously irradiated patients with one to four progressive brain metastases and Karnofsky performance scale score ≥60 % enrolled in three sequential cohorts: temozolomide 100, 150 or 200 mg/(m(2) day) administered for 5 days. Stereotactic radiosurgery (SRS) was administered on day 5. The SRS dose was dependent on target diameter: 15 Gy (31-40 mm), 18 Gy (21-30 mm) or 21 Gy (<20 mm). The primary endpoint was safety of increasing temozolomide doses. Secondary endpoints included local control and survival. 26 subjects were enrolled and 49 total metastatic lesions were treated. The median number of brain metastases was 1.5, with a median target diameter of 21 mm. The most common grade 1-2 adverse events irrespective of causality were vomiting (23 %), nausea (23 %), edema (12 %), seizure (8 %), psychosis (4 %) and thrombocytopenia (4 %). The frequency of nausea and vomiting did not appear to be dose-dependent. Grade 3-4 toxicities were not observed. Median overall survival was 10.2 months. Crude local control was 87.5 %, with a radiological response seen in eight of 24 evaluable patients (33.3 %), and stable disease >6 months in 13 of 24 patients (54.2 %). Temozolomide, at doses up to 200 mg/(m(2) day) × 5 days, prior to SRS is well tolerated, with no dose-limiting toxicities in patients with recurrent brain metastases. Local control of target lesions was >80 %.

Safety and feasibility of motexafin gadolinium administration with whole brain radiation therapy and stereotactic radiosurgery boost in the treatment of ≤ 6 brain metastases: a multi-institutional phase II trial.

To determine the safety, tolerability, and report on secondary efficacy endpoints of motexafin gadolinium (MGd) in combination with whole-brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS) for patients with ≤ 6 brain metastases. We conducted an international study of WBRT (37.5 Gy in 15 fractions) and SRS (15-21 Gy) with the addition of MGd (5 mg/kg preceding each fraction beginning week 2). The primary endpoint was to evaluate the rate of irreversible grade 3 or any grade ≥ 4 neurotoxicity and establish feasibility in preparation for a phase III trial. Sixty-five patients were enrolled from 14 institutions, of which 45 (69%) received SRS with MGd as intended and were available for evaluation. Grade ≥ 3 neurotoxicity attributable to radiation therapy within 3 months of SRS was seen in 2 patients (4.4%), including generalized weakness and radionecrosis requiring surgical management. Immediately following the course of MGd plus WBRT, new brain metastases were detected in 11 patients (24.4%) at the time of the SRS treatment planning MRI. The actuarial incidence of neurologic progression at 6 months and 1 year was 17 and 20%, respectively. The median investigator-determined neurologic progression free survival and overall survival times were 8 (95% CI: 5-14) and 9 months (95% CI: 6-not reached), respectively. We observed a low rate of neurotoxicity, demonstrating that the addition of MGd does not increase the incidence or severity of neurologic complications from WBRT with SRS boost.

Radiosurgery scope of practice in Canada: a report of the Canadian association of radiation oncology (CARO) radiosurgery advisory committee.

Radiosurgery has a long history in Canada. Since the treatment of the first patient at the McGill University Health Center in 1985, radiosurgery programs have been developed from coast to coast. These have included multidisciplinary teams of radiation oncologists, neurosurgeons, medical physicists, radiation technologists and other health professionals. In 2008, the CARO Board of Directors requested that a working group be formed to define the role of the radiation oncologist in the practice of radiosurgery. Taking into account evolving technology, changing clinical practice and current scope of practice literature, the working group made recommendations as to the role of the radiation oncologists. These recommendations were endorsed by the Canadian Association of Radiation Oncology board of directors in September 2009 and are present herein. It is recognized that patients benefit from a team approach to their care but it is recommended that qualified radiation oncologists be involved in radiosurgery delivery from patient consultation to follow-up. In addition, radiation oncologists should continue to be involved in the administrative aspects of radiosurgery programs, from equipment selection to ongoing quality assurance/quality improvement.

Combined hypofractionated radiation and hormone therapy for the treatment of intermediate-risk prostate cancer.

PURPOSE: Because of the low alpha/beta value of prostate cancer, a therapeutic gain may be possible with a hypofractionated radiation scheme, and this gain may be further increased with the adjunct of hormone therapy. A Phase II study was undertaken to study the toxicity of such a treatment. METHODS AND MATERIALS: Forty-two patients with intermediate-risk prostate cancer were recruited for this study. Neoadjuvant and concomitant hormone therapy consisted of one injection of leuprolide acetate (4-month preparation) and 1 month of oral nonsteroidal, anti-androgen medication starting on the day of the injection. Radiation treatment was started 8 weeks after the injection and patients received 57 Gy in 19 fractions. RESULTS: Median follow-up was 46 months. The treatment was well tolerated and no interruptions occurred. The majority (59%) had Grade 0 or 1 acute genitourinary (GU) toxicity, whereas 36% had Grade 2 and 5% had Grade 3 acute GU toxicity. Only Grade 1 or 2 gastrointestinal toxicity was seen. All chronic toxicity was of Grade 1 or 2 except for 3 patients (8%) with Grade 3 toxicity. Sixty-eight percent (68%) of patients had no long-term side effects from the treatment. At time of analysis, 79% showed no sign of treatment failure. CONCLUSIONS: Hypofractionated radiation with neoadjuvant and concomitant hormone therapy is well tolerated with no significant short- or long-term morbidity. Control for this risk group is good, and comparative Phase III studies should be undertaken to determine whether this treatment is superior to new evolving treatments.