Integrated care pathway for rectal cancer treatment: cross-sectional post-implementation study using a logic model framework.

BACKGROUND: Management of rectal cancer has become more complex with multimodality therapy (neoadjuvant chemoradiotherapy and surgery) and this has led to the need to organize multidisciplinary teams. The aim of this study was to report on the planning, implementation and evaluation of an integrated care pathway for neoadjuvant treatment of middle and lower rectal cancer. DESIGN AND SETTING: This was a cross-sectional post-implementation study that was carried out at a public university cancer center. METHODS: The Framework for Program Evaluation in Public Health of the Centers for Disease Control and Prevention (CDC) was used to identify resources and activities; link results from activities and outcomes with expected goals; and originate indicators and outcome measurements. RESULTS: The logic model identified four activities: stakeholders' engagement, clinical pathway development, information technology improvements and training programs; and three categories of outcomes: access to care, effectiveness and organizational outcomes. The measurements involved 218 patients, among whom 66.3% had their first consultation within 15 days after admission; 75.2% underwent surgery < 14 weeks after the end of neoadjuvant treatment and 72.7% completed the treatment in < 189 days. There was 100% adherence to the protocol for the regimen of 5-fluorouracil and leucovorin. CONCLUSIONS: The logic model was useful for evaluating the implementation of the integrated care pathways and for identifying measurements to be made in future outcome studies.

Early Palliative Care and Its Impact on End-of-Life Care for Cancer Patients in Brazil.

BACKGROUND: Integrating palliative care into standard oncology care has been recommended for cancer patients. Early palliative care is associated with less aggressive treatment at the end of life. OBJECTIVE: To describe cancer patients receiving palliative care in Brazil, determining the time from entry into palliative care to death, and investigating whether late referral to palliative care is associated with aggressive end-of-life treatment. DESIGN: This was a cross-sectional study of cancer patients receiving palliative care in Brazil. SETTING/SUBJECTS: Subjects were 2985 cancer patients ≥18 years of age who received at least two palliative care visits at the São Paulo State Cancer Institute, in the city of São Paulo, Brazil, and died between 2010 and 2013. MEASUREMENTS: We evaluated the time from the first palliative care consult to death, stratifying cases by the timing of entry into palliative care (≥3 or <3 months before death). The associations between early palliative care and indicators of aggressive treatment were assessed by Pearson's chi-square test and Fisher's exact test. RESULTS: The overall median time between entry into palliative care and death was 34 days (mean, 72 days) and was significantly shorter in 2013 than in 2010 (p < 0.001). The number of emergency department visits was significantly lower among the patients who entered palliative care earlier (p < 0.001). CONCLUSIONS: Among cancer patients in Brazil, late referral to palliative care is common. Patients who enter palliative care earlier appear to receive less aggressive end-of-life treatment.

Fibroxanthoma of the conjunctiva - case report / Atypical fibroxanthoma of the conjunctiva - case report

Neoplasias fibro-histiocíticas da conjuntiva säo raras. O fibroxantoma atípico é considerado uma variante superficial do fibro-histiocitoma maligno (FHM). Relatamos o primeiro caso da literatura nacional em uma mulher de 78 anos. Os aspectos clínicos e histopatológicos desta neoplasia säo discutidos.