NCCN Patient Advocacy Summit: Delivering Value for Patients Across the Oncology Ecosystem.

As the oncology ecosystem shifts from service-based care to outcomes and value-based care, stakeholders cite concerns regarding the lack of patient experience data that are important to the patient community. To address the patient perspective and highlight the challenges and opportunities within policy and clinical decision-making to improve patient-centered care, NCCN hosted the NCCN Patient Advocacy Summit: Delivering Value for Patients Across the Oncology Ecosystem on December 11, 2019, in Washington, DC. The summit featured multidisciplinary panel discussions, keynote speakers, and patient advocate presentations exploring the implications for patient-centered care within a shifting health policy landscape. This article encapsulates and expounds upon the discussions and presentations from the summit.

NCCN Policy Summit: Defining, Measuring, and Applying Quality in an Evolving Health Policy Landscape and the Implications for Cancer Care.

Quality measurement is a critical component of advancing a health system that pays for performance over volume. Although there has been significant attention paid to quality measurement within health systems in recent years, significant challenges to meaningful measurement of quality care outcomes remain. Defining cost can be challenging, but is arguably not as elusive as quality, which lacks standard measurement methods and units. To identify industry standards and recommendations for the future, NCCN recently hosted the NCCN Oncology Policy Summit: Defining, Measuring, and Applying Quality in an Evolving Health Policy Landscape and the Implications for Cancer Care. Key stakeholders including physicians, payers, policymakers, patient advocates, and technology partners reviewed current quality measurement programs to identify success and challenges, including the Oncology Care Model. Speakers and panelists identified gaps in quality measurement and provided insights and suggestions for further advancing quality measurement in oncology. This article provides insights and recommendations; however, the goal of this program was to highlight key issues and not to obtain consensus.

The State of Cancer Care in America: Impact of State Policy on Access to High-Quality Cancer Care.

Health policy in America has shifted rapidly over the last decade, and states are increasingly exercising greater authority over health policy decision-making. This localization and regionalization of healthcare policy poses significant challenges for patients with cancer, providers, advocates, and policymakers. To identify the challenges and opportunities that lay ahead of stakeholders, NCCN hosted the 2019 Policy Summit: The State of Cancer Care in America on June 27, 2019, in Washington, DC. The summit featured multidisciplinary panel discussions to explore the implications for access to quality cancer care within a shifting health policy landscape from a patient, provider, and lawmaker perspective. This article encapsulates the discussion from this NCCN Policy Summit.

Quality Measurement in Cancer Care: A Review and Endorsement of High-Impact Measures and Concepts.

Although oncology care has evolved, outcome assessment remains a key challenge. Outcome measurement requires identification and adoption of a succinct list of metrics indicative of high-quality cancer care for use within and across healthcare systems. NCCN established an advisory committee, the NCCN Quality and Outcomes Committee, consisting of provider experts from NCCN Member Institutions and other stakeholders, including payers and patient advocacy, community oncology, and health information technology representatives, to review the existing quality landscape and identify contemporary, relevant cancer quality and outcomes measures by reevaluating validated measures for endorsement and proposing new measure concepts to fill crucial gaps. This manuscript reports on 22 measures and concepts; 15 that align with existing measures and 7 that are new.

Advocating for Equity in Cancer Care.

Demographic factors such as race, socioeconomic status, gender identity, area of residence, native language, and cultural barriers have an effect on outcomes in cancer care. To identify unmet needs, challenges, and opportunities in achieving high-quality, patient-centered cancer care for all, NCCN conducted a yearlong environmental scan, which involved stakeholder meetings with patients and patient advocacy groups to discuss these topics. The findings from this scan informed the corresponding NCCN Patient Advocacy Summit: Advocating for Equity in Cancer Care, held in Washington, DC, on December 10, 2018. In addition to the many patient advocacy groups, the summit featured a number of other stakeholders that advocate for equity in cancer care. This article encapsulates the findings of the environmental scan and the discussion from the NCCN Patient Advocacy Summit.

The effect of weight training on bone mineral density and bone turnover in postmenopausal breast cancer survivors with bone loss: a 24-month randomized controlled trial.

SUMMARY: This study examined whether 24 months of weight training exercises enhanced the effectiveness of risedronate, calcium, and vitamin D in maintaining or improving bone mineral density (BMD) in 223 postmenopausal breast cancer survivors. Subjects who were > or =50% adherent to exercise had no improvement in BMD but were less likely to lose BMD. INTRODUCTION: This study examined whether (1) postmenopausal breast cancer survivors (BCS) with bone loss taking 24 months of risedronate, calcium, and vitamin D had increased bone mineral density (BMD) at the total hip, femoral neck, L1-L4 spine, total radius and 33% radius, and decreased bone turnover; (2) subjects who also participated in strength/weight training (ST) exercises had greater increases in BMD and greater decreases in bone turnover; and (3) subjects who also exercised were more likely to preserve (at least maintain) BMD. METHODS: Postmenopausal BCS (223) were randomly assigned to exercise plus medication or medication only groups. Both groups received 24 months of 1,200 mg of calcium and 400 IU of vitamin D daily and 35 mg of risedronate weekly, and the exercise group additionally had ST exercises twice weekly. RESULTS: After 24 months, women who took medications without exercising had significant improvements in BMD at the total hip (+1.81%) and spine (+2.85%) and significant decreases in Alkphase B (-8.7%) and serum NTx (-16.7%). Women who also exercised had additional increases in BMD at the femoral neck (+0.29%), total hip (+0.34%), spine (+0.23%), total radius (+0.30%), and additional decreases in Alkphase B (-2.4%) and Serum NTx (-6.5%). Additional changes in BMD and bone turnover with exercise were not significant. Subjects who were > or =50% adherent to exercise were less likely to lose BMD at the total hip (chi-square [1] = 4.66, p = 0.03) and femoral neck (chi-square [1] = 4.63, p = 0.03). CONCLUSION: Strength/weight training exercises may prevent loss of BMD in postmenopausal BCS at risk for bone loss.

Bone mineral density in postmenopausal breast cancer survivors.

PURPOSE: The overall purpose of this longitudinal 18-month study was to test the feasibility and effectiveness of a multicomponent intervention for prevention and treatment of osteoporosis. The purpose of this article is to describe the baseline bone mineral density (BMD) findings for 30 postmenopausal women and to compare these BMD findings to time since menopause, body mass index, and tamoxifen use. DATA SOURCES: Baseline data of BMD findings for 30 postmenopausal women, who have had a variety of treatments including surgery, adjuvant chemotherapy and or tamoxifen, and are enrolled in the 18-month longitudinal study. A demographic questionnaire and a three day dietary record were used to collect baseline data. CONCLUSIONS: Eighty percent of the women with breast cancer history had abnormal BMDs at baseline (t-scores below -1.00 SD). Thinner women showed a greater risk for accelerated trabecular bone loss at the spine and hip. IMPLICATIONS FOR PRACTICE: These findings suggest the need for early BMD assessments and for aggressive health promotion intervention strategies that include a multifaceted protocol of drug therapy for bone remodeling, 1500 mg of daily calcium, 400 IU vitamin D and a strength weight training program that is implemented immediately following chemotherapy treatment and menopause in this high risk population of women.

Weight change and lung cancer: relationships with symptom distress, functional status, and smoking.

The pattern of weight change (at five 6-week intervals beginning 2 months after diagnosis of advanced disease) is described in adults with progressive lung cancer (N = 60). Weight loss of 10% or more at study entry occurred in 35% of subjects; 37% lost weight at three or more intervals; and 25% lost weight at only one interval. Pre-illness weight loss was moderately correlated with subsequent decreased functional status (Enforced Social Dependency Scale) at Times 1, 2, and 3 (r = -.49, r = -.43, r = -.48, p < .001). Weight loss correlated with subsequent increased symptom distress (Symptom Distress Scale, SDS) at three times (Times 2, 4, and 5: r = -.34, r = -.30, r = -.43, p < .05). Chemotherapy (50% of subjects) and smoking (25% at study entry) predicted weight loss from Time 1 to 5, explaining 28% of the variance.

Continuous insulin infusions in neonates: pharmacologic availability of insulin in intravenous solutions.

Continuous insulin infusion is sometimes used in very low birth weight infants with glucose intolerance. We studied the availability of insulin to the neonate by means of a laboratory-simulated clinical infusion under both flushed and non-flushed conditions. Although loss of insulin was noted with both solutions (0.5 U/ml), under the nonflushed condition only 55.9% of the prescribed dose for the first 2 hours was delivered before the delivery rate of the flushed system, 71.4%, was approached. These findings have implications for neonatal insulin administration.

Comorbidity, nutritional intake, social support, weight, and functional status over time in older cancer patients receiving radiotherapy.

It is essential that nurses gain insight about the responses of older adults to standard anticancer therapies because there is ongoing concern about whether the elderly are affected adversely by the prescribed therapy. The purpose of this longitudinal prospective study was to describe selected outcomes and their relationships in a sample of 45 elderly (mean age 69.8 years; range 61-86) patients receiving radiotherapy for either breast (42%) or lung (58%) cancer. The outcome variables were weight and multidimensional functional status; moderator variables were co-morbidity, nutritional intake, estimated adequacy of intake, radiation dose, side effects, and social support. Data were collected at the beginning of radiation (T1), the middle of therapy (T2), the conclusion of therapy (T3), and three months post radiation (T4). Although 81.4% had some concurrent condition, those with a comorbid condition did not respond significantly differently from those without a comorbid condition on any of the major variables at any of the four times. At none of the four times was the caloric intake adequate to meet the estimated energy requirements for usual activity (range 67.9-71.5%). However, caloric intake was not significantly related to weight at any of the four times. There was a significant weight decrease from beginning of therapy to the middle of therapy and from the beginning of therapy to conclusion of therapy. The percentage of calories contributed by protein was significantly correlated with weight during radiotherapy, and protein calories consumed at the previous time were correlated with weight at T2 and T3. In contrast, the percentage of calories contributed by carbohydrate intake was significantly negatively correlated with two of the four functional status measures at each time, but was not related to weight. In addition carbohydrate calories consumed at the previous time also were related to one or more functional status measures at succeeding time points. Almost no relationships were found between social support and the outcome measures of weight and functional status. Scores on three of the four functional status measures suggest improvement over time from initiation of radiation to 3 months after therapy. Scores on the fourth measure, Overall Health Rating, suggest a slight decline; however, the average score reflects good overall health. These findings provide evidence that this group of elderly, the great majority of whom had at least one comorbid condition, tolerated the course of radiation with less than adequate intake for usual activity, a slight decrease in mean weight, but without major disruptions in functional status.(ABSTRACT TRUNCATED AT 400 WORDS)

Influence of age on problems experienced by patients with lung cancer undergoing radiation therapy.

The purpose of this prospective, longitudinal study was to determine if patients with lung cancer who are 65 years of age or older experience problems differently than do patients younger than age 65 during and following radiation treatment. The moderator and outcome variables selected for study were recognized attendant problems that may develop during lung cancer treatment and that may influence the treatment regimen and response. No statistically significant differences were found between patients age 65 or older and those younger than age 65 on caloric intake, adequacy of energy intake, total radiation dose, concurrent illnesses, and social support at any of four data-collection periods. Similarly, there were no significant differences on weight, body mass index, and multidimensional functional status. The relationship between the social support subscales and functional status measures for the 65-or-older group suggested that those subjects with lower social support perceived themselves to have better functional status. There was no relationship between social support and two functional status measures for the under-65 group. The significant relationships between social support and the overall health rating were in opposite directions for the two age groups. The results suggest that chronologic age alone may not be a sufficient criterion to determine therapeutic regimen or to suggest that unique problems may result.

Nutritional intake, weight change, symptom distress, and functional status over time in adults with lung cancer.

The purpose of this descriptive longitudinal study was to describe the relationship of nutritional intake to weight change, symptom distress, and functional status over a six-month period in 28 subjects with progressive lung cancer. The majority of the subjects had non-small cell lung cancer and had lost less than 10% of their body weight at the time of study entry. Body weight, hunger, symptom distress, and functional status were measured every six weeks, beginning two months after diagnosis, for a six-month period. Three-day diet records, which were completed immediately prior to each time point, were averaged to obtain nutrient intake data. Average weight change and nutritional intake showed little variation over time, but the ranges were large. Lower intake of kilocalories was moderately related to functional status at Times 1 and 5 (r = -0.56; r = -0.66, respectively). Kilocalorie intake at a previous time was related to subsequent functional decline at two of the six-week data points (r = -0.71; r = -0.75). Weight change was not directly related to kilocalorie intake. Percentage of weight loss over time was greater in subjects younger than 65 years of age, in those with small cell lung cancer, and in those who received chemotherapy. Symptom distress and symptoms of hunger, nausea, and appetite disturbance showed subtle fluctuations over the six-month period and had inconsistent relationships with food intake over time. Further study is needed to describe nutritional changes that follow a diagnosis of lung cancer and to identify areas for nursing intervention.

Fatigue mechanisms in patients with cancer: effects of tumor necrosis factor and exercise on skeletal muscle.

Fatigue is a common adverse effect of cancer and its therapy. However, the specific mechanisms underlying cancer fatigue are unclear. One physiologic mechanism may involve changes in skeletal muscle protein stores or metabolite concentration. A reduction in skeletal muscle protein stores may result from endogenous tumor necrosis factor (TNF) or from TNF administered as antineoplastic therapy. This muscle wasting would require patients to exert an unusually high amount of effort to generate adequate contractile force during exercise performance or during extended periods of sitting or standing. This additional effort could result in the onset of fatigue. Additionally, cancer fatigue may develop or become exacerbated during exercise as a consequence of changes in the concentration of skeletal muscle metabolites. These biochemical alterations may interfere with force that is produced by the muscle contractile proteins. These physiologic changes may play a role in the decision to include exercise in the rehabilitation plans of patients with cancer. They also may affect ideas about fatigue.