Integrating regional and community lung cancer services to improve patient care.

Lung cancer is the leading cause of cancer death in Canada. The organization of health care services is central to the delivery of accessible, high-quality medical care and may be one factor that influences patient outcome. An exciting opportunity arose for clinicians to initiate the redesign of lung cancer services provided by three institutions in the Greater Toronto Area. This qualitative report describes the integrated lung cancer network that they developed, the innovation it has facilitated, and the systematic approach being taken to evaluate its impact. Available clinical resources were deployed to restructure services along patient-centred lines and to provide greater access to the specialist lung cancer team. A non-hierarchical clinical network was established that consolidates the lung cancer team. A multi-institutional and multidisciplinary tumour board and comprehensive thoracic oncology clinics are at its core. This innovative organizational paradigm considers all of the available services at each facility and aims to fully integrate specialists across the three institutions, thereby maximizing resource utilization. We believe that this paradigm may have wider applicability. The network is currently working to complete a current program of further service improvements and to objectively assess its impact on patient outcome.

The efficacy and safety of oral anticoagulation in patients with cancer.

OBJECTIVES: To compare the complication rate (bleeding and thrombosis) of oral anticoagulation in a cohort of patients with cancer to a cohort without cancer. DESIGN: Prospective cohort study. SETTING: Outpatient anticoagulation clinic in a community hospital. PATIENTS: Consecutive patients enrolled in an anticoagulation clinic: 44 with cancer, 64 without cancer. INTERVENTIONS: Patients received prophylactic doses of Warfarin (target INR 2-3 in the majority of instances) and complication rates were assessed. MEASUREMENTS: Major bleeding (strictly defined), minor bleeding, recurrent thrombosis, proportion of time with therapeutic INR, frequency of clinic visits. RESULTS: The rates of major bleeding, minor bleeding, and recurrent thrombosis were not statistically significantly different in the two groups of patients. Therapeutic INR's were more difficult to sustain in the cancer patients as compared to the non-cancer patients (43.3% vs 56.9%, p < 0.0001). There was a non significant trend towards more frequent monitoring for the cancer patients compared with the non-cancer patients (4.6 vs 3.5 visits per treatment month, p = 0.14). CONCLUSIONS: Oral anticoagulation is safe and effective in the patient with cancer. It is more difficult to sustain a therapeutic INR in the cancer patients and they may need more frequent monitoring to achieve a low complication rate.