VA Articles of Interest
Adv Radiat Oncol. 2017 Jul 12;2(3):416-419.
Initiative to reduce bone scans for low-risk prostate cancer patients: A quasi-experimental before-and-after study in a Veterans Affairs hospital.
Ojerholm E1,2, Van Arsdalen KN3,4, Roses RE5,6, Tripp P1,2.
Department of Radiation Oncology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
Department of Urology, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania.
Department of Surgery, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
Bone scans (BS) are a low-value test for asymptomatic men with low-risk prostate cancer. We performed a quality improvement intervention aimed at reducing BS for these patients.
Methods and materials:
The intervention was a presentation that leveraged the behavioral science concepts of social comparison and normative appeals. Participants were multidisciplinary stakeholders from the Radiation Oncology and Urology services at a Veterans Affairs hospital. We determined the baseline rate of BS by retrospectively analyzing cases of asymptomatic men with newly diagnosed low-risk prostate cancer. For social comparison, we presented contemporary peer BS rates in the United States-including Veterans Affairs hospitals. For normative appeals, we reviewed guidelines from various professional groups. To analyze the effect of this intervention, we performed a quasi-experimental, uncontrolled, before-and-after study.
During the 1-year period before the intervention, 32 of 37 patients with low-risk prostate cancer (86.5%) received a BS. The contemporary peer rate was approximately 30%. All reviewed guidelines recommended against BS. During the 1-year period after the intervention, the rate of BS was reduced to 65.5% (19 of 29 patients; P = .043 by one-sided Fisher's exact test).
We observed a modest reduction in guideline-discordant BS after the quality improvement intervention. BS rates might be influenced by initiatives that combine social comparisons with appeals to professional norms.
Psychooncology. 2017 Nov 14. doi: 10.1002/pon.4584. [Epub ahead of print]
Costs of an Ostomy Self-Management Training Program for Cancer Survivors.
Hornbrook MC1, Cobb MD2, Tallman NJ3, Colwell J4, McCorkle R5, Ercolano E5, Grant M6, Sun V6, Wendel CS7,8, Hibbard JH9, Krouse RS10,11.
1Kaiser Permanente Center for Health Research, Portland, Oregon.2University of Arizona College of Nursing, Tucson, AZ.3Wound Ostomy Continence Nurse, Unaffiliated, Tucson, AZ.4University of Chicago School of Medicine, Chicago, IL.5Yale University School of Nursing, New Haven, CT.6City of Hope National Medical Center/Beckman Research Institute, Duarte, CA.7University of Arizona College of Medicine, Tucson, Arizona.8Southern Arizona Veterans Affairs Health Care System, Tucson, AZ.9University of Oregon Health Policy Research Group, Eugene, OR.10University of Pennsylvania School of Medicine, Philadelphia, PA.11CMC Veterans Affairs Medical Center, Philadelphia, PA.OBJECTIVE:
To measure incremental expenses to an oncologic surgical practice for delivering a community-based, ostomy nurse-led, small-group, behavior skills-training intervention to help bladder and colorectal cancer survivors understand and adjust to their ostomies and improve their health-related quality of life, as well as assist family caregivers to understand survivors' needs and provide appropriate supportive care.
The intervention was a five-session group behavior skills training in ostomy self-management following the principles of the Chronic Care Model. Faculty included Wound, Ostomy, Continence Nurses (WOCNs) utilizing an ostomy care curriculum. A gender-matched peer-in-time buddy was assigned to each ostomy survivor. The four-session Survivor curriculum included: Self-management practice and solving immediate ostomy concerns; Social well-being; Healthy lifestyle; and a Booster session. The single Family Caregiver session was co-led by a WOCN and an ostomy Peer staff member and covered relevant caregiver and Ostomate support issues. Each cohort required eight weeks to complete the intervention. Non-labor inputs included ostomy supplies, teaching materials, automobile mileage for WOCNs, mailing, and meeting space rental. Intervention personnel were employed by the University of Arizona. Labor expenses included salaries and fringe benefits.
The total incremental expense per intervention cohort of four Survivors was $7,246, or $1,812 per patient.
A WOCN-led group self-help ostomy survivorship intervention provided affordable, effective, care to cancer survivors with ostomies.
Contemp Clin Trials. 2017 Oct 16. pii: S1551-7144(17)30504-9. doi: 10.1016/j.cct.2017.10.008. [Epub ahead of print]
Ostomy telehealth for cancer survivors: Design of the Ostomy Self-management Training (OSMT) randomized trial.
Sun V1, Ercolano E2, McCorkle R2, Grant M3, Wendel CS4, Tallman NJ5, Passero F6, Raza S7, Cidav Z8, Holcomb M9, Weinstein RS9, Hornbrook MC10, Krouse RS11.
Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA, USA. Electronic address: firstname.lastname@example.org.
School of Nursing, Yale University, New Haven, CT, USA.
Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA, USA.
University of Arizona, Tucson, AZ, USA.
Unaffilated, Wound, Ostomy, and Continence Nurse, Tucson, AZ, USA.
Unaffiliated, Patient Stakeholder, Philadelphia, PA, USA.
Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
University of Pennsylvania, Philadelphia, PA, USA.
Arizona Telemedicine Program, University of Arizona, Tucson, AZ, USA.
Kaiser Permanente Center for Health Research, Portland, OR, USA.
Corporal Michael J. Crescenz Veterans Affairs Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
An ostomy adversely affects health-related quality of life (HRQOL) in a diverse population of cancer survivors and their caregivers. Hit-or-miss ostomy care, nurse counseling, and community referral have been the primary modes of self-management education and support in the peri-operative setting. Few evidence-based, systematic ostomy self-management programs are available to ensure optimal post-operative care. This paper describes the study design of a telehealth-based Ostomy Self-management Training (OSMT) program for cancer survivors and their caregivers.
The study is a three-year, randomized trial that tests the effectiveness of the OSMT program on survivor activation, self-efficacy, and HRQOL. The intervention integrates goal setting and problem-solving approaches to enhance survivor activation and self-efficacy to carry out ostomy care. The curriculum is delivered via four group sessions administered by trained ostomy certified nurses (WOCNs) and peer ostomates. An additional session is offered to caregivers to address their needs in relation to ostomy care. Telehealth approaches through videoconferencing are used to enhance program delivery to participants in three different geographic areas across two time zones. Participants join sessions via real-time videoconferencing from their homes.
The OSMT program has high potential to make a positive impact on the unique physical, psychological, social, and spiritual needs of cancer survivors living with a permanent ostomy. The study design, process, and telehealth approach contributes to the success of future dissemination efforts of the intervention into diverse clinical and community settings.
Pathol Oncol Res. 2017 Nov 4. doi: 10.1007/s12253-017-0342-z. [Epub ahead of print]
Possible Predictive Markers of Response to Therapy in Esophageal Squamous Cell Cancer.
Zoltan L1,2, Farkas R1,2, Schally AV2,3, Pozsgai E2,3, Papp A2,4, Bognár L2,4, Tornoczki T2,5, Mangel L1,2, Bellyei S6,7.
Department of Oncology, University of Pécs, Edesanyak street 17, Pécs, 7624, Hungary.
Department of Biochemistry and Medical Chemistry, University of Pécs, Pécs, Hungary.
Veterans Affairs Medical Center and South Florida Veterans Affairs Foundation for Research and Education, Miami, FL, USA.
Department of Surgery, University of Pécs, Pécs, Hungary.
Department of Pathology, University of Pécs, Pécs, Hungary.
Department of Oncology, University of Pécs, Edesanyak street 17, Pécs, 7624, Hungary. email@example.com.
Department of Biochemistry and Medical Chemistry, University of Pécs, Pécs, Hungary. firstname.lastname@example.org.
The aim of the present study was to investigate the relationship between the intensity of biomarker expression and the response to radiochemotherapy in patients with advanced esophageal squamous cell cancer (ESCC). Ninety-two patients with locally advanced ESCC were examined retrospectively. Pre-treatment tumor samples were stained for proteins SOUL, Hsp 16.2, Growth Hormone-Releasing Hormone Receptor (GHRH-R) and p-Akt using immunhistochemistry methods. Kaplan-Meier curves were used to show the relationship between intensity of expression of biomarkers and clinical parameters and 3-year OS. A significant correlation was found between high intensity staining for Hsp 16.2, p-Akt and SOUL and poor response to NRCT. Application of a higher dose of radiation and higher dose of cisplatin resulted in better clinical and histopathological responses, respectively. Among the clinical parameters, the localization of the tumor in the upper-third of the esophagus and less than 10% weight loss were independent prognostic factors for increased 3-year OS. Hsp16.2, p-Akt and SOUL are predictors of negative response to NRCT, therefore these biomarkers may become promising targets for therapy. Furthermore, level of expression of p-Akt, weight loss and the localization of the tumor are significant factors in the prediction of OS in ESCC.
JAMA Surg. 2017 Oct 18. doi: 10.1001/jamasurg.2017.3827. [Epub ahead of print]
Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections.
Vo E1, Massarweh NN1,2,3, Chai CY1,2, Tran Cao HS1,2, Zamani N1, Abraham S2, Adigun K2, Awad SS1,2.
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy.
To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy.
Design, Setting, and Participants:
A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs.
Main Outcomes and Measures:
Surgical site infections within 30 days of the index procedure and time to adjuvant therapy.
Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs.
Conclusions and Relevance: The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.
Cancer. 2017 Oct 10. doi: 10.1002/cncr.31047. [Epub ahead of print]
Improvements in hospice utilization among patients with advanced-stage lung cancer in an integrated health care system.
Sullivan DR1,2,3, Ganzini L2,4, Lapidus JA5, Hansen L6, Carney PA7, Osborne ML1,8, Fromme EK8,9, Izumi S6, Slatore CG1,2,3,10.
Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.
Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon.
Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.
Division of Geriatric Psychiatry, Department of Psychiatry, Oregon Health and Science University, Portland, Oregon.
Biostatistics, School of Public Health, Oregon Health and Science University, Portland, Oregon.
School of Nursing, Oregon Health and Science University, Portland, Oregon.
Department of Family Medicine, Oregon Health and Science University, Portland, Oregon.
Palliative Care Service, Oregon Health and Science University, Portland, Oregon.
Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.
Section of Pulmonary and Critical Care Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon.
Hospice, a patient-centered care system for those with limited life expectancy, is important for enhancing quality of life and is understudied in integrated health care systems.
This was a retrospective cohort study of 21,860 decedents with advanced-stage lung cancer diagnosed from January 2007 to June 2013 in the national US Veterans Affairs Health Care System. Trends over time, geographic regional variability, and patient and tumor characteristics associated with hospice use and the timing of enrollment were examined. Multivariable logistic regression and Cox proportional hazards modeling were used.
From 2007 to 2013, 70.3% of decedents with advanced-stage lung cancer were enrolled in hospice. Among patients in hospice, 52.9% were enrolled in the last month of life, and 14.7% were enrolled in the last 3 days of life. Hospice enrollment increased (adjusted odds ratio [AOR], 1.07; P < .001), whereas the mean time from the cancer diagnosis to hospice enrollment decreased by 65 days (relative decrease, 32%; adjusted hazard ratio, 1.04; P < .001). Relative decreases in late hospice enrollment were observed in the last month (7%; AOR, 0.98; P = .04) and last 3 days of life (26%; AOR, 0.95; P < .001). The Southeast region of the United States had both the highest rate of hospice enrollment and the lowest rate of late enrollment. Patient sociodemographic and lung cancer characteristics were associated with hospice enrollment.
Among patients with advanced-stage lung cancer in the Veterans Affairs Health Care System, overall and earlier hospice enrollment increased over time. Considerable regional variability in hospice enrollment and the persistence of late enrollment suggests opportunities for improvement in end-of-life care.
Cancer. 2017 Sep 19. doi: 10.1002/cncr.30987. [Epub ahead of print]
Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: The memory & motion study.
Hartman SJ1,2, Nelson SH1,2, Myers E2, Natarajan L1,2, Sears DD1,2,3, Palmer BW4,5, Weiner LS1,2, Parker BA2,3, Patterson RE1,2.
Department of Family Medicine and Public Health, University of California-San Diego, La Jolla, California.
University of California-San Diego Moores Cancer Center, University of California-San Diego, La Jolla, California.
Department of Medicine, University of California-San Diego, La Jolla, California.
Department of Psychiatry, University of California-San Diego, La Jolla, California.
Veterans Affairs San Diego Healthcare System, San Diego, California.
Increasing physical activity can improve cognition in healthy and cognitively impaired adults; however, the benefits for cancer survivors are unknown. The current study examined a 12-week physical activity intervention, compared with a control condition, on objective and self-reported cognition among breast cancer survivors.
Sedentary breast cancer survivors were randomized to an exercise arm (n = 43) or a control arm (n = 44). At baseline and at 12 weeks, objective cognition was measured with the National Institutes of Health Cognitive Toolbox, and self-reported cognition using the Patient-Reported Outcomes Measurement Information System scales. Linear mixed-effects regression models tested intervention effects for changes in cognition scores.
On average, participants (n = 87) were aged 57 years (standard deviation, 10.4 years) and were 2.5 years (standard deviation, 1.3 years) post surgery. Scores on the Oral Symbol Digit subscale (a measure of processing speed) evidenced differential improvement in the exercise arm versus the control arm (b = 2.01; P < .05). The between-group differences in improvement on self-reported cognition were not statistically significant but were suggestive of potential group differences. Time since surgery moderated the correlation, and participants who were ≤2 years post surgery had a significantly greater improvement in Oral Symbol Digit score (exercise vs control (b = 4.00; P < .01), but no significant improvement was observed in patients who were >2 years postsurgery (b = -1.19; P = .40). A significant dose response was observed with greater increased physical activity associated with objective and self-reported cognition in the exercise arm.
The exercise intervention significantly improved processing speed, but only among those who had been diagnosed with breast cancer within the past 2 years. Slowed processing speed can have substantial implications for independent functioning, supporting the potential importance of early implementation of an exercise intervention among patients with breast cancer.