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2014 Innovations in Cancer Treatment and Care Conference

Developing a quality cancer system was the theme of our third annual Innovations in Cancer Treatment and Care Conference held on Friday 17 October 2014.

Event details

Date:        Friday 17 October 2014
Time:       8:00am –to 5:00pm
Venue:     Sydney Olympic Park

Keynote speakers

The keynote presentations were delivered by the dynamic duo of Gerry Marr (Chief Executive, South Eastern Sydney LHD) and Carrie Marr (Executive Director, Organisational Effectiveness, Western Sydney LHD), who provided key insights into data-driven healthcare and reflected on their time transforming healthcare in Scotland. Also speaking at the event was Ingrid Plueckhahn from the Peter MacCallum Cancer Centre who presented on the Smoking Cessation Clinic she set up at Peter Mac to provide quit smoking strategies and support to cancer patients. 

 

Abstracts

Authors

J Young (Lead)

C McAulay

I Stacey

M Varlow

D Currow

 

Aims

This paper describes differences in beliefs, behaviours and systems in primary care in NSW.

Method

A core questionnaire was developed by the ICBP team to address GPs’ beliefs about the early diagnosis of cancer and their role in the cancer system, their investigation and referral practices for a patient presenting with a symptom that could be cancer and the availability and timeliness of diagnostic tests and specialist referrals.  In addition, a series of case vignettes was developed to test GPs’ knowledge and self-reported behaviours regarding further investigation, treatment and follow-up of patients with a variety of symptoms that could suggest a possible cancer diagnosis.  Using a commercial mail-house, invitations to participate in the survey were sent to 2246 GPs in NSW.  To maximise the response rates, each GP was mailed a primer, invitation and three reminder letters.

Results

Responses received from 140 GPs in rural NSW and 133 in urban NSW, for an overall response rate of 12.2%. Most respondents agreed that early diagnosis is important for outcomes of breast, ovarian, colorectal, and lung cancer. However there were marked differences in the access GPs reported to investigation and specialists between urban and rural areas and the public and private sector, and distance to treatment was raised as an issue particularly by rural GPs. Most GPs surveyed agreed that they would like more information on cancer referral pathways and procedures, diagnostic services, specialists and clinic availabilities and waiting times, and more opportunities for ongoing professional learning in cancer and to share patient care following cancer treatment.

Implications

GPs in NSW surveyed as part of the ICBP identified many opportunities for enhancing their role in cancer control and this paper will highlight how we are beginning to take advantage of these opportunities.

Authors

L Holloway (Lead)

S Arumugam

A Xing

T Young

D Thwaites

Aims

To investigate the clinical significance of different Volumetric Modulated Arc Therapy (VMAT) delivery errors and the sensitivity of the ArcCHECK detector to those errors.

Method

Two Prostate and two Head and Neck radiotherapy VMAT plans were considered. Three types of errors in Multi Leaf Collimator (MLC) position and dose delivery were simulated. i. Gantry Independent ii. Gantry dependent and iii. Control point (CP) specific errors. The impact of simulated errors was evaluated using clinical dosimetric end points.  The plans with simulated errors were measured using ArcCHECK and compared with the error free plan.

Results

A minimum 3 mm MLC error and 5% output error was detectable for the gantry angle independent errors and a minimum 4 mm MLC error and 4% dose error was identifiable for gantry dependent errors. For the prostate plan all these errors resulted in a greater than 5% reduction in mean Planning Target Volume (PTV) dose and greater than 5% increase in rectum equivalent uniform dose (EUD), and thus would be expected to have a clinical impact. Errors introduced to the CPs did not have a clinically significant impact.

Implications

ArcCHECK is able to detect VMAT delivery errors that are clinically significant. This work will help establish more specific quality assurance procedures for radiotherapy.

Authors

S Turley (Lead)

M Cumming

 

Aims

  • Promote CCC throughout primary health care system and specialist services inside and outside local region - as the initial referral point to local cancer services.
  • Improve communication strategies between care providers across cancer services, and other services to ensure continuity of care for patients, locally and beyond.
  • Maintain and support profile of cancer services in Broken Hill
  • Develop and implement CCRP into general practice.

Method

Step 1: Scoping study to map services, identify gaps and delineate referral pathways.

Step 2: Development of Cancer Care Referral Pathway CCRP (funding through CINSW) across GP practices in Broken Hill (including Maari Ma Aboriginal Health & Royal Flying Doctor Service (RFDS).

Step 3: Public launch and implementation of CCRP

Step 4: Project Evaluation – formal evaluation of the project is currently underway.

Results

The promotional strategy resulted in an increase in referrals to CCRP over a two year period: 2012–to13 n= 53, 2013–to14 n= 148. New referral sources to CCC came from medical sources n >50 (37 were patient self referrals). Improved communication through the CCRP and the integration of care between health services has resulted in patients reporting increased benefits from care co-ordination at a local level.

Implications

Sustainability

Even when a rural cancer service is without direct medical oncology services, locally co-ordinated care can be established through strong partnerships and referral pathways. This relationship building has direct benefits for patients and carers as it uses local services and a sustained collaborative approach to patient centred care.

Transferability

The cancer care referral pathway can be used in other rural locations where capacity exists for CCC to assist cancer patients with care coordination.

Authors

L Holloway (Lead)

P Vial

G Goozee

A Xing

S Arumugam

Aims

To develop software to automate this plan checking process and validate this software in a clinical setting.

Method

In-house software, PlanChecker, was developed using the Python programing language. Inputs are: the treatment plan generated in the treatment planning system; and plan parameters within the record and verify system which is used to deliver the treatment.

To validate the tool, different types of errors were introduced for two advanced technique clinical plans by modifying the parameter assessed in the file exported from the record and verify system. The PDF report generated by PlanChecker was reviewed to verify if the program detected the errors and if these errors were recorded in the correct categories.

To validate use within the clinical setting, PlanChecker, has also has been used over the last 6 months (50 patients) in parallel with the manual process. Over 50 patient clinical plans were checked manually and with PlanChecker.

Results

In total 126 simulated errors were successfully validated to be detected by PlanChecker with the simulated errors in the clinical plans.

In comparison with manual plan check, the software is also able to check the plan parameters which are not reviewed manually. There are significant efficiency gains with the use of PlanChecker, reducing the time on average from 10 –to 20 minutes for manual checking to less than 2 minutes, depending on plan complexity.

Implications

The developed software tool, PlanChecker,  is be able to correctly detect possible errors that may occur during data transfer of radiotherapy plans and can improve clinical workflow and accuracy.

Authors

P Metcalfe (Lead)

A Walker

G Liney

L Holloway

Aims

MRI provides unrivalled detail on tumour and normal tissue location, extent and biological status. Evidence for benefit of use of MRI is clear for some clinical sites and emerging in others (Metcalfe et al Technology in cancer research and treatment journal, 12, 429–to446, 2013). One technical difficulty associated with use of MRI is image distortion. The aim of this project is to assess the impact of MRI distortion within the radiation therapy planning process, particularly for MRI alone planning.

Method

We have previously demonstrated that MRI distortion varies between sequences and scanners (Walker et al Australasian Physical & Engineering Sciences in Medicine, 37, 103–to113, 2014). However this work was limited due to the commercial phantoms which were available, with limitations in field of view (FOV) and in particular the phantom length. To overcome this problem we have constructed a new phantom (the Sunrise phantom). This phantom enables image distortion to be assessed for the full FOV and 512mm scan length. We have used this phantom to assess a number of MRI sequences on a 3T Siemens Skyra scanner and then used this analysis to simulate the potential impact of this distortion for MRI alone breast radiotherapy planning.

Results

The Sunrise phantom has been successfully constructed and imaged for the required extended FOV and length. For 6 sequences considered, the greatest distortion observed was 9.8mm and distortions were demonstrated to be less than 2mm, at distances within 100mm of isocentre.

Implications

The phantom can be used to accurately assess distortion for the entire MRI FOV, as required for radiotherapy treatment planning. It will also have implications for developing technologies such as the Australian MRI-linac, currently under development at Ingham. MRI-linac technologies will require direct use of MRI data hence the distortion corrections will be essential for this equipment.

Acknowledgement:  MRI-linac project is part of a NHMRC program grant. CIs: P Keall, S Crozier and M Barton.

Authors

T Shaw (Lead)

S York

K White

D McGregor

N Rankin

S Rushton

S Aranda

Aims

CINSW commissioned the University of Sydney to identify and prioritise a set of key ‘success factors’ in the coordination of care that could be used to guide the development of Key Performance Indicators.

Method

A systematic process was used to define a set of success factors. This included a scoping review of the literature and a broad invitation to stakeholders to submit their own success factors. Three cycles of review were then conducted on initial success factors to reduce duplication and exclude factors not related to the coordination of care. A final set of factors was then subjected to a prioritisation process previously developed by Sydney Catalyst. This consisted of a day-long priority setting workshop attended by a purposive selection of stakeholders. Factors were prioritised against significance and ease of measurement.

Results

Results: 48 success factors were identified through the review of literature and stakeholder input. This was refined to a final set of 20 factors. Five success factors were identified through the consensus priority setting process.

Implications

This project was successful in obtaining consensus across a broad range of stakeholders in terms of the identification of success factors that are both significant and measurable. Further validation will be under taken with consumers and practitioners. This work lays strong foundations for the development of key performance indicators that can be used in funding reform being undertaken by CINSW. This is the first time such a piece of work has been performed and represents an important step in improving the coordination of cancer care and improving patient outcomes.

Authors

T Robinson (Lead)

A Janssen (Lead)

J Kirk

A DeFazio

A Goodwin

K Tucker

T Shaw

Aims

The QStream program aimed to increase participant knowledge about the latest evidence regarding genetic assessment and consideration of genetic testing for women with a particular type of ovarian cancer.

Method

Participants completed an online, case based program with multiple choice questions in October, 2013. The cases could be accessed by email or phone. If questions were answered incorrectly the case was repeated in five days. If questions were answered correctly, they were repeated in eight days. After the program semi structured interviews (N=12) were conducted and were subject to thematic analysis by two researchers. In addition, the number of women diagnosed with ovarian cancer and the number subsequently referred for assessment and consideration of genetic testing over a 12 month period will be identified from gynaecological oncology records to further ascertain the program’s impact on the referral behaviour of participants.

Results

The main themes to emerge from the interviews (N=12) include improved knowledge about referring women for assessment and consideration of genetic testing, the curriculum and format of QStream (which most found highly engaging) and the program’s usefulness for disseminating updated clinical guidelines. In addition, eight participants reported the program had changed the way they would now refer women for genetic counselling and consideration of testing.

Implications

Although more research is needed to identify optimal spacing patterns that facilitate retention, QStream has obvious benefits for disseminating new research or updated clinical guidelines among clinicians in high work volume environments.  It may also prove more effective than face- to- face education and training but it may be necessary to supplement QStream programs with implementation techniques such as audit and feedback to ensure that behaviour changes are sustained.

Authors

D Gillies (Lead)

P Pockney

J Gani

R Foster

A Duggan

Aims

To reduce the median / mean time from GP referral to colonoscopy for public patients referred to the Greater Newcastle Sector (GNS) following a +FOBT.

Method

  1. To review and record current processes across 3 hospitals (GNS) and 2 specialties and make changes accordingly to improve time from GP referral to colonoscopy for +FOBT referrals who meet the NHMRC guidelines.
  2. Change Process: Employ a colorectal coordinator / project officer. Develop: a process for fast track (FT) colonoscopy, a screening tool for assessing patients for direct access (DA) colonoscopy (no endoscopist consultation), a standard phone conversation when screening patients, a standard bowel preparation and instruction sheet, a process to fairly allocate patients to endoscopist and hospital. Create a database to record information.

Results

Pre N=71 post N=111 patients, 75 progressed to DA colonoscopy, a further 4 were FT to colonoscopy.  26 patients were not suitable for DA: 11 (<50 or >75yrs), 4 recent colonoscopy (<18months), 11 complex medical conditions.  A further 6 had their colonoscopy in the private system. Median / mean days to colonoscopy pre:  82 (102), post change process:  DA 42 (46), FT 27 (31).  Pathology: 12% had a carcinoma, 33% had tubular adenomas or high risk sessile adenomas.

Implications

Multifaceted and systemised coordinated approach to processing +FOBT patients reducing the time to diagnosis and definitive treatment of colorectal cancer. The process changes introduced in our study would be adaptable to other institutions.

Authors

N Mackay

Aims

To improve patient satisfaction, reduce hospital incurred drug costs and create bed capacity through a better managed system of co-ordinated care that avoids unplanned inpatient admissions for chemotherapy treatments using the OIS.

Method

As part of the extension of the OIS to the inpatient setting, a process mapping exercise of service wide chemotherapy referrals was attended with key clinicians and administrators. This exercise reviewed patient admission trends, related drug costs and referral pathways across the service. The barriers to a systematic process of referral were identified, and a small team was established with the objective of avoiding patient chemotherapy admissions by utilising vacant outpatient resources. The OIS enabled the organisation of service wide chemotherapy referrals so that patient care could be provided in the appropriate location.

Results

Timely access to patient information using a process supported by an OIS enabled opportunities for the appropriate co-ordinated management of cancer services chemotherapy referrals. A comparison of patients treated with outpatient chemotherapy regimens in the inpatient setting showed that in 9 months prior to August 2013, 235 patients were treated with outpatient regimens. In the 9 months following the changes, 166 patients were treated with outpatient regimens, a reduction of 30%.  The project was also able to measure a total of 89 bed days saved by avoidance of admission, resulting in increased bed capacity for the inpatient unit. Drug cost savings were also calculated for the hospital as outpatient treatment was paid federally through the PBS and not encumbered upon the hospital. A drug cost saving to the hospital of $35,000 was calculated for the 9 months following the changes.

Implications

The improved co-ordination of referrals for chemotherapy care throughout our service has improved inpatient bed capacity and reduced hospital incurred inpatient drug costs. In addition, the provision of care in the appropriate location aligned with reported improved patient experience.

Authors

J Kipritidis (Lead)

F Hegi-Johnson

E Eslick

J Barber

A Shieh

P Keall

Aims

To perform the first cross-modality correlation study of pulmonary function changes between daily CT ventilation images, nuclear medicine imaging and spirometry.

Method

Lung cancer patients received daily CT imaging as part of image guided radiotherapy treatment at Nepean Cancer Care Centre. Ventilation images (VIs) were generated using in-house software to measure regional lung volume changes within the respiratory cycle, a surrogate for ventilation. Daily ventilation changes were quantified, with VIs correlated against pre- and post-treatment nuclear medicine functional lung imaging.

Results

CT ventilation imaging is capable of achieving good similarity with `gold standard’ nuclear medicine functional lung imaging, with pixel-to-pixel correlations as high as 0.6 in some patients. A cross modality analysis of functional changes is underway and we are investigating the potential for CT image enhancement to improve the accuracy and sensitivity of this technique.

Implications

CT-based ventilation imaging is potentially useful for imaging pulmonary function in lung cancer radiotherapy patients. Once optimised and validated, CT-based ventilation imaging will give clinicians a powerful, cost-effective and highly accessible new tool to measure, predict and minimise the side effects of lung cancer radiotherapy treatment.

Authors

 L Phillipson (Lead)

L Pitts

J Hall

Aims

Objectives designed to address fatalistic attitudes and taboos associated with cancer screening using project resources, community forums, recruitment of community champions to share cancer screening and survival narratives, promote discussion about breast and bowel screening and agreement that timely screening reduces the risk of dying from cancer.

Method

‘The Cancer Good News Project’ (2012–to2013) utilised an Action-Research framework to address cancer related stigma and improve cancer screening rates amongst Macedonian and Serbian community members in the Illawarra. Research insights were translated into a tailored, integrated and evidenced based program to promote ‘good news’ about cancer survival and screening behaviours for two priority cancers – breast and bowel.  Multiple strategies were utilised to address literacy and language barriers.

Results

The Cancer Good News Project has achieved high community engagement and success in promoting discussions around cancer, reducing stigma and promoting screening intentions. More than 391 community members participated in community forums/events and used tailored resources. Surveys confirmed that Good News Stories and information had promoted helpful community discussion about cancer; elicited agreement that mammogram is important to detect breast cancer early and to reduce the risk of dying from breast cancer; and that the Faecal Occult Blood Test (FOBT) is important to detect bowel cancer early and to reduce the risk of dying from bowel cancer. Intention to screen increased significantly.

Implications

Project success was underpinned by the strategic partnerships, involvement of local bi-cultural health workers and inclusivity of community champions. The emphasis on engaging community members in participatory research was significant in promoting cancer discussions within CALD communities.

Authors

D Simar (Lead)

S Eslami

R J Cohn

K Johnston

R Barres

Aims

We aimed to investigate the mechanisms responsible for the development of metabolic complications in childhood cancer survivors treated using radiotherapy.

Method

We recruited 78 childhood cancer survivors, who were 16 years or older and who had been in full remission for at least 5 years. Participants were grouped based on the use of total body irradiation (TBI) as a treatment or no irradiation (non-IRR). Anthropometric data and blood samples were collected. Lipid and glucose profiles were established and the level of insulin resistance was calculated. Circulating levels of pro and anti inflammatory cytokines were measured using a multiplex assay. Peripheral blood mononuclear cells (PBMCs) polarised activation was assessed using flow cytometry, as well as intracellular signalling activation upon mitogen activation. Global DNA methylation was measured in different PBMCs sub-types using flow cytometry.

Results

The TBI group was characterised by impaired glucose metabolism and increased prevalence of insulin resistance. The same group also showed increased circulating levels of pro-inflammatory cytokines. PBMCs from the TBI group showed a preferential Th1 polarised activation upon mitogen stimulation which was linked to increased activation of both the mitogen activation protein kinase p38, as well as mammalian target of rapamycin complex 1. We further identified that the over activation of those two signalling pathways was not due to a direct action of irradiation but rather a bystander effect. We further identified a very specific epigenetic signature in T helper and T cytotoxic cells in survivors treated using irradiation.

Implications

Our results suggest that metabolic complications in childhood cancer survivors treated using total body irradiation are linked to a systemic and long-lasting inflammation, potentially due to the hyper-activation of intracellular signalling pathways in those cells. This long-term memory effect of irradiation could be explained by epigenetic changes. These alterations could represent useful markers to support early identification of survivors at risk of developing metabolic complications.

Authors

C Adams (Lead)

D Sue

D Bellamy

F Ord

J Tuart

J Conning

T Proietto

B Kelly

Aims

  1. Improve team connections between rural, remote and metropolitan teams, including GP, community, Aboriginal health and acute care providers through development of local interdisciplinary and cross sectoral networks to support the MOC using existing services.
  2. Provide skills based Psycho-Oncology training for all rural and remote health care providers.
  3. Introduce technology to enhance Psycho-Oncology care provision.
  4. Work individually with local Aboriginal Health Services to ensure understanding of Aboriginal cultural and health issues within the framework of the MOC.

Method

Networks were identified via rural cancer treatment centres (Armidale, Taree, Moree and Muswellbrook). Local workshops were held to identify need and service provision options and availability. Training in building effective partnerships and communication skills was held in Tamworth and Newcastle. Participants were asked about willingness to participate in telehealth options to improve care within existing resources.

Results

The network development workshops included 44 attendees (GP’s, LHD staff, NGO’s, private practitioners, support groups, charities and academics) and 29 people completed the partnership/communication skills training. Disciplines included oncology nursing, social work, radiation therapy, palliative care, occupational therapy, and clinical trials and management. Evaluations were very positive and will be described qualitatively and quantitatively. The most tangible development is the Armidale network developed website called “New England Cancer Connect”.

Implications

Interdisciplinary partnerships in patient care play a crucial role in developing sustainable patient centred psychosocial care. The stepped MOC and heath pathway are easily adapted to reflect local and external resources including teleheath. Significantly improved patient support networks and inter/multi-disciplinary communication and coordination can be achieved through efficient resource usage and engagement with GP’s, NGO’s, private practitioners and charities in local communities. This MOC and health pathway could be applied across NSW Health and beyond.

Authors

R Sharman (Lead)

V Murray

Aims

The "Let’s yarn with the Aboriginal community of Albury/Wodonga”  project  was  led by  Lung Foundation Australia  in collaboration with Hume RICS and aimed  to  raise awareness  and understanding of lung cancer in  the local Aboriginal community. Greater awareness was achieved by providing education for Aboriginal Health Workers and the wider community about lung cancer, treatments and support services.

This initial project has led to the involvement of Hume RICS in further work; such as the Aboriginal Cancer Partnership Project funded by the Cancer Institute of NSW, which focuses on increasing the knowledge of Aboriginal Health Workers along the Murray River of NSW around cancer screening, treatment and palliative care by facilitating placements within cancer services.  This project aims to develop a two-way learning between Aboriginal services and mainstream cancer services to build skills, knowledge and capacity of the Aboriginal health work force in cancer care.

Method

An Aboriginal Project Steering Group with 50% Aboriginal membership, was established to advice on the Aboriginal projects and a Project Coordinator and an Aboriginal Project Officer were appointed.   Successful  education sessions and placements  were conducted at  radiation, chemotherapy  and  palliative care units which  provided  an understanding of treatment options , referral pathways and  supportive care services.

Results

Several digital resources were developed in addition to an Aboriginal cancer awareness pin and an Aboriginal support group. Cultural awareness training has been provided for private oncology practices and a DVD is being developed around radiation and chemotherapy treatment. Hume RICS will continue to partner with Aboriginal Health Workers in the Border and Hume region cancer network, as further funding has been received from the Victorian Aboriginal Palliative Collaborative to undertake a project to provide culturally appropriate education around palliative care and advanced care planning for Aboriginal Health and Community Workers to enable them to inform their communities about end of life issues.

Implications

The success of these projects demonstrates the benefits of Aboriginal mainstream cancer services and Aboriginal organisations working together to achieve better outcomes for the Indigenous community. Aboriginal Health Workers in the Border East Cancer Network region have embraced the education provided which has enabled them to inform their community around cancer awareness and symptoms.  Further work is required to extend the education to other areas of Victoria and NSW.

Authors

D Nguyen (Lead)

M Robotin

M Porwal

M Hopwood

C Treloar

J George

Aims

To address the unmet need of people diagnosed with primary liver cancer and their carers.

Method

We researched the information needs and preferred sources of health information of people affected by HCC using in-depth interviews (IDI) and focus group discussions (FGD) conducted in English, Vietnamese, Cantonese and Mandarin. The findings informed the development of customized multi-media information and support resources for people affected by HCC (patients and carers).

Results

Four FGDs involved 29 participants (2 FGDs were conducted in English and one each in Cantonese and Mandarin); another 18 people took part in IDI (in all 4 languages). FGD and IDI transcripts were transcribed, translated and subjected to thematic content analysis. Key themes were analysed; they related to doctor-patient communication, HCC-related investigations, diagnosis and staging, treatment options, availability of practical support and preferred sources of health information. They formed the basis for developing scripts for the multimedia resources, which were filmed in 4 languages, featuring liver specialists, hepatology nurses, patients and consumer representatives.

Implications

The resources will be distributed through liver clinics, private specialists, and made available to community organisations serving migrant communities and through the B Positive program to ensure they reach the intended recipients in a timely fashion. This model of action research and resource development can meet the information needs of a wide range of people affected by hepatitis, chronic illness or cancer in CALD and Indigenous communities.

Authors

E Wales

Aims

To evaluate the impact of a tailored online oral anti-cancer education package on the knowledge and confidence of community pharmacists required to dispense oral anti-cancer agents.

Method

The education program used clinical scenarios to focus on the indication, dosing and counselling points of PBS listed oral anti-cancer medications, based on the previous focus group results. Participants completed a series of pre- and post-intervention survey questions. Each comprised a knowledge based component and participates were also asked to rate their confidence in the answer’s correctness based on Charles Mitchell’s method.

Results

Click he Preliminary analysis has been conducted on 20 completed education programs. Most participants reported having 2 to 5 years of pharmacy experience (n=10). 95% reported not having received adequate oncology education at the undergraduate level (n=19), but only 40% attended oncology continuing education in the last two years (n=8). Of the pre-intervention knowledge based questions an average of 57% were answered correctly (range 25–to85%), while all participants achieved the minimum required 80% correct answers in the post-assessment survey. Pre-intervention when asked ‘how certain are you’ the most commonly reported answer was ‘No idea; it’s a guess’ (58%, 232/400), yet post-intervention it was ‘Moderately’ certain (55%, 55/100). re to enter text.

Implications

With a substantial number of oral anti-cancer medications available on the PBS, this research suggests that targeted education improves is community pharmacists’ knowledge and confidence in dispensing oral anti-cancer medications and is an essential means of doing so.

Authors

S Vinod (Lead)

L Holloway

E Juresic

R Rai

L Cassapi

A Xing

G Goozee

D Moses

G Liney

Aims

To describe the implementation of dedicated MRI simulation for common tumour sites treated with radiotherapy.

Method

Following installation of a 3T MRI scanner within the radiotherapy department, a multidisciplinary group devised protocols for MRI scanning specifically for radiotherapy requirements.  Volunteers were scanned to optimise scan requirements prior to clinical implementation. Input from site-specific radiation oncology groups was sought in order to refine scanning protocols.

Results

The basic requirements identified for MRI simulation were use of a flatbed couch with MRI compatible immobilisation devices, a small field of view to minimise distortion but allow adequate anatomical information for registration to CT, and thin slice thickness to allow detailed visualisation of anatomy. Patient positioning and strict bowel and bladder protocols were crucial for incorporation of MRI for radiotherapy planning. Routine MRI simulation has been successfully implemented for prostate cancer, rectal cancer, cervix cancer, head and neck cancers and brain tumours. The number of patients undergoing MRI simulation has increased from 13 patients per month (Aug-Dec 2013) to 33 patients per month (Jan-June 2014). MRI simulation is most frequently used for prostate and cervical cancer patients.

Implications

The presence of a departmental MRI simulator has allowed MRI simulation to be incorporated in many tumour sites. Better quality imaging results in improved delineation of cancers leading to more precise radiotherapy.

Authors

T Robinson (Lead)

A Janssen

P Provan

K Lyon

T Shaw

K Museth

P Harnett

Aims

The study aims to identify the factors that assist MDTs to translate new evidence and improve the quality and coordination of care for people living with cancer. The findings will be used to identify practice gaps and inform the development of implementation studies.

Method

Phase 1 of the study used mixed methods to identify organizational systems and structures that support the generation of research in MDTs. Semi structured interviews (n=15) were conducted with MDT leaders and champions to collect baseline information about how teams interact with and generate research and implementation initiatives. In addition, observations of MDT meetings (n=34) were undertaken to identify gaps and enabling factors for strengthening implementation research. The findings from qualitative interviews and observations of MDT meetings were transcribed, de-identified and subject to thematic analysis in order to identify key themes and categories.

Results

Despite variations in the way MDTs use and generate research, most are active in some basic science research and clinical trials. Very few MDTs are active in implementation science or quality improvement research. Findings from interviews and observations confirm the importance of leadership and processes for identifying gaps and quality improvement activities. Additional results from observations and interviews will be further discussed in relation to their significance and feasibility.

Implications

This study identified key enabling factors for MDTs to use to generate implementation science research. The findings will inform the development of implementation studies and are likely to have relevance for MDT care across a range of clinical settings. 

Authors

D Thwaites (Lead)

A Dekker

J van Soest

L Holloway

M Bailey

A Miller

S Vinod

G Delaney

M Carolan 

G Goozee

A Ghose

F Hegi-Johnson

D Stirling

S Greenham

D Fraser

R Alvandi

K Foo

Aims

To share and combine routinely-available information from multiple NSW cancer centres in a data-protected manner; to use bioinformatics tools for data-mining and modelling to provide meaningful decision support systems (DSS);  and to integrate  radiomics (imaging-based) and clinical patient features. To demonstrate proof-of-principle using datasets for non-small cell lung cancer (NSCLC) patients receiving radiotherapy.

Method

Treatment, imaging and outcome data for lung patients from one NSW and one European radiotherapy centre have been extracted, standardized and linked, using Semantic Web based tools; keeping each centre’s data secure within its own protected systems. Outcome prediction models have been learned and validated and a model-based DSS produced to predict whether a specific patient may benefit from radical radiotherapy. An extended distributed learning network is currently being developed to include data from 6 more NSW cancer centres.

Results

The single-centre (Liverpool/Macarthur CTC) pilot study initially identified 4000 lung patient datasets,  modelling those meeting eligibility criteria, including having complete data.  The resulting model-based DSS provided new knowledge, capable of helping clinical decisions where standard treatment guidelines are less strong.  Specifically it predicted good prognosis sub-groups in both palliatively and curatively treated patients, enabling prospective DSS use to reconsider palliative treatment decisions for patients where a good prognosis is predicted. The available lung patient dataset numbers will increase to 20,000 in the extended collaborative network, providing stronger models and DSS and widening their use.

Implications

The work will support optimized clinical decisions between radical or palliative radiotherapy for treatment of advanced stage lung cancer patients; and for when to use complex treatment methods. The approaches are generalizable to other cancers and treatment modalities.

Authors

A Knight (Lead)

G Delaney

A Girgis

K McDonald

Aims

To improve the timeliness of communication to GPs from cancer services about their patients and to explore and implement appropriate technological solutions to facilitate timely communication from cancer services to GPs.

Method

An expert reference panel was convened to determine the improvement aim, the improvement measures and suggest ideas for improvement.  The panel developed a process map of the current approach to writing to GPs.  A microteam was convened to use the map to improve the process using the Langley and Nolan Model for Improvement.  Through a series of rapid improvement cycles ideas were tested and implemented to decrease the time from specialist cancer consultation to GP receipt of specialist letter.  Technological solutions such as secure messaging, direct faxing and voice recognition dictation were explored.

Results

The improvement process will continue from August to October 2014.  The process map will be shared together with run charts of the improvement measures.

Implications

Quality Improvement is a useful paradigm for working with primary and secondary care to improve integration through improved communication.

Authors

A Arnold (Lead)

G Bell

K Masters

Aims

To develop a reliable and secure access portal to patient care applications to improve clinician accessibility, facilitating improved patient management and more efficient support for clinical decisions.

Method

Opportunity existed to purchase an add-on to the cancer system IT infrastructure to connect remote users to the system with adherence to the key foundations of access, security and usability.

This gateway offered a possible alternative to the VPN access model. It offered opportunity to utilise an externally available single point of access to the various corporate applications.

A small team was assembled to explore the gateway as an alternative to the VPN access model.

Results

Initial pilot testing began within Cancer Services. Early indications were unanimously positive, and this cancer only access pilot was promptly expanded to additional clinical patient management applications.

Implications

The gateway provides every service in NSW a method of increasing mobility and remotely accessing their critical applications anytime, anywhere.

The success of this pilot project will transform the entire ISLHD remote access portal to this same system, thus further providing sustainability into the future.

Authors

M Hamidul Huque (Lead)

R Walton

N Gilroy

S Woolford

L Ryan

Aims

To have a better understanding of the burden of infection in patients receiving myelosuppressive treatment regimens. 

Method

We analysed data obtained by linking population-based, state mandated and routinely collected health records of cancer diagnosis, treatment, co-morbidity and death associated with adult cancer patients (age ≥ 20 years) receiving myelosuppressive chemotherapy in New South Wales during 2006–to2007.

Results

A total of 6245 patients were matched across the 4 registries, of which 2175 (35%) had an organism (bacterial or fungal) or site of infection (organism not specified) as a contributory cause of discharge diagnosis. Neutropenia was associated with 871(40%) of all infection-related diagnoses. In general, younger patients, patients with haematological malignancies and recipients of chemotherapy alone (without adjunctive radiotherapy or surgery) were most likely to have neutropenia related infections.  Fever with neutropenia was associated with 85.4% of patients receiving chemotherapy for acute leukaemia or conditioning for blood and marrow transplantation, followed by other haematological cancer diagnoses (29%), lung cancer (16.4%) and breast cancer (13.1%).  E. coli accounted for 360/749 (48%) of coded gram negative infections, and Staphylococcus aureus for 333/758 (44%) of coded gram positive infections. Candida sepsis was coded in 8/26 (30.7%) fungal infections. A higher proportion of patients with neutropenia had device-related infections, whereas pneumonia and urinary tract infections were more common in those with non-neutropenic sepsis.

Implications

Infection is a major cause of preventable morbidity and mortality in cancer patients receiving myelosuppressive chemotherapy.  Understanding the types of infections and their distribution will inform strategies and interventions aimed at improving cancer treatment outcomes. This Australian study, linking data from multiple contemporary cancer and population registries, has enabled a better understanding of the burden of infection in patients receiving myelosuppressive treatment regimens.  

Authors

G Gabriel (Lead)

M Barton

G Delaney

Aims

To calculate actual RTU and identify factors affecting RTU with special emphasis on the effect of distance.

Method

Data collected from all radiotherapy departments (RTD) were linked to NSW/ACT Central Cancer Registries (CCR). Geographic Information System (GIS) software was used to calculate road distance between patient residence and the closest RTD. Patients were excluded from the study if their nearest RTD was outside NSW.

Results

Road distance from patient residence to the nearest RTD ranged from 0.1–to772km.

Overall RTU rate was 26%. This represents 54% of the estimated optimal RTU. RTU rates decreased with increasing distance from patient residence to the nearest RTD (p <0.0001).

Multivariate logistic regression shows that male gender, younger age and shorter travel distance were significantly associated with receiving radiotherapy. Patients were 10% less likely to receive radiotherapy for each extra 100km they had to travel to the nearest RTD (p<0.001).  Patient diagnosed with regional or distant stage were more likely to receive radiotherapy than patients diagnosed with unknown stage (p<0.001). Survival analysis shows increased survival for patients receiving radiotherapy.

Implications

This study is unique because individual radiotherapy data were collected from all public and private RTDs and were matched to NSW-ACT CCR records. By using GIS software, it has been possible to calculate actual road distance from patient residential address to the nearest RTD and to identify the magnitude of cross-border flows.

Our study showed that actual RTU rate was 26%. This represents only half of the estimated optimal RTU rate. Based on the optimal and actual rates, it is estimated that 22% of the study cohort or 21,560 patients have missed out on the potential benefits of evidence-based radiotherapy during the study period.

While our actual RTU rate is low compared to the optimal utilisation rate, it is comparable with other Australian and the North American data.

Authors

J Holland

Aims

Investigate e-Health models of care that could provide a service that is currently not available for many rural clients, on identification and early self management principles for secondary lymphoedema following cancer treatment.

Method

Review of existing services and the potential incidence of secondary lymphoedema for the Hunter New England Local Health District (HNE LHD). A needs analysis was conducted via working party group consisting of staff and a patient representative and the “Listening Post” focus groups conducted by HNE LHD Cancer Network. Patients attending Calvary Mater Newcastle (CMN) from rural locations were surveyed to identify the early information they are given and the support within their local area.

Results

Lack of services outside Greater Newcastle was identified. Patients indicated very little knowledge obtained early on lymphoedema from their local area. Equipment was installed at CMN to enable the physiotherapy department to videoconference the Lymphodema Clinic to rural sites. A calendar of group sessions for rural sites was developed. Problems with establishing contacts at rural sites to co-ordinate the project has been the largest issue and still in progress.

Implications

Patients understanding and identifying the development of lymphoedema and having strategies to self manage the condition. Patients having the skills to understand when to seek further assistance when the condition is more easily managed. As a telehealth service this could be rolled out across the state.

Speakers

Gerry Marr is a passionate advocate for quality in healthcare delivery. He took up the position of Chief Executive, South Eastern Sydney Local Health District (SESLHD) in February 2014 after leaving Scotland where he had a 40-year career in healthcare, including 13 years in senior executive roles. 

Gerry has led the implementation of a range of quality programs within the Scottish health system, was a Non Executive Board member of Healthcare Improvement Scotland, and is an international guest speaker on the topic of quality and safety in healthcare.

In his role as Chief Executive, NHS Tayside between 2010 and 2013 Gerry was responsible for the provision of community through to tertiary level services, including specialist cancer services, for a population of over 400,000 people. He was also responsible for an operation budget of $1.6 billion. Facing performance challenges when Gerry took up the role of Chief Executive, NHS Tayside is now seen as one of the top performing NHS Boards in Scotland. 

Carrie Marr has had a long-term interest and hands on involvement in patient safety and the science of improvement. Her previous healthcare system at NHS Tayside was the first site in Scotland, and one of only four in the UK, to be a pilot site for The Health Foundation's Safer Patients Initiative. The significant successes of this project encouraged Carrie to drive forward a pioneering approach to building capability and capacity for clinical quality and patient safety.

As a result, NHS Tayside became a centre of excellence for improvement methodologies which culminated with the launch in February 2011 of the Tayside Centre for Organisational Effectiveness. This Centre acts as an Innovation Hub, supporting and enabling innovation and quality improvement both nationally and internationally.

In her current role as Executive Director Organisational Effectiveness at the Western Sydney Local Health District (WSLHD), Carrie aims to support and enable WSLHD to continue its quality improvement journey. 

Ingrid Plueckhahn has worked at the Peter MacCallum Cancer Centre for the past 16 years where she has undertaken a variety of positions involved with lung and head and neck cancer. Ingrid project led Peter Mac to become the first totally smoke free Melbourne metropolitan hospital in 2007, aligning the hospital as a lead member of the Victorian Network of Smokefree Healthcare Services.

She established a Smoking Cessation Clinic at Peter Mac where she provides quit smoking strategies to a stream of cancer patients, family members and staff. Ingrid has been recognised with a High Commendation from theVictorian Public Health Care Awards in 2006 for outstanding individual achievement for her work in setting up the Smoking Cessation Clinic, as well as The Jen Rusden Memorial Award for service to cancer nursing and commitment to patient care.

Ingrid has contributed to the writing of the National Health and Medical Research Council’sClinical Practice Guidelines for the Prevention, Diagnosis and Management of Lung Cancer, has been published in the Australian Journal of Cancer Nursing and has presented to several national and international cancer conferences.