Weekly treatment with irinotecan plus fluorouracil and leucovorin is superior to a widely used regimen of fluorouracil and leucovorin for metastatic colorectal cancer in terms of progression-free survival and overall survival.

Oral capecitabine was more active than 5-FU/LV in the induction of objective tumor responses. Time to disease progression and survival were at least equivalent for capecitabine compared with the 5-FU/LV arm. Capecitabine also demonstrated clinically meaningful benefits over bolus 5-FU/LV in terms of tolerability.

XELOX is noninferior to FOLFOX-4 when administered as second-line treatment in patients with metastatic colorectal cancer.

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Cancer patients with multiple chronic conditions pose a unique challenge to how primary care and specialty care teams provide well-coordinated, patient-centered care. Effectiveness of these care teams in providing optimal healthcare depends on the extent to which they coordinate their goals and knowledge as components of a multi-team system (MTS). This paper outlines challenges of care coordination in the context of an MTS, illustrated through the care experience of Mr. Fuentes, a patient in Dallas County’s integrated safety-net system, Parkland. As a continuing patient with chronic illnesses, Mr. Fuentes is managed through one of Parkland’s community-oriented primary care clinics. However, a cancer diagnosis triggered additional needs for augmented coordination between his different provider teams. Further research and practice should investigate the relationships of MTS coordination for shared care management, transfer to and from specialty care, treatment compliance, barriers to care, and health outcomes of chronic co-morbid conditions, as well as cancer control and surveillance.

This is the first of a two-part review, concentrating on the ability of oncology electronic health records (EHRs) to enhance patient safety through the chemotherapy ordering and administration process, and on standardization of workflow processes in the practice. In this article, we endeavor to outline broad principles that should be considered when integrating an EHR, and in particular, a chemotherapy ordering module, into practice. We strongly advocate attention to these principles, as any fundamental change in a drug ordering process may compromise safeguards that are present in the practice. Computerized Order Entry and Workflow PolicyEHRs are being adopted with increasing frequency. They bring efficiencies to practice record keeping and billing. They allow data to be accessed for multiple purposes by different providers and employees of a practice, thereby cutting down on inefficiencies created by relying on one paper record. A true EHR will collect patient data, integrate this information with data from other sources, and guide the provider with clinical decision support in real-time care of a patient. EHRs can also provide data for multiple purposes such as for analysis of practice demographics and reporting on quality measures.EHRs that support oncologists must take into account key areas of practice that differentiate oncology from other specialties. Accurate tumor staging, flow sheets, the need for multidisciplinary workflow documentation, integration of laboratory and imaging reporting, and dealing with chemotherapy ordering and toxicities are some of these unique demands. 1 Particularly demanding is the ordering, documentation, and management of chemotherapy and ancillary medications.Regrettably, medication errors related to chemotherapy from the use of paper-based records and manual systems are not uncommon, and have been the source of some notorious cases of patient harm in recent years. Even when computerized order entry systems are used, errors are still possible because of human error in the process or due to inherent properties of the computerized system. Data collected from three different outpatient infusion centers at the Dana-Farber Cancer Institute in Boston in the year 2000, using a first-generation computerized order entry system, showed a medication error rate of 3% in adult patients (249 errors of 8,008 medication orders reviewed). Of these, more than one third were related to chemotherapy, which constituted 4% of all adult chemotherapy orders written during the interval studied. 2 Of the potential adverse drug events identified, 26% were serious, including such things as missed orders for premedications and overlooked chemotherapy treatment parameters such as a low WBC count.Workflow is the source of much of the risk to patients during a typical visit to the clinic for chemotherapy. In the typical treatment day, the patient proceeds from laboratory to physician visit to the infusion suite for chemotherapy, and each step involves numerous manual processes and hand-offs that are subject...

No abstract

This is the second of a two-part review, concentrating on the ability of oncology electronic health records (EHRs) to enhance patient safety through the chemotherapy ordering and administration process and the standardization of workflow processes in the practice. In part one we outlined broad principles that should be considered when integrating an EHR, and in particular, a chemotherapy ordering module, into practice. 1 We strongly advocate attention to the principles listed in the sidebar, as any fundamental change in a drug ordering process may compromise safeguards that are present in the practice. In this article we endeavor to highlight concrete operational issues that are informed by the use of these principles. Intersection of Computerized Order Entry and Workflow PolicyTwo key concepts raised in part one need to be reemphasized. The first concept introduced in part one is the importance of workflow. A practice must recognize that chemotherapy ordering safety with EHRs can be impacted not only by the EHR product (the software) but to an even greater extent by the workflow in the clinic. 3 When an existing clinic workflow does not work well with the EHR to be implemented, both should be carefully evaluated. It should not be assumed that the existing workflow is ideal, and changes should be considered that improve safety, efficiency, and compatibility with the EHR.The second concept is that in order to institute these principles, the practice must have a formal governance structure in place to address the many decisions demanded by the system and the changes in workflow. In large institutions, existing committees such as a pharmacy and therapeutics committee may take on this responsibility. Smaller practices will need to create this process. The committee can be small but should be multidisciplinary, including oncologists, nurses, nurse practitioners, pharmacists, and administrators who are completely engaged in the process. The committee serves to standardize regimens for antineoplastic agents including ancillary medications and to ensure that all orders are supported by credible literature. In addition, the committee analyzes errors and near misses that occur in the practice to alter systems or work flow to reduce the likelihood of subsequent errors. We cannot overemphasize the need to General Principles for Integrating an EHR Into PracticeAccuracy: Orders should reflect the intent of the ordering clinician and the independent understanding, confirmation and approval of the nurse and pharmacist.Standardization: All aspects of the ordering process should be standardized.Automation: Whenever possible, calculations should be performed automatically by the computer system to reduce clinician workload and avoid errors. 2Decision Support: The system should contain embedded tools that allow for computerized clinical decision support, including dose ranges, maximum dose thresholds that cannot be exceeded, dose reductions, drug interactions, and allergy alerts. Flexibility:The system should be able to be modified...