Myeloid growth factors (MGFs) are given as supportive care to patients receiving myelosuppressive chemotherapy to reduce the incidence of neutropenia. This selection from the NCCN Guidelines for MGFs focuses on the evaluation of regimen- and patient-specific risk factors for the development of febrile neutropenia (FN), the prophylactic use of MGFs for the prevention of chemotherapy-induced FN, and assessing the risks and benefits of MGF use in clinical practice.
Purpose Precision oncology develops and implements evidence-based personalized therapies that are based on specific genetic targets within each tumor. However, a major challenge that remains is the provision of a standardized, up-to-date, and evidenced-based precision medicine initiative across a geographic region. Materials and Methods We developed a statewide molecular tumor board that integrates academic and community oncology practices. The Precision Medicine Molecular Tumor Board (PMMTB) has three components: a biweekly Web-based teleconference tumor board meeting provided as a free clinical service, an observational research registry, and a monthly journal club to establish and revise evidence-based guidelines for off-label therapies. The PMMTB allows for flexible and rapid implementation of treatment, uniformity in practice, and the ability to track outcomes. Results We describe the implementation of the PMMTB and its first year of activity. Seventy-seven patient cases were presented, 48 were enrolled in a registry, and 38 had recommendations and clinical follow-up. The 38 subjects had diverse solid tumors (lung, 45%; GI, 21%; breast, 13%; other, 21%). Of these subjects, targeted therapy was recommended for 32 (84%). Clinical trials were identified for 24 subjects (63%), and nontrial targeted medicines for 16 (42%). Nine subjects (28%) received recommended therapy with a response rate of 17% (one of six) and a clinical benefit rate (partial response + stable disease) of 38% (three of eight). Although clinical trials often were identified, patients rarely enrolled. Conclusion The PMMTB provides a model for a regional molecular tumor board with clinical utility. This work highlights the need for outcome registries and improved access to clinical trials to pragmatically implement precision oncology.
Our single institution experience with fluoroquinolone prophylaxis for allogeneic hematopoietic stem cell transplant patients supports continuation of this practice. Expansion to autologous hematopoietic stem cell transplant patients may be appropriate based on guideline recommendations and our institution-specific experience with fluoroquinolone prophylaxis.
Cancer treatment costs in the United States are rising. Evidence suggests that increased costs do not always correlate with improved outcomes. Several organizations have developed tools and frameworks to assess cancer treatment value; however, many centers have reported difficulty in implementing these tools and effectively incorporating value-based decision making into clinical practice. After evaluating existing frameworks, the Carbone Cancer Center at UW Health set out to create a value-based tool that could be used to inform the decisions of clinicians and patients. This tool was piloted in metastatic or advanced non-small cell lung cancer, specifically in the second-line setting to assess the value of immune checkpoint inhibitors nivolumab, atezolizumab, and pembrolizumab. The results of the pilot suggest that atezolizumab is the best value of the three agents in this patient population. Challenges and opportunities for improvement that were identified during the pilot process have helped refine the tool for use in a variety of disease states within oncology.
PROBLEM FACED: Broad use of oral chemotherapy poses safety challenges that are not manageable by systems designed for intravenous chemotherapy. Our institution, the University of Wisconsin Carbone Cancer Center, was experiencing challenges in safety and uniformity of processes for delivering oral chemotherapy and associated care.WHAT WE DID: ASCO and the Oncology Nursing Society jointly published safety standards for administering chemotherapy that offered a framework for improving oral chemotherapy practice. We used these standards to define gaps in the safety and uniformity of our oral chemotherapy practice and to develop recommendations for improving processes. Areas for improvement were addressed by multidisciplinary workgroups that focused on education, workflows, and information technology. Key changes included defining chemotherapy, standardizing patient and caregiver education, mandating the use of comprehensive electronic order sets, routing all oral chemotherapy prescriptions for review by an independent pharmacy before dispensing, and standardizing documentation of dose modification. In addition, drug-specific materials were developed to create uniformity in adherence and toxicity monitoring. Collectively, these processes enabled significant safety mechanisms for oral chemotherapy analogous to those in place for intravenous chemotherapy. Revised processes were implemented over a 5-month period.WHAT WE FOUND: Defining oral chemotherapy allowed creation of a list of oral chemotherapies that could be recognized and grouped in our electronic health record (EHR), which enabled EHR-facilitated solutions,includingconsent verification, prospectiveorderreview,education, and monitoring.Thefollowing are key performance indicators: 92.5% of oral chemotherapy orders (n = 1,216) were initiated within comprehensive electronic order sets (N = 1,315), 89.2% compliance with informed consent was achieved, 14.7% of orders (n = 193) required an average of 4.4 minutes review time by the pharmacist, and 100% compliance with first-cycle adherence and toxicity monitoring was achieved. We defined elements needed for complete patient education and provided staff education on this effort but did not build any EHR-based forcing functions. Subsequent assessment showed poor performance in documenting all elements of oral chemotherapy education (36%), which demonstrated the need for continued improvement. CONFOUNDING FACTORS, DRAWBACKS:We achieved demonstrable success in improving oral chemotherapy practice. Our approach relied heavily on the ability to electronically recognize oral chemotherapy prescriptions and apply all of the safety systems designed for intravenous chemotherapy. Our institution uses a well-established EHR and can dispense many oral chemotherapies because we have a specialty pharmacy. Potential limitations of our approach include EHR specificity, as well as ongoing time commitments by pharmacists for prospective order review. The capacity to fill many prescriptions mitigates the risk of pharmacy-related errors an...
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