From Diagnosis to Medical Oncology

The cancer care continuum begins at screening and diagnosis and continues onto treatment. Some cancer types— such as skin, breast, and prostate— may be detected by routine self-exams or other screening measures. Cancer may also be diagnosed incidentally when investigating or treating other medical conditions. Further examination is required when abnormalities are noticed by either the patient or a healthcare professional.

This investigation involves a thorough physical exam and is enhanced with laboratory studies. When the presence of a tumor is suspected, imaging tests, such as X-rays, computed tomography, magnetic resonance imaging, and endoscopy examinations are ordered. In the final step, to confirm diagnosis, a biopsy is performed in which a tissue sample is removed and studied to identify the presence of cancer cells. These actions help the physicians and the care team determine the cancer’s stage, location, and size.

It is generally during the diagnosis stage that physicians – primary care doctors, gynecologists, dermatologists and others – refer suspected or confirmed cancer patients to oncologists. As cancer is complex, its treatment often requires a mix of therapies in addition to lifestyle changes. Depending on the type and stage of cancer, the patient may need a special type of oncologist, or even more than one kind. There are three basic types of cancer treatment doctors [1]:

1) Medical Oncologists

2) Surgical Oncologists

3) Radiation Oncologists

Throughout the duration of the cancer care continuum, patients may go through a combination of treatments to slow tumor growth or eradicate it. It is the cancer and treatment type that will dictate the patient’s main doctor. The relationship built between the cancer care doctor, care team, and patient will most likely last through treatment and into survivorship.

In this article, we will focus on the scenario that the care team recommends systemic therapies – such as chemotherapy or immunotherapy – to get rid of cancer cells. We will explore the role of a medical oncologist in providing care along with the latest innovations in medical oncology.

Medical oncologists are a core member of the cancer care multidisciplinary team, and offer cancer patients a comprehensive and evidence-based approach to treatment and care. They aim to use safe and cost-effective cancer drugs, while maintaining the quality of life of cancer patients throughout the cancer journey. Contributions of medical oncologists are essential in integrating information, at all levels and settings.

For most referrals of suspected or confirmed cancer cases to a medical oncologist, the patient is unsure whether they have a malignant tumor. Understandably, when patients learn that they might have cancer, they want to ensure that they receive the best possible care and treatment. Therefore, good communication and effective patient engagement strategies will facilitate the transmission of realistic information.

It then becomes the oncologist’s role to manage a patient’s care throughout disease. This includes:

  • Explaining the cancer diagnosis and stage of cancer
  • Talking about all treatment options – may be one or a combination of oncology specialty treatment options – and the preferred option for the patient
  • Delivering continuous quality and compassionate care throughout all phases of care
  • Assisting with symptom management and

Medical oncologists aim to treat cancer using systematic approaches, which target the entire body. Based on the type and stage of cancer, the medical oncologist may suggest one or a few treatment options [2]

1. Chemotherapy

Chemotherapy is the traditional anti-cancer therapy. Chemotherapy drugs circulate throughout the bloodstream and disperse to destroy cancerous cells in multiple locations. Due to its nature, chemotherapy is often used to treat cancers that have spread beyond their original point of development.

Chemotherapy is a useful approach for: treating cancer, keeping cancer from spreading and slowing the growth of a tumor. In most cases, chemo increases survival time. Nevertheless, it is accompanied with acute and insidious side effects. Colon and breast cancer tumors have seen an improvement in survival using chemotherapy, but these benefits have to be weighed against the impact of persistent symptoms such as fatigue or neuropathy [3]. In addition, a significant proportion of cancer patients suffering from cancer types, such as melanoma and renal cell carcinoma, may not respond to chemotherapy or relapse after treatment. For these cancers, patients have received minimal benefit but significant toxicity

 

2. Immunotherapy

Immunotherapy – also called biotherapy – uses biologic agents, concentrated amounts of the body’s natural substances, to boost the immune system to fight cancer cells. The immune system is the body’s defense mechanism. When it detects a threat or abnormal behavior, it reacts. This is called the immune response. At times, the immune system is not strong enough. This is where immunotherapy enhances the actions of the immune system to fight cancer cells.

Kames Allison, of the United States of America, and Tasuku Honjo, of Japan, won the 2018 Nobel Prize in Medicine for pioneering this ground-breaking cancer treatment approach [4]. They laid the foundation for the development of a number of medicines now approved by the Food and Drug Administration to treat cancers.

In 2011, the FDA approved ipilimumab, an anti-CTLA-4 antibody, as a treatment for late-stage melanoma. This drug results in the stimulation of an immune response against melanoma. Even though, there are still a handful of side-effects that need to be monitored by the cancer care team during and post-treatment.

Vaccines, medicines that can train the immune system to recognize and destroy unwanted substances, are being utilized to prevent and treat cancers. With regards to cancer treatment vaccines, it may prevent the cancer from recurring, destroy any cancer cells still in the body after other treatments have ended, or stop a tumor from growing or spreading. Researchers are currently testing vaccines for several types of cancers in clinical trials, including breast, cervical, and prostate cancer.

3. Hormone Therapy

Hormone therapy uses drugs, and in some cases surgery, to stop cancer cells from growing. This treatment method works in two ways:

1) Prevents the production of abnormal hormones that can cause cancer;
2) Alters the actions of hormones.

Hormones are produced by many glands in the body, and act as the body’s chemical messengers. They travel throughout the body to regulate the activity and behavior of cells and organs. In women, estrogen and progesterone, produced by the ovaries, play a role in a woman’s reproduction functions as well as sexual characteristics, which can also trigger the growth of breast cancer.

In men, testosterone and dihydrotestostrone, produced by the testicles and adrenal glands, play a role in regulating a man’s sexual development and function. When too many of these hormones are made, prostate cancer may occur.

Hormone therapy uses synthetic hormones or drugs to disrupt the action of the body’s natural hormones. It aims to stop the flood of hormones to the affected tissues and prevents the cancer cells from growing.

The type of hormone therapy used is unique to the cancer type. For instance, a form of treatment for breast cancer may require Tamoxifen, which is a drug that blocks the receptors on the breast cancer cell. This blockage prevents estrogen from binding to cancer cells. Hormonal therapy in breast cancer has improved disease free survival by 10% in 10 years [5]. Similarly, for prostate cancer, there are several types of hormone therapy measures used to treat prostate cancer, including surgery that removes the testicles. As surgery is a permanent treatment, many patients may resort to medical castration, using drugs to lower the amount of hormones made by the body [6].

 

4. Targeted Therapy

Targeted therapies use drugs to interact with cancer cells by targeting specific molecules, such as genes and proteins, involved in cancer growth and spread. These therapies are different from traditional cancer drugs used in chemotherapy, which act on all fast-growing cells. As oncologists are able to match targeted treatments to the patient’s tumor characteristics, these therapies may work more effectively, with fewer side effects. Our previous article explores targeted therapy as a precise method of fighting cancer with drugs.

It is clearly evident in our exploration of the field of medical oncology and its main systemic therapies that this field has made incredible advances and will continue to evolve. With strategic collaboration and documentation of information at all levels of care, shortcomings can be alleviated.

In our next article, we will explore non-systemic therapies in the fields of surgical and radiation oncology, and discuss how the continuous emergence of health technologies is confronting the growing cancer burden worldwide.

 

Exploring Cancer Treatment Strategies — Target Therapies

The global cancer burden is driving technological advances in cancer research and treatment. Currently, nearly nine million people a year lose their lives to cancer. This equates to approximately 22,000 cancer deaths per day [1]. This burden is expected to grow as the world’s population expands and ages. There is a clear urgency to finding better treatments for current and future cancer patients navigating through the phases of cancer care.

The number of new US Food and Drug Administration (FDA) approved therapies and new uses of cancer therapies have been increasing dramatically in recent years. Majority of these improvements are associated with enhancements in patient survival and/or quality of life. Over the next few weeks, we will explore the pertinent cancer care areas of targeted therapy [2], medical, surgical, and radiation oncology.

Advances in cancer care and research allow for precision, and targeted therapy is the foundation of precision medicine. Targeted therapy aims to treat cancer by targeting the changes in cancer cells that help them grow, divide, and spread. This cancer treatment uses drugs and is different from traditional chemotherapy. It works by targeting specific genes and proteins related to cancer growth and spread of tumors.

To better understand the “targets” of targeted therapy, it is beneficial to know how cancer cells grow. Cells are the building blocks of every tissue in our bodies. There are many different cell types with different, yet specific functions. Cancer starts when a cell has a mutation – certain genes of healthy cells change. Genes play the most critical role as they tell cells how to function. If genes are altered, so is the functionality of the cell, it might either divide abnormally or live too long. When cells grow out of control, tumors form.

As knowledge and findings about cellular level changes increases, cancer researchers are able to design intricate and promising therapies that target erroneous changes and ultimately block their effects. These aim to:

1) Block or turn off signals that tell cancer cells to grow and divide
2) Prevent cells from living longer than normal
3) Destroy the cancer cells

There are two main types of targeted therapy:

1) Small-molecule drugs: these drugs aim to block the process that helps cancer cells multiply and spread. An example of this type of targeted therapy is angiogenesis inhibitors. These drugs keep the tissue around the tumor from making blood vessels. Hence, anti-angiogenesis therapies starve the tumor by keeping new blood vessels from forming.

2) Monoclonal antibodies: these drugs block a specific target on the outside of cancer cells. They can also send toxic substances directly to cancer cells.

It is important to remember that not all cancers type are the same, and not all tumors have the same targets. Therefore, targeted therapies must match the mutation. For instance, if an individual has colorectal cancer, they are tested for the KRAS mutation. This mutation controls the growth and spread of a tumor, and about 40% of colorectal cancers have this gene. When this mutation is present, some targeted therapies are not effective. This identification helps the cancer care team provide the most effective treatment, and protects the patient from unnecessary side effects or treatment costs. With advances such as targeted therapy, healthcare professionals have the ability to match every tumor to the best possible treatment.

In the case of breast cancer, approximately 25% of all cases have too much of a protein called human epidermal growth factor receptor 2 (HER2). This protein induces tumor cell growth [3]. Fortunately, if the type of breast cancer is HER2 positive, then several targeted therapies are available to stop and limit its functionality. HER2-targeted therapies include Trastumab, Pertuzumab, and Neratinib. Some are taken in combination with one another, or along with chemotherapy.

Nearly all novel interventions have their own set of limitations and challenges, and targeted cancer therapies are no exception. One limitation is that cancer cells may become resistant to the therapy, meaning that this method will no longer be effective. This may happen if the target changes itself through mutation, or if the tumor finds a new alternative way to induce tumor growth. It is because of this limitation that most targeted therapies may work best in combination with multiple targeted therapies, and/or in combination with one or more chemotherapy drugs. A challenge is that drugs for some identified targets are difficult to develop as the target’s structure and its pathway are regulated within the cell and are not easily accessible.

One expected goal for targeted therapies is for them to be less toxic than traditional chemotherapy drugs. However, they too can have side effects that need to be tracked by healthcare professionals. Patients may easily assist in reporting their symptoms through patient-reported toxicity questionnaires. This sharing of knowledge and information will further assist the refinement and enhancement of targeted therapies.

Considering these identified obstacles, targeted therapies remain a novel and growing approach to curtailing cancer progression. Cancer care and research are no longer approached through a one-size-fits-all model. Care and treatment have become much more personalized. Doctors and the cancer care team now know that one cancer, whether it be colorectal or breast, can come in many different genetic types. Targeted therapy through the use of drugs and other substances has the ability to more precisely identify and attack cancer cells, providing a promising conduit to diminish or eliminate the cancer care journey altogether.

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing

Equicare Health: Bridging Gaps and Enhancing Networks of Cancer Care

A comprehensive cancer care system encompasses the entire spectrum of care – from prevention and screening to diagnosis, treatment, and survivorship. At the secondary prevention stage, screening is utilized to detect potential cases. At diagnosis, the presence or absence of cancer is confirmed, and the patient is directed to the best course of treatment. Survivorship commences at diagnosis and continues onto long-term survival.

Early detection through cancer screening is paramount to the control and management of cancer cases. Each cancer type has a different screening procedure, making it imperative to understand the different modalities. The differences range in the administration of procedure to its specificity, sensitivity, and unintended consequences.

Once screening procedures are available and accepted, patient engagement initiatives play an important role in helping health professionals attract patients and better tailor treatment plans to specific tumor characteristics. As individuals move through the cancer care continuum – from screening to the stages of care – clear communication and access to education tools improve patient engagement.

Currently, digital technologies are utilized to enhance engagement with patients, physicians, and allied healthcare professionals by ensuring that accurate information is gathered and transferred throughout the health system in an efficient manner. For instance, patient reported outcomes (PROs) and questionnaires allow self-reporting of symptoms that provide invaluable information for timely risk management and assessing the overall effectiveness of cancer interventions. These tools have proven that enhanced communication and a well-coordinated system is not only advantageous for the patient, but also the medical team, and healthcare system.

Equicare Health – a leading provider of comprehensive care coordination solutions  – aims to assist patients and the medical team through the cancer care continuum. The key is a platform that bridges the gaps and seamlessly connects health professional team members to each other and their patients. For patients, through the patient portal, they can connect with their care team and engage in their healthcare journey. The portal facilitates patient activation and engagement. Once patients receive an invitation letter to sign up, they will be welcomed to Equicare Health’s portal. There, the dashboard guides patients to access resources such as health information, test results, educational material, and appointment schedule. Regular visits to the portal will help patients and their caregivers keep up-to-date on the progress of their treatment and maintain contact with their care team.

The healthcare team enhances patient activation by selecting the appropriate resources available within Equicare CS (ECS). For instance, a physician and/or allied healthcare professional can assign questionnaires to a patient based on the disease site and topic of concern (i.e. depression screening, sleep disorders screening, and/or distress screening). In addition, care teams can assign relevant education covering topics from pre-treatment to survivorship care to assist patients in their own care management. By doing so, patients become actively involved in their own health, and conversations between the care team and the patient are facilitated.

In addition to the care team guiding patients and processing referrals to specialists and health services, they can efficiently coordinate tasks within the care team through Equicare CS. The platform assists with navigation referrals and consults to medical services (i.e. imaging, surgery, radiation oncology), and support services (i.e. counseling, pain management, nutrition, and hospice care). This results in streamlined communication within and between departments and services, making it easier to support patients and enhance the care they need within the many facets of a healthcare team. Once ECS is adequately utilized, patient navigation reports and provider productivity reports can be generated to evaluate quality of care provided to support goals and compliance standards.

The key functionalities of navigation platforms and informatics tools described include the ability to:

 1) Do distress management for CoC accreditation

2) Track navigation activity to support the navigator role to administrator

 3) Standardize documentation throughout departments

 4) Provide timely information to patients

 5) Communicate to the entire cancer care team through the platform

Care becomes more difficult during survivorship, as patients are often lost to follow-up or unaware of the heightened health risks that arise post-treatment. This disconnect with the health system proves to be a challenge in managing patients’ medical and psychosocial concerns. Hence, electronic communication tools are imperative to maintaining contact both during and after active care: within the healthcare team and between the team and the patient.

Each step of cancer care is complex and multimodal. There is a need to create a chronic care model to improve clinical outcomes for patients as well as to maximize the operational efficiency for cancer centers. To date, Equicare Health has served over 250,000 oncology patients and 300 cancer centres who continue to utilize the diverse tools that ECS has to offer. With ECS, care coordination and center specific goals are supported through the Service Team and Workflow Specialist at Equicare, who connect with cancer centers and healthcare professionals to assist them in reaching their goals (i.e. number of PROs filled, meeting accreditation standards, and/or enhancing patient engagement). ECS supports patients and healthcare professionals through the care continuum. With its efficient communication tools, tailored educational content, and patient reported outcomes, ECS gathers information, data and education into a comprehensive platform that empowers healthcare providers, patients, and caregivers in the healthcare journey.

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing

Survivorship: Transitioning in a New Way of Life

Diagnostics, workup, and treatment may be complete, but the journey across the cancer care continuum will continue through survivorship management. There are currently over 15 million cancer survivors, and that is to increase to 20.3 million (a 31% increase) by 2026 in the United States alone [1]. In contrast, statistics from about 50 years ago was a count of 3 million survivors in 1971. This dramatic increase is primarily attributed to an aging population, earlier detection, and advanced treatment [2].

The concept of cancer survivorship is not new; it has been over 30 years since Dr. Fitzhugh Mullan described survivorship as a unique phase of cancer care and introduced the idea of “seasons of survivorship. [3]” Since then, this concept has evolved and continues to create some controversy with regards to its exact onset and duration [4]. These can generally be categorized into three categories:

  • Phase 1 – acute survival –  time from diagnosis to completion of initial treatment
  • Phase 2 – extended survival – time from completion of treatment to remission, with careful observations of outcomes from treatments
  • Phase 3 –  long-term survival

Our focus and attention will be on the period following final treatment and prior to the development of cancer recurrence – long-term survival. Historically, this stage has not been a focus of the care continuum and has several areas of concern, including a less frequent check-in with healthcare providers. Once primary treatment is completed, many patients are often lost to follow-up; are unaware of the heightened health-risks and are ill prepared to manage their medical and psychosocial concerns.

Part of the difficulty with this phase is that it is unique not only for each cancer, but also its various types. For instance, the 5-year survival for breast cancers diagnosed during 2010-2014 is 90.2% in the United States. Its hazard of reoccurrence is highest during the first 5 years at approximately 10%, with the estrogen receptor positive disease maintaining a significant recurrence rate beyond 5 years [5]. For prostate cancers in the United States, the 5-year survival is nearly a 100% [6], with a wide recurrence of 30% – 90% [7]. The high variety of survival rates along with the range of cancer reoccurrence informs the need for tailored surveillance programs.

Follow-up care concerns have become more pertinent in recent years as the new generation of cancer survivors are living longer due to improved access to effective screening, diagnosis, and treatment initiatives. Consequently, the health care delivery system is looking at solutions to efficiently and effectively navigate the long-term and late effects of cancer care as well as other chronic conditions, while taking into account the demands for patient-centered quality of care across the cancer care continuum.

The transition from active treatment to post-treatment care is a critical period for maintaining and enhancing long-term individual and population health. Evidence-based strategies need to be implemented across health systems to ensure that optimal health outcomes are met. Quality of care during survivorship is dependent on essential components of care, as well as ease of access to comprehensive and coordinated care.

Cancer survivorship encompasses:

  1. Prevention through screening of new and recurrent cancers
  2. Surveillance of cancer recurrence
  3. Monitoring of medical and psychosocial late-effects, incorporating interventions for intended and unintended consequences of cancer treatment
  4. Coordination of care between health professionals to ensure that all the health needs of survivors are met

In order to deliver optimal cancer survivorship care, fundamental changes are needed to ensure that all survivors receive care that is safe, timely, effective, efficient, patient-centred, and equitable. Leading health care systems foster and embrace the creation of an infrastructure to support evidence-based practices. In a world that is complex and continuously enhancing, leading health care systems utilize information technology to better assist health care professionals and patients with cancer care navigation.

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing

Patient Reported Toxicities

In a given year, over 1.5 million new cases of cancer are diagnosed in the United States alone [1]. Their journey on the cancer care continuum starts with screening and continues through survivorship, getting matched with the most appropriate form of care. Radiation, chemo, or hormonal therapy as well as surgery, all have side-effects that are experienced first-hand by the patient and impact their families.

Currently, traditional biomedical outcome measures, such as survival and disease-free survival rates, are widely used to track the effectiveness of cancer treatment interventions [2]. Symptomatic toxicities are often underreported when collected by healthcare professionals [3]. In a chemo radiation cancer study, comparing patient-reported outcomes (PROs) with hospital charts of acute symptoms, the patients reported diarrhea and inflammation approximately 20% more often than clinicians [4]. Patients generally report symptoms earlier and more frequently than clinicians. They are also able and willing to self-report their own adverse symptoms, even when severely ill. [5]

In one clinical trial, it was concluded that physician reporting is neither sensitive or specific in detecting common chemotherapy adverse effects [6]. To enhance current assessment measures, novel approaches to evaluating symptomatic toxicities associated with cancer treatments (e.g. headaches, nausea, vomiting) need to be incorporated into the health tracking systems. The aim is to better capture the rate of toxicity of interventions at a personalized level.

Direct patient reporting through electronic platforms offers a mechanism that will enhance the efficiency and precision of current approaches. Accurate knowledge of the potential harms and risks of cancer treatment modalities is important to decision makers including patients, researchers, health professionals, and regulatory authorities. Patient reported toxicities help guide healthcare professionals in real time in an effort to reduce treatment-related side effects. Patients are also better able to identify baseline symptoms related to pre-existing conditions, and misinterpretation or transformation of information is avoided. Undoubtedly, they will receive more accurate information based on their own reporting and previous experiences of their peers, and will be more at ease about the care provided. Tools developed that enable the translation of side effects, from the patient perspective, would allow tremendous improvements in risk-benefit analyses.

A systematic collection of patient-reported outcomes has been proven to be a valid, reliable, and sustainable approach in obtaining symptomatic toxicities. E-platforms have the ability to positively complement clinician toxicity reports. The widespread adoption of patient-reported outcome toxicity monitoring in oncology care is on the rise. Companies including Equicare Health try to address the need through comprehensive patient-reported outcome questionnaires. They aim to address the previously dominant challenges pertaining data collection logistics, validated analytical approaches, and resource utilization.

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing

Patient engagement and empowerment tools enhance cancer care process

According to a recent survey, approximately 90% of patients with chronic illnesses need assistance with disease management, and 70% need healthcare providers to supply them with more educational resources [1]. However, the tools that have traditionally been in place do not provide the optimal level of assistance and communication to meet the needs of patients.

In essence, to improve health outcomes, patients and caregivers need to have access to tools that provide prognosis and procedural education, allowing for effective communication with the cancer care team. When patients are informed, they are able to express the urgency of their needs to better navigate through their care continuum.

In oncology, controlling and treating cancer ranges across a combination of surgery, radiation, and chemotherapy. Treatment measures can be effective in stopping tumor progression, managing pain, and extending life. These may be accompanied with unintentional side effects, ranging from short-term and transient to long-term and persistent that can arise years after the first treatment.

Patient portals containing electronic personal health records linked to health systems, patient reported outcomes, and patient-centered education are currently recognized as promising tools to enhance health outcomes. Studies show that patient engagement throughout diagnostic, workup, and treatment, improves patient-provider relationships, enhances patient safety, and empowers patients and their caregivers [2].

Portals allow health professionals the ability to efficiently “track preventive measures such as screening tests and immunizations [3]”, and enable shared-decision making between health professionals and the patient. Communication between patients and the care team is enhanced with careful documentation of each interaction. A study by Easley et al. highlights that better communication among health professionals and with patients is the most common factor contributing to a positive experience within cancer care coordination [4]. When health professionals are given suitable tools to further enhance health literacy and promote self-management – patient outcomes throughout cancer treatment and survivorship planning improve.

Patient safety is further enhanced through the usage of portals that allow the tracking of stages of care in a centralized manner [5]. When supplemented with other software tools (i.e. tailored evidence-based educational articles, and patient reported outcomes and questionnaires) patients are able to monitor their health and efficiently report their status to the care provider.

 

Equicare Health is amongst the leading patient navigation health IT companies, currently serving over 250,000 oncology patients at over 240 cancer centers across the globe. Equicare Health provides efficient communication tools, a platform of educational content, and patient reported outcomes and questionnaires. The aim is to empower oncology navigation teams, caregivers and their patients.

The educational content provided is personalized for the patient and their care team. Equicare’s partnership with Oncolink and the inclusion of comprehensive drug fact sheets provides patients access to an extensive set of cancer educational content. Equicare has integrated Oncolink’s Education Library into their system to allow for timely and appropriate education provision.

Patient reported outcomes and questionnaires are measurements of any aspect of a patient’s health status that are provided directly from the individual [6]. They can provide invaluable information for timely risk management and assessing the overall effectiveness of cancer interventions. Cancer care organizations have begun integrating patient reported outcomes into their routine clinical practice. The hope is to improve cancer symptom screening and management across their jurisdiction.

Informal patient reported outcome measures in cancer care have always been in play. However, it has only been recently that there is growing interest on collecting information in a systematic and efficient manner through electronic collection and e-patient reported outcomes. Electronic collection yields reliable data that are of higher quality than health professional reported data that, in turn, facilitate conversation and increase patient involvement in their care.

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing. 

Cancer Care: From screening positive to diagnosis, and oncology team connection

Cancer screening procedures strive for effective early detection. In order to screen large numbers of at risk individuals, screening practices need to be simple, cheap and efficient. Diagnostic tests are used to determine the presence or absence of cancer. Symptomatic individuals, or individuals with positive cancer screening results, go through potentially invasive and expensive diagnostic procedures to establish the presence of a tumor.

As the cancer journey is complex and convoluted, the patient needs to meet with health professionals with different skill sets to facilitate the process. An oncologist oversees a patient’s care from diagnosis and throughout the course of treatment. Patients consult with their general practitioner and, at times in combination with, health insurance providers to be referred to the most appropriate oncologist. Databases, such as the American Society of Clinical Oncology (ASCO) [1], also provide open access lists.

Within the United States, approximately one third of patients aged 0 – 64 years (a population of approximately over 90 million) are referred to a specialist by their primary care physician [2]. A well-coordinated referral system needs to be established to accommodate this high frequency of referrals, in addition to connecting primary and specialty care.

All members of the oncology care team (oncologists, general practitioners, radiologists, nurse navigators, patient coordinators, registered dietitians, etc.) play an integral role in enhancing the quality of care received. The care provided encompasses diverse aspects of health services. In addition to appropriate care that is timely and appropriate, other elements of cancer care include psychosocial assessment, suitable and timely referral, and individualized treatment that considers each patient’s needs and preferences. A multidisciplinary team is needed to address these tasks, which may create complexities to care coordination in both hospital and community settings. Challenges include recognizing health professional roles and responsibilities, communication between the care team and with the patient, managing scarce resources, and transitioning patients through care.

Digital technologies have aimed to address these challenges [3]. These include:

  • Electronic portals

  • Electronic Health Records (EHRs)

  • Patient reported outcomes measures

  • Patient-centered education

They are utilized to enable collaborative care coordination systems. Patient experience and outcome is enhanced when implementation of optimal technologies are coupled with proper training and support for patients and the care team.

Recent evidence-based research has proven that improving quality of care through enhanced communication and a well-coordinated system is advantageous for the patient, the medical team, and healthcare system. Researchers have embarked on a series of studies aimed at identifying quality measures. Two examples of these cover:

1. The impact of EHRs and oncology EMR tools used by multidisciplinary teams in GP-oncologist communication and facilitation of cancer care. [4]

2. Use of IT-enabled measurements and patient reported outcomes by patients and the care team to enhance patient-centered care (allowing for a seamless incorporation of patient perspectives into cancer care practices). [5]

As a patient moves through from screening and diagnostics to workup, treatment plan, and the care planning stages – clear communication, education tools, and access improve patient engagement.

In our next article, we will take a closer look at different ways of engaging patients and their caregivers (e.g. patient portals, patient reported outcomes, and patient-centred education), and how they can ultimately improve the quality of health outcomes.

Main resources: https://www.ncbi.nlm.nih.gov/books/NBK223387/

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing. 

Impacts of Cancer Screening on Patients, Oncologists, and the Care Process

Cancer screening revolutionized the world of cancer care with its aim to detect cancer before symptoms appear. Early detection is paramount for the control of any disease. When symptoms are detected or apparent, diagnostic tests are used to find out the cause of the symptoms. A procedure, ranging in complexity and invasiveness, can have significant influences on detection, diagnosis, and trajectory of care. Once detected, engaging an oncologist early and connecting the screening results to the expertise needed enhances patient outcomes.

There are different cancer screening procedures in use across the range of cancer types. In the case of breast cancer and colorectal cancer, early detection is correlated with lowering mortality rates [1]. There are times that early detection does not lengthen the life of the patient, but may have other benefits with creating patient awareness. In general, screening tests are recommended and offered to all at-risk individuals, regardless of the outcome. This makes it imperative to be aware of the positive and negative impacts.

Two procedures that have been proven to be very effective at reducing cancer mortality rates are colorectal cancer and breast cancer screening. Colorectal cancer is the second leading cause [2] of cancer deaths in the United States. It mainly develops from abnormal growths in the colon or rectum. Screening tests can identify these abnormal growths. They can also detect tumors, and prevent the development of cancer before growths metastasize.

Interestingly, breast cancer mortality rates are lower than colorectal cancer rates. However, the rate of breast cancer diagnosis are higher within American women [3]. How is it that death rates are lower and diagnoses are higher for breast cancer, when compared to colorectal cancer? The answer is complex and depends on the screening tools used along with the nature of the cancer type and stage. Mammography is currently the most commonly supported screening procedure for breast cancer. Its greatest benefit is the decrease in breast cancer mortality: mammography screening has been associated with a 15% to 20% reduction in breast cancer mortality in women aged 40 to 74 years [4]. Despite the differences between colorectal and breast cancer, it is evident that timely and regular screening is key in lowering mortality rates.

An example of where early screening does not necessarily decrease mortality rates is the prostate-specific antigen (PSA) test for prostate cancer detection [5]. This blood test is able to detect prostate cancer at an early stage. However, routine PSA testing is debated. It is unclear whether early detection and treatment lead to significant changes in the cancer trajectory and the patient’s quality of life. The inadequate evidence of benefits for PSA testing hinders support for this screening test, and shines light on some unintentional consequences.

Recognizing the diversity of cancer screening modalities allows us to understand the scope of their influence across the cancer care spectrum. All tests are followed by results, and cancer screening is no exception. The test has either identified cancer in the individual, or it has not. However, there are truly four outcomes:

 

True Negative The screening test says the patient does not have cancer when they do not truly have cancer
False Positive The screening test says the patient has cancer when they do not truly have it
False Negative The screening test was not able to detect cancer when the patient truly has cancer
True Positive The screening test says the patient has cancer and the patient truly has cancer

 

In the True Negative scenario (an ideal case as a patient is cancer free), the potential implications from the screening test are procedural and financial. For example, when screening for colorectal cancer through colonoscopy, perforation and bleeding may occur.

For False Positive and Negative results, the screening test was not able to accurately identify the true state of the disease. When screening results appear abnormal even though there is no cancer (False Positive), anxiety may arise and each additional procedure may pose its own risks. For breast cancer, on average, 10% of women will be recalled from each screening examination for follow-up, only 5 of the 100 women recalled will have cancer [6]. In the case of False Negative, medical care is not sought in a timely manner. Treatment may even be delayed if cancerous symptoms are present. Understandably, the severity of the unintended consequences depend on the type and stage of the cancer.

It has been argued that screening may result in unnecessary earlier treatment or over-treatment. For breast cancer, the diagnosis and treatment of cancers that would otherwise never have caused symptoms or death in a woman’s lifetime can expose a woman to immediate risks. These include surgical deformity or toxicity from radiation therapy, hormone therapy, or chemotherapy, and late effects of therapeutic radiation – new cancers, scarring, cardiac toxicity.

Timely screening has proven to be an effective tool in curtailing cancer mortality rates. With early screening and engagement, health professionals are able to better tailor treatment plans to the individual tumor characteristics. Some screening tests and treatments are almost always recommended as the benefits outweigh the risks posed.

In our next article, we will explore the need for tools that facilitate the transition of care following a positive screening (False Positive and True Positive) through diagnostic, workup, and treatment plan. We will also elaborate further on directly engaging oncologists and the care team.

Written by Dorri Mahdaviani , who holds a Masters of Public Health (MPH) from the University of British Columbia (UBC). Her academic and professional interests include the areas of chronic illnesses, health care systems and childhood health and development. 

Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing. 

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*Infographics and Design by Ann Wong, who holds a PhD in Biochemistry and Molecular Biology from the Faculty of Medicine at the University of British Columbia (UBC), Canada. She is an author of over 10 SCI publications, having taught at UBC and the Peking University Health Science Center (PUHSC) in Beijing. 

Closing the information gap: Web-based PROs systems hold promise in supportive cancer care

TYPICAL CARE CAN GENERATE AN INCOMPLETE VIEW OF A CANCER PATIENT’S EXPERIENCES.

Patients with cancer suffer from disease and treatment related symptoms. Many of these clinically- relevant details are often missed or forgotten as these patient-reported outcomes (PROs) are typically only discussed at clinic visits. “Prior research has shown that doctors miss up to half of patients’ symptoms during cancer treatment,” noted medical oncologist Ethan Basch Director of the UNC Lineberger Cancer Outcomes Research Program and an Associate Professor of UNC School of Medicine Division of Hematology and Oncology [1]. Symptoms can also arise from medical comorbidities, such as diabetes and chronic obstructive pulmonary disease (COPD), especially with an aging population [2].  Greater diversity of expertise is needed to address these added complexities.  Results from a comorbidity study in skin cancer patients suggest that patient-reported questionnaires may better identify any coexisting disorders (n=44; 79.5% and 88.6% by traditional medical interview and patient-reported questionnaire, respectively) even when there are discordant observations [3].

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