Cheuk AV

Background: Unplanned radiation treatment breaks are shown to be related to increased risk of local recurrence, lower survival rates and reduced tumor control rates. Weight loss, along with other side effects, can be a major factor in radiation treatment breaks. This quality improvement project aimed to review weight changes and treatment breaks via retrospective chart review to better understand how to improve the combined nutritional and radiation oncology care of head and neck cancer (HNC) patients.

Methods: Utilizing the Lean Six Sigma Project Management approach to ensure critical components were assessed, this quality improvement project reviewed HNC cases via retrospective chart review that started and/or completed definitive radiation treatment from January 1, 2014 - December 31, 2018. Weights were assessed during the timeframe of treatment and limited to weights obtained within the same unit. Treatment breaks were confirmed via Electronic Medical Records (EMR) systems and defined as one or more missed or cancelled treatments, excluding those missed for nonclinical reasons. Charts were reviewed for documented dysphagia, mucositis, and skin reactions. Information on nutrition visits were assessed.

Results: The incidence of patients who experienced treatment breaks was 47.8%. Patients averaged 5.5 missed treatments. More than half of the patients who experienced treatment breaks had Stage IV disease and 62.5% experienced clinically significant weight loss within their treatment time frame. Approximately 15% of patients were seen within a designated oncology nutrition clinic. Side effects, such as mucositis, dysphagia, and skin reactions, were documented to have contributed to weight changes and treatment breaks.

Conclusion: This project highlighted the multifactorial nature associated with radiotherapy treatment of HNC patients. Based on prior experience with integration of nutrition and radiation oncology services and understanding expected treatment side effects, we recommend that nutrition services are integrated as part of the initial radiation consultation process to proactively approach the known weight loss and nutritionally relevant side effects. It is imperative to integrate medical informatics infrastructure to modernize the process of documenting treatment side effects and outcomes. Continued in-depth review of this data will facilitate us in creating a comprehensive multidisciplinary treatment approach for HNC patients undergoing radiation therapy.

Background: Unplanned radiation treatment breaks are shown to be related to increased risk of local recurrence, lower survival rates and reduced tumor control rates. Weight loss, along with other side effects, can be a major factor in radiation treatment breaks. This quality improvement project aimed to review weight changes and treatment breaks via retrospective chart review to better understand how to improve the combined nutritional and radiation oncology care of head and neck cancer (HNC) patients.

Methods: Utilizing the Lean Six Sigma Project Management approach to ensure critical components were assessed, this quality improvement project reviewed HNC cases via retrospective chart review that started and/or completed definitive radiation treatment from January 1, 2014 - December 31, 2018. Weights were assessed during the timeframe of treatment and limited to weights obtained within the same unit. Treatment breaks were confirmed via Electronic Medical Records (EMR) systems and defined as one or more missed or cancelled treatments, excluding those missed for nonclinical reasons. Charts were reviewed for documented dysphagia, mucositis, and skin reactions. Information on nutrition visits were assessed.

Results: The incidence of patients who experienced treatment breaks was 47.8%. Patients averaged 5.5 missed treatments. More than half of the patients who experienced treatment breaks had Stage IV disease and 62.5% experienced clinically significant weight loss within their treatment time frame. Approximately 15% of patients were seen within a designated oncology nutrition clinic. Side effects, such as mucositis, dysphagia, and skin reactions, were documented to have contributed to weight changes and treatment breaks.

Conclusion: This project highlighted the multifactorial nature associated with radiotherapy treatment of HNC patients. Based on prior experience with integration of nutrition and radiation oncology services and understanding expected treatment side effects, we recommend that nutrition services are integrated as part of the initial radiation consultation process to proactively approach the known weight loss and nutritionally relevant side effects. It is imperative to integrate medical informatics infrastructure to modernize the process of documenting treatment side effects and outcomes. Continued in-depth review of this data will facilitate us in creating a comprehensive multidisciplinary treatment approach for HNC patients undergoing radiation therapy.

Background: Unplanned radiation treatment breaks are shown to be related to increased risk of local recurrence, lower survival rates and reduced tumor control rates. Weight loss, along with other side effects, can be a major factor in radiation treatment breaks. This quality improvement project aimed to review weight changes and treatment breaks via retrospective chart review to better understand how to improve the combined nutritional and radiation oncology care of head and neck cancer (HNC) patients.

Methods: Utilizing the Lean Six Sigma Project Management approach to ensure critical components were assessed, this quality improvement project reviewed HNC cases via retrospective chart review that started and/or completed definitive radiation treatment from January 1, 2014 - December 31, 2018. Weights were assessed during the timeframe of treatment and limited to weights obtained within the same unit. Treatment breaks were confirmed via Electronic Medical Records (EMR) systems and defined as one or more missed or cancelled treatments, excluding those missed for nonclinical reasons. Charts were reviewed for documented dysphagia, mucositis, and skin reactions. Information on nutrition visits were assessed.

Results: The incidence of patients who experienced treatment breaks was 47.8%. Patients averaged 5.5 missed treatments. More than half of the patients who experienced treatment breaks had Stage IV disease and 62.5% experienced clinically significant weight loss within their treatment time frame. Approximately 15% of patients were seen within a designated oncology nutrition clinic. Side effects, such as mucositis, dysphagia, and skin reactions, were documented to have contributed to weight changes and treatment breaks.

Conclusion: This project highlighted the multifactorial nature associated with radiotherapy treatment of HNC patients. Based on prior experience with integration of nutrition and radiation oncology services and understanding expected treatment side effects, we recommend that nutrition services are integrated as part of the initial radiation consultation process to proactively approach the known weight loss and nutritionally relevant side effects. It is imperative to integrate medical informatics infrastructure to modernize the process of documenting treatment side effects and outcomes. Continued in-depth review of this data will facilitate us in creating a comprehensive multidisciplinary treatment approach for HNC patients undergoing radiation therapy.

Background: Palliative radiotherapy plays an important role in metastatic lung cancer (LC) treatment. Of VHA LC patients, 46% present with metastatic disease. The American Society for Radiation Oncology (ASTRO) has developed evidenced-based guidelines regarding management of metastatic LC.

Methods: In May 2016, an electronic survey of 84 VHA Radiation Oncologists (ROs) was conducted to assess metastatic LC management. Information on years in practice, employment status, academic appointment, board certification, and familiarity with ASTRO lung cancer guidelines was obtained. Two clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/ against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or YAG laser technology. Survey results were assessed for concordance with ASTRO guidelines.

Results: The survey response rate was 64%. Among respondents, 96% were board certified, 90% held academic appointments, 85% were full-time employees, 11% were part-time employees, and 3% were employed on contract. When asked about use of palliative radiotherapy for lung cancer, 88% were familiar with ASTRO guidelines, 13% had used Stereotactic Body Radiotherapy (SBRT) for palliation, and 26% referred to outside centers for EBB.

Clinical Scenarios: Case 1 – Metastatic (M1b) disease with local chest wall pain and 3 month life expectancy: All respondents recommended palliative radiotherapy, and most (98%) did not recommend concurrent chemotherapy. The fractionation schemes most often used were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%).

Case 2 – Metastatic (M1a) disease with endobronchial tumor blockage: 87% of the respondents would use conventional radiotherapy for symptoms such as hemoptysis, intractable cough, and pain, and the remainder would use SBRT. Almost half of respondents (49%) recommended EBB or YAG lung re-expansion before external beam radiotherapy.

Conclusion: In our study of VHA ROs and their knowledge of management of advanced (M1a/M1b) lung cancer, we found no distinction in clinical decisions based on demographic profiles. Almost all reported knowledge of evidence-based treatment guidelines for palliative radiotherapy of lung cancer and most recommended treatment according to current guidelines.”

Background: Palliative radiotherapy plays an important role in metastatic lung cancer (LC) treatment. Of VHA LC patients, 46% present with metastatic disease. The American Society for Radiation Oncology (ASTRO) has developed evidenced-based guidelines regarding management of metastatic LC.

Methods: In May 2016, an electronic survey of 84 VHA Radiation Oncologists (ROs) was conducted to assess metastatic LC management. Information on years in practice, employment status, academic appointment, board certification, and familiarity with ASTRO lung cancer guidelines was obtained. Two clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/ against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or YAG laser technology. Survey results were assessed for concordance with ASTRO guidelines.

Results: The survey response rate was 64%. Among respondents, 96% were board certified, 90% held academic appointments, 85% were full-time employees, 11% were part-time employees, and 3% were employed on contract. When asked about use of palliative radiotherapy for lung cancer, 88% were familiar with ASTRO guidelines, 13% had used Stereotactic Body Radiotherapy (SBRT) for palliation, and 26% referred to outside centers for EBB.

Clinical Scenarios: Case 1 – Metastatic (M1b) disease with local chest wall pain and 3 month life expectancy: All respondents recommended palliative radiotherapy, and most (98%) did not recommend concurrent chemotherapy. The fractionation schemes most often used were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%).

Case 2 – Metastatic (M1a) disease with endobronchial tumor blockage: 87% of the respondents would use conventional radiotherapy for symptoms such as hemoptysis, intractable cough, and pain, and the remainder would use SBRT. Almost half of respondents (49%) recommended EBB or YAG lung re-expansion before external beam radiotherapy.

Conclusion: In our study of VHA ROs and their knowledge of management of advanced (M1a/M1b) lung cancer, we found no distinction in clinical decisions based on demographic profiles. Almost all reported knowledge of evidence-based treatment guidelines for palliative radiotherapy of lung cancer and most recommended treatment according to current guidelines.”

Background: Palliative radiotherapy plays an important role in metastatic lung cancer (LC) treatment. Of VHA LC patients, 46% present with metastatic disease. The American Society for Radiation Oncology (ASTRO) has developed evidenced-based guidelines regarding management of metastatic LC.

Methods: In May 2016, an electronic survey of 84 VHA Radiation Oncologists (ROs) was conducted to assess metastatic LC management. Information on years in practice, employment status, academic appointment, board certification, and familiarity with ASTRO lung cancer guidelines was obtained. Two clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/ against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or YAG laser technology. Survey results were assessed for concordance with ASTRO guidelines.

Results: The survey response rate was 64%. Among respondents, 96% were board certified, 90% held academic appointments, 85% were full-time employees, 11% were part-time employees, and 3% were employed on contract. When asked about use of palliative radiotherapy for lung cancer, 88% were familiar with ASTRO guidelines, 13% had used Stereotactic Body Radiotherapy (SBRT) for palliation, and 26% referred to outside centers for EBB.

Clinical Scenarios: Case 1 – Metastatic (M1b) disease with local chest wall pain and 3 month life expectancy: All respondents recommended palliative radiotherapy, and most (98%) did not recommend concurrent chemotherapy. The fractionation schemes most often used were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%).

Case 2 – Metastatic (M1a) disease with endobronchial tumor blockage: 87% of the respondents would use conventional radiotherapy for symptoms such as hemoptysis, intractable cough, and pain, and the remainder would use SBRT. Almost half of respondents (49%) recommended EBB or YAG lung re-expansion before external beam radiotherapy.

Conclusion: In our study of VHA ROs and their knowledge of management of advanced (M1a/M1b) lung cancer, we found no distinction in clinical decisions based on demographic profiles. Almost all reported knowledge of evidence-based treatment guidelines for palliative radiotherapy of lung cancer and most recommended treatment according to current guidelines.”

Background: Prostate cancer is the most common cancer in the Veterans Health Administration. Radiation is an important treatment option for prostate cancer patients. Imaging is done before each daily radiation treatment to ensure the radiation beam is aimed accurately. Imaging can be inaccurate due to excess gas or stool in the rectum, which alters the treatment field and leads to delays in the daily treatment schedule, increased radiation exposure due to re-imaging, repetitive staff treatment delivery interventions, and an unsatisfactory veteran experience.

Methods: A quality improvement project utilizing A3.9 box process improvement methodology (problem solving template) was undertaken to address identified gastrointestinal concerns hindering daily treatment. A dietitian integrated services into the radiation oncology clinic by providing dietary education and counseling to avoid gasproducing foods and manage bowel regularity for prostate cancer patients. Daily images were reviewed for accuracy. For 3 months prior to intervention, we examined daily treatment images and documented any interruption in treatment delivery from gas or stool in the rectum as a nutrition-related defect. Initial data analysis revealed that 62 of 195 (31.79%) daily treatment deliveries experienced nutrition-related defects.

Results: As a result of changing the radiation therapy process to include dietary education to patients, we experienced a 53% reduction rate in nutrition-related defects (from 31.79% to 14.87%). Calculated cost avoidance showed an annual savings of approximately $19,300 with
implementation of a multidisciplinary approach. A total of 120 daily treatment visits and 90 patient treatment hours can be saved annually with this approach.

Conclusions: This project improved overall clinic function by implementing a multidisciplinary approach to prostate cancer radiation oncology care, increased patient’s satisfaction, reduced excess radiation exposure, and improved department efficiency.

Background: Prostate cancer is the most common cancer in the Veterans Health Administration. Radiation is an important treatment option for prostate cancer patients. Imaging is done before each daily radiation treatment to ensure the radiation beam is aimed accurately. Imaging can be inaccurate due to excess gas or stool in the rectum, which alters the treatment field and leads to delays in the daily treatment schedule, increased radiation exposure due to re-imaging, repetitive staff treatment delivery interventions, and an unsatisfactory veteran experience.

Methods: A quality improvement project utilizing A3.9 box process improvement methodology (problem solving template) was undertaken to address identified gastrointestinal concerns hindering daily treatment. A dietitian integrated services into the radiation oncology clinic by providing dietary education and counseling to avoid gasproducing foods and manage bowel regularity for prostate cancer patients. Daily images were reviewed for accuracy. For 3 months prior to intervention, we examined daily treatment images and documented any interruption in treatment delivery from gas or stool in the rectum as a nutrition-related defect. Initial data analysis revealed that 62 of 195 (31.79%) daily treatment deliveries experienced nutrition-related defects.

Results: As a result of changing the radiation therapy process to include dietary education to patients, we experienced a 53% reduction rate in nutrition-related defects (from 31.79% to 14.87%). Calculated cost avoidance showed an annual savings of approximately $19,300 with
implementation of a multidisciplinary approach. A total of 120 daily treatment visits and 90 patient treatment hours can be saved annually with this approach.

Conclusions: This project improved overall clinic function by implementing a multidisciplinary approach to prostate cancer radiation oncology care, increased patient’s satisfaction, reduced excess radiation exposure, and improved department efficiency.

Background: Prostate cancer is the most common cancer in the Veterans Health Administration. Radiation is an important treatment option for prostate cancer patients. Imaging is done before each daily radiation treatment to ensure the radiation beam is aimed accurately. Imaging can be inaccurate due to excess gas or stool in the rectum, which alters the treatment field and leads to delays in the daily treatment schedule, increased radiation exposure due to re-imaging, repetitive staff treatment delivery interventions, and an unsatisfactory veteran experience.

Methods: A quality improvement project utilizing A3.9 box process improvement methodology (problem solving template) was undertaken to address identified gastrointestinal concerns hindering daily treatment. A dietitian integrated services into the radiation oncology clinic by providing dietary education and counseling to avoid gasproducing foods and manage bowel regularity for prostate cancer patients. Daily images were reviewed for accuracy. For 3 months prior to intervention, we examined daily treatment images and documented any interruption in treatment delivery from gas or stool in the rectum as a nutrition-related defect. Initial data analysis revealed that 62 of 195 (31.79%) daily treatment deliveries experienced nutrition-related defects.

Results: As a result of changing the radiation therapy process to include dietary education to patients, we experienced a 53% reduction rate in nutrition-related defects (from 31.79% to 14.87%). Calculated cost avoidance showed an annual savings of approximately $19,300 with
implementation of a multidisciplinary approach. A total of 120 daily treatment visits and 90 patient treatment hours can be saved annually with this approach.

Conclusions: This project improved overall clinic function by implementing a multidisciplinary approach to prostate cancer radiation oncology care, increased patient’s satisfaction, reduced excess radiation exposure, and improved department efficiency.