Christopher M. Booth

Background: To our knowledge, there is no literature that has described medical oncology (MO) workload in the global context. Here, we report results of an international study of global MO workload. Methods: An online survey was distributed through a snowball method via national oncology societies to chemotherapy-prescribing physicians in 65 countries. Countries were classified into low- or low-middle–income countries (LMICs), upper-middle–income countries (UMICs), and high-income countries (HICs) on the basis of World Bank criteria. Workload was measured as the annual number of new consultations provided to patients with cancer per oncologist. Results: A total of 1,115 physicians completed the survey: 13% (147 of 1,115) from LMICs, 17% (186 of 1,115) from UMICs, and 70% (782 of 1,115) from HICs. Eighty percent (897 of 1,115) of respondents were medical oncologists, 10% (109 of 1,115) were clinical oncologists, and 10% (109 of 1,115) were other. The median number of annual consults per oncologist was 175 (interquartile range, 75 to 275); 13% (140 of 1,103) saw ≥ 500 new patients in a year. Annual case volume in LMICs (median consults, 425; 40% of respondents seeing > 500 consults) was substantially higher than in UMICs (median consults, 175; 14% > 500) and HICs (median consults, 175; 7% > 500; P < .001). Among LMICs, UMICs, and HICs, median working days per week were 6, 5, and 5, respectively ( P < .001). The highest annual case volumes per oncologist were in Pakistan (median consults, 950; 73% > 500 consults), India (median consults, 475; 43% > 500), and Turkey (median consults, 475; 27% > 500). Conclusion: There is substantial global variation in medical oncology case volumes and clinical workload; this is most striking among LMICs, where huge deficits exist. Additional work is needed, particularly detailed country-level mapping, to quantify activity-based global MO practice and workload to inform training needs and the design of new pathways and models of care.

Background: Utilization of chemotherapy for patients with muscle-invasive bladder cancer (MIBC) is low. In earlier qualitative work we used the Theoretical Domains Framework (TDF) to determine barriers and enablers of chemotherapy use. In this project we aimed to determine the prevalence of these barriers and enablers in Canadian physicians. Methods: Practicing Canadian urologists, medical oncologists (MOs) and radiation oncologists (ROs) participated in a specialty-specific web-based quantitative survey to assess potential barriers and enablers to chemotherapy use. Survey questions were developed that were thematically mapped to TDF domains. Logistic regression was used to identify TDF domains associated with high referral/use of chemotherapy. Results: 110 urologists, 47 MOs and 43 ROs completed the survey; response rates were 20%, 35% and 31% respectively. The mean reported survival gain associated with neoadjuvant chemotherapy (NACT) was 9%, 8%, and 7% for urologists, MOs, and ROs respectively. Among participating urologists, the TDF domains ‘ social and professional role’ (OR = 16.5, 95% CI 4.6–59.2), ‘ social influences’ (OR = 5.7, 95% CI 2.4–13.4) ‘ beliefs about consequences’ (OR = 4.9, 95% CI 1.8–13.3) and ‘ memory, attention and decision-making’ (OR = 0.50, 95% CI 0.27–0.91) were associated with MO referral rates. Among MOs, the TDF domains ‘ behavioural regulation’, ‘ social influences’, and ‘ social and professional role’ were associated with greater use of chemotherapy ( p < 0.05). No TDF domains were associated with RO referral to MO. Conclusions: We have identified several factors associated with referral/use of chemotherapy for MIBC. Optimization of multidisciplinary patient care needs to be considered when designing future interventions to close the gap between evidence and practice.

Introduction: Use of chemotherapy for muscle-invasive bladder cancer (MIBC) is known to be low. To understand factors driving practice we use the Theoretical Domains Framework (TDF) to identify barriers and enablers of chemotherapy use. Methods: A convenience sample of Canadian urologists, medical oncologists (MOs) and radiation oncologists (ROs) participated in individual, semi-structured, one-hour telephone interviews. An interview guide was developed using the TDF to assess potential barriers and enablers of chemotherapy use. Interviews were recorded and transcribed. Two investigators independently identified barriers and enablers and assigned them to specific themes. Participant recruitment continued until saturation. Results: A total of 71 physicians were invited to participate and 34 (48%) agreed to be interviewed: 13 urologists, 10 MOs, and 11 ROs. We identified the following barriers to the use of chemotherapy (relevant TDF domains in parentheses): (1) belief that the benefits of chemotherapy are not clinically important (beliefs about consequences); (2) inadequate multidisciplinary collaboration (environmental context and resources); (3) absence of ‘champions’ advocating the use of chemotherapy (social and professional role); and (4) a lack of organizational clarity/policy regarding the referral process (environmental context and resources). The predominant enablers identified included: (1) ‘champions’ who believe in the value of chemotherapy (social and professional role); (2) urologists who refer all patients to MO (behavioural regulation; memory, attention, and decision-making); and (3) system-level factors, including automatic multidisciplinary referral (environmental context and resources). Conclusions: We have identified several system-level factors associated with delivery of chemotherapy. Behaviour change interventions should optimize multidisciplinary care of patients with MIBC.

We read with interest the report by Cherny et al. [1] describing the updated European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS v1.1). We have previously noted only fair correlation between the American Society of Clinical Oncology Value Framework-Value Framework (ASCO-VF) and the original ESMO-MCBS (v1.0) outputs [2]. With the updated framework we explored (i) the extent to which revisions to the updated ESMO-MCBS (v1.1) modified ‘clinically meaningful’ therapies in our previously published cohort and (ii) if there was now a stronger correlation between the ESMO-MCBS and ASCO-VF [1, 3].

58 Background: Documenting goals of care (GOC) is integral to patient centered care, decision making and quality performance. Studies show patients value conversations about GOC after receiving a terminal diagnosis. Positive effects have been demonstrated for survival, quality of life, disease management and healthcare savings. The ASCO QOPI recommends documentation within 3 visits from diagnosis of metastatic cancer. For hospital inpatients, GOC are more often integrated into care planning, as admissions frequently reflect changes in illness trajectory, yet documentation remains poor. This Quality Improvement (QI) initiative aims to increase GOC documentation for ambulatory patients and referral rates to Palliative Medicine. Methods: A retrospective cohort receiving palliative chemotherapy for metastatic lung, pancreas, colorectal and breast cancers during 2010-2015 were identified from pharmacy records at a Canadian Regional Cancer Centre. Inclusion criteria required a minimum of 4 clinic visits post treatment. Clinical notes of Oncologists and Palliative Medicine Physicians were reviewed for GOC documentation and referrals to Palliative Medicine. Baseline data determined improvement target rates. A clinical practice QI initiative applied passive and active phases, beginning May 2016. Passive phase included the development of a guideline, documentation template and referral process. The active phase is the implementation process (ongoing). Results: A cohort included 456 patients with metastatic cancer, 63% lung cancer. Oncologists documented GOC in 6% (26/456) and referred 47% to Palliative Medicine. GOC rate was 48% post-referral. Improvement target rates were set at 40% and for referrals 70% by March 2017. Analysis during the passive phase showed Oncologists’ GOC documentations increased to 15%. Analysis of the active phase is ongoing and preliminary results will be presented. Conclusions: Low rates of GOC documentation and referrals to Palliative Medicine persist. The passive phase of engaging physicians in the QI development positively influenced GOC documentation. This QI initiative will inform the sustainability of GOC documentation, Palliative Medicine referrals and standardization of institutional guidelines.