Melanie Powis

PURPOSE: Despite growing demand for medical oncology services, there is limited literature on trends in service utilization, and current workload models focus solely on incident caseloads. We characterized population-level trends in outpatient medical oncology service utilization among patients diagnosed with common solid tumors. METHODS: A cohort of all patients age ≥18 years, diagnosed between January 2015 and December 2022 with one of the seven solid tumors (lung, colon, rectal, pancreas, breast, melanoma, or prostate cancer) was identified from the Ontario Cancer Registry. Administrative data were used to assess cancer incidence, and medical oncologist and systemic therapy outpatient visits during the first 2 years following the initial medical oncology consultation; analyses were stratified by year of diagnosis. RESULTS: The cohort consisted of 332,604 patients across the seven target cancers. Although we observed a modest increase in the number of new incident cancer cases per year (39,688 in 2015 to 45,011 in 2022) and the proportion of new patients with a consult with a medical oncologist (0.4%-5.3%), with the exception of pancreatic cancer (19.2%), these changes translated to a large absolute increase of 3,589 more consultations and 43,193 more follow-ups annually in the first year following initial consultation. The absolute number of systemic therapy visits during the first year increased by 36,185 visits during the same time period, with utilization remaining high in the second year. CONCLUSION: There has been a substantial rise in medical oncology outpatient health services utilization with more patients seeing a medical oncologist and going on to receive systemic treatment. These findings highlight the critical need for new comprehensive, data-driven medical oncology workforce requirements models that capture the complexity of delivering modern medical oncology care.

Introduction: While there has been a rapid uptake of virtual care in recent years, understanding of its impact on the quality of cancer care remains fragmented due to the heterogeneity of evaluation measures used to date and the lack of a framework to guide the work. We aimed to develop a comprehensive evaluation framework for virtual care in routine oncology practice. Methods: We conducted separate nominal consensus groups with key informants (knowledge users, policy makers, clinicians, patients, and caregivers) to generate and prioritize lists of potential virtual cancer care measures. To identify measures from the health equity perspective, we undertook a structured consultation with an established health equity expert patient and caregiver panel. Findings were thematically grouped through a cognitive mapping exercise using a virtual whiteboard. Virtual cancer care-specific initial construct definitions were derived first from a systematic review of the literature, then refined through iterative consensus discussions and voting. Results: Measurement priorities varied by key informant group, underscoring the need to consider the impacts of virtual cancer care from multiple key informant perspectives. The final framework included 17 constructs with definitions and operationalization considerations distributed across five domains: implementation, service, and client outcomes, with equity and cost as separate, overarching domains. Discussion: Our findings highlight the need to consider the impacts of virtual care from multiple key informant perspectives. Our final, comprehensive virtual cancer care evaluation framework can help guide and standardize future evaluations to improve comparability, inform policy, and guide practice optimization.

There is a growing number of artificial intelligence (AI) models; however, few have made it into routine clinical practice to date. We describe the synthesis of existing knowledge on the barriers to AI implementation in healthcare settings into a consolidated theoretical Framework for Artificial Intelligence Implementation Research in Healthcare (FAIIR-H) to help guide future implementation evaluation and planning. We undertook a scoping literature review; elevant articles published between 01/2020 to 05/2024 were retrieved from Medline, Embase and Web of Science. Additional relevant frameworks were then identified through snowball sampling. Constructs and domains were consolidated across theories using affinity diagramming. The final consolidated framework included 12 domains and 63 constructs across five themes: Design and Development (data, model performance, design, regulation), Organization and Culture (resources, readiness, buy-in), and Deployment and Maintenance (integration, user-centredness, maintenance), with Quality and Safety, and Equity as separate, overarching themes. The findings of this work will help to guide the development of implementation plans tailored to current evidence on known barriers and enablers of adoption, and guide the systematic evaluation of the implementation of AI-driven technologies in healthcare settings.

PURPOSE: Electronic health record (EHR) systems aim to improve efficiency, care coordination, and patient safety, yet implementation often introduces workflow challenges and staff burden. In 2024, the Cancer Centre of Southeastern Ontario (CCSEO), a regional academic cancer center in Canada, transitioned from a hybrid paper-electronic system to a fully integrated regional EHR. Although hospital EHR adoption has been studied, limited research has examined its impact within ambulatory oncology care, particularly among nonphysician staff, or how institutions responded to the findings. Our study explored oncology healthcare worker perspectives on EHR implementation at CCSEO and identified resulting quality-improvement (QI) initiatives. METHODS: Using purposeful maximum variation sampling, we recruited clinical, administrative, and research staff. Semistructured interviews explored workflow efficiency, documentation burden, staff wellness, patient safety, communication, and training. Data were audio-recorded, transcribed, and analyzed thematically using MAXQDA. RESULTS: Nineteen interviews were conducted until thematic saturation. Three major themes emerged. (1) Efficiency and workflow: Staff valued consolidated records and regional connectivity but reported navigation complexity, time burden, duplicate orders, reliance on multiple programs, and frequent workarounds. (2) Staff and patient wellness: Staff noted limited training, increased workload, cognitive overload, and reliance on peer support contributed to burnout. (3) Patient safety: Identified risks included order and medication errors, communication breakdowns, poor system visualization, imaging delays, and wristband or labeling issues. Several QI initiatives were implemented in response, including education and navigation rounds, formation of working groups, and integration of artificial intelligence. CONCLUSION: EHR implementation introduced both benefits and challenges in oncology workflows. Findings informed multidisciplinary QI initiatives targeting role-specific training, workflow optimization, and safety, offering a framework for other cancer centers transitioning to new EHR systems.

Background: Older and medically frail adults are underrepresented in clinical trials evaluating immune checkpoint inhibitors, leading to a knowledge gap on their risk of acute care use and immune-related adverse events. We performed a population-level study to evaluate the impact of age and frailty among older adults receiving immune checkpoint inhibitors on acute care use and immune-related adverse events–related hospitalizations. Methods: Patients with cancer aged 65 years or older who initiated therapy with immune checkpoint inhibitors between June 2012 and October 2018 (Ontario, Canada) were identified using systemic therapy administration data. The cohort was linked to other databases to obtain covariates and outcomes. Multivariable Cox proportional models evaluated the impact of age and frailty on acute care use and hospitalization for immune-related adverse events. Results: Among 2737 patients, the median age was 73 years; 26% were prefrail, and 4% were frail; 72% required acute care use, whereas 8% had an immune-related adverse event–related hospitalization. Increasing frailty was associated with increased risk of acute care use (prefrail vs robust, adjusted hazard ratio [HR] = 1.20, 95% confidence interval [CI] = 1.07 to 1.36, P = .003; frail vs robust, adjusted HR = 1.45, 95% CI = 1.12 to 1.86, P = .004), but age was not associated with acute care use. Increasing age was associated with reduced risk of hospitalization for immune-related adverse events (adjusted HR = 0.97 per year, 95% CI = 0.95 to 0.99, P = .01); compared with patients aged 65-69 years, patients 80 years of age or older had reduced risk of hospitalization for immune-related adverse events (adjusted HR = 0.63, 95% CI = 0.39 to 1.01, P = .05). Frailty was not associated with immune-related adverse event–related hospitalizations. Associations remained consistent when evaluating age and frailty in the same models. Conclusions: Age was associated with reduced risk of hospitalization for immune-related adverse events but not acute care use, whereas increasing frailty was associated acute care use but not immune-related adverse event–related hospitalization. Age and frailty may need to be considered independently when evaluating their impact on toxicity among older adults receiving immune checkpoint inhibitors.

Background: Virtual care is here to stay; however, there remains no comprehensive measurement framework to guide evaluation of its impacts, to inform policy decisions, and to support optimization of practice. Objective: This study aimed to conduct a scoping review of reviews to synthesize measures related to virtual care evaluation across clinical conditions and contexts to identify gaps in current evaluation measures and to inform the development of recommendations for future work. Methods: Citations published from 2015 to 2023 were retrieved from MEDLINE, Cochrane Database of Systematic Reviews, Embase, Emcare, Scopus, CINAHL, and Web of Science using search terms grouped by key concepts (virtual care and evaluation or quality measurement). Measures were defined as any quantitative or qualitative evaluation of performance or impact of virtual care on processes, outcomes, or systems. Articles were excluded if they were not a literature review (eg, primary results, commentaries, letters, protocols), dealt exclusively with pediatric populations, were published in a language other than English, or were abstracts only. Measures from retained articles (1233) were thematically grouped against the Proctor Implementation Research Outcomes framework. The study was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline extension for scoping reviews. Results: There has been substantial growth in the virtual care literature, particularly since the start of the COVID-19 pandemic. The majority of articles (900/1233, 73.0%) evaluated client outcomes, including satisfaction with virtual care, usability or functionality of platforms, or clinical outcomes. Relative to the other domains of the Proctor framework, implementation measures were poorly defined, and many of the measures were proxy rather than direct measures. Despite the potential impacts of virtual care on health equity, most studies examining health equity were purely qualitative. Measures of safety, privacy, and security of virtual care were sparse and poorly defined. Caregivers play an important role in facilitating virtual visits and providing informal technical support; however, few studies examined implementation or satisfaction with virtual care from the perspective of caregivers. Additionally, clinician experience and acceptance of virtual care have implications for availability and adoption; however, relative to patients, few articles examined this perspective. Conclusions: Our study highlights gaps in current evaluations of virtual care. Work is needed to improve the quality and standardization of virtual care evaluation to ensure reproducibility, generalizability, and comparability of findings. Additionally, compliance with existing measure definitions and conventions should extend to virtual care. Finally, additional theoretical work is needed to standardize and conceptually frame future virtual care evaluations. Future studies should include both the caregiver and clinician as unique perspectives in evaluations and should embed systematic evaluations of the impact of social determinants of health on virtual care access, adoption, and perceptions of care.

Black-identifying patients face many barriers to the receipt of equitable breast cancer care; however, little is currently known about the unique needs of this patient population, particularly in Canada. To address this gap, we identified and thematically grouped constructs from the published literature reporting on the needs of Black-identifying patients with breast cancer and compared these findings to a list generated through a virtual nominal consensus group (NG) attended by Canadian patients with breast cancer who self-identified as Black (n = 3). A scoping review was undertaken, and relevant citations published from database inception until January 2025 were identified from MEDLINE, Embase, and CINAHL. The literature review yielded 34 articles from the United States and identified 15 constructs consistent with the NG, which spanned the cancer continuum from screening to survivorship. The NG identified four additional constructs that were not found in the literature: advocacy and outreach, communication and health literacy, comorbidities and personalized care, and end-of-life care. The final set of constructs was then validated and prioritized by an expert panel consisting of patients with lived experience and relevant community partner organizations (n = 9) to drive future research, advocacy, and policy work. Patient navigation was identified as the top need, with financial support, access to culturally tailored information and resources, culturally relevant care, racialized data for treatment decision-making, and emotional support identified as high-priority needs.

PURPOSE: The early phase of the COVID-19 pandemic affected cancer care globally. Evaluating the impact of the pandemic on the quality of cancer care delivery is crucial for understanding how changes in care delivery may influence outcomes. Our study compared care delivered during the early phase of the pandemic with the same period in the previous year at two institutions across continents (Princess Margaret Cancer Center [PM] in Canada and A.C. Camargo Cancer Center [AC] in Brazil). METHODS: Patients newly diagnosed with colorectal or anal cancer between February and December 2019 and the same period in 2020 were analyzed. Sociodemographic and clinical characteristics and performance of individual indicators within and between centers and between the peri–COVID-19 and control cohorts were tested using Cohen's h test to assess the standardized differences between the two groups. RESULTS: Among 925 patients, distinct effects of the early COVID-19 pandemic on oncology services were observed. AC experienced a 50% reduction in patient consultations (98 v 197) versus a 12.5% reduction at PM (294 v 336). Similarly, AC experienced a higher proportion of stage IV disease presentations (42.9% v 29.9%; P = .015) and an increase in treatment delay (61.9% v 9.7%; P < .001) compared with prepandemic. At PM, a 10% increase in treatment interruption (32.4% v 22.3%; P < .001) and a higher rate of discontinuation of radiotherapy (9.4% v 1.1%; P < .001) were observed during the pandemic. Postsurgical readmission rates increased in both AC (20.9% v 2.6%; P < .001) and PM (10.5% v 3.6%; P < .01). CONCLUSION: The early phase of the COVID-19 pandemic affected the quality of care delivery for colorectal and anal cancers at both centers. However, the magnitude of this impact was greater in Brazil.

PURPOSE: COVID-19 catalyzed rapid implementation of virtual cancer care (VC); however, work is needed to inform long-term adoption. We evaluated patient and staff experiences with VC at a large urban, tertiary cancer center to inform recommendations for postpandemic sustainment. METHODS: All physicians who had provided VC during the pandemic and all patients who had a valid e-mail address on file and at least one visit to the Princess Margaret Cancer Centre in Toronto, Canada, in the preceding year were invited to complete a survey. Interviews and focus groups with patients and staff across the cancer center were analyzed using qualitative descriptive analysis and triangulated with survey findings. RESULTS: Response rates for patients and physicians were 15% (2,343 of 15,169) and 41% (100 of 246), respectively. A greater proportion of patients than physicians were satisfied with VC (80.1 v 53.4%; P < .01). In addition, fewer patients than physicians felt that virtual visits were worse than those conducted in person (28.0 v 43.4%; P < .01) and that telephone and video visits negatively affected the human interaction that they valued (59.8% v 82.0%; P < .01). Major barriers to VC for patients were respect for care preferences and personal boundaries, accessibility, and equitable access. For staff, major barriers included a lack of role clarity, dedicated resources (space and technology), integration of nursing and allied health, support (administrative, clinical, and technical), and guidance on appropriateness of use. CONCLUSION: Patient and staff perceptions and barriers to virtual care are different. Moving forward, we need to pay attention to both staff and patient experiences with virtual care since this will have major implications for long-term adoption into clinical practice.

We undertook a retrospective study to compare the quality of care delivered to a cohort of newly diagnosed adults with colon, rectal or anal cancer during the early phase of COVID-19 (02/20–12/20) relative to the same period in the year prior (the comparator cohort), and examine the impact of the pandemic on 2-year disease progression and all-cause mortality. We observed poorer performance on a number of quality measures, such as approximately three times as many patients in the COVID-19 cohort experienced 30-day post-surgical readmission (10.5% vs. 3.6%; SD:0.27). Despite these differences, we observed no statistically significant adjusted associations between COVID-19 and time to either all-cause mortality (HR: 0.88, 95% CI: 0.61–1.27, p = 0.50) or disease progression (HR: 1.16, 95% CI: 0.82–1.64, p = 0.41). However, there was a substantial reduction in new patient consults during the early phase of COVID-19 (12.2% decrease), which appeared to disproportionally impact patients who traditionally experience sociodemographic disparities in access to care, given that the COVID-19 cohort skewed younger and there were fewer patients from neighborhoods with the highest Housing and Dwelling, ands Age and Labour Force marginalization quintiles. Future work is needed to understand the more downstream effects of COVID-19 related changes on cancer care to inform planning for future disruptions in care.