Putting cancer care quality under the microscope

Latest RCN research grants look at new ways to impact patient quality of life and survival

Last fall, the RCN announced the recipients of its 2015 Cancer Quality & Innovation (CQI) Research Fund. Totalling $460,000 in grants, six innovative studies will be funded to advance cancer care quality throughout the trajectory of care. In this issue, we profile three of these projects which will impact hematological cancer, colon cancer and head and neck cancer.  

Improving survival by tracking guideline compliance

“In terms of the treatment of cancer, chronic myeloid leukemia (CML) is a pioneer of targeted therapy,” says grant recipient Dr. Sarit Assouline, a hemotologist-oncologist at the Jewish General Hospital (JGH). “We use a tyrosine kinase inhibitor as a single treatment and that drug improves the overall survival and, for the majority of patients, also restores normal life expectancy.” Proper administration of this therapy is vital for achieving these results. Yet not all CML patients benefit from the full impact of this spectacularly successful treatment. Dr. Assouline and her colleagues want to find out if doctor deviation from CML guidelines could be a factor and, if so, how to fix it to improve outcomes for all CML patients.

Using a Quebec-wide database of 500 CML patients, Dr. Assouline and her team will analyse treatment data going back to 2009 to see how closely physicians have been following the protocols set out in the guidelines. In the US, for example, it's been demonstrated that three-month detection testing, which is essential to guiding therapy, is done in under 30% of cases, says Dr. Assouline. She's pretty sure that in Quebec, where access to healthcare isn't an issue like in the US, adherence rates will be much better. Problems here will likely have to do with how many CML patients a physician treats; whether it's an academic or non-academic centre, in a rural or urban setting; and practical issues such as slow test results from central lab; as well as patient compliance.

“But those are things that can be fixed if you know it's a problem,” notes Dr. Assouline. Some possible solutions could be for doctors to concentrate their CML patients on certain days so as to focus on them more fully; to improve turnaround times for test results; and to help patients understand how important it is to be vigilant about taking their medicine.

Dr. Assouline and her colleagues from the McGill University Health Centre (MUHC) and St. Mary's Hospital Center (SMHC) plan to share what they have gleaned from the CML experience to improve practice in other cancers where targeted therapies have been introduced, such as lung cancer, across the province and internationally. The study will wrap up by next October.

Pre-habilitation helps elderly frail cancer patients

Building on previous research on how preoperative pre-habilitation can improve recovery for colorectal cancer surgery patients, Dr. Francesco Carli, professor of anaesthesia working at the MUHC, and his team are now turning their focus on frail elderly patients. “Ultimately the idea is to put them in a better physical, nutritional and mental state so they can encounter surgery in a better condition,” explains Dr. Carli.

“Our previous study showed that in the general population, without pre-habilitation only 30% returned to their pre-surgery baseline. But for those who have had pre-habilitation, over 80% go back to normal.” Frail elderly patients recover more slowly and have more complications, seriously impacting their quality of life while also adding extra pressure on hospital resources. Interestingly, Dr. Carli and his team discovered that the frail elderly patients in the study group were the ones who benefitted most from the cost-effective prehabilitation approach. “We thought, maybe this is the population we need to put our money on,” says Dr. Carli. The aim of the new RCN-funded study is to prove the benefit and look for a decrease in complications.

The study, which involves 120 patients — 60 at the Montreal General Hospital of the MUHC and 60 at the JGH  — is made up of a four-week training period (one week supervised and three weeks home-based) that includes nutrition, exercise and relaxation. Improvement is measured by walking capacity. So how do these frail elderly patients like prehab? “They love it. They are so keen and enthusiastic,” says Dr. Carli. “Remember, these patients have just had a diagnosis of cancer. They have bowel problems. They are also very depressed and they are doing nothing, just waiting at home for tests and for the operation. So they like to come — we had a 99% compliance rate.”

Better cancer staging thanks to new image analysis techniques

The majority of cancer diagnoses are now made with imaging and the technology is advancing at a dizzying rate. “It is amazing how well we see tumors and their extent before surgery” says Dr. Reza Forghani, associate chief of radiology at the JGH. His new RCN-funded study will look at how to exploit cutting-edge dual-energy CT scans and sophisticated image analysis to their full potential to improve cancer staging, and ultimately prognosis, in head and neck cancer patients.

Dual-energy CT uses two beams of X-ray rather than the one in a conventional CT, giving physicians a vastly enhanced picture of the tumour. “There's much more data in the image than we can just analyze by the eye,” explains Dr. Forghani. He and his team want to take things a step further and run the image through a computer program whose analysis will aid in staging and therapy choice. “If you take a tumour and you draw around the whole area and if you get a computer to analyse every dot on that image — the gradient, the intensity, the variations — there is a lot more information and right now it's not being used at all.” The hope is that the very genetic makeup of the tumour can be predicted. “Then you can determine how it will behave to certain treatments,” explains Dr. Forghani. “So we can say maybe this patient is better treated with this kind of drug.” This would also result in fewer biopsies and scans.

There is currently just one other dual-energy CT machine in Montreal, at the CHUM, but Dr. Forghani anticipates that as these machines show their value, hospitals will replace older CT scanners with the dual-energy versions which, though more expensive, can save by increasing accuracy and potentially reducing the overall number of scans a patient requires. The study will look at data from 35 patients with data analysis done in collaboration with the MUHC. Eventually it should be possible to apply this technology to other cancers, such as breast and colorectal cancer. 

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