麻豆传媒

A team-based, coordinated-care program at the University of Michigan allowed patients with breast cancer and central nervous system (CNS) metastasis to receive more timely care and better access to specialists and clinical trials, creators of the program said.

Nicole Grogan Fleege, MD, now at the University of Iowa in Iowa City, and colleagues reported results of the program in . The program included a team of specialists and a dedicated coordinator who provided navigation, education, specialty referral, and clinical trial screening. A unique intake form developed for the program facilitated personalized, coordinated, and expedited specialty referrals, the researchers explained.

A total of 60 patients were initially enrolled. The median time to first visit was 5 days compared with the usual 2-4 weeks. Furthermore, 47 patients were referred to six specialists, including physical medicine and rehabilitation (10 patients), radiation oncology (10 patients), and neuropsychology (10 patients). Nineteen patients (36%) were enrolled in clinical trials.

"We demonstrate that it is feasible to develop and implement a care coordination program on the basis of a multi-team care delivery model," the authors wrote. "Distribution of our unique program intake form at other institutions and subsequent implementation of a multidisciplinary program could lead to improvement in health care access for patients with breast cancer and CNS metastases."

In the following interview, Fleege and co-author Aki Morikawa, MD, PhD, of the Breast Oncology Clinic at Rogel Cancer Center of the University of Michigan Health in Ann Arbor, offered additional details about the program and the study.

The nurse coordinator was key to this program. Can you tell us more about the coordinator's role?

Fleege and Morikawa: The nurse coordinator is an integral part of our program, functioning as the main point of contact for patients enrolled in IMPACT the Brain. After completing the intake form with patients, she coordinates necessary subspecialist appointments and assists with other identified needs during the intake process.

Her involvement at all levels of our program ensures a short time to program intake for our patients, coordinated communication for the team members, and that follow-up for patients is scheduled appropriately.

What is unique about the intake form, and how can other institutions get it if they want to use it?

Fleege and Morikawa: In addition to collecting demographic information, one of the unique aspects of our intake form is that it includes questions pertaining to subspecialists involved in our program. For example, if patients are struggling with severe or undiagnosed pain or having difficulty with activities, a referral is placed to physical medicine & rehabilitation (PM&R).

For patients concerned about memory problems or difficulty thinking, a referral to neuropsychology is offered. The intake form also assesses symptoms of anxiety and depression, and referrals to Social Work are placed as appropriate. The intake form is available in the from the JCO OP article so that it can be used at other institutions as desired.

What were some of the patient-reported outcomes of this program?

Fleege and Morikawa: Multiple patient-reported outcomes (PROs) were collected in this program, including the PROMIS Cancer Function Brief 3D Profile, the MD Anderson Symptom Inventory Brain Tumor (MDASI-BT), and the Short Form Zarit Burden Interview (ZBI-12), which was collected for caregivers. The PROMIS profile is collected by PM&R to assess changes in physical function, fatigue, and social participation in patients with cancer. The MDASI-BT measures the severity of cancer-related symptoms across program enrollment.

Finally, we are also collecting measures of the degree of caregiver burden experienced by caregivers of patients enrolled in our program. Collecting these measures is incredibly important, as there is currently a knowledge gap in the published literature for PROs in this patient population. Our findings could potentially provide information necessary to develop subsequent interventions.

Why is it important for patients with breast cancer and CNS metastasis to be referred to clinical trials?

Fleege and Morikawa: For patients with CNS tumors, including those with breast cancer and a history of CNS metastases, the availability of clinical trials is limited despite both ASCO and the FDA recognizing the need to include this subset of patients in research. As a result, the standard therapies available are limited. By improving the participation of our program participants in clinical trials, we hope to support knowledge gains and opportunities that often aren't available to this cohort of patients.

Do you plan any additional studies of or tweaks to the IMPACT program?

Fleege and Morikawa: The incorporation of patient-reported outcomes is increasingly considered to be an integral part of cancer care. Part of the ongoing work we are doing is to improve the serial collection of PROs in our study. We found that the rate of follow-up PRO collection was relatively low. Therefore, we are assessing different approaches to improve the follow-up PRO collection.

In addition, one of the important findings from the intake form collected in our patient population was a scarcity of early palliative care involvement. Currently, we are exploring how we can better introduce or incorporate early palliative care to address this finding.

Overall, we are very excited about our approach to multidisciplinary care coordination. We would like to expand this approach to other clinical settings where multidisciplinary care coordination is critical. In addition, we are planning to examine how a program like this can impact clinical outcomes for our cancer patients.

Read the study here and expert commentary about it here.