PURPOSE Among patients receiving chemotherapy, symptom monitoring with electronic patient-reported outcomes (ePROs) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established, warranting evaluation in community cancer practices. We present implementation findings of ePRO symptom monitoring across a large multisite community oncology practice network. METHODS Patients initiating a new systemic therapy at one of the 210 practice sites at Texas Oncology were invited to use the Navigating Cancer ePRO platform, with stepped-wedge implementation from July to December 2020. Participating patients received a weekly prompt by text message or e-mail to self-report common symptoms and well-being. Severe self-reported symptoms triggered a real-time notification to nursing triage to address the symptom. Enrollment and compliance were systematically tracked weekly with evaluation of barriers and facilitators to adoption and sustainability. RESULTS Four thousand three hundred seventy-five patients planning systemic treatment were enrolled and participated. Seventy-three percent (1,841 of 2,522) of enrolled patients completed at least one ePRO assessment. Among these individuals, 64% (16,299 of 25,061) of available weekly ePRO assessments were completed. Over a 10-week period, compliance declined from 72% to 52%. Barriers currently being addressed include lack of a second reminder text or e-mail prompt, inconsistent discussion of reported ePROs by clinicians at visits, and COVID-related changes in workflow. Facilitators included ease of use and patient and staff engagement on the importance of PROs for symptom management. CONCLUSION ePROs can be effectively implemented in community oncology practice. Utilization of ePROs is high but diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.

Notwithstanding promising multi-institutional efficacy results, further development of this regimen will require additional modifications to mitigate toxic effects.

COVID-19 places unprecedented demands on the oncology ecosystem. The extensive pressure of managing health care during the pandemic establishes the need for rapid implementation of telemedicine. Across our large statewide practice of 640 practitioners at 221 sites of service, an aggressive multidisciplinary telemedicine strategy was implemented in March by coordinating and training many different parts of our healthcare delivery system. From March to September, telemedicine grew to serve 15%-20% of new patients and 20%-25% of established patients, permitting the practice to implement safety protocols and reduce volumes in clinic while continuing to manage the acute and chronic care needs of our patient population. We surveyed practice leaders, queried for qualitative feedback, and established 76% were satisfied with the platform. The common challenges for patients were the first-time use and technology function, and patients were, in general, grateful and happy to have the option to visit their clinicians on a telemedicine platform. In addition to conducting new and established visits remotely, telemedicine allows risk assessments, avoidance of hospitalization, family education, psychosocial care, and improved pharmacy support. The implementation has limitations including technical complexity; increased burden on patients and staff; and broadband access, particularly in rural communities. For telemedicine to improve as a solution to enhance the longitudinal care of patients with cancer, payment coverage policies need to continue after the pandemic, technologic adoption needs to be easy for patients, and broadband access in rural areas needs to be a policy priority. Further research to optimize the patient and clinician experience is required to continue to make progress.

the Centers for Medicare & Medicaid Services (CMS) Innovation Center released details of a proposed alternative payment model for medical oncology care, called Oncology Care First (OCF), for public comment. 1 The OCF model will succeed the Oncology Care Model (OCM), which will expire at the end of 2020. When it started in 2016, the OCM, which was voluntary, was important in oncology due to its emphasis on value-based care transformation.The OCM requires practices to implement the following care transformation activities for patients receiving systemic cancer treatment: (1) 24/7 patient access to a clinician who can view the medical record; (2) patient navigation services; (3) documentation of a care plan that contains all components of the National Academy of Medicine's Care Management Plan; (4) delivery of guideline-recommended care; (5) use of a federally certified electronic health record system; and (6) use of data for continuous quality improvement. There are currently 140 participating practices, which represents about 10% of US oncology practices. Because some of the largest multisite community and academic networks in the country are included, this represents about 25% of patients receiving systemic cancer treatment in the United States.Recognizing that care enhancements can be expensive and cumbersome to implement, the CMS provides OCM practices with upfront monthly payments of $160, in addition to standard fee-for-service, for each patient receiving systemic cancer treatment (chemotherapy, immunotherapy, targeted therapy, or hormonal treatment). Practices can use these funds to support care transformation by hiring patient navigators, social workers, and care coordinators; building acute care alternatives to the emergency department; implementing treatment pathway programs; and creating or licensing software for population management. 2 Practices are incentivized to reduce costs of care via shared savings based on benchmark prices and quality measurement. Although it is still early, there is some evidence that the OCM features have led to reduced emergency department visits, intensive care unit admissions, and hospitalizations at the end of life, 3 which provide value and improve the patient experience. The early experience with the OCM also reveals how difficult it is to actualize care transformation because it requires changes in technology, patient engagement, communications, personnel, workflow, data reporting, and perhaps at the most fundamental level, a change in culture and mindset.Building on the success of the OCM, the CMS structured the OCF model as a capitated model with upfront

PurposeStudies treating adenocarcinoma of the pancreas with gemcitabine alone or in combination with a doublet have demonstrated modest improvements in survival. Recent reports have suggested that using the triple-drug regimen FOLFIRINOX can substantially extend survival in patients with metastatic disease. We were interested in determining the clinical benefit of another three-drug regimen of gemcitabine, docetaxel and capecitabine (GTX) in patients with advanced pancreatic adenocarcinoma.Patients and methodsThe cases of 154 patients, who received treatment with GTX chemotherapy with histologically confirmed locally advanced or metastatic pancreatic adenocarcinoma, were retrospectively reviewed. All demographic and clinical data were captured including prior therapy, adverse events, treatment response and survival.ResultsOne hundred and seventeen metastatic and 37 locally advanced cases of adenocarcinoma of the pancreas were reviewed. Partial responses were noted in 11% of cases, and stable disease was observed in 62% of patients. Responses significantly correlated with toxicity (neutropenia, ALT elevation and hospitalizations). Grade 3 or greater hematologic and non-hematologic toxicities were noted in 41% and 9% of cases, respectively. Overall median survival was 11.6 months. Chemotherapy naïve patients with metastatic and locally advanced disease achieved a median survival of 11.3 and 25.0 months, respectively.ConclusionsWe observe a substantial survival benefit with GTX chemotherapy in our cohort of patients with advanced pancreatic cancer. These findings warrant further investigation of this combination in this patient population.Electronic supplementary materialThe online version of this article (doi:10.1007/s00280-011-1704-y) contains supplementary material, which is available to authorized users.