With NCCN Grant, GI Clinicians Tackle Fractured Care

May 28, 2019
By: Julie Poucher Harbin, Writer, DCI

A multi-disciplinary team of researchers led by Duke Cancer Institute surgical oncologist Dan Blazer III, MD, surgery resident Daniel P. Nussbaum, MD, and Duke Cancer Network medical director Linda M. Sutton, MD, has been awarded $100,000 by the National Comprehensive Cancer Network Oncology Research Program (NCCN) and Eli Lilly and Company for a two-year study aimed at optimizing multi-disciplinary gastric and gastroesophageal junction (GEJ) cancer care across the Duke Cancer Network (DCN).

Their study “The DCN Passport: A Novel, Patient-Centered Approach to Improve Care for Gastric/Gastroesophageal Junction Cancer Across an Academic-Community Oncology Network” is one of six quality improvement projects for gastric and GEJ cancers awarded nationwide “to identify disparities in care between the community and academic setting, and define scalable, shareable solutions that will rapidly improve adherence to guidelines and quality of care.”

“Because the challenges faced by our academic-community partnership in the Duke Cancer Network are also broadly experienced at the national level, this study represents a unique opportunity to study this nationwide challenge locally,” said Blazer.

Duke Cancer Network (DCN) is a well-established academic-community partnership between DCI and 12 affiliate community treatment centers in the Southeast.

Most of these affiliates are located in rural, traditionally underserved communities — among the poorest and most diverse in the region and the nation. These underserved communities frequently report considerably higher incidences of cancer and cancer related deaths, including in gastric and GEJ cancers.

Relatively rare malignancies, the combined DCI and DCN gastric and GEJ cancer programs is one of the highest-volume programs of its kind in the U.S.; with about 75 new cases treated at DCN affiliates each year, and around 150 treated at DCI.

Per NCCN guidelines, multidisciplinary management of gastric or esophageal cancers using chemotherapy, radiation therapy and surgery is optimal for achieving the best outcomes in these diseases. It’s not an option for everyone, however.

Blazer explained that patients afflicted with gastric and esophageal cancers are often diagnosed late and their treatment options are limited to primarily palliative approaches. Those who are identified early enough in their disease to be candidates for multi-modal treatment are frequently quite debilitated and adherence to evidence-based care can be challenging.

“We develop these plans in our centralized DCI/DCN gastric/GEJ cancer tumor boards,” said Blazer. “We want to know why they frequently fail to complete their planned course of therapy. Despite having this great partnership with the DCN, we believe there are still barriers and this has an effect on clinical outcomes. Maybe we’re not doing as much as we should.”

Fractured Care

The Duke team of clinicians, behavioral scientists, biostatisticians, community engagement specialists will spend the first six months of the DCN Passport study conducting surveys of, and in-depth interviews with, gastric and GEJ cancer patients, their families and providers within DCI and the Duke Cancer Network about symptoms and quality-of life, ease of obtaining care, barriers to care, and satisfaction with care.

They already have some clues as to what they’ll find :

  • In a recent study analyzing the National Cancer Database, gastric/GEJ cancer survival was found to be worse in those patients who received care from multiple institutions (designated “fractured care”) as opposed to one center. The region in which the Duke Cancer Network resides, the researchers noted, has one of the highest rates of fractured care in the country.
  • In a survey last year of DCN and DCI patients (who were undergoing surgery, radiation and chemotherapy for gastric or GEJ cancer) and their providers to assess treatment compliance challenges, the investigators found patient-physician communication, hospital navigation, transportation, and low-volume services to be the top concerns.

During the next phase of the study, the research team will test market the new patient navigation tool they’re developing — “DCN Passport”— to try and break down some of those barriers; beginning with a projected 30 patients from DCI and three DCN affiliate hospitals: Maria Parham Health (Henderson), Scotland Health Care System (Laurinburg), and Southeastern Health (Lumberton).

The concept of the DCN Passport came from Nussbaum and was conceived as a tool to improve delays in or noncompliance with care. As the (study-enrolled) patient’s treatment plan/goals of care are decided at the weekly DCI/DCN gastric/GEJ cancer tumor board, it will be entered into a computerized form using DCN PassPoint software, printed on stickers and affixed to a physical booklet, the DCN Passport. (The data, which will be stored on a secure server, can easily be edited to accommodate any changes)

“Having a hard copy in the patient’s hands will ensure accessibility,” said Blazer. “The expectation is that patients will carry their DCN Passport to all appointments, and mark the completion of each scheduled treatment.”

Patient Empowerment

Eventually, the study will be expanded to the remaining DCN affiliates in the Southeast— for a total estimated enrollment of between 180 and 230 patients by the time of project completion. A full evaluation will be conducted at close-of-project.

“We anticipate higher rates of patient adherence to their multi-disciplinary treatment plans that could potentially translate to improvements in their quality of life and overall survival,” said Blazer. “We also anticipate greater satisfaction with complex treatment plans across diverse hospital settings.”

Sutton, medical director of the Duke Cancer Network, believes that enrollment in the DCN Passport program could improve treatment plan compliance by as much as 50 percent, based on a similar project she led in the breast cancer setting.

“The patient experience along the diagnostic and treatment journey can be challenging and frustrating to both patients and providers as patients travel between health systems; the resulting fractured care  can negatively impact outcomes,” said Sutton. “This project addresses the threat to successful outcomes in a novel way that empowers and engages patients in their care.”

If the DCN Passport works as expected, the team plans to offer the program to other disease sites in the DCN, and potentially provide a no-cost template to other institutions and providers. 

Principal Investigators: Dan Blazer III, MD, associate professor of Surgery, Duke University School of Medicine || Daniel P. Nussbaum, MD, resident in General Surgery, Duke University School of Medicine || Linda M. Sutton, MD, associate professor of Medicine, Duke University School of Medicine, associate chief medical officer, Duke Network Services, and medical director, Duke Cancer Network || Advisor, DCN Passport Program Development: Thomas D’Amico, MD, director of the DCI Thoracic Cancer disease group, chief of General Thoracic Surgery and co-chair of the NCCN Esophageal and Esophagogastric Junction Cancers Guidelines Panel || Team Leader, Qualitative Analysis: Laura Fish, PhD, assistant director of the Behavioral Health and Survey Research Core || Advisors, DCN Passport Development: Jennifer Gierisch, PhD, MPH, associate professor of Population Health Sciences and associate director of the CTSA Community Engagement Core || Nadine Barrett, PhD, associate director of community engagement and stakeholder strategy for Duke Cancer Institute and the Duke Clinical & Translational Science Institute (CTSI) || Advisor, Survey Development: Rachel Greenup, MD, MPH, a breast cancer surgeon and health services researcher with extensive experience in survey development and qualitative methodology || Biostatisticians: Donna Niedzwiecki, PhD, professor of Biostatistics and Informatics and lead biostatistician on the study || Christel Rushing, MS.