joseph herman, md, msc barbara biedrzycki, phd, crnp amol ... · • 12:30‐2 pm: multi‐d team...
TRANSCRIPT
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Development of a Retrospective and Prospective Multidisciplinary Pancreas Database
Joseph Herman, MD, MSc
Barbara Biedrzycki, PhD, CRNP
Amol
Narang, MD
Radiation and Medical Oncology
The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
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Why is Multidisciplinary Care Important?
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Multi‐D Care Benefits
• Less confusion for patients/families
• Improved communication between staff
• Inter‐disciplinary teaching• “One stop shop”• Improved outcomes
• Less errors?• Cost effective?
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Rational for Pancreatic MDC
• Pancreatic cancer is highly lethal
• Time is of the essence
• Correct staging is necessary for correct therapy
• Optimal care for pancreatic cancer involves numerous
specialties
• “Standard Care”
my not be best care for any given individual
– Tailored therapies• Relatively rare so that, in general, no one community
physician is an expert on pancreatic cancer
• Diagnosis can often be paralyzing and overwhelming
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Standard Scenario PCA DiagnosisJa
undi
ce
Med
ical
Onc
olog
ist
PP
CT
Sur
geon
Rad
iatio
n O
ncol
ogis
t
Bor
derli
ne R
esec
tabl
e??
Liver
Met
Ther
apy
Sta
rts1 week 1 week 1 week 2 weeks 1 week
6 weeks!!
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PMDC Scenario Ja
undi
ce
Surgeon
1 week Days
PM
DC
Medical Oncology
PPCT/Expert Review
Radiation Oncology
Pathology Review
Clinical Trial Assessment
Pain MedicineNutrition
Consensus on Optimal Treatment
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Pancreatic MDC Website
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• 7‐9 AM: Necessary imaging and lab studies obtained
• 9‐10 AM: Patients given overview of support services (10‐15 min briefings by nutrition, nursing, social work and National Familial Pancreas Tumor
Registry)
• 10‐12 PM: Patients seen by fellows, residents, NPs and PAs
for a complete
history and physical exam
• 12:30‐2 PM: Multi‐D team meets
Pancreatic MDC: Patient Schedule
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Pancreatic MDC: Case Review
Review ImagesCT/PET/MRI/
EUS
Discuss Caseand reach
consensus
ReviewPathology
See patients anddiscuss options
Present Casesusing outline
Enroll in trials/studies
Dictate note and cc toreferring physicians
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Patients and Methods
• Pancreatic Multidisciplinary Clinic • 203 pts (November 2006 – October 2007)
• Data Collection• Patient demographics • Clinicopathologic factors• Outside vs. MDC findings / recommendations
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Geographic Distribution of Referrals
International: 4
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Results: Initial Cross‐Sectional Imaging
N = 174
Resectable 46
Locally advanced / unresectable 35
Metastasis 18
Locally advanced / unresectable + metastasis
1
Initial Assessment Percent of Patients (%)
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MDC Review: Cross‐Sectional ImagingChange in Clinical Stage
38 out of 174 (22%)
Resectable
Locally advanced/ Unresectable
N = 3
No Metastasis
Metastatic
Disease
N = 26
Locally advanced/ Unresectable
Resectable
N = 5
Suspicious Mass
No Lesion
N = 4
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MDC Review: Pathology
Change in Diagnosis
7 out of 203 (3%)
• Neuroendocrine tumor (n=2)
• Breast metastasis (n=1)
• Gastrointestinal stromal tumor (n=1)
• Gallbladder cancer (n=1)
• Benign inflammatory process (n=1)
• Serous cystadenoma (n=1)
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Conclusions
Pancreatic MDC is an efficient means to assess patients with presumed pancreatic cancer
MDC format facilitates consensus recommendations and less confusion regarding the therapeutic plan
A single day MDC may help to improve patient education, permit greater interaction with support staff (e.g. social work, nutrition, etc.) and decrease patient anxiety
Pancreatic MDC provides an important expert opinion for many patients that may lead to dramatic changes in their care
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PMDC Coordination
• Identify appropriate patients• Educate on different levels• Optimize treatment options
• Follow‐up for outcomes
• Enhance patient satisfaction
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Original Data Management System
Microsoft Excel Spreadsheet
•Simple
•Weekly log
•Track numbers
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Excel Variables
• Demographics
• Diagnosis
• Imaging
• Disciplines
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Original Data Management System
Microsoft Excel Spreadsheet
•Validity•0 or 1•Versionitis•Integrity
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Better Data Management System Needed
PMDC and Technology
•Patients•Clinicians•Researchers•Administrators
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Work to date
• Database design based on relevant clinical and research needs of multidisciplinary team
– Temporal organization• Preclinic, clinic, post‐clinic
– Information type• Pathology, radiology, recommendations, treatment,
etc.
• Construction of prospective and retrospective databases with attention to data compatibility
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Barriers in Database Construction
• Compatibility between multiple databases to ensure appropriate analysis
• Data abstraction• Real‐time modification and testing of forms
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Barriers of Combining Retrospective and Prospective data
• Recall bias• Error of data entry with retrospective data:
the prospective data is reviewed again at the pancreatic mdc
consensus conference
• Ability to link both datasets for analysis• Need to get updated data for retrospective
patients
• Integration with biomarker data
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Other Challenges
• Working with data programmers to develop forms that are complete, concise, but efficient
and realistic for clinicians to enter data
• IRB approval for both research and clinical use• Ability to export data for clinical notes• Knowing “when to say when”, collect what
you really need
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Acknowledgements
• JHU: Dan Ford, Diana Gumas, Dorothy Damron, Susan Booker
• Harris Corporation: Raju
Prasannappa, Seth Puckett, Christian Hertel