The incidence of cancer increases with age. Given the increasing older population, one may expect that by the year 2030 about 70% of all malignancies will occur in individuals aged 65 and older. The following information is obtained from clinical epidemiology: the elderly are more vulnerable than are younger individuals to environmental carcinogens and may represent a natural monitoring system for new carcinogens in the environment; the biology of cancer may change with age, with some cancers becoming more aggressive (leukemias, lymphomas, ovarian) and others more indolent (breast, lung); most cancers present at a more advanced stage in the elderly, which suggests underutilization of screening and ignorance of symptoms; cancer affects preferentially healthy older individuals; and multiple cancers become more common with age. On the basis of these findings, preventative and therapeutic strategies for the elderly may be formulated.
As the need for cancer care grows, so does the need for facilities that address the needs of patients and their families. The design of a cancer center must support the treatment and interventional process and maximize the feeling of comfort and reassurance while the patient is present for care. This article will focus on outpatient cancer-care design and the issues involved to assist the administrator in leading this effort.
The delivery of high-quality, comprehensive cancer care and the treatment environment go hand in hand with the patient's recovery. When the planning and design of a comprehensive cancer care program runs parallel to the operational expectations and functional standards, the building users (patients, staff, and physicians) benefit significantly. This behavioral response requires a sensitive interface during the campus master planning, architectural programming, and design phases. Each building component and user functioning along the "continuum of care" will have different expectations, programmatic needs, and design responses. This article addresses the community- and hospital-based elements of this continuum. The environment does affect the patient care and the care-giving team members. It may be a positive or, unfortunately, a negative response.
Although there are a number of complaints about the complexity of coding rules and regulations, physicians and facilities are still responsible for knowing the guide- lines-or employing someone who does. Also, the practice needs to establish processes to monitor compliance with payor guidelines. The good news is that physicians have an opportunity to improve their income through appropriate coding. According to MD Compliance Alert, April 15, 2002: "In fact, improper coding is the number one most visible and correctable problem in any given practice. Corrected, it can have the simplest, biggest, and quickest impact on most doctors' income".
A key challenge in cancer control is the need for translational research to link discovery research with improved health outcomes. In British Columbia, we have built upon the idea of communities of practice to develop networks that will meet our cancer-control mandate.
The objective of this phase I study was to investigate the safety of an all-oral combination chemotherapy regimen: topotecan and capecitabine. Topotecan was administered once a day for 5 consecutive days followed by 2 days of rest and was administered again for 5 consecutive days. The starting dose of topotecan was 0.5 mg/m2/d(-1). Capecitabine was administered concurrently at an oral dose of 1800 mg/m2/d(-1) divided twice daily for 14 concurrent consecutive days. Each cycle of treatment was 21 days. Topotecan pharmacokinetic studies were performed on day 1 of cycles 1 and 2. Nineteen patients with refractory cancer were treated. Dose-limiting toxicity (thrombocytopenia, diarrhea) was observed in 2 of 3 patients at a topotecan dose of 2.0 mg/m2/d(-1). A total of 10 patients were treated at the maximum-tolerated dose of topotecan (1.5 mg/m2/d(-1)) and only 1 treatment-related grade 3 nonhematologic toxic event was demonstrated; however, grade 3 hematologic toxicity was observed in 8 of 10 patients at the maximum-tolerated dose, although no correlated clinical sequela resulted. One patient achieved a partial response and 7 achieved stable disease for 4 months or longer. Measurement of plasma topotecan showed pharmacokinetics consistent with no alteration by capecitabine. In conclusion, we recommend further investigation of oral topotecan (1.5 mg/m2/d(-1)) on days 1 to 5 of each week for 2 weeks in combination with capecitabine (180 mg/m2 twice daily) on days 1 to 14 within a 21-day cycle.
New procedures and new technology often outpace the development of medical codes to report these services to the insurance payors. Although unlisted procedure codes are not the first choice for reimbursement, it is essential that services be reported with only the code that accurately describes the procedure. For new equipment and techniques, this may result in an increased need for preauthorizing, reporting an unlisted procedure code, and ensuring that complete documentation accompany the claim. Practices should educate the insurance community where necessary to ensure that everyone is working toward the same goal: the best patient care possible.
To better serve their patient population, South Carolina Oncology Associates consolidated their services from 4 locations into a freestanding, 107,000 square foot facility. The new facility houses comprehensive cancer treatment services in a patient-centered facility. The design has also created excellent throughput flow, enabling South Carolina Oncology Associates to enhance their service offering without requiring additional staff.
Keeping members of the oncology team from being overwhelmed by the stress of their jobs is a major concern at the Helen E. Graham Cancer Center and every cancer center around the country. The impact of stressors experienced as a result of caring for people is felt heavily not only by physicians and nurses, but also by each staff member in a cancer center. In addition to caregiving stressors, all cancer center staff experience corporation-style stressors such as staffing shortages, long hours, tight schedules, and limited resources. Therefore, the importance of finding innovative mechanisms for all staff to reduce their stress levels and develop stronger bonds with their coworkers is paramount. Given the stressors mentioned above, the Daily Moment program was developed. This involves staff gathering before morning rounds to listen to a staff member read an inspirational quote or an appropriate joke. The Daily Moment was developed with the following goals: (1) occur daily but not require much time, (2) energize staff for the day, (3) be effective for all levels of staffing, and (4) improve coworker relationships and interactions. Participation in the Daily Moment was voluntary. After 6 weeks of implementation, a survey was administered to all staff. Results indicated that all goals for the program were accomplished, and they demonstrated that innovative stress reduction programs may require little time and still generate positive influences on a cancer center staff. Finally, the simplicity of this program allows it to be instituted at any facility at any time with no cost.
Although diagnosis and procedure codes are primarily assigned to ensure correct reimbursement, a number of codes can be used for patient tracking purposes. These codes are generally located in the "Supplementary Classification of Factors Influencing Health Status and Contact With Health Services" section of the ICD-9-CM manual, also known as the "V Codes." By using these codes to track certain segments of patient population, a practice can be prepared to forecast patient mix and anticipate specific collection or self-pay issues.
The current US healthcare system, focused mostly on acute and episodic care, has difficulty meeting the needs of ill, frail elderly and their families or other caregivers. Because of their low mobility and complex medical conditions, these "oldest old" patients and their families or caregivers must make frequent, difficult, and expensive trips to multiple physicians to receive care. The result is that the frail elderly most often receive delayed or crisis care rather than timely primary care. To address these and other needs, a coordinated approach to the care of the oldest old requires a new model that includes primary medical care in the home. This article discusses how the Medical House Call Program (MHCP) model can provide high-quality primary healthcare to the frail elderly at home, improve the continuity of care between the home and the hospital, provide support and education to families or caregivers, and provide linkage to a broad range of social and supportive services in the community. The MHCP model is one of a number of evolving for-profit and nonprofit approaches that seek to provide medical care in the home. This article also discusses how the MHCP model, working with oncology physicians and programs, can have similar benefits and applications for the growing number of elderly cancer patients and their families or caregivers.
My January/February 2005 column described the strategic assessment process. The cancer program assessment process is essential to evaluate the current cancer program position and to identify critical strategic planning issues and opportunities. Once the assessment is completed, the detailed findings must be translated into opportunities and critical issues. In most cases, many of the “issues” initially identified are really symptoms of a broader and real issue. The issues analysis must be an introspective and intellectually honest process in the strategic business planning process. A variety of methods can be used to move from symptoms to issues. Some of the activities that might be considered include:
Older patients may benefit from chemotherapy to an extent comparable with that of younger patients if some proper precautions are taken. These include selection of the patients on the basis of life expectancy and tolerance of treatment, prophylactic use of hemopoietic growth factors for moderately toxic chemotherapy (cytoxan, adriamycin, oncovin [vincristine], prednisone [CHOP] and CHOP-like regimens), adjustment of the first treatment dose to the glomerula filtration rate, maintenance of hemoglobin levels > or = 12 g/dL, and selection of agents with a more favorable toxicology profile. This approach is outlined in the National Cancer Center Network guidelines for the management of cancer in the older person.
