In 2022, the RCN awarded 5 Quality Improvement Grants (QI2). The RCN is updating the QI2 terms of reference to include broader inclusion criteria for applicants. Stay tuned for a new call for applications later in 2023. The grants awarded in 2022 include:
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1. Enhancing Head and Neck Cancer Care in the Elderly (ENHANCE): A trajectory-based quality improvement program (Principal Applicants Dr Marco Mascarella & Dr Nader Sadeghi)
Most patients with head and neck cancer (HNC) require multimodal treatment with upfront surgery followed by adjuvant therapy for cure to be achieved. Despite advances in surgical care, up to 40% of patients suffer from a major postoperative adverse event with most events occurring in the elderly. In some cases, the postoperative period renders patients too fragile to undergo further therapy with consequent worse oncologic and functional outcome. Poor treatment tolerance, including the failure to complete multidisciplinary cancer treatments or significant treatment-related toxicity, occurs in roughly 50% of patients and is associated with reduced survival. Moreover, delays to treatment are associated with incremental increases in tumor recurrence. Despite the integration of multidisciplinary teams in the care of HNC patients, the current trajectory of care reveals large gaps and leads to poor treatment tolerance in older adults with HNC.
The ENHANCE program is a trajectory-based care protocol that aims to improve the cancer care of elderly undergoing HNC treatments. Specifically, this program aims to address issues throughout cancer care and is divided into 4 categories: cancer treatment, pre-treatment evaluation and optimization, diagnostics and research.
The ENHANCE protocol will be evaluated using well validated key performance indicators. The primary outcome will be treatment tolerance and will represent a composite outcome of any grade 3 or greater common terminology criteria for adverse event (CTCAE, version 5) or non-completion of MDT cancer therapy. Grade 3+ events are severe complications which interfere with the patient鈥檚 activities and require intervention. Secondary outcomes achievement of benchmark timelines (time from diagnosis to initiation of treatment <28 days, time from surgery to adjuvant radiotherapy <6 weeks). All data will be recorded using the 平特五不中 Head and Neck Cancer database on REDcap and Encare.
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2. Capacity for Culture Change in Serious Illness Communication (C3SIC) (Principal Applicants Dr. Justin Sanders & Dr. Sonia Skamene)
Patients with advanced cancer and their caregivers commonly experience psychological听distress related to disease progression and face complex decisions about treatments for听which there is risk of no benefit or even harm. Within Rossy Cancer Network (RCN)听hospitals, AOPSS data suggests that 鈥淓motional Support鈥� is the lowest rated of the six听dimensions of care for the RCN, consistent with the rest of Canada (51.9 % vs 53.4%).听A growing body of evidence suggests that conversations that cultivate听prognostic awareness and elicit patients goals and values, so-called serious illness听conversations, improve both psychological well-being and the likelihood that听patient鈥檚 receive care that aligns with their preferences. Furthermore, these听conversations may result in lower utilization of invasive and costly care, to the benefit of听systems, and improve clinicians鈥� experience providing care.
The proposal is to undertake foundational steps for a system-wide quality improvement (QI) initiative focused on the delivery of high-quality serious illness communication to patients听with advanced cancer and based on Ariadne Labs Serious Illness Care Program. Our听specific objectives include:
a) To assess infrastructure of available administrative and quality-related data sets听and measure readiness for change at three institutions for implementation of听serious illness communication-focused culture change initiatives and听measurement of related patient-caregiver-clinician outcomes.
b) To pilot and assess feasibility of training multi-disciplinary dyads and triads (nurse,听physician and social work combination) of clinical champions at three sites in use听of a previously piloted structured conversation guide training.
c) Using qualitative methods, to explore the impact of individual or team-based听conversations on relationships between patients and the caregivers and clinicians听who care for them.
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3. Early screening for distress for geriatric-oncological patients (Principal Applicants Karine Lepage, Christine Bouchard, Jos茅phine L茅may-Dantica, Renata Benc)
According to Statistics Canada, the incidence of cancer in people aged 65 and over is 63% with a mortality of 88% in subjects aged 60 and over. Taking into account the expected increase in the population over 65 years of age, the increased incidence of cancer in the coming decades will be due mainly to the aging of the population. With these statistics in mind, it is important to consider the specific needs of older people with cancer in order to improve their management.
Thus, when caring for an elderly person with cancer, a comprehensive, integrative and personalized approach is required to address their diverse and complex needs.
The overall health status of the older person during their cancer trajectory will be influenced by a multitude of factors including functional and cognitive ability, co-morbidities, social context, psychological status and mobility.
Cancer patients are at a high-risk of experiencing significant levels of distress, and distress is a common concern across the cancer care trajectory. Screening for distress is mandated by the Programme Qu茅b茅cois de Canc茅rologie (PQC), at the ministry level. Detecting distress in cancer patients, which can be incorporating patient reported outcome measures (PROMs) into routine clinical practice, needs to be systematic and repeated at vulnerable moments along the patient鈥檚 cancer care pathway.
The International Society of Geriatric Oncology and the American Society of Clinical Oncology (ASCO) recommend an oncogeriatric assessment as a pre-treatment for patients. In addition, an oncogeriatric assessment is part of the National Comprehensive Cancer Network (NCCN) guidelines for the elderly.
To facilitate their cancer trajectory, and the identification of the vulnerability factors using PRO and PROMs aide in implementation of patient-centered interventions that highlight the strengths of the patient and family. In addition, identifying patient vulnerabilities allows for a proactive approach to patients who have been identified as being at high risk for high toxicities during systemic therapies, or who may require specialized care (.i.e. home care services) or necessary resources The use of PRO and PROMs has been shown to increase patient survival, promote self-care and strengthen communication between patients and the medical team.
Currently, this screening for risk factors and concerns specific to the geriatric population is done by a specialized team at the MUHC and at the JGH upon referral. These referrals arise for pre-operative assessment or whenever the patient is in crisis.
Therefore patients and families who are at risk, or unaware that they are at risk are not being screened at the onset. Only those who are captured by the distress screening for the oncology clinic, or the radiation oncology clinic as being screened once they are in their treatment course already.
The proposed intervention includes all newly diagnosed elderly patients being able to complete an initial questionnaire (PROM + Geriatric Clinic screening tool) on either a ipads in clinic or electronic designated tools at each institution ( Qualtrics, Opal, DART etc) prior to their visit with the consulting oncology doctor (i.e. surgeon, medical oncologist, radiation oncologist). This result to be reviewed by the health care team at the next health care visit. The exact process is to be established by each site/ institution (ST-Mary鈥檚, JGH, MUHC).
This screening would consist of standardized, evidence based screening tools encompassing the physical, psychological, emotional, functional and cognitive levels aspects.
Patients will be offered the appropriate tools to manage the side effects, and follow up as required.
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4. Evaluating two autologous stem cell transplant conditioning regimens for relapse/refractory Hodgkin鈥檚 and Non-Hodgkin鈥檚 lymphoma and development of a uniform treatment algorithm (Principal Applicants Dr. Rayan Kaedbey, Dr Sarit Assouline , Dr. Kelly Davison and Dr. Anna Nikonova)
Autologous stem cell transplantation (ASCT) is a standard therapy for certain relapsed non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL) and has been used since the 1990s, because of the associated long term remission/cure. Eligibility for ASCT is determined by age (usually 70yrs and under), co-morbidities and response to prior chemotherapy. There are several conditioning regimens used globally with various success rates and toxicity profiles. The procedure usually requires hospitalization, transfusion of blood products and use of antibiotics for infection. BEAM (carmustine, etoposide, cytarabine and melphalan) has been the conditioning regimen for ASCT at the MUHC and the JGH for over 20 years. Since 5. 2015, a shortage as well as a striking increase in price of carmustine has made this regimen impossible to obtain. As a result, two other regimens, BeAM (bendamustine, etoposide, cytarabine and melphalan), now used at the JGH and VP16/mel (etoposide and melphalan), used at the MUHC have been selected, but it is not known which is preferable. BeAM is the standard practice at other transplant centres in Quebec, whereas VP16/mel is used in transplant centres across the rest of Canada. In the last two years, there have been concerns of unacceptable toxicities in patients being treated with BeAM with frequent need for total parenteral nutrition, ICU transfers and higher death rates than observed with BEAM. On the other hand, there is concern that the VP16/mel regimen is not as effective at eradicating lymphoma. While conditioning regimens for ASCT have been used for decades, none have been formally compared and it is unclear which is better to use in a given clinical context.
Proposed approach and intervention: We aim to retrospectively compare BeAM and VP16/mel transplant conditioning regimens to determine:
a) The efficacy of each regimen as defined by: i) Response assessed at 100 days post-transplant using either a CT or PET CT scan (Lugano criteria), ii) Disease free survival, iii) Progression free survival, and iv) Overall survival
b) The toxicity profile of each regimen, as defined by: i) Transfusion rates, ii) ICU admission, iii) Febrile neutropenia, iv) Infection, v) Death, vi) Requirement for parenteral nutrition, vii) Number of hospital days, viii) Time to recovery of neutrophil and platelet count, ix) ER visits.
In addition, we will examine these efficacy and toxicity outcomes according to diagnosis (NHL vs HL), patient age, gender, and socio-economic status (region of the city in which they live).
Intervention: By analyzing the data, we hope to create an algorithm to optimize outcomes for patients by selecting a conditioning regimen that would most appropriately balance the efficacy with the toxicity for a given patient profile. Rationale: This intervention will help guide better patient selection for a particular conditioning regimen thereby allowing for an optimal balance of efficacy and toxicity. This will impact patient care across the JGH and MUHC, by ensuring that the right treatment is chosen for the right patient, rather than a 鈥渙ne size fits all鈥� approach. Thereafter, we will assess the implementation of the better regimen on patient outcomes. The JGH and MUHC treat patients from the entire 平特五不中 hospital network and from other Quebec hospitals. The ability to build a useful algorithm will therefore impact many Quebecers.
We hypothesize that BeAM is a more effective regimen, as measured by durable remission, but that it is associated with greater toxicity particularly in older patients. We expect that VP16/mel is more tolerable and can be given to older patients. 鈥淥lder鈥� will be determined by testing various age cut-offs and looking at outcomes.
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5. 平特五不中 Health Centre Optilab Validation of Whole Slide Imaging Systems for Clinical Diagnostic Purposes (Principal Applicants Dr Pierre-Olivier Fiset, Dr Alan Spatz, Dr Marie-Christine Guiot)
The 平特五不中 Health Centre (MUHC) Department of Pathology has begun the steps of adopting digital Whole Slide Imaging (WSI) for clinical diagnosis. MUHC Pathologists will soon be joining other Pathologists in giving their diagnoses entirely from a computer workstation, without the need of a conventional microscope. It is a technology with the greatest future potential for the department, but at the same time will cause significant workflow disruption. Successful integration of WSI will allow for remote access, increased accuracy, decreased error in slide management, improved and faster inter-site pathologist consultation, faster preparation for tumor boards, machine learning and artificial intelligence capabilities, education applications, and research applications. However, the usual Pathology laboratory workflows need to be changed with a need for superior quality of prepared slides for scanning, increased steps and costs for digitization and the requirement of validation and quality assurance.
The validation procedure involves several steps that require careful coordination and preparation of validation sets for the pathologists involved in the project. Coordination will be important across the MUHC network to perform inter-hospital validation. This will involve first the Glen site, the JGH and MNH. The expert recommendations of the (CAP) College of American Pathologists, which are supported by extensive literature review, include review of 60 cases that reflect the spectrum and complexity of specimen types that are likely to be encountered during routine practice. This would include cancer biopsies and cancer specimens and the ancillary special stains and immunohistochemistry necessary for the diagnosis. The microscope slides are to be scanned by the WSI and transferred to a secure Azure cloud server. Access is performed through the slide management platform Tribun Health and the latest generation of slide visualization software, CaloPix 5. These are accessed by the pathologists from the validation teams at the different sites, who give a diagnosis. A two-week washout period is recommended before the project pathologists perform diagnoses on conventional microscope slides. Validation requires establishing a diagnostic concordance between the digital and glass slides for the same observer. Only an intra-observer concordance of more than 95% is acceptable, and if lower, would require investigation to determine the cause and improve processes as necessary. Each hospital site should carry out their own validation studies, but an inter-hospital project allows for collaborative efforts, sharing of validation cases and improved troubleshooting. This would include inter-pathologist consultation on cases in efforts to emulate real-world clinical environment. Therefore, it is important the entire WSI system and associated processes is validated, rather than individual components (eg. computer hardware, scanners, or network).