prostate cancer treatment selection after counseling in a multidisciplinary prostate cancer clinic

2
2735 Medical Error Disclosure Attitudes Among Radiation Oncologists S. B. Evans 1 , J. B. Yu 1 , A. B. Chagpar 2 1 Yale University, Therapeutic Radiology, New Haven, CT, 2 Yale University, Department of Surgery, New Haven,CT Purpose/Objective(s): Few medical and surgical specialists disclose medical errors (Gallagher et al, Arch Intern Med, 2006). We sought to assess medical error disclosure practices within radiation oncology. Materials/Methods: A survey with hypothetical patient vignettes was sent to 425 radiation oncologists, in order to assess their attitudes towards disclosure of medical mistakes. A disclosure score was calculated from 12 questions with 1 point for ‘‘no dis- closure’’, 2 points for ‘‘partial disclosure’’ and 3 points for ‘‘full disclosure’’ (max 36 points). Based on tertiles, participants were divided into low- (#27 points), intermediate- (28 - 31 points) and high- (.31 points) disclosure groups. Results: 176 individuals (response rate = 41.4%) completed the survey: 117 (66.5%) were academic radiation oncologists, 12 (6.8%) were in private practice and 47 (26.7%) were residents. 52 (29.5%) were in the ‘‘low disclosure’’ group, 75 (42.6%) in the ‘‘intermediate disclosure’’ group, and 49 (27.8%) in the ‘‘high disclosure’’ groups. 167 (94.9%) of respondents stated they either agreed or strongly agreed that they would be more likely to disclose a serious error. 128 (72.7%) did not feel that the person responsible for the error mattered when considering disclosure, and (23.4%) considered themselves more likely to disclose if they were immediately responsible for the error. 57 (32.4%) felt that disclosure was associated with an increased risk of lawsuits, and 114 (64.8%) felt disclosure offered an opportunity to seek forgiveness. Only 24 (13.6%) and 47 (26.6%) felt that near-misses and correctable errors should be disclosed, respectively. 158 (89.7%) had never been sued. Respondents in the ‘‘high disclosure’’ group were more likely to feel that this was an opportunity to seek forgiveness (p= 0.025), and to have never seen significant medical errors (p= 0.004), with a trend towards increased disclosure in the setting of a serious error (p= 0.051). When the error was not apparent to the patient, 81.2% would explicitly use theword ‘‘error’’ in their description of the events (full disclosure), 17.6% would omit theword ‘‘error’’ but disclose (partial disclosure)and 1.1% would not disclose. When the radiation therapy error was more apparent to the patient, 96.5% would provide full disclosure. Conclusions: Most radiation oncologists would disclose a medical error. Such disclosure is associated with the desire for forgive- ness and to have never seen a significant medical errors. Author Disclosure: S.B. Evans: None. J.B. Yu: None. A.B. Chagpar: None. 2736 Characteristics of Medically Underserved Cancer Patients Who Choose Navigation N. M. Hanna 1 , S. A. McCloskey 1 , D. Khan 2 , E. Cobb 3 , M. Steinberg 1 1 University of California, Los Angeles, Los Angeles, CA, 2 21st Century Oncology, El Segundo, CA, 3 Urban Latino African American Cancer (ULAAC) Disparities Project, Inglewood, CA Purpose/Objective(s): Patient navigation has been evaluated as a means to address known health disparities. Although the impact of navigation on cancer screening and treatment delays has been assessed, limited data exist examining navigation during cancer therapy and factors that may impact patient choice for navigation. Materials/Methods: The Urban Latino African American Cancer (ULAAC) Disparities Project implemented a program in which culturally and linguistically appropriate lay persons volunteered as navigators for cancer patients receiving radiation therapy in a medically underserved community. Following completion of radiation therapy, patients who had opted in or out of navigation during treatment were administered a demographics and experience with care survey as well as the Functional Assessment of Cancer Therapy-General (FACT-G), a validated quality of life instrument. Differences based on navigation status were assessed using Chi square and Mann Whitney tests. Multivariable logistic regression was used to assess the impact of patient navigation on quality of life domains including physical, social/family, emotional, and functional well being. Results: Between June 2005 and December 2007, 182 patients were offered navigation prior to beginning radiation therapy. Of the 182 patients offered navigation, 68 accepted (37%) and 114 (63%) declined. The most common reasons endorsed for declining navigation included being an independent person (53.5%), having a supportive family (43.9%) or supportive friends (31.6%), or being a spiritual/religious person (28.9%) or private person (28.1%). There were no significant differences detected in baseline race, educational, or socioeconomic status between the groups, however, among the 182 patients offered navigation, 76% were African American or Hispanic, 67% reported completing no further education beyond high school, and 89% reported an annual income of less than $50,000. A significantly higher proportion of patients who declined navigation reported living with a spouse or significant other (45 vs. 31%, p= 0.06) and endorsed a good understanding of their cancer treatment (32% vs. 19%, p \0.05). Patients declining navigation were found to have a higher median social/family well being score on the FACT-G than patients accepting navigation (p= 0.005). Multivariable logistic regression confirmed a significant impact of navigation status on the so- cial/family well-being score when adjusting for covariates. Conclusions: Our findings indicate that navigation may be of greater perceived benefit among radiation therapy patients who lack social and family support and who lack an understanding of their prescribed cancer treatment. These findings may allow for improved targeting of patient navigation among the medically underserved. Author Disclosure: N.M. Hanna: None. S.A. McCloskey: None. D. Khan: None. E. Cobb: None. M. Steinberg: None. 2737 Prostate Cancer Treatment Selection after Counseling in a Multidisciplinary Prostate Cancer Clinic K. E. Hoffman, L. T. Madsen, L. Levy, C. Pettaway, L. Pisters, S. Choi, J. Kim, J. W. Davis, J. F. Ward, D. A. Kuban M.D. Anderson Cancer Center, Houston, TX Purpose/Objective(s): Newly diagnosed prostate cancer patients, particularly those with early disease, are faced with a daunting array of treatment options. Population-based studies show the majority of men with early prostate cancer see only a urologist with a smaller portion of men seeing both a urologist and a radiation oncologist. Specialists often advocate for their own treatment Proceedings of the 53rd Annual ASTRO Meeting S563

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Proceedings of the 53rd Annual ASTRO Meeting S563

2735 Medical Error Disclosure Attitudes Among Radiation Oncologists

S. B. Evans1, J. B. Yu1, A. B. Chagpar2

1Yale University, Therapeutic Radiology, New Haven, CT, 2Yale University, Department of Surgery, New Haven, CT

Purpose/Objective(s): Fewmedical and surgical specialists disclose medical errors (Gallagher et al, Arch InternMed, 2006).Wesought to assess medical error disclosure practices within radiation oncology.

Materials/Methods: A survey with hypothetical patient vignettes was sent to 425 radiation oncologists, in order to assess theirattitudes towards disclosure of medical mistakes. A disclosure score was calculated from 12 questions with 1 point for ‘‘no dis-closure’’, 2 points for ‘‘partial disclosure’’ and 3 points for ‘‘full disclosure’’ (max 36 points). Based on tertiles, participants weredivided into low- (#27 points), intermediate- (28 - 31 points) and high- (.31 points) disclosure groups.

Results: 176 individuals (response rate = 41.4%) completed the survey: 117 (66.5%) were academic radiation oncologists, 12(6.8%) were in private practice and 47 (26.7%) were residents. 52 (29.5%) were in the ‘‘low disclosure’’ group, 75 (42.6%) inthe ‘‘intermediate disclosure’’ group, and 49 (27.8%) in the ‘‘high disclosure’’ groups. 167 (94.9%) of respondents stated theyeither agreed or strongly agreed that they would be more likely to disclose a serious error. 128 (72.7%) did not feel that the personresponsible for the error mattered when considering disclosure, and (23.4%) considered themselves more likely to disclose if theywere immediately responsible for the error. 57 (32.4%) felt that disclosure was associated with an increased risk of lawsuits, and114 (64.8%) felt disclosure offered an opportunity to seek forgiveness. Only 24 (13.6%) and 47 (26.6%) felt that near-misses andcorrectable errors should be disclosed, respectively. 158 (89.7%) had never been sued. Respondents in the ‘‘high disclosure’’group were more likely to feel that this was an opportunity to seek forgiveness (p = 0.025), and to have never seen significantmedical errors (p = 0.004), with a trend towards increased disclosure in the setting of a serious error (p = 0.051). When the errorwas not apparent to the patient, 81.2% would explicitly use the word ‘‘error’’ in their description of the events (full disclosure),17.6% would omit the word ‘‘error’’ but disclose (partial disclosure)and 1.1% would not disclose. When the radiation therapyerror was more apparent to the patient, 96.5% would provide full disclosure.

Conclusions:Most radiation oncologists would disclose a medical error. Such disclosure is associated with the desire for forgive-ness and to have never seen a significant medical errors.

Author Disclosure: S.B. Evans: None. J.B. Yu: None. A.B. Chagpar: None.

2736 Characteristics of Medically Underserved Cancer Patients Who Choose Navigation

N. M. Hanna1, S. A. McCloskey1, D. Khan2, E. Cobb3, M. Steinberg1

1University of California, Los Angeles, Los Angeles, CA, 221st Century Oncology, El Segundo, CA, 3Urban Latino AfricanAmerican Cancer (ULAAC) Disparities Project, Inglewood, CA

Purpose/Objective(s): Patient navigation has been evaluated as ameans to address known health disparities. Although the impactof navigation on cancer screening and treatment delays has been assessed, limited data exist examining navigation during cancertherapy and factors that may impact patient choice for navigation.

Materials/Methods:TheUrban Latino African American Cancer (ULAAC)Disparities Project implemented a program in whichculturally and linguistically appropriate lay persons volunteered as navigators for cancer patients receiving radiation therapy ina medically underserved community. Following completion of radiation therapy, patients who had opted in or out of navigationduring treatment were administered a demographics and experience with care survey as well as the Functional Assessment ofCancer Therapy-General (FACT-G), a validated quality of life instrument. Differences based on navigation status were assessedusing Chi square andMannWhitney tests. Multivariable logistic regression was used to assess the impact of patient navigation onquality of life domains including physical, social/family, emotional, and functional well being.

Results: Between June 2005 and December 2007, 182 patients were offered navigation prior to beginning radiation therapy. Ofthe 182 patients offered navigation, 68 accepted (37%) and 114 (63%) declined. Themost common reasons endorsed for decliningnavigation included being an independent person (53.5%), having a supportive family (43.9%) or supportive friends (31.6%), orbeing a spiritual/religious person (28.9%) or private person (28.1%). There were no significant differences detected in baselinerace, educational, or socioeconomic status between the groups, however, among the 182 patients offered navigation, 76% wereAfrican American or Hispanic, 67% reported completing no further education beyond high school, and 89% reported an annualincome of less than $50,000. A significantly higher proportion of patients who declined navigation reported living with a spouseor significant other (45 vs. 31%, p = 0.06) and endorsed a good understanding of their cancer treatment (32% vs. 19%, p\0.05).Patients declining navigation were found to have a higher median social/family well being score on the FACT-G than patientsaccepting navigation (p = 0.005). Multivariable logistic regression confirmed a significant impact of navigation status on the so-cial/family well-being score when adjusting for covariates.

Conclusions:Our findings indicate that navigationmay be of greater perceived benefit among radiation therapy patients who lacksocial and family support and who lack an understanding of their prescribed cancer treatment. These findings may allow forimproved targeting of patient navigation among the medically underserved.

Author Disclosure: N.M. Hanna: None. S.A. McCloskey: None. D. Khan: None. E. Cobb: None. M. Steinberg: None.

2737 Prostate Cancer Treatment Selection after Counseling in a Multidisciplinary Prostate Cancer Clinic

K. E. Hoffman, L. T. Madsen, L. Levy, C. Pettaway, L. Pisters, S. Choi, J. Kim, J. W. Davis, J. F. Ward, D. A. Kuban

M.D. Anderson Cancer Center, Houston, TX

Purpose/Objective(s):Newly diagnosed prostate cancer patients, particularly those with early disease, are faced with a dauntingarray of treatment options. Population-based studies show the majority of men with early prostate cancer see only a urologist witha smaller portion of men seeing both a urologist and a radiation oncologist. Specialists often advocate for their own treatment

S564 I. J. Radiation Oncology d Biology d Physics Volume 81, Number 2, Supplement, 2011

modality and there is a strong link between type of specialist seen and primary therapy administered. We studied men seen ina Multidisciplinary Prostate Cancer Clinic who were evaluated by both a urologist and a radiation oncologist to characterizeprostate cancer treatment selection in the context of multidisciplinary care.

Materials/Methods: We identified 1,375 newly diagnosed prostate cancer patients with non-metastatic disease who werereferred to the Multidisciplinary Prostate Cancer Clinic from 2004 to 2008. Men were categorized by treatment offered and re-ceived. We used chi-square analysis and logistic regression to evaluate the impact of tumor, patient, and physician characteristicson treatment selection.

Results:Median age was 64 years (range 41 - 87). 32% of men had low-risk (NCCN definition), 49% intermediate-risk and 19%high-risk disease. Overall, 80% were offered radical prostatectomy (RP), 96% external beam radiation (EBRT), 42% brachyther-apy (BR), 26% active surveillance (AS), and 18% cryotherapy (CR). Overall 50% selected RP, 28%EB, 6%BR, 11%AS, and 3%CR. When only patients offered a particular modality were considered, 62% chose RP, 30% EBRT, 14% BR, 42% AS, and 17%CR. RP treatment selection varied by age (p\0.001) and risk group (p = 0.007) with younger men more likely to receive RP.EBRT treatment selection varied by age (p\0.001) and risk group (p\0.001) with older men and men with higher risk diseasemore likely to receive EBRT. AS treatment selection varied by risk group (p\0.001) with men with earlier disease more likely toselect AS. However, AS treatment selection did not vary by age (p = 0.277).

Conclusions: This study characterizes prostate cancer treatment selection in the context of multidisciplinary care. After consul-tation in a multidisciplinary clinic by both a urologist and a radiation oncologist, the majority of eligible patients select RP anda substantial portion of eligible patients select AS. While RP and EBRT selection varied by age, the proportion of men selectingAS was stable across age groups.

Treatment selection stratified by age and risk group

\ 60 years old

60 - 70 years old . 70 years old p-value Low-risk Intermediate-risk High-risk p-value

RP

72% 49% 15% p\0.001 46% 54% 46% p = 0.007

EBRT

13% 29% 49% p\0.001 18% 29% 42% p\0.001

AS

10% 11% 14% p = 0.277 24% 6% 2% p\0.001

BR

5% 6% 7% p = 0.263 10% 5% 0% p\0.001

Author Disclosure: K.E. Hoffman: None. L.T.Madsen: None. L. Levy: None. C. Pettaway: None. L. Pisters: None. S. Choi: None.J. Kim: None. J.W. Davis: None. J.F. Ward: None. D.A. Kuban: None.

2738 Racial Disparities In Survival Outcomes Disappear In Early-stage Type 2 Endometrial Cancer With

Utilization Of Adjuvant Radiation Therapy After Hysterectomy

K. V. Albuquerque I. Berzins

Loyola University Medical Center, Maywood, IL

Purpose/Objective(s):Despite higher incidence rates for Endometrial cancer (EC) in white women (WW) compared to African-American (AA) women, mortality rates are almost twice for AA. Inadequate access to care with poor quality treatment is oftencited as one of the causes for this difference. We studied the outcomes of early stage EC (I-II) in AA compared to WW who re-ceived optimal therapy (defined as hysterectomy [H] followed by adjuvant radiation [RT]). Thesewomen were further subdividedby histological type 1(endometrioid) and type 2 EC cancers (papillary and clear cell). Hypothesis was with utilization of optimaltherapy the disparities in outcomes would be reduced.

Materials/Methods:We used SEER-13 registries from 1992 to 2005. Variables selected include uterine carcinoma, histologicaltype, grade, type of therapy, and patient outcome. Study population was non-Hispanic WW (n = 38368) and AA (n = 2078) di-agnosed with Stage 1and 2 EC (total 40446). These were stratified according to stage, tumor type, and type of therapy received.Chi-squared tests were used to examine frequency distributions. Kaplan-Meier and Cox proportional hazard models were used tocompare survival while accounting for prognostic variables. The outcome was EC specific mortality. Indirect comparisonbetween the groups receiving H ± RT was made.

Results: The distribution of race, histology and treatment type are shown in table 1. For type I tumors impact of race as a poorprognostic factor persisted despite addition of RT to H. Risk of dying from early Stage EC was significantly higher for AA com-pared to WWwith H alone or with optimal therapy with H+ RT .In the latter group , risk of death from EC was 94% higher in AA(HR 1.94; 95%CI 1.50 - 2.50). The poor prognostic impact of race was independent factor persisting after adjusting for stage andgrade in a multivariate analysis For type 2 tumors , (considered poorer prognostic cancers); though percentage of AAwith thistype was greater - the addition of RT to H resulted in an improvement of survival compared to hysterectomy alonewith equivalentsurvival for WW and AAwith optimal therapy.

Conclusions:RTafter H for Type 2 early stage EC improves survival in AA compared toWW reversing poor prognostic impact ofrace , however this effect is not seen in Type 1 EC indicating possible role of other extrinsic (socioeconomic status) or intrinsic(variation in tumor biology) factors influencing prognosis in AAType1 cancers.

Hysterectomy followed by adjuvant radiation Hysterectomy alone

WW

AA TOTALS WW AA TOTALS

Type I

7225 92.63% 405 80.68% 7630 29,675 99.70% 1,433 90.92% 31,108

Type II

575 7.37% 97 19.32% 672 893 0.30% 143 9.08% 1,036

Author Disclosure: K.V. Albuquerque: None. I. Berzins: None.