Browsing by Author "Chandarana, Shamir"
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Item Open Access An evaluation of in-office flexible fiber-optic biopsies for laryngopharyngeal lesions(2018-05-09) Lee, Francisco; Smith, Kristine A; Chandarana, Shamir; Matthews, T. W; Bosch, J. D; Nakoneshny, Steven C; Dort, Joseph CAbstract Background Operative endoscopy and flexible fiber-optic in-office tissue biopsy are common techniques to assess suspicious laryngopharyngeal lesions. Methods The primary outcome was the delay to the initiation of treatment. Secondary outcomes were delay to biopsy, histopathological diagnosis, and assessment at a multidisciplinary oncology clinic. A retrospective analysis was performed to assess the relative delays between these approaches to biopsy of laryngopharyngeal lesions. Results There were 114 patients in the study cohort; 44 in-office and 70 operative endoscopic biopsies). The mean delay from consultation to biopsy was 17.4 days for the operative endoscopy group and 1.3 days for the in-office group. The mean delay from initial otolaryngology consultation to initiation of treatment was 51.7 days and 44.6 days for the operative endoscopy and in-office groups, respectively. Conclusion In-office biopsy reduced the time from initial consultation to biopsy. The temporal gains via in-office biopsy did not translate into faster access to treatment. This outcome highlights the opportunity to improve access to treatment for patients with early diagnosis.Item Open Access Bax expression measured by AQUAnalysis is an independent prognostic marker in oral squamous cell carcinoma(BioMed Central, 2012-08-01) Dort, Joseph C; Bose, Pinaki; Klimowicz, Alexander C; Kornaga, Elizabeth; Petrillo, Stephanie K; Matthews,T Wayne; Chandarana, Shamir; Magliocco, Anthony M; Brockton, Nigel T; MedicineItem Open Access Cost-effectiveness analysis of molecular testing for cytologically indeterminate thyroid nodules(2022-12-21) Dharampal, Navjit; Smith, Kristine; Harvey, Adrian; Paschke, Ralf; Rudmik, Luke; Chandarana, ShamirAbstract Background Thyroid nodules affect up to 65% of the population. Although fine needle aspirate (FNA) cytology is the gold standard for diagnosis, 15–30% of results are indeterminate. Molecular testing may aid in the diagnosis of nodules and potentially reduce unnecessary surgery. However, these tests are associated with significant costs. The objective of this study was to evaluate the cost-effectiveness of Afirma, a commercially available molecular test, in cytologically indeterminate thyroid nodules. Methods The base case was a solitary thyroid nodule with no additional high-risk features and an indeterminate FNA. Decision tree analysis was performed from the single payer perspective with a 1-year time horizon. Costing data were collected through micro-costing methodology. A probabilistic sensitivity analysis was performed. The primary outcome was the incremental cost effectiveness ratio (ICER) of cost per thyroid surgery avoided. Results Over 1 year, mean cost estimates were $8176.28 with 0.58 effectiveness for the molecular testing strategy and $6016.83 with 0.07 effectiveness for current standard management. The ICER was $4234.22 per surgery avoided. At a willingness-to-pay (WTP) threshold of $5000 per surgery avoided, molecular testing is cost-effective with 63% certainty. Conclusion This cost-effectiveness analysis suggests utilizing Afirma for indeterminate solitary thyroid nodules is a cost-effective strategy for avoiding unnecessary thyroid surgery. With a $5000 WTP threshold, molecular testing has a 63% chance of being the more cost-effective strategy. The cost effectiveness varies based on the cost of the molecular test and the value of Afirma for patients with indeterminate thyroid nodules depends on the WTP threshold to avoid unnecessary thyroid surgery. Graphical AbstractItem Open Access Designing and integrating a quality management program for patients undergoing head and neck resection with free-flap reconstruction(2020-06-23) Dort, Joseph C; Sauro, Khara M; Schrag, Christiaan; Chandarana, Shamir; Matthews, Jennifer; Nakoneshny, Steven; Manoloto, Vida; Miller, Tanya; McKenzie, C. D; Hart, Robert D; Matthews, T. WAbstract Background Care pathways (CPs) offer a proven method of systematically improving patient care. CPs are particularly helpful in complex clinical conditions where variation in care is a problem such as patients undergoing major head and neck resection with free flap reconstruction. Although CPs have been used to manage this patient group, most CPs are implemented as part of relatively short-term quality improvement projects. This paper outlines a detailed methodology for designing and delivering a quality management program sustained for 9 years. Methods We describe a change management approach informed by Kotter’s “8 Step Process” that provided a useful framework to guide program development and implementation. We then provide a detailed, step by step description of how such a program can be implemented as well as a detailed summary of time and costs for design, implementation and sustainability phases. An approach to design and delivery of a measurement, audit and feedback system is also provided. Results We present a summary of resources needed to design and implement a head and neck surgery quality management program. The primary result of this study is a design for a sustainable quality management program that can be used to guide and improve care for patients undergoing major head and neck resection with free flap reconstruction. Conclusions A change management approach to design and delivery of a head and neck quality management program is practical and feasible.Item Open Access Exploring Transitions in Care Among Patients with Head and Neck Cancer: A Multimethod Study(2023-12-20) Kersen, Jaling Kathleen; Sauro, Khara; Ronksley, Paul; Roach, Pamela; Chandarana, ShamirIntroduction: Head and Neck Cancers (HNC) are the 6th most common cancer worldwide. Due to the complex nature of HNC, treatments are multifaceted and focus on diverse anatomical structures. As such, patients with HNC experience many Transitions in Care (TiC), which occur when patients transfer between healthcare providers, institutions, and settings. Although a necessary component of patient care, TiC represent a vulnerable point in the journey and are associated with compromised patient safety, decreased patient satisfaction, and increased healthcare costs. However, our understanding of TiC among patients with HNC is lacking. The objective of this multimethod study was to understand TiC among patients with HNC and identify opportunities to improve care for patients with HNC. Methods: This multimethod study consisted of two phases: a retrospective cohort study and qualitative description. Phase I was a retrospective population-based cohort study that characterized the number and type of TiC that patients with HNC experienced using routinely collected populations-based administrative health databases including the Alberta Cancer Registry, Discharge Abstract Database, the National Ambulatory Care Reporting System, and Physician Claims between January 1, 2012, to December 1, 2019. Both patient demographic and TiC variables were dichotomously coded and described using descriptive statistics. In Phase II, semi-structured interviews were used to explore the lived experiences of patients with HNC and their healthcare providers during TiC. Two independent reviewers used an inductive approach to thematically analyze the semi-structured interview transcripts. Results: In Phase I, there were 2,208 patients with HNC who were mostly male (71.1%), classified as Stage IV HNC at diagnosis (62.4%) and had two or more tumours (91.3%). Patients with HNC often underwent multiple treatment modalities (average: 1.5), with the most common treatment transitions being from surgery to radiotherapy (29.7%). Many patients with HNC were admitted to the hospital and emergency department during the study period, averaging 2.0 hospital admissions and 13.2 emergency departments per patient during the study period. Patients with HNC also experienced many TiC between healthcare providers, with the highest number of physician visits being to general practitioners (average= 62.24 per patient). In Phase II, there were 16 semi-structured interviews conducted with ten patients with HNC and six healthcare providers. The experiences of patients with HNC and their healthcare providers revealed three interconnected themes related to TiC: 1) Navigating the Healthcare System (subthemes include: Head and Neck Cancer Care Complexities, Disrupted Continuity of Head and Neck Cancer Care, and Healthcare System Pressures), 2) Relational Head and Neck Cancer Care (subthemes include: Patient Expectations during Transitions in Care, Feeling Valued as a Head and Neck Cancer Patient and Healthcare Provider Roles and Responsibilities) and 3) System and Individual Impact of Transitions in Care (subthemes include: Impact of Resource-intensive Nature of TiC and the Impact of Transitions in Care on Quality of Care). Conclusions: In sum, this study identifies the challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within HNC. This study suggests TiC may have an impact on the quality of care and provides crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of care during TiC within this patient population. These findings also identified potentially feasible interventions for further exploration, such as shared decision-making, telehealth, or a patient navigator within HNC care.Item Open Access Exploring transitions in care among patients with head and neck CANCER: a multimethod study(2024-09-05) Kersen, Jaling; Roach, Pamela; Chandarana, Shamir; Ronksley, Paul; Sauro, KharaAbstract Background Patients with head and neck cancers (HNC) experience many transitions in care (TiC), occurring when patients are transferred between healthcare providers and/or settings. TiC can compromise patient safety, decrease patient satisfaction, and increase healthcare costs. The evidence around TiC among patients with HNC is sparse. The objective of this study was to improve our understanding of TiC among patients with HNC to identify ways to improve care. Methods This multimethod study consisted of two phases: Phase I (retrospective population-based cohort study) characterized the number and type of TiC that patients with HNC experienced using deterministically linked, population-based administrative health data in Alberta, Canada (January 1, 2012, to September 1, 2020), and Phase II (qualitative descriptive study) used semi-structured interviews to explore the lived experiences of patients with HNC and their healthcare providers during TiC. Results There were 3,752 patients with HNC; most were male (70.8%) with a mean age at diagnosis of 63.3 years (SD 13.1). Patients underwent an average of 1.6 (SD 0.7) treatments, commonly transitioning from surgery to radiotherapy (21.2%). Many patients with HNC were admitted to the hospital during the study period, averaging 3.3 (SD 3.0) hospital admissions and 7.8 (SD 12.6) emergency department visits per patient over the study period. Visits to healthcare providers were also frequent, with the highest number of physician visits being to general practitioners (average = 70.51 per patient). Analysis of sixteen semi-structured interviews (ten patients with HNC and six healthcare providers) revealed three themes: (1) Navigating the healthcare system including challenges with the complexity of HNC care amongst healthcare system pressures, (2) Relational head and neck cancer care which encompasses patient expectations and relationships, and (3) System and individual impact of transitions in care. Conclusions This study identified challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within cancer care, which was perceived to have an impact on quality of care. These findings provide crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of TiC within this patient population.Item Open Access The feasibility of patient-reported outcomes, physical function, and mobilization in the care pathway for head and neck cancer surgical patients(2022-05-27) Daun, Julia T.; Twomey, Rosie; Capozzi, Lauren C.; Crump, Trafford; Francis, George J.; Matthews, T. W.; Chandarana, Shamir; Hart, Robert D.; Schrag, Christiaan; Matthews, Jennifer; McKenzie, C. D.; Lau, Harold; Dort, Joseph C.; Culos-Reed, S. N.Abstract Background Head and neck cancer (HNC) patients are an understudied population whose treatment often includes surgery, causing a wide range of side effects. Exercise prehabilitation is a promising tool to optimize patient outcomes and may confer additional benefits as a prehabilitation tool. The primary objective of this study was to assess the feasibility of measuring patient-reported outcomes (PROs), physical function, and in-hospital mobilization across the HNC surgical timeline in advance of a future prehabilitation trial. The secondary objective was to examine potential changes in these outcomes across the surgical timeline. Methods HNC patients scheduled to undergo oncologic resection with free-flap reconstruction completed assessments of PROs and physical function at three timepoints across the surgical timeline (baseline, in-hospital, and postsurgical/outpatient). Mobilization was measured during the in-hospital period. The feasibility of recruitment and measurement completion was tracked, as were changes in both PROs and physical function. Results Of 48 eligible patients, 16 enrolled (recruitment rate of 33%). The baseline and in-hospital PROs were completed by 88% of participants, while the outpatient assessments were completed by 81% of participants. The baseline and in-hospital assessment of physical function were completed by 56% of participants, and 38% completed the outpatient assessment. Measuring in-hospital mobilization was completed for 63% of participants. Conclusion Measuring PROs and in-hospital mobilization is feasible across the surgical timeline in HNC; however, the in-person assessment of physical function prior to surgery was not feasible. A multidisciplinary collaboration between exercise specialists and clinicians supported the development of new clinical workflows in HNC surgical care that will aid in the implementation of a future prehabilitation trial for this patient population.Item Open Access The impact of a quality management program for patients undergoing head and neck resection with free-flap reconstruction: longitudinal study examining sustainability(2020-06-23) Dort, Joseph C; Sauro, Khara M; Chandarana, Shamir; Schrag, Christiaan; Matthews, Jennifer; Nakoneshny, Steven; Manoloto, Vida; Miller, Tanya; McKenzie, C. D; Hart, Robert D; Matthews, T. WAbstract Background Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction. Methods The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made. Results Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing. Conclusions Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.Item Open Access Treatment de-escalation for HPV-associated oropharyngeal squamous cell carcinoma with radiotherapy vs. trans-oral surgery (ORATOR2): study protocol for a randomized phase II trial(2020-02-14) Nichols, Anthony C; Lang, Pencilla; Prisman, Eitan; Berthelet, Eric; Tran, Eric; Hamilton, Sarah; Wu, Jonn; Fung, Kevin; de Almeida, John R; Bayley, Andrew; Goldstein, David P; Eskander, Antoine; Husain, Zain; Bahig, Houda; Christopoulous, Apostolos; Hier, Michael; Sultanem, Khalil; Richardson, Keith; Mlynarek, Alex; Krishnan, Suren; Le, Hien; Yoo, John; MacNeil, S. D; Mendez, Adrian; Winquist, Eric; Read, Nancy; Venkatesan, Varagur; Kuruvilla, Sara; Warner, Andrew; Mitchell, Sylvia; Corsten, Martin; Rajaraman, Murali; Johnson-Obaseki, Stephanie; Eapen, Libni; Odell, Michael; Chandarana, Shamir; Banerjee, Robyn; Dort, Joseph; Matthews, T. W; Hart, Robert; Kerr, Paul; Dowthwaite, Samuel; Gupta, Michael; Zhang, Han; Wright, Jim; Parker, Christina; Wehrli, Bret; Kwan, Keith; Theurer, Julie; Palma, David AAbstract Background Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches. Methods This is a multicenter phase II study randomizing one hundred and forty patients with T1–2 N0–2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50–60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity. Discussion This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials. Trial Registration Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.