Evaluation of end-of-life best practices and implementation of a tool to predict near-term death among patients with metastatic breast cancer in an oncology clinic

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PROJECT SUMMARY A “good death” is often desired but seldom delivered for patients with cancer. Because oncologists often do not recognize when a patient is near the end of life (EOL), many patients receive aggressive care until death. To remedy this, prognostic tools are needed to identify patients nearing death. How to incorporate these tools into routine cancer care and use them to prompt best practices, such as serious illness conversations and hospice referrals, is not well understood. The long-term goal is to leverage evidence-based tools to improve EOL care for patients with metastatic breast cancer (MBC). The main objective is to integrate a validated breast cancer prognostic tool into routine practice using implementation science. This research study will pursue three aims: 1) Define the baseline frequency of documented serious illness conversations and hospice referrals among patients with metastatic breast cancer and their relationship to prognostic risk scores; 2) Co-design an implementation protocol with patient, caregiver, and care team partners for use of a metastatic breast cancer prognostic tool in an oncology clinic; and 3) Pilot implementation of a metastatic breast cancer prognostic tool in an oncology clinic and assess implementation outcomes. For the first aim, a retrospective study using EHR data from patients with MBC will quantify baseline EOL best practices and define their relationship to prognostic scores. For the second aim, interviews and user-centered research with oncologists, patients, and caregivers will evaluate factors that impede or enable implementation of the tool in practice and identify desired features of the prognostic tool implementation. These key partners will co-design an implementation protocol. For the third aim, the tool will be piloted in an oncology clinic according to the protocol and evaluated for implementation outcomes using surveys, interviews, and secondary data in a mixed method design. This project seeks to innovate by shifting the paradigm from sole reliance on clinician judgement towards use of evidence-based tools to estimate prognosis. The proposed study is significant for its potential to improve EOL quality for patients with MBC through timely identification of high-risk patients and earlier initiation of EOL best practices. This proposal is submitted by Emily Ray, MD, MPH, a breast medical oncologist and health services researcher at the University of North Carolina in the Cancer Outcomes Research Program. The proposed career development plan will equip her with skills in implementation science, mixed methods, cancer care quality, and multi-site trials to accelerate her research from its evidence basis in large datasets towards interventions aimed at improving cancer care quality. The academic environment at the University of North Carolina, with leading programs in breast oncology, cancer outcomes research, and public health, and her outstanding mentoring team including Dr. Jennifer Leeman, a well-funded, national expert in implementation science, positions Dr. Ray to make an impact through designing, testing, and implementing evidence-based interventions to deliver high-quality, patient-centered end-of-life cancer care.