Developing the Medical Oncology Treatment Plan and Summary

Two recent publications have highlighted the need for improved chart documentation in the medical oncology office, particularly related to chemotherapy administration. In one, researchers from ASCO's National Initiative on Cancer Care Quality (NICCQ) found that it was often difficult to find complete documentation of the chemotherapy administered to breast and colorectal cancer patients.¹ The second, the Institute of Medicine report From Cancer Patient to Cancer Survivor: Lost in Transition, described cancer survivors' need for clear documentation of the cancer treatments they received.²

Incomplete documentation is a significant issue for cancer patients who move or change physicians (as was dramatically illustrated after Hurricane Katrina), and for survivors and their providers who need a clear record to make informed treatment decisions. Within the medical oncology office, identifying and transferring the necessary components of the patient chart to other providers can be a complex and time-consuming process. Also, as demonstrated by the NICCQ study, quality monitoring and improvement are hampered by the inability to find basic data.

After soliciting input from peers, past Chair of ASCO Health Services Committee and current ASCO Quality Advisory Group member Deborah Schrag, MD, is leading an ASCO effort to develop documentation tools for medical oncologists. In partnership with Ellen Stovall at the National Coalition for Cancer Survivorship and Patricia Ganz, MD, who chairs the Quality Advisory Group for ASCO, Schrag is developing templates for summarizing the essential components of chemotherapy treatment at both the initiation and conclusion of a treatment regimen. The treatment plan and summary are envisioned as tools for both physician-patient and physician-physician communication, which will streamline documentation.

Steps Toward a Summary

The creation of a chemotherapy treatment summary is formulated as a two-step process (see sidebar, “Chemotherapy Treatment Summary: A Two-Step Process”). The first step coincides with the initiation of a treatment regimen. The second and final step coincides with the completion of a regimen. This may occur at the end of a course of adjuvant therapy, before a planned surgical resection, or after disease progression. Treatment breaks, holidays, and minor modifications are not envisioned as triggering preparation of such a summary.

Chemotherapy treatment summaries are not meant to replace flow sheets or informed consent documents. The summaries are intended to include information that medical oncologists would easily identify for their own patients. Yet, quickly distilling key information can be difficult for various cancer specialists and other treating physicians because of inconsistent formatting, longitudinal organization, and, in some cases, an overwhelming level of detail. Facilitating coordination as patients transition between various cancer specialists and other settings of care is an important aspect of coordination.

Cancer specialists in the fields of pathology, radiation, and surgery provide similar synoptic documentation in the form of pathology reports, radiation summaries, and operative reports. Medical oncology presents documentation challenges because the treatment episodes often span many months and visits, and do not typically have clearly defined boundaries.

The Bottom Line

The goal of this project is to improve physician-physician and patient-physician communication and coordination of care across health care settings. It will also make gathering data to evaluate and improve quality of care and patient outcomes more accurate and efficient.

It will be critical to engage practitioners' help in identifying the key components of treatment plans and summaries. Such summaries are intended to be useful now for oncologists who dictate or write notes and to provide a guide for vendors to incorporate into oncology information systems. It is possible that these summaries may eventually supplant the need for the detailed documentation of physical exams and systems review at oncology visits with moderate complexity.

Next Steps

Schrag, together with a core team of ASCO volunteers, is working to develop templates for chemotherapy treatment summaries. Participation and feedback from membership, especially community practitioners, will be encouraged. The chemotherapy treatment summary tools will be pilot tested in oncology practices and revised as needed. As this unfolds, templates and other documentation tools will be published in future issues of the Journal of Oncology Practice.

Chemotherapy Treatment Summary: A Two-Step Process.

Step 1: Highlighting the plan

When a patient embarks on a new chemotherapy regimen, the medical oncologist completes the first section of the treatment summary. This highlights the plan for treatment by answering a series of basic questions:

• What is the diagnosis (e.g., disease, histology)?

• What is the context of treatment (e.g., neoadjuvant, adjuvant, combined modality with radiation, or treatment of metastatic disease)?

• What regimen is to be administered (e.g., name and drugs, route of administration, frequency, planned number of cycles before reassessment)?

• What is the patient's clinical status at the start of treatment (e.g., functional status, presence or absence of cancer related symptoms)?

Step 2: Assessing the treatment

When a patient completes a chemotherapy regimen, the medical oncologist appends the treatment summary with an assessment of how the treatment was tolerated and the results achieved:

• How much treatment was delivered (e.g., number of cycles, duration from first to last treatment)?

• How was the treatment tolerated (e.g., major toxicity, drugs discontinued)?

• What outcomes were achieved (e.g., best radiographic response and clinical response, if applicable)?

• What was the reason for treatment discontinuation (e.g., disease progression, completion of planned course, toxicity)?