ACT 2024 Presentation

Transcript

• 01:55Hey, good morning, everyone.
• 01:56My name is Varun Bansal.
• 01:58I'm a research fellow working
• 01:59with daughter Taraga at Yale.
• 02:01We will begin in just about a minute.
• 02:03I think there are a few in person
• 02:05attendees who might be walking over and
• 02:06a few others who are joining us in Zoom.
• 02:50All right, I think we can get started.
• 02:51Sure. Hi, good morning, everyone.
• 02:53Once again, my name is Arun Bansal.
• 02:55I'm a research fellow working
• 02:57with Lauda Torada at Hill and the
• 02:59Division of Surgical Oncology.
• 03:00As many of you know,
• 03:01we have made substantial progress with
• 03:04the Peritoneal Surfaces Malignancies
• 03:06Consortium and I would like to take
• 03:08the next 20 minutes to touch upon major
• 03:11updates so far and some next steps.
• 03:14We have no disclosures.
• 03:17Yeah, just to recap,
• 03:19the BSM consortium represents a national
• 03:21multidisciplinary group of experts,
• 03:23trainees and patient advocates
• 03:25with a three-part focus.
• 03:27The primary focus is guidelines
• 03:28for which we have taken the hybrid
• 03:31consensus and evidence based approach.
• 03:33And the other two areas of interest are
• 03:35in building an educational curriculum
• 03:38and outlining standards for building
• 03:40and coding for CRS and Hypec procedures.
• 03:43With this multi level approach,
• 03:44our goal is to streamline clinical
• 03:47care for patients with peritoneal
• 03:49surface malignancies.
• 03:51And yeah,
• 03:52I'd like to start off with the
• 03:54guidelines and outline what
• 03:56really makes our process unique.
• 03:59So in alignment with the original
• 04:01Chicago consensus framework,
• 04:03we updated clinical management pathways
• 04:05for various conditions associated
• 04:07with peritoneal surface malignancies.
• 04:10We did this using a modified Delphi
• 04:13consensus with two rounds of wording
• 04:16as many of you have seen already.
• 04:19Here is an example of the neuroendocrine
• 04:22neoplasms pathway to the left
• 04:24of to my left of the screen.
• 04:26It is organized into seven independent
• 04:28blocks with levels of agreement
• 04:30indicated towards each block using
• 04:33the five point lighted scale.
• 04:35Now in order to support the
• 04:37evidence basis for these pathways,
• 04:38we conduct our systematic reviews
• 04:41for pre specified key questions and
• 04:43I will touch upon this part shortly.
• 04:46And while designing the pathways,
• 04:48we also realize and need to summarize
• 04:50principle of systemic therapy across
• 04:52disease sites and the pathologic
• 04:55nomenclature of appendicil neoplasms.
• 04:57And for this purpose,
• 04:58we worked with medical oncologists and
• 05:00geopathologists in the conservation group.
• 05:03And lastly, to close the loop
• 05:04on all of these recommendations,
• 05:06we concluded each document with
• 05:08perspectives from patients,
• 05:09advocates and international experts.
• 05:12Yeah,
• 05:13moving on to the consensus results,
• 05:16we are very excited with the progress
• 05:18thus far.
• 05:18We received a total of 227 responses
• 05:21for the first LP round and 186
• 05:24responses so far for the second round.
• 05:27About 70% of experts were surgical
• 05:30oncologists and 20% were medical oncologists.
• 05:33Voting was conducted for 9
• 05:35pathways across 6 disease sites.
• 05:38There were two pathways for colorectal,
• 05:403 for the appendix group and
• 05:42one each for gastric cancer,
• 05:43peritoneal meso,
• 05:44neuroendocrine neoplasms and malignantia
• 05:47obstruction in the setting of carcinomatosis.
• 05:51As seen here,
• 05:52we have achieved over 95% consensus
• 05:54across most blocks in the second round.
• 05:58And of note,
• 05:59there were improvements in the level
• 06:01of concurrence from the first to the
• 06:03second round across all pathways.
• 06:05And just for example,
• 06:06in the first pathway that is the
• 06:08colorectal synchronous peritoneal
• 06:10Nets pathway,
• 06:10there were four blocks with
• 06:12less than 90%
• 06:13consensus in the first round.
• 06:14After modifying these,
• 06:15in line with all the feedback
• 06:18received and all the comments,
• 06:19most of these blocks have either
• 06:22approximately 90% or more than 90%
• 06:24of consensus in the second round.
• 06:30Moving on to the rapid systematic reviews,
• 06:33these were performed to
• 06:34address contentious matters.
• 06:35For each disease site,
• 06:36we were able to narrow down to
• 06:3811 key questions cumulatively,
• 06:403 for colorectal, 3 for appendix,
• 06:422 for gastric and one each for meso near,
• 06:45endocrine neoplasms,
• 06:46and malignant GI obstruction.
• 06:48We used the standard pico model
• 06:50for defining these questions and
• 06:52verified every step of the systematic
• 06:54review process for the departmental
• 06:56librarian and a methodologist.
• 06:58To begin with,
• 07:00we screened over 13,000
• 07:02abstracts in duplicate fashion,
• 07:05of which over 1300 full texts were reviewed.
• 07:10We finally boiled down to 250
• 07:12articles cumulatively across the
• 07:14disease sites for data extraction
• 07:16and quality assessment with relevant
• 07:18outcomes referenced throughout
• 07:20the guideline manuscripts.
• 07:21Yeah,
• 07:22and I'm very thankful to all
• 07:24surgical trainees across the
• 07:26country who helped sift through
• 07:27the above steps as this was a very
• 07:30rigorous and time consuming process.
• 07:32Also in line with Cochrane
• 07:34and Prisma recommendations,
• 07:35we uploaded protocols for the
• 07:37systematic reviews to an online
• 07:39repository called Prospero beforehand.
• 07:41And to the right of to my right
• 07:43of the screen is a snippet of the
• 07:46neuroendocrine neoplasms pathway,
• 07:47which we're taking as a prototype.
• 07:49And to the left is a list of all
• 07:51the 11 protocols which were defined
• 07:53before data extraction and we're
• 07:54happy to share these separately
• 07:59and tying it all together.
• 08:01We are very proud to have engaged
• 08:03with patient advocacy groups
• 08:05in this guideline initiative.
• 08:06So far we have partnered with Colling Town,
• 08:09ACB, MB, B, MB Bowels,
• 08:11the Mesothelioma Applied Research Foundation,
• 08:13HOPE for Summer Cancer and Learn,
• 08:16Advocate and Connect for Neps
• 08:18representing all the disease sites that
• 08:20we have for this guideline iteration.
• 08:24And I would just like to share
• 08:26some insights that are patients
• 08:27can read about guidelines,
• 08:28research and resources for patients
• 08:31with peritoneal metastases.
• 08:33They expressed barriers not only
• 08:34to clinical trial enrollment,
• 08:36but also for receiving standard of care
• 08:39treatment due to accessibility issues.
• 08:42And in terms of research,
• 08:44there was a significant emphasis
• 08:45on balancing quality of life
• 08:47measures with survival metrics,
• 08:49which are often the primary
• 08:51outcomes of existing studies.
• 08:52And again,
• 08:53this is just a glimpse into some of
• 08:55their voices and we are really looking
• 08:57forward to consolidating these perspectives.
• 08:59So how does this all come together?
• 09:02After a lot of coordination we have,
• 09:05we finally have working drafts for
• 09:06each of the disease site papers,
• 09:09and I will take a moment to highlight a
• 09:11few points from the neuroendocrineoplasms
• 09:14manuscript as a prototype, as seen here.
• 09:17After the introduction section,
• 09:19we outline the methodology for
• 09:20the consensus and rapid reviews,
• 09:22with further details linked up
• 09:24to a separate methods paper.
• 09:27Moving on,
• 09:27before really getting into the ways
• 09:29with the recommendations and results,
• 09:31we provide a summary of major updates
• 09:34since the 2018 guideline iteration and
• 09:37along with the final pathway version,
• 09:40we have added the summary tables from
• 09:42systematic reviews with relevant
• 09:44descriptions of study populations,
• 09:46interventions and outcomes.
• 09:49We then get deep into the paper
• 09:52with all block wise recommendations
• 09:54and this includes a percentage of
• 09:56consensus with levels of agreement in
• 09:58both the 1st and the second round,
• 10:00as well as the levels of evidence and
• 10:02grades of recommendation within each block.
• 10:10The principles of Systemic therapy
• 10:11are summarized in a table and an
• 10:13accompanying commentary towards the end.
• 10:15And we culminate the manuscript
• 10:18with external perspectives.
• 10:19Yes, and these include patient perspectives,
• 10:21which we discussed and international
• 10:23perspectives assessing the alignment of
• 10:26our recommendations with global practices.
• 10:29I will brush over the next two sections
• 10:31quickly in the interest of time.
• 10:33So the overarching goal we're designing A
• 10:36curriculum was to provide a single accessible
• 10:40educational resource regarding DSMS.
• 10:42For this purpose,
• 10:43we started with the needs assessment for
• 10:45attending surgical oncologists and trainees,
• 10:47including residents and fellows.
• 10:50Our results were helpful in delineating
• 10:53expectations from both stakeholders
• 10:55regarding curriculum content as well as time
• 10:58commitments required to review this content.
• 11:01These results helped us delineate
• 11:03specific learning objectives for the
• 11:05curriculum in collaboration with program
• 11:07directors in the conservation group.
• 11:09And lastly,
• 11:10with regards to the content,
• 11:11we were able to employ large
• 11:13language models to help expedite
• 11:14the process for content creation.
• 11:16So we cut down three months of
• 11:18work into three hours and just
• 11:20spent a lot of time thereafter in
• 11:22reviewing this content and making
• 11:24sure it was appropriate overall.
• 11:28For now,
• 11:28we have uploaded all the content
• 11:30onto an online learning management
• 11:32system called Canvas,
• 11:33which looks something like this.
• 11:38Yeah. The proposed curriculum
• 11:39is divided into disease site
• 11:41specific modules as seen here.
• 11:43These can be potentially covered
• 11:45over 4 weeks, which is approximately
• 11:48the time that a surgical resident
• 11:50would spend on the surgical surface.
• 11:52The curriculum outline summarizes
• 11:54the structure of each module and
• 11:57provides a rubric of core and
• 11:59advanced learning objectives much
• 12:01in line with the SCORE curriculum.
• 12:03I would like to highlight here that
• 12:05this layout is very user friendly.
• 12:07Let's say I'm a resident tomorrow
• 12:09and want to review the content
• 12:11before any case or clinic.
• 12:12I can do so by scrolling over the
• 12:14content on my phone while on the go.
• 12:16So we have a lot of written
• 12:18content over here,
• 12:19other things summarized into
• 12:21tables to keep it simple,
• 12:22and also some supplementary audio
• 12:24and visual content which is linked
• 12:26out towards the end of each module.
• 12:28And I guess I don't think we
• 12:30could see it here immediately.
• 12:31But we've also added the most
• 12:33updated versions of the pathways
• 12:35to supplement the current content.
• 12:40As discussed previously about
• 12:41the standards component,
• 12:42we surveyed attending surgical oncologists
• 12:44regarding their practices for billing
• 12:47and coding for CRS and HYPEC procedures.
• 12:49The report in making a median of 79 work,
• 12:52our views for a large CRS HYPEC case
• 12:54and what is important to stress here
• 12:57is the distribution of compensation
• 12:59which is extremely variable as
• 13:01seen in this histogram over here.
• 13:04Upon investigating factors
• 13:05associated with these variations,
• 13:07we noted that attendings with lesser
• 13:10experience in PSM practice and these are
• 13:13often early career faculty reported making
• 13:16fewer work RP US per CRS HYPEC case.
• 13:19We also noted substantial heterogeneity
• 13:21encoding practices across surgeons seen here.
• 13:24This involved the assignment of CPD codes,
• 13:26relevant modifiers and dummy codes
• 13:28to critical components of CRS
• 13:30and hypec procedures.
• 13:32So there's clearly a lot of work which needs
• 13:35to be done to streamline these processes.
• 13:38So what is next for us?
• 13:40This is probably the most
• 13:42important part of the customer.
• 13:45Now talk about the guidelines first.
• 13:47Over the next two weeks we hope
• 13:49to close the second Delphi round
• 13:52and consolidate results.
• 13:53If anyone has yet to vote,
• 13:55please do so as soon as possible
• 13:57and we're happy to share the
• 13:59questionnaires for this again.
• 14:00Leading up to the SSO meeting in March,
• 14:02we will upload the finalized guideline
• 14:04documents on a pre pin server called
• 14:07MET Archives and we are very eager to
• 14:09receive your feedback about these documents.
• 14:12We will also share details regarding
• 14:15confirming authorship credentials
• 14:16during this time for everyone who
• 14:19has contributed to the initiative
• 14:21and right after the SSO meeting,
• 14:22we plan to submit the documents
• 14:25to the Quality Committee as well
• 14:27as our journal partners.
• 14:28Should these manuscripts be accepted.
• 14:30We will share details about COI
• 14:32disclosures later and we plan to do that
• 14:34with an online system called Conway,
• 14:36which is run by the double AMC
• 14:39For the curriculum.
• 14:40We are working with the SSO Education
• 14:43Council to try and deploy the
• 14:45contents for a suitable online
• 14:46learning management system.
• 14:48And there are certain parts of
• 14:50the curriculum which need a lot
• 14:52of work which we are trying to do
• 14:54paralleling especially in terms
• 14:56with designing assessments and even
• 14:58some bite sized videos in order to
• 15:00review the content very quickly.
• 15:03And the standard space is also in progress.
• 15:06So yeah, in summary,
• 15:07just looking at the numbers,
• 15:09I think it is remarkable what
• 15:11we have achieved thus far.
• 15:12As a group,
• 15:14we are a national consortium
• 15:16group with 227 experts,
• 15:18over 40 trainees and six
• 15:21patient advocacy groups.
• 15:22We have had six major meetings over
• 15:24the last year and the first one was
• 15:27of course none other than Advanced
• 15:28Cancer Therapies in San Diego.
• 15:30And today we're at the verge
• 15:33of having seven guidelines,
• 15:36a single curriculum and an online
• 15:38depository of shared resources
• 15:40across institutions.
• 15:42I would like to extend our gratitude
• 15:44to everyone who has supported
• 15:45our group this far.
• 15:47The ACT Organizing Committee
• 15:48and the SSO have given us
• 15:50a robust platform to connect with the
• 15:52best and the brightest in the field.
• 15:54Our journal partners,
• 15:55the Annals of Surgical Oncology and Cancer,
• 15:57have been very generous in lending
• 16:00advice about the submission process.
• 16:02The Surgery Executive Council members
• 16:04have volunteered to help align our
• 16:06recommendations with major national
• 16:08and international guidelines.
• 16:09And the Yale Sinkers for Medical
• 16:11and Graduate Education have offered
• 16:13expertise in curriculum development.
• 16:18Yeah. And I think the biggest shout out
• 16:20goes to our team of residents and medical
• 16:22students who have been very persistent
• 16:24in carrying this work to fruition.
• 16:26And I've sincerely believe that each one of
• 16:28the faces over here, they're superstars.
• 16:30We have David on Nets,
• 16:32Gus Carly on Education,
• 16:33Forrest and Elizabeth on appendix,
• 16:35Sarah and Leanne on Meso Curtin Colorectal,
• 16:39Sam on Gastric and Hunter with
• 16:42the work RVU and Standards Base.
• 16:45And of course we have benefited
• 16:47from the outstanding mentorship Dr.
• 16:50Schierzo and everyone else present
• 16:51here today. And virtually yes.
• 16:55And I think with that I would
• 16:56like to conclude.
• 16:57Thank you for your time.
• 16:58If you would like to know more
• 16:59about the work we are doing,
• 17:00please feel free to check out the website.
• 17:02We'll share that again.
• 17:03If anyone is yet to vote,
• 17:05please do so again as soon as possible.
• 17:08We have AQR code pulled up.
• 17:09We will can.
• 17:10We are happy to share the links separately.
• 17:12And for those who are on Zoom,
• 17:14I think David can put them
• 17:15into the chat right now.
• 17:17Yeah.
• 17:17Thank you.
• 17:17OK
• 17:26Or see. So it's over. All right.
• 17:29He's going to see it
• 18:20Can you tell us which educational
• 18:22platforms I think you're starting
• 18:24on Canvas, is that right?
• 18:26Yeah. So the plan was with Canvas because
• 18:29that's a platform we've used before and
• 18:32we have piloted at a single institution.
• 18:35But we're just trying to figure
• 18:36out as to is there another platform
• 18:38that might be more suitable?
• 18:39For example, with the Education Council,
• 18:41we have expert Ed through SSO,
• 18:43so that might be a potential
• 18:46home for the content.
• 18:47And another advantage with that would be
• 18:49if you're able to hand it over to the SSO,
• 18:51it can again be taken up by the organization
• 18:54and slated for relevant updates with time.
• 18:56So I think that really contributes
• 18:59to the longevity of this effort. I
• 19:07just want to clarify the
• 19:10term curriculum issues.
• 19:13Again, it's a little bit confusing,
• 19:16especially if you this is prior to
• 19:20the competence based model, right?
• 19:24You can teach for the middle
• 19:26surface moment with cannons,
• 19:27right? It just
• 19:31it doesn't work like that.
• 19:32First, the outcomes,
• 19:35Some outcomes pointing the well,
• 19:37the outcomes could not be cheap by
• 19:39by feeding and watching videos.
• 19:43So we've got to come up
• 19:45with another term for this,
• 19:47like you sometimes say,
• 19:50materials or like that,
• 19:52but could be a foundation,
• 19:54not a foundation, but
• 19:58feasible resource for the curriculum,
• 20:01but not the curriculum itself.
• 20:04Yes, I think that's a well taken feedback
• 20:07and we've had this discussion within the
• 20:10education Group A couple of Times Now.
• 20:12I think the overarching goal with this
• 20:15part and releasing in terms of what
• 20:17we will be able to deploy in the short
• 20:20term would be a summary of online
• 20:22content or materials as you recommended.
• 20:24And the part about really trying to
• 20:26look at how we can achieve competencies
• 20:29and operative efficiency,
• 20:30that's something we are hoping to
• 20:32brainstorm in the long term as a group.
• 20:34The
• 20:38next steps for the for the standards part,
• 20:43the you mentioned that there's a
• 20:44lot of work to be done in that area.
• 20:46Do you know what's happening next for that?
• 20:49So in terms of that,
• 20:50as far as I can recollect,
• 20:51and this might not be perfect,
• 20:53we had a set of few recommendations
• 20:55in the 2018 document.
• 20:57There was again a standards paper over there.
• 20:59We will carefully re examine those
• 21:01points and see if there are any
• 21:04major modifications that need to be
• 21:06made in terms of how some of the
• 21:08experts that are within the group are
• 21:10recommending to go about building
• 21:12and coding for the procedures.
• 21:14I also believe there was a recent
• 21:16update into the CPD core terminology.
• 21:18So we will also have to align
• 21:21our recommendations with that.
• 21:22So that's something we'll work
• 21:24on in the back end,
• 21:27yes. Are there plans long term license
• 21:31groups for collaborative multi?
• 21:33Yes, of course. And I think that
• 21:35is the most important part again.
• 21:36So this was just in an important
• 21:40effort to build a foundation and
• 21:41bring everyone together in the group.
• 21:43And I think we have been able
• 21:45to do that successfully on a
• 21:47relatively short time scale.
• 21:49And I think now that we have
• 21:51engaged everyone so far,
• 21:52the real next step,
• 21:54and this is something Doctor
• 21:55Terada always emphasizes,
• 21:56would be to run registries and
• 21:59potentially trials as a group.
• 22:01And that's something we're hoping
• 22:03to touch upon more regularly
• 22:05moving forwards and we will
• 22:07communicate for the details.
• 22:21All right. Thank you so much.