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Objectives To develop an expert-group, consensus-based list of system performance indicators to be used for monitoring, evaluating, and benchmarking progress for cancer care and control in adolescents and young adults (AYAs) in Canada. Methods A national multidisciplinary panel of AYA oncology experts was convened; they prepared a literature review and undertook a brainstorming exercise to create a comprehensive list of indicators based on a previously defined framework for AYA cancer care and control in Canada. A modified Delphi process was then undertaken to cull the list based on 3 quick screen criteria. Three rounds of ranking were required. The fourth stage employed a face-to-face meeting, and the final stage utilized a survey to rank the indicators on the basis of importance and feasibility. Results Nineteen participants contributed to the 5-stage process. From an initial list of 114 indicators, 14 were ultimately endorsed, representing 5 themes: active care, survivorship, psychosocial issues, palliative care, and research. The 5 highest ranked indicators were assessed as very to moderately feasible, with only a single indicator (clinical trial enrollment) in the top 5 assigned a least feasible ranking. Conclusion The 14 indicators provide a starting point for the development of a standard set of metrics for AYA cancer care and control in Canada and have potential for international utility.

e22027 Background: Pediatric cancer patients undergoing treatment are often at risk for infertility or subfertility. Healthcare providers do not consistently deliver fertility information prior to therapy. Our objective was to assess if development and implementation of a fertility guideline improves the frequency of pre-treatment fertility discussions with pediatric cancer families. Methods: This retrospective cohort study analyzed all consecutively eligible patients over two time periods. The pre-guideline time period was 18 months prior to implementation and the post-guideline time period was 12 months after implementation. Guideline implementation included an education session with oncology staff. Eligible patients were < 19 years old at cancer diagnosis and received chemotherapy and/or radiation therapy. Patients treated with palliative intent were excluded. Pre-guideline rate of pre-treatment fertility discussions was estimated at 40%. An estimated 40 participants in the post-guideline cohort can detect a 30% increase in fertility discussions with β 0.8 and α 0.05. Exploratory analysis assessed factors associated with the frequency of fertility risk discussions. Results: Ninety-five patients were included. Fifty-seven percent were < 10, 26% were 10-15, and 17% were ≥ 16 years old. Pre- and post-guideline cohorts are compared in table. In the pre-guideline cohort, 41% of patients had a discussion about risks of fertility impairment documented, while post-guideline cohort had 49% documented ( p = 0.531). Exploratory assessment of combined cohorts found males (OR 0.2.7, 95% CI 0.1.2-6.3-0.87) and patients ≥ 10 years old (OR 5.0, CI 2.1-12.1) were more likely to receive fertility discussions prior to therapy. Radiation and cancer type did not influence whether fertility discussions occurred. Conclusions: Implementation of a fertility guideline did not increase discussions of fertility risk, and less than half of patients had a documented fertility risk discussion. Male patients and age ≥ 10 years old were more likely to have documented discussions about risks to future fertility. Effective strategies are needed to improve the rate of discussions regarding fertility risk to ensure families receive this information prior to therapy. [Table: see text]

The present population-based study evaluates the management and complications of peripherally inserted central catheters (PICC) in all pediatric oncology patients diagnosed in Maritimes, Canada from 2000 to 2014. A total of 107 PICCs were placed in 87 (10.1%) pediatric oncology patients. A high percentage (33% and 44%, respectively) of the first and second PICC lines was associated with complications. Thrombosis, occlusion, and infection were the most frequent complications. Age above 10 years and left body side of insertion were significantly associated with PICC complications. Given the frequent use of PICCs and the high incidence (>33%) of complications, there is a need to mitigate PICC line complications.

Terms used to label types of clinical recommendations and guidance are applied inconsistently and do not reflect the methods used to create each type. Here, the international Pediatric Oncology Supportive Care Guideline Network proposes a lexicon for types of recommendations and guidance documents. A lexicon describing three types of recommendations (clinical practice guideline-derived, good practice statement, and expert opinion statement) and two types of guidance documents (clinical practice guideline and expert opinion) is presented. Consistent use of this lexicon will allow pediatric oncology clinicians to readily appreciate the methods used to create clinical guidance.

BACKGROUND Fever in the setting of neutropenia is a potentially life-threatening complication of cancer treatment. A time of less than 60 minutes from presentation to antibiotic administration is therefore recommended. OBJECTIVE To use Lean Six Sigma methodology, a quality improvement initiative, to improve time to antibiotics (TTA) for children with chemotherapy-induced febrile neutropenia presenting to the emergency department. METHODS Lean Six Sigma is a quality improvement method that engages all impacted stakeholders and focuses on streamlining the process by removing process wastes. Stakeholders identified multiple process wastes in an in-depth study of 49 fever episodes in patients attending a tertiary care pediatric hospital, including patients waiting to be registered, waiting for laboratory technicians, delay in accessing central venous access device, waiting for absolute neutrophil count, and delayed antibiotics orders. We implemented multiple solutions: engaging patients in the process through predischarge tours of the emergency department, home application of topical anesthetic, nurse-initiated pathway, early access of central venous access device for all blood work, and planned antibiotic administration no later than 45 minutes after triage. We prospectively determined the impact of these interventions on TTA. RESULTS The TTA significantly improved to a median of 59 minutes (interquartile range, 38.5-77.5 minutes) compared with the baseline of 99 minutes (interquartile range, 72.0-132.0 minutes; P < 0.0001). CONCLUSIONS Lean methodology effectively identifies barriers and provides solutions to remove barriers and improve administration of antibiotics in febrile oncology patients. These can be widely applied, including in smaller institutions with minimal increased utilization of resources.

The Figure 1 used in the originally published version of this article was incorrect.

Background Chemotherapy-induced nausea and vomiting (CINV) impacts quality of life for patients. Guidelines for emetogenicity classification and prevention of CINV in children were recently published and endorsed by pediatric oncology organizations. Procedure A multicenter chart review was performed at four Canadian pediatric oncology centers examining rates of prescribing adherence to CINV guidelines between January 2012 and December 2015. Eligible patients received their first chemotherapy course of highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC). Results Guideline adherence was described in 204 patients as antiemetic-only guideline adherence (AGA; examined medication/class prescribed only) and complete guideline adherence (CGA; examined medication/class, dose, frequency, and duration prescribed). Adherence was 29% (HEC 30%, MEC 19%, P = 0.1) and 2% for AGA and CGA patients, respectively. Vomiting in the first 24 h was experienced by 24% of AGA and 34% of non-AGA patients (P = 0.13), with mean breakthrough medication doses similar between AGA and non-AGA groups (HEC 1.8 vs 1.5, P = 0.45; MEC 3 vs 1.42, P = 0.35). In the first 24 h, HEC AGA patients achieved a complete control rate of 37% vs 45% for non-AGA patients (P = 0.31), while patients receiving AGA therapy for MEC achieved a complete control rate of 80% vs 24% for non-AGA patients (P = 0.02). Conclusions Adherence to guidelines was low across all four pediatric institutions. Each center used different approaches to implement pediatric CINV guidelines. Complete CINV control was low, with reports of emesis high, indicating that patients are not receiving optimal treatment.

Venous thromboembolism (VTE) is a well-recognized complication in pediatric oncology patients. Studies in adult oncology patients have suggested a potential negative association between VTE and survival, but this association has not been examined in pediatric patients yet. The aim of this study was to assess the association of VTE with survival in pediatric oncology patients. Data from all pediatric oncology patients treated at the two tertiary care centers in Atlantic Canada were pooled to create a population-based cohort. The association between VTE and survival was analyzed using a Cox proportional hazards model stratified by diagnosis group (leukemia, lymphoma, and other; sarcoma) and adjusted for age at diagnosis and sex. Out of 939 patients included in this study, 73 had a VTE (8%) and 131 (14%) patients died during the study period. Children in the leukemia/lymphoma/other group with a VTE had significantly poorer survival relative to children in the same group who did not have a VTE. Although children with sarcoma and VTE had poorer survival compared to children with sarcoma with no VTE, this association was not statistically significant. In this population-based study, we found a negative association between VTE and survival in pediatric oncology patients. If future studies confirm this association, this finding may have prognostic implications and potentially offer new avenues for the management of pediatric patients with cancer.

Venous thrombotic events (VTE) are a well-recognized complication in pediatric cancer patients. Population-based data on the incidence and characteristics of VTE in all pediatric cancer patients are limited. This information is crucial to identify patients at high risk and design targeted interventions accordingly. The present study was designed to determine the incidence and characteristics of VTE in the pediatric oncology population.We conducted a retrospective, population-based, cohort study of patients treated in the Maritimes, Canada between 1995 and 2015.There were 1210 pediatric hematology/oncology patients from the Maritimes, Canada, treated at the IWK Health Centre between 1995 and 2015. Fifty-eight (4.8%) experienced at least 1 VTE and the majority of patients experienced it within 6 months of cancer diagnosis. The median age of patients who experienced VTE was 10.7 years (SD = 6.0). The most common presenting symptom of thrombosis was central venous line dysfunction, and the most common location for thrombosis was within the upper venous system. We observed that 65.6% of the patients with VTE required1 central venous catheters (CVC). The presence of a VTE increased the odds of requiring1 CVC to 3.6 (95% confidence interval: 1.76-7.3).Thus, in this large, population-based study, we present the incidence and characteristics of VTE in the pediatric oncology population and demonstrate the clinical impact of VTE in terms of loss of CVC. Larger, prospective studies are required to confirm these findings and to develop a risk model for managing and preventing VTE in this patient population.

BACKGROUND Central venous catheter (CVC) dysfunction is a common complication among pediatric cancer patients. Tissue plasminogen activator (tPA) is administered to resolve CVC dysfunction. The present study was designed to determine risk factors associated with requirement of tPA for CVC dysfunction and to assess the clinical impact of CVC dysfunction in terms of CVC loss and venous thrombotic events (VTE). PROCEDURE Case records of all pediatric patients with cancer from the Maritimes, Canada were reviewed following ethics approval. Data regarding demographics, clinical diagnosis, CVC dysfunction, characteristics of CVCs, and VTE were pooled from multiple data sources. RESULTS Seven hundred and forty-one patients required ≥1 CVC. 26.3% of patients required tPA for ≥1 episodes of CVC dysfunction. Requirement of one or more doses of tPA for episodes of CVC dysfunction increased the odds of VTE by two times (95% confidence interval, 1.1-3.6). Patients that required ≥1 doses of tPA required significantly more CVCs (2.05 ± 1.29 per individual patient, 55% of the patients needed >1 CVCs) as compared to the remainder (1.52 ± 0.95 per individual patient, 32% needed >1 CVCs) (P = 0.0001). Multivariate analysis revealed age > 10 years, diagnosis of sarcoma, and tunneled line were independently associated with tPA requirement. CONCLUSION We determined independent risk factors associated with requirement of tPA for CVC dysfunction. Requirement of tPA for CVC dysfunction was associated with significantly increased risk of VTE and requirement of more CVCs. These observations can assist in identification of patients at increased risk of CVC dysfunction and inform approaches to reduce CVC loss and VTE.

Background: Symptomatic venous thrombotic events (sVTE) are a well-recognized complication in pediatric oncology patients. Although data exists on incidence, risk factors and outcome of sVTE, the association of sVTE with survival outcome in pediatric oncology patients has not been previously assessed. The present study was designed to assess the survival outcome in pediatric oncology patients who developed sVTE as compared to those who did not develop sVTE. Aims: To assess the overall survival (OS) and event free survival (EFS) in pediatric oncology patients with and without sVTE. Methods: The Maritimes constitutes the 3 Canadian Provinces of Nova Scotia, New Brunswick and Prince Edward Island (total population = 1.8 million). All pediatric oncology patients from the Maritimes are treated at IWK Health Centre (IWK) in a shared care model with regional provincial hospitals. This provides a population-based cohort. Institutional ethics board approval for this retrospective study was obtained. A database of all pediatric oncology patients treated at the IWK Health Centre from 2000-2015 was created by amalgamating data from (i) pediatric oncology hospital database (ii) Provincial Cancer in Young People registry (iii) pharmacy database and (iv) hospital health records. All pediatric oncology patients who developed sVTE were identified using the above databases. Data from all databases was cross-verified for accuracy and then pooled. Data on patient demographics, diagnosis, date of diagnosis, date of last follow up, date of first relapse, and date of death were extracted. Status of every patient on or up to 31 December 2015 was reviewed. SPSS version 22 was used for statistical analysis. Survival outcome was assessed using the Kaplan Meier method. Survival was reported in complete months. sVTE was defined as radiologically documented VTE with at least one sign/symptom directly associated with VTE. First relapse or death were classified as events for calculation of EFS. Both OS and EFS were calculated from diagnosis of cancer. Results: Forty-seven (5.02±0.01%) of the 936 patients had sVTE. The mean age at diagnosis for sVTE patients was 10.1 years. The gender ratio was male:female= 1.8:1 in patients with sVTE. Central veins were the most common location for sVTE (72.3%, n=34). The underlying cancer diagnosis in patients with sVTE were leukemia (36.2%, n=17), lymphoma (19.1%, n=9), sarcoma (19.1%, n=9), brain tumor (2.1%, n=1) and others (23.4%,n=11). The OS of patients with sVTE was significantly inferior (p Of the 47 patients with sVTE, 17 (36.2%) died. In comparison, among patients without sVTE, 133 (15%) died (p=0.001). The EFS of patients with sVTE was significantly inferior (p Conclusion: In a large population-based cohort, we demonstrate that the survival outcome of pediatric oncology patients with sVTE is inferior as compared to those without sVTE. A plausible explanation is that patients at higher risk for death: poor prognosis/advanced cancers and those with more intense multimodality therapy are more likely to be diagnosed with sVTE. Validation of these findings is necessary, as is a better understanding of the drivers for this association of sVTE with early death and the possible role of thromboprophylaxis in optimizing outcomes. Disclosures No relevant conflicts of interest to declare.