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Background: Addressing patients’ social determinants of health is a national priority for cancer treatment centers. Transportation insecurity is one major challenge for patients undergoing active cancer treatment, and missing treatments can result in worse cancer treatment outcomes, including worse morbidity and mortality. How cancer treatment centers are addressing transportation insecurity is understudied. Methods: In January and February 2022, the NCCN Best Practices Committee conducted a survey of NCCN’s 31 Member Institutions (currently 32 member institutions as of April 2022) to assess how centers were addressing patient transportation insecurity: how they screen for transportation insecurity, coordinate transportation, and fund transportation initiatives, and their plans to address transportation insecurity in the future. Results: A total of 25 of 31 (81%) NCCN Member Institutions responded to the survey, of which 24 (96%) reported supporting the transportation needs of their patients through screening, coordinating, and/or funding transportation. Patients’ transportation needs were most often identified by social workers (96%), clinicians (83%), or patients self-declaring their needs (79%). Few centers (33%) used routine screening approaches (eg, universal screening of social risk factors) to systematically identify transportation needs, and 54% used the support of technology platforms or a vendor to coordinate transportation. Transportation was predominantly funded via some combination of philanthropy (88%), grants (63%), internal dollars (63%), and reimbursement from insurance companies (58%). Over the next 12 months, many centers were either going to continue their current transportation programs in their current state (60%) or expand existing programs (32%). Conclusions: Many NCCN Member Institutions are addressing the transportation needs of their patients. Current efforts are heterogeneous. Few centers have systematic, routine screening approaches, and funding relies on philanthropy more so than institutional dollars or reimbursement from insurers. Opportunities exist to establish more structured, scalable, and sustainable programs for patients’ transportation needs.

Introduction: The utilization of advanced practice providers (APPs) in oncology has been growing over the last decade; however, there is no standard method for assessing an APP’s contributions to oncology care. Methods: The NCCN Best Practices Committee (BPC) created an APP Workgroup to develop recommendations to support the roles of APPs at NCCN Member Institutions. The Workgroup conducted surveys to understand how NCCN centers measure productivity. This article will review the survey results and provide recommendations for measuring APP productivity. Results: Although 54% of responding centers indicated they utilize relative value units (RVU) targets for independent APP visits, 88% of APPs are either unsure or do not believe RVUs are an effective measurement of overall productivity. Relative value units do not reflect non-billable hours, and APPs perform a significant number of non-billable tasks that are important to oncology practices. Sixty-six percent of APPs believe that measuring disease-based team productivity is a more reasonable assessment of APP productivity than measuring productivity at the individual level. Conclusion: Our recommendation for cancer centers is to focus on the value that APPs provide to overall care delivery. Advanced practice provider productivity metrics should consider not only the number of patients seen by APPs, but also the high quality and thorough care delivered that contributes to the overall care of the patient and practice. Advanced practice providers can help improve access to care, deliver improved outcomes, and increase patient and provider satisfaction. Reducing the focus on RVUs, accounting for important non-RVU–generating activities, and incorporating quality and team metrics will provide a better overall picture of APP productivity.

ZusammenfassungDas hormonelle System ist hochkomplex und vielfältig vernetzt. Endokrine Störungen nehmen auch aufgrund unseres Lebensstils, externer Störfaktoren sowie Fremdsubstanzen zu und erfordern daher ein entsprechend multimodales Vorgehen. Die Speicheldiagnostik ist jener mittels Blut und Urin überlegen und liefert wertvolle Hinweise über die tatsächliche Regulationssituation. Damit ermöglicht sie unter Berücksichtigung des klinischen Kontexts sowie der vielen potenziellen Einflussfaktoren konkrete und individuelle therapeutische Ansätze zur Rebalancierung des Endokriniums.

The NCCN Best Practices Committee, which is composed of senior physician, nursing, and administrative leaders from NCCN Member Institutions, evaluated the status of cancer center operations after 1 year of operating during the COVID-19 pandemic. Two major initiatives stood out: the increase in the utilization of network sites, and the gains made in telemedicine operations and reimbursement. Experts from NCCN Member Institutions participated in a webinar series in June 2021 to share their experiences, knowledge, and thoughts on these topics and discuss the impact on the future of cancer care.

SummaryDie Darmmikrobiota ist unter anderem mit ihren immunregulatorischen, antiinflammatorischen und energieliefernden Effekten an Stoffwechselprozessen der Darm-Leber-Achse beteiligt. Störungen der Darmmikrobiota können Erkrankungen (mit)verursachen, welche die Leber direkt betreffen (z. B. Fettleber) oder das Organ belasten (z. B. Gallensäure-Verlustsyndrom). Störungen der Leberfunktion können über eine Einschränkung der Fettverdauung und -resorption die Darmmikrobiota beeinflussen und in diversen Darmbeschwerden resultieren.

Introduction: The National Comprehensive Cancer Network (NCCN) Best Practices Committee created an Advanced Practice Provider (APP) Workgroup to develop recommendations to support APP roles at NCCN Member Institutions. Methods: The Workgroup conducted three surveys to understand APP program structure, staffing models, and professional development opportunities at NCCN Member Institutions. Results: The total number of new and follow-up visits a 1.0 APP full-time equivalent conducts per week in shared and independent visits ranged from 11 to 97, with an average of 40 visits per week (n = 39). The type of visits APPs conduct include follow-up shared (47.2%), follow-up independent (46%), new shared (6.5%), and new independent visits (0.5%). Seventy-two percent of respondents utilize a mixed model visit type, with 15% utilizing only independent visits and 13% utilizing only shared visits (n = 39). Of the 95% of centers with APP leads, 100% indicated that leads carry administrative and clinical responsibilities (n = 20); however, results varied with respect to how this time is allocated. Professional development opportunities offered included posters, papers, and presentations (84%), leadership development (57%), research opportunities (52%), writing book chapters (19%), and other professional development activities (12%; n = 422). Twenty percent of APPs indicated that protected time to engage in development opportunities should be offered. Conclusion: As evidenced by the variability of the survey results, the field would benefit from developing standards for APPs. There is a lack of information regarding leadership structures to help support APPs, and additional research is needed. Additionally, centers should continuously assess the career-long opportunities needed to maximize the value of oncology APPs.

PURPOSE: The National Comprehensive Cancer Network (NCCN) formed an Infusion Efficiency Workgroup to determine best practices for operating efficient and effective infusion centers. METHODS: The Workgroup conducted three surveys that were distributed to NCCN member institutions regarding average patient wait time, chemotherapy premixing practices, infusion chair use, and premedication protocols. To assess chair use, the Workgroup identified and defined five components of chair time. RESULTS: The average patient wait time in infusion centers ranged from 25 to 102 minutes (n = 23; mean, 58 minutes). Five of 26 cancer centers (19%) routinely mix chemotherapy drugs before patient arrival for patients meeting specified criteria. Total planned chair time for subsequent doses of the same drug regimens for the same diseases varied greatly among centers, as follows: Administration of doxorubicin and cyclophosphamide ranged from 85 to 240 minutes (n = 22); of FOLFIRINOX (folinic acid, fluorouracil, irinotecan hydrochloride, and oxaliplation) ranged from 270 to 420 minutes (n = 22); of rituximab ranged from 120 to 350 minutes (n = 21); of paclitaxel plus carboplatin ranged from 255 to 380 minutes (n = 21); and of zoledronic acid ranged from 30 to 150 minutes (n = 22) for planned total chair time. Cancer centers were found to use different premedication regimens with varying administration routes that ranged in administration times from zero to 60 minutes. CONCLUSION: There is a high degree of variation among cancer centers in regard to planned chair time for the same chemotherapy regimens, providing opportunities for improved efficiency, increased revenue, and more standardization across centers. The NCCN Workgroup demonstrates potential revenue impact and provides recommendations for cancer centers to move toward more efficient and more standard practices.

PURPOSE: The field of psycho-oncology is relatively undeveloped, with little information existing regarding the use of psychologists at cancer centers. Comprising 30 leading cancer centers across the United States, the National Comprehensive Cancer Network (NCCN) set out to understand the trends in its Member Institutions. METHODS: The NCCN Best Practices Committee surveyed NCCN Member Institutions regarding their use of psychologists. The survey was administered electronically in the spring/summer of 2017. RESULTS: The survey was completed by 18 cancer centers. Across institutions, 94% have psychologists appointed to provide direct care to their cancer center patients. The number of licensed psychologist full-time equivalents (FTEs) on staff who provide direct patient care ranged from < 1.0 FTE (17%) to 17.0-17.9 FTEs (6%). Regarding psychologist appointments, 41% have both faculty and staff appointments, 41% have all faculty appointments, and 18% have all staff appointments. Forty-three percent of institutions indicated that some licensed psychologists at their centers (ranging from 1%-65%) do not provide any direct clinical care, and 57% indicated that all licensed psychologist on staff devote some amount of time to direct clinical care. The percent of clinical care time that is spent on direct clinical care ranged from 15%-90%. CONCLUSION: There is great variability in psychology staffing, academic appointments, and the amount of direct patient care provided by on-staff psychologists at cancer centers.

ZusammenfassungBei vielen chronischen Erkrankungen werden Veränderungen der Darmmikrobiota als ätiologischer Mit-Faktor diskutiert. Doch was haben beispielsweise rheumatoide Arthritis und Diabetes mit dem Darm zu tun? Nach derzeitiger Erkenntnislage scheinen Barrierestörungen (Leaky Gut) mit daraus resultierenden, latenten chronischen Entzündungen der Schlüssel zu sein. Entsprechend wichtig sind die frühzeitige Erkennung und Behandlung solcher vom Darm ausgehenden „silent“ oder „low-grade inflammations“.

SummaryUnsere körpereigene Mikrobiota trägt in Form der Kolonisationsresistenz entscheidend zum direkten Schutz vor Infektionen bei. Darüber hinaus hat insbesondere die Darmmikrobiota großen Einfluss auf die Funktionsfähigkeit der Immunabwehr. Entsprechend weitreichend sind die Folgen von Störungen dieses Barrieresystems. Stuhluntersuchungen bieten dann die Möglichkeit einer mikroökologischen Status-quo-Erfassung sowie die Basis für gezielte pro- und präbiotische Therapien auch im Sinne einer Infektprävention bzw. -behandlung.

Background: Financial distress from medical treatment is an increasing concern. Healthcare organizations may have different levels of organizational commitment, existing programs, and expected outcomes of screening and management of patient financial distress. Patients and Methods: In November 2018, representatives from 17 (63%) of the 27 existing NCCN Member Institutions completed an online survey. The survey focused on screening and management practices for patient financial distress, perceived barriers in implementation, and leadership attitudes about such practices. Due to the lack of a validated questionnaire in this area, survey questions were generated after a comprehensive literature search and discussions among the study team, including NCCN Best Practices Committee representatives. Results: Responses showed that 76% of centers routinely screened for financial distress, mostly with social worker assessment (94%), and that 56% screened patients multiple times. All centers offered programs to help with drug costs, meal or gas vouchers, and payment plans. Charity care was provided by 100% of the large centers (≥10,000 unique annual patients) but none of the small centers that responded (P=.008). Metrics to evaluate the impact of financial advocacy services included number of patients assisted, bad debt/charity write-offs, or patient satisfaction surveys. The effectiveness of institutional practices for screening and management of financial distress was reported as poor/very poor by 6% of respondents. Inadequate staffing and resources, limited budget, and lack of reimbursement were potential barriers in the provision of these services. A total of 94% agreed with the need for better integration of financial advocacy into oncology practice. Conclusions: Three-fourths of NCCN Member Institutions reported screening and management programs for financial distress, although the actual practices and range of services vary. Information from this study can help centers benchmark their performance relative to similar programs and identify best practices in this area.

Veranderungen der Zusammensetzung der Darmflora konnen Hinweis sein auf Erkrankungen, die Stuhlflora-Diagnostik gibt Aufschluss uber den Zustand der Darmbarriere Die Befunde sind jedoch immer im Kontext der Symptome und bezogen auf den jeweiligen Patienten zu interpretieren. Erganzende Stuhluntersuchungen erfassen die intestinale Umgebung der Darmkeime.

Die Vermehrung bzw. die Verminderung bestimmter Bakterienspezies bzw. -gruppen innerhalb der menschlichen Darmflora werden derzeit als ursachliche Faktoren fur Ubergewicht diskutiert. Allerdings handelt es sich dabei um Hypothesen, fur die bislang kein konkreter Beweis erbracht werden konnte. Vieles deutet eher darauf hin, dass nicht einzelne Mikroorganismen, sondern unspezifische Veranderungen in der intestinalen Mikrobenvielfalt im Sinne einer gestorten Darmbarriere (leaky gut) fur metabolische Fehlregulationen wie Ubergewicht mitverantwortlich sein konnten.

Die Hormonbestimmung aus dem Speichel bietet einige Vorteile gegenuber der aus dem Blut: Im Speichel kann die Konzentration der freien, biologisch aktiven Hormone gemessen werden, im Blut sind die Steroidhormone zum Grosteil inaktiv. Der Beitrag erlautert am Beispiel der Steroidhormone was bei der Speicheldiagnostik zu beachten ist, um zu aussagefahigen Resultaten zu gelangen. Fur Cortisol, DHEA und Melatonin werden ausgehend von deren Bedeutung fur den Organismus Hinweise zur Bestimmung gegeben sowie ein Ausblick auf therapeutische Optionen bei auffalligen Hormonbefunden. Die Erlauterung zweier Beispielbefunde zeigt das Vorgehen in der Praxis.

11615 Background: Deficiencies and barriers exist to delivering comprehensive and affordable cancer care. Understanding the variation in organizational commitment, existing programs, and expected outcomes for screening and management of financial distress is needed. Methods: Representatives from 17 of 27 NCCN Member Institutions (63%) completed an online survey in November 2018 conducted by the NCCN Best Practices Committee. Centers were classified based on number of unique patients seen per year, as large ( > 10,000) (76%), or small ( < 10,000) (34%). The survey focused on institutions’ screening and management practices for patient financial distress, perceived barriers in implementation, and leadership attitudes. Results: Routine screening for financial distress was reported by 77% of centers, and most used social worker assessments (94%). 56% screened patients throughout the cancer journey. Help with drug costs, meal or gas vouchers and payment plans were offered by 100% of centers. Formal pre-authorization programs and assistance with claims and denials was offered by 81%. Charity care for medical costs was provided by 100% of the large centers compared to only 33% of small centers (p = 0.03). Median number of social workers (24 vs. 3; p = 0.01) and pharmacy representatives (6 vs. 2; p = 0.02) was also different between large and small centers. 76% evaluated the impact of financial advocacy services through number of patients assisted (85%), bad debt and charity write-offs (85%) or patient satisfaction surveys (54%). 6% and 12% reported overall effectiveness of institutional practice for screening and management of financial distress as poor/ very poor respectively. Inadequate staffing and real time resources (69%), limited institutional budget (50%), lack of reimbursement (50%), and clinical time constraints (50%) were reported as potential barriers in provision of these services. 94% agreed about stronger integration of financial advocacy services into oncology practice and 84% felt that success of these services should be a quality metric. 31% of large centers vs. 100% of small centers plan to increase staffing in this area in the next 5 years. Conclusions: Majority of NCCN Member Institutions report screening and management programs for financial distress, though the actual practices and range of services vary widely. Information from this study can help centers benchmark their performance relative to similar cancer programs and identify best practices in this area.

Blahungen sind ein haufiges, fur Betroffene oft ausgesprochen peinliches Phanomen. Zahlreiche Ursachen konnen sich dahinter verbergen. Deren Differenzialdiagnostik wird kurz dargestellt. Dabei findet auch der physiologische gastrointestinale Gashaushalt Berucksichtigung, denn auch ein gesunder Darm enthalt immer eine gewisse Gasmenge.

Functional digestive problems are widespread. Herbs and spices are possibly an option for a positive influence. They contain substances, which are already successfully used in phytotherapy. The overview lists the herbs and spices which can be cultivated in Central Europe, and presumably have a digestive effect. However, the open question remains, to what extent the normal use of these herbs and spices in the kitchen can be expected to have a clinical effect. A certain supportive or preventive effect is quite possible.