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      Personalising clinical pathways in a London breast cancer service

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          Abstract

          Using interview and observational data from a busy and research‐intensive breast cancer service in the United Kingdom, we discuss recent developments in personalised medicine. Specifically, we show how clinical and research practices meet in clinical pathways that are reconfigured in response to changing approaches of diagnosing, monitoring, treating and understanding cancers. Clinical pathways are increasingly sensitive to changes in evidence deduced through new technologies and therapies as well as decisions based on intensive, iterative analysis of data collected across a range of platforms. We contribute to existing research by showing how the organisation of clinical pathways both maintains established clinical practices and responds to new research evidence, managing a threshold between evidence‐based and experimental medicine. Finally, we invite comparisons with other forms of personalisation to understand how they depend on the ‘real time’ collection, analysis and application of data.

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          Personalized Detection of Circulating Tumor DNA Antedates Breast Cancer Metastatic Recurrence

          Purpose: Up to 30% of patients with breast cancer relapse after primary treatment. There are no sensitive and reliable tests to monitor these patients and detect distant metastases before overt recurrence. Here, we demonstrate the use of personalized circulating tumor DNA (ctDNA) profiling for detection of recurrence in breast cancer. Experimental Design: Forty-nine primary patients with breast cancer were recruited following surgery and adjuvant therapy. Plasma samples (n = 208) were collected every 6 months for up to 4 years. Personalized assays targeting 16 variants selected from primary tumor whole-exome data were tested in serial plasma for the presence of ctDNA by ultradeep sequencing (average >100,000X). Results: Plasma ctDNA was detected ahead of clinical or radiologic relapse in 16 of the 18 relapsed patients (sensitivity of 89%); metastatic relapse was predicted with a lead time of up to 2 years (median, 8.9 months; range, 0.5–24.0 months). None of the 31 nonrelapsing patients were ctDNA-positive at any time point across 156 plasma samples (specificity of 100%). Of the two relapsed patients who were not detected in the study, the first had only a local recurrence, whereas the second patient had bone recurrence and had completed chemotherapy just 13 days prior to blood sampling. Conclusions: This study demonstrates that patient-specific ctDNA analysis can be a sensitive and specific approach for disease surveillance for patients with breast cancer. More importantly, earlier detection of up to 2 years provides a possible window for therapeutic intervention.
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            Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs.

            Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US\(favouring usual care to WMD -4919 US\) favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.
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              The care pathway: concepts and theories: an introduction

              This article addresses first the definition of a (care) pathway, and then follows a description of theories since the 1950s. It ends with a discussion of theoretical advantages and disadvantages of care pathways for patients and professionals. The objective of this paper is to provide a theoretical base for empirical studies on care pathways. The knowledge for this chapter is based on several books on pathways, which we found by searching in the digital encyclopedia Wikipedia. Although this is not usual in scientific publications, this method was used because books are not searchable by databases as Pubmed. From 2005, we performed a literature search on Pubmed and other literature databases, and with the keywords integrated care pathway, clinical pathway, critical pathway, theory, research, and evaluation. One of the inspirational sources was the website of the European Pathway Association (EPA) and its journal International Journal of Care Pathways. The authors visited several sites for this paper. These are mentioned as illustration of a concept or theory. Most of them have English websites with more information. The URLs of these websites are not mentioned in this paper as a reference, because the content of them changes fast, sometimes every day.
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                Author and article information

                Contributors
                w.viney@gold.ac.uk
                Journal
                Sociol Health Illn
                Sociol Health Illn
                10.1111/(ISSN)1467-9566
                SHIL
                Sociology of Health & Illness
                John Wiley and Sons Inc. (Hoboken )
                0141-9889
                1467-9566
                10 February 2022
                March 2022
                : 44
                : 3 ( doiID: 10.1111/shil.v44.3 )
                : 624-640
                Affiliations
                [ 1 ] Department of Anthropology Goldsmiths, University of London London UK
                [ 2 ] ringgold 4615; Patient Experience Research Centre School of Public Health Imperial College London London UK
                [ 3 ] Cancer Research UK Imperial Centre Faculty of Medicine, Imperial College London London UK
                [ 4 ] Breast Cancer Translational Research Imperial College London London UK
                [ 5 ] ringgold 129367; Breast Cancer Services Charing Cross Hospital London UK
                Author notes
                [*] [* ] Correspondence

                William Viney, Department of Anthropology, Goldsmiths, University of London, London, SE14 6NW, UK.

                Email: w.viney@ 123456gold.ac.uk

                Author information
                https://orcid.org/0000-0003-1693-7191
                https://orcid.org/0000-0002-9822-9094
                https://orcid.org/0000-0003-4477-4940
                https://orcid.org/0000-0001-8238-5036
                Article
                SHIL13441
                10.1111/1467-9566.13441
                9303177
                35143700
                718e2d38-670f-4d8e-89c6-25907deb1117
                © 2022 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for SHIL (SHIL).

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                History
                : 17 May 2021
                : 16 January 2022
                Page count
                Figures: 0, Tables: 0, Pages: 0, Words: 9314
                Funding
                Funded by: National Institute for Health Research , doi 10.13039/501100000272;
                Funded by: Wellcome Trust , doi 10.13039/100004440;
                Award ID: 205456/Z/16/Z
                Categories
                Original Article
                Original Articles
                Custom metadata
                2.0
                March 2022
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.1.7 mode:remove_FC converted:21.07.2022

                Sociology
                breast cancer,clinical pathways,personalisation,personalised medicine,translational research

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