bluuebunny/crossref_metadata_2025 huggingface dataset:
Examining the relationships between pain, activities of daily living, and perceptions of overall health in older adults with breast cancer: Results from a brief geriatric screening.
Authors: Arrato Nicole A. , Kimmick Gretchen Genevieve , White Heidi K. , Cohen Harvey Jay , Shelby Rebecca A.
Published: September 2024

273

Background:
Geriatric assessment has been identified as an essential component to caring for patients with cancer who are over 65 years old. Prior research suggests that physical pain and illness perceptions each impact important health behaviors. This retrospective study utilized a brief geriatric screen to examine the relationships between pain levels, activities of daily living (ADLs), and perceptions of overall health for older adults with breast cancer. Implications for methods to improve the patient experience for this population are considered.
Methods:
The Senior Adult Oncology Program (SAOP) screening tool was administered to 429 patients age 65 or older at a breast oncology clinic. A total ADL score was computed by summing patient-reported responses to 13 ADL items, such as ability to dress oneself, feed oneself, and remember to take medications. A higher ADL score indicates greater difficulty with these responsibilities. Pain was assessed using a 10-point scale; scores were dichotomized to form a low-pain group (scores 0-4) and high-pain group (scores 5-10). Overall Health was assessed on a 1-10 scale, with higher scores indicating perceptions of greater health. Demographic and medical information was abstracted from patients’ electronic health records. Independent samples t-tests examined differences between the high-pain and low-pain groups in total ADL score and self-assessed Overall Health.
Results:
The average age of the sample was 76 years old (range = 65-89 years). Approximately half of the sample identified as White (48%); 20% identified as Black. In comparing the high-pain and low-pain groups, the high-pain group reported significantly greater difficulty with ADLs (M score = 3.25, 1.41, respectively; p=.026). Additionally, patients endorsing high pain levels reported significantly worse Overall Health as compared to patients endorsing low levels of pain (M= 7.50, 6.11, respectively; p=.001).
Conclusions:
Older adults with breast cancer experiencing high levels of pain demonstrated greater difficulty with ADLs and worse perceptions of overall health. It is critical that pain is assessed early and often for older adults with breast cancer. Early identification of high pain levels in this population could allow those in need to receive pharmacological and/or behavioral treatments for pain, which may maintain stability or promote improvement in ADLs and perceptions of one’s health. Incorporating brief pain assessments into future geriatric screening tools could improve the process of aging during and after breast cancer.
Navigating financial risk: Unlocking the power of modeling and risk quantification in episode-based payment models.
Authors: Indurlal Puneeth , Altieri Jason , Thomas Hope Ives , Neeb Jessica louise , Staggs Stuart George , Wilfong Lalan S.
Published: September 2024

28

Background:
The Centers for Medicare and Medicaid Innovation’s (CMMI) Enhancing Oncology Model (EOM) is a voluntary value-based care (VBC) model that requires physician group practices (PGPs) to assume financial risk and performance accountability for episodes of care related to seven common cancers. However, PGPs often lack the means to assess the financial impact and risks associated with these alternative payment models. To address this, we employed Monte Carlo Simulations (MCS) to calculate the likelihood of outcomes and associated risks. This information can assist PGPs in making informed decisions about assuming risk and participating in the EOM.
Methods:
Using historical episode files from 2019 to 2022 for 23 PGPs in The US Oncology Network, along with the EOM Price Prediction Model provided by CMMI, we calculated the predicted baseline price and savings per episode. We then determined the average savings for each PGP per time-period and utilized the MCS technique to simulate savings and risk, under each EOM risk arrangement. We shared the simulation results with the PGPs to support their decision-making process and participation.
Results:
Despite having enough episodes per time-period (ranging from 105 to 6100) for the 23 PGPs, the limited number of time-based populations (only 6) based on case mix and patient volume made traditional probability assessments inadequate. To overcome this, we utilized MCS with 5000 simulations per PGP, assuming a normal distribution based on population characteristics. By assessing the savings outcomes of each simulation, we developed probability distributions and confidence intervals to determine the likelihood of generating shared savings, recoupment, or landing in the neutral zone within the EOM. Factors such as episode counts, baseline price, and risk arrangement had the greatest impact on the range of outcomes. We shared the MCS results with all 23 PGPs, highlighting the limitations of the original data and facilitating their decision-making process. Ultimately, 12 PGPs chose to assume risk based on the probability of financial outcomes with the model, and to select the appropriate risk arrangement in the EOM.
Conclusions:
Compared to the status quo measures of central dispersion, MCS yields a wide range of expected financial outcomes per PGP. MCS is a robust technique for quantifying outcome probabilities in VBC models despite low data volumes but relies on the representativeness and quality of the original data. Conducting sensitivity analysis with MCS to assess the impact of individual assumptions or data inputs on outcome probabilities is an area for further exploration.
Decreasing adverse events from concurrent Vinca-alkaloid and azole antifungals in a pediatric oncology population: Patient safety improvement process.
Authors: Mehta Brinda M. , Collins Cassandra , Kumar Prerna , Williams Grant , Lowry Di'Reon , Espejo Kyle
Published: September 2024

297

Background:
Azole-antifungals like posaconazole and voriconazole have a documented significant risk of adverse drug events (ADE) when concomitantly administered with vinca-alkaloid chemotherapy (vincristine, vinblastine, vinorelbine) due to inhibition of vinca clearance. Potential ADE’s include paralytic ileus, severe, potentially permanent neuropathies, cranial nerve dysfunction, seizures, etc. Aim: Assess a standardized process to hold azole-antifungal around vinca-alkaloid drug administration to decrease the risk of adverse events associated with this drug-drug interaction in pediatric oncology patients. Intervention: Azole-antifungals (fluconazole*, voriconazole, posaconazole, itraconazole) will be held the day before, day of, and day after the vinca-alkaloid administration (with flexibility given provider discretion*) in the outpatient and inpatient setting at a single site.
Methods:
Development of a Standard Operating Procedure (SOP), informational technology (IT) processes such as Best Practice Advisory (BPA), nursing orders, Vinca Time-Out order and standard nursing note template for telephone encounter to remind patient/parents. Retrospective data was assessed in three 6-12 month phases, Pre-SOP (Phase 0), Post- SOP and Pre-IT support (Phase 1), and Full implementation (Phase 2). Study Outcomes: 1.Hold the azole-antifungal in 100% of encounters where vinca-alkaloid is due. 2. Decrease number of adverse events by 10%. 3. Maintain adequate fungal prophylaxis (or treatment) with a 0% incidence of breakthrough fungal infections.
Results:
Average number of concomitant azole/vinca administrations for each Phase was 39. A 97% improvement was seen in the number of vinca administrations dose reduced or held from 28 (Phase 0) to 1 (Phase 2). A 66% improvement in SOP compliance was observed (19 % in Phase 0, and 85% in Phase 2). Significant adverse effects were decreased by 33-50% between Phase 0, and Phase 1 and 2, respectively. Three patients in Phase 2 experienced fungal infection breakthrough; all had documented compliance issues prior to the study period.
Conclusions:
Implementation of the SOP and IT processes helped achieve a process to hold azole antifungals and led to significant decrease in the need to dose reduce or hold vinca-alkaloids thereby allowing less chemotherapy interruption/dose adjustments. Further modification of the SOP may be developed to exclude those patients on anti-fungal therapy for an active fungal infection.
Proteasome inhibitors and risk of cardiovascular events in patients with multiple myeloma.
Authors: Sayer Michael F. , Ozaki Aya , Lee Benjamin J. , Naqvi Ali , Mai Karen , Patel Pranav M.
Published: September 2024

300

Background:
Proteasome inhibitors (PI) represent a significant advancement in the treatment of multiple myeloma (MM). While recent studies have stressed the cardiovascular (CV) risk associated with carfilzomib (CARF) use, the risk with ixazomib (IXA) is underreported and no large comparative analysis is available. This study aims to compare CV and dose-limiting toxicities in MM patients treated with CARF and IXA.
Methods:
We conducted a retrospective cohort study analyzing TriNetX electronic medical records, including MM patients age 18 years and older who initiated CARF or IXA between January 1, 2016 to December 31, 2023. Patients with a prior history of heart failure (HF) or arrhythmias were excluded. We evaluated the incidence of new onset of HF and arrhythmia within three months of initiating PIs. Secondary outcomes included the incidence of diarrhea, nausea and vomiting during this period. Propensity score matching (PSM) was performed using 1:1 nearest neighbor matching to balance baseline characteristics. Matching covariates included patients’ demographics (age, sex, race/ethnicity), cardiovascular comorbidities and medications (cardiovascular and chemotherapy). Hazard ratios (HRs) for the outcomes were calculated using Cox proportional hazards models with a significance threshold of p<0.05.
Results:
We identified 950 and 2,872 patients in the IXA- and CARF-treated cohorts, respectively. After PSM, each cohort included 753 patients, with a mean age of 65 years, 52% male and 65% white. Matched populations had no significant differences with respect to matching criteria. The new onset of HF within three months was 2.8% in the IXA group and 5.4% in the CARF group (HR: 0.50, 95% CI: 0.30–0.85, p=0.009). The new onset of arrhythmias was also significantly lower in the IXA group (4.3%) compared to the CARF group (6.6%) (HR:0.63, 95% CI:0.40–0.98, p=0.04). There was no significant difference in the incidence of diarrhea (HR: 0.92, 95% CI: 0.68–1.26, p=0.61), while nausea/vomiting was significantly lower in the IXA group (HR:0.71, 95% CI:0.54–0.93, p=0.013).
Conclusions:
Our study indicates that ixazomib is associated with a significantly lower risk of cardiac side effects compared to carfilzomib in the treatment of MM, with similar gastrointestinal side effects. Enhanced cardiac monitoring may be necessary for patients on carfilzomib. Further research is needed to validate these cardiovascular risk differences.
Evaluation of cardiovascular risk in patients with prostate cancer initiating novel hormonal therapy.
Authors: Sayer Michael F. , Ozaki Aya , Kaakour Dalia , Cho Eunah , Di Tomasso Pamela Maree , Naqvi Ali , Farihi Bahman , Manansala Bjorn D. , Patel Pranav M. , Mar Nataliya
Published: September 2024

301

Background:
Cardiovascular risk factor modification is crucial for cancer patients, particularly for those receiving hormonal therapy due to the increased risk of cardiovascular disease (CVD). However, the evaluation of cardiovascular risk in prostate cancer patients undergoing novel hormonal therapy (NHT) remains not well understood. This study aimed to assess the incidence of cardiovascular events in patients with prostate cancer initiating NHT and compare the risk with non-cancer matched controls.
Methods:
This study is a retrospective cohort analysis that examined electronic medical records from a global federated health research network, TriNetX. The study included male patients with prostate cancer who were 18 years or older and had initiated treatment with abiraterone, enzalutamide, apalutamide, or darolutamide between January 1, 2015, and December 31, 2020. The cohort was stratified based on diabetes mellitus (DM) and prior CVD status. We evaluated the incidence of myocardial infarction (MI) within 1 and 3 years after NHT initiation. MI risk was compared between each strata of cancer patients and propensity score matched non-cancer patients with cox proportional hazards models, with a significance threshold of p<0.05.
Results:
There were 11,536 patients with prostate cancer receiving NHT, having a mean age of 70.4 years and predominately White (70%). Of this cohort, 22% had DM, 23% had CVD, and 62% had neither condition. One- and 3-year incidence of MI was 5% and 7% amongst all patients; those with DM, CVD, or both had higher incidences of MI at 3 years, with the rates of 13%, 18%, 22% respectively. Adjusted analyses showed that prostate cancer patients initiating NHT had significantly higher hazards of MI compared to matched non-cancer controls (HR: 1.57 [95% CI: 1.32-1.86] for DM, 1.31 [95% CI: 1.14-1.50] for CVD, and 1.29 [95% CI: 1.05-1.57] for both DM and CVD).
Conclusions:
The incidence of MI is relatively low in prostate cancer patients starting NHT without DM or CVD comorbidities. However, those patients with pre-existing DM and/or CVD are at significantly higher risk of MI, even more than age matched controls without cancer with those co-morbidities. This highlights the need for comprehensive cardiovascular risk stratification and management in high-risk patients with prostate cancer.
Optimising outcomes for frail patients with oesophagogastric (OG) cancers: The impact of dose reduction and comprehensive geriatric assessment.
Authors: Shi Jiaqi , Evan Theodore , Naseer Humna , Ngan Sarah , Sita-Lumsden Ailsa , Maisey Nick R.
Published: September 2024

303

Background:
Delivery of appropriate management of elderly patients with OG malignancies in the palliative setting remains challenging and unpredictable. Incidence of OG cancers increases markedly with age, and there are growing numbers of elderly, frail and medically complex patients referred to oncology services for treatment. An adaptive approach to their management is required, tailored to their complex medical needs. The GO2 study sought to optimise chemotherapy delivery in this cohort and demonstrated that upfront dose reductions do not reduce progression-free survival in OG cancers. We analysed the treatment and outcome of elderly patients undergoing first-line palliative chemotherapy at our centre, with or without comprehensive geriatric assessment (CGA).
Methods:
We retrospectively analysed the records of patients over the age of 75 treated at our centre between May 2011 and March 2023. Progression-free survival (PFS) was calculated from the date of treatment initiation to date of radiological progression, or 19
th
March 2024 if patients had not progressed. Overall survival (OS) was calculated from treatment initiation to date of death per the electronic health record, or 19
th
March 2024 if patients had not died. Grade 3 (G3) toxicities and dose reductions (DRs) were identified from medical records. Statistical analyses were performed using R v4.3.3.
Results:
82 patients were included in the analysis. Overall median PFS was 6.5 months (1-107 months) and median OS was 10 months (1-107 months). Patients who qualified for chemotherapy with immunotherapy had improved PFS (median 16 months, range 2-27 months) and OS (median 16 months, range 10-27 months). G3 toxicities were increased in patients without upfront DR (44% vs. 30%). The most significant predictor for survival in multivariate analysis was performance status (PS), which was associated with worse PFS (hazard ratio 2.66, range 1.35–5.35, p = 0.004), and OS (hazard ratio 6.13, range 2.79–13.44, p < 0.001). Age was not associated with survival. Consistent with the GO2 trial, there was no association between upfront DR and PFS (p = 0.13) or OS (p = 0.72). 38% of patients underwent CGA as part of their workup for chemotherapy. These patients were more likely to have upfront DR (61% vs. 47%). In this cohort, G3 toxicity rates were comparable in patients with PS 0-1 who underwent CGA (39% vs. 35%). In patients with PS ≥ 2, G3 toxicity rates were higher in those who did not undergo CGA (67% vs. 30%).
Conclusions:
Upfront DR in elderly patients is safe and does not impact survival but does reduce the burden of toxicity. PS, rather than age, is a better predictor of survival and treatment outcome. CGA may help mitigate toxicity burden in patients with poor performance status.
Improving the quality and guideline concordance of multidisciplinary gastric cancer care in a safety net hospital.
Authors: Wabl Chiara A. , Rees Hannah , Alseidi Adnan , Dixit Niharika , Friedlander Terence W. , DeBoer Rebecca Jane
Published: September 2024

314

Background:
Gastric cancer is a leading cause of cancer death worldwide and disproportionally affects people of East Asian and Latin American ethnicities. This study aimed to implement and evaluate an intervention to improve the quality and guideline concordance of multidisciplinary gastric cancer care at a public safety net hospital, Zuckerberg San Francisco General Hospital (ZSFG).
Methods:
A quality improvement (QI) intervention was developed and evaluated by pre-post comparison of clinical data. (1) An in-depth chart review of all patients with gastric adenocarcinoma in 2017-2019 (n=17) evaluated concordance with evidence-based guidelines and quality metrics. (2) Multidisciplinary meetings identified barriers to high quality care and established targets for improvement. (3) A clinical algorithm tailored for ZSFG was disseminated to standardize gastric cancer management. (4) A post-intervention chart review was conducted of all patients from 2021-2022 (n=22). (5) Descriptive statistics and pre-post comparison of QI metrics with Chi square and Kruskal Wallis tests were performed.
Results:
Pre-intervention clinical data and multidisciplinary input identified gaps in care: variation in provider knowledge and practices, rapidly evolving guidelines, limited access to advanced diagnostic modalities, and non-standardized surgical documentation. After implementation of a standardized approach to address these gaps, pre-post improvement was seen in rates of tumor board presentation (36.3% vs. 85.7%,
P=
0.033), use of endoscopic ultrasound (9.09% vs. 64.2%,
P=
0.017), pre-treatment nodal staging (27.2% vs. 78.5%,
P=
0.030), receipt of neoadjuvant chemotherapy (20% vs. 80%,
P=0.007
), documentation of lymphadenectomy type (25% vs. 100%,
P=
0.015), and a trend toward reduced time to PET/CT scan (median, 8.5 weeks pre vs 7.1 weeks post,
P=
0.268).
Conclusions:
A QI intervention was successfully implemented to standardize gastric cancer care at ZSFG. Significant improvements were seen in all targeted metrics except time to outside PET scan. Potential confounders affecting pre-post care quality included personnel changes in a small workforce and the COVID-19 pandemic. Nevertheless, our intervention led to sustained improvements in practice patterns. We aim to replicate this success with other malignancies.

Category
Pre-Intervention
Target
Post-Intervention
P value*

Tumor Board% cM0 cases presented
36% (n=11)

>90%

86% (n=14)
0.033

Endoscopic ultrasound (EUS)% cM0 cases referred for clinical staging
9% (n=11)

>90%

64% (n=14)
0.017

Nodal staging (with EUS or PET)
27% (n=11)

N/A

79% (n=14)
0.030

Receipt of neoadjuvant chemotherapy% eligible patients
20% (n=10)

>80%

80% (n=10)
0.007

Surgery documentationLymphadenectomy type (i.e., D1 or D2)
25% (n=8)

100%

100% (n=7)
0.015

Time from diagnosis to PET/CT (median)
8.5 wks

<5 wks

7.1 wks
0.268

*Chi square test, Kruskal-Wallis test.
Validating a simplified financial toxicity screening tool for patients with cancer.
Authors: Thom Bridgette , Tin Amy L. , Chino Fumiko , Vickers Andrew , Aviki Emeline Mariam
Published: September 2024

318

Background:
Medical-related financial hardship (called financial toxicity) can negatively impact patient clinical outcomes and overall well-being. Routine financial toxicity screening is recommended to facilitate referrals to resources for patients experiencing, or at risk for, financial toxicity. The validated Comprehensive Score for Financial Toxicity (COST) tool is widely used in research to measure financial toxicity; however, its 11-question length and lack of standardized screening threshold make it challenging to implement in clinical practice. This analysis sought to develop and validate an abbreviated version of the tool, suitable for routine screening in clinical practice.
Methods:
The full COST was administered as part of clinical care from June 2022-August 2023. Patients receiving treatment for breast, gynecologic, thoracic, or gastrointestinal cancer at an urban comprehensive cancer center were queried via patient portal or in clinic. Using 38,330 observations, we calculated the correlation of abbreviated tools of varying length with the full COST score (0-44, lower scores=higher FT). We then used a validation dataset of 19,196 observations to assess the positive and negative predictive values (PPV, NPV) of an abbreviated tool against the full COST score, when compared to thresholds for risk previously used in the literature (score ≤15, ≤20).
Results:
Including two questions (Q3: “I worry about the financial problems I will have in the future as a result of my illness or treatment”; Q6: “I am satisfied with my current financial situation”) yielded r=0.922 correlation with the full COST. For this 2-item tool, PPV ranged from 74-91%, and NPV ranged from 91-98% when compared to the full COST tool. Table 1 shows the PPV and NPV of varying score thresholds for the abbreviated COST against full scores ≤15 and ≤20.
Conclusions:
Using a large and clinically diverse sample of patients with cancer,we demonstrate the predictive value of an abbreviated COST tool and show its approximate accuracy when compared to the full tool. Simplified, clinically integratedscreening for financial hardship can efficiently ensure appropriate intervention for patients experiencing medical-related financial hardship and can also be a first step toward mitigating hardship among those at risk for developing it.

Predictive value of 2-item COST vs. full COST score in the validation set.

Full COST score ≤ 15

Yes

No

2-question, COST score ≤ 1

Yes

2337 (14%)
253 (1.5%)
PPV = 90%

No
822 (4.8%)
13844 (80%)
1-NPV = 5.6%

Full COST score ≤ 15

Yes

No

2-question, COST score ≤ 2

Yes

2924 (17%)
1045 (6.1%)
PPV = 74%

No
235 (1.4%)
13052 (76%)
1-NPV = 1.8%

Full COST score ≤ 20

Yes

No

2-question, COST score ≤ 2

Yes

3626 (21%)
343 (2.0%)
PPV = 91%

No
1199 (6.9%)
12088 (70%)
1-NPV = 9.0%

Full COST score ≤ 20

Yes

No

2-question, COST score ≤ 3

Yes

4359 (25%)
1272 (7.4%)
PPV = 77%

No
466 (2.7%)
11159 (65%)
1-NPV = 4.0%
General versus disease-specific medical oncology consults and impact on inpatient quality of care.
Authors: Prsic Elizabeth Horn , Deshpande Hari Anant , Wei Wei , Strait Michael , Chiang Anne C.
Published: September 2024

321

Background:
Hospitalization is a time of crisis for patients and caregivers. Subspeciality oncologists may bring more timely, effective support compared to a general oncologists. Attendings, fellows and advance practice providers (APPs) may benefit from focused expertise for consultative care and education.
Methods:
Subspeciality oncology consults launched July 2023, with consults staffed by 4 oncologists from: 1) breast 2) head and neck/thoracic 3) gastrointestinal and 4) genitourinary/melanoma. Previously, 3 oncologists staffed all patients, regardless of primary malignancy. Throughout the study period, oncologists were supported by at least 1 fellow or 1 APP. Using Epic and Tableau, we collected LOS, time to consult (TTC), ICU rate, hospice referral rate, 30-day readmission, 30-day emergency department (ED) visit data. Using Qualtrics, we collected fellow, attending, and APP satisfaction feedback pre- and post-intervention. Data was analyzed using R-4.40. Oncologists, fellows, and APPs completed Qualtrics surveys pre- and post-intervention regarding their experience.
Results:
Subspeciality oncology consults were associated with a significant decrease in LOS, TTC, and ICU rate. Median LOS decreased by 2.0 days (P<0.001), with median TTC decreasing by 1.0 hour (P=0.003). ICU rate decreased from 27.5% to 16.4% (P<0.001). There was no difference in hospice referrals or 30-day ED visits. A significant increase in 30-day readmission during post-intervention was observed (Table). Oncologists reported a high level of satisfaction with the program. Oncologist, fellow, and APP overall experience and educational rankings increased after the introduction of subspeciality consults. Inpatient productivity measured by wRVU increased by 30% following the intervention, without associated changes to outpatient productivity.
Conclusions:
Transition to a subspeciality oncology consult model improved inpatient quality of care, as well as clinician experience. Additionally, inpatient productivity increased without decrease in outpatient metrics. Subspeciality medical oncology consultation can improve inpatient quality of care, education, clinician satisfaction and productivity.

Subspeciality oncology consult outcomes.

General Consults (Baseline)*
Subspeciality Consults (Intervention)
P-value

Median TTC (Hours)
4.0 (1.5-6.0)**
3.0 (0-5.0)**
P=0.003

Median LOS (Days)
7.0 (4.0-13.0)**
5.0 (3.0-10.0)**
P<0.001

ICU Rate
148 (27.5%)
161 (16.4%)
P<0.001

Hospice Referral Rate
56 (10.4%)
95 (9.7%)
0.655

30-Day Readmission Rate
136 (25.3%)
301 (30.7%)
0.028

30-Day ED Rate
157 (29.2%)
315 (32.1%)
0.247

*Baseline data reflects outcomes for general oncology consult staffing, prior to initiation of subspeciality consult model (pre-intervention).

**Interquartile Range (IQR).
Improving flu vaccination rates among adult patients with cancer at Kaiser Permanente.
Authors: Lee Michael Jisoo , Laurent Cecile , Roh Janise M. , Kushi Lawrence H. , Liu Raymond , Hill Kristy , Sheehan Tammy Rene , Wang Stephen E. , Srivastava Piyush , Law Lisa Y.
Published: September 2024

326

Background:
Vaccines protect cancer patients from developing severe illness, hospitalization, and death. At Kaiser Permanente (KP) South Sacramento Medical Center (KPSSC), oncology patients on active chemotherapy had an overall flu vaccination rate of 13% between September 1, 2022, and December 1, 2022. Our aim was to increase this rate to 33% during the 2023 flu season.
Methods:
In conjunction with the ASCO Quality Training Program, we applied quality improvement initiatives to improve flu vaccination. Our population of interest included adult cancer patients on active chemotherapy at KPSCC. We evaluated the barriers to vaccination assessment by distributing surveys to infusion nurses. We performed three Plan-Do-Study-Act (PDSA) cycles for quality improvement and monitored flu vaccination rates. Cycle 1 (9/11/2023 to 11/5/2023): We distributed the ASCO flu vaccine handout at oncology clinic. We had medical assistants and infusion nurses administer flu vaccines during clinic visits and chemotherapy sessions. Cycle 2 (11/6/2023 to 11/21/2023): We added the vaccine handout in Chinese and Spanish and updated our receptionists’ script to strongly encourage patients to receive flu vaccine. Cycle 3 (11/22/2023 to 12/6/2023): KP flu clinic set up an onsite flu vaccine cart one half day per week in the oncology clinic.
Results:
Barriers to vaccination assessment in the clinic included lack of time (60%), difficulty remembering to ask (10%), and non-influenza season (10%). Our interventions resulted in an increased flu vaccination rate from 13% in 2022 to 36% in 2023. During cycle 1, 298 out of 615 patients received their vaccine (48.5%). During cycle 2, 16 out of 118 patients received their vaccine (13.6%). PDSA cycle 3 resulted in 14 out of 178 patients receiving their vaccine (7.9%).
Conclusions:
Promoting vaccine awareness via active engagement with nurses and medical assistants early on and having onsite vaccine availability in the oncology clinic were keys to improve the overall flu vaccination rate. While most vaccines were administered at the beginning of flu season, the addition of language-tailored vaccine handouts and having an onsite vaccine cart towards the end of the season did result in late season vaccinations. Our findings do support the importance of providing timely vaccine information in the oncology clinic. Our future goal is to expand these efforts to other KP Northern California oncology centers to establish stable onsite vaccine availability in clinics and include additional vaccine types.
Exploring healthcare workers' barriers to effective cancer pain management at a comprehensive cancer center.
Authors: AlZamel Osama N. , Sewaralthahab Sarah , AlHaidary Abdulelah , Alghamdi Mohammed Abdullah
Published: September 2024

329

Background:
Cancer-related pain remains a paramount concern for patients, families, and healthcare providers, significantly impacting quality of life. Numerous barriers often impede optimal pain management strategies, posing challenges to effective care delivery.
Methods:
This study employed a non-experimental, descriptive, cross-sectional approach within the setting of King Khalid University Hospital (KKUH), a tertiary care facility with a 1100-bed capacity, renowned for its comprehensive cancer care services. A sample of 200 healthcare workers (137 nurses, 68 physicians) working in the oncology center at KKUH participated in the study. Data were collected using the revised Barriers Questionnaire-II (BQ-II). Statistical analysis was performed using SPSS software (version 21), employing descriptive statistics and the unpaired t-test to explore differences in participant categories.
Results:
Healthcare providers expressed substantial barriers to cancer pain management, reflected in a mean questionnaire score of 2.5 (standard deviation [SD] = 0.8). Particularly noteworthy were the high mean scores for the harmful and physiological effects of medications subscales, at 2.7 (SD = 1.1) and 2.6 (SD = 0.9), respectively. Nurses and physicians had overall BQII scores of 1.8 (SD = 1.1) and 1.7 (SD = 0.9), respectively. A one-way analysis of variance indicated significant differences in the overall BQII scores among physicians and nurses, F(2, 182) = 6.81, p < .01. Significant differences were also found in the communication (F(2, 182) = 10.55, p < .01) and harmful effects (F(2, 182) = 7.26, p < .01) subscales among the two groups.
Conclusions:
There are significant perceived barriers to cancer pain management among healthcare providers in general with a notable difference between physicians and nurses. These findings suggest the need for improved education and communication to address concerns about medication effects and enhance pain management strategies. Tailored interventions that would lead to more effective and empathetic care have been initiated.
Adherence to pretreatment hepatitis B virus (HBV) screening in patients with cancer after implementation of built-in order set.
Authors: Cui Zhu Jenny , Julian Alexander , Schwartz Jake , Bopp Emily , Mico Vasil , Gordon Fredric , Schlam Ilana
Published: September 2024

330

Background:
Patients with a history of HBV exposure are at risk of reactivation when receiving treatments that affect the immune system, such as cancer-directed therapies. ASCO guidelines recommend universal HBV screening prior to initiation of cancer-directed therapies to prevent hepatic dysfunction and delays in cancer care. However, significant variation remains in clinical practice. Improving HBV screening is of special interest at our institution, given that we serve a large proportion of Asian immigrants at high risk of prior HBV exposure. With our institution’s transition to EPIC on Apr 1, 2022, the HBV serology order set was incorporated into the pre-treatment checklist of every cancer therapy plan. We studied the rates of HBV screening before and after implementing this change.
Methods:
We identified patients with cancer starting systemic cancer treatment at our institution between Oct 1, 2021 – Mar 31, 2022 (pre-EPIC period), and Oct 1, 2023 – Mar 31, 2023 (post-EPIC period). Patients who received only endocrine therapy, transferred care, or lost to follow-up prior to treatment initiation were excluded. To select a random sample from each time-period of interest, patients were assigned a random number, sorted based on this random number, and then reviewed in order. All data was collected retrospectively by manual chart review.
Results:
We randomly selected and reviewed 69 patients from pre-EPIC period, and 75 from post-EPIC period. Their demographic, disease, and treatment characteristics are summarized in the table. HBV screening rates were 42% and 80% in the pre-and post-EPIC periods, respectively (p<0.001). Twenty-one (14.6%) patients screened positive for HBV core antibody, among whom six (5.1%) had negative surface antibodies.
Conclusions:
The built-in HBV serology order set significantly improved rates of hepatitis B screening prior to starting systemic cancer-directed treatment. It is a low-cost and highly effective intervention. Our next steps are to determine how a higher adherence to HBV screening guidelines impacted the management of patients with prior HBV exposure.

Pre-EPIC:Oct 1, 2021 - Mar 31, 2022 (N=69)
Post-EPIC: Oct 1, 2022 – Mar 31, 2023 (N=75)
P values

Age at diagnosis (years), mean (SD)
62.1 (1.4)
65.2 (1.6)
0.15

Female (%)
40 (58.0)
35 (46.7)
0.18

Race (%):

0.051

White
51 (73.9)
49 (65.3)

Asian
8 (11.6)
20 (26.7)

Other
10 (14.5)
6 (8.0)

Cancer type (%):

0.39

Hematological Malignancies
19 (27.5)
16 (21.3)

Solid Tumor
50 (72.7)
59 (78.7)

Metastatic Disease (%)
24 (34.8)
25 (33.3)
0.95

Treatment Type (%):

0.13

CD20 mAb+/- other
3 (4.4)
9 (12.0)

Chemotherapy+/-other
52 (75.4)
57 (76.0)

Other
14 (20.3)
9 (12.0)

mAb: monoclonal antibody.
Optimizing infusion experience for patients in GI oncology at Hartford Hospital Cancer Institute.
Authors: Nadkarni Rajani P. , Patel Rajvi , Dunn Sabra , Pindar Shannon , Brennan Kelly , Stallings Holley
Published: September 2024

331

Background:
Cancer Treatments have become increasingly complex and the volume of patients requiring infusion treatments have increased in the outpatient setting. As a part of our Clinical Care Redesign Quality Initiative, the Hartford Healthcare Team identified that our GI Oncology patients receiving chemotherapy at the Hartford Hospital Infusion Center were experiencing a mean wait time of 81 minutes from the start of check-in to the start of their first medication, resulting in patient and staff dissatisfaction and inefficient use of resources. Our objective was to reduce the mean wait time to less than 60 minutes from the start of check-in to the start of the first medication by December 2023, which in turn would improve patient and staff satisfaction.
Methods:
By process mapping, creation of a fishbone diagram, and multi-voting, we demonstrated that waiting for laboratory results for patients who had provider and chemotherapy visits on the same day was a large contributor to long wait times. We implemented an Advanced Preparation Process that included Unlinking infusion visits from Provider visits and obtaining patient labs prior to chemotherapy treatment day to achieve the goal.
Results:
By Unlinking visits beginning mid-October 2023, we were able to decrease the mean wait time from 81 minutes to an average of 53 minutes, reflecting a 54% reduction in wait time. This allowed Pharmacy and Infusion Nurses additional time to review orders and complete safety checks and spend more time with patients at the chairside. An estimated amount of 12.6 hours of chair time was made available per week, representing a potential revenue increase of $188,021 annually. Most patients appreciated the decrease in wait time even if it meant coming in two separate days.
Conclusions:
The project aim of reducing wait times for GI Oncology patients was achieved. A reduction in time to first drug for other patients receiving chemotherapy during our pilot period was also noted, which we attributed to Hawthorne effect. Patient and staff satisfaction were improved. Our next steps will include continuing to optimizing the process.
Improving distress screening in radiation oncology consultation.
Authors: Chen William Chun-Ying , Somerstein Gayle , Potters Louis
Published: September 2024

332

Background:
Receiving a cancer diagnosis and awaiting initial management recommendations is a stressful time. Distress should be recognized, documented, and treated promptly as part of quality oncologic care. The NCCN Distress Thermometer (DT) is a useful tool for patients to quantify their level of distress. This pilot study assesses the rate of distress screening at a high-volume academic healthcare network, before and after institutional quality improvement (QI) intervention.
Methods:
All patients seen for Radiation Medicine between 1/1/22 - 12/31/23 were reviewed. Rates of DT documentation at the time of consultation were assessed as the QI metric. Patients seen in 2022 served as a baseline of departmental compliance. The importance of distress assessment was formally introduced to physicians and advanced care practitioners (ACPs) in Q4 2022 during monthly departmental quality reports, with notice that a formal QI metric would be monitored beginning 1/1/23. Chi-square test was used to compare rates of DT documentation. Monthly departmental DT documentation rates were back presented to the physicians and ACPs during quality meetings.
Results:
9391 patients were seen for radiation oncology consultation (2022 = 4311; 2023 = 5080). Baseline DT documentation was 51.0%. Initial compliance with the metric was below baseline, at 41.4% for Jan 2023. With continued feedback, education, and goal-setting, rates of DT use continually improved over Q1/Q2 2023 and remained relatively steady through the remainder of Q3/Q4 2023, reaching a monthly high of 89.8%. Overall DT documentation significantly improved for 2023 was 81.4% (χ
2
= 977.9, p < 0.0001). The rates of DT documentation were relatively consistent based on diagnoses codes, though lower amongst consults seen for metastatic disease (84.0% vs 73.4%, χ
2
= 24.28, p < 0.0001).
Conclusions:
Screening rates at consultation are modifiable and maintainable, but distress management remains a continuous quality improvement project as we explore services to address identified stressors and reassess distress levels at future visits.
Improved access to genetics for individuals with potential germline mutations identified on somatic testing.
Authors: Manderski Elizabeth , Monahan Rachel , Sigireddi Meenakshi , Nelson Rachel , Aviki Emeline Mariam
Published: September 2024

339

Background:
Somatic testing is increasingly common in treating cancer and may identify mutations that necessitate confirmatory germline genetic testing. Management of these results varies by institution. From 2021-2024, we completed an iterative approach to determine the most effective method for follow-up germline testing.
Methods:
We conducted 3 six-month sequential phases to determine the most effective approach to follow up on somatic findings concerning for germline origin. Phase I (3-9/2021), consisted of weekly e-mail notifications sent by the genetics program to the referring provider regarding patients who had somatic mutations of potential germline origin, and recommended providers refer the patient to genetics. Phase 2 (10/2021-4/2022), consisted of monthly e-mail notifications to the referring provider, clinical staff and included cancer center leadership. In phase 3 (10/2023-4/2024), GC assistants and medical secretaries facilitated referrals and direct outreach to schedule patients for germline follow-up. We measured the percentage of patients referred to genetics, who completed germline testing, and had confirmed pathogenic germline mutations.
Results:
In Phase I, 38% of patients were referred to genetics, 23.5% completed germline testing, and 37% had positive results (Table 1). In Phase 2, 19% of patients were referred to genetics, 4.7% completed germline testing, and 43% had positive results. In Phase 3, using the GC facilitated approach, 87.5% (70/80) of patients were referred. Those not referred had already undergone germline testing, were deceased or transferred care out of state. Of the 70 patients, 38 met with a GC and 30 elected to proceed with germline testing. There are 25 (36%) genetic test results available to date. 37% (26/70) patients did not complete a genetics appointment. 58% (15/26) could not be reached to schedule an appointment. Nine individuals declined or deferred an appointment. Five patients were deceased before a genetics appointment could be coordinated. For those that received referrals to genetics in phase 3, the germline positive results rate was 92% (23/25).
Conclusions:
The GC driven referral pathway was most effective at facilitating referral and completion of confirmatory testing for patients with somatic findings concerning for germline origin. Follow-up of these results shows an extremely high rate of germline positive results, making subsequent testing imperative for centers treating cancer patients. Given implications for cascade testing, future research is needed to study upfront consenting approaches to automate subsequent germline testing and notification in this population.

Phase
Intervention

Potential Germline
n,
(%)

Referred
n
, (%)

Completed
n
, (%)

Germline Positive
n
, (%)

1
Weekly Emails
162
62 (38%)
38 (61%)
14 (37%)

2
Monthly Emails
150
28 (19%)
7 (25%)
3 (43%)

3
GC Driven Referrals
80
70 (87.5%)
25 (36%)
23 (92%)
A comparative analysis of patients with breast cancer with and without language barriers.
Authors: Schiaffino Melody Karen , Rash Dominique , Fernandez Alicia
Published: September 2024

340

Background:
About 20% of Americans speak a language other than English at home, among these over one-third experience language barriers when interacting in English. These populations face additional barriers, which can lead to adverse outcomes in the case of a cancer diagnosis. Diverse older adults are at highest risk for sub-optimal care and toxicity from cancer therapies due to the intensity of treatment, their age, comorbidities, in addition to the burden of historic inequities they experience due to sub-optimal communication and insufficient communication of risk.
Methods:
This retrospective observational study explores the role of language barriers on patient characteristics among patients diagnosed with advanced left-side breast cancer (LSBC). LSBC requires radiotherapy which can pose a risk for cardiotoxicity. Electronic medical records for N=1795 patients were extracted at a tertiary cancer center; analyses were conducted on a secure virtual research desktop using SAS 9.4. This study was IRB approved.
Results:
Overall, most patients were female (99.5%) and NH White, with a large proportion of Latine patients 17.8%. Most were married or had a partner (49.6%) and were on Medicare (43.2%) or private insurance (34.7%), very few were on Medicaid (5.0%). 9.7% reported a disability that left them unable to work and 13.3% of patients requested an interpreter at their last encounter. Nearly 9% of patients reported a history of heart disease. When we compared patients by those that did and did not request an interpreter as a proxy for limited English proficiency (LEP), we found that patients who were reported Spanish as their preferred language (84.8%, p<.0001) were more likely to be request an interpreter. This group was followed closely by speakers from languages spoken in the Middle East and N. Africa (MENA) region (80.5%, p<.0001). Conversely, we observed patients on Medicaid to be more likely to request an interpreter vs other payer types (39.3%, p<.0001), finally we found significantly fewer patients with a history of heart disease experiencing language barriers.
Conclusions:
Our assessment demonstrates language barriers remain a significant barrier for Spanish and MENA-region breast cancer patients. Patients with language barriers may have different risk factors and unique needs that require further study. Thus, improved outcomes can be encouraged with tailored management and support for communication barriers.
Association of frailty with annual healthcare expenditures of older adults during cancer survivorship.
Authors: Qin Xuanzi , Paris Max Brasher , Zelaya Carina , Schoenborn Nancy Li , MANDELBlatt Jeanne S.
Published: September 2024

352

Background:
Frailty contributes to healthcare expenditures. Cancer and its therapies can further increase or accelerate the rate of frailty. Addressing geriatric deficits contributing to frailty of older cancer survivors (ages 65+) could potentially reduce health expenditures. However, little is known about how frailty affects health expenditures during the continuing survivorship period, a period after initial treatment but before the end-of-life. Given that older adults with cancer can live for years, it is important to examine health expenditures during this period by levels of frailty.
Methods:
We used the 2-year longitudinal panels of the Medical Expenditure Panel Survey, a nationally representative survey, to identify cancer survivors who are likely in the continuing survivorship period. We created 5 cohorts who were surveyed in 2016, 2017, 2019, 2020, and 2021, and in the previous year. In each cohort, we selected older individuals with an invasive cancer diagnosis in both previous and current years who did not die in the current year. We pooled the cohorts to estimate annual healthcare expenditures, representing a cancer population of 11,802,386 in the US (n=2,206). We constructed a deficit accumulation frailty index using survey items and divided patients into 3 categories: robust, pre-frail, and frail. We used generalized linear regression to estimate the associations of frailty with annual healthcare expenditures during the continuing survivorship period for older adults, controlling for age, sex, race/ethnicity, marital status, immigration background, insurance coverage, family size, family income, and education. Costs were inflated to 2023 US dollars.
Results:
The per person annual healthcare expenditure among older adult survivors of all cancer types was $13499.13, $24698.77, and $34352.23 for those who were robust (75.2%), pre-frail (12.0%), and frail (12.8%), respectively, and being pre-frail and frail was associated with higher expenditures (P<0.001). In analyses by cancer type, being frail (vs. robust) was associated with higher expenditures for bladder (P<0.05), breast (P<0.01), cervical (P<0.01), and prostate (P<0.01) cancers. Pre-frail breast cancer patients also incurred more costs than those who were robust (P<0.01).
Conclusions:
Increased frailty was associated with higher annual healthcare expenditures among older cancer survivors during the continuing survivorship period. Addressing geriatric deficits and intervening to maintain function and prevent frailty progression during survivorship care could improve quality of life and reduce healthcare expenditures.