bluuebunny/crossref_metadata_2025 huggingface dataset:
Financial conflicts of interest among the National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline (CPG) Panelists in 2019.
Authors: Desai Aakash , Chengappa Madhuri , Go Ronald S. , Poonacha Thejaswi
Published: October 2019

15

Background: CPG are evidence-based guidelines, which serve as a standard of care in practice, quality improvement, and reimbursement. The extent of financial conflicts of Interest (FCOI) in NCCN guidelines has not been recently evaluated. Our study evaluated the extent of FCOI in the NCCN CPG among the 10 most common malignancies in the US. Methods: We examined the latest 2019 version of the NCCN CPG for the 10 most common cancers by incidence in the US. Using disclosure lists, we catalogued the FCOIs for the panelists under various categories outlined in the CPG. We also tabulated the companies/institutions involved in each disclosure. An “episode” describes 1 instance of participation of a panelist in 1 company in 1 category of each guideline. “Affiliation” describes a commercial, industry, or institute affiliation reported by a panelist in each episode. Results: Of the 491 panelists on the CPG, 483 (98.3%) completed FCOI disclosures. 224 (46.38%) reported at least 1 FCOI. A total of 1,103 episodes were disclosed with an average of 4.9 episodes per panelist with FCOI. Being a part of scientific advisory boards, consultant, or expert witness was the most common FCOI category (19.9%). A total of 191 companies were associated with 1,103 episodes of FCOI. The top companies were Bristol Myers Squibb, Merck, Genentech and AstraZeneca. Among the top 10 cancers, the prevalence of FCOI were lung (56%), bladder (52%), pancreatic (52%), non-Hodgkin lymphoma (50%), kidney (49%), colorectal (43%), breast (42%), melanoma (40%), prostate (38%), and uterine (32%). Among the panelists with FCOI, 26%, 17%, and 57% reported 1, 2, and > 3 episodes, respectively. There were 127 episodes among the CPG chairs/vice chairs who reported FCOI (mean 6.4). The chairs/vice chairs of uterine, pancreatic, melanoma, and prostate cancer CPG did not have any FCOI. Conclusions: FCOI are very prevalent among the top 10 NCCN CPG panelists. In almost half of the CPG, the majority of the panelists had at least 1 FCOI. Over half of the CPG chairs/vice chairs reported multiple FCOI. Further studies are necessary to determine the impact of these FCOI.
Employer provided health benefits among cancer survivors in the United States.
Authors: Zheng Zhiyuan , Han Xuesong , Banegas Matthew P. , Zhao Jingxuan , Rai Ashish , Tucker-Seeley Reginald , Jemal Ahmedin , Yabroff K Robin
Published: October 2019

155

Background: Nearly 40% of cancer survivors are of working age in the U.S. Access to high quality diagnosis, treatment, and survivorship care requires both health insurance coverage and sick leave, key components of employer health benefits. This study examines work limitations, paid sick leave, and employer offered health insurance among cancer survivors. Methods: We used the National Health Interview Survey (2001-2017) to identify cancer survivors aged 18-64 years. Work limitations were asked among all cancer survivors regardless of work status (n = 15,247), and categorized into unable to work, limited in type/amount of work, and not limited at all. Paid sick leave and employer offered health insurance offered were asked of cancer survivors who were working in the last week (n = 8741). We used generalized ordinal logistic regressions to examine work limitation and employer health benefits among cancer survivors, controlling for demographic characteristics, time since cancer diagnosis, number of cancer diagnoses, income, and comorbidities. Stratified analyses by type of workplace (private sector, federal/state/local government, and self-employed), and hours worked per week (full time with 35+ hours per week vs part time < 35 hours per week) was conducted. Results: Among cancer survivors aged 18-64 years, 10.7% and 5.3% reported unable to work at all and limited in types/amounts of work, respectively; 57.7% and 67.6% of those working in the last week received paid sick leave and employer offered health insurance, respectively. In stratified analyses, government jobs were associated with the highest paid sick leave and employer insurance (85.7% and 85.6%, respectively), followed by private sector (58.3% and 70.7%, respectively), and self-employed (8.3% and 15.7%), respectively. Moreover, full time jobs had higher paid sick leave (65.2% and 21.9%, respectively) and employer insurance (75.7% and 29.1%, respectively) then part time jobs. Conclusions: Cancer survivors experience work limitations and many working cancer survivors do not receive paid sick leave or health insurance from their employers. Evaluation of the effects of employer-based health benefits on survivorship care and outcomes will be important for future research.
Building international partnerships to improve global oncological care: Perspective from Rutgers-CINJ Global Oncology Fellowship Program.
Authors: Chandar Ashwin , Kaur Sukhdeep , Ralefala Tlotlo Bathethi , Toppmeyer Deborah , Philipp Claire , Marlink Richard , Antony Reena , DiGiacobbe Marilyn , Lebelonyane Refeletswe , Gaolathe Tendani , Mayer Tina M.
Published: October 2019

159

Background: With cancer accounting for 1 in every 7 deaths worldwide and 60-70% of cancer deaths occurring in low- and middle-income countries, any advancement in cancer care should include understanding to alleviate structural inequalities that produce these global oncological disparities. Rutgers-Cancer Institute of New Jersey (R-CINJ) Oncology Fellowship program, through partnerships with Rutgers Global Health and University of Botswana (UB), established a global oncology program in 2018 to provide young oncologists in training with this educational opportunity. Aims included understanding challenges faced by cancer patients in Botswana, evaluating opportunities to improve oncology care at Princess Marina Hospital (PMH), scholarly collaborations, and exchange knowledge. Methods: In partnership with PMH, UB, and Ministry of Health and Wellness (MOHW), R-CINJ created a global oncology program consisting of a 1 month rotation at PMH in Gaborone, Botswana, as well as longitudinal research/quality improvement (QI) projects. Two 3rd year oncology fellows rotated with house officers and oncologist at PMH. Weekly video conferences facilitated communication during the elective. Projects continued throughout 3rd year of fellowship, in conjunction with programmatic meetings. Results: Fellows gained exposure to cancer care using limited resources. In working with PMH staff, mentorship was provided, QI ideas were shared, and organizational changes were implemented. Scholarly activity was undertaken to examine trends in chemotherapy utilization at PMH over a 12-month period to assess patterns of malignancy and issues with stock outs. Relationship between pathology at PMH, UB, and Rutgers-CINJ and Rutgers Biomedical Engineering was established to expand digital pathology services in Botswana. Conclusions: Our global oncology program is a successful start to an ongoing partnership to help improve cancer care in Botswana. Future directions include development of cancer protocols in Botswana, helping limit medication shortages, and establishing telemedicine based collaboration to assist with diagnosis and improve pathology turnaround time.
Disparities in receipt of guideline concordant treatment for early-stage non-small cell lung cancer (NSCLC) patients in California.
Authors: Obrochta Chelsea A , Murphy James Don , Nara Atsushi , Thompson Caroline A.
Published: October 2019

160

Background: Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the U.S. In 2013, the U.S. Preventive Services Task Force began recommending lung cancer screening, which has resulted in earlier stage diagnosis for many tobacco users. The National Comprehensive Cancer Network (NCCN) provides evidence-based cancer treatment recommendations. Evidence suggests that a patient’s receipt of guideline-concordant treatment (GCT) increases survival, especially for screen-detected, earlier stage cancers. The objective of this study is to describe nonadherence to GCT and treatment delay in California NSCLC patients by sociodemographic characteristics and geography. Methods: 53,746 patients diagnosed with stage I/II NSCLC (2000-2015) in the California Cancer Registry were included in our study. We classified GCT according to NCCN guidelines and treatment delay as >60 days after diagnosis. We report proportion of nonadherence to GCT and treatment delay overall, in 5-year periods and by patient race/ethnicity, socioeconomic status, payer, and marital status. Hotspot analysis is underway to identify regions at increased risk for nonadherence to GCT and treatment delay by patient residential census tract. Results: Overall, 55.9% of patients received GCT, 14.1% of patients received no treatment, and nonadherence to GCT increased over time. Among those who received treatment, 26.7% experienced a treatment delay. Nonadherence to GCT and delay was more frequent in patients who were black or Hispanic, unmarried, had public insurance, and were of lower socioeconomic status. Based on preliminary analyses, we expect nonadherence to GCT and treatment delay to be non-uniformly distributed across California neighborhoods. Conclusions: Nonadherence to GCT and treatment delay disproportionately affect priority populations. With rising numbers of early stage lung cancers due to screening smokers, administration of timely proper treatment of lung cancer is critical.
Comparing nonconscious nonverbal synchrony in racially concordant and racially discordant oncology interactions.
Authors: Hamel Lauren M. , Moulder Robert , Eggly Susan , Albrecht Terrance Lynn , Boker Steven , Dougherty David W. , Penner Louis
Published: October 2019

169

Background: Communication in racially discordant (Black patient, non-Black physician) oncology interactions, which constitute about 80% of Black patients’ interactions, is generally poorer than in racially concordant interactions, and likely contributes to treatment disparities. However, the nonverbal behaviors that contribute to this problem are largely unknown. We examined nonverbal synchrony, or the nonconscious coordination of movement, which can reflect relationship quality. We hypothesized that racially discordant interactions will have lower levels of nonverbal synchrony. Methods: Data include video recordings of 68 Black patients and 163 White patients discussing treatment with their non-Black oncologists. Recordings were submitted to motion detection software to measure nonverbal synchrony. This software measures global synchrony (all correlated motion), peak synchrony (all positively correlated motion), who is leading the interaction (similar to who is leading in ballroom dancing), and how much synchrony occurs based on who is leading the interaction. Using multi-level models, we investigated whether nonverbal synchrony differed in racially concordant and racially discordant dyads. Results: Findings showed greater levels of global synchrony (p < .05) and greater peak synchrony (p < .05) in racially discordant interactions compared to racially concordant interactions. Global synchrony was the same in racially concordant interactions regardless of who was leading, but greater global synchrony occurred in racially discordant interactions when the patient was leading (p < .05). Conclusions: This is the first study to use a dynamic jointly determined measure of behavior to assess oncology interactions. Contrary to our hypothesis, nonverbal synchrony was greater in racially discordant interactions than in racially concordant interactions. Patients are driving more of the synchrony in racially discordant interactions. This may suggest that patients in racially discordant interactions adapt to their physicians to bridge racial differences. Findings could contribute to physician training to enhance coordination and outcomes in oncology interactions.
Real-world practice patterns of providers managing older patients with non-small cell lung cancer.
Authors: Das Devika Govind , Bhatia Avnish K , Wujcik Debra , Owenby Susie , Hall Wanda D. , Smith Tasha , Zinner Ralph
Published: October 2019

17

Background: Most patients with non-small cell lung cancer (NSCLC) have advanced disease at diagnosis and are older with median age 72 years. Evidence-based treatment (EBT) selection requires availability of molecular testing (MT) results at time of treatment decision and geriatric assessment (GA) helps determine a patient’s ability to tolerate therapy. This study describes practice patterns and evidence based treatment selections of providers managing older patients with NSCLC. Methods: After provider education and using care planning software (CPS), 50 patients with advanced NSCLC from two academic centers completed surveys regarding treatment goals and decision-making preferences, and patients ≥ 65 completed a modified GA that included activities of daily living and comorbidity assessment. Once treatment was selected, a personalized care plan was generated. Comparison treatment data from 17 community patients was obtained. Results: Participants were mean age 65, 52% female, and 78% white. Of 28 stage IV patients, 79% had MT and results available at time of treatment decision, and 100% met EBT guidelines. The community cohort had 47% testing, 29% results available, and 65% met guidelines. GA results in 24 patients were 46% frail, 29% intermediate fit, and 25% fit. Two patients (8%) were frail and had a plan change due to GA results. Conclusions: Obtaining timely MT results remains challenging. Continued strategies to ensure MT and timely results should be explored, including quality assurance monitoring given the increasing importance of MT in treatment selection. GA was less impactful in this setting, likely due to later stage patients, presumed frailty, and treatment goal being palliation. We believe GA would have greater impact in early stage NSCLC where aggressive treatments are offered with curative intent.
Comparison of attitudes and beliefs about cancer clinical trial enrollment between physicians, research staff, and cancer patients.
Authors: Hillyer Grace , Beauchemin Melissa , Hershman Dawn L. , Kelsen Moshe A. , Brogan Frances L , Sandoval Rossy , Schmitt Karen M. , Reyes Andria , Terry Mary Beth , Lassman Andrew B. , Schwartz Gary K.
Published: October 2019

170

Background: Essential to bringing innovative cancer treatments to patients is voluntary participation in clinical trials but fewer than 10% of cancer patients are enrolled onto a trial. We used a domain-oriented framework to assess barriers to cancer clinical trial enrollment (CTE). Methods: Physicians and research staff completed an online survey in 2017; adult cancer patients not currently enrolled in a trial were interviewed in 2018. Perceived structural, provider- and patient-level barriers to CTE were assessed. Differences in perceptions, attitudes and beliefs toward CTE between physicians and staff, patients by ethnicity, and physicians/staff and patients were examined. Results: In total, 120 physician/staff (64.4% response rate) and 150 cancer patient completed surveys. Interacting with the patients’ family was seen as a CTE barrier by nearly one-third of physicians/staff overall, however, staff much more often stated this barrier than did physicians (44.0% vs. 18.2%, p= 0.007). Hispanic patients more often stated they would join a trial, even if standard therapy was an option compared to non-Hispanic patients ( p= 0.004). Overall, patients, more often than physicians/staff, believed that clinical trials are only offered to people whose disease is hopeless (27.3% vs. 8.7%, p < 0.001) and that CTE does not help patients personally (32.9% vs. 1.8%, p < 0.001). More often physicians/staff believed that patients decline CTE due to language or cultural barriers (57.5% vs. 27.3%, p < 0.001), lack of understanding about clinical trials (63.3% vs. 9.1%, p = 0.001), and mistrust of the medical system (69.2% vs. 36.4%, p= 0.043) than was reported by patients. Patients less often reported declining CTE because of concerns about invasive procedures (9.1% vs. 41.7%, p = 0.02), toxicity (18.2% vs. 60.0%, p= 0.006) or reluctance to be randomized/receive a placebo (27.3% vs. 70.8%, p= 0.005). Conclusions: Our findings indicate a wide gap between provider and patient attitudes and beliefs about CTE. Reconciling these differences will require tailored education to dispel misperceptions and strategies to improve the quality of patient-provider communication.
Patient and provider perceptions of emergency room visits during chemotherapy.
Authors: Panattoni Laura Elizabeth , Jones Salene M.W. , Bolt Kaylin J. , Kreizenbeck Karma L. , Ittes Annika , Ramsey Scott David
Published: October 2019

183

Background: Emergency room (ER) visits during chemotherapy are costly. To identify potential causes of ER visits, we interviewed oncology patients and providers about symptoms and other factors related to ER visits. Methods: People with cancer (n = 19) and oncology physicians and nurses (n = 11) were interviewed using a semi-structured protocol. Interviews were transcribed. The study team developed a codebook and interviews were coded deductively. Four of the interviews were double coded. Results: Patients reported communicating with their physicians mostly by telephone. Patients reported a variety of distressing symptoms from chemotherapy including infection, mouth sores, distress, fatigue, neuropathy, gastrointestinal (GI) effects. Pain, fever, neuropathy, and dizziness were symptoms that motivated ER visits. Patients reported that contact with their care team and having a specific plan for symptoms helped prevent ER visits. Patients also reported that going through chemotherapy the first time was harder because they did not know what to expect and the patient education can be overwhelming. Providers did not always have formal protocols for proactively contacting patients but those that did contacted patients early in treatment. Providers reported GI symptoms, pain, shortness of breath, dizziness, and infection as causes of ER visits. They reported difficulties assessing symptoms due to reporting inaccuracies and reticence to share details. Providers cited financial insecurity, remote living, and lack of social support as factors increasing risk of ER visits. Providers reported some patients would not call frequently enough while a smaller subset called more frequently than providers perceived as needed. Conclusions: Results suggest contact with the care team is crucial for preventing ER visits during chemotherapy. Symptoms causing ER visits were consistent with previous literature
Examining patient and visit characteristics associated with the cancer patient experience.
Authors: Bridge Erica , Singh Simron , Murdoch Amanda , Mozuraitis Mindaugas , Nicholls Brett , Moody Lesley
Published: October 2019

204

Background: Your Voice Matters (YVM) is a 28-item patient experience survey for adult cancer outpatients undergoing treatment in Ontario.The purpose was to examine patient and visit characteristics associated with YVM responses. Methods: YVM was administered to eligible patients (n=8,704) at 14 centres in 2017.Respondents answered items on a five-point Likert scale (4 or 5 = positive response). A multivariable logistic regression (MLR) was undertaken for each YVM item.Variables (reference group) included: disease site (heamatology), age group (65+), sex (female), rurality (urban), last visit type (consult), income quintile(highest) and immigration tercile (lowest). Significant results ( p<.05) vary by MLR model. Therefore a p-value range is provided for all significant variables for all MLR models. Results: Patients were more likely to have a less positive experience if they had central nervous system ( p =.000-.013), gastrointestinal ( p =.004-.026), head and neck ( p =.002-.025), or lung cancer ( p =.017-.049); were between the ages of 18-39 years ( p = <.0001-.048); were female ( p =.0001-.022); received chemotherapy( p =.0001-.047); lived in a rural location ( p =.042); from a mid-( p =.027-.045) and mid-high income quartile ( p =.021); and in the high- ( p =.002-.043) and middle-immigrant terciles ( p =.028-.047), when compared to the reference group. Patient were more likely to have a more positive experience if they had skin cancer ( p =.004-.032); were between the ages of 40-64 years ( p =.003-.033); receiving radiation ( p =.0001-.041) or a minor procedure ( p =.015); and were from the mid-low ( p =.003-.042) and low income quartile ( p =.001-.032), when compared to the reference group. Conclusions: The cancer patient experience varies by patient and visit characteristics. Future initiatives should examine these characteristics to better understand their populations to create a more tailored approaches to cancer care.
Feasibility of collecting survey-based patient-reported outcome measures (PROMs) from patients living with advanced cancer: Emerging findings from the Living with Colorectal Cancer study.
Authors: Kerba Marc , Kassam Shireen , Beaumont Crystal , Biondo Patricia , Earp Madalene , Tang Patricia A. , Simon Jessica , Watanabe Sharon , Sinnarajah Aynharan
Published: October 2019

207

Background: The “Living with Colorectal Cancer study” seeks to characterize the experiences of patients diagnosed with advanced colorectal cancer to inform care improvements. Here we describe our experiences recruiting patients and collecting patient reported outcome measures (PROMs). Methods: Eligible patients were identified by oncologists in Alberta, Canada’s two tertiary cancer centres and approached for consent to participate during routine appointments. Following baseline surveys, participants were given a choice of completing monthly surveys via email, phone, post, or in person. We purposively chose previously validated surveys already in use provincially, including EQ-5D-5L and Putting Patients First. We endeavoured to include non-English speaking participants by providing translated study materials and interpretation. Results: In one year of recruitment, 88 patients were enrolled. Edmonton, Alberta’s patient recruitment (N = 62) is double that of Calgary, Alberta (N = 26), despite similar population sizes. In Calgary and Edmonton, 81% and 56% of participants chose email-based PROMs surveys, respectively. The current missing survey rate is 12% (i.e. surveys not completed per month). Forty-eight participants (55%) completed ≥6 sets of monthly PROMs data; 26 (30%) transferred “off study” (61% of which died). Several participants expressed the desire to describe their experiences beyond what the surveys could accommodate. Despite language accommodation, all participants chose to complete surveys in English; however, 21% reported speaking another language daily. Conclusions: It is challenging but possible to engage and retain patients with advanced cancer in research focused on PROMs. Speaking with patients face-to-face in cancer clinics increased the burden on healthcare providers (i.e. clinic flow and time spent with patients), but appears to be a practical and appropriate way to recruit participants. Offering multiple methods of communication allowed patients to participate in a manner most practical for their lifestyle and did not impact PROMs collection. Clinical trial information: NCT03572101.
Quality of care for cancer survivors: Does a model of shared care affect experience of care?
Authors: Halpern Michael T. , Cohen Julia , Lines Lisa M , Mollica Michelle , Kent Erin E
Published: October 2019

213

Background: Cancer survivors may have unique medical care needs due to chronic/late-occurring effects of cancer or cancer treatment. “Shared care,” survivorship care delivered by both oncologists and primary care providers (PCPs), may better address these needs. Little is known about outcomes for survivors receiving shared care vs. oncologist-led or PCP-led patterns of care. We compared patient reported experiences of care for survivors receiving oncologist-led, PCP-led, shared care, or other patterns of care. Methods: Analyses of SEER-CAHPS, a data resource linking NCI's Surveillance, Epidemiology, and End Results (SEER) registry data, Medicare claims, and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses. Individuals age ≥ 65 in SEER-CAHPS diagnosed 2000-2011 with breast, cervical, colorectal, lung, renal, or prostate cancer or hematologic malignancies who completed a Medicare CAHPS survey ≥ 18 months after diagnosis and were continuously enrolled in Medicare A & B ≥ 6 months before and 6 months after survey completion were included. CAHPS included ratings of Overall Care, Personal Doctor, Specialist Physician, Health Plan, and composite scores for Doctor Communication, Care Coordination, Getting Needed Care, Getting Care Quickly, and Getting Needed Drugs. Survivorship care patterns were identified using proportions of oncologist, PCP, and other physician encounters. Multivariable regressions examined associations between survivorship care patterns and CAHPS outcomes. Results: Among 10,132 survivors, 15% received Shared Care; 10% Oncologist-led; 33% PCP-led; and 42% Other. Compared with Shared Care, we found no significant differences in survivors' experience of care except for Getting Needed Drugs (lower for PCP-led and Other). Sensitivity analyses using different pattern of care definitions showed no associations between survivorship model and experience of care. Conclusions: Survivors’ experiences of care were similar for those in Shared Care vs. Oncologist-led, PCP-led, and Other patterns of care. Within the study’s limitations, these results do not indicate enhanced patient reported medical care experiences for survivors receiving shared care.
Meeting lung cancer value based care requirements with documentation of patient goals and preferences.
Authors: Bhatia Avnish K , Das Devika Govind , Wujcik Debra , Owenby Susie , Hall Wanda D. , Smith Tasha , Zinner Ralph
Published: October 2019

222

Background: Non-small cell lung cancer (NSCLC) accounts for 25% of all cancer deaths with 5-year survival of 6%. Recent scientific advances in molecular based treatments and immunotherapy and insurers’ emphasis on patient-centered care is changing patient care. This study sought to incorporate patients’ perceptions, goals, and preferences into treatment planning. Methods: After provider education and using electronic care planning software (CPS), a pilot of 50 patients with advanced NSCLC from two academic centers completed tablet-based surveys addressing treatment goals, decision-making preferences, and interest in clinical trials. Results were shared with the provider during the visit. Once treatment was selected, the CPS generated a personalized care management plan. Results: Participants were mean age 65 (range 41-86), 52% female, and 78% white. 60% (12/20) Stage IV patients believed that their cancer was curable. 62% (31/50) were not interested in clinical trial participation. 48% (24/50) wanted to share treatment decision making; 34% (12/50) wanted to make the final decision after seriously considering the doctor’s opinion; 6% (3/ 50) wanted the provider to make the final decision but consider their opinion, and 10% (5/50) wanted to leave all decisions to the provider. Conclusions: Patient perception of curability and decision-making preferences were important domains identified by personalized-care management planning in this Lung Cancer pilot study. Pre-visit CPS use provided the opportunity for the provider to address treatment intent and decision-making at the point-of-care. Academic centers generally expect their patients to have strong interest in clinical trials; Investigation for the reasons for disinterest warrants further exploration.
Women at risk for hip fracture following decline in bisphosphonate use.
Authors: Perraillon Marcelo Coca , Bradley Cathy J
Published: October 2019

239

Background: Hip fractures in older adults are associated with increases in morbidity, mortality, and costs of care. Breast cancer treatment, including chemotherapy and endocrine treatment, interfere with bone health, increasing the risk of hip fracture for breast cancer survivors. Multiple studies report large and steady declines in hip fracture incidence coinciding with the availability of bisphosphonates to prevent osteoporosis, although black label warnings about side effects in 2011 steered physicians away from their widespread use. This study estimates trends in hip fracture incidence in a cohort of women with breast cancer before and after 2011. Methods: Retrospective observational study using 2007-2015 SEER-Medicare data for women aged 66 years or older continuously enrolled in fee-for-service Medicare with a first primary diagnosis of breast cancer. Primary outcome was an inpatient admission for a hip fracture within two years of cancer diagnosis. Monthly discrete time survival models were used to estimate the probability of hip fracture after diagnosis conditional on observable factors including demographic characteristics, comorbidities, and the concurrent use of bisphosphonates and cancer treatment. Results: A total of 67,577 patients met the inclusion criteria. The age adjusted incidence of hip fracture declined by 25.1% from 2007 to 2011; from 1093.662 (95% CI, 1027.9-1159.4) to 819.224 (95% CI, 762.1-876.4) per 100,000. However, the incidence of hip fractures stabilized after 2011, with a decline of only 4% from 2011 to 2014, when the incidence was 785.4 (95% CI, 728.6-842.1). The risk of hip fracture increases with age and the number of comorbid conditions. Although more women are prescribed bisphosphonates after a cancer diagnosis, prescription rates declined after 2011. Conclusions: The incidence of hip fractures in breast cancer survivors stabilized after years of steady declines. This significant change in incidence coincided with a large reduction in the use of bisphosphonates after warnings of rare but serious side effects were issued. More research is needed to prevent hip fracture in women with breast cancer and further consideration of available treatments is required for women at high risk for hip fracture.
Implementation of a pregnancy screening protocol prior to chemotherapy for women of childbearing potential.
Authors: Eastlake Christian , Jeffers Kate
Published: October 2019

246

Background: Many cancer therapies currently available are teratogenic in nature. Several patients cared for within our community ambulatory oncology infusion center are women of childbearing potential (WOCP). Pregnancy testing of these women within our oncology infusion center was sporadic at best. There currently are no standardized guidelines related to pregnancy testing of these women. Methods: A retrospective chart analysis of WOCP receiving chemotherapy was done to determine baseline pregnancy screening rates. Subsequently a protocol was developed in which WOCP was defined as women under 50 years of age, without a history of hysterectomy or tubal ligation. The nurse-driven protocol allowed the infusion nursing staff to order a pregnancy screen to be done within the infusion center if testing had not already taken place within 48 hours of initiation of treatment. Following protocol implementation a retrospective chart analysis was performed to re-examine screening rates. Results: Utilizing patients with an active treatment plan within a one month time period, retrospective analysis of pregnancy screening prior to initiation of chemotherapy was performed. Baseline pregnancy screening rate was 21%. Point of care pregnancy equipment was obtained and nursing staff was educated on the protocol to include a medical delegation. Post-implementation chart analysis of WOCP initiating chemotherapy within a six-week timeframe resulted in improved pregnancy screening to 57% compliance. Continued education and clarification of the protocol was provided to the nurses in an effort to further improve compliance. Conclusions: Lack of standard guidelines regarding pregnancy screening of WOCP led to the development and implementation of a protocol for pregnancy screening for this at-risk population. Medical delegation allowed nursing to initiate the screening for these patients allowing for improvements in the safety and quality of patient care provided.
Using deep learning with registry linked claims data to predict hospitalization during chemotherapy: Feasibility study.
Authors: Panattoni Laura Elizabeth , Li Li , Fedorenko Catherine R. , Silgard Emily , White Scott , Rhine Adam , Kreizenbeck Karma L. , Egan Kathryn , Ittes Annika , Ramsey Scott David
Published: October 2019

270

Background: Approximately half of cancer patients undergoing outpatient chemotherapy experience unplanned Emergency Department (ED) visits and Inpatient (IP) stays. Current machine learning algorithms that identify high-risk patients are based on pre-treatment variables which can not detect changes in risk over time. Deep learning recurrent neural networks can model complex longitudinal patient histories. This study tests the feasibility of using an interpretable recurrent neural network to predict a patient’s daily likelihood of ED and unplanned IP stays in the six months following chemotherapy initiation. Methods: Medicare and commercial claims data were linked with cancer registry records for patients in Washington State from 2011 to 2017. The study included patients diagnosed with any primary tumor site, excluding leukemia, and treated with chemotherapy. We used the Reverse Time Attention model (RETAIN) with a 1:10 case-control match and included registry elements; diagnoses, procedures, medication, and utilization pre-and post-chemotherapy initiation. Patients were randomly divided into internal training, validation, and test sets (75%, 10%, 15%). Model accuracy was measured by the areas under the receiver operating curve (ROC) and precision-recall curve (PRC), and the Youden sensitivity and specificity. Results: Of the 15,400 eligible patients; 4,037 (26.2%) visited the ED a median of 1 time (6,080 total visits); 5,116 (33.2%) had a median of 1 IP stay (7,839 total stays). Both models had good predictive accuracy: The top 20 predictors for ED visits included 5 chemotherapy regimes, 12 procedures, and 2 tumor characteristics; IP stays included all chemotherapy regimes. Conclusions: The promising performance of RETAIN supports the possibility of building a tool capable of estimating daily hospitalization risk. However, future research, particularly with alternative data sources, may be required to predict hospitalization in a real time clinical setting.

[Table: see text]
Concurrent opioid and benzodiazepine use after breast cancer diagnosis.
Authors: Check Devon , Winn Aaron N. , Fergestrom Nicole , Neuner Joan Marie , Roberts Andrew
Published: October 2019

28

Background: Benzodiazepines contribute to one-third of opioid overdose deaths in the U.S. Guidelines caution against co-prescribing these two drug classes. Although patients with cancer commonly experience pain and anxiety, no studies have assessed trends in concurrent opioid/benzodiazepine use after cancer diagnosis. Our study examined trends in, and predictors of concurrent opioid/benzodiazepine use in older women diagnosed with breast cancer. Methods: We conducted a retrospective cohort analysis using 2012-2016 SEER-Medicare data for women diagnosed with stage 0-III breast cancer who had no concurrent opioid/benzodiazepine use in the 3 months prior to diagnosis. Using modified Poisson regression, we estimated the adjusted probability of concurrent use (≥1 day of overlapping opioid/benzodiazepine supply) in the 12 months post-diagnosis for patients diagnosed in each calendar quarter from Q2:2013 to Q4:2015. We also estimated the overall relative risk (RR) of concurrent use associated with patient demographic and clinical characteristics. Results: Among the 19, 267 women in our cohort, the quarterly adjusted probabilities of concurrent use were stable over time, ranging from 12% to 15%. Risk of concurrent use decreased with age but increased with cancer stage. Prior opioid use and prior benzodiazepine use increased the risk of concurrent use in the 12 months post-diagnosis (RR prior vs. no prior opioids = 2.57, 95% CI = 2.27-2.92; RR prior vs. no prior benzodiazepines = 15.05, 95% CI = 13.19-17.19). Women who underwent mastectomy (vs. no or minimal surgery) were 71% more likely to have concurrent use (RR = 1.71, 95% CI = 1.40-2.10). Similarly, women who received chemotherapy (vs. no chemotherapy) were 28% more likely to have concurrent use (RR = 1.28, 95% CI = 1.07-1.54). Finally, Black women (vs. White women) were 38% less likely to have concurrent use (RR = 0.62, 95% CI = 0.50-0.76). Conclusions: Up to 1 in 8 older women diagnosed with breast cancer exhibited concurrent opioid/benzodiazepine use in the 12 months after diagnosis. Clinicians must be mindful of exposing patients to this high-risk combination during cancer and survivorship care, particularly among patients with more intensive cancer treatment or prior use of either drug.
Effect of high patient out-of-pocket (OOP) cost for oral tyrosine kinase inhibitors (TKIs) on survival in EGFR and ALK positive stage IV non-small cell lung cancer (NSCLC).
Authors: Goulart Bernardo H. L. , Unger Joseph M. , Chennupati Shasank , Egan Kathryn , Fedorenko Catherine R. , Ramsey Scott David
Published: October 2019

3

Background: Patients with EGFR+ or ALK+ NSCLC benefit from oral TKIs, but high patient OOP TKI costs could negatively impact survival by reducing likelihood of continuing TKI therapy. We assessed the association of high OOP TKI costs with overall survival (OS), medication possession ratio (MPR) and duration of TKI therapy (DOT) in patients with metastatic EGFR+ and ALK+ NSCLC. Methods: We identified patients with EGFR+ and ALK+ NSCLC diagnosed between 01/01/2010 and 12/31/2016 in the Washington State SEER registry using natural language processing, followed by manual confirmation of molecular tests. We linked registry records to commercial and Medicare (including part D) claims. Eligible patients had stage IV NSCLC, sensitizing EGFR mutations or ALK+ by FISH, ≥1 pharmacy claims for EGFR or ALK TKIs, ≥3 months survival from TKI start, and ≥12 months of insurance enrollment post diagnosis. We estimated OOP TKI costs by subtracting the amount paid from the amount allowed in pharmacy claims. We categorized patients by quartiles of monthly OOP costs calculated for the first 3 months of TKI therapy (Q1 < Q2 < Q3 < Q4). We used landmark survival analysis with multivariate Cox regression to test the association of monthly OOP costs in the first 3 months of TKIs and OS starting at 3 months of TKI therapy between Q1-Q3 vs Q4. We used t-tests to compare MPR and DOT for the 1st TKI between Q1-3 and Q4. Results: For 106 eligible patients (median age 69; 67% female; 73% White; 35% Medicare, 85% EGFR+), the median monthly OOP TKI costs at 3 months were $0 (Q1); $1,432 (Q2); $1,798 (Q3); $2,888 (Q4). Mean MPR was 1.20 vs. 1.06 (P = 0.02), and median DOT was 8 vs. 4 months (P < 0.01) for Q1-3 vs. Q4. Median OS was 22 vs. 9 months for Q1-3 vs 4. Compared with Q1-3, Q4 patients had a hazard ratio for death of 1.76 (95% CI = 1.05; 2.94; P = 0.03), adjusted for age, sex, insurance, mutation, income, chemotherapy use, and time to TKI start. There were no statistically significant associations comparing Q1 to Q2-4, or Q1-2 to Q3-4. Conclusions: Higher patient OOP TKI costs are associated with lower number of TKI prescriptions, shorter duration of TKI therapy and inferior survival in advanced EGFR+ and ALK+ NSCLC.
Development of a time to treatment metric across an NCI designated academic health system.
Authors: Najarian Maya L , Shaw Pooja , Severino Kimberly M , Hamrick James , Adelson Kerin B.
Published: October 2019

307

Background: Time to treatment (TTT) is an important quality metric as shorter times improve patient satisfaction and retention, overall survival, as well as reduce distress. Multiple factors can lengthen TTT including provider availability, biopsy, pathology review, assembly of medical records, multidisciplinary care coordination, staging studies, and patient preference. No national benchmarks exist for TTT, however one large health system noted baseline TTT (indexed on diagnosis date) of 29d for internally diagnosed and 41d for externally diagnosed patients ( Khorana & Bolwell, NEJM Catalyst, 2019 ). Limited guidance exists on how best to measure TTT for cancer patients across an institution. Methods: We developed a consistent TTT metric across Yale’s Smilow Cancer Hospital, comprised of an academic hub and community practices, using data obtained from Flatiron Health’s EHR-derived de-identified database, with disease team assigned for each provider. Qualifying patients had a new patient visit between Jan - Dec 2018, and scheduled treatments from Jan 2018 - Mar 2019. We defined TTT as calendar days from the first qualifying visit to the sooner of either an IV antineoplastic administration or interventional surgery. Results: The population sample included 1,090 patients seen by five disease teams. 558 (51%) patients had a qualifying intervention. The overall median TTT was 26d (IQR14 - 44). The median TTT for IV antineoplastic administration was 24d (IQR 14 - 43). The median TTT for interventional surgery was 27d (IQR 15 - 45). The median TTT by disease team: Breast 24d (IQR 14 - 38), GI 24d (IQR13 - 36), Head & Neck 27d (IQR 15 - 40), Hematology 35d (IQR 11 - 76), and Thoracic 28d (IQR 16 - 51). Conclusions: Evaluating TTT across an institution can help identify opportunities for practice improvements. We hypothesize that recurring delivery of this metric will enable assessment and benchmarking of quality improvement interventions. Future work will focus on improving this measure by incorporating additional cancer treatments (e.g. radiation therapy), and development of interventions to shorten TTT at our center.
Artificial Intelligence (AI) and machine learning (ML) in risk prediction of hospital acquired pressure injuries (HAPIs) among oncology inpatients.
Authors: Ravi Vinod , Zheng Jing , Subramaniam Aparna , Thomas Lavonia G , Showalter John , Frownfelter John , Miller Kelly
Published: October 2019

309

Background: Utilizing AI and ML is an emerging method to improve risk identification, characterization and stratification for clinical outcomes such as HAPIs. The Jvion Cognitive Clinical Success Machine (CCSM) utilizes the Eigen Sphere technique to factor in clinical, socioeconomic, and behavioral covariates at the individual patient level to maximize accuracy of risk prediction and provide insights on prevention of HAPIs. Methods: A retrospective analysis was performed utilizing claims and EHR data on 63,476 inpatient admissions between June 2016 and June 2018 at M D Anderson Cancer Center, a 660-bed oncology facility (Table 1) . All risk assessment indicators in the data were removed prior to analysis by the CCSM to compute unbiased risk probabilities for HAPIs. The performance of the CCSM risk prediction for all new stage 2 and above HAPIs (>=Stage 2 HAPIs) was compared with the Braden scale using AUC. Results: The Jvion CCSM had an AUC of 0.84 compared to the AUC of 0.72 for the Braden scale in the prediction of >=Stage 2 HAPIs. Conclusions: The AUC indicates that the Jvion CCSM has better predictive accuracy than the Braden scale. It also has better discrimination in risk identification. Thus, Jvion CCSM can be a valuable tool in risk screening for HAPIs which can lead to early preventative interventions. Characteristics of admission records used to compare accuracy of Jvion CCSM and Braden scale in predicting new >=Stage 2 HAPIs (N=58,228).

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Methods of implementation for an electronic ongoing professional practice evaluation system.
Authors: Park Woo Yeon , Patel Dhruvkumar , Samedy Patrick , Li Alicia
Published: October 2019

313

Background: Hospitals accredited by the Joint Commission are required to provide Ongoing Professional Practice Evaluation (OPPE) for all privileged providers. Historically, OPPE reports had been created and completed by a peer review process on a paper-based system, where the data was managed in spreadsheets. The Division of Quality and Safety (DQS) developed an electronic system of collecting clinical and administrative data, with the goal of assessing quality of care in an impartial, modernized, and efficient process. Methods: Electronic implementation of the OPPE process can be divided into three main parts: metric development using electronic medical records (EMR), report automation, and application development for review. We designed queries to extract EMR data to validate the quality measures developed in collaboration with clinical leadership. Data pulls are then automated to populate outcomes to a table, from which the OPPE reports are populated according to selected parameters such as provider’s unique ID and OPPE period. Reports are then accessed by supervisors and providers directly through a web application developed by DQS. After verifying the data, clinicians can sign off in the application to complete the OPPE review process. Results: We have distributed 8,630 electronic OPPE report since 2012, and 1,486 distinct physicians had received reports. We evaluated engagement of the process by looking at engagement rate (number of OPPE signed reports divided by the total number of OPPE reports). The engagement rate varies by department, but the median of engagement rates of the OPPE process is 100%. Conclusions: Moving from paper chart reviews to an electronic process enables the institution to scale, lower the burden on employees, and improve the convenience of OPPE for busy providers. It also provides opportunities to evaluate quality of care on the provider level by analyzing outliers using the OPPE measure outcomes and finding the correlation of engagement rate and the quality outcomes.