bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of in-house specialty pharmacy on access to novel androgen axis inhibitors in men with advanced prostate cancer.
Authors: Handley Nathan , Kirk Siobhan , Driscoll Anna , Binder Adam , Kelly William Kevin
Published: October 2019

132

Background: Novel androgen axis inhibitors are standard of care treatments in advanced prostate cancer. The billed amounts for these medications are often very high, which may create significant financial toxicity for patients and lead to delays in treatment. Our institution implemented an in-house specialty pharmacy in 2014, that provides these medications and evaluates copay assistance options for all patients. We evaluated the program’s impact on out of pocket cost (OOP) and turnaround time (TAT). Methods: We reviewed available internal specialty pharmacy records to identify prescriptions for abiraterone or enzalutamide filled between 1/1/17 and 12/31/18. Payments were stratified by primary payment (amount reimbursed by the patient’s prescription plan based on the benefit’s design) and copayment assistance. Turnaround times (TAT) in business days were stratified by prescriptions requiring intervention (prior authorization, copayment assistance, or insufficient inventory) and clean prescriptions (those requiring no intervention). Results: One thousand for hundred seventeen prescriptions for 175 unique patients requiring abiraterone (n = 869, 61.3%) or enzalutamide (n = 548, 38.7%) were filled through the institution’s specialty pharmacy. The average amount paid by primary payer was $9,492.96 for a 30 day supply (range: $3,382.48-$12,939.84). Average quoted copay was $577.53 (range $3.08-$10,560.39). 64% of patients received copayment assistance. Average OOP cost per prescription after co-pay assistance was $100.83 (range $0-$8556.64). Three patients declined treatment due to cost (1.7% of overall). Average TAT was 2.98 days for clean prescriptions and 3.36 days for prescriptions needing intervention (p = 0.055). Conclusions: OOP cost varied significantly based on plan design and copayment assistance eligibility. The majority of patients received copayment assistance, which markedly reduced OOP cost. Cost rarely precluded access to treatment. TAT was not significantly prolonged for prescriptions requiring intervention. Further studies to determine impact of pharmacy type on access to specialty medications are indicated.
Call center performance to drive patient access.
Authors: Cummings Chad W. , Comer George , Bealer Nicole , Costantino Patricia , Davis Jonathan , Heard Laphia , Johnson Markita , Kantzes Deborah , Snyder Josette M. , Oh Kimberly
Published: October 2019

135

Background: Access to oncology care through a specialty call center within a large academic institution was analyzed to determine service levels necessary to schedule patient consults within 7 days of contact. The specialty call center is the primary resource for ambulatory appointment scheduling, and staffed by 1 licensed provider and 6 agents who administratively coordinate patient care. Hours of operation are 8AM-5PM. Methods: Data was analyzed between a period of 1/1/2018 and 9/30/2018 (P1), providing call statistics (S1): inbound & outbound calls, calls not answered, average speed of answer, agent availability. Observations of agents identified key processes, staffing analysis, and productivity levels. A dependency map was developed to identify key inputs and outputs for all call center activities. The number of dependencies were identified for each activity. Results: A dependency map identified 22 unique agent activities, categorized by administrative tasks (n = 9), multi-disciplinary team coordination (n = 7), direct patient interaction (n = 5), and patient benefit processing (n = 3). Average number of inputs per activity yielded 2.4 (Range = 0 to 8), while outputs were 2.0 (Range = 0 to 6). Inbound and outbound calls spanned multiple categories, with 28,730 calls received or placed during P1. 77% of inbound calls were answered, and remaining calls were directed to voicemail. 89% of all calls occurred between 9AM and 4PM, with slight variation each hour. Staffing Analysis revealed 91.3% availability rate equivalent to 5.48 agents available per day. Average call hours (inbound and outbound) per agent ranged from 2.45hrs/day to 5.18 hours/day, with variation attributed to the unique activities. An algorithm was created to determine appropriate staffing levels to ensure S1 requirements and timely coordination of care. Conclusions: A specialty call center requires a detailed understanding of dependencies that contribute to timely scheduling, while maximizing customer service. Dependency mapping provides visibility to clinical and non-clinical teams of necessary activities to coordinate appointments. Staffing models can assist in understanding the variables that influence S1, and provide support for staffing decisions in periods of high/low demand.
Barriers to fertility preservation (FP) in a prospective pan-Canadian study of young women with breast cancer (YWBC).
Authors: Warner Ellen , Yee Samantha , Seminsky Maureen , Lipson David , Glass Karen , Foong Shu , Kennedy Erin Diane , Narod Steven , Quan May Lynn
Published: October 2019

136

Background: Despite ASCO recommendations that oncologists routinely offer FP to young cancer patients prior to treatment, studies show that only a minority of YWBC are given this option. We sought to determine whether an intervention, including educational materials and regular reminders to breast surgeons, would improve FP referral. The current report examines the rates of FP discussion, referral, uptake and reasons for declining, according to participants’ self-reported pre-diagnosis fertility plans. Methods: Consecutive women ≤ age 40 newly diagnosed with breast cancer at 30 Canadian sites were offered enrolment in a national study of YWBC. At 3 months each participant was surveyed regarding her pre-diagnosis (dx) fertility plans and post-dx oncofertility management. Results: Of the 712 recruits (09/15 to 08/18) with invasive disease (mean age 36), 46%, 15% and 29% had 0, 1 or 2 children respectively and 77% were in a stable relationship. Among the 480 women who completed the fertility survey, 392 (82%) indicated they had a pre-treatment fertility discussion initiated by a health care provider (HCP) - in 232 cases (48%) the surgeon/nurse and in 130 cases (27%) the medical oncologist/ nurse. Only 14 (16%) of the 88 women not approached by a HCP initiated such a discussion. Rates of FP discussion, referral and uptake are shown below. Among the 38 women who definitely wanted (more) children prior to dx and were offered FP but declined the consult or procedure, the commonest reasons were cost (n = 9) and fear that treatment delay (n = 8) or FP (n = 4) could cause recurrence. Conclusions: Post-intervention FP discussion rates were higher than previously reported. Yet 26% of patients who had definitely/probably not completed their family were not referred for a FP consult. Cost remains a significant FP barrier. Studies are needed to confirm the long-term safety of FP for ER+ patients. [Table: see text]
Partnership with an independent genetic counselor and standardized screening: Effect on the identification, referral, and genetic testing of eligible patients in a community oncology clinic.
Authors: Bilbrey Larry Edward , Dickson Natalie R. , Rao Smita K , Shepard Gregg Christian , McGee Kathy , Frailley Susan A , Poole Stacey L , Patton Jeffrey
Published: October 2019

138

Background: A nine provider, community oncology clinic had limited local access to genetic counseling. Additionally, the practice had no process for identifying appropriate patients for genetic counseling or testing and no method to track referrals and test results. The practice partnered with a contracted genetic counselor and a study was completed to standardize screening and follow-up and to increase referrals and testing. Methods: Baseline data on genetic testing performed in 2018 was obtained from three major genetic testing labs. Based on the NCCN guidelines for genetic assessment, the practice created automated screening reports from the EMR, supplemented by manual chart review, to identify appropriate patients for genetic counseling. Front office, clinical and billing workflows were created. Patients were scheduled to see the counselor via in-person appointments or remotely via a HIPAA compliant telemedicine platform. The genetic counseling sessions included education and consent for testing followed by review and discussion of results. Consultations and genetic testing results were documented in the practice’s EMR. Results: Baseline data showed that the clinic tested 7 patients in 2018; 2 patients in the first quarter. During the pilot from Jan-Mar 2019, 34 patients were referred for genetic counseling; 30 consented to testing. This is a 329% increase over 2018; 1400% for the first quarter. Of the 30 patients tested during the pilot, 6 were positive for a pathogenic mutation. Conclusions: By contracting with a genetic counselor, and establishing procedures for screening, counseling, consenting, testing and follow-up, the practice was able to increase the number of appropriate genetic testing considerably. This process will be scaled to multiple sites of a community practice.
Emergency department-mediated cancer diagnosis among older adults in the United States.
Authors: Sheridan Paige , Lyratzopoulos Georgios , Murphy James Don , Thompson Caroline A.
Published: October 2019

139

Background: It is estimated that 20-50% of breast, colon and lung cancers are diagnosed in an emergency department (ED) globally. Cancer diagnosis via the ED worsens short-term survival and reduces quality of care. Studies in Europe have shown that older and socioeconomically deprived patients are at a higher risk of ED diagnosis. However, no studies in the U.S. have reported patterns of cancer patients initially presenting to the ED. We identified and characterized older patients who are diagnosed with a malignant tumor following presentation to an ED using data from the Surveillance, Epidemiology and End Results Medicare linked database. Methods: We studied 415,395 Medicare beneficiaries with histologically confirmed first malignant invasive tumors of the breast, colon and rectum, lung and prostate between 2004 and 2013. Patients were excluded if they did not have continuous coverage in the year prior to diagnosis, had more than one primary tumor, or were diagnosed after death. ED-mediated diagnosis was defined as having at least one ED claim in the month before the date of cancer diagnosis. Covariate adjusted generalized linear models were used to estimate prevalence odds ratios for marital status, race, comorbidity, and income levels. Results: Overall, 42,186 (11%) of cancer diagnoses were ED-mediated (by site: breast: 5%, colorectal: 13%, lung: 15%, prostate: 6%). Patients presenting to the ED were more likely to be: unmarried (OR:1.32; 95% CI: 1.29-1.34), Hispanic (OR:1.47; 95% CI: 1.37-1.57) or Black (OR:1.41; 95% CI:1.37-1.45), have 3+ comorbidities (OR:3.08; 95% CI: 3.00-3.16), and in the lowest income quartile (OR:1.26; 95% CI:1.21-1.30). Conclusions: While some cancers diagnosed in the ED may indicate incidental findings, later stage symptomatic cancers not identified until they become an emergency may reflect the failure of public health campaigns and primary care services. Reducing emergency presentation of cancer patients may improve patient outcomes and healthcare system efficiency.
Racial disparities in utilization of gene expression testing in breast cancer patients at an academic medical center.
Authors: Alder Laura , Bear Harry Douglas , Hackney Mary Helen
Published: October 2019

142

Background: Gene expression profiling of breast cancers, such as the OncotypeDx (ODX) test, PAM 50 and Mammaprint, can define the risk of distant recurrence and assist with decisions about adjuvant chemotherapy. A recent study of all breast cancer patients in Virginia found that only 11.7 % of Caucasian Americans (CA) and 5.1% of African Americans (AA) received genomic testing. Methods: We utilized the Virginia Commonwealth University Health System (VCUHS) Tumor Registry and billing data from 2010-2017 to identify all patients that met the following criteria per NCCN guidelines for genomic testing: early stage (stage I or II) breast cancer, estrogen and/or progesterone receptor positive and lymph node-negative breast cancer. We also obtained records from Genomic Health on ODX testing ordered through VCU Health. Additionally, ODX utilization was stratified by race. We then performed Chi Square analysis. Results: 1080 patients were eligible per NCCN Guidelines. Of these, 248 were eliminated due to having only radiation performed at VCU. 39 were eliminated because initial treatments were at outside hospitals. Of the remaining 793, 536 were CA, 232 AA, 9 Asian and 16 other. Among the patients for whom a genomic test was appropriate, the proportion who actually had such a test performed were: 83.4% for CA, 71.98% for AA, 55.56% for Asians, 81.25 % for Others and 79.7% overall. There was a significant difference between utilization in CAs and AAs (p < 0.001). Conclusions: Breast cancer patients at VCU Health are far more likely to receive gene expression profiling overall compared to the Commonwealth of VA as a whole. This may reflect more equitable and guideline-compliant care in an academic/safety net health system.
Factors affecting treatment in small cell and non-small cell lung cancer patients.
Authors: Ngo Phuong , Pinkston Christina M , Kloecker Goetz H.
Published: October 2019

146

Background: Kentucky has the highest incidence of lung cancer death and despite improvements in treatment and survival, some small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) patients remain untreated. We looked at factors preventing these patients from receiving necessary treatment. Methods: Data was collected from the Kentucky Cancer Registry (KCR) for SCLC and NSCLC patients from 2012-2015 and included race, gender, age at diagnosis, treatment history, insurance and overall survival. Treatment included any combination of surgery, radiation, chemotherapy or immunotherapy. Patient demographics were summarized based on treatment status and derived odds ratio (OR) and 95% confidence intervals (CI) were reported. Significant associations were assessed at the p < 0.05 level. Results: KCR identified 2,992 SCLC and 13,975 NSCLC patients from 2012-2015. More NSCLC patients [3,608 (25.8%)] were untreated than SCLC patients [621 (20.8%), p < 0.001], and untreated patients overall were more likely to be older, have more comorbidities (SCLC only), and have Medicare, Medicaid or no insurance. Stage at diagnosis was also a factor but differed based on histology. NSCLC stage III and stage IV patients had higher odds of being untreated compared to stage I (Stage III OR: 2.91, 95% CI: 2.57-3.28; Stage IV OR: 4.82, 95% CI: 4.29-5.41) where these odds in SCLC patients were non-significant (Stage III OR: 0.94, 95% CI: 0.56-1.55) or lower (Stage IV OR: 1.61, 95% CI: 1.01-2.55). SCLC patients also had lower odds of delayed treatment (defined as > 4 weeks to treatment) in stage III and stage IV compared to stage I (Stage III OR: 0.33, 95% CI: 0.23-0.48; Stage IV OR: 0.27, 95% CI: 0.20-0.38). Conclusions: This study shows an overall significant number of untreated lung cancer patients with treatment being strongly associated with insurance status, histology and stage at diagnosis. SCLC patients are more likely to be treated than NSCLC, and advanced stage is less a factor in treating SCLC than NSCLC. The difference may be due to the more aggressive nature of SCLC with physicians feeling more urgency to treat SCLC given its rapid progression and chemotherapy sensitivity compared to NSCLC.
Impact of dual-eligible status on survival in Medicare patients with lung cancer.
Authors: Ragavan Meera Vimala , Gardner Rebecca , Cunanan Kristen , Sundaram Vandana , Wakelee Heather A. , Han Summer S.
Published: October 2019

149

Background: Dual-eligible (DE) patients are insured by both Medicaid and Medicare and are known to have complex medical and social needs. While DE patients with cancer have been shown to be less likely to undergo definitive surgical resection of early stage disease and more likely to be diagnosed at a later stage, they have also been shown to be more likely to adhere to cancer treatment due to lower copays with Medicaid. Lung cancer (LC) is the most common cancer diagnosed in the DE population, but little is known about the outcomes of DE patients with LC compared to non-DE patients. Our study sought to assess the impact of DE status on overall survival in lung cancer patients. Methods: We conducted a cross-sectional secondary analysis of data extracted from the Medicare-SEER database, including Medicare patients diagnosed with LC where complete survival data was available. Patients were defined as “DE” if they were designated as DE status during the month they were diagnosed with LC. Categorical variables were compared between DE and non-DE patients using the chi2 test. A Cox regression analysis was performed to evaluate the association between mortality and dual-eligibility, adjusting for demographic and clinical factors including age, ethnicity, gender, stage at time of diagnosis, type of lung cancer, and place of residence (urban vs. rural). Results: A total of 118,816 patients were included in the analysis, of which 81% were non-DE and 19% were DE. DE patients were more likely than non-DE patients to be female, non-white, younger, have squamous cell carcinoma, and be diagnosed at a later stage (P-values all < 0.001). After adjusting for all demographic and clinical characteristics included in the analysis, the hazard ratio for mortality was 1.243 (95% confidence interval: 1.222-1.264, p < 0.001) for DE patients compared to non-DE patients. Conclusions: DE patients with LC have a significantly higher mortality rate than non-DE patients in the Medicare population after adjusting for confounding factors. Future studies should explore the factors that influence this survival differential and consider targeted interventions at the policy level to improve outcomes in this population.
Identifying levels of financial toxicity and unmet needs in cancer patients receiving financial assistance: Exploring trends in populations lacking adequate resources to overcome healthcare barriers.
Authors: Barris Brittnee , Deehr Katie , Anderson Eric , Gallagher Kathleen D. , Chambers Shonta , Balch Alan James
Published: October 2019

151

Background: The inability to afford healthcare has a widespread effect on cancer patients, notably impacting treatment decisions and outcomes. Patients receiving financial assistance to offset medication costs still face challenges overcoming cost of care barriers. This study investigated sources of concern and financial stress among racial groups and identified solutions to address patients’ needs beyond medication-related costs. Methods: This cross-sectional study utilized secondary survey data collected from cancer patients who received co-payment and/or financial aid from PAF in 2018. Respondents answered questions describing their financial distress and the COmprehensive Score for financial Toxicity (COST) tool (0-44 with lower scores indicating worse toxicity). Descriptive statistics were calculated using means and standard deviations (SD) for continuous variables and frequencies for categorical variables. Two sample t-tests were used for bivariate comparisons between racial groups. Results: Of 494 cancer patients surveyed, 72% were Caucasian, 11% were African American (AA), and 71% indicated a household income of < $48,000. Although this population received financial assistance, cost of medications was still a major barrier to adhering to treatment (59% vs 69%). AA patients reported greater financial burden caused by cost of deductibles/copay/coinsurance (58% vs 50%) and treatment costs not covered by insurance (49% vs 21%). AA patients highly rated day-to-day living expenses as an unmet need (64% vs 40%). COST scores differed significantly between Caucasian (mean 17.7, SD 8.6) and AA cohorts (mean 12.1, SD 8.6; p < .001), driven by the inability to meet monthly expenses at all (35% vs 11%). Of AA, 80% felt they do not have enough money in savings/retirement to cover treatment costs. Overall, the AA cohort reported higher frustration with not being able to work or contribute as much as usual (45% vs 26%). Conclusions: Under-resourced AA cancer patients identify a need for a comprehensive approach to cost of care conversation, to drive better adherence and improved treatment outcomes.
Navigating costs of care in women with breast cancer: Examining racial differences in non-treatment costs and financial toxicity in under-resourced populations struggling to afford medical care.
Authors: Gallagher Kathleen D. , Barris Brittnee , Anderson Eric , Deehr Katie , Chambers Shonta , Williams Courtney , Rocque Gabrielle Betty , Balch Alan James
Published: October 2019

156

Background: Patients with cancer struggle to afford needed medical care alongside daily financial obligations due to rising healthcare costs. This may be more pronounced among minorities who are less likely to seek resources to mitigate their financial distress. This study sought to identify racial differences in non-treatment costs for under-resourced women with breast cancer who sought assistance from Patient Advocate Foundation (PAF). Methods: This cross-sectional study utilized secondary survey data collected from breast cancer patients receiving case management services from PAF in 2018. Respondents answered questions describing their financial distress and COmprehensive Score for financial Toxicity (COST) tool (0-44 with lower scores indicating worse toxicity). Descriptive statistics were calculated using means and standard deviations (SD) for continuous variables and frequencies for categorical variables. Two sample t-tests were used for bivariate comparisons between racial groups. Results: Of 267 breast cancer patients surveyed, 54% were Caucasian, 29% were African American (AA), and 83% indicated a household income of < $48,000. Cohorts expressed strong dissatisfaction with their financial situation with AA impacted more acutely (78% vs 56%) and acknowledged inability to pay for treatment costs (83% vs 58%). Compared to Caucasians, AAs were more often concerned with transportation costs (33% vs 16%) and with day-to-day living expenses (83% vs 59%). Younger (≤55 years) AA respondents were twice as often unable to meet monthly expenses (60% vs. 27%). Older AA respondents ( > 55 years) reported greater distress than older Caucasians (74% vs 57%), while younger Caucasians reported greater distress than their AA counterparts (72% vs 65%). COST scores differed significantly between Caucasians (mean 13, SD 9) and AAs (mean 11, SD 8; p = 0.04). Conclusions: While the impacts of medical care costs were felt by all survey respondents, under-resourced AA breast cancer patients may be at higher risk for household material hardships as financial resources are diverted toward essential healthcare costs.
Worry about quality of life for younger versus older adult thyroid cancer survivors.
Authors: Thomas Stefanie Marie , Reyes-Gastelum David , Milam Joel , Miller Kimberly Ann , Ritt-Olson Anamara , Hamilton Ann S. , Ward Kevin C. , Gay Brittany L. , Hawley Sarah T. , Haymart Megan Rist
Published: October 2019

157

Background: Thyroid cancer is one of the most common cancers in young adults, age 18-39 years. Since this population has distinct medical and developmental needs, it is important to understand age differences in worry about quality of life. Methods: Thyroid cancer patients diagnosed between 2014-15 were accrued from the Surveillance, Epidemiology and End Results Program (SEER) registries of Georgia and Los Angeles County and surveyed between 2017-18. The primary outcome was patient reported worry about quality of life. Covariates for this analysis included age (categorized 18-25, 26-39, 40-64, and 65-79), involvement in surgical decision making (low, just right, high) and amount of information received on treatment side effects (low, just right, high). Race/ethnicity, sex, and tumor characteristics were also evaluated. Multivariable analyses were used to assess associations between worry about quality of life and independent variables. Results: In the cohort of 2,632 patients, 39.8% were somewhat to very much worried about quality of life not being the same as before thyroid cancer diagnosis, 15.1% reported low involvement in surgical decision making, and 32.6% reported low amount of information regarding side effects. Younger age was associated with high worry about quality of life (p < 0.001), low involvement in decision making (p < 0.001) and low amount of information on treatment side effects (p < 0.001). In multivariable analyses, high worry was significantly associated with female sex (Odds ratio [OR]: 1.29 95% confidence Interval [CI]:1.04-1.59), non-white, non-Hispanic race/ethnicity (OR: 1.64 CI: 1.38-1.95), positive lymph nodes (OR: 1.41 CI: 1.14-1.75) and younger age (ages 18-25 years OR: 2.34 CI: 1.45-3.76; ages 26-39 years OR: 2.26 CI: 1.68-3.05; and ages 40-64 years OR:1.94 CI 1.50-2.51). Age differences remained significant after adding either involvement in decision-making or information received. Conclusions: Young adults report higher worry about quality of life. Controlling for decision-making involvement or information received about side effects did not eliminate age differences in worry. Ongoing psychosocial support addressing quality of life worries among younger survivors is needed.
Socioeconomic deprivation and cancer outcomes in patients treated in clinical trials.
Authors: Unger Joseph M. , Moseley Anna , Ramsey Scott David , Osarogiagbon Raymond U. , Symington Banu , Hershman Dawn L.
Published: October 2019

162

Background: Studies using cancer registry data have shown that cancer patients living in socioeconomically disadvantaged areas have worse cancer outcomes. Socioeconomic deprivation (SD) has not been systematically examined in clinical trial patients, who are uniformly staged according to trial eligibility criteria and have access to protocol-directed care. Methods: We examined survival for patients enrolled in phase III clinical trials for all major cancers conducted by SWOG from 1985-2012. SD was measured using trial participant’s residence zip codes linked to the Area Deprivation Index (ADI) , a comprehensive index composed of 17 indicators reflecting a diverse set of socioeconomic variables, scored from 0-100, split into quintiles. Five-year overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS) were examined using Cox regression, adjusting for age (in 5 year intervals), sex, race (black v. non-black), and, for a subset of patients, insurance status (Medicaid/no insurance v. other). Analyses were stratified by cancer histology and stage. Results: In total, n = 41,182 patients from 55 trials comprising 24 cancer histology and stage-specific strata were examined. Compared to trial participants in the most affluent areas (ADI 0%-20%), trial participants from areas with the highest SD (ADI 80%-100%) had worse OS (HR = 1.26, 95% CI, 1.18-1.35, p < .001), PFS (HR = 1.19, 95% CI, 1.12-1.27, p < .001) and CSS (HR = 1.25, 95% CI, 1.17-1.35, p < .001). Results were similar after also adjusting for insurance status. For each outcome, there was a continuous increase in risk of an event as the ADI quintile increased. Conclusions: In cancer patients with access to protocol-directed care in clinical trials, area-level SD was associated with worse survival, even after adjusting for patient-level race and insurance. Future research should examine whether the etiology of this residual disparity is related to reduced access to supportive care or post-protocol therapy, and/or to differences in health status not reflected by protocol staging criteria. Policies to mitigate socioeconomic differences in cancer outcomes should emphasize access to cancer care services beyond initial therapy.
Outcomes and care patterns for advanced pancreatic cancer patients treated in tertiary vs regional/community cancer centres in Northern Alberta.
Authors: Anaka Matthew , Lee Minji , Ghosh Sunita , Cheung Winson Y. , Spratlin Jennifer L.
Published: October 2019

163

Background: Cancer care in Northern Alberta (Canada) is delivered at a single tertiary cancer centre, and 11 regional and community cancer centres (RCCC). We compared outcomes and care patterns for patients with advanced pancreatic cancer (APC; locally advanced or metastatic) in Northern Alberta treated with palliative chemotherapy at either the tertiary centre or an RCCC. Methods: This is a retrospective cohort analysis of APC patients treated with palliative chemotherapy from 2012-2015 in Northern Alberta (Canada). Data were obtained from outpatient medical oncology and palliative care notes and the provincial cancer registry. Survival analysis used a multivariate Cox-regression model. All other tests were Chi-squared/Fisher’s Exact. Results: We identified 106 patients, 90 treated in the tertiary centre, and 16 in a RCCC. Baseline characteristics were not significantly different. There were significant differences in first line chemotherapy regimen use (P = 0.037), with patients treated at RCCC more likely to receive gemcitabine during the study period (68.8% vs 36.6%), and less likely gemcitabine/nab-paclitaxel (12.5% vs 36.5%) or FOLFIRINOX (18.8% vs 28.7%). Patients treated at RCCC were less likely to see an outpatient palliative care physician (P = 0.020, 6.3% vs 35.6%), or have a documented goals of care designation (P = 0.005, 12.5% vs 52.2%). There was no significant difference in overall survival in a multivariate analysis (median 199 vs 232 days, HR = 1.080, 95% CI 0.594 – 1.966). Conclusions: We found that survival was not different for APC patients treated at the tertiary vs RCCC in Northern Alberta. However there were significant differences in the use of palliative care resources and 1st line chemotherapy regimens, which represent important disparities that should be the focus for future quality improvement.
Quality improvement pilot to engage rural Kentucky frontline against lung cancer death.
Authors: Hall Laura Lee , Weigel Joseph , Campbell Grace Libby , Miller Will , Louis J'Aimee , Hood Gregory A
Published: October 2019

164

Background: Kentucky is the epicenter of smoking and lung cancer in the U.S.: over half the population is a current or former smoker (second only to WV); and it has the highest annual lung cancer incidence—89.6 per 100,000 population—according to the most recent CDC data. While offering a significant, double-digit death benefit due to early recognition and improved therapies, LDCT lung cancer screening of at-risk individuals remains extremely low. Helping primary care practices identify their at-risk patients, promote reduced tobacco use, and refer for screening is critical. Methods: In this pilot, family practice and internal medicine practices, residency programs, and federally qualified health centers (FQHCs) were recruited in rural regions of Eastern Kentucky with populations at highest risk. The Sustainable Healthy Communities Quality Improvement Education (SHC-QIE) model—which engages multidisciplinary practice leaders, rapid cycle improvement or a PDSA approach to QI, geoanalytics, and community engagement support—was implemented to promote better screening while enhancing clinician satisfaction. Results: Each practice significantly improved their identification of smokers and patients qualifying for lung cancer screening in the Medicare program as well as screening referrals by nearly 2-fold. For example, in one FQHC, accurate reporting of tobacco history data in the medical record increased from 34.6% to 56.9%. Another example showed referrals for LDCTs increased from 230 in 2017 to 412 in 2018, with a 71% increase over baseline. While survey data from the participating clinics conceded challenges in implementing a QI initiative, significant satisfaction with the initiative, ongoing plans for activities building on the program, and community engagement were found as well. Pre-, post-survey data also revealed significant improvement in screening, tobacco counseling, and LDCT referral. Conclusions: In spite of EMR barriers, significant increases in smoking history taking, counseling for tobacco cessation, and referral for lung cancer screening was achieved over the course of 9 months.
Assessing cancer programs' financial resources for rural cancer patients.
Authors: Petermann Victoria Marie , Vanderpool Robin C. , Eberth Jan Marie , Rohweder Catherine , Teal Randall , Stradtman Lindsay , Frost Elizabeth , Trapl Erika , Koopman Gonzalez Sarah , Vu Thuy , Ko Linda , Cole Allison , Farris Paige E. , Shannon Jackilen , Zahnd Whitney , Lee Jessica ,   Cancer Prevention Control Research Network Rural Cancer Workgroup
Published: October 2019

165

Background: The National Cancer Institute (NCI) has identified rural cancer control as a research priority. Rural patients may have greater cancer-related financial burdens due to high travel costs, low insurance coverage, and less flexible work schedules. To better understand geographic differences in cancer-related financial toxicity from an organizational perspective, we interviewed staff from a range of cancer treatment settings in counties across the rural-urban continuum. The goal was to qualitatively assess the financial resources available to cancer patients, particularly those residing in rural areas. Methods: Seven research teams within the Cancer Prevention and Research Control Network interviewed personnel providing financial navigation services across four types of cancer care facilities and three urban/rural classifications. Interviews were audio-recorded and transcribed. We identified themes using inductive content analysis. A total of 28 interviews were collected across 7 states and preliminary results have been generated from 20 interviews. Results: Study participants identified transportation and housing costs as primary financial stressors for rural patients. A few personnel from centers in urban counties did not observe clear differences in experiences of financial toxicity between rural and urban patients. No personnel mentioned resources that are long-term or specifically for rural patients. Gas cards and temporary housing are often provided to help rural and urban patients access treatment. Insufficient staffing is a barrier to addressing patients’ financial concerns in rural and urban centers. Urban institutions, particularly NCI-designated facilities, employ more cancer-specific financial navigators than rural institutions. Conclusions: Patients across the rural-urban continuum experience financial hardship, but rural patients may be disproportionately affected by transportation and housing costs. Improving transportation and housing support may improve their ability to access treatment. Financial navigation practices within states vary; thus, patients and cancer centers may benefit from more streamlined approaches to address financial needs for all cancer patients.
Does the innovative 4R Cancer Care Delivery Model improve patient self-management in safety net and non-safety net centers?
Authors: Trosman Julia Rachel , Gradishar William John , Makower Della F. , Rapkin Bruce D. , Bozier Moreen , Knightly Eileen , Schaeffer Cathleen M. , Hoskins Kent , Gallagher Christopher , Lo Shelly S. , Grace-Louthen Cathy , Throckmorton Alyssa , Vanderwalde Lindi , Krueger Editha A. , Van Horn Jennifer , Ravelo Arliene , Schapira Lidia , Santa-Maria Cesar Augusto , Benson Al Bowen , Weldon Christine B.
Published: October 2019

172

Background: Under the NCI ASCO Teams Project, we proposed a 4R Model of teamwork and patient self-management (pSM) (Trosman JOP ’16). 4R (Right Info/Care/Patient/Time) enables patient (pt) and care team to manage complex care continuum with an innovative multimodality 4R Care Project Plan. 4R includes a novel “project” feature – a graphical description of care interdependencies. 4R was previously piloted at 3 Chicago centers (Trosman ASCO ‘18). Methods: In this new study, we improved and tested 4R for impact on pSM at 4 safety net and 3 non safety net centers across the US. 4R Plans were provided to stage 0-III breast cancer pts Jan - Nov’18 (4R cohort). We surveyed the 4R cohort and a historical control cohort of pts who received care at same centers pre-4R, Jan - Dec ’17. Results: Survey response rates: 65%, 105/162 (4R cohort); 44%, 190/432 (control). 4R markedly improved 4 of 5 pSM metrics vs control (Table). Additional analyses showed that safety net pts had a significant increase in 4R vs control cohort in “seldom overwhelmed” (84%, 49/58 vs 64%, 67/104 respectively, p = .007), while non safety net pts had nonsignificant increase. Other metrics improved to a similar extent for safety net vs non safety net pts. Within the 4R cohort, 85% found 4R useful in organizing their care and 73% found 4R’s novel “project” feature useful in understanding care interdependencies. Safety net pts reported similar usefulness of 4R in organizing their care as non safety net pts (88%, 51/58 vs 81%, 38/47, NS) and similar usefulness of the “project’ feature in understanding care interdependencies as non safety net pts (74% vs. 72%, NS). Conclusions: 4R significantly improved patient self-management, but further efforts are needed to expand the benefit to as close to a 100% of pts as feasible. Safety net pts benefited from 4R at similar or higher rates than non safety net pts, indicating that 4R may reduce care disparities. An expansion of 4R across the US continues this work.

[Table: see text]
A pilot study of a comprehensive financial navigation program in cancer patients and caregivers.
Authors: Steelquist Jordan , Watabayashi Kate , Overstreet Karen , Leahy Tony , Balch Alan James , Bradshaw Erin , Gallagher Kathleen D. , Lobb Rebecca , Lavell Laura , Linden Hannah M. , Ramsey Scott David , Shankaran Veena
Published: October 2019

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Background: Few studies have reported on interventions to alleviate financial toxicity (FT) in cancer patients (pts) and informal caregivers (cgs). We developed a financial navigation program in collaboration with Consumer Education and Training Services (CENTS), Patient Advocate Foundation (PAF), and Family Reach Foundation (FRF), to offer financial coaching, insurance navigation, and assistance with unpaid non-medical bills. We conducted a pilot study to assess feasibility of enrolling cgs with pts and to describe the assistance provided. Methods: Pts with any stage solid tumor actively receiving treatment (tx) at the Seattle Cancer Care Alliance were asked to identify a cg who could participate. Pts or pt/cg dyads received an online financial education course and monthly contact for 6 months (mo) with CENTS and PAF. Subjects were referred to FRF for assistance in paying non-medical bills. We describe pt and cg characteristics, and assistance provided by the program. Results: Of 54 pts approached, 30 (median age 59.5, 61% white, 97% stage III/IV disease) were consented. Most pts (53%) had income ≤ $25,000, and all were insured (48% commercial, 28% Medicare, 21% Medicaid). 18 cgs (67% spouse/partner) were consented. At consent, 55% of pts reported debt in the prior 3 mo. Mean score using the COST PRO FT measure (range 0-44, lower score = higher FT) was 17.4 at baseline. After pts’ physical health, out-of-pocket costs were the most stressful aspects of tx for cgs. Cgs with high financial burden from caregiving more often reported taking on new debt, dipping into retirement accounts, or changing their jobs or hours. CENTS coaches assisted with budgeting, updating wills, and employment rights counsel. PAF case managers assisted with financial assistance for drugs, cost of living (e.g. transportation), disability applications, and secured $6,950 in debt relief. FRF dispersed $4,133, primarily for housing expenses. Conclusions: Implementing a financial navigation program that engages both pts and cgs is feasible. This lower income, financially stressed population received $11,000 in financial assistance. Future work will focus on evaluating the impact of this program on financial and psychosocial outcomes in pts and cgs.
Employment outcomes, anxiety, and depression among caregivers of African American cancer survivors.
Authors: Hastert Theresa A. , Ruterbusch Julie J. , Schwartz Kendra L. , Harper Felicity W. K. , Baird Tara , Beebe-Dimmer Jennifer Lynn , Schwartz Ann G.
Published: October 2019

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Background: Cancer patients commonly rely on loved ones to act as informal caregivers during and after treatment. Caregivers may need to take time off work or make other employment changes to handle caregiving demands. Employment changes due to caregiving and their impacts on psychological outcomes are not well understood, especially among caregivers of African American cancer survivors. Methods: Results include information from caregivers of participants in the Detroit Research on Cancer Survivors (ROCS) cohort, a population-based study of African American survivors of breast, colorectal, lung, or prostate cancer from Metropolitan Detroit. ROCS participants nominated a friend or family member who acted as a caregiver to participate in the caregiver study. Caregivers provided information on employment and PROMIS depression and anxiety measures. The relationship between work outcomes and anxiety/depression was assessed using logistic regression models controlling for age, sex, income, and the caregiver’s relationship to the survivor. Results: For the first 350 caregivers enrolled, more than half (56%) were employed (42% full time, 14% part time) at the time of the survivor’s diagnosis. 53% of employed caregivers took time off work, including 40% who took unpaid time off to provide care. 16% took one month or more off work, including 12% who took at least one month of unpaid time. Taking at least one month off was associated with 2.3 (95% CI: 1.0, 5.4) times the odds of depressive symptoms but was not associated with anxiety. Extended unpaid time off was not associated with depression or anxiety. 38% of employed caregivers reported that it was somewhat, very or extremely difficult to balance work and caregiving. Difficulty balancing work and caregiving was associated with 3.1 times the odds of depressive symptoms (95% CI: 1.5, 6.2), and 2.2 times the odds of any anxiety (95% CI: 1.1, 4.3) compared with those who reported little or no difficulty. Conclusions: Difficulty balancing work and caregiving is common among caregivers of African American cancer survivors, and is associated with symptoms of depression and anxiety. Supports for caregivers facing employment challenges may improve their psychosocial wellbeing.
A dyadic study of employment outcomes and quality of life in patients with breast cancer and their support persons.
Authors: Veenstra Christine M , Braun Thomas , McLeod Chandler , Wittmann Daniela , Hawley Sarah T.
Published: October 2019

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Background: Many women with breast cancer face job loss related to their diagnosis, but little is known about employment outcomes among their partners and other supporters. Moreover, virtually nothing is known about associations between patients’ quality of life and supporters’ employment outcomes. Methods: Breast cancer patients reported to Georgia and LA SEER registries in 2014-15 (N = 2,502, 68% RR) and their key decision support person (DSP) were surveyed separately. 1234 DSPs responded (71% RR). Patients and DSPs were asked about employment impacts of the patient’s breast cancer. Patients’ quality of life (QOL) was measured with the PROMIS scale for global health. Descriptive analyses of employment outcomes (job loss, missed days due to cancer) were generated for patients and DSPs. Associations between patients’ QOL and employment outcomes of patients and their DSPs were assessed using linear mixed model regression analyses stratified by dyad type (partner vs. non-partner DSP). Results: Among DSPs, 43% were partners. 57% were non-partners (daughters, other family, friends). 67% were employed at time of patient’s diagnosis. Among these, 11% were no longer employed at survey completion. 39% missed >30 days work. Non-partner DSPs were as likely as partners to lose their job or miss work because of the patient’s cancer. 65% patients were employed at diagnosis. Compared to patients whose DSP was a partner, patients with non-partner DSP were more likely to lose their job (39% vs. 24%; p<0.01) or miss >30 days work (55% vs. 45%; p<0.01). For patients with partner and non-partner DSPs, having an employed DSP at diagnosis and having an employed DSP who stays employed were associated with improved patient QOL after adjustment for DSP sociodemographic and patient clinical variables. Conclusions: Both non-partner and partner DSPs faced negative employment impacts related to patients’ breast cancer. Job loss and >30 days of missed work were more likely among patients with non-partner DSPs. Having an employed DSP and having an employed DSP who stays employed positively contributed to patients’ QOL.
Integrating family caregiver identification into a gynecologic oncology practice: An ASCO quality training program project.
Authors: Campbell Grace , Boisen Michelle M. , Hand Lauren , Lersch Nora , Suchonic Barbara , Donovan Heidi AS
Published: October 2019

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Background: Family caregivers (CGs) in gynecologic (gyn) cancer are essential members of the care team, but no formal systems exist to provide CGs with information and support. A needs assessment of family caregivers (CGs) in our clinic found 50% of CGs report > 9 distressing unmet needs, but chart reviews found only 19% of patients had a documented CG--the first step in mitigating unmet needs. Our ASCO QTP-supported project aim was to identify (ID) and document primary CGs for 85% of patients within 2 clinic visits of a gyn cancer diagnosis. Methods: An Interprofessional team reviewed baseline data, defined the problem and project aim, created process maps, and identified root causes of poor CG documentation. After securing stakeholder buy-in we implemented eight successive PDSA cycles to intervene on root causes. Biweekly team meetings were held to study results, troubleshoot, and plan each PDSA cycle. Primary outcome was the percentage of patients with a CG documented. Results: Root causes of poor CG ID were 1) no protocol for IDing CGs, 2) no designated EHR field for CGs, 3) no designated staff to “own” CG ID, and 4) lack of CG awareness of available support in clinic. Interventions to prepare for project launch (PDSA 1) included protocol development, staff training, spirit activities, and selection of staff ‘champions’. In PDSA 2 CGs were ID’d for 25.3% of all patients in the clinic. By PDSA 4, CG ID dropped to a low of 12.5%. Major changes to PDSA 5 sought to reduce staff burden by narrowing focus to newly diagnosed patients, with an increase in CG ID to 56% of new patients. PDSA cycles 6-8 focused on increasing process efficiency while broadening CG ID to other times of high CG stress (e.g. recurrence; inpatient stays); CG ID rate stabilized at 57-60% over the last 6 weeks. In total, 288 primary CGs were documented. Conclusions: Proportion of CGs ID’d increased initially and then again after PDSA 4 as process efficiency improved. Despite falling short of our benchmark, CG ID more than doubled and we are planning further PDSA cycles to continue this momentum. Our results demonstrate systematic CG ID is feasible in a high volume Gyn Onc clinc and sets the stage for CG assessment and intervention.