bluuebunny/crossref_metadata_2025 huggingface dataset:
Patient characteristics and outcomes at the University of Kansas Cancer Urgent Care (CUC).
Authors: Parikh Rahul Atul , Thomas Stevani , Hento Haylee , Janes Thu , Solis Gloria , McGuirk Joseph , Wright Jeff , Tsue Terry , Sun Weijing
Published: May 2020

e19154

Background: An increasing proportion of advanced cancer patients live longer and seek urgent or emergent care due to complex treatment regimens. Prolonged wait times and excessive cost of care are common deterrents for these patients to seek care in the Emergency Department (ED). Cancer Urgent Care (CUC) was established in February 2019 with the goal to provide timely and specialized care and improve outcomes for symptomatic cancer patients. Methods: CUC is staffed by two advanced nurse practitioners and two registered nurses and operates from 7am till 7 pm, Monday to Friday. Between 2019-2020, 471 patients were seen at the University of Kansas CUC. Visit information including diagnosis, duration of stay and outcome was retrospectively collected and analyzed using the REDcap database. Patient satisfaction and feedback surveys were conducted for each visit. Results: Most common causes for which patients sought care were dehydration 41.6%, nausea or vomiting 25.9%, pain 16.8%, diarrhea 9.8%, fever 9.6%, fatigue 8%, pneumonia 6.4% and sepsis 2.1%. Nearly 34% patients seen had underlying hematologic malignancy, other common disease sites included gastro-intestinal (26.8%), genito-urinary (14.6%) and breast cancer (13%). Average time to patient evaluation was 17 minutes and patients spend a mean of 3.2 hours in the CUC. Escalation of care (ED transfer) was required in 36 patients (7.6%), a majority of which (n = 28, 78%) required inpatient admission. An additional 58 patients (12.3%) required direct inpatient admission while a majority of patients (n = 385, 79.6%) were discharged home from the CUC. Overall patient satisfaction was very high, 68% patient noted that they would have sought care in ED if they were not seen in CUC while 30% patients would have waited for their next clinic appointment to discuss symptoms. Conclusions: Greater than 90% patients seen in CUC had a diagnosis being evaluated under Chemotherapy Measure (OP-35) by CMS. CUC provides a viable mechanism to provide specialized care to cancer patients resulting in improved patient satisfaction. Additional studies are ongoing to evaluate its impact on ED utilization and cost-effectiveness.
Impact of travel distance on timeliness of adjuvant chemotherapy in veterans with colorectal cancer.
Authors: Martin Richard Lewis , Edwards Gretchen C. , Samuels Lauren R. , Eng Cathy , Roumie Christianne L.
Published: May 2020

e19159

Background: Rural patients have well described disparities in quality cancer care. The VA Budget and Choice Improvement Act (2015) and VA Mission Act (2018) were passed to increase timely access to cancer care for veterans living at greater distances from VA facilities by paying for community oncology care. We sought to evaluate the baseline timeliness of adjuvant colorectal cancer (CRC) chemotherapy among patients living at increased distances from the Veterans Health Administration Tennessee Valley Healthcare System (VHA-TVHS) to determine local metrics for quality improvement initiatives. Methods: We reviewed 1,107 electronic medical records of patients with colorectal surgeries from January 1, 2000 to December 31, 2015 at the VHA-TVHS. We included patients with NCCN eligible pathologic high-risk stage II (T4/perf, R1, < 12LN, LVI) or stage III CRC and excluded those age ≥80, age ≥75 hospitalized in the prior year with a major co-morbidity, and death or hospice within 30 days of surgery. Primary exposure was travel distance from central zip code of patient residence to VHA-TVHS, categorized < 50 miles (N = 64), 55-99 miles (N = 60), and ≥ 100 miles (N = 56) to account for changes in referral patterns. Outcomes were days from surgery to first chemotherapy treatment and achieving a VHA timeliness standard of 56 days. Eligible patients not receiving chemotherapy were capped at 120 days per Commission on Cancer standard. Results: Of 1,107 colorectal resections, we excluded 623 for non-cancer, 212 for stage I or low risk stage II, 47 for metastases, and 45 for age, co-morbidity, death, and hospice, yielding a final cohort of 121 colon and 59 rectal cancer patients. Patients were predominantly male (96%), white (79%), and median age 64 years [Interquartile Range 60, 70]. Median days to chemotherapy were 62.5 days [48.5, 120] for those who lived < 50 miles, 58.5 days[46.5, 120] for distance 50-99 miles, and 84 days [50.5, 120]) for distance ≥ 100 miles. There were only 41%, 48%, and 32% in each distance group meeting the 56-day standard, respectively. Adjusting for known correlates, time to chemotherapy was 10.6 days longer for patients living ≥ 100 miles compared to < 50 miles (p = 0.08). Conclusions: Distance to care may influence timeliness of chemotherapy among southeast regional veterans. Given the observed overall low rate of timely chemotherapy, understanding modifiable health system factors associated with omissions and delays, as well as the impact of recent VA legislation merits further exploration.
Clinical decision support tools (CDST) provide education at the point-of-care to assist provider treatment choices.
Authors: Ginsburg Aimee , Wilfong Lalan S. , Denduluri Neelima , Howell Josh , Dickens Andrea , Casey Kelly Leigh , Hsieh Angela , Burke John M. , Cowey Charles Lance , Hoverman J. Russell , Knowles Lynne M. , Konduri Kartik , Larson Tim , Paulson Andrew Scott , Schnadig Ian D. , Andorsky David Jacob , Neubauer Marcus A. , Patt Debra A.
Published: May 2020

e19165

Background: Cancer care is complex and requires synthesis of increasing amounts of clinical and financial data to optimize treatment decisions. The heightened differentiation of individual cancers, therapy sequencing, and increasing number of treatment options make it more challenging for oncologists to stay current. A survey showed that 82% of Network providers validated the utility of clinical evidence and decision-making assistance at the point-of-care. Providing education on efficacy, toxicity, and cost in the form of evidence tables (ET) as CDST may assist in value-based decision-making. Methods: We retrospectively reviewed utilization of ET developed to provide clinical and financial data about regimens included within the Value Pathways powered by NCCN. Thirty ET were embedded in the electronic health record (EHR) and posted on our intranet between June-December 2019, covering over 90% of cancers. Utilization was queried from roll out through January 2020. ET include a summary of primary literature (primary/secondary endpoints, adverse events) and monthly Medicare allowable reimbursement rates. ET are updated with each change to pathways and quarterly for cost updates. We also conducted a survey to understand provider ET utilization patterns. Results: Utilization was evaluated for 1,200 physicians across 470 sites that have access to ET. ET have been accessed 1178 times by 586 providers within the EHR and accessed 1363 times by 260 providers via intranet. Our rate of repeat users of the ET is 35% in the EHR and 97% on the intranet. A survey of 200 physicians after ET release showed that 19% of physicians use ET with every new chemotherapy start and an additional 50% refer to ET only if they are uncertain about the best option. Conclusions: Utilization patterns underscore the importance of ET as a CDST within the EHR and on the intranet. While early ET use is high, continued tracking of utilization and addition of content to assist in complex clinical decisions is a priority. Providers surveyed found that clinical informatics tools like ET are useful to enhance decision-making in complex cancer care. [Table: see text]
Impact of cardiologist monitoring on inpatient hospitalizations in breast cancer patients receiving doxorubicin.
Authors: Sheth Karna , Fabbiano Maria , Hill Melinda , Webster Jennifer
Published: May 2020

e19168

Background: Value-based care (VBC) programs, like Medicare’s Oncology Care Model (OCM), hold medical oncology practices financially responsible for their patients’ cancer and non-cancer expenses. A well established factor in financial success under OCM is the complete capture of hierarchical condition categories (HCCs). Within Integra Connect’s OCM Network, one-third of all breast cancer IP was due to non-cancer HCCs with about 40% of non-cancer IP due to a cardiology-related HCC (Cardiac HCC IP). We evaluated Cardiac HCC IP rates in breast cancer patients receiving doxorubicin or docetaxel with or without Cardiologist Monitoring (Card-M). Methods: Retrospective claims review was performed from 11 practices with an episode start date July 1, 2016 – July 1, 2018. Cardiac HCC IP was identified using inpatient principal or admitting diagnosis codes matched to CMS-HCC Model Category V_22 ICD-10 diagnoses. Cardiac HCC IP rate was number of admissions per 100 episodes. Cardiologist monitored (Card-M) were patients with an office or non-emergency outpatient service by a cardiology specialist during their episode, unless their 1st cardiologist service was on or after a Cardiac IP or ED visit. Results: For both agents, Card-M patients had lower Cardiac HCC IP rates and higher % with Cardiac HCC coded vs. No Card-M. Conclusions: The results suggest that doxorubicin cardiotoxicity significantly contributes to OCM IP utilization and this risk can be mitigated but not eliminated by cardiologist monitoring. An unexpected benefit of increased HCC coding appears to be improved clinical and financial outcomes for patients when comorbidities are identified and managed, in this case by either selecting a less toxic agent or by ensuring that the patient is followed by a cardiologist. Specialist referral may be able to minimize non-cancer expense. Note that increase cost from cardiologist services may offset cardiac HCC IP savings. Improved quality of life may also be a consideration. This methodology excludes patients who have cardiac risk that is undetected. Moving forward, we may attempt to develop predictive models to identify these patients. [Table: see text]
PROMIS-10 scores at six months post-baseline among breast and gynecologic oncology patients participating in a text-based symptom monitoring program with patient navigation.
Authors: Naughton Michelle Joy , Salani Ritu , Lustberg Maryam B. , Peng Juan , Moon Jennifer , Loyan Hibaq , Paskett Electra D.
Published: May 2020

e19173

Background: Unreported symptoms during cancer treatment can lead to poorer patient care and quality of life. eHealth technologies enable effective means to track patients’ health in real time to provide assistance in meeting patients’ needs and facilitating symptom management. Methods: Gynecologic (endometrial and ovarian) and breast oncology patients were enrolled in a quality improvement program post-surgically to respond to 12-monthly, text-based symptom surveys assessing fatigue, sleep quality, pain, and depression (PHQ-9). At baseline, 6 and 12 months, patients also completed the PROMIS-10 to assess their physical and mental health functioning. All patient responses were captured in REDCap and monitored by program staff, with patients’ oncologists receiving monthly feedback for patient follow-up. Patient navigators were also engaged for patients needing assistance with non-medical concerns. We provide the interim results of this program on PROMIS-10 scores from baseline to 6 months. Results: 198 breast and 120 gynecologic oncology patients (ovarian [n = 70] and endometrial [n = 50]) were enrolled. Multiple regression examined the impact of demographic (age, race, education), clinical (stage, chemotherapy, radiation), and monitoring program variables (# of monthly surveys completed, navigation services [yes/no]) on PROMIS-10 physical and mental health subscale scores at 6 months, adjusting for baseline PROMIS scores. For the breast patients, the only significant predictor of worse PROMIS physical health scores was a cancer stage of 4 vs 1 (p = 0.049), whereas a higher number of symptom surveys completed was associated with worse mental health functioning (p = 0.033). For the gynecologic oncology patients, worse PROMIS physical health scores were only associated with higher age (p = 0.037), but higher PROMIS mental health was also associated with higher age (p = 0.029) and borderline significantly associated with not using navigation services (p = 0.07). Conclusions: These results indicate that greater adherence in completing monthly symptom surveys and using navigation services were more likely to be associated with patients reporting lower mental health. PROMIS physical health scores, however, were not significantly associated with adherence to monthly surveys or navigation services. These interim results suggest that monitoring programs, such as this, may assist in identifying and treating patients with lower mental health functioning during treatment.
Oncology team perception and patient experience discordances in triple-negative breast cancer (TNBC) care.
Authors: Hurvitz Sara A. , Crawford Rebecca R , Sapir Tamar , Carter Jeffrey D.
Published: May 2020

e19176

Background: In TNBC, ensuring patients understand their treatment options and engaging them in shared decision-making (SDM) is vital to patient centered care; however, system-, team-, and individual-level barriers may challenge optimal SDM. As part of a quality improvement, accredited initiative, we identified areas of discordance between oncology healthcare professionals (HCP) perception and actual patient reported experiences. Methods: From 02/2019 – 10/2019, we administered surveys to assess challenges, barriers, attitudes, and experiences of HCP who care for patients with TNBC (N = 77) and their patients with TNBC (N = 65) at 6 community oncology practices. Results: Despite indications of high levels of SDM – 86% of patients indicated that they are always or mostly involved with treatment decisions – survey responses highlight discordances. For example, when asked to identify the most influential factors to patient treatment choice, HCP most commonly indicated side effects (94%), while patients most commonly indicated quality of life (48%). Additionally, when asked to identify the side effect of greatest concern to patients, 61% of patients indicated alopecia, while 45% of HCP indicated gastrointestinal (GI) distress. While both HCP and their patients indicate that the oncology team is the most useful source of patient education, HCP underestimated the extent to which patients rely on their primary care providers (PCPs). Patients and HCP each identified limited time as a barrier to SDM, but patients indicated not knowing what to ask, while HCP indicated that low health literacy was the top barrier to SDM. 31% of patients and their care team identified that improvements in discussions about realistic prognosis were vital to improved care. Conclusions: These survey findings reveal discordances between oncology HCP’s perceptions and patient reported experiences when receiving treatment for TNBC. These findings may highlight areas for improvement in co-productive patient-centered care. [Table: see text]
Trend in incidence, first course of treatment, and survival in patients with glioblastoma.
Authors: Yang Eunyoung , Egorova Natalia , Moskowitz Gil , Bickell Nina A.
Published: May 2020

e19178

Background: Glioblastoma (GBM) is the most common form of primary brain cancer and notoriously difficult to treat. Over the last 15 years, the population has been aging, yet, there are gaps in analysis of incidence of GBM associated with demographic changes. Further, several important treatment changes over time have led to 3 combined therapies becoming the standard of care since 2005, but their impact on GBM survival are not well established. Methods: The Surveillance, Epidemiology and End Results (SEER) database was analyzed from 2000-2015. We identified 30,955 GBM patients. We calculated the incidence rate and adjusted incidence rate using 2015’s population as a standard, then identified the trends in incidence and treatment using JoinPoint. Survival was analyzed with Kaplan-Meier and Cox proportional hazard models. Results: The incidence of GBM was highest among elderly (≥65yr), followed by adult (19-64yr) and pediatric population (≤18yr) (6.24, 1.64 and 0.10 per 100,000, respectively). The GBM incidence was significantly higher among white than black and other race (2.10 vs. 0.78 vs. 0.77 per 100,000; p < 0.001) and among males than females (2.12 vs. 1.46 per 100,000; p < 0.001). The incidence of GBM has increased from 1.63 to 1.96 (per 100,000) during this period with an annual percent change (APC) of 1.39 (p < 0.001). After adjusting for patient age, the APC was 0.72 (p < 0.001). Combination therapy has increased dramatically since 2000: from 29.3% to 60.9%. Those who underwent all three treatments had better overall survival than those who did not (p < 0.001) after adjusting for comorbidities and demographics. Median survival increased from 7 months (2000-2003) to 11 months (2012-2015) (p < 0.001). In the multivariable model, advanced age, stage, white race, and large tumor size were associated with worse survival, while combination treatment with improved survival (HR = 0.2; CL 0.22-0.24). Conclusions: While there appears to be a growth in the incidence of GBM, it is tempered by the aging of the population. Patients who underwent all three therapies had greater survival than those who did not. Efforts should focus on increasing the proportion of patients who undergo the standard care.
What constitutes high-quality NSCLC care? Overarching quality considerations for improving NSCLC care at US cancer centers.
Authors: Socinski Mark A. , Boehmer Leigh
Published: May 2020

e19181

Background: While clinical guidelines for non-small cell lung cancer (NSCLC) provide recommendations on specific individual components of care and advocate multidisciplinary collaboration, guidance on multidisciplinary care spanning the complete patient journey is lacking. Quality-focused recommendations for the multidisciplinary team, along with selected clinical criteria for ideal NSCLC care, were compiled, and a new set of metrics encompassing the entire care continuum was proposed. These metrics were used to set a new benchmark for ideal NSCLC care through the Association of Community Cancer Centers’ (ACCC) national quality care initiative for patients with advanced (stage III/IV) NSCLC. Methods: The ACCC convened an expert steering committee of multidisciplinary specialists and representation from patient advocacy, who identified and compiled evidence-based recommendations via a systematic search of clinical and quality care guidelines and peer-reviewed journals. Ideal quality recommendations were organized within key care areas of the patient journey: care coordination, diagnosis, and treatment. Results: A total of 32 recommendations were included. Of these, 9 were key unpublished recommendations on NSCLC care, including diagnosis and biomarker testing, treatment planning, care coordination, and patient education (Table). Conclusions: These recommendations define the criteria for ideal NSCLC care and serve as a valuable resource to guide multidisciplinary practice and quality improvement initiatives. [Table: see text]
Using an ePRO tool to help meet quality metric reporting standards: Screening for tobacco usage and falls risk.
Authors: Buzaglo Joanne S. , Stepanski Edward , Joiner Mary , Taylor Deb , Musallam Alexander , Richey Sylvia S. , Schwartzberg Lee S. , Vanderwalde Ari M. , Decker Veronica B.
Published: May 2020

e19191

Background: ASCO has implemented the Quality Oncology Practice Initiative (QOPI), a certification program established to evaluate oncology practice performance. Also, a growing number of accreditation (JCAHO) and merit-based organizations (MIPS) maintain falls risk assessment standards. Practices often lack the necessary resources to comply with required metric reporting standards. The study purpose was to document the effectiveness of using an electronic Patient Reported Outcome (ePRO) system to facilitate compliance with a core QOPI standard, documentation of smoking status by second office visit, and with JCAHO and MIPS falls risk assessment. Methods: This study used a retrospective, observational design with ePRO collected via the Patient Care Monitor (PCM), a web-based ePRO system linked to electronic medical record data. All study data were collected as part of routine clinical care at a community oncology practice during an 11-month interval (1/2019–11/2019). Patients at an initial clinic visit completed a tobacco usage survey and a brief falls risk survey on the PCM platform via a handheld e-tablet. Results: Overall, 6,613 unique patients completed the PCM survey (mean age 59; 33% male/67% female; 55.4% White, 38% Black). Cancer type was known for a subset of patients (22% breast, 9% hematologic, 4% lung, 5% colorectal, 3% prostate, 11% other types). Across the collected PRO measures, there was an over 98% completion rate with only 1-2% missing data. A relatively significant proportion (51%) indicated they had never used tobacco products and 15% indicated that they were current users. Among patients who ever used tobacco products, 34% indicated they smoked cigarettes, 4% smoked cigars, and 3% used electronic cigarettes. Over a fifth of patients (22%) indicated they had at least one fall over six months; 10% indicated having experienced one fall; 6% indicated two falls; 6% indicated 3 falls or more. 17% indicated they use an ambulatory aid and 12% reported a recent fall within the past 3 months. Conclusions: This study demonstrates that using an ePRO system is an effective way to screen for tobacco usage and falls risk and can be used to: 1) monitor health-related behaviors to enhance physician-patient communication; 2) provide an audit trail for QOPI, JCAHO, MIPS and other quality metric reporting. Automated collection of PRO data allows the healthcare team to focus their clinical time on patients showing increased risk. Overall, an ePRO system contributes to creating a culture of excellence at community oncology practices.
The impact of a multidisciplinary approach (MA) in the management of pancreatic disease (PD).
Authors: Di Stefano Brunella , Quero Giuseppe , Bagalà Cinzia , Fiorillo Claudio , Bensi Maria , Menghi Roberta , Cina Caterina , Mattiucci Gian Carlo , Manfredi Riccardo , Cellini Francesco , Brizi Maria Gabriella , D'Aversa Francesca , Perri Vincenzo , Larghi Alberto , Attili Fabia , Inzani Frediano , Alfieri Sergio , Tortora Giampaolo , Salvatore Lisa
Published: May 2020

e19196

Background: The management of PD is very insidious, mainly due to the often difficult differential diagnosis between benign and malignant diseases, and, in case of pancreatic ductal adenocarcinoma (PDCA), to the frequently hard differentiation among resectable/borderline PDCA susceptible to upfront surgery, locally advanced PDCA susceptible to a neoadjuvant approach and never resectable or metastatic PDCA in which a palliative treatment is the only option. A correct PD evaluation and the subsequent choice of the most appropriate treatment strategy, thus, need a MA, involving surgeons, oncologists, radiologists, radiation oncologists, endoscopists, gastroenterologists and pathologists. On the basis of such considerations, we investigate the impact of the multidisciplinary meeting (MM) in the management of PD at our Institution. Methods: We retrospectively evaluated all the cases discussed by surgeons at our MM. We collected data, both pre- and post-MM, regarding diagnosis (cyst vs pancreatitis vs IPMN vs PDCA), and, in case of PDCA, tumor burden at baseline (resectable vs border-line resectable vs locally advanced vs metastatic disease) and disease response to treatment (disease control vs progression). Primary endpoint was the overall rate of discrepancy in diagnosis and/or PD evaluation between pre- and post-MM. Results: From October 2018 to December 2019, a total of 139 cases were presented by surgeons. After MM, a total of 38 diagnosis and/or PD evaluation were modified, for an overall discrepancy rate of 27%. In particular, of the 38 discordant cases, 9 (24%) were initial diagnosis, 24 (63%) baseline tumor burden assessments and 5 (13%) were PDCA response evaluations. Among the 24 cases of tumor burden evaluations, treatment strategy changed in 17 out of 24 cases. More specifically, of the 19 cases, evaluated as borderline/resectable before the MM, 15 were defined as locally-advanced or metastatic disease after the MM; of the 5 cases, evaluated as not resectable before the MM, 2 were considered border-line/resectable after the MM. Similarly, out of 9 cases of discrepant initial diagnosis, 5 cases, considered as malignant disease before MM, were assessed as benign after the MM. Conclusions: Our analysis demonstrates a significant rate of discrepancy in diagnosis and/or PD evaluation between pre- and post-MM. Our results show that a MA allows a considerable modification in PD diagnosis and evaluation, maximizing the treatment strategy, in particular avoiding unnecessary and detrimental pancreatic surgery.
Associations between safety and tolerability and reporting of health-related quality of life in phase III randomized trials in common solid tumors.
Authors: Saleh Ramy , Meti Nick , Ribnikar Domen , Goldvaser Hadar , Ocana Alberto , Templeton Arnoud J. , Seruga Bostjan , Amir Eitan
Published: May 2020

e19206

Background: Anti-cancer drugs are approved typically on the basis of efficacy and safety as evaluated in phase III randomized trials (RCTs). Health related quality of life (HRQoL) is a direct measure of patient benefit from drugs. Despite this, HRQoL is not reported universally for all anti-cancer drugs. Here we explore associations with reporting of HRQoL data in phase III RCTs in common solid tumors. Methods: We searched ClinicalTrials.gov to identify phase III oncology RCTs evaluating new drugs in adult patients with breast, colorectal, lung, or prostate cancers. We included all completed or active trials that completed accrual between January 1, 2005 and October 31, 2016. Data were extracted from published trials including HRQoL data and toxicity data on toxic death, treatment discontinuation and commonly reported grade 3 or 4 adverse events (AEs). Then, we explored associations between these safety and tolerability measures and the odds of reporting HRQoL data and whether HRQoL were favourable or not. Analysis comprised logistic regression and was performed in SPSS version 25. Results: A total of 377 phase III RCTs were initially identified. After excluding ineligible studies, a total of 143 studies were analysed. All trials (100%) were in the metastatic setting with 79 (55%) being positive trials. 40 (28%) were breast cancer trials, 38 (26%) were focused on evaluating chemotherapy, and 128 (90%) of trials were industry sponsored. 84 (59%) trials reported measuring HRQoL data, however of these, only 47 (56%) reported HRQoL data. In 14 (30%) HRQoL was improved with experimental therapy. There was no association between treatment related death (OR 1.25, 95%CI 0.74-2.12, p = 0.398) or treatment discontinuation (OR 1.12, 95%CI 0.73-1.72, p = 0.61) with reporting of HRQoL data. Associations with grade 3 or 4 AEs are shown in the Table. Conclusions: HRQoL is reported for only around a half of RCTs that collect such data. Reporting of HRQoL is not associated with safety and tolerability of anti-cancer drugs. [Table: see text]
4R Program results: What is the impact of 4R care delivery model on patient self-management and which patients benefited?
Authors: Trosman Julia Rachel , Weldon Christine B. , Makower Della F. , Rapkin Bruce D. , Bozier Moreen , Perez Claudia Beth , Kulkarni Swati , Schaeffer Cathleen M. , Hoskins Kent , Gallagher Christopher , Lo Shelly S. , Grace-Louthen Cathy , Throckmorton Alyssa , Krueger Editha , Van Horn Jennifer , Ravelo Arliene , Yu Elaine , Schapira Lidia , Benson Al Bowen , Gradishar William John
Published: May 2020

e19211

Background: We previously proposed a 4R model of teamwork and patient self-management (pSM) in cancer care (NCI ASCO Teams Project, Trosman JOP 2016). 4R (Right Info / Care / Patient / Time) enables patient and care team to manage complex care with an innovative 4R Care Sequence plan, including a novel visual feature describing timing and sequence of care. We report final results of a program which tested 4R at 5 safety net and 5 non safety net US centers from 2016 to 2019. Methods: Patients with stage 0-III breast cancer received 4R plans (4R Cohort). We surveyed 4R cohort and a historical control cohort of patients receiving care at same centers pre-4R. We assessed the usefulness of 4R to the 4R cohort and the impact on pSM in 4R cohort compared to historical cohort. Results: Survey response rates: 63%, 422/670 (4R cohort); 47%, 466/992 (control). 4R significantly increased the composite pSM score and 5 of 7 pSM metrics vs control (Table). The increase was not influenced by patient age, stage or whether treated at safety net site. pSM scores increased in 4R vs control cohort to a similar extent for patients < 65 years old (74% vs 51%, p = .0001) as for patients ≥ 65 years old (78% vs 57%, p = .0002). pSM improved similarly for patients with stage 0 or I breast cancer (77% vs 56%, p = .0001) as for patients with stage II or III breast cancer (72% vs 54%, p = .0001). Safety net patients showed pSM increase (77% vs 51%, p = .0001) similar to non safety net patients (74% vs 58%, p = .0002). Within the 4R cohort, 80% found 4R useful for organizing care and 70% found the novel visual feature useful to manage care timing and sequence. Usefulness was similar for age groups and stages, but higher for safety net than non safety net patients (88% vs 74%, p = .0008). Conclusions: 4R markedly improved patient self-management in early breast cancer across age groups and cancer stages, but further enhancements are needed to benefit as many patients as possible. 4R benefits in safety net setting indicate that 4R may reduce disparities. [Table: see text]
Colorectal cancer: Improving screening in rural clinic.
Authors: Le Thuy Thanh Thi , Fleckenstein Lorraine , Jiang Zhaozhi , Davis Shellian , Yarlagadda Lakshmi
Published: May 2020

e19215

Background: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. From 2010 to 2014, CRC was also the second leading cause of cancer deaths in North Carolina (NC). Between 2012-2016, the age adjusted mortality rate was 18-25 per 100,000 persons in Robeson County, NC. During this timeframe, it is estimated that if all people aged 50 and older in NC were routinely screened, 40 out of 100 deaths from late stage CRC can be prevented. A chart review in a rural primary care clinic identified patients not being appropriately screened for targeted intervention. Methods: Retrospective chart review at Lumberton Medical Clinic, a rural outpatient Internal Medicine Clinic, reviewed 1622 records from adults 50-75 years old during the timeframe September 2017 - August 2018 for phase I and 1588 records from September 2018-August 2019 for phase II. Patients with history of CRC or status-post colectomy for other reasons were excluded from this study. Patient records were assessed for compliance with USPTF CRC screening guidelines – adults aged 50 to 75 years receive screening as follows: 1) Fecal occult blood testing (FOBT) annually 2) Flexible sigmoidoscopy every 5 years 3) Colonoscopy every 10 years OR 4) Combined FOBT (every 3 years) + flexible sigmoidoscopy (every 5 years). Following data analysis in phase I, interventions to increase screening rates were initiated – provider education, posters hung in exam rooms, and individualized letters mailed to patients found deficient. The success of this effort was measured in phase II. Results: For phase I, the review showed 56% of patients received appropriate screening and 44% were found with no documentation of screening. Following interventions, 76% received appropriate screening and 24% with no documentation. Thus, there is ~35% improvement in screening rate. Conclusions: The mortality rate from CRC is higher in Robeson County compared to the NC state rate. Additionally, 40% of deaths from late-stage CRC may be prevented by doing a routine screening. It is the responsibility of providers to emphasize the importance of proper screening. This retrospective review showed ~ 35% improvement in screening rates following interventions. The result might not be as high as expected due to several factors: 1) new resident physicians and faculty 2) few posters were taking down due to disagreement with the guidelines by one of the 3 main providers 3) patients might not receive the letters. To further increase the screening rate, we are implementing the “Preventive Maintenance” tab in our electronic medical record system at the end of clinic visits.
Plant-based diet trends in oncology patients.
Authors: Webster Bradley R , Ton-That Matthew V , Hashemi-Sadraei Neda , Shah Satyan K
Published: May 2020

e19224

Background: Plant-based diets are beneficial in several cancers such as colorectal and prostate. However, their adoption among oncology patients is not well studied. We report trends in plant-based diet selection among medical and surgical oncology patients at a comprehensive cancer center. Methods: An IRB-approved retrospective review of all patients admitted to the University of New Mexico Hospitals between October 2009 and October 2017 was conducted. Inclusion criteria included: 1) vegetarian Ovo-Lacto (dairy and eggs ok) or vegan (no animal-derived foods) inpatient diet request and 2) age >= 18 years. For each individual, the dietary orders and discharge summaries were reviewed. Patients with cancer diagnosis principally related to admission and/or admission to an oncology inpatient service were defined as oncology patients. Surgical oncology services included 8 different surgical branches. Results: A total of 181 oncology patients ordered plant-based diets. Median age was 62 years (range 18 to 90) and 69% were female. Vegetarian Ovo-Lacto (66%) was requested more than vegan diet (34%). The services on which the greatest number of these patients were treated were Medical Oncology (31%), General Surgical Oncology (23%), and Gynecology-Oncology (20%). Comparing medical and surgical oncology patients, there was no difference in terms of median age (63 vs. 62 years, p=0.62), nor in the % requesting vegan diet (30 vs. 35%, p=0.50), respectively. However, females comprised 95 of 124 (77%) surgical patients, but only 29 of 57 (51%) medical patients (p<0.001). The number of patients requesting a plant-based diet grew from 81 in the first half of the study period to 100 in the second half (a 23% increase). During this time period, vegetarian diet became more popular than vegan with an increase from 48 patients (59%) in the first half to 72 (72%) in the second half (p=0.05). Conclusions: Oncology patients are increasingly requesting plant-based diets. Most are female and prefer vegetarian over vegan meals. These findings can help cancer centers improve quality of care by tailoring nutritional offerings.
Changes in intravenous immunoglobulin (IVIG) usage for hypogammaglobulinemia (HG) after implementation of a stewardship program.
Authors: Derman Benjamin Avi , Schlei Zachary , Mullane Kate M. , Parsad Sandeep , Knoebel Randall W
Published: May 2020

e19225

Background: IVIG is used to replenish immunoglobulins in HG due to hematologic malignancies (HM) or their treatment (stem cell transplantation (ASCT) and chimeric antigen receptor T-cell therapy (CAR-T)), in an effort to reduce the risk of infections. There is limited high-level evidence to support this use, and IVIG supplies are limited with a recent shortage leading to restricted allotments. We report the results of a stewardship program designed to safely reduce IVIG usage. Methods: An IVIG stewardship plan (ISP) was implemented with the following requirements for IVIG administration: IgG level < 400 mg/dL (corrected for paraprotein) for post-ASCT and post-CAR-T patients, or IgG < 400 mg/dL with evidence of a bacterial infection within the last 3 months that required hospitalization or an emergency department encounter for those with HM. We evaluated the amount of IVIG administered, the incidence of infections, and antibiotic administration before and after implementation of an ISP. Results: In the 3 months pre-ISP, HG accounted for 38% (72/188) of total IVIG orders. 86 pts received IVIG for HG in the 3 months pre-ISP. The amount of IVIG given decreased from 1907 g/month pre-ISP to 670 g/month post-ISP; estimated cost savings in IVIG was $57,561/month. The pre-ISP median IgG level prior to dosing of IVIG was 550 (range 40-1189) mg/dL. Compared to pre-ISP, pts who stopped receiving IVIG post-ISP had lower median pre-dose IgG (444, range 93-819 mg/dL, p<0.05), infections/patient-months (14/141 vs 56/255, p<0.001), antibiotic usage (12/47 vs 44/86, p<0.05), and hospitalization rate for infection (4/55 vs 21/86, p<0.05); no deaths occurred. For those receiving IVIG post-ISP, adherence to guidelines was 64%. Compared to pre-ISP, median pre-dose IgG was lower (328, range 51-1011 mg/dL, p<0001), infections/patient-months decreased (27/163 vs 56/255, p<0.001), and antibiotic usage, hospitalization rate for infection, and deaths from infection all remained stable. Conclusions: An ISP for HG led to a dramatic and sustainable decrease in IVIG usage, primarily by selecting out patients who are low risk for infection after discontinuation of IVIG. Such an ISP is replicable and warrants adoption.
Implementation of the Institute of Medicine treatment plan in oncology practice.
Authors: Sivendran Shanthi , Wilfong Lalan S. , Horenkamp Elizabeth , Rocque Gabrielle Betty
Published: May 2020

e19233

Background: Participation in the Center for Medicare and Medicaid Services (CMS) value-based payment reform, The Oncology Care Model, requires that every beneficiary has a documented 13-point Institute of Medicine (IOM) treatment plan (TP) when commencing antineoplastic therapy. The intent of this document is to enhance shared decision making between the patient and care team by providing transparent treatment recommendations and engaging patients and caregivers in meaningful discussion. There is limited discussion in the literature on how to adapt the CMS recommendations to diverse practice settings while maintaining fidelity to the intent of the TP. Methods: We compare how three clinically and geographically unique OCM participating institutions implemented the TP in their respective institutions within the domains of the Consolidated Framework for Implementation Research (CFIR). Settings include a community cancer institute in the northeast, an academic hospital setting in the southeast, and a large community cancer network in the southern United States. Results: We identified similar themes in implementation including engaging stakeholders, leveraging information technology, structuring the TP, development of clinic processes and considering scalability. We also describe adaptations unique to the culture and setting of each site. Conclusions: Although studies have shown patients do not feel informed of their diagnosis, there are currently many approaches to improving shared decision making including utilizing the 13 points of the IOM TP as mandated by the OCM. We provide practical strategies for incorporation of the TP into clinical care with lessons from diverse settings. As shown by the wide variability in implementing shared decision making, further research is needed to optimize illness understanding. Additionally, optimal implementation of CMS’s IOM TP would ideally include concrete metrics measuring impact on shared decision making, illness understanding, or patient satisfaction.
Physician perceptions about goals of care of hospitalized patients with malignancies.
Authors: Balanchivadze Nino , Slota Alexander Antoni , Mangano Andrew , Kudirka Adam , Alkhatib Yaser
Published: May 2020

e19234

Background: More sophisticated treatment techniques in cancer management have led to increased complexity in patient care. The perception of cancer outcomes is different between physicians and may result in premature hospice referral in hospitalized patients with or without cancer-related acute illness. We created a clinical scenario-based survey to assess perceptions of goals of care choices of inpatient primary providers while caring for patients with malignancies. Methods: A survey was developed and sent to all internal medicine and primary care residency programs nationwide via “Survey Monkey” online platform. Cases were adapted from real patient encounters. A total of 8 cases were presented and physicians were asked to determine level of care. Two cases represented potentially curable disease, three described patients with treatable but incurable malignancies, and the remainder described patients with advanced malignancies appropriate for hospice care. Physicians were also questioned about patterns of consulting hematology/oncology (HO) and their opinions regarding barriers in providing care to patients with malignancies. Results: Of 269 physicians who took the survey, 184 physicians (68%) fully completed it. 37% reported consulting HO for every patient with underlying malignancy, while 2% of the providers do not have access to HO consultants. In curable cancers, 65% of physicians would request inpatient oncology consultation while 11% would initiate hospice referral. There was a significant variation in choices for care in treatable cancer cases. In case 1, 13% of surveyed physicians thought that patients were hospice appropriate, while a higher percentage felt the same for the 2nd and 3rd cases with 18% and 52%, respectively. For hospice-appropriate patients, 25% of providers felt that further cancer treatment should be performed in younger patients, while the majority agreed on hospice referral (91%) for older patients. The most reported barrier to providing care to hospitalized patients with malignancies was a disconnect between the perception of goals of care of the primary treating oncologist/hematologist and patient’s actual condition. Conclusions: Perceptions about goals of care in hospitalized patients with malignancies varies and is affected by patient age and perceived severity of disease, which doesn’t necessarily translate into outcome statistics reported in literature. A multidisciplinary approach and treating oncologist involvement might be warranted when patient goals of care change is planned in hospital setting.
Real-world clinical and economic burden associated with hospitalization in metastatic triple-negative (ER-/PR-/HER2-) breast cancer.
Authors: Tan Amie , Han Xu , Near Aimee , Tse Jenny , Preger Luciana
Published: May 2020

e19236

Background: Metastatic triple-negative breast cancer (mTNBC) is associated with poorer disease prognosis and higher healthcare utilization and costs compared with other breast cancer subtypes, with hospitalizations being a major cost driver. This study aimed to understand reasons for hospitalization and describe the clinical and economic burden associated with hospitalizations in mTNBC patients following 1L treatment initiation. Methods: mTNBC patients were identified in the IQVIA Real-World Data Adjudicated Claims-US database (Jan. 2012 – Jan. 2019) and indexed on the day of 1L treatment initiation. Women ≥18 years of age with mTNBC who had continuous enrollment for ≥12 months before (baseline) and ≥30 days after (follow-up) index and no evidence of other primary cancers during baseline were included. Patient baseline characteristics and all-cause hospitalizations during follow-up were described. Results: 4,617 mTNBC patients were identified (mean age 54 years; 99.7% with chemotherapy as IL); 1,595 (35%) had ≥ 1 hospitalization during follow-up (mean duration 17 months). More hospitalized patients had ≥2 metastasis sites (25% vs. 15%, p < 0.01) as well as visceral (15% vs. 7%, p < 0.01) or bone metastases (15% vs. 8%, p < 0.01) than non-hospitalized patients. The average time from index to first hospitalization was 7.4 months and hospitalized patients had a mean of 2.4 hospitalizations per patient per year (PPPY), with mean length of stay of 6 days. 25% of hospitalized patients were admitted from the ED. Reasons for hospitalization included chemotherapy-related adverse events (AEs; 76%), followed by disease progression (72%), breast-related surgeries (6%), and others (4%). Common chemotherapy-related AEs included infection or pyrexia (46%), anemia (35%), and neutropenia (17%). Total cost associated with hospitalization was $57,115 PPPY, with the annual out-of-pocket cost averaging $3,659 per patient; mean out-of-pocket cost per hospitalization was $1,840. The proportion of patients with hospitalization was similar between metropolitan and rural patients (35% vs. 37%, p = 0.51), yet metropolitan patients had slightly longer hospital stays (mean 6 vs. 5 days, p = 0.03). Conclusions: Approximately one-third of mTNBC patients were hospitalized following 1L treatment initiation and in turn, bear a high economic burden. New therapies are needed to mitigate the clinical and economic burden associated with hospitalizations in this population.
Similar negative emotional impact on hair loss in neoadjuvant endocrine therapy compared to neoadjuvant chemotherapy in young women with breast cancer from patient reported outcomes.
Authors: Gwark Sung-chan , Ahn Sei Hyun , Noh Woo Chul , Lee Eun Sook , Jung Yongsik , Kim Lee Su , Han Wonshik , Nam Seok Jin , Gong Gyungyub , Kim Seon-Ok , Kim Hee Jeong
Published: May 2020

e19242

Background: We aimed to evaluate patient-reported outcomes (PROs) in the NEST phase III trial, in which neoadjuvant endocrine therapy (NET) compared to conventional neoadjuvant chemotherapy (NCT) for hormone-responsive lymph node-positive premenopausal breast cancer. Methods: Premenopausal women with estrogen receptor (ER)-positive, HER2-negative, and lymph node-positive premenopausal breast cancer patients were enrolled. Patients were randomized to either 24 weeks of neoadjuvant chemotherapy with doxorubicin plus cyclophosphamide followed by taxane (T) or neoadjuvant endocrine therapy with goserelin and tamoxifen. PROs were assessed at day 1 (baseline) and at the end of treatment, using the breast cancer module of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 23 (EORTC QLQ BR23). ClinicalTrials.gov: NCT01622361. Results: 187 patients were randomly assigned to chemotherapy (n=95) or endocrine therapy (n=92), and 174 patients completed the 24 weeks of neoadjuvant treatment period (n=87, both). Baseline scores were similar between arms. No statistically significant between-treatment differences were observed for the function scales including body image, sexual functioning, and sexual enjoyment although endocrine treatment showed significant improvement in future perspective (HR=8.3, 95% CI:1.72-18.38; P=0.021). Even though no alopecia was reported in NET group, no statistically significant difference between both arms in the “upset by hair loss” was observed, in which NET group showed even worse score. Conclusions: Patients who received NET had significant improvement in a future perspective, however, a similar emotional negative impact on hair loss was observed compared with NCT despite no reported alopecia. Key words: breast cancer, patient-reported outcomes, quality of life, hair loss, EORTC QLQ-BR 23. Clinical trial information: NCT01622361 .