bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of the end of public health emergency oral dispensing flexibilities for at-risk patients in a community oncology practice.
Authors: Wilfong Lalan S. , Dave Neal , Hemmen Wendy , Feinberg Erica , Doshi Gury K.
Published: October 2023

209

Background: Many studies have shown the benefit of medically integrated pharmacies for cancer specialty oral drugs in improving patient adherence and reducing waste compared to external pharmacies. Anti-kickback regulations have limited practice’s ability to deliver prescriptions to patient’s homes from physician offices. During the Covid Public Health Emergency (PHE), flexibility for prescription delivery by a physician owned pharmacy was allowed leading many practices to deliver oral cancer therapies to patients who could not otherwise come to clinics to fill their medications. With the end of the PHE, CMS reversed this flexibility. We sought to determine the impact on patients with this change in CMS regulations. Methods: Utilizing the pharmacy database of prescriptions delivered to a patient’s home for a large statewide community oncology practice in Texas during the PHE, we identified patients with Medicare part D who would no longer be able to utilize their physician’s pharmacy for home delivery of their specialty medications. We determined the distance of those patient’s primary address to the nearest clinic and further matched them to the address deprivation index (ADI) a well-validated approach that rank orders zip codes in deciles from lowest to highest need. Results: We found 970 patients receiving home delivered prescriptions with traditional Medicare Part D. 687 or 71% of patients lived within 20 miles of the nearest clinic. 213 or 22% lived between 20 and 50 miles with 70 or 7% more than 50 miles from the nearest clinic. 60 addresses could not be matched to the ADI database. Focusing on those available addresses in the top half of the ADI at highest need, we found that 40% of patients living within 20 miles of the clinic are at significant risk of disparity vs 67% of those 20-50 miles and 61 % of those living more than 50 miles from the clinic. Conclusions: The removal of the PHE flexibility for home delivery of prescriptions from physician offices will significantly increase the burden on patients in Texas, forcing many to drive long distances to obtain drugs and disproportionately affecting those at greatest risk of disparity. We encourage revising policies to allow medically integrated pharmacies to allow home delivery of cancer specialty drugs to meet CMS stated goals of improving health equity.
Association of state policies modifying Supplemental Nutrition Assistance Program (SNAP) eligibility and cancer stage at diagnosis.
Authors: Barnes Justin Michael , Kazmi Ali Rashed
Published: October 2023

214

Background: Food insecurity is associated with access to care and is particularly prevalent among adolescents and young adults (AYA) with cancer. The Supplemental Nutrition Assistance Program (SNAP) was designed to minimize food insecurity for low-income households. Under the broad-based categorial eligibility (BBCE) policy, states were given the ability to relax requirements for qualifying for SNAP through increasing the income limit or eliminating the asset test. While most SNAP policy changes under the BBCE policy occurred from 2009-2011, it is unknown whether these policies affect access to care among AYA with cancer. We sought to determine whether state SNAP eligibility policies were associated with stage at diagnosis among AYA patients. Methods: We utilized the Surveillance, Epidemiology, and End Results database to obtain data from 2006-2019 for newly diagnosed patients with cancer ages 18-39 years from 11 states. All cancer types were included with the exception of liquid tumors and other unstaged cancers. Difference-in-differences analyses were utilized to evaluate changes in the percentage of localized and distant stage diagnoses from pre- to post-policy enactment between states that enacted (1) asset test elimination or (2) increased income limit policies. Linear probability models were adjusted for state and year fixed effects, race, ethnicity, sex, metropolitan residence, marital status, county-level income, cancer type, and Medicaid expansion effects. We also accounted for state-level clustering via clustered standard errors. Event study analyses were utilized to assess the plausibility of the parallel trends assumption. Results: A total of 157,380 AYAs with cancer were identified. In adjusted difference-in-differences analyses, there was a 0.67 percentage point (PP) (95% CI = 0.15 to 1.19, P=.012) increase in localized stage cancer diagnoses and a -0.81 PP (95% CI = -1.41 to -0.21, P=.008) decrease in distant stage cancer diagnoses in states with increased income limits for SNAP eligibility relative to other states. There were no statistically significant changes in the percentage of localized (0.87 PP, 95% CI = -1.27 to 3.00, P=.43) or distant (0.05 PP, 95% CI = -1.44 to 1.55, P=.94) stage cancers with policies eliminating the asset test. Among patients with cervical cancer, where screening is recommended in this age group, there were extremely similar patterns. Conclusions: State policies increasing income eligibility limits for the Supplemental Nutrition Assistance Program were associated with a higher percentage of localized stage and a lower percentage of distant stage cancers among adolescents and young adults. These data add to a growing body of literature suggesting that policies that address social determinants of health may improve access to care.
Hospital use at the end-of-life among elderly Medicare beneficiaries diagnosed with poor prognosis cancers.
Authors: Kwon Youngmin , Hu Xin , Shi Kewei Sylvia , Zhao Jingxuan , Jiang Changchuan , Han Xuesong , Warren Joan , Yabroff Robin , Zheng Zhiyuan
Published: October 2023

232

Background: Hospital care for patients with cancer near the end of life (EOL) may reflect poor symptom management and be associated with worse quality of life. We quantified hospital use and in-hospital deaths among elderly Medicare beneficiaries with cancer. Methods: Medicare fee-for-service beneficiaries aged ≥65 years diagnosed with poor prognosis cancers, i.e., breast (stage IV), prostate (stage IV), non-small cell lung (NSCLC; stages III-IV), small cell lung (SCLC; all stages), and pancreas (all stages) cancers in 2008-2019 and died of cancer in 2014-2019 were identified from the linked SEER-Medicare data. The number of hospitalizations, intensive care unit (ICU) admissions, and in-hospital deaths during the last six months and last 30-days of life were examined with descriptive statistics (proportions, means, and rates per 100 person-months [PM]) by cancer site. Results: The final sample consisted of 40,304 patients diagnosed with poor prognosis cancers (mean age: 75.0 years). Among patients with pancreas and SCL cancers, nearly half died within 6 months of diagnosis. In contrast, six-month mortality was lower among patients with stage IV breast and prostate cancers. Among all patients in the last 6 months of life, there were 31.2 hospitalizations per 100 PM, with a mean of 2.02 hospitalizations among patients with any hospitalization. In patients with last 30 days of life, 34.7% had any hospitalization. Among hospitalized in the last 30 days, 43.4% were treated in an ICU and 35.2% died in hospital. Hospitalizations were high across all cancer types measured. Conclusions: Utilization of inpatient services among patients diagnosed with poor prognosis cancers is high near the EOL, which suggests sub-optimal care. Future studies should investigate patient and provider factors associated with such utilizations and identify opportunities to improve EOL care.[Table: see text]
Quality of end-of-life care for women diagnosed with metastatic breast cancer.
Authors: Brazee Rachel , Rosenzweig Margaret Q.
Published: October 2023

238

Background: Metastatic breast cancer (MBC) is a progressive, non-curative disease, with multiple therapy options. The toxicities and side effects from these therapies, as well as the signs and symptoms of advancing cancer, can cause patient and family related distress. To address these end-of-life (EOL) care needs, standards of care were established and recommendations provided. However, it is not clear if these standards are comprehensive in describing current MBC populations and their EOL experiences. Methods: This study used a sequential quantitative-qualitative mixed methods design to examine the quality of EOL care. The deceased patient’s designated personal representative (DPR) completed the Quality of Death and Dying (QODD) survey, with a subsequent/optional telephone interview. Results: The DPRs were predominately male (n=18; 72%), white (n=23; 92%), had some college education or more (n=24; 96%), and was the spouse/partner (n=16; 64%). The range in age was 25-95 years (SD 14.51), with the length of relationship varying between 7-63 years (SD 14.38). In the QODD survey (N=25), 40% (n=10), rated the overall quality of their loved one’s dying experience as ‘poor’ (score 0-4), yet 60% (n=15) rated the care they received from their healthcare team as ‘excellent.’ During the interview (N=16), the DPR was then asked to explore what made or what would have made for high quality EOL care. Four major categories emerged: resilience in response to transitions of care and adaptations to lifestyle changes; communication between healthcare providers and the patient/DPR in both content quality and delivery style; perceived support from the healthcare team, family, or spiritual advisors, specifically during changes in treatment goals; and knowledge as it relates to past experiences, when it was perceived as missing, or lack the knowledge regarding how to gather new information. Conclusions: The care needs for both the patient and DPR dynamically evolve throughout an MBC diagnosis and treatment. While resilience, communication, support, and knowledge all play a key role in the perception of the DPR regarding the quality of death experienced by their loved one, it is important to note that these experiences took place well before the EOL occurred and should be considered at the start of MBC treatment.
Implementation and assessment of an advanced practice nurse-led early palliative care initiative for patients with advanced pancreatic cancer.
Authors: Jia Sangyang , Lelond Stephanie , Kim Christina
Published: October 2023

262

Background: Early palliative care (EPC) referral reduces health care costs and improves quality of life and survival in some advanced cancers. Barriers to EPC exist. In April 2022, our provincial cancer centre (CCMB) implemented a clinical nurse specialist (CNS)-led intervention for patients with advanced pancreatic cancer (PANC), circumventing known barriers. New PANC referrals received at the provincial centralized referral office are triaged by an oncologist and concurrently referred to the CNS. CNS consultation focuses on physical and psychological symptoms, medication review, patient and family coping, and goals of care. Education is provided on PANC diagnosis, prognosis, symptoms, potential treatment options, navigating the cancer system, and community palliative care/hospice supports, with close collaboration with the patient’s primary care provider. This study reports on the impact of the CNS role and patient perceptions of this role on patient-centered care. Methods: We compared patients with PANC in the pre-implementation period (Jan 1, 2021, to December 31, 2021) to the post-implementation period (April 1, 2022, to March 31, 2023). Patients were identified using the Manitoba Cancer Registry and the CNS clinical database. Descriptive statistics were used to report quality measures. Results of patient reported perception of patient-centered care during the post-implementation period will also be reported. Results: In the pre-implementation period, 83 patients were referred to CCMB with PANC. In the post implementation period, 135 patients were referred. 125 (93%) accepted a consultation with the CNS, with a median time to meeting of 5 days (range, 0-18). After CNS consultation, 35% declined biopsy, oncology appointment or both. In the pre-implementation period, 29 (55%) patients were referred to palliative care/hospice within 8 weeks of diagnosis, compared to 66 (77%) in the post-implementation period. The mean time to palliative care referral was 18.2 weeks pre-implementation vs 8.0 weeks post-implementation (p=0.0007). Data on number of diagnostic biopsies, medical oncology consultations, and receipt of chemotherapy are in the attached table. Conclusions: This novel approach of CNS assessment and education soon after diagnosis of PANC, at the time of referral to CCMB, is acceptable to patients. It results in increased early referral to community-based palliative care/hospice. Exploring patient goals early may also spare patients from treatments that are time-consuming and associated with adverse effects, allowing those with a life limiting illness to focus on quality of life.[Table: see text]
Does financial assistance reduce catastrophic spending for patients prescribed oral anti-cancer medications at an integrated Specialty Pharmacy?
Authors: Swartz Scott , Clark Mackenzie , Lo Mimi , Gupta Arjun , Chino Fumiko , Lin Tracy Kuo , Ragavan Meera Vimala
Published: October 2023

27

Background: High copayments for oral anti-cancer medications (OAMs) can lead to detrimental financial and clinical outcomes for patients. Most patients insured by Medicare and prescribed an OAM reach the catastrophic phase of spending.1 Financial assistance programs are increasingly used to defray high out of pocket costs, though their ultimate impact on catastrophic spending has not been well-characterized. This study investigated whether receipt of financial assistance reduced likelihood of catastrophic spending for patients prescribed OAMs. Methods: This retrospective, single-institution, cross-sectional study included all patients prescribed an OAM with a >$0 annual copay at an academic integrated Specialty Pharmacy between 1/1-12/31/2021. Data were sourced through a prescribing-level pharmacy database and through a third-party (Vivor/TailorMed) database. A fixed-effects linear regression model was used to identify the impact of financial assistance (binary predictor) on catastrophic spending (binary outcome), defined as spending above $4430/yr based on the average Medicare Part D threshold from 2022 to enter the catastrophic copayments phase. The model was adjusted for demographic and clinical covariates. Results: 1,186 patients were included in the analysis. Average annual copayment on OAMs was $862.50 (SD = $4,673.47) with 5.6% of patients faced catastrophic spending. 37% of patients received some form of financial assistance. Patients who received assistance had significantly lower annual spending on OAMs overall (ß= -$1236; 95% CI: -$1841-658, p<0.001), but assistance was not associated with less catastrophic spending (OR=0.44; 95% CI: 0.14-1.38, p=0.16). Patients who were male, older, retired, insured by Medicare, and had higher annual household income by census tract were more likely to face catastrophic spending. Those who spoke English as a second language and lived in rural settings were less likely to face catastrophic spending. (Table). Conclusions: Financial assistance programs can decrease overall spending on OAMs but may not address financial burden for patients facing catastrophic level spending. Older adults with incomes too high to qualify for safety net or financial assistance programs may be at uniquely increased risk of catastrophic spending. Future studies should evaluate OAM-induced financial toxicity across diverse delivery systems and develop targeted interventions for patients who spend at catastrophic levels. [Table: see text]
Receipt of only palliative care among patients with advanced-stage head and neck cancer.
Authors: Abouelella Dina K , Gonzalez Katherine , Watts Tammara L , Pusapadi Ramkumar Shreya , Adjei Boakye Eric , Osazuwa-Peters Nosayaba
Published: October 2023

272

Background: Roughly two-thirds of patients diagnosed with head and neck cancer (HNC) have advanced-stage disease and many are eligible for palliative care. However, only approximately 20% of patients actually receive palliative care after their HNC diagnosis. The factors that affect access to palliative care for these individuals are not well understood. This study investigates the sociodemographic and clinical variables associated with receipt of only palliative care among patients with HNC. Methods: Based on data from the National Cancer Database (NCDB), a retrospective cohort was built, consisting of adult individuals diagnosed with advanced-stage (stages III and IV) HNC between 2004 and 2018. Outcome of interest was receipt of only palliative care. Independent variables included race/ethnicity, sex, distance from the treatment facility, health insurance status, and comorbidity burden. To estimate the likelihood of receiving palliative care, we used a multivariable logistic regression model that took accounted the independent variables and adjusted for other demographic and clinical factors. Results: Among the 233,109 patients included in our cohort, 6,146 received only palliative care, forming our analytic cohort. In our final models, male patients had a lower odds of receiving palliative care only (adjusted odds ratio [aOR] = 0.91; 95% confidence interval [CI]: 0.84, 0.99). Non-Hispanic Black (NH Black) patients had a higher odds of receiving only palliative care, (aOR = 1.37; 95% CI: 1.22, 1.53), compared to Non-Hispanic White (NH White) patients. Patients who were uninsured (aOR = 2.22; 95% CI: 1.88, 2.61), on Medicaid (aOR = 2.66; 95% CI: 2.36, 3.00), or Medicare/other government insurance (aOR = 1.60; 95% CI: 1.44, 1.79) had a higher odds of receiving only palliative care compared to those with private insurance/managed care. Additionally, higher comorbidity burden was associated with higher the odds of receiving only palliative care only (aOR = 1.67; 95% CI: 1.37, 2.02). Conclusions: Among patients with HNC presenting with advanced-stage disease, receipt of only palliative care is mostly associated with being a Black patient, having a greater comorbidity burden, and inadequate health insurance status. It is critical to improve equitable access to care for patients with HNC in order to optimize survivorship and mitigate disparities in HNC.
Evaluating the impact of therapy dogs on patients with cancer.
Authors: Curley Priya Belur , Patel Abhishek , Famoso Justin
Published: October 2023

278

Background: Chemotherapy/Immunotherapy infusion visits are unique experiences for cancer patients that can often increase stress and anxiety. Multiple papers have shown that therapy dogs can decrease anxiety, improve mental health, and increase relaxation. It has not been established that therapy dog visits during infusions can improve stress and anxiety similar to other clinical experiences. Our purpose was to explore if during this stressful experience therapy dogs would have the same impact as previously researched situations. Methods: At Virginia G. Paper Cancer Care Network North Scottsdale (HonorHealth) we drafted a survey. This anonymous and voluntary survey abstracted patient data that included: age, gender, dog ownership, and pet affinity. Patients were asked prior to a therapy dog visit to grade their anxiety and relaxation level and answered identical questions post-visit. Questions were drafted with Yes/No and scale of 1-10. Surveys were collected over an eight-week period from January 1, 2023 through February 28, 2023. Patients were surveyed in an outpatient infusion center. Results: 61 surveys were collected and analyzed. Statistical analysis was performed with a t-test for numeric and a binomial regression was fit to the data. 100% of patients surveyed liked animals & felt that therapy dogs helped with anxiety and relaxation. Anxiety levels significantly decreased by 31.1% (p <0.00001) after a therapy dog visit and relaxation levels increased by 25.8% (p = 0.0001). Age surveyed ranged from 40-85 with an average age of 63, with more females than males being surveyed. Conclusions: Patients at a small community hematology/oncology center can benefit from additional supportive services. In our prospective survey project, having a visiting therapy dog significantly decreased patient anxiety and improved relaxation during chemotherapy/immunotherapy infusion visits.
Economic evaluation of a non-medical financial assistance program on missed treatment appointments among adults with cancer.
Authors: Biddell Caitlin , Spees Lisa P. , Trogdon Justin G. , Kent Erin E. , Rosenstein Donald L. , Angove Rebekah SM , Rogers Cindy , Wheeler Stephanie B.
Published: October 2023

282

Background: Addressing patients’ cancer-related financial needs is critical to ensuring equitable cancer care delivery. Although many cancer centers report having financial support programs available to meet patients' medical and non-medical financial needs, formal evaluation of these programs has been limited. We retrospectively evaluated the impact of a program providing non-medical financial assistance on missed treatment appointments among patients receiving cancer treatment at a large, Southeastern public hospital system. Methods: We used patient electronic health records, program records, and cancer registry data to examine the impact of the program on rates of missed (or “no-show”) radiation therapy and infusion chemotherapy/immunotherapy appointments in the six months following treatment initiation. We employed propensity weighting to estimate the average treatment effect on those exposed to the program, stratified by treatment appointment type (radiation therapy, infusion chemotherapy/immunotherapy). We developed a decision tree-based economic model to assess the program’s cost-effectiveness from the health system perspective in a hypothetical cohort over a six-month time horizon. Results: Of 1,347 patients receiving radiation therapy between 2015 and 2019, 53% (N=715) had ≥1 no-shows, and 28% (N=378) received program assistance. Receipt of any assistance was associated with a 2.1 percentage point (95% CI: 0.6 – 3.5) decrease in the proportion of no-shows, corresponding to a 51% decrease in the overall mean no-show proportion. Under the current funding model, the program is estimated to save the health system $153 per missed appointment averted, relative to not providing non-medical financial assistance. Of the 1,641 patients receiving infusion chemotherapy/immunotherapy, 33% (N=541) received program assistance, and only 14% (N=223) had ≥1 no-shows. The financial assistance program did not have a significant effect on no-show proportions among infusion visits. Conclusions: This study employed a novel approach to retrospectively evaluate a non-medical financial assistance program for patients undergoing active cancer treatment. Findings support investment in programs that address patients’ non-medical financial needs, particularly for those undergoing intensive radiation therapy.
Associations among spiritual pain and the frequency and intensity of physical and psychological distress in patients with advanced cancer evaluated in a supportive care center during COVID-19 pandemic.
Authors: Delgado-Guay Marvin Omar , Baez Gonzalez Joannis , Guzman Diana , De la Cruz Maxine Grace , Fellman Bryan M. , Bruera Eduardo
Published: October 2023

284

Background: Patients with cancer are considered a highly vulnerable group, especially during the COVID-19 pandemic. There is limited literature describing the level of spiritual distress during the COVID pandemic and its association with the physical and psychological and distress in this population. Methods: Retrospective chart review of 1264 patients seen by the Outpatient Palliative Care Team from May 1st, 2020 to December 31st, 2020 (during COVID-19), 85% of the consults was delivered by Telemedicine. The association with ESAS-FS physical symptoms, Spiritual Pain (SP), anxiety and depression (none=0/10, the worst 10/10 were measured. Spiritual Pain was defined as “Pain deep in your Soul/Being that is not physical” (SP ≥1/10). Results: Spiritual Pain was present in 284/1264 (23%). Patients with Spiritual Pain were younger [Median years (Min-Max): 61 (21-90) vs. 62 (21-97), p=0.008], Hispanic [20% vs 16%, p<0.001], more single [15% vs. 10%, p<0.001], and divorced [13% vs. 9% p<0.001]. There was no association with gender and race. The frequency (%) and median intensity (0-10/10, 95%CI) of symptoms in patients with and without Spiritual Pain were, pain [90% vs 81%, 5 (0-10) vs 4 (0-10), p=0.691], fatigue [96% vs 90%, 6 (0-10) vs 5 (0-10), p<0.001], anxiety [90% vs 60%, 5 vs. 2 (0-10), (p<0.001], depression [87% vs 44%, 4 vs 0 (0-10), p<0.001], well-being [97% vs 81%, 5 (0-10) vs 3 (0-10), p=0.011], financial distress [78% vs 26%, 3 (0-10) vs 0 (0-10), p<0.001], total ESAS-FS distress [51 (7-113) vs 30 (0-92), p<0.001], respectively. 49% of patients with spiritual pain were evaluated by our psychological team vs. only 29% of those who did not have it (<0.001). Multivariate analysis for Spiritual Pain was financial distress (OR:1.24, p<0.001) and depression (OR:1.16, p<0.001). Conclusions: Important percentage of patients living with cancer experienced Spiritual Pain during COVID pandemic, this spiritual distress affected the expression of physical, psychological symptoms and worse well-being. An inclusive interdisciplinary team approach including spiritual care is needed. More research is warranted.
Cost-of-care discussions for individuals with newly diagnosed advanced non-small cell lung cancer and melanoma: Findings from a population-based study.
Authors: Yabroff Robin , Halpern Michael T.
Published: October 2023

3

Background: Growing costs of cancer care can result in patient financial hardship and many professional organizations, including the American Society for Clinical Oncology, recommend patient-physician discussions about expected treatment costs as part of high-quality care. Documentation of these discussions is critical as even privately insured patients may find care unaffordable without additional assistance. This study examined medical records of individuals diagnosed with advanced non-small cell lung cancer (NSCLC) and melanoma, cancers with recently approved expensive treatment options, for documentation of cost discussions. Methods: Individuals newly diagnosed 2017-2018 with stage III/IV NSCLC (n = 1767) and melanoma (n = 689) in participating SEER regions were randomly selected for the population-based National Cancer Institute Patterns of Care study. Medical records were reviewed for reported cost discussions; terms used and record location were abstracted. Patient-, treatment- and hospital- factors, including age, sex, race/ethnicity, comorbidities, and health insurance coverage, were examined for associations with cost discussions in multivariable logistic regression analyses. Results: Cost discussions were documented in the medical records of 24.6% of NSCLC and 25.5% of melanoma patients. “Out-of-pocket costs”, “patient assistance plan”, and “inability to pay” were most commonly used terms. Cost discussions were most frequently noted in physician or nursing progress notes and assessment plans. Documentation of cost discussions varied little by patient and hospital factors. In adjusted analyses, privately insured (vs. publicly insured) patients were less likely to have documented cost discussions (odds ratio (OR) = 0.54; 95% CI:0.37-0.80). Patients who did not receive systemic therapy or did not receive any cancer-directed treatment were less likely to have documented cost conversations than patients who received systemic therapy (OR = 0.39; 95% CI:0.19-0.81 and OR = 0.46; 95% CI:0.30-0.70, respectively). Conclusions: Cost discussions were infrequently documented in medical records of patient with newly diagnosed advanced NSCLC and melanoma; variability in documentation may hinder identifying this information and tracking referrals to address patients’ financial needs. The findings underscore the importance of systematic documentation of cost of care discussions to ensure high quality care for all patients.
Reducing stress and anxiety in cancer patients with the use of virtual reality.
Authors: Muzammil Zeeshan , Rajendran Ramji Ramaswamy , Gordon Alex
Published: October 2023

303

Background: Applications of virtual reality (VR) have impacted every sphere of civilization, from speculative architecture to the practice of medicine. Building on the body of research already showing the benefits of immersive VR experiences, the goal of our study was to determine whether the stress and anxiety experience of different types of cancer could be mitigated by using virtual reality, specifically through relaxing VR experiences. Methods: A comparative observational study was conducted at community outpatient offices for patients who wanted to improve patient experience throughout their cancer treatment. Patients who had symptoms of nausea, dizziness, and vision issues were excluded from the study. The VR intervention consisted of patients watching a relaxation VR 360 video on the YouTube app every day for one week on the Google Cardboard VR headset. Pre- and post VR intervention scores were recorded using a DASS21 questionnaire. The mean differences in scores as well as t-tests were compared between individuals to see if VR improved patient’s experience through one’s cancer treatment. Results: There were 115 subjects ( n = 115). There was an average reduction score of 6.50 points with stress seeing the biggest drop in score of 2.71 points. Breast cancer was the most common cancer diagnosis. Metastatic cancer was the cancer with the biggest change in VR intervention with an average decrease of 12.83 points. Conclusions: Virtual reality (VR) has been proven to significantly reduce the psychological discomfort, including stress, anxiety, and depression experienced during treatment, in the context of caring for cancer patients. The empirical results strongly imply that VR is an effective therapeutic intervention modality in the inpatient setting, with compelling implications for the use of VR technology in the future to lessen the physical and psychological suffering of cancer patients.[Table: see text]
Improving lung cancer screening starts with the primary care provider: Enhancing shared decision making for optimal patient outcomes.
Authors: Menakuru Sasmith R. , Beirat Amir F. , Dhillon Vijaypal S. , Emran Joseph , Salih Ahmed , Hanna Nasser H.
Published: October 2023

306

Background: Despite the critical importance of lung cancer screening (LCS), its uptake remains dismally low, with only 5.8% of eligible individuals undergoing screening. To harness the potential benefits of LCS, there is an urgent need for shared decision making (SDM) between patients and primary care physicians (PCPs), who often serve as the initial point of contact. Recognizing this need, the Centers for Medicare and Medicaid Services endorse LCS through low-dose computed tomography (LDCT) following SDM. This study aims to enhance SDM and increase LCS utilization by providing PCPs with a comprehensive checklist to address key points and better utilize their time. Methods: A concise checklist was created, which included pertinent points to address during an SDM meeting. This checklist was then given to the PCPs. Fifty-eight (58) PCPs affiliated with two hospitals in the Indiana University Health system agreed to implement the LCS-SDM checklist during office visits with eligible patients. All participating PCPs had existing relationships with LCS-eligible patients, received specific instructions for implementing the LCS-SDM checklist, and agreed to allocate a portion of their visits for SDM. In total, 194 patients on Medicare participated in this study and were interviewed: 158 had no documented history of LCS discussions, while 36 had previously been offered and refused LDCT. Following SDM interviews, PCPs completed written surveys to evaluate the impact of the LCS-SDM checklist on their practice and the perceived effectiveness of SDM. The patients were also surveyed to assess their receptiveness to the SDM process. Results: The majority of the 58 PCPs expressed support for utilizing SDM in LCS; however, time constraints emerged as a significant limiting factor. Despite feeling rushed during the SDM sessions, the PCPs acknowledged the value of the checklist as a helpful reference tool. Among the 158 patients who had not previously discussed LCS, 91 out of 158 patients (57.6%) opted to undergo screening. Among the 36 patients who initially declined LDCT, 20 out of 36 patients (55.5%) chose to participate in LCS after revisiting the topic. Impressively, 192 out of 194 patients (98.9%) expressed appreciation for the opportunity to engage in SDM. Conclusions: The results underscore the significant benefits of SDM in LCS, demonstrating its potential to improve uptake and patient outcomes. While time constraints present challenges for PCPs, both patients and physicians generally respond positively to SDM sessions. By implementing comprehensive checklists and facilitating dedicated time for SDM, primary care providers can effectively enhance LCS utilization and empower patients to make informed decisions regarding their lung health.
Addressing barriers in care management, shared decision-making alignment, and educational needs on novel immunotherapy combinations in melanoma.
Authors: Ackbarali Tariqa , Arnone Maria , Schollenberger Megan Davis , Hamid Omid , Lipson Evan J.
Published: October 2023

309

Background: Immunotherapy is being used increasingly to treat patients with locally-advanced unresectable or metastatic melanoma. To optimize patient care, members of the multidisciplinary healthcare team and their patients need up-to-date information about the latest therapies and the myriad factors that can influence outcomes. To assess patient-clinician alignment on perceptions of care, an educational initiative was designed for clinicians and patients/caregivers. Methods: A patient/caregiver educational activity was held in January 2023 in partnership with the Melanoma Research Foundation and remains on-demand at CancerCoachLive.com. An accredited clinician activity was held in February 2023 in collaboration with Partners for Advancing Clinical Education and remains on-demand at OMedLive.com. The Melanoma Action Coalition collaborated on both the patient and clinician activities. Behavioral assessment of preferences, attitudes, and barriers toward managing patients with melanoma were examined throughout the CME and patient/caregiver program. Data from these sessions were analyzed to determine behavioral and/or practice impact. Outcomes from the patient program were analyzed and provided as a supplemental resource for participants in the CME activity. Results: To date, 456 patients and 2,797 clinicians have participated in the educational initiative. Of the patient-reported experiences and preferences: 43% indicated they are under the care of a multidisciplinary team and only 42% were very satisfied with their current treatment regimen. The top two identified barriers in managing melanoma were anxiety about treatment efficacy (33%) and participating in normal activities (25%); these barriers were not aligned with those identified by clinicians. Upon evaluation of confidence in treatment decision-making; 70% of patients were not confident collaborating with their team while 74% of clinicians indicated low confidence in shared decision-making with their patients. At baseline, there was low awareness of safety and efficacy data regarding novel immunotherapy combinations and only 50% were likely to consider administering novel combinations to patients with unresectable locally advanced or metastatic melanoma. Clinicians additionally provided insight into barriers to patient enrollment in clinical trials with lack of trials at their institution being the greatest barrier (56%). Conclusions: Patient and clinician assessments provided an opportunity to determine misalignments in perceptions of barriers and insights into patient care experiences as well as clinician education needs. As novel immunotherapy combinations continue to become available for patients with unresectable melanoma, it is important to increase awareness of the clinical data and foster practical strategies to improve patient-centered care.
A randomized controlled trial of treatment planning process to enhance shared decision-making in patients with metastatic breast cancer.
Authors: Rocque Gabrielle Betty , Eltoum Noon , Caston Nicole E. , Williams Courtney , Oliver Marian Mead , Moradi Lauren , Ingram Stacey A. , Azuero Andres , Pisu Maria , Bhatia Smita
Published: October 2023

311

Background: A unique opportunity exists for patients with metastatic breast cancer (MBC) to engage in shared decision-making. Presenting patient-reported data, including patient treatment preferences, to oncologists before or during a treatment planning decision may improve patient engagement in MBC treatment decisions. This study tested the impact of a patient-reported data-driven, oncologist-engaged, shared decision-making treatment planning process compared to the standard treatment planning process. Methods: This randomized controlled trial tested a novel treatment planning process focused on shared decision-making, including oncologist review of patient-reported data and treatment preferences (e.g., impact on daily activities, financial concerns), prior to or during treatment decisions compared to the standard of care treatment planning process where this data was infrequently viewed and treatment plans were delivered as education following decisions. The trial was conducted in women with metastatic breast cancer receiving cancer treatment at a single National Cancer Institute-designated comprehensive cancer center. The primary outcome was patient perception of shared decision-making. Secondary outcomes included patient activation, physician perception of treatment decision-making, and physician use of the intervention. Descriptive statistics were calculated for all study outcomes. Cramer’s V and logistic regression models were used to evaluate effect. Subgroup analyses were conducted by race. Results: Among the 109 evaluable patients enrolled from 12/2018-6/2022, median age at consent was 59 years (interquartile range 49-65); 28% were Black, 12% lived in highly disadvantaged neighborhoods, and 24% lived in a rural setting. Patients receiving the intervention had a slightly higher perception of shared decision-making than patients receiving standard of care (63% vs 59%; V=0.05; OR 1.19; 95% CI 0.55-2.57). Among Black patients receiving the intervention, 77% of patients perceived the treatment decision to be shared, compared to 65% of Black patients in the control arm (V=0.10). Almost a third (31%) of patients in the intervention arm were at the highest level of patient activation compared to 19% of those in the control arm (V=0.18). In 82% of decisions, oncologists agreed the patient-reported data helped engagement in shared decision-making and 45% reported changing management due to patient-reported data. Conclusions: Oncologist review of patient-reported data in decision-making may be a promising approach to improve patient activation and patient-centric decision-making, particularly for Black women who may face challenges effectively communicating preferences during treatment discussions. This intervention should be tested in larger studies. Clinical trial information: NCT03806738 .
Evaluating shared-decision making among women with metastatic breast cancer.
Authors: Hendrix Emma , Henderson Nicole , Bourne Garrett , Thigpen Haley , Ingram Stacey A. , Triebel Kristen , Rocque Gabrielle Betty
Published: October 2023

313

Background: There are a multitude of treatment trajectories available for patients with metastatic breast cancer (MBC). Shared decision-making (SDM), which involves the incorporation of patient preferences and concerns into clinical conversations, is recommended in this context in order to encourage well-informed, patient-centered decisions. Little is known about how these conversations occur in practice. Methods: This qualitativestudy includedwomen with MBC participating in a randomized control trial (RCT) of a SDM intervention at the University of Alabama at Birmingham. Real-world MBC treatment decision-making encounters were audio-recorded, transcribed, and inductively analyzed using thematic content analysisvia NVivo software by two independent coders. Key themes and quotes were identified pertaining to patient treatment preferences and their influence on patient-oncologist treatment decisions. Results: From January 2020-December 2020, 59 decision-making encounters were recorded. Participants were primarily middle aged (Mean: 57.3, SD 10.8), White (70%), and many had travelled over an hour to their appointment (46.7%). Encounter discussions typically consisted of patient histories, scan or test results, symptoms, and treatment options. Key preference themes included logistics, ability to continue daily activities, physical side effects, previous experience with a particular treatment, survival, cosmetic concerns, and time with family. Patients most frequently expressed logistical preferences (“ We were hoping that, like if I have to go through any kind of chemo, if there's things that we could do in Tuscaloosa as opposed to driving up here.”). Some preferences were indirectly expressed via questions about treatment cost, efficacy, physical side effects, and cosmetic concerns. In 44% of the conversations (n=26), the oncologist explicitly invited the patient to share in decision-making by asking about their specific preferences. Most patients (77%, n=20) accepted the invitation ( “I will try [exemestane] again. I've had the same thought, maybe I should give it a wing. Maybe I'm different. And see if that helps.”), while 23% (n=8) deferred the decision to their physician (“ Whatever you think, because you the doctor. You know more than I do.”). Conclusions: More work is necessary in order to incorporate patient preferences efficiently and accurately into medical decision-making. Patients have varied needs and preferences that are not all directly related to efficacy or survival and are willing to participate in SDM care when directly engaged by oncologists.
Information needs when deciding to start a new line of therapy for advanced cancer: Are patients, caregivers, and oncologists aligned?
Authors: Sloss Elizabeth A , Staes Catherine Janes , McPherson Jordan P. , Scheese Carolyn M , Taft Teresa , Guo Jia-Wen
Published: October 2023

315

Background: Effective decision-making on whether to start the next line of therapy for advanced cancer requires comprehensive, tailored information aligned with needs and preferences of patients and caregivers. Our study aimed to compare patient and caregiver information needs to information that oncologists consider and share when discussing prognosis before starting a new line of therapy. Methods: Our study used Latent Dirichlet Allocation (LDA)-based topic modeling, a text mining method, to extract topics embedded in semi-structured interview transcripts from patient and caregiver (n=20) and oncologist (n=10) participants. Transcripts were collected as part of a larger study to design an interface for a prognostic tool. Patients and caregivers were asked to identify information needs when deciding to start a new line of therapy. Oncologists were asked through critical incident technique to recall a recent patient encounter and, with probing questions, describe information they consider and how they communicate expected survival time. Two members of the study team identified extracted topics using an interactive, intertopic distance map, then compared topics between patient/caregiver and oncologist datasets. Results: Results revealed 6 distinct topics from patients and caregivers and 6 distinct topics from oncologists that we grouped into 3 overall themes (Table 1). While topics across both participant groups were similar, two notable differences were found in patient and caregiver interviews: 1) the desire for information about support-related resources, which was not noted by oncologists, and 2) topics included keywords like “helpful” and “clear” to describe information needs, highlighting the importance of how information is presented by oncologists. Conclusions: LDA-based topic modeling was useful to identify topics from transcripts, highlighting information needs and what is shared when discussing prognosis and starting a new line of therapy. Limitations include use of self-reported descriptions and lack of actual conversations between patients and oncologists. However, findings show the ongoing gap in communication about support-related resources when discussing prognosis. Opportunities exist to enhance communication about prognosis and promote access to resources using decision support tools.[Table: see text]
Consuming patients’ days: Time spent on ambulatory visits by persons with cancer.
Authors: Kagalwalla Sana , Tsai Alexander K , George Manju , Waldock Anna , Davis Sydney , Jewett Patricia , Vogel Rachel I. , Ganguli Ishani , Booth Christopher M. , Dusetzina Stacie B , Rocque Gabrielle Betty , Blaes Anne Hudson , Gupta Arjun
Published: October 2023

324

Background: Health care-related time burdens faced by persons with cancer can be substantial. In qualitative work, patients report that ‘’seemingly short clinic visits (e.g., a supposed 10-minute blood draw) often turn into all-day affairs.” We sought to estimate the total time spent (home-to-home) by patients with cancer on ambulatory services at an urban cancer center. Methods: We conducted a retrospective study of all patients with cancer scheduled for any ambulatory care (e.g., laboratory testing, imaging, procedures, infusions, clinician visits) at a Midwestern academic cancer center during a randomly selected week (Monday-Friday) in January 2023. We extracted sociodemographics, clinical characteristics, and services received from the electronic medical record. The primary exposure was the ambulatory care type or combination received by a patient on a day (e.g., clinician visit only, labs and infusion, etc.). Using data from the Real-Time Location System (RTLS) badge that patients wear from clinic entry to exit (standard of care to optimize clinic workflow), we tracked time spent in each patient location (e.g., exam room) and in the clinic overall. We estimated round-trip travel times using home and clinic zip codes and SAS/Google Maps. We calculated median parking time by directly observing 20 random patients between the clinic and their vehicles (e.g., parking ramp or valet). We calculated and summarized clinic and total (clinic + travel + parking) times for different ambulatory care types. Results: We analyzed 468 encounters by 436 unique patients (median age, 64 years, 52% women, 82% white race, 19% breast cancer). Median (IQR) clinic time per encounter was 118 (76-200) minutes. The median (IQR) round-trip driving distance and travel time was 33 (21-53) miles and 50 (36-68) minutes. The median parking time was 8 (6-10) minutes. The median (IQR) total time was 189 (136-277) minutes. Table 1 presents the times by type(s) of ambulatory services. Conclusions: In this single-center retrospective study, pursuing ambulatory cancer care on a given day required patients (and their accompanying care partners) to commit several hours to their care. These findings highlight the need to decrease care time demands on patients to mitigate time toxicity. Accounting for opportunity time costs and the coordination of other daily activities around ambulatory care, these results support our previously proposed practical measure of the time burdens of cancer care—that any day with in-person healthcare contact may represent a ‘’lost day.”[Table: see text]