bluuebunny/crossref_metadata_2025 huggingface dataset:
Improving radiotherapy quality of care: Examining practice patterns in regional centers.
Authors: Stosky Jordan , Wu Jackson S.Y. , Fairchild Alysa M. , Kerba Marc
Published: September 2018

53

Background: Radiotherapy (RT) is a resource intensive cancer treatment. Benefits may take weeks to realize, whereas side effects are more immediate. RT is commonly delivered with palliative intent often near the end of life (EOL). In patients with limited life expectancy, single fractions (sf) may substitute for multi-fraction (mf) treatments. Objectives were to document RT courses delivered to patients with cancer at EOL, with the goal of informing treatment practices, developing a clinical decision-making tool and reducing potentially futile treatment and side effects for patients. Methods: Cancer Registry data was examined with ethics approval. Patient and prospective treatment data were collected and analyzed to determine the number of RT courses starting within 90 days of death (EOL) among those with cancer diagnoses who died between January 1, 2016, and July 31, 2017. Data was stratified by demographics, disease factors, RT center and prescription factors. Results are reported in aggregate and explored using tests of association (Stata 11.1). Results: Among 1874 patients who died, 2448 RT courses were identified across 4 RT centers. Of those prescribed RT at the EOL, there were 442 sf courses 100% completed, 1267 2-5 fraction courses 90% completed, 552 6-10 fraction courses 77% completed, and 187 11+ fraction courses 57% completed. Among patients prescribed RT 14 days prior to death, 24% had been prescribed a sf of RT compared to 18% of those within 90 days of death (Chi2 17.92, p < 0.001). Among patients prescribed RT 90 days prior to death, 25% of patients in tertiary Centre A were prescribed a sf compared to 13% of patients in tertiary Centre B (Chi2 121.90, p < 0.001). Patients were half as likely (RR = 0.47, 95% CI [0.39, 0.56], p < 0.001) to complete a mf treatment within 14 days of their death as compared to within 90 days. Patients who had a diagnosis to death interval of under a year were less likely to complete RT than those over a year (RR = 0.82, 95% CI [0.79, 0.85], p < 0.001). Conclusions: Multi-fraction RT is often not completed prior to death. Treating RT center is associated with differences in prescribing patterns. Better understanding of factors influencing RT practice patterns may lessen the proportion of potentially futile RT.
Implementing an EHR guideline–based intervention in paper ordering systems.
Authors: Bell-Brown Ari , Egan Kathryn , Kreizenbeck Karma L. , Watabayashi Kate , Lyman Gary H. , Hershman Dawn L. , Bansal Aasthaa , Barlow William E. , Sullivan Sean D , Ramsey Scott David
Published: September 2018

56

Background: Studies show Colony Stimulating Factor (CSF) prescribing is inconsistent with national guidelines. SWOG trial S1415CD is a pragmatic study comparing outcomes of CSF use in usual care with care that uses guideline-informed standing CSF orders. The intervention includes embedded CSF orders based on Febrile Neutropenia (FN) risk and system note wording describing guideline recommendations. Of 24 intervention sites, five (20.8%) use paper, presenting the challenge of translating an electronic health record (EHR) intervention to paper order entry systems (OES). Methods: Paper sites were surveyed on their chemotherapy OES to inform translation of the intervention. We worked with sites to develop a workflow consistent with the key principles of the intervention: Recommendation language 1) is present before prescribing CSF, 2) reaches all study-authorized orders, 3) reaches all patients on study-authorized orders, and 4) chemotherapy and CSF are ordered before the patient is enrolled. Results: Each site had a distinct workflow that was reworked (Table 1). Paper sites took 4-10 months (average 7.6) for implementation; EHR sites took 1-10 months (average 4.5). Conclusions: Implementing an EHR-centric intervention in paper sites is feasible with appropriate time and resources built into a project to account for the unique challenges. As paper sites represented one fifth of the intervention sites, it is vital to include paper sites in OES interventions for generalizability of results. Clinical trial information: NCT02728596. [Table: see text]
Utilization of a web-based supportive oncology training curriculum for healthcare professionals (HCPs).
Authors: Lo Shelly S. , Roggenkamp Betty , Hasson Kristin , Trosman Julia Rachel , Rosenberg Carol A. , Lillis Teresa , Knightly Eileen , Pasquinelli Mary , Wiebe Lauren Allison , Gerhart James , Penedo Frank J. , Martin Joanna , Robinson Patricia A. , Scheu Amy , Berardi Rosa , Weldon Christine B.
Published: September 2018

59

Background: A challenge in supportive oncology is training the HCP workforce. The Coleman Supportive Oncology Collaborative clinicians (faculty) from 25 institutions (academic, community & safety net) developed a unique and easily accessible supportive oncology training curriculum (Trosman JR JNCCN 2017). Methods: Using data provided by The National Comprehensive Cancer Network (NCCN) Continuing Education team, we evaluated completion rates of survivorship and supportive oncology education courses using simple frequencies. Results: Over 4748 on-line courses were completed (pretest, course, post-test, evaluation) of 7184 accessed. Of 4748 courses, nurses completed 45%, physicians 17%, advance practice clinicians 16%, and others 22% (social workers, chaplains, MAs). Course completion improved from 65% to 69% after articles describing collaborative work were published in Cure and Oncology Nursing News, p = 0.0014. Conclusions: A variety of HCPs successfully completed supportive oncology guideline education via the NCCN’s education portal. These on-line courses are an efficient way to train HCPs in supportive oncology. Curriculum advertising improves course completion.[Table: see text]
Referral rates and supportive care metrics for a first-year community oncology AYA program.
Authors: Cull Elizabeth H. , Mcalhany John , Taylor Sarah B , Bowers Heather , Susko Kerri , Saha Aniket
Published: September 2018

63

Background: Adolescent and young adult (AYA) oncology patients have a unique set of needs compared to younger and older patients that are often not addressed by primary providers in a busy clinical setting. Genetic counseling, fertility preservation, clinical trial enrollment and psychosocial support are a few of the key needs to address in this group. The AYA Cancer Program was created to specifically address these issues and mitigate the disparity in care and outcomes often seen in the AYA cohort. This study examines the number of patients referred to the AYA Cancer Program in its first year and evaluates the role of the program in addressing the supportive care needs of AYA patients. Methods: The study assessed patients actively under treatment between ages 15-39 from September 1, 2016 to September 1, 2017. The number of referrals to the AYA program, participation in the AYA program, and met supportive care needs (fertility, genetics, clinical trial participation) were examined. Results: During the first year of the clinic, 63 (22%) of the 288 AYA patients seen throughout the whole institution were seen in the AYA clinic. An additional 34 (12%) patients were referred but did not come to the appointment. 192 (69%) patients were not referred. Compared to non-referred patients, AYA clinic patients were more likely to be enrolled on a clinical trial (54% vs. 18%), have a documented fertility counseling discussion (94% vs. 16%) and receive a genetics referral (69% vs. 43%). Patients that were referred to the clinic but did not come were slightly more likely than non-referred patients to be offered the above services as well but still trailed the group of patients seen in the AYA clinic. Conclusions: Patients that were seen in the AYA program were more likely to receive fertility referrals, genetic referrals and had increased clinical trial participation compared to patients that were not referred. This highlights the essential role of the AYA clinic in meeting these under addressed needs in the AYA population. [Table: see text]
Implementation of a fellow-initiated financial toxicity screening tool in medical oncology clinics.
Authors: Brondfield Samuel Craig , Borno Hala , Mulvey Claire , Huang Li-Wen , Cinar Pelin
Published: September 2018

64

Background: Financial toxicity is an increasingly recognized problem for patients receiving cancer treatment, particularly in the high-cost precision medicine era. Financial toxicity is linked to asset depletion, debt, and bankruptcy. To address this imminent concern, we designed, implemented, and evaluated a fellow-initiated financial toxicity screening tool for use in medical oncology clinics. Methods: An interprofessional team of University of California San Francisco (UCSF) social workers and physicians selected three highly rated items from the COST measure, a published financial toxicity tool with validity evidence. We oriented all UCSF hematology/oncology fellows to the tool and the concept of financial toxicity. We instructed fellows to screen all patients other than second-opinion visits and to offer a social work referral to high-scoring patients. Implementation was from August 2017 to March 2018. While screening was initially documented in the progress note, in October 2017 we built a navigator into the electronic medical record to facilitate screening. We randomly selected one half-day per week for each fellow and reviewed charts for screening scores. The cumulative goal was to screen 30% of eligible patients during implementation. Results: Fellows (n = 8) rotated in five disease-specific medical oncology clinics. Prior to implementation, fellows did not document financial toxicity (0%). At the mid-point of implementation, fellows had screened 32% of patients. By the end, the cumulative screening rate decreased to 18%. The screening tool will be presented. Qualitative fellow feedback identified lack of provider familiarity with financial toxicity, packed clinic visits, and difficulty remembering to screen as barriers. Fellows suggested that screening performed by clinic staff prior to the encounter might better inform the visit. Conclusions: Fellow-initiated financial toxicity screening was initially successful but decreased over time. Future iterations could include screening prior to the encounter, augmenting provider financial toxicity training, and continual reminders. Future work is needed to improve screening and mitigate the impact of financial toxicity.
A focus on culturally sensitive communication to transform institutional awareness of health care disparities.
Authors: Maples William James , Argenio Sandra L , Scaz Linda , Krippner Jennifer
Published: September 2018

69

Background: Healthcare organizations can cultivate the strength of a diverse workforce in creating a culture of excellence. Enabling the team to understand how personal and cultural beliefs affect our decision making and how we interact with patients and colleagues is integral. Gaps in care exist in cancer diagnoses and treatment in many minority groups. A need for education in the nature of assumptions, unconscious biases, and awareness around the existence of healthcare disparities, was identified through culture transformation work within multiple healthcare institutions. Methods: An experiential course was designed for multi-disciplinary groups of providers. Designed to meet the evolving demographics in the country and help participants recognize how their own cultural beliefs and values affect their decision making. Topics include cultural awareness, assumptions and unconscious bias, effective use of interpreters, and skills to recognize when cultural differences may be playing a role and how to successfully navigate these situations. Raising awareness of healthcare disparities is highlighted, including disparities in cancer care diagnosis, treatment and outcomes for different ethnicities and socioeconomic groups. Examples include disparities in diagnosis, treatment and outcomes of lung cancer, colon cancer and breast cancer in minorities. Results: Participants engage in skills-based work. Participants develop a plan how they can take this information and education back to help create an awareness of disparities and skills to successfully navigate these situations. After this program, participants will be cognizant of the nature of assumptions and unconscious bias and understand the strength of diversity as an asset rather than a hindrance. Conclusions: Healthcare disparities can have a significant impact on patient experience, quality and outcomes. Specific inequities in cancer diagnosis and treatment in minorities is highlighted. Participants are provided with information and skills that can be introduced to their home institutions to have all caregivers recognize and successfully navigate culturally sensitive situations.
Reducing the impact of distance on hematopoietic cell therapy patients.
Authors: Burns Diane , Simanovski Vicky , Hagens Victoria Karuna , Matheson Garth
Published: September 2018

74

Background: Hematopoietic Cell Therapy (HCT) patients experience unique travel challenges and high out-of-pocket costs due to the highly specialized care required. We conducted a mixed methods study to understand current patient support programs in Ontario and other jurisdictions and a cost analysis to inform the development of recommendations to reduce the impact of remoteness on HCT patients and caregivers. Methods: Qualitative information on patient transportation and accommodation supports was gathered through informal and structured input from fourteen Ontario Regional Cancer Program Directors, Hematologists, Patient and Family Advisory Council and Aboriginal Navigators. An environmental scan of medical travel assistance programs within Ontario and in other jurisdictions was performed. A scoping literature review was conducted of published studies focused on inequities in receipt of cancer care in countries with Universal Health care. HCT patient travel patterns to each of the transplant facilities in Ontario were obtained from analysis of Cancer Care Ontario data holdings. Results: We concluded that travel assistance for cancer patients in Ontario varies considerably across the province, and that Ontario lags behind other jurisdictions in Canada and internationally. The scoping literature review revealed that patients who live far from specialist centres, for some diseases, have later stage at diagnosis, less timely access to specialist care, poorer outcomes, lower patient experience scores, and make treatment decisions based on distance. From the analysis of travel patterns for HCT patients, provincially 4 – 79% of patients travel for HCT based on their location (see table below). Conclusions: This study highlights the need to better support HCT patients in Ontario. As a result, a proposal to support accommodations for HCT patients was developed and approved by the Ontario government for implementation in 2018/19.[Table: see text]
Comparing quality of care for Medicaid and commercially insured patients with cancer in Washington State.
Authors: Fedorenko Catherine R. , Panattoni Laura Elizabeth , Walker Julia Rose , Li Li , Kreizenbeck Karma L. , Ramsey Scott David
Published: September 2018

75

Background: Uniformity in receipt of high quality cancer care is imperative to reduce health care disparities. In order to help prioritize efforts aimed at reducing disparities in care, we compared several quality metrics for Washington State cancer patients enrolled in Medicaid and commercial insurance plans. Methods: We linked 2014-2016 Washington state cancer registry records for cancer patients under the age of 65 with enrollment and claims records for the two largest commercial insurers in the state and Medicaid. We then generated thirteen nationally recognized quality measures. Outcome measures were adjusted for age, sex, comorbidity score, stage, cancer site, and treatment factors where appropriate. Process measures were not adjusted. Results: 6,868 commercially insured and 2,379 Medicaid patients are represented in the reported quality measures. Conclusions: Care of Washington state cancer patients enrolled in Medicaid is comparable or superior to commercially insured patients, except for significantly higher ED use during chemotherapy. Further research is needed to understand why Medicaid-enrolled cancer patients utilize the ED at more than double the rate of commercially insured patients.[Table: see text]
Financial toxicity of cancer treatment at a diverse county hospital.
Authors: Ahuja Parikh Divya , Ragavan Meera Vimala , Maitra Debeshi , Aggarwal Sangeeta , Patel Manali I.
Published: September 2018

76

Background: The rising costs of cancer care increasingly results in financial distress for patients and their families. Low-income patients face a greater burden of financial toxicity, but few studies have characterized what factors contribute to this, and what interventions can relieve toxicity. Methods: From October 2017 to December 2017, we used a validated COST survey tool to understand the extent of financial burden that patients with cancer experience. We surveyed patients who receive their oncology care in a medical system that serves predominantly minority and low-income patients in Santa Clara County. We collected demographic information including sex, education level, ethnicity, income, insurance status, monthly out of pocket costs (OOPC) and employment status prior to diagnosis. We used a multivariable linear regression to study the association between the patient factors and financial burden as demonstrated by the COST score. All data were analyzed using Stata 14. Results: Demographic information is presented in Table 1. A total of 152 patients completed all 11 items of the COST survey. In the multivariate model, there was no significant difference in COST score by sex, education level, or ethnicity. However, income ≤$25,000 was associated with higher COST scores (p = 0.019), as was higher monthly OOPC (p = 0.003). Medicare patients and patients who were employed prior to diagnosis tended to have higher COST scores although not quite statistically significant (p = 0.057, p = 0.083). Conclusions: Patient-reported financial toxicity is an unmet concern among patients in this single institution study with a high proportion of underinsured patients. Higher OOPC and low income was associated with a higher financial burden. These findings suggest that patients would benefit from targeted interventions to mediate out of pocket costs of cancer care.[Table: see text]
Assessment of language needs and resource use among Canadian immigrant patients with cancer.
Authors: Liu Sophia , Smith Elliot Charles , McCartney Alexandra , Basgaran Amedra , Balaratnam Karmugi , Brown M Catherine , Howell Doris , Jones Jennifer M. , Giuliani Meredith Elana , Xu Wei , Liu Geoffrey , Eng Lawson
Published: September 2018

77

Background: Canada's foreign-born population is estimated to reach up to 30% by 2036. Immigrants diagnosed with cancer can face poorer cancer outcomes compared to non-immigrants due to language barriers affecting physician-patient communication and non-equivalent interpretation by untrained translators. Reducing this disparity is a growing challenge due to continued high immigration rates. As Canadian data is lacking, we explored the language needs and resource utilization of Canadian cancer patients. Methods: Adult cancer survivors from Princess Margaret Cancer Centre were surveyed in English on their socio-demographics, perceived communication difficulties, and interpreter use. Results: Of 470 patients, 45% were foreign-born; 37% self-identified as immigrants; 78% spoke mostly English at home. Among self-identified immigrants, median age at diagnosis was 60 years, 46% were female, and 59% completed post-secondary education. Top three countries of origin were China (23%), India (10%), and Italy (9%). Although 73% of immigrants reported English as their most comfortable language in which to receive healthcare information, 18% reported difficulties communicating with the doctor in English at a few visits or more, 14% indicated some discomfort communicating with their oncologist in English, and 4% of immigrants felt their cancer care was affected by a language barrier. Twenty-six percent of immigrants required interpretation, with 91% employing family, 7% utilizing professional interpreters, and only 19% have ever used the institutional language services. Conclusions: Although most immigrants identify English as their most comfortable language for healthcare delivery, some still experience communication difficulties with their oncologist during at least a few visits. However, most patients felt comfortable communicating with their oncologists and do not feel their cancer care is affected. Most relied on family members to interpret, while local hospital language resources were largely underutilized. Strategies for promoting professional translation service use may help improve immigrants’ experience, caregivers’ burden, and enhance physicians’ ability to counsel patients directly.
Safety of delivering chemotherapy by community nursing staff supervised by telemedicine in remote New South Wales (NSW).
Authors: Honeyball Florian
Published: September 2018

82

Background: Outcomes for cancer patients living in rural and remote areas are worse than for their metropolitan peers. Disparity in access to treatment is one of the causes for this difference. Using non-oncology, community based nurses with basic training in safe handling of chemotherapy to administer cancer treatments under the supervision of a medical oncologist and senior oncology nurse via telemedicine has been successful in remote Queensland. This is the pilot study analysing Remote Video Assisted Chemotherapy (RVAC) in NSW. Methods: Demographic data, regimens, and toxicity profiles of patients at the trial site in Coonabarabran was extracted from the electronic medical record. Similar data was extracted from all patients receiving the same treatment regimens in Dubbo, the referral hospital for Western NSW, 160km to the south. Data was analysed using a two-sample proportions z-test. Results: Data was collected in the 7 months after opening the trial site. This is summarised in the table below. There is no evidence to suggest differences in toxicity between the hub site and the trial site. Of those with grade 3 or 4 toxicity, 6 at the main site (40% of those on chemotherapy) and 2 at the trial site (50%) received chemotherapy. A higher proportion of patients receiving chemotherapy at the trial site may explain this difference. Although there was a significantly increased number of delayed doses at the trial site, the majority were due to logistic issues in the first two months. Conclusions: Using this model to deliver chemotherapy is safe. Toxicity numbers are low in this cohort, given the high number of patients receiving low risk anticancer drugs including endocrine and monoclonal antibody therapy.[Table: see text]
Real-world comparison of biosimilar filgrastim and reference filgrastim in cancer patients receiving chemotherapy.
Authors: Chen Xiaoxue , Barron John , Agiro Abiy , Debono David Joseph , Fisch Michael Jordan
Published: September 2018

85

Background: The approval pathway for biosimilars was established in 2010 to facilitate drug competition and generate cost savings. Biosimilar filgrastim products (filgrastim-sndz or tbo-filgrastim) were the first approved biosimilars in the US. This study examined study outcomes (incidence of febrile neutropenia (FN), growth factor related adverse events (AE) and filgrastim treatment cost) between users of biosimilar and reference filgrastim drugs among the commercially-insured US population. Methods: A retrospective observational design was used to analyze administrative claims data on adults with cancer treated with chemotherapy between 09/01/2012 - 4/30/2017. The population was grouped into biosimilar filgrastim users (B) and filgrastim users (F) according to the earliest filgrastim use (index date). FN risk factors were assessed within 6 months prior to the index date. Study outcomes were assessed within 21 days post index date using multivariable regression modelling. Results: Among 1,694 biosimilar users and 10,460 filgrastim users, no meaningful differences in baseline FN risk factors were observed. In adjusted results, no difference in incidence of FN was observed between the two groups (B: 13.3%; F: 11.0%; odds ratio [OR]: 1.17; 95% confidence intervals [CI] 0.99-1.38; p = 0.06). Rates of AE were similar between the two groups (B: 6.9%; F: 6.4%; OR: 1.04; 95% CI: 0.84-1.29, p = 0.72). The mean number of filgrastim doses administered was 3.4 in both groups (Relative difference: 0.01; 95% CI: -0.02-0.04; p = 0.53). The mean filgrastim drug costs were similar between the two groups (B: $2,491; F: $2,510, Cost Ratio [CR]: 0.96; 95% CI: 0.91-1.01; p = 0.12). However, the mean filgrastim drug cost was 6.7% less for filgrastim-sndz when compared to reference filgrastim (sndz: $2,342; CR: 0.91; 95% CI: 0.84-0.99; p = 0.04); but not for tbo ($2,549; CR: 0.97; 95% CI: 0.91-1.04; p = 0.40). Conclusions: Biosimilar filgrastim is similar to the reference filgrastim in drug safety and effectiveness. The early adoption and saving impact of biosimilar filgrastim has been modest, which highlights the structural and regulatory challenges to biosimilar uptake.
The impact of financial toxicity on quality of life in older patients with cancer: Baseline data from the University of Rochester NCI Community Oncology Research Program (NCORP).
Authors: Arastu Asad , Ciminelli Joseph , Culakova Eva , Lei Lianlian , Xu Huiwen , Dougherty David W. , Mohamed Mostafa Refaat , Wells Megan , Duberstein Paul , Flannery Marie Anne , Morrow Gary R. , Kamen Charles Stewart , Pandya Chintan , Berenberg Jeffrey L. , Aarne Valerie , Mohile Supriya Gupta
Published: September 2018

87

Background: Financial toxicity (FT), or the stress and strain patients (pts) experience as a result of paying for cancer care, can have profound negative impacts on pts’ overall quality of life (QoL). This study examined associations of FT with anxiety, depression, and QoL in older pts with advanced cancer. Methods: This is a secondary analysis of baseline data from a Geriatric Assessment intervention study conducted by UR NCORP across 31 practice sites (PI: Mohile). Pts were categorized as experiencing FT if they reported any one of the following: delaying medications due to cost, insufficient income in a typical month for food and housing, or insufficient income in a typical month for other basic needs. Pts also completed the Generalized Anxiety Disorder-7 (GAD7, score 0-21) to evaluate anxiety, the Geriatric Depression Scale (GDS, score 0-15) to assess depression, and the Functional Assessment of Cancer Therapy- Generation (FACT-G, score 0-108), to measure overall QoL. Associations of FT with anxiety, depression, and QoL were assessed in separate multivariate linear regression models controlling for covariates at p < 0.1. Results: Among 542 pts (mean age 77; range 70-96, 49% female), 18% (98 pts) experienced FT. In separate regression analysis, FT was significantly associated with all 3 outcome measures. On average, pts experiencing FT scored 1.76 higher (p < 0.01) on the GAD7 (indicating greater anxiety severity), 0.76 points higher (p = 0.02) on the GDS (indicating greater depression severity), and 5.16 points lower (p < 0.01) on the FACT-G (indicating lower QoL). Conclusions: Older pts with advanced cancer who experience income and cost-related barriers to quality cancer care reported worse anxiety, depression, and QoL than those without FT. Given the association between FT and these outcomes, these 3 FT questions may help identify vulnerable older pts and allow providers to intervene sooner and thereby enhance the quality of care pts receive.
Understanding epidermal growth factor receptor mutation (EGFRm) testing in patients (pts) with non-small cell lung cancer (NSCLC) in a large community oncology network.
Authors: Nadler Eric , Fernandes Ancilla , Pavilack Melissa , Amirian Susan , Clark Jamyia , Frytak Jennifer R.
Published: September 2018

9

Background: EGFR TKI therapy improves outcomes in pts with EGFRm+ NSCLC. NCCN guidelines recommend EGFRm testing for pts with NSCLC. Testing patterns and predictors of documented EGFRm testing were studied in a real-world setting. Methods: Adult pts with stage IV NSCLC treated from 1/1/2012 to 8/31/2017, identified from the iKnowMed (US Oncology Network) EHR were analyzed. Rates of documented EGFRm testing were calculated. Multivariable stepwise logistic regression analysis was conducted to identify characteristics associated with documented EGFRm testing. Results: Of 14,461 pts, 59.8% had adenocarcinoma and 17.5% had squamous cell carcinoma. Median age of pts was 69.3 years, 52.3% were male, and 14.6% were non-smokers. Testing rates were ~36% overall, an increase in rates was seen over time: ~30% in 2012 to 41% in 2016 (p < .001). Histology, practice size, and several characteristics were associated with documented EGFRm testing (Table). Conclusions: Testing rates steadily increased over time, but were still low, implying suboptimal/under-documented testing. This analysis presents practice site characteristics to target educational programs to improve testing and/or documentation in community settings. [Table: see text]
Experience of financial toxicity among gynecologic oncology patients.
Authors: Bouberhan Sara , Kennedy Alice , Buss Mary K. , Moss Laureen , Nolan Kathleen , Awtrey Christopher , Dalrymple John Lee , Garrett Leslie A. , Liu Fong W. , Hacker Michele R. , Esselen Katharine , Shea Meghan
Published: September 2018

90

Background: “Financial toxicity” (FT) is increasingly recognized as an adverse outcome associated with cancer treatment. The degree of FT in the gynecologic oncology patient population has not been studied. This study used the comprehensive score for financial toxicity (COST) tool, a recently-validated survey, to examine FT in the gynecologic oncology population. Methods: All follow-up patients at a gynecologic oncology practice were invited to complete a cross-sectional survey including the COST (scale = 0-44) tool and a quality-of-life (QOL) survey, the EQ-5D-5L. Demographic and treatment data were gathered with additional survey questions and chart review. We dichotomized COST scores into low FT (top two tertiles) and high FT (bottom tertile); a lower COST score indicates higher FT. We assessed the correlation between COST and QOL scores using the Spearman correlation coefficient (r) and used univariable and multivariable linear regression to identify predictors of greater FT. We used log-binomial regression to calculate risk ratios (RR) and 95% confidence intervals (CI) for patient-reported financial outcomes. Results: Approximately 75% of approached patients responded; 224 were included in this analysis. The median FT score was 29.0. Greater FT was correlated with worse QOL (r = 0.43, p < 0.01). In multivariable regression, income < $50,000 (p < 0.01) and income from $50,000-$99,999 (p < 0.01) compared to income ≥$100,000; younger age (p < 0.01); and part-time employment (p = 0.01) and unemployment (p = 0.01) compared to full time employment were significant predictors of greater FT. The high FT group had an increased risk of delaying or avoiding care (RR: 4.5, 95% CI: 1.6-12.3); borrowing money or applying for financial assistance (RR: 17.0, 95% CI: 4.0-71.6); and using savings or reducing spending to meet healthcare costs (RR: 2.5; 95% CI: 1.9-3.4) relative to the low FT group. Conclusions: High FT was common in the gynecologic oncology population and was strongly associated with delays or avoidance of clinical care, requiring financial assistance, and worse QOL scores. Further study is needed to investigate FT in a broader patient population within gynecologic oncology and to identify strategies for intervention in clinical practice.
Disability burden in patients with tenosynovial giant cell tumors in the United States from employer perspective.
Authors: Lin Feng , Ionescu-Ittu Raluca , Pivneva Irina , Wynant Willy , Shi Sherry , Shohudi Mojdehi Azadeh , Wu Eric , Kwong Jackie , Abraham John A.
Published: September 2018

92

Background: Tenosynovial giant cell tumor (TGCT) is a rare locally aggressive tumor causing pain, swelling, joint destruction, and limited mobility. This study assessed the disability burden and the associated costs in TGCT patients from an employer’s perspective. Methods: A retrospective analysis was performed using medical and disability claims from the OptumHealth database. Incident patients 18-64 years old with a diagnosis of TGCT (as identified by ICD-9: 727.02, 719.2x; ICD-10: D48.1, D21.x, M12.2) were matched 1:10 to controls without TGCT based on age, gender, index year, and follow-up duration. Patients without earning and disability data were excluded. Days of work loss due to disability claims and absenteeism associated with medical visits were compared using Poisson regression models. Costs were compared using generalized linear models. Results: A total of 1,395 eligible TGCT patients were matched with 13,950 controls without TGCT. Despite similar demographics (36% female, mean age 45-47) and only slightly higher comorbidity burden (mean Charlson Comorbidity Index (CCI): 0.3 versus 0.2), TGCT patients had increased usage of analgesic drugs (44% versus 20%) and MRI tests (37% versus 3%), prior to their diagnosis, compared with controls. During follow-up, TGCT patients were more likely to have disability claims (15.1% vs. 5.6%; p < 0.001), had more disability claim days (9.5 versus 2.0; p < 0.001), medically related absenteeism days (9.9 versus 4.3; p < 0.001), and total days of work loss (19.4 versus 6.3; p < 0.001) per person-year compared with their matched controls. After adjusting for age, gender, index year and CCI score, the average annual indirect cost per person was greater for patients with TGCT than controls ($4,653 versus $1,902; p < 0.001). Conclusions: In addition to the known problems of pain, limitation of mobility, and eventual joint destruction, TGCT patients had substantial indirect costs associated with increased work absenteeism and disability. These findings highlight the unmet need for more effective treatments to reduce not only the medical, but also the economic burden of TGCT.
Can oral chemotherapy parity laws reduce patients’ out-of-pocket (OOP) costs?
Authors: Sitlinger Andrea Phillips , Ubel Peter A. , Zhang Tian , Wong Charlene , Sachdev Rishi , Anderson David , Zafar Yousuf
Published: September 2018

97

Background: Insurance plans vary coverage for infusional (IV) vs oral drugs, leading some to suggest that patients on oral drugs pay more OOP than those on IV drugs. 43 states have passed laws requiring insurers to cover oral drugs equivalently to IV drugs. Yet, there is little evidence that these “parity laws” are effective. Our aim was to estimate impact of parity laws on OOP expenses for oral vs IV drugs. Methods: We sought to determine how quickly patients on oral vs IV drugs reach their plan’s annual OOP maximum (max) as a surrogate for OOP expense. We used 2017 data from Healthcare.gov public use files to generate cost-sharing profiles for all 3,092 unique Marketplace plans. Chronic lymphocytic leukemia (CLL) and metastatic hormone sensitive prostate cancer (mHSPC) were chosen as two representative malignancies since both have accepted, first-line, IV and oral treatment options. We created guideline-concordant, first-line treatment regimens for simulated patients with CLL (oral ibrutinib vs IV bendamustine/rituximab) or mHSPC (oral abiraterone vs IV docetaxel). Drug, professional, facility, imaging, and lab claims were simulated to calculate OOP costs. The mean number of days to reach the OOP maximum for each Marketplace plan and treatment regimen were recorded. We assessed variation according to insurance coverage levels (“metal tier”: Catastrophic, Bronze, Silver, Gold, Platinum). Results: For CLL patients, 95% of plans reached OOP max in approximately one month of treatment for both oral and IV drugs (oral: mean 36 days; IV: mean 29 days). 99% of mHSPC patients reached their OOP max for oral treatment in a mean 15 days, but only 57% of plans reached OOP max for IV mHSPC treatment. Metal tier impacts time to reach OOP max (table). Conclusions: Parity laws do not lower patient costs when both IV and oral treatment options are expensive. In these cases, patients reach the OOP max rapidly. The small subset of patients most likely to benefit from parity laws are those on oral therapy for a disease where the comparable IV drug is inexpensive (eg, generic docetaxel for mHSPC). [Table: see text]
Survival gains in multiple myeloma from 2003 to 2014.
Authors: Fonseca Rafael , Jena Anupam B. , Peneva Desi , Clancy Zoe
Published: September 2018

98

Background: Survival probabilities for patients with multiple myeloma have increased considerably over the past several decades, and a conservative estimate of 5-year survival today is approximately 50%, perhaps higher with optimal treatment. Treatment options for multiple myeloma have grown significantly beginning in 2003 with the approval of bortezomib, followed by approvals for lenalidomide and thalidomide in 2006. The second wave of novel agent approvals began in 2012 with carfilzomib, followed by pomalidomide in 2013. The aim of this study was to estimate the survival gains associated with multiple myeloma therapies after the introduction of novel therapies beginning in 2003 in the United States. Methods: We estimated survival gains for multiple myeloma patients diagnosed in the 5-year period from 2010-2014—who had access to newer therapies like lenalidomide, bortezomib, pomalidomide, and carfilzomib—compared with patients diagnosed in the 5 years prior to the approval of bortezomib (1998–2002). We used data from the Surveillance, Epidemiology, and End Results (SEER) Program cancer registry and a generalized gamma regression survival model. The sample from SEER included patients aged > 18 years who had a diagnosis of multiple myeloma between 1983 and 2014. Results: Of 88,462 patients identified in the full sample, 14,446 patients were diagnosed in 1998–2002 and 25,948 patients were diagnosed in 2010–2014. Overall survival was 51% longer ( P< 0.001) in multiple myeloma patients diagnosed in 2010–2014 than in patients diagnosed in 1998–2002. Patients diagnosed in 2010–2014 had median and mean survival of 1.32 and 2.27 years longer, respectively, than patients diagnosed in 1998–2002. Conclusions: Patients diagnosed with multiple myeloma during 2010–2014 had significant improvement in survival relative to patients diagnosed in 1998–2002. This study found continued improvement in survival in multiple myeloma patients in the most recent 5-years of survival data available, demonstrating the considerable progress made since the wave of multiple myeloma innovation began in 2003.
Optimizing the design of population-based patient-derived tumor xenograft studies to better predict clinical response
Authors: Floc'h Nicolas , Guerriero Maria Luisa , Ramos-Montoya Antonio , Davies Barry R. , Cairns Jonathan , Karp Natasha A.
Published: September 2018

The high attrition rate of preclinical agents entering oncology clinical trials has been associated with poor understanding of the heterogeneous patient response, arising from limitations in the preclinical pipeline with cancer models. Patient-derived tumor xenograft (PDX) models have been shown to better recapitulate the patient drug response. However, the platform of evidence generated to support clinical development in a drug discovery project typically employs a limited number of models, which may not accurately predict the response at a population level. Population PDX studies, large-scale screens of PDX models, have been proposed as a strategy to model the patient inter-tumor heterogeneity. Here, we present a freely available interactive tool that explores the design of a population PDX study and how it impacts the sensitivity and false-positive rate experienced. We discuss the reflection process needed to optimize the design for the therapeutic landscape being studied and manage the risk of false-negative and false-positive outcomes that the sponsor is willing to take. The tool has been made freely available to allow the optimal design to be determined for each drug-disease area. This will allow researchers to improve their understanding of treatment efficacy in the presence of genetic variability before taking a drug to clinic. In addition, the tool serves to refine the number of animals to be used for population-based PDX studies, ensuring researchers meet their ethical obligation when performing animal research.
Kindlin-2 interacts with a highly conserved surface of ILK to regulate focal adhesion localization and cell spreading
Authors: Kadry Yasmin A. , Huet-Calderwood Clotilde , Simon Bertrand , Calderwood David A.
Published: September 2018

The integrin-associated adaptor proteins integrin-linked kinase (ILK) and kindlin-2 play central roles in integrin signaling and control of cell morphology. A direct ILK–kindlin-2 interaction is conserved across species and involves the F2PH subdomain of kindlin-2 and the pseudokinase domain (pKD) of ILK. However, complete understanding of the ILK–kindlin-2 interaction and its role in integrin-mediated signaling has been impeded by difficulties identifying the binding site for kindlin-2 on ILK. We used conservation-guided mapping to dissect the interaction between ILK and kindlin-2 and identified a previously unknown binding site for kindlin-2 on the C-lobe of the pKD of ILK. Mutations at this site inhibit binding to kindlin-2 while maintaining structural integrity of the pKD. Importantly, kindlin-binding-defective ILK mutants exhibit impaired focal adhesion localization and fail to fully rescue the spreading defects seen in ILK knockdown cells. Furthermore, kindlin-2 mutants with impaired ILK binding are also unable to fully support cell spreading. Thus, the interaction between ILK and kindlin-2 is critical for cell spreading and focal adhesion localization, representing a key signaling axis downstream of integrins.

This article has an associated First Person interview with the first author of the paper.
DrosophilaDNA/RNA methyltransferase contributes to robust host defense in ageing animals by regulating sphingolipid metabolism
Authors: Abhyankar Varada , Kaduskar Bhagyashree , Kamat Siddhesh S. , Deobagkar Deepti , Ratnaparkhi Girish S.
Published: September 2018

Drosophila methyltransferase (Mt2) has been implicated in methylation of both DNA and tRNA. In this study, we demonstrate that loss of Mt2 activity leads to an age dependent decline of immune function in the adult fly. A newly eclosed adult has mild immune defects that exacerbate in a fifteen-day old Mt2−/− fly. The age dependent effects appear to be systemic, including disturbances in lipid metabolism, changes in cell shape of hemocytes and significant fold changes in levels of transcripts related to host defense. Lipid imbalance, as measured by quantitative lipidomics, correlates with immune dysfunction with high levels of immunomodulatory lipids, sphingosine-1phosphate (S1P) and ceramides, along with low levels of storage lipids. Activity assays on fly lysates confirm the age dependent increase in S1P and concomitant reduction of S1P lyase activity. We hypothesize that Mt2 functions to regulate genetic loci such as S1P lyase and this regulation is essential for robust host defense as the animal ages. Our study uncovers novel links between age dependent Mt2 function, innate immune response and lipid homeostasis.
Mentors or Teachers? Microenterprise Training in Kenya
Authors: Brooks Wyatt , Donovan Kevin , Johnson Terence R.
Published: September 2018

We use a randomized controlled trial to demonstrate that inexperienced female microenterprise owners in a Kenyan slum benefit from mentorship by an experienced entrepreneur in the same community. Mentorship increases profits by 20 percent on average with initially large effects that fade as matches dissolve. We conduct a formal business education intervention, which has no effect on profits despite changes in business practice. Our results demonstrate that missing information is a salient barrier to profitability, but the type of information matters: access to the localized, specific knowledge of mentors increases profit while abstract, general information from the class does not. (JEL D83, J16, L25, L26, O14, O15)
Economic Shocks and Crime: Evidence from the Brazilian Trade Liberalization
Authors: Dix-Carneiro Rafael , Soares Rodrigo R. , Ulyssea Gabriel
Published: September 2018

This paper studies the effect of changes in economic conditions on crime. We exploit the 1990s trade liberalization in Brazil as a natural experiment generating exogenous shocks to local economies. We document that regions exposed to larger tariff reductions experienced a temporary increase in crime following liberalization. Next, we investigate through what channels the trade–induced economic shocks may have affected crime. We show that the shocks had significant effects on potential determinants of crime, such as labor market conditions, public goods provision, and income inequality. We propose a novel framework exploiting the distinct dynamic responses of these variables to obtain bounds on the effect of labor market conditions on crime. Our results indicate that this channel accounts for 75 to 93 percent of the effect of the trade–induced shocks on crime. (JEL D31, F13, F16, H41, K42, O17, O19)
ИСПОЛЬЗОВАНИЕ ПРОЕКТНОГО МЕТОДА В ПРЕПОДАВАНИИ РУССКОГО ЯЗЫКА КАК ИНОСТРАННОГО
Authors: Gasparyan Larisa Alekseevna , Lashova Svetlana Nikolaevna , Pipchenko Elena Leonidovna
Published: September 2018

Статья посвящена актуальному в современном образовании вопросу – значимости проектного метода обучения в формировании основных компетенций студентов. Целью данной работы является изучение теории и практики использования проектного метода при обучении русскому языку как иностранному, а также выявление наиболее адекватных специфике преподаваемого предмета типов проблемно-исследовательских проектов. Основу исследования образуют теоретические и эмпирические методы исследования, такие как: сравнительно-исторический анализ отечественной и зарубежной литературы по теме и проблеме исследования; педагогическое наблюдение; анализ речевых продуктов и письменных работ студентов. Результатами исследования стали разработка, обоснование и характеристика проблемно-исследовательских проектов, применяемых при обучении студентов-медиков русскому языку как иностранному.