bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of a web-based decision aid on socioeconomically disadvantaged patients’ engagement in decision making (Alliance A231701CD).
Authors: Schumacher Jessica R. , Hanlon Bret M , Zahrieh David , Rathouz Paul J , Tucholka Jennifer L , Tan Angelina D. , Breuer Catherine , Bailey Lisa , Higham Anna M , Wecsler Julie Sara , Vinyard Alicia Y , Froix Anthony J. , Abbott Andrea M. , Dull Scott , Fine Stephanie G , McGuire Kandace P , Seydel Anna S. , McNamara Patricia , Chow Selina Lai-ming , Neuman Heather B.
Published: June 2023

6520

Background: Increased patient engagement in decision making may mitigate disparities in breast cancer surgical care. Socioeconomically disadvantaged patients disproportionately experience barriers to engagement. Decision aids (DA) increase engagement by providing information, establishing role expectations during the consult, and increasing confidence in surgeon interactions. The objective was to test the effectiveness of a surgical web-based DA in increasing engagement among breast cancer patients in clinics that care for a high proportion of socioeconomically disadvantaged patients. Methods: A stepped wedge trial was conducted with 10 NCI Community Oncology Research Program clinics (Alliance for Clinical Trials in Oncology Research Base, 6/19-12/21). Clinics were randomized to time of transition from usual care (UC) to delivery of a web-based DA. Patients with stage 0-3 breast cancer eligible for surgery provided consent prior to a surgical consult. Socioeconomic disadvantage was assessed with the Area Deprivation Index measured at the zip+4 level and dichotomized. Patient engagement was measured by Patient’s Self-Efficacy in Patient-Physician Interactions (PEPPI-5, follow-up survey) and count of Active Patient Behaviors (Street protocol, audio recorded consult). Intervention effects were tested with linear mixed-effects models, accounting for surgeon and clinic-level clustering, time, and enrollment post-COVID. Heterogeneity of treatment effect by socioeconomic disadvantage was assessed with an interaction term. Results: 573 patients enrolled. 44% (136/309) reviewed the DA. No significant difference in engagement was observed comparing DA and UC for PEPPI-5 (-0.80 [95% CI -2.13, 0.54], p = 0.24) or Active Patient Behaviors (2.52 [CI -4.11, 9.15], p = 0.46). Enrollment post-COVID was associated with increased Active Patient Behaviors (9.59 [CI 1.76, 17.43], p = 0.02) but no change in PEPPI-5 (-1.31 [CI -2.88, 0.26], p = 0.10). No heterogeneity of treatment effect was observed. Conclusions: In this trial conducted in clinics that serve diverse populations, no significant relationship was observed between a web-based DA and patient engagement. Conducting this stepped wedge trial during the pandemic was challenging. Future analyses will explore the impact of COVID on outcomes and effect of the decision aid for patients who reviewed it. UG1 CA189823; AHRQ R01HS025194; https://acknowledgments.alliancefound.org . Clinical trial information: NCT03766009 . [Table: see text]
Selection biases in the systematic collection of breast biobank specimens.
Authors: Bar Yael , Wang Gary X. , Gioia Gabrielle E. , Bossuyt Veerle I. , Shinn-Huey Chou Shirley , Isakoff Steven J. , Moy Beverly , Ellisen Leif W. , Lehman Constance Dobbins , Spring Laura
Published: June 2023

6533

Background: A breast biopsy tissue biobank is a valuable resource for studying breast cancer biology and treatment response. However, underrepresentation of patient populations in biobanks limits the generalizability of findings. The aim of this study was to assess potential age and racial/ethnic disparities in the recruitment process for an institutional breast biopsy tissue bank. Methods: Ultrasound-guided (USG) research biopsy cores were collected immediately after routine clinical biopsy from January 2019 to October 2022 at a large academic center. Study eligibility included patients (pts) aged > 18 years undergoing USG clinical breast biopsy with a radiographically evident mass ≥ 0.6 cm in the longest dimension. Eligible pts, identified by a research associate on the day of the biopsy, were invited to participate at the discretion of the radiologist performing the biopsy. Those approached either consented or declined a research biopsy. Demographic and clinical data of eligible pts were extracted from the EMR. Results: 2449 pts underwent USG breast biopsy and 1309 were deemed eligible for a research biopsy. Of the eligible population, 564 (43%) consented to the study, 322 (25%) declined, and 423 (32%) were not approached. Consented pts were younger compared to those who declined or to those not approached (median age 49, 51, and 51 years, respectively; p = .01). Comparison of study groups by age and race categories are shown in the table. Pts > 70 were less likely to be approached compared to pts < 70 (p = .01). However, The likelihood of pts being approached to consent did not differ significantly with age (p=.09 ). Of the eligible pts, 951 (73%) were White, 327 (25%) were non-White (10% Asian, 8% Black, 1% Hispanic, and 7% other race), and race was unknown for 31 (2%) pts. White and non-White pts were equally likely to be approached (p = .3). However, approached non-White pts were significantly less likely to consent compared to White pts (p =.01). Within the non-White population, Black pts were more likely to decline a research biopsy, with only 50% of approached Black pts consenting compared to 66% of White pts, 61% of Asian pts and 55% of pts of other race. Conclusions: We found disparities based on age and race/ethnicity in participation in a breast biopsy tissue biobank. Older pts were less likely to be offered participation but equally likely to consent when invited, while Black pts were equally likely to be offered participation, but less likely to consent when invited, compared to other racial subgroups. Our findings support targeted interventions to increase participation across diverse subgroups of pts. [Table: see text]
Beyond transportation: Financial hardship, food insecurity, and care access barriers among US cancer survivors with transportation barriers to care.
Authors: Jiang Changchuan , Yabroff Robin , Deng Lei , Wang Qian , Perimbeti Stuthi , Nipp Ryan David , Han Xuesong
Published: June 2023

6534

Background: Health care payers and providers increasingly focus on addressing social determinants of health (SDoH) in order to reduce disparities in care and patient outcomes in the US. Transportation barriers to health care, a key SDoH, are associated with increased emergency department use and mortality risk among cancer survivors. Transportation barriers may also be associated with other potentially addressable aspects of SDoH and access barriers. To inform future interventions, we examined financial hardship and barriers to timely care among cancer survivors with transportation challenges in a nationally representative sample. Methods: We identified 18,140 adults with a history of cancer from the 2011-2018 National Health Interview Survey. Transportation barriers were defined as delay in care due to lack of transportation over the past 12 months. Primary outcomes included 1) medical financial hardship (FH) in any of the three following domains: material (problems paying medical bills), psychological (worrying about medical bills), and behavioral hardship (delaying/forgoing care due to cost); 2) food insecurity (worrying food would run out); and 3) delayed care due to other factors (long wait times, inability to get an appointment quickly). We estimated the proportion of survivors who report any financial hardship, food insecurity, or other factors that lead to care delays and compared the age-sex adjusted prevalence of these barriers among cancer survivors by whether or not they reported transportation barriers using logistics regression. Results: Of the 18,123 cancer survivors, 2.9% reported having transportation barriers to care. Survivors with transportation barriers experienced significantly higher financial hardship, food insecurity, or other factors that lead to care delays than survivors without transportation barriers (86.0% vs 45.3%, p<0.001). Additionally, survivors with transportation barriers were more likely to experience medical financial hardship (73.2% vs 38.3%, p<0.001), including material (50.3% vs 27.1%, p<0.001), behavior (57.5% vs 20.4%, p<0.001), and psychological (33.5% vs 15.4%, p<0.001) hardship than survivors without transportation barriers. Additionally, survivors with transportation barriers were more likely to experience food insecurity (43.9% vs 12.0%, p<0.001) and care delays due to other factors (45.6% vs. 11.6%, p<0.001). Conclusions: Most cancer survivors with transportation barriers to care also report struggling financially and experiencing additional barriers to timely care. Findings highlight the importance of screening and addressing social needs and comprehensive interventions to address barriers to care access in this vulnerable population.
Associations of cancer history, food insecurity, and nonmedical financial worry and mortality risk in the US.
Authors: Zheng Zhiyuan , Zhao Jingxuan , Shi Kewei Sylvia , Hu Xin , Han Xuesong , Banegas Matthew P. , Yabroff Robin
Published: June 2023

6537

Background: Cancer survivors often face substantial out-of-pocket medical costs, which can adversely affect their financial well-being. Cutting expenses on food and housing to save money are common coping strategies. However, little is known about the extent to which food insecurities and non-medical financial worries affect mortality risk after consideration of medical financial hardship. Methods: The 2013-2018 National Health Interview Survey (NHIS) and the NHIS linked mortality files with vital status through December 31, 2019 were used to identify cancer survivors (ages 18-64: n=5,110; ages 65-79: n=4,949) and individuals without a cancer history (ages 18-64: n=115,643; ages 65-79: n=24,785). Medical financial hardship included 3 domains: material, psychological, and behavioral. Food insecurity (e.g., worry about food running out) and non-medical financial worries (e.g., paying for monthly bills and housing) were separately summarized and categorized as severe, moderate, and minor/none levels. Using age as the time scale, associations of cancer history, food insecurity and non-medical financial worry and mortality risk were examined with weighted Cox proportional hazards models. Adjusted models included medical financial hardship, sex, educational attainment, marital status, health insurance, comorbid conditions, and survey year. All estimates accounted for complex survey design. Results: In our sample, about 13.8% (ages 18-64) and 7.9% (ages 65-79) reported moderate to severe levels of food insecurity, respectively; 32.1% (ages 18-64) and 19.2% (ages 65-79) reported moderate to severe levels of non-medical financial worries, respectively. In adjusted analyses, cancer survivors had increased mortality risk. After controlling for medical financial hardship, food insecurity was associated with higher mortality risk in both age groups, following a dose-response relationship (Table); Non-medical financial worry was associated with higher mortality risk in the 65-79 age group (Table). Conclusions: Standardized and comprehensive assessment of financial hardship and other social needs, such food insecurity, is essential to identify and mitigate adverse economic impacts of cancer. [Table: see text]
Disparities in uptake of novel therapies for acute myeloid leukemia.
Authors: Hantel Andrew , Cernik Colin , Uno Hajime , Walsh Thomas , Viswanath Kasisomayajula , Lathan Christopher S. , DeAngelo Daniel J. , Abel Gregory A.
Published: June 2023

6540

Background: Multiple novel therapies have recently been approved to treat acute myeloid leukemia (AML). Inequities in the uptake of novel treatments have been seen in other cancers but are not known for this population. Methods: We performed a retrospective analysis of the nationwide Flatiron Health electronic health record (EHR)-derived deidentified database. We assessed sociodemographic associations with novel AML therapies use within two-years of Food and Drug Administration (FDA) approval from 1/2014-8/2022. Therapies were: glasdegib, venetoclax, ivosidenib, midostaurin, CPX-351, gilteritinib, enasidenib, and gemtuzumab ozogamicin (GO). Univariable associations were assessed using X2 testing. Logistic regression modeling of community practices assessed associations between novel therapy receipt and sociodemographics adjusted by treatment year. Variable categories are shown. Results: Of 8081 patients in 280 clinics, 3102 (38%) received at least one novel therapy. The cohort was predominately older (69; interquartile range [57, 77]), male (56%), non-Hispanic (NH)-White (88%), and treated at a community practice (75%). There were 4808 patients treated within 24-months of a novel therapy approval, of which 1937 (40%) received a novel therapy. Venetoclax represented 59% of novel treatments prescribed. Bivariate associations were seen between novel therapy receipt within 24-months of approval and high SES and non-Hispanic (NH)-White race-ethnicity; similar associations were seen when assessed at the treatment regimen level. In a logistic regression model of community practices (N=2,459), older patients (OR 1.01; 95%CI 1.00, 1.02), females (OR 1.2; 95% CI 1.0,1.4), and those from high (vs low) SES (OR 1.4; 95%CI 1.1, 1.6) were more likely to receive novel therapy; there were no associations with sex or race-ethnicity. Conclusions: In this large national database of adults with AML, almost half received novel therapy within 24-months of FDA approval. Though there was no dichotomous difference in uptake by race-ethnicity in community practices, younger and more affluent patients were more likely to receive novel therapy, concerning for disparities in uptake. [Table: see text]
Talk, test, and take one click to curb prostate cancer mortality.
Authors: Cautha Sandhya , Bhatta Shekhar , Lui Asona , Moirangthem Valentina , Luong Thanh-Ha T. , Ferris David , Jain Kevin R.
Published: June 2023

6541

Background: Prostate cancer remains the most commonly diagnosed cancer and the second leading cause of cancer-related death in men in the United States. BronxCare Health System (BCHS) serves the Bronx neighborhoods of Morris Heights, Fordham South, and Mount Hope, notable for the highest prostate cancer incidence rate in New York City as per the American Cancer Society Cancer Action Network report 2019, highlighting the need for prostate cancer screening among the patient population we serve. An anonymous voluntary paper survey was performed in 2019 at BCHS to determine primary care physician understanding and implementation of current PSA testing guidelines. The study showed that primary care providers at BCHS approach PSA testing in a wide variety of ways and screen a wide age range of patients suggesting a need for intervention. An electronic medical record (EMR) decision support tool activated during primary care visits for men aged 55-69 years was implemented beginning January 1, 2021 which facilitates the provider and patient engagement in a shared decision-making discussion. This a follow-up study to determine the effect of this EMR application on PSA order rates and prostate cancer diagnosis rates at BCHS. Methods: The total number of patients who had PSA and lipid panel (LP) screening were extracted from the EMR of BCHS for potentially eligible men (aged 55-69) seen during primary care visits during the years 2016-2022. LP is done annually as a part of routine screening for adults aged 55-69 and is taken as an equivalent of primary care visits. PSA screening rates were compared to LP screening rates to control for unforeseen variables. Similarly, the number of newly-diagnosed prostate cancers among the same population of men was extracted for the years 2016-2021. Data for 2022 is still not available. 2016-2020 are pre-EMR and 2021 and 2022 are post-EMR flag years. The pre and post-EMR flag PSA and prostate cancer diagnosis numbers were compared by calculating Z scores and p-values. Results: The year-wise PSA, LP, and newly-diagnosed prostate cancers (PC) are tabulated below. The proportion of men who had PSA testing among all men aged 55-69 who had LP testing in each pre-EMR flag year was compared to each post-EMR flag year. A significant increase (p < 0.00001) was noted in the proportion of men who had PSA screening after implementation of the EMR application. Similarly, the proportion of men with newly-diagnosed prostate cancer among all men aged 55-69 who had PSA screening significantly increased after EMR application (p < 0.00001). Conclusions: A decision support tool embedded in the EMR has been an effective approach in increasing prostate cancer screening rates and may help curb prostate cancer mortality in our patient population as early detection in right men at the right age has the potential to reduce prostate cancer mortality. [Table: see text]
Association of major adverse financial events and later stage cancer diagnosis in the US.
Authors: Yabroff Robin , Mariotto Angela , Stevens Jennifer , Davidoff Amy J. , Shankaran Veena , Ward Kevin C , Wu Xiao-Cheng , Schwartz Stephen M. , Warren Joan
Published: June 2023

6545

Background: Studies have documented an increased risk of bankruptcy and other financial hardships for individuals following a cancer diagnosis in the US. Few studies, however, have examined how patients’ financial situation prior to cancer diagnosis is associated with cancer stage at diagnosis. This study assessed the prevalence of the specific major adverse financial events (AFEs) of bankruptcies, liens, and evictions prior to cancer diagnosis and their association with later stage diagnosis. Methods: Individuals aged 21 to 69 years diagnosed with cancer during 2014-2015 were identified from the SEER population-based registries for Seattle, Louisiana and Georgia. Registry data were linked with LexisNexis consumer data to identify patients with a history of court-documented AFEs. All AFEs occurring at any time prior to cancer diagnosis were identified. The association of AFEs and later stage cancer diagnoses (Stages III/IV) was assessed with sex-specific multivariable logistic regression. Results: Among 101,649 individuals diagnosed with cancer linked to LexisNexis data, 36,791 (36.2%) had a major AFE reported prior to diagnosis. The most recent event occurred a mean of 7.8 years prior to diagnosis. For individuals with an AFE, one-third experienced multiple events. Within each registry, AFEs were most common among non-Hispanic Black, unmarried, and low-income individuals. However, even in the highest income group, 27% had a prior AFE. Individuals with prior AFEs were more likely to be diagnosed with later stage cancer than individuals with no prior AFE (males-odds ratio (OR) 1.09; 95% CI, 1.03 to 1.14; P < .001 and females-OR 1.11; 95% CI, 1.06 to 1.17; P < .0001), after adjusting for age, race and ethnicity, marital status, income prior to diagnosis, registry, and type of cancer. The association between a major AFE and later stage diagnosis was observed regardless of when the event occurred relative to cancer diagnosis. Conclusions: In this novel cancer registry, LexisNexis consumer data linkage, we found that one-third of individuals newly diagnosed with cancer had a pre-diagnosis bankruptcy, lien, or eviction. Individuals with these AFEs were more likely to have later stage diagnosis, even after accounting for traditional measures of socioeconomic status, such as income. The prevalence of pre-diagnosis AFEs underscores patient financial vulnerability at the time of their cancer diagnosis, even before experiencing any subsequent financial burden associated with cancer treatment. Our findings are especially timely, with growing efforts by health care providers to screen and address patient social needs as part of oncology care.
Sexual orientation and gender identity data collection among NCI community oncology research program (NCORP) practices: A 5-year landscape update.
Authors: Cathcart-Rake Elizabeth Jane , Jatoi Aminah , Dressler Emily Van Meter , Kittel Carol A , Weaver Kathryn E. , Nightingale Chandylen L , Neuman Heather B. , Kamen Charles Stewart ,   The Landscape Committee
Published: June 2023

6548

Background: National organizations (ASCO, ACS, ACCR) have advocated for routine collection of sexual orientation and gender identity (SOGI) in cancer clinics to advance cancer health equity. In 2017, only 24% of NCI Community Oncology Research Program (NCORP) practices collected sexual orientation (SO) data, while 10% collected gender identity (GI) data; recent progress in collection is unknown. Methods: In 2022, NCORP practices again completed a Landscape Assessment to assess research capacity (funding support from 2UG1CA189824) and were asked whether they routinely collect SOGI data in the electronic health record (EHR). The proportions of practices reporting collection of SO and/or GI data and population level differences over time were calculated using Fisher’s exact tests. Univariate associations between SOGI data collection and site-related variables were evaluated using logistic regression; significant associations were then tested in separate multivariate logistic regression models. Results: 271 practices responded to the Landscape Assessment; 42% (114) reported that they routinely collect SO data, 58% (157) reported that they collect GI data; both were significantly higher than 2017 (p<0.001). Compared to other regions, practices in Northeastern states were significantly more likely to report collecting GI, but not SO. Practices with higher proportions of White patients were also more likely to collect GI (p < 0.001). Practices with community outreach staff were more likely to collect SO (Table 1). There were no significant differences in SOGI collection by Medicaid/Medicare patients, new cancer cases per year, or practice ownership. In both 2017 and 2022, sites in Southern states were less likely to collect GI than sites in other regions. Conclusions: Progress was made in SOGI collection between 2017 and 2022, but fewer than half of NCORP sites routinely collect SOGI data, in spite of national guidelines. Further examination of the cultural context of SOGI collection could inform efforts to improve data collection in the South and other regions. The lack of data on sexual and gender minority patients in the EHR contributes to health inequity and deficiencies in patient-centric care. [Table: see text]
Impact of the COVID-19 pandemic on insurance transitions among commercially insured cancer patients in Washington state.
Authors: Ramsey Scott David , Sun Qin , Fedorenko Catherine R. , Bansal Aasthaa , Kreizenbeck Karma L. , Shankaran Veena
Published: June 2023

6552

Background: Insurance transitions following cancer diagnosis can disrupt care and impact outcomes. The COVID-19 pandemic impacted employment for millions of Americans, threatening their ability to maintain insurance. Using a large database linking commercial insurance to cancer registry records, we evaluated insurance transitions among newly diagnosed cancer patients in the pre- and post-COVID periods. Methods: We linked Western Washington SEER cancer registry records and enrollment records from two commercial insurers covering 3 million persons and Medicaid in Washington State. Eligible persons were ages 18-63 and commercially insured in the 12 months prior to their first cancer diagnosis. Post-diagnosis follow-up periods were stratified into pre-COVID (January 2017 – February 2020) and post-COVID (March 2020 - December 2020). We created logistic regression models to look at factors associated with (1) disenrollment for any reason and (2) transition to Medicaid, accounting for age, sex, race, year of diagnosis, cancer site, AJCC stage, comorbidities, and Area Deprivation Index (ADI), and diagnosis during the pandemic. Results: Among 5,458 newly diagnosed solid tumor patients enrolled in commercial plans pre-COVID, 16.9% disenrolled for any reason over 12 months following diagnosis. Among disenrollees, 10.0% transitioned to Medicaid. Patients with Lung, Oral, and Myeloma cancers had the highest disenrollments (21.2%, 21.0%, and 19.3% respectively). Among the 1,224 diagnosed post-COVID, 9.7% disenrolled for any reason. Among those who disenrolled, 21.0% enrolled in Medicaid. Patients with Leukemia, Melanoma, Oral, and Gynecologic cancers had the highest disenrollments (23.3%, 14.5%, 13.6%, and 13.6% respectively). In logistic regression, persons diagnosed after the pandemic were less likely to disenroll compared to the pre-pandemic period (Table). Transitions to Medicaid was not greater post-Pandemic. Advanced stage, comorbidity, and living in high ADI regions were significantly associated with transitioning to Medicaid. Conclusions: Newly diagnosed cancer patients with commercial insurance during the COVID-19 pandemic were substantially less likely to disenroll than those diagnosed before the pandemic. The findings may reflect pandemic-related preferences for job stability during a time of personal and societal crisis. [Table: see text]
Reducing infusion center wait times in a resource-limited setting.
Authors: Jones Amy Little , Cobb Robyn , Anderson Bryana , Kainthla Radhika
Published: June 2023

6567

Background: Time toxicity is increasingly recognized as an important factor in quality of life in cancer patients, and this effect may be amplified in under-resourced oncology settings. In the safety-net oncology center at Parkland Health (PH), wait time from infusion appointment check-in to treatment start was 147 minutes in June 2022, which led to significant patient frustration, delays in care, and staff dissatisfaction. We aimed to decrease wait time by 20% by December 2022. Methods: Baseline wait time data for patients getting infusions in the oncology infusion center was collected daily from the electronic medical record (EMR) time stamps of check in and infusion start (first IV medication given), and the average time was calculated. A value stream map detailing the steps required to start infusion with time stamps was produced. Stakeholders were queried to identify causes of delay, an Ishikawa diagram was constructed, and a priority matrix was developed to determine the most impactful interventions. The first PDSA cycle (July-Oct 2023) intervention consisted of working group formation and implementation of separate infusion pathway for patients getting injections (“fast track”). The second PDSA cycle (Nov-Dec 2023) intervention was rescheduling infusion-only patients to the least congested times of the day to relieve the bottleneck that occurred in the late mornings for patients with labs or provider visit prior to infusion. Patients and infusion center providers were surveyed about their perception of wait times. Results: Average wait times decreased from 147 minutes to 131 minutes during first PDSA cycle, a 10.8% improvement from baseline. From Nov-Dec 2023 during second PDSA cycle, wait time improved to 127 minutes, a 15.7% improvement from baseline. The average daily number of infusions and injections increased from 106/day baseline to 115/day by Dec 2023; an increase of 8.5%. Qualitative surveys of patients and infusion providers endorsed increased satisfaction with infusion process. Conclusions: Using established quality improvement methods, we improved average wait times for Parkland Health oncology infusion patients by 15.7% over a 6 month period. While we did not meet our goal, we increased daily capacity to treat patients by 8.5% while improving overall infusion wait time. We also improved perceptions of quality of care.
Multimodal interventions targeting identified barriers to improve lung cancer screening in northeast Georgia.
Authors: Kanakamedala Swathi , Danak Shivang , Caton Andria P
Published: June 2023

6570

Background: Lung cancer is the leading cause of cancer deaths with over 50% of patients diagnosed at an advanced stage. Lung cancer screening (LCS) guidelines were recently updated in 2021, which expanded the age group and reduced the pack years, and thereby increased eligibility. However, the underutilization of low dose computed tomography (LDCT) scans is seen nationwide. In 2015, the National Health Interview Survey found that only 3.9% of eligible adults underwent LCS. The barriers for LCS identified in national literature included failure of electronic medical records (EMR) to notify providers of eligible patients, lack of insurance coverage, patient refusal, and lack of patient and provider awareness. This quality improvement project was performed to improve LCS in primary care clinics (graduate medical education [GME] and non-GME) at a tertiary medical center in northeast Georgia by addressing these barriers. Methods: In GME clinics, the goal was to double LDCT scans from 14 to 28 monthly. In non-GME clinics, the goal was to increase LDCT scans by at least 50% from 28 to 42 weekly. LDCT scans performed between January 1st to May 31st 2022 was used as baseline data. The interventions spanned over six months, from June 1st to November 30th 2022. Multimodal interventions were used to target various barriers. Accurate tobacco history in the EMR was improved by participating in the nationwide Just Ask Campaign. Flyers posted in clinics provided information on current guidelines and a QR code for patients to determine their LCS eligibility. Provider reference guides highlighted LCS guidelines and billing codes. Community events and social media were used to spread LCS awareness. Results: During the implementation phase, the average monthly LDCT scans increased to 23 scans in GME clinics and 40 scans weekly in non-GME clinics. In GME clinics, the goal of 28 scans monthly was achieved in one out of six months. In non-GME clinics, the goal of 42 scans weekly was surpassed in four out of six months. The Long-Range Acoustic Device (L-RAD) scoring system helped diagnose three cancers in the GME clinics and about one cancer for every 10 L-RAD4 in non-GME clinics. The baseline period LDCT scans of 78 (GME) and 656 (non-GME) increased to 177 (GME) and 1109 (non-GME) during the intervention period. Conclusions: This multimodal approach in addressing known barriers to increase LCS across primary care clinics in a single healthcare system is feasible and was associated with short-term improvements. Although the targets were not met every month, there was a notable improvement during the intervention period. A major limitation was the inability to determine which intervention had the greatest impact. A newly identified barrier was the lack of follow up scans being ordered by providers. This project demonstrates the potential to increase LCS using a multimodal approach, which can be implemented in similar healthcare systems.
The association between systemic anticancer therapy (SACT) at the end of life (EOL) and acute care use among patients treated at oncology practices participating in the Oncology Care Model (OCM).
Authors: Canavan Maureen , Sheth Karna , Scott Jeffrey A. , Westvold Sarah , Adelson Kerin B.
Published: June 2023

6580

Background: Receipt of chemotherapy near EOL has been shown to harm patient and caregiver experience, increase hospitalizations, intensive care unit (ICU) and emergency department (ED) use and drive-up costs. As rates of chemotherapy at EOL have declined, we have seen increases in the rates of immunotherapy at EOL. It is unknown whether use of EOL immunotherapy is associated with the same pattern of higher downstream acute care use and cost. Using data from OCM, a Centers for Medicare and Medicaid Services (CMS) alternative payment model, we evaluated the relationship between SACT type and acute care utilization within 30 days of death. Methods: Using anonymized Integra Connect data for OCM episode claims attributed to 8 multi-site OCM practices between July 2016 and December 2021, we stratified patients by SACT type received within 30 days of death (immunotherapy (IO), chemotherapy (CT), or none) and used chi-square tests to compare the proportion of decedents who had inpatient admission, ICU stay, ED visits without inpatient admission, and hospice use within 30 days of death. Results: Among 14,169 OCM decedents, 2,227 (15.7%) received IO within 30 days of death, 6,627 (46.8%) received CT and 5,315 (37.5%) received no SACT (table). Patients who received no SACT at EOL were significantly more likely to start hospice within 30 days of death (76%) and to be in hospice for ≥3 days prior to death (61%) compared with IO (65% and 40%) and CT patients (59% and 37%) respectively (all p-values<0.05). Patients who received IO or CT were significantly more likely to have an inpatient stay within 30 days of death (66% and 68% respectively) compared with patients who received no SACT at EOL (58%, p-values <0.001). No difference in ED visits within 30 days of death between IO (18%), CT (20%), and no SACT (19%) p < 0.270. Conclusions: Patients who received chemotherapy or IO therapy within 30 days of death had higher proportion of inpatient admissions, ICU stay and lower rates of hospice than patients who received no SACT at the EOL. Patients who did not have any SACT at EOL were more likely to utilize hospice services and for a longer time. Further research should explore whether these findings are generalizable to patients outside of OCM and the magnitude of costs associated with these acute care metrics. [Table: see text]
Multicenter, retrospective population-based study on the incidence of medication-related osteonecrosis of the jaw in patients with breast cancer with bone metastases.
Authors: Brunner Christine , Marth Christian , Egle Daniel , Ritter Magdalena , Baumgart Florentina , Emmelheinz Miriam Elisabeth , Walch Benjamin , Iannetti Claudia , Zabernigg August , Castellan Maria , Andraschofsky Oliver Tibor , Markl Alice , Hubalek Michael , Schnallinger Michael , Woell Ewald , Puntscher Sibylle , Arvandi Marjan , Siebert Uwe , Bruckmoser Emanuel , Laimer Johannes
Published: June 2023

6588

Background: Antiresorptive therapy with bisphosphonates or denosumab is standard care for patients with primary or secondary osseous metastasized breast cancer. The most important toxicity of this class of drugs is medication-related osteonecrosis of the jaw (MRONJ). MRONJ represents a major medical burden and impairs quality of life. Based on recent studies, the risk of MRONJ occurrence ranges from 1% to 3%. The objective of this study was to assess the population-based incidence of MRONJ in breast cancer patients with bone metastases in Tyrol, Austria. Methods: This retrospective multicenter study was conducted between 2000 and 2020 at nine centers across Tyrol, Austria, including 8,860 patients with breast cancer. Depending on whether patients with bone metastases received denosumab, bisphosphonates or denosumab following bisphosphonates they were allocated to one of three groups. Data was collected using an electronic case report form (e-CRF) and managed via the web-based database AskiMed. MRONJ incidences with 95% confidence intervals and the differences between the median of cumulative incidences were calculated in patients treated with bisphosphonates and/or denosumab. Results: A total of 639 patients had bone metastasis and received antiresorptive therapy. MRONJ was diagnosed in 56 (8.8%) patients. Regarding the 292 (45.7%) patients treated with denosumab alone, the MRONJ incidence was 11.6% (95%CI 8.2%-15.9%). The group of patients treated with only bisphosphonates included 255 (39.9%) patients; their MRONJ incidence was 2.7% (95%CI 1.1%-5.6%). Of the 92 (14.4%) patients receiving both antiresorptive therapies consecutively, the MRONJ incidence was 16.3% (95%CI 9.4%-25.5%). Thus, a total of 49 (12.8%) MRONJ cases were detected in patients using denosumab alone as well as using the combination of denosumab following bisphosphonates. Patients treated with denosumab developed a MRONJ in median 60 months earlier than with bisphosphonates alone or followed by denosumab. The hazard ratio for MRONJ from start of therapy of denosumab compared to bisphosphonates alone or followed by denosumab was 7.9 (3.8-16.2; p-value < 0.0001). Conclusions: This study showed a substantially higher MRONJ incidence for denosumab alone or bisphosphonates followed by denosumab in the tyrolean cohort when compared to other recent studies. Future comparative real-world-evidence research provide explicit benefit-harm tradeoffs to inform treatment decision making.
Measuring variation in the quality of systemic anti-cancer therapy delivery across hospitals: A national population-based evaluation.
Authors: Boyle Jemma Megan , van der Meulen Jan , Kuryba Angela , Cowling Thomas E , Booth Christopher M. , Fearnhead Nicola S , Braun Michael , Walker Kate , Aggarwal Ajay Kumar
Published: June 2023

6593

Background: To date, there has been little systematic assessment of the quality of care associated with systemic anti-cancer therapy (SACT) delivery across national healthcare systems. We evaluated hospital-level toxicity rates during SACT treatment as a means of identifying variation in care quality. Methods: All colorectal cancer patients receiving SACT within 106 English National Health Service hospitals between 2016 and 2019 were included. Severe acute toxicity rates were derived from hospital administrative data using a validated coding framework. Variation in hospital-level toxicity rates was assessed separately in the adjuvant and metastatic settings. Toxicity rates were adjusted for age, sex, comorbidity, performance status, tumour site, and TNM staging. Results: Of the 8,173 patients receiving SACT in the adjuvant setting, 2,074 (25%) had a toxicity with adjusted hospital-level rates varying from 11% to 49%. Of the 7,683 patients receiving SACT in the metastatic setting, 3,625 (47%) had a toxicity with adjusted hospital-level rates varying from 25% to 67%. Compared to the national mean toxicity rate in the adjuvant cohort, six hospitals were more than 2 standard deviations (2SD) above, and four hospitals were more than 2SD below. Similarly, in the metastatic cohort, six hospitals were more than 2SD above, and seven hospitals were more than 2SD below the national mean toxicity rate. Conclusions: There is substantial variation in hospital-level severe acute toxicity rates in both the adjuvant and metastatic settings, despite comprehensive risk-adjustment. Ongoing reporting of this performance indicator can be used to focus further investigation of toxicity rates and stimulate quality improvement initiatives to enhance care.
Commercial vs. Medicaid insurance and use of high-priced anticancer treatments.
Authors: Mitchell Aaron Philip , Kinlaw Alan C , Peacock Hinton Sharon , Dusetzina Stacie B , Sanoff Hanna Kelly , Lund Jennifer Leigh
Published: June 2023

6599

Background: Financial incentives presented by the larger markups on cancer drugs among commercial payors may result in increased use of high-priced drugs among commercially insured vs. Medicaid insured patients. We evaluated the association between patient insurance type and the likelihood of receiving higher-priced treatments. Methods: We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004-2011, who had either commercial or Medicaid insurance. We selected cancer types with multiple FDA-approved, guideline-recommended chemotherapy options, and large differences in price between the higher-priced and lower-priced options during the study period: advanced colorectal, lung, and head-and-neck cancer (HNC). The primary outcome was receipt of the higher-priced treatment option, and the primary exposure was insurance type: commercial vs. Medicaid. We estimated risk ratios (RR) for the association between insurance type and higher-priced treatment using log binomial models with inverse probability of exposure weights to control confounding by age, county-level poverty prevalence, and selected comorbidities. We assessed for potential modification of the RR by setting (hospital outpatient vs. physician office) and academic designation (NCI-designated comprehensive cancer center vs. other); these were exploratory analyses due to sparse data and subsequently limited confounding control. Results: Of 812 patients: 209 (26%) had Medicaid insurance; 311 (38%) had NHC, 263 (32%) colon or rectal cancer, and 238 (29%) lung cancer. The crude risk of higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR:1.31, 95%CI 1.02-1.67). After weighting the association was attenuated (RR:1.15, 95%CI 0.81-1.65). While limited by imprecision and the potential for uncontrolled confounding, exploratory subgroup analysis suggested that, compared to Medicaid insurance, commercial insurance was associated with numerically higher risk of higher-priced treatment among patients treated by non-NCI designated providers (RR:1.53, 95%CI 1.14-2.04), and within both the physician office (RR:1.36, 95%CI 0.95-1.95) and hospital outpatient (RR:1.08, 95%CI 0.58-2.02) settings, but lower risk of high-priced treatment within NCI cancer centers (RR:0.39, 95%CI 0.22-0.71). Conclusions: Individuals with Medicaid vs. commercial insurance access high-priced treatments at a similar proportion after accounting for differences in case mix, morbidity, and SES. However, modification of the association by and academic setting, observed in exploratory subgroup analysis, suggests the possibility that insurance type may affect treatment for some patient groups. This study was limited by focus on a single state and the potential for residual confounding.
Integrating the 31-gene expression profile test into clinical decision-making to guide risk-aligned care decisions for patients with stage I-III cutaneous melanoma: NCI-SEER Analysis.
Authors: Hyams David , Petkov Valentina I. , Byun Jung S. , Martin Brian , Bailey Christine N. , Gastman Brian
Published: June 2023

6601

Background: Cutaneous melanoma (CM) management depends on an estimate of recurrence risk or death. Because of recognized disease risk and drug efficacy, pembrolizumab immunotherapy has been approved for stage IIB-C patients. However, it is a treatment with potential financial and biological toxicities with 16% of patients experiencing severe treatment related adverse events. Improved risk stratification could identify individuals for whom more selective management would be appropriate. In collaboration with the NCI Surveillance, Epidemiology, and End Results (SEER) program, which includes information on patients tested with a 31-gene expression profile (31-GEP) test in an unbiased and unselected manner, we confirm the 31-GEP adds independent prognostic value in patients with stage I-III CM, and investigated whether the 31-GEP could identify stage IIB-C patients who might reasonably avoid adjuvant therapy while also identifying patients with stage I disease who might benefit from more aggressive diagnostic and/or therapeutic intervention. Methods: SEER registries linked CM cases diagnosed 2013-2018 to 31-GEP test results provided by Castle Biosciences (9,207 matched) using a registry trusted third party (honest broker), including subsets of stage IIB-IIC (n=775) and stage I (n=5,651) melanoma. The primary endpoint was melanoma-specific survival (MSS). The 31-GEP risk-groups included Class 1A (low), Classes 1B/2A (intermediate), and Class 2B (high). Each was compared using Kaplan-Meier analysis and the log-rank test. Results: In the overall cohort, patients with a Class 1A result had a significantly higher 5-year MSS than a Class 1B/2A or Class 2B result (97.4% vs. 93.5% vs. 83.3%, p<0.001). In multivariable analysis, a Class 2B result (HR=3.26, p<0.001) and positive lymph node status (HR=3.41, p<0.001) were the strongest predictors of diminished MSS. In stage IIB-C, 18.8% (146/775) of patients received a Class 1A result with an associated 5-year MSS of 89.1% (vs. Class 2B: 76.6%, p=0.001), despite the absence of pembrolizumab approval for the evaluated SEER population. Alternatively, 4.6% (260/5,651) of patients with stage I disease had a Class 2B result, with an associated 5-year MSS of 92.3% (vs. Class 1A: 98.0%, p<0.001). Conclusions: The SEER database allowed a non-biased analysis of a large cohort of patients with stage I-III CM who were tested with the 31-GEP. The 31-GEP identifies patients, including those with stage IIB-C disease, with favorable outcomes and could help physicians and patients decide whether to pursue adjuvant therapy. Moreover, the 31-GEP identities high-risk patients, including those with stage I disease, for whom more aggressive follow-up and early intervention should be considered.
Demographic disparities in lung cancer mortality and trends in the United States between 1999 and 2020: A population-based CDC database analysis.
Authors: Didier Alexander , Roof Logan , Stevenson James
Published: June 2023

6603

Background: Lung cancer is the leading cause of cancer-related mortality in the US and is projected to account for 127,070 deaths in 2023. While the lung cancer mortality rate has been decreasing over the last decade, demographic disparities in mortality still exist. We sought to determine the impact of demographic factors on lung cancer mortality and trends in the US. Methods: We queried the Centers for Disease Control database for mortality statistics with an underlying cause of death of lung and bronchus cancer (ICD-10 code C34.0.x) between the years 1999 – 2020. Age-adjusted mortality rates (AAMR) were calculated per 100,000 deaths. We assessed the AAMR by demographic variables, including race (Hispanic, Non-Hispanic White, Non-Hispanic Black, Non-Hispanic Asian or Pacific Islander, Non-Hispanic American Indian/Native American), geographic density (Urban, Suburban, Rural), sex, age (25-44, 45-64, 65+ years), and US Census Region. Temporal trends were evaluated using Joinpoint regression software. Average annual percent change (AAPC) was considered statistically significant if p < 0.05. Results: Between 1999 and 2020, lung cancer led to 3,380,830 deaths. The AAMR decreased by 42% from 55.1 to 31.8 with an associated AAPC of -2.6% (p < 0.001). In 1999, men had an AAMR of 76.8, almost twice as high as women, who had an AAMR of 40.2. These differences became less pronounced over time, and in 2020 men had an AAMR of 38.1, while women had an AAMR of 26.9. Between 1999 and 2020, rural populations experienced the highest AAMR at 52.3, and the slowest rate of decrease at -1.7% annually (p < 0.001), compared with urban populations who experienced the lowest AAMR of 40.6 and fastest AAPC decrease of -3.1% (p < 0.001). Non-Hispanic Black individuals experienced the highest AAMR at 49.8, with an annual decrease of -3.0% (p < 0.001), followed by Non-Hispanic White individuals who had an AAMR of 48.5 with an annual decrease of -2.5% (p < 0.001). Subgroup analysis demonstrated that Non-Hispanic Black men who resided in rural counties experienced the highest mortality at 60.2, with an associated decrease of -2.9% annually (p < 0.001). States in the 90th percentile of mortality included Arkansas and Kentucky; states in the 10th percentile of mortality included Hawaii and Utah. The West experienced the fastest decrease at -3.1% annually (p < 0.001), while the Midwest experienced the slowest decrease at -2.0% annually (p < 0.001). Conclusions: While lung cancer mortality has been decreasing since 1999, not all demographic groups have experienced the same rates of decline, and disparities in outcomes remain prevalent. Vulnerable subgroups may benefit from targeted interventions, such as tailored smoking cessation education and efforts to increase participation in clinical trials. Expansion of screening CT scans and telehealth platforms may also improve access to care for these populations.