bluuebunny/crossref_metadata_2025 huggingface dataset:
Perturbational and nonperturbational inversion of Love-wave velocities
Authors: Haney Matthew M. , Tsai Victor C.
Published: October 2019

We describe a set of MATLAB codes to forward model and invert Love-wave phase or group velocities. The forward modeling is based on a finite-element method in the frequency-wavenumber domain, and we obtain the different modes with an eigenvector-eigenvalue solver. We examine the issue of parasitic modes that arises for modeling Love waves, in contrast to the Rayleigh wave case, and how to discern parasitic from physical modes. Once the matrix eigenvector-eigenvalue problem has been solved for Love waves, we show a straightforward technique to obtain sensitivity kernels for S-wave velocity and density. In practice, the sensitivity of Love waves to density is relatively small and inversions only aim to estimate the S-wave velocity. Two types of inversion accompany the forward-modeling codes: One is a perturbational scheme for updating an initial model, and the other is a nonperturbational method that is well-suited for defining a good initial model. The codes are able to implement an optimal nonuniform layering designed for Love waves, invert combinations of phase and group velocity measurements of any mode, and seamlessly handle the transition from guided to leaky modes below the cutoff frequency. Two software examples demonstrate use of the codes at near-surface and crustal scales.
An approach for attenuation-compensating multidimensional constant-Q viscoacoustic reverse time migration
Authors: Fathalian Ali , Trad Daniel O. , Innanen Kristopher A.
Published: October 2019

Simulation of wave propagation in a constant-[Formula: see text] viscoacoustic medium is an important problem, for instance, within [Formula: see text]-compensated reverse time migration (RTM). Processes of attenuation and dispersion influence all aspects of seismic wave propagation, degrading the resolution of migrated images. To improve the image resolution, we have developed a new approach for the numerical solution of the viscoacoustic wave equation in the time domain and we developed an associated viscoacoustic RTM ([Formula: see text]-RTM) method. The main feature of the [Formula: see text]-RTM approach is compensation of attenuation effects in seismic images during migration by separation of amplitude attenuation and phase dispersion terms. Because of this separation, we are able to compensate the amplitude loss effect in isolation, the phase dispersion effect in isolation, or both effects concurrently. In the [Formula: see text]-RTM implementation, an attenuation-compensated operator is constructed by reversing the sign of the amplitude attenuation and a regularized viscoacoustic wave equation is invoked to eliminate high-frequency instabilities. The scheme is tested on a layered model and a modified acoustic Marmousi velocity model. We validate and examine the response of this approach by using it within an RTM scheme adjusted to compensate for attenuation. The amplitude loss in the wavefield at the source and receivers due to attenuation can be recovered by applying compensation operators on the measured receiver wavefield. Our 2D and 3D numerical tests focus on the amplitude recovery and resolution of the [Formula: see text]-RTM images as well as the interface locations. Improvements in all three of these features beneath highly attenuative layers are evident.
A methodology for integrating unconventional geologic and engineering data into a geocellular model
Authors: Tamulonis Kathryn
Published: October 2019

Unconventional field development and well performance analysis encompass multiple disciplines and large data sets. Even when seismic and other data sets are not available, geologists can build geocellular models to determine factors that improve operational efficiency by incorporating well log, geosteering, stratigraphic, structural, completion, and production data. I have developed a methodology to integrate these data sets from vertical and horizontal wells to build a sequence stratigraphic and structurally framed geocellular model for an unconventional Marcellus Formation field in the Appalachian Basin, USA. The model would benefit from additional data sets to perform a rigorous investigation of performance drivers. However, the presented methodology emphasizes the value of constructing geocellular models for fields with sparse data by building a geologically detailed model in a field area without seismic and core data. I used third-order stratigraphic sequences interpreted from vertical wells and geosteering data to define model layers and then incorporate completion treating pressures and proppant delivered per stage into the model. These data were upscaled and geostatistically distributed throughout the model to visualize completion trends. Based on these results, I conclude that geologic structure and treating pressures coincide, as treating pressures increase with stage proximity to a left-lateral strike-slip fault, and completion trends vary among third-order systems tracts. Mapped completion issues are further emphasized by areas with higher model proppant values, and all treating pressure and proppant realizations for each systems tract have the greatest variance away from data points. Similar models can be built to further understand any global unconventional play, even when data are sparse, and, by doing so, geologists and engineers can (1) predict completion trends based on geology, (2) optimize efficiency in the planning and operational phases of field development, and (3) foster supportive relationships within integrated subsurface teams.
Improved seismic interpretation of a salt diapir by utilization of diffractions, exemplified by 2D reflection seismics, Danish sector of the North Sea
Authors: Montazeri Mahboubeh , Boldreel Lars Ole , Uldall Anette , Nielsen Lars
Published: October 2019

Development of salt diapirs affects the hydrocarbon trapping systems in the Danish sector of the North Sea, where the reservoirs mainly consist of chalk. Seismic imaging and interpretation of the salt structures are challenging, primarily due to the complex geometry of the salt bodies and typically strong velocity contrast with the neighboring sediment layers. The quality of seismic imaging in the North Sea is highly dependent on the quality of the estimated velocity model. We have studied diffracted arrivals originating from the salt flanks and adjacent sedimentary structures using a diffraction imaging technique. The diffracted waves carry valuable information regarding seismic velocity and the location of geologic discontinuities, such as faults, fractures, and salt delimitations. We apply a plane-wave destruction method to separate diffractions from our stacked data. We optimize imaging based on diffraction analysis by using a velocity continuation migration technique, which leads to an estimation of the optimum focusing velocity model. We determine that the diffraction-based approach significantly improves the seismic imaging adjacent to the salt diapirs and the neighboring layers when compared with a standard approach in which we mostly ignore the diffractions. The new poststack time-migrated results provide detailed information that optimizes our interpretation of the salt diapir itself (e.g., the width of the salt neck) as well as the sediment layers related to the rim synclines. Processing schemes such as prestack depth migration and full-waveform inversion may potentially provide high-resolution images of the salt structures. We only account for diffractions in nonmigrated stacked data to better constrain seismic velocity and improve imaging around the salt diapir. The obtained results are critical for reservoir characterization.
Metrics to evaluate the performance of cancer center leadership.
Authors: Halpern Michael T. , Gasoyan Hamlet , Aaronson William E.
Published: October 2019

10

Background: Cancer centers are diverse health care organizations that involve clinicians and researchers focused on understanding, treating, and controlling cancer in the populations they serve. While there are many metrics used to evaluate cancer center performance, few standardized measures have been identified to evaluate the performance of cancer center leadership. The goal of this manuscript is to systematically identify, compare, and categorize metrics used to evaluate the leadership of U.S. cancer centers. Methods: We performed a structured, systematic electronic search of peer-reviewed journals using Medline to identify English language articles discussing metrics used to evaluate cancer center leadership. Identified studies were reviewed by two independent reviewers to determine appropriateness for inclusion. Metrics were classified using ten a priori-defined categories of evaluation for data abstraction. Results: We included 34 manuscripts in this review. The most commonly-discussed evaluation metric category is organizational strategy/planning (31 of the 34 papers), followed by leader characteristics (25 papers), clinical performance (21), and facility characteristics (20). Organizational strategy/planning include governance structure; strategic development; quality assurance/improvement; mission/vision; business planning; and program development. Leader characteristic metrics include communication; vision/strategic thinking; personal skills; team coordination; leadership style; and staff development. Clinical Performance metrics focus on delivery of and outcomes from clinical services while facility characteristics include space allocation and access to support services. Conclusions: The metrics reviewed and synthesized in this report may be considered measurable outcomes to evaluate whether cancer center leadership demonstrates key competencies. Additional research is needed to explore the link between metrics used to evaluate cancer center leaders, the desired competencies for healthcare leaders, and objective measures of whether a cancer center is “successful”.
Comparing health utility scores, treatments, and outcomes in lung cancer patients with rare EGFR mutations with those with exon 19 deletion (del) and L858R mutations.
Authors: Dodbiba Lorin , Hueniken Katrina , Jiang Shirley Xue , Chan Sze Wah Samuel , Smith Elliot Charles , Eng Lawson , Patel Devalben , Razooqi Maryam , Brown M. Catherine , Shepherd Frances A. , Leighl Natasha B. , Bradbury Penelope Ann , Xu Wei , Sacher Adrian G. , Liu Geoffrey
Published: October 2019

102

Background: Precision oncology divides patients into smaller cohorts each with unique characteristics, treatment and outcomes. Cost-effectiveness assessments that rely on quality-adjusted life years will require mutation-specific health utility scores (HUS). We assessed the impact of having exon 19 del, L858R and rare EGFR mutations on outcomes and HUS. Methods: From a retrospective database of 719 patients with EGFR mutations, specific baseline EGFR mutations, clinicodemographic and treatment characteristics, and outcomes (overall survival, OS; progression-free survival, PFS) were analyzed using Cox models (adjusted hazard ratios, HR). In a subset of 289 patients with metastatic disease, serial HUS data collected through EQ-5D-5L at clinic visits were compared by mutation using t-tests. Results: Of 380 (53%) patients with exon 19 del, 288 (40%) with L858R, and 51 (7%) with rare mutations (mostly G719A/C, Exon 18 or 20 insertion, L861Q, compound mutations): 68% were female; median age was 74 years; 51% were Asian; and 74% were never smokers. In 334 Stage I-III pts, recurrence-free survival was not associated with specific mutations. In contrast, among 365 stage IV pts on TKIs, when compared to a reference of patients with exon 19 del, outcomes were worse in patients with L858R mutations (PFS: 1.35, 95% CI 1.1-1.7; OS: HR 1.39, 95% CI 1.0-1.9) and for rare mutations (PFS: 1.16 95% CI 0.7-1.9; OS: 1.45 95% CI 0.7-2.9). From an analysis of 1064 clinic encounters, different TKIs were used in similar proportions by mutation. In stable disease, mean HUS [SEM] were 0.80 [0.008] (exon 19), 0.81 [0.009] (L858R), and 0.82 [0.02] (rare mutation). Progressive disease led to significant drops in mean HUS for exon 19 (0.76 [0.01]; p = 0.01 compared to stable disease) and L858R, mean HUS = 0.74 [0.02] p < 0.001, but less so for rare mutations, mean HUS = 0.79 [0.05] p = 0.65. Conclusions: Patients in this EGFR mutated cohort had similar exposures of different TKI therapy regardless of specific EGFR mutation. L858R and rare mutations had inferior survival outcomes but similar HUS as patients with exon 19 del mutations.
Evaluating end-of-life (EOL) care at the University of Rochester Medical Center (URMC) using quality oncology practice initiative (QOPI) metrics.
Authors: Banerjee Titas , Mendler Jason Harold , Badri Nabeel , Hettler Dwight , Berkhof Julie Ann , Abbas Karen J. , Lekkala Manidhar Reddy , Moftakhar Bahar , Welaya Karim , Treptow Carissa , Babu Dilip Sankar , Baumgart Megan
Published: October 2019

12

Background: Inpatient mortality, defined as death within 30 days of an acute hospital admission, is often used as a quality benchmark for healthcare institutions and is an important metric for evaluating quality of care of patients with advanced malignancies. In this study we aimed to utilize QOPI performance data to identify areas of weakness in our practice that may contribute to inpatient mortality. Methods: We analyzed 11 EOL measures within the QOPI database which we collected between 2015 and 2018. These included all EOL measures related to hospice enrollment (measure IDs 42-47), chemotherapy administered within the last 2 weeks of life (ID 48), percentage of patients who died from cancer with at least one emergency department (ED) visit in the last 30 days of life (ID 49ed), and the percentage of patients who died from cancer admitted to the Intensive Care Unit (ICU) in the last 30 days of life (ID 49icu). Our rate was calculated for each measure and compared against QOPI aggregate data. We used a fisher’s exact test to determine statistical significance for each metric. Results: The number of patients from our institution included in each analysis ranged from 27 to 46. Compared to our peers, patients treated at our institution were more likely to visit an ED in the last 30 days of life (68% vs. 32%; P < 0.0001), more likely to be admitted to the ICU in the last 30 days of life (29% vs. 9%; P = 0.0003), and more likely to be enrolled on hospice within the last 7 days of death (63% vs. 32%; P = 0.001). Conclusions: Analysis of QOPI EOL performance scores identified several metrics that may contribute to inpatient mortality at URMC. Ongoing participation in QOPI with a focus on EOL metrics will strengthen this analysis. We plan to use this data to guide quality improvement initiatives aimed at reducing impatient mortality and improving end of life care at our institution.
Costs after incident breast cancer diagnosis among high-deductible health plan members.
Authors: Wharam James , Wallace Jamie , Lu Christine , Wagner Anita K. , Soumerai Stephen , Earle Craig , Nekhlyudov Larissa , Ross-Degnan Dennis , Zhang Fang
Published: October 2019

120

Background: High-deductible health plans (HDHP) are associated with breast cancer treatment delays of up to 10 months, but their impact on health outcomes is unknown. We hypothesized that, compared with women in generous plans, HDHP members would present with more advanced disease and thus experience higher total costs of early care. Methods: We studied 2004-2014 claims data from a large US health insurer. We included women aged 25-64 who were in traditional low-deductible (≤$500) health plans for 1 baseline year then experienced either an employer-mandated switch to HDHPs (≥$1000) for up to 4 or years or an employer-mandated continuation in low deductible plans. We defined the HDHP switch date as the index date. We then restricted to women who developed incident breast cancer after the index date. Using baseline characteristics, we closely matched HDHP members with incident breast cancer to contemporaneous women with incident breast cancer who remained in low-deductible plans. We measured total costs of all health care services in the 60 days after incident breast cancer diagnosis as a proxy for the intensity of incident breast cancer care. We used negative binomial regression adjusted for baseline characteristics to compare total 60-day costs among HDHP and control members. We also subset analyses to low-income women. Results: We included 1514 HDHP members and 9283 matched controls. 60-day costs after incident breast cancer diagnosis were $24,151 (95% CI: $22,766, $25,535) among HDHP members and $22,474 ($21,952, $22,996) among controls, an absolute difference of $1677 ($197, $3156) and a relative difference of 7.5% (8.1%, 14.1%). Low-income HDHP members had corresponding absolute and relative differences of $2653 ($368, $4939) and 12.5% (1.5%, 23.5). Conclusions: HDHP members with incident breast cancer had 7.5% higher health care costs in the 60 days after incident breast cancer than women with more generous coverage, a finding driven 12.5% higher costs among low-income HDHP members. Results raise concerns that delays in breast cancer care among HDHP members are associated with more advanced disease and adverse outcomes.
The association between health insurance coverage disruptions and access to care and affordability among cancer survivors in the United States.
Authors: Zhao Jingxuan , Han Xuesong , Nogueira Leticia Maciel , Jemal Ahmedin , Yabroff K Robin
Published: October 2019

121

Background: Having health insurance is a strong predictor of access to care and affordability. To date, most studies evaluating the effects of insurance coverage measured it only at a single time point. Little is known about the effects of coverage disruptions. This study aims to assess associations of a health insurance coverage disruption with access and affordability among cancer survivors in the United States. Methods: We identified 6476 cancer survivors aged 18-64 years with current health insurance coverage from the 2011-2017 National Health Interview Survey. Coverage disruption was measured by the question “In the past 12 months, was there any time when you did not have any health insurance or coverage?”. Access to care and affordability was measured by: 1) preventive services use (e.g. blood pressure check); and 2) forgoing care because of cost, respectively, in the past 12 months. We used separate multivariable logistic models to evaluate the associations between a coverage disruption and healthcare access and affordability, by current health insurance coverage. Results: Among survivors with current health insurance coverage, 3.7% of those with private and 8.1% with public insurance reported a coverage disruption in the past 12 months. Among survivors with current private coverage, those with a recent coverage disruption reported lower likelihood of any preventive services use (OR = 0.1, 95% CI: 0.1-0.3) and higher likelihood of forgoing any care because of cost (OR = 6.0, 95% CI: 3.9-9.5) compared to those with continuous private coverage. Among survivors with current public coverage, those with a recent coverage disruption reported lower likelihood of any preventive services use (OR = 0.4, 95% CI: 0.2-0.9) and higher likelihood of forgoing any care because of cost (OR = 4.3, 95% CI: 2.5-7.3) compared to those with continuous public coverage. Conclusions: Currently insured cancer survivors with a recent health insurance coverage disruption were more likely to report problems in access to care and affordability compared to the continuously insured. Improving private and public insurance coverage continuity may be effective in addressing these problems.
Barriers and facilitators to the implementation of routine ototoxicity screening for head and neck cancer patients.
Authors: Bapat Priya , Chow Pansy , Hueniken Katrina , Mahler Mary , Brown M. Catherine , Falls Carolyn , Hope Andrew J. , Hansen Aaron Richard , Goldstein David Paul , Rutka John , Howell Doris , Xu Wei , Liu Geoffrey
Published: October 2019

127

Background: Ototoxicity after cisplatin +/- radiation occurs in 22-58% of patients with head and neck cancers. Routine post-treatment hearing tests are useful in the early detection of hearing loss, allowing for possible early intervention. This study aimed to identify current hearing screening practices for follow-up, barriers to screening, and recommendations for its implementation. Methods: Stakeholders (physicians, nurses, coordinators, audiologists) identified barriers and facilitators to the implementation of a routine hearing screening follow-up program at Princess Margaret Cancer Centre. Themes were identified using an inductive approach and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices. Results: The problem: While all patients received baseline hearing tests, follow-up testing was inconsistently performed in asymptomatic patients. Patients may also lack awareness of subclinical hearing loss. A formalized follow-up hearing test program was identified as the best approach by stakeholders. Barriers: Individual-level barriers included limited knowledge about intervals for hearing testing and lack of time during clinic visits. Institutional-level factors included personnel, financial resources and logistical supports. Patient travel distances and times were barriers, as well as scheduling tests on the same day as other clinic visits. Societal stigma of hearing loss was a possible barrier. Facilitators: These included greater staff and patient education, and designating a local clinic champion. Instructions for follow-up after identifying hearing loss was deemed essential. Adapting to the local context: Automated flagging post-treatment and auto-referrals to the Hearing Clinic through the electronic medical record system could facilitate increased rates of participation. Mail/phone reminders could be useful adjuncts. Conclusions: Participants supported a formal post-treatment hearing test program for patients with head and neck cancers treated with cisplatin +/- radiation. Individual and institutional barriers were identified, but could be mitigated by appropriate facilitators.
Patterns of palliative symptom management (PSM) medication use at end-of-life (EoL) among Medicare beneficiaries with advanced lung cancer (advLC).
Authors: Davidoff Amy J. , Prsic Elizabeth Horn , Saphire Maureen , Canavan Maureen , Wang Shi-Yi , McCorkle Ruth , Presley Carolyn J
Published: October 2019

130

Background: Patients with advLC experience high symptom burden; undertreatment may result in poor quality of life for patients and caregivers. Hospice enrollment often happens late or not at all, yet little is known about EoL outpatient PSM medication use in the non-hospice setting. Methods: Using SEER-Medicare linked registry and claims data, we selected decedents diagnosed with advLC between 2008-2013 who survived ≥6 months (death between 2008-2014). Using non-hospice claims, we identified receipt of oral and parenteral medications to manage symptoms such as pain (any pain medications, any opioids), nausea/ vomiting and dyspnea at 6 (EoL-6) and 1 (EoL-1) months prior to death. Antiemetics were excluded if concurrent with chemotherapy (CTx). T-tests compared sample proportions receiving PSM between EoL-6 and EoL-1. Logistic regression estimated associations between PSM medication receipt at EoL-1 and patient demographic characteristics, comorbidity, and ongoing CTx or radiation. Results: We identified 16,246 decedents: mean age 77 years, 50% male, and 81% non-Hispanic white. PSM medication for individual symptom areas increased from EoL-6 to EoL-1 [Table]. Adjusted results indicate that pain medication receipt was higher for females, and patients with multimorbidity, dual Medicare/Medicaid, higher poverty, living in rural areas, and receiving concurrent radiation but lower among those with increasing age and for non-white race/ethnicity groups. We saw similar trends for PSM using opioids, and for emotional distress, and dyspnea. Conclusions: Among patients with advLC at EoL, medication use for symptom relief was common and increasing toward EoL-1. Lower use by males, older adults, and non-whites may reflect poor access or poor patient-provider communication. Further research is needed to assess adequacy of PSM in the outpatient setting. [Table: see text]
Specialized new patient scheduling unit to improve patient access.
Authors: Philip Tony , Gleason Karen , Weisman Rosemarie
Published: October 2019

131

Background: New patient unit is responsible for scheduling initial appointment, obtaining pertinent medical records and pathology slides prior to initial visit. Original workflow utilized dedicated schedulers to answer new patient appointment phone calls and emails, obtain patient demographics, brief medical history, and financial counseling referral. A separate chart preparation team gathered records for clinical review by two nurse navigators the day prior to the appointment. There were on average 6 patients/day waiting for appointments on the Pending List and phone wait times were thought to contribute to abandoned call rate and missed appointments. Methods: A workgroup of administrators, schedulers and clinicians was formed to redesign the workflow. The new workflow, starting April 2018, combined new patient and chart preparation team and divided them into three disease specific scheduling teams. Based on appointment volume, there is Team 1 Breast/GYN, Team 2 GI/GU/Thoracic/Head & Neck, Team 3 Malignant/Benign Hematology. Team members are responsible for answering phones, completing intake, and gathering records customized to needs of the specific care teams and enabled nurse navigator to be deployed elsewhere. Results: New workflow has reduced call volume, wait time, call abandonment and no show rates with increased new patient visits. Conclusions: Creating sub-specialty based scheduling teams to work with the clinical team has improved patient access to cancer care and reduced wait time. Further steps are being taken to further streamline process. [Table: see text]
Financial hardship associated health care utilization among cancer survivors in the United States.
Authors: Zheng Zhiyuan , Tucker-Seeley Reginald , Han Xuesong , Zhao Jingxuan , Banegas Matthew P. , Rai Ashish , Jemal Ahmedin , Yabroff K Robin
Published: October 2019

133

Background: A cancer diagnosis is associated with medical financial hardship in the U.S. However, little is known about health consequences associated with financial hardship. This study examines associations between medical and non-medical financial hardship on healthcare utilization among cancer survivors. Methods: We used the National Health Interview Survey (2013-2017) to identify cancer survivors (18-64 years: n = 5200; 65+ years: n = 7326). Medical financial hardship included material (e.g., problems paying medical bills), psychological (e.g., worry about medical bills), and behavioral (e.g., forgoing care due to cost) domains, and non-medical financial hardship included food hardship and worry for other financial needs (e.g. retirement, monthly bills, standard of living, and housing costs). We compared cancer survivors by intensities of medical and non-medical financial hardships in: 1) emergency department (ED) visits; 2) preventive services use (receipt of influenza vaccine, and blood pressure/cholesterol screenings); and 3) cervical/breast/colorectal cancer screenings among eligible cancer survivors. We used generalized ordinal logistic regressions, controlling for demographic characteristics, time since diagnosis, number of cancer diagnoses, insurance, income, and comorbidities. Results: Across age groups, both higher medical and non-medical hardship intensities were associated with higher ED visits and lower use of preventive services. Compared to cancer survivors with lowest intensity, higher percentages of ED visits were observed among those with highest medical hardship intensity (ages 18-64: 42% vs 26.2%; ages 65+: 37.2% vs 27.9%, all p < .01) and highest non-medical hardship intensity (ages 18-64: 37.6% vs 24.3%, p = .01). Moreover, compared to lowest intensity, highest medical hardship intensity was associated with lower influenza vaccination (ages 18-64: 45.6% vs 52.5%; ages 65+: 64.6% vs 75.6%, p < .05) and breast cancer screening (54.4% vs 65.9%, p < .05). Conclusions: Cancer survivors with higher medical and non-medical financial hardships have more ED visits and medical financial hardship was also associated with less use of preventive services and some cancer screening.
Predictors of delays in initiation of oral tyrosine kinase inhibitors (TKIs) in EGFR and ALK positive advanced non-small cell lung cancer (NSCLC).
Authors: Goulart Bernardo H. L. , Chennupati Shasank , Egan Kathryn , Fedorenko Catherine R. , Ramsey Scott David
Published: October 2019

134

Background: Molecular testing practices and cost-sharing policies may result in delayed initiation of TKI therapy. We assessed predictors of delayed initiation of TKIs in metastatic EGFR+ or ALK+ NSCLC. Methods: We identified patients with EGFR+ and ALK+ NSCLC diagnosed between 01/01/2010 and 12/31/2016 in the Washington State SEER registry using validated natural language processing methods. We linked registry records to commercial and Medicare (including part D) claims. Eligible patients had stage IV NSCLC, sensitizing EGFR mutations or ALK+ by FISH, ≥ 1 pharmacy claims for EGFR or ALK TKIs, and ≥12 months of insurance enrollment post-diagnosis. Potential predictors included age, sex, race, Census-level median household income, urban status, insurance type, comorbidity, histology, mutation type, and receipt of chemotherapy prior to first TKI claim (pre-TKI chemo). We defined time to TKI initiation as the interval from diagnosis to first pharmacy claim for EGFR or ALK TKIs. We fitted Cox regression models to identify predictors of delays in TKI initiation, defining covariates with a P < 0.05 in a final multivariate model as independently associated with delays. Results: For 122 patients (median age 70; 65% female; 74% White; median income $66,580; 98% metropolitan; 35% Medicare; 80% EGFR+; 12% using pre-TKI chemo), the median time to TKI initiation was 6.7 weeks (IQR = 3.9 to 14.0). Independent predictors of TKI delays included male sex (HR = 0.51; 95%CI = 0.34; 0.76); Medicare insurance (HR = 0.32; 95% CI = 0.20; 0.53) and pre-TKI chemo (HR = 0.37; 95% CI = 0.20; 0.66). Median time to TKI initiation was 9.7 vs. 5.8; 7.8 vs. 4.1; and 16.0 vs. 6.3 weeks in male vs. female, Medicare vs. commercial insurance, and pre-TKI chemo (yes vs no), respectively. Conclusions: Male sex, Medicare insurance, and chemotherapy prior to TKI are associated with delays in TKI initiation for EGFR+ and ALK+ stage IV NSCLC patients. Possible explanations include higher prevalence of smoking in males resulting in lower priority for molecular testing, high cost-sharing policies for TKIs in Medicare patients, and prolonged time to obtain molecular test results leading patients to start chemotherapy first.
Geographic distribution of clinical trials for breast cancer across the United States, 2011-2015.
Authors: Malapati Sindhu Janarthanam , Singh Sunny R K , Kumar Rohit , Ahmed Jibran , Katiyar Vatsala , Vohra Ishaan
Published: October 2019

140

Background: Access to clinical trials is paramount for delivery of high quality cancer care. We aim to study the geographical distribution of phase 3 & 4 clinical trials for females with breast cancer across 51 states between 2011 & 2015. Methods: We searched Clinicaltrials.gov registry for phase 3 & 4 clinical trials in US for females with breast cancer & those first posted from 01/01/2011 to 12/31/2015. New cases of female breast cancer from 2011 to 2015 were estimated with U.S. Cancer Statistics Data Visualizations Tool (www.cdc.gov/cancer/dataviz). Results: We found 88 phase 3 & 4 clinical trials over 51 states. The average number (no.) of new cancer cases and no. of trials per state were 22,985 and 34.4 (range: 16 - 57) respectively. On average, each state had 0.003 (SD: 0.002) trials per case. States with maximum number of cases and trials were California, New York, Texas and Florida. These accounted for 30.7% of total cases, but only 12.5% of total trials. Also, these four states had the lowest no. of clinical trials per case while District of Columbia had the highest (0.0123). The states with the lowest no. of clinical trials included Rhode Island, Vermont, Wyoming & Alaska (3.7% of total trials). Table with data regarding states with lowest and highest cancer burden is attached. Conclusions: For breast cancer in females during the years 2011 to 2015, the ratio of available phase 3 & 4 clinical trials to new cancer cases was quite low when examined state-wise. The gap widened as the cancer burden increased resulting in the lowest no. of clinical trials per case in the states with maximum cancer burden. This highlights the need of better allocation of resources and efforts across the nation when conducting clinical trials. [Table: see text]
Mortality disparities in insured patients with cancer.
Authors: Cooper Robert Michael , Chung Joanie , Schottinger Joanne E. , Haque Reina
Published: October 2019

150

Background: We examined mortality related to socioeconomic status (SES) in an insured Southern California population diagnosed with cancer and how healthcare settings can affect these differences. Methods: We identified adults diagnosed with the eight most common cancers from 2009-2014 from the California Cancer Registry and followed them through 2017. We calculated person-year mortality rates by SES and healthcare system (integrated healthcare system [IHS] or private insurance [PI]). Adjusted hazard ratios for the association between all-cause mortality and SES were estimated using Cox proportional hazards models accounting for covariates (race/ethnicity, demographics, stage, treatments). Results: The cohort was followed a maximum of 8 years. A total of 164,197 adults were diagnosed with cancers of the breast, prostate, lung, colon, melanoma, uterus, kidney and bladder (N=47,039 in IHS and N=117,158 in PI). In the whole cohort, we found an increased mortality risk between the highest and each of the lower SES quintiles. Specifically, the adjusted mortality risk was 16 to 37% greater in the lower SES groups as compared to the highest. We then examined the mortality in the IHS and PI groups separately. Overall mortality for all cancers combined was slightly lower in the IHS group (74.7/1,000 PY) than in the PI group (87.8/1,000 PY). In multivariable models, mortality risk was 6% to 16% greater in the lower SES groups versus the highest SES in the IHS population, while the risk was 19% to 45% greater in the lower SES groups in the PI population. Conclusions: Even among insured patients, and after multivariable adjustment, we found disparities in mortality in the lower SES groups. However, the magnitude of these differences was lower in patients cared for in IHS than those with PI. Preliminary data suggest that IHS may be well positioned to reduce disparity gaps in cancer outcomes. [Table: see text]
Identifying the gap in goals of care communication across care settings in a flagship cancer research and treatment facility.
Authors: Bhatnagar Mamta , Ormond Ellen , Bhosale Swati , Felice Rebecca , Chu Edward
Published: October 2019

180

Background: There is widespread recognition of the importance of having and documenting timely Goals of Care (GOC) conversations with seriously ill patients. Inpatient oncology teams at UPMC have noted the limited availability in the Electronic Medical Record (EMR) of documentation of patient preferences about end of life care. This project aims to identify the gaps in GOC communication across care settings for cancer patients at UPMC. Methods: We identified sources of information regarding goals of care available to inpatient oncology providers. Using the EMR we accessed the following for each patient of interest: CPR status, GOC documentation, scanned Advance Directives and/or POLST and last two available outpatient notes. Patients of interests were older than 65 years with metastatic cancer and 2 hospital admissions in the past year, or any cancer patient > 90 years. We reviewed outpatient notes for words suggesting that GOC conversations had occurred, and for a subset (50%), we did a detailed review identifying documentation of prognosis, treatment options, treatment decisions and patient values. Results: Of a total 114 high risk patients admitted over a 6-month period, 73 (64%) died within 6 months, with 52 (46%) dying within one month of their last hospitalization. Thirty nine (34%) patients had at least 5 admissions. Only 35% patients had GOC documented using the EMR template, and only 38% had a completed POLST. Rates of CPR status completion were high (95%). However, when tracking CPR status across multiple admissions, 73% of patients were full code on their first admission, with 31% of patients with five admissions remaining full code. The qualitative analysis of outpatient notes revealed that most documentation (87%) reflected continued treatment with minimal discussion of hospice or patient values. Conclusions: In a cohort of patients with advanced cancer, documentation of GOC discussions is limited in both inpatient and outpatient settings. Available documentation suggests minimal discussion of the limited benefits of medical interventions to prolong life. Future efforts will be designed to improve the quality and frequency of documentation of GOC conversations.
Adherence to clinical practice guidelines for the prevention of acute chemotherapy-induced nausea and vomiting in children, adolescents, and young adults with cancer receiving their first cycle of highly emetogenic chemotherapy.
Authors: Beauchemin Melissa , Weng Chunhua , Dupuis L. Lee , Sung Lillian , Hershman Dawn L. , Schnall Rebecca B.
Published: October 2019

19

Background: Prescribing guideline-recommended anti-emetics for the prevention of chemotherapy-induced nausea and vomiting (CINV) is an effective strategy to prevent a common treatment-related adverse effect in children, adolescents and young adults (AYAs) with cancer that impacts quality of life. The rate of guideline-concordant care (GCC) is not well-understood. Methods: Using electronic health record data Columbia University Irving Medical Center from a 3-year period, we conducted a retrospective single-institution cohort study to investigate how often children and AYAs (age 26 or less) receive GCC to prevent CINV prior to the first administration of highly-emetogenic chemotherapy. We defined GCC from the Pediatric Oncology Group of Ontario guideline for patients < 18 years and the American Society of Clinical Oncology guideline for those ≥ 18 years. Independent variables included: sex, age, insurance status, race, ethnicity, cancer type, chemotherapy regimen, clinical setting (adult or pediatric oncology), and patient location (inpatient or outpatient). Predictors of GCC were determined using multiple logistic regression. Results: Of 91 included patients, 39 (43%) received GCC. Those treated in adult oncology setting (OR 7.5, 95% CI: 2.7–20.7), receiving cisplatin-based chemotherapy (OR 3.5, CI: 1.4–8.5), or with commercial insurance (OR 2.7, CI: 1.1–6.3) were more likely to receive GCC. In multivariable analysis, patients treated in adult oncology had 6.4 higher odds (CI: 2.1–19.1, p<.001) and those receiving cisplatin 4.6 higher odds (1.6–13, p<.01) of GCC. Conclusions: Clinical setting and chemotherapy regimen independently predicted GCC for prevention of CINV in children and AYAs receiving highly-emetogenic chemotherapy. These findings can inform current efforts to optimize implementation strategies for supportive care guidelines by focusing on specific provider- and patient-level factors.
The effect of clinical pathways utilization on total cost of care for the treatment of prostate cancer.
Authors: Sereday Karen Ann , Boulware David C. , Kailasam Vasanth , Shi JuQing , Blazevich Diane L. , Burkett Jason M. , Stewart Sandra C. , Pow-Sang Julio M. , Johnstone Peter Anthony , Rollison Dana Elise , Fields Karen K.
Published: October 2019

20

Background: Moffitt Cancer Center (MCC) has developed evidence-based cancer care pathways which are integrated into the Electronic Health Record (EHR). We retrospectively compared the 1 year (yr) total cost of care in patients (pts) with newly diagnosed prostate cancer (PCA) treated at MCC based on EHR tool utilization and pathway alignment. Methods: Using existing Cancer Registry data, we retrospectively identified all pts presenting with newly diagnosed PCA between 7/1/2015-6/30/2017 who received all 1st course treatment (tx) at MCC. Pts direct costs were tracked for 1 yr from the Cancer Registry “date of 1st contact.” Tx was categorized as either radiation (RT) +/- hormone tx (HT), surgery (S) +/- HT, active surveillance only (ASO), HT only, palliative care, chemotherapy (CT), or mixed (a combination of S, RT, or CT). Pathway alignment was either electronically tracked through the EHR pathway tool or determined through manual chart review for pts tx’ed off the pathway tool. Results: 477 pts met inclusion criteria, including men with: low or favorable intermediate (n=259); unfavorable intermediate, high, or very high (n=186); and metastatic (n=32) risk group PCA. The majority (n=396, 83%) had tx in alignment with a pathway. The major tx modalities on pathway were S-HT (n=139), RT-HT (n=113), or ASO (n=110) and off pathway were RT-HT (n=52, 64%), S-HT (n=10), or ASO (n=9). Overall, treatment in alignment with a pathway was significantly associated with lower 1 yr total cost compared to off pathway tx (p <0.001) with a mean difference of $5,500 per pt yr. Conclusions: Clinical pathway alignment was significantly associated with less aggressive therapy and lower 1 yr cost of care for PCA pts treated at MCC. Cost of care was highly associated with tx modality selected. Further analyses are needed to understand the association between pathway alignment, patient risk factors and tx modality selection.
Understanding palbociclib practice patterns in a real-world setting.
Authors: Rocque Gabrielle Betty , Blum Joanne Lorraine , Montero Aldemar , Wilks Sharon , Anderson Daniel M. , Salkeni Mohamad Adham , Diab Sami , Migas John J. , Nakhoul Ibrahim , Spell Derrick W. , Sleckman Bethany G. , Cappelleri Joseph C , Wang Yao , Tripathy Debu
Published: October 2019

200

Background: Real-world practice patterns often differ from treatment in clinical trials. We assessed real-world standard-of-care treatment with palbociclib (PAL) in the context of previously reported PALOMA trial results. Methods: POLARIS is a prospective, observational study of PAL in patients (pts) with hormone receptor–positive, human epidermal growth factor receptor 2–negative advanced breast cancer. Baseline demographics, clinical characteristics, initial treatment dose, dose modifications, dose delays, and adverse events (AEs) during the first 6 months (mo) of treatment were analyzed. Results: 412 pts enrolled at 92 US sites had at least 6 mo of PAL treatment; 73% received PAL in the first-line setting and 27% in second or later line. While a majority of pts received the recommended dose of 125 mg/d; 6% and 1% started at 100 mg and 75 mg, respectively. Physician-reported reasons for choosing a lower dose were: comorbidities (31%), pt age (21%), past treatment (10%), patient preference (3%), and other (34%). Selected pt and clinical characteristics, dosing, and treatment outcomes in POLARIS and in PALOMA-2 are shown in Table. Conclusions: In a real-world data set of 6 mo of PAL treatment, most pts started at the recommended dose, with tolerability and safety outcomes consistent with those reported in clinical trials. Differing populations, treatment patterns, and outcome reporting in real world vs trial settings underscore the need to study real-world practices and outcomes. Clinical trial information: NCT03280303

[Table: see text]
Challenges in implementing a mobile-based patient-reported outcome (PRO) tool for cancer patients.
Authors: Yocavitch Liana , Binder Adam , Leader Amy , Garber Gregory D. , Chapman Andrew E. , Handley Nathan
Published: October 2019

206

Background: Electronic patient reported outcomes (ePROs) can bridge the communication gap with a patient’s care, providing insight into patients’ symptoms between clinical visits and improving both symptom management and overall survival. PROs are typically monitored through standardized questionnaires given to patients at specific times during their treatment. We endeavored to implement a mobile application-based ePRO tool at an urban academic cancer center. Methods: During an 8-week period, cancer patients on active intravenous chemotherapy were approached for enrollment during their infusion appointment. English-speaking patients with a smartphone and an active email address were eligible to download the app and enroll in the program. Two patient coordinators enrolled patients and demonstrated the use of the ePRO tool. Barriers to enrollment were tracked; subsequent utilization by enrolled patients was assessed. Results: 108 patients (63% White, 22% African American, 7% Asian, 2% Hispanic, 6% unknown; mean age 65 years) were approached for enrollment. Among those, 32 (30%) were ineligible. The most common reasons for ineligibility were the lack of a smart phone or active email address. 76 patients (70%) were eligible for enrollment. Of the 76 patients, 19 (25%) declined, 20 (26 %) were unable to complete registration due to technical barriers, and 37 patients (49 %) successfully registered. Of registered patients, 19 (25%) utilized the ePRO tool on at least one occasion. Patients who utilized the ePRO tool tended to be younger, female, and white. Conclusions: A mobile application-based ePRO presented several challenges to implementation in our patient population. Nearly 50% of patients were either ineligible or experienced technical issues that precluded enrollment. Successful ePRO implementation may benefit from a variety of mechanisms by which to collect data, such desktop-based, text-based, and or telephonic-based approaches. Ongoing iterations are in process at our institution.