bluuebunny/crossref_metadata_2025 huggingface dataset:
Polypharmacy in the treatment of people diagnosed with borderline personality disorder: repeated cross-sectional study using New Zealand's national databases
Authors: Tennant Matthew , Frampton Chris , Mulder Roger , Beaglehole Ben
Published: October 2023

Background

There is insufficient evidence to support the pharmacological treatment of borderline personality disorder. However, previous out-patient cohorts have described high rates of polypharmacy in this group. So far, there have been no national studies that have considered polypharmacy in borderline personality disorder.

Aims

To describe psychotropic polypharmacy in people with borderline personality disorder in New Zealand.

Method

New Zealand's national databases have been used to link psychotropic medication dispensing data and diagnostic data for borderline personality disorder. Annual dispensing data for 2014 and 2019 have been compared.

Results

Fifty percent of people with borderline personality disorder who were dispensed medications had three or more psychotropic medications in 2014. This increased to 55.9% in 2019 (P < 0.001). Those on seven or more psychotropics increased from 8.4 to 10.7% (P < 0.023). Quetiapine was the most dispensed psychotropic medication, being given to 53.8% of people dispensed medication with borderline personality disorder in 2019. Lorazepam dispensing showed the largest increase, going from 15.5 to 26.7% between 2014 and 2019 (P < 0.001).

Conclusions

There is a large burden of psychotropic polypharmacy in people with borderline personality disorder. This is concerning because of the lack of evidence regarding the efficacy of these medications in this group.
Radiotherapy for Brain Metastases Near the End of Life: Characterizing Patients and Tumor Features
Authors: Silva Saulo Brito , Barreto Rafael Balsini , de Oliveira Fernanda Cristina Gonçalves , Martin Gabriela Schmidt Defende , Takiguchi Ofelia Maria Yukie , Chirichela Iasmin Alves , Miranda Mário Henrique Furlanetto , Bodnar Denize , Alves Reis Luiz Augusto , Pereira Gabriel Clemente Brito , Miranda Isabela Lacerda , Pereira Bruno Rodriguez , Arruda Gustavo Viani , Peria Fernanda Maris
Published: October 2023

PURPOSE

Patients with brain metastases are often referred for brain radiotherapy (BrRT) when exclusive palliative management would be more appropriate. To assess the indication of BrRT during end-of-life (EOL) care and evaluate the characteristics of the patients who underwent the treatment.

METHODS

This retrospective study comprised patients from four independent oncology centers who had undergone BrRT for metastases. The variables included were Karnofsky performance status (KPS), primary tumor site, metastatic status, neurologic symptomatic status, the number and size of metastases, posterior fossa or meningeal involvement, type of BrRT, having undergone brain metastasectomy, and the availability of systemic therapies after BrRT. Patients were allocated into three subgroups with ≤30, 31-60, and 61-90 days of survival, and a control group of patients who survived >90 days.

RESULTS

A total of 546 patients were included in the study. A KPS of <70 ( P = .021), the number of brain metastases ( P = .001), the lack of brain metastasectomy ( P = .006), and the lack of systemic therapies after BrRT ( P = .047) were significantly associated with the EOL subgroups. Multivariate analysis showed that a KPS of <70 ( P < .001), the lack of brain metastasectomy ( P = .015), and the lack of systemic therapies after BrRT ( P = .027) were significantly associated with worse survival. In all, 241 (44.1%) patients died within 90 days—120 (22.0%) within 30 days, 75 (13.7%) within 31-60 days, and 46 (8.4%) within 61-90 days of BrRT. Patients with colorectal cancer were significantly more likely to die within 90 days of BrRT than >90 days.

CONCLUSION

Considering patients' performance status and whether they are candidates for brain metastasectomy or systemic therapies after BrRT is critical to improving BrRT benefits in scenarios of EOL.
Eflornithine as Postimmunotherapy Maintenance in High-Risk Neuroblastoma: Externally Controlled, Propensity Score–Matched Survival Outcome Comparisons
Authors: Oesterheld Javier , Ferguson William , Kraveka Jacqueline M. , Bergendahl Genevieve , Clinch Thomas , Lorenzi Elizabeth , Berry Don , Wada Randal K. , Isakoff Michael S. , Eslin Don E. , Brown Valerie I. , Roberts William , Zage Peter , Harrod Virginia L. , Mitchell Deanna S. , Hanson Derek , Saulnier Sholler Giselle L.
Published: October 2023

PURPOSE

Long-term survival in high-risk neuroblastoma (HRNB) is approximately 50%, with mortality primarily driven by relapse. Eflornithine (DFMO) to reduce risk of relapse after completion of immunotherapy was investigated previously in a single-arm, phase II study (NMTRC003B; ClinicalTrials.gov identifier: NCT02395666 ) that suggested improved event-free survival (EFS) and overall survival (OS) compared with historical rates in a phase III trial (Children Oncology Group ANBL0032; ClinicalTrials.gov identifier: NCT00026312 ). Using patient-level data from ANBL0032 as an external control, we present new analyses to further evaluate DFMO as HRNB postimmunotherapy maintenance.

PATIENTS AND METHODS

NMTRC003B (2012-2016) enrolled patients with HRNB (N = 141) after standard up-front or refractory/relapse treatment who received up to 2 years of continuous treatment with oral DFMO (750 ± 250 mg/m2 twice a day). ANBL0032 (2001-2015) enrolled patients with HRNB postconsolidation, 1,328 of whom were assigned to dinutuximab (ch.14.18) treatment. Selection rules identified 92 NMTRC003B patients who participated in (n = 87) or received up-front treatment consistent with (n = 5) ANBL0032 (the DFMO/treated group) and 852 patients from ANBL0032 who could have been eligible for NMTRC003B after immunotherapy, but did not enroll (the NO-DFMO/control group). The median follow-up time for DFMO/treated patients was 6.1 years (IQR, 5.2-7.2) versus 5.0 years (IQR, 3.5-7.0) for NO-DFMO/control patients. Kaplan-Meier and Cox regression compared EFS and OS for overall groups, 3:1 (NO-DFMO:DFMO) propensity score–matched cohorts balanced on 11 baseline demographic and disease characteristics with exact matching on MYCN, and additional sensitivity analyses.

RESULTS

DFMO after completion of immunotherapy was associated with improved EFS (hazard ratio [HR], 0.50 [95% CI, 0.29 to 0.84]; P = .008) and OS (HR, 0.38 [95% CI, 0.19 to 0.76]; P = .007). The results were confirmed with propensity score–matched cohorts and sensitivity analyses.

CONCLUSION

The externally controlled analyses presented show a relapse risk reduction in patients with HRNB treated with postimmunotherapy DFMO.
Patient-recommended communication strategies to enhance clinical trial participation among Black people with cancer.
Authors: Gomez Omar B , Akeke Oluwatumilara , Morris Hayley , Carpenter Aaron , Opoku Annabella , Barreiro-Rosado Jeenn A , Matthews Lauren , Charlot Marjory
Published: October 2023

106

Background: People racialized as Black and/or African American (AA) represent less than 10% of participants enrolled in therapeutic cancer clinical trials that may improve cancer survival. AAs have higher cancer-related mortality rates but are less likely to be invited to participate in clinical trials compared to their white counterparts. We surveyed Black patients with cancer to assess their clinical trial discussion experiences and to identify opportunities to improve clinical trial participation. Methods: A purposive sample of 100 Black patients from a North Carolina Comprehensive Cancer Center were recruited to complete a survey between November 2021 and January 2023. Survey participants were identified through a clinical data warehouse and had to meet the following eligibility criteria: self-identified Black or AA race, diagnosis of either multiple myeloma, breast, prostate, colon, or lung cancer, and actively receiving or undergoing follow up cancer care. Surveys were conducted by a research assistant via phone. This analysis focused on those asked to participate in a clinical trial but declined participation. Results: All participants identified as Black or AA race with 2 participants additionally identifying as American Indian. Half of all surveyed participants were asked to participate in a clinical trial. Of those asked, 58% (n=29) declined and nearly half (n=12) indicated specific barriers that influenced their decision to not participate. Barriers included time constraints, distrust, fear of being harmed or being used as a guinea pig, not understanding the purpose of the study, and feeling rushed in their clinical trial decision making. All 29 participants were asked to select how they would prefer to receive clinical trial information and 97% selected speaking with their oncologist, 90% by video, 66% by internet and by a pamphlet or magazine, 52% at church and only 10% from a barber shop or salon. They also suggested simple and clear messaging about clinical trial opportunities, eligibility criteria, time commitment, taking time to discuss clinical trial options, and recruitment materials that can be taken home. Conclusions: Increasing participation in cancer clinical trials among Black patients with cancer necessitates careful discussion and consideration of fear, distrust, and system level barriers that influence the decision or capacity to enroll. Study recruitment should utilize patient centered communication tools that acknowledge the history of research exploitation in Black communities and clearly describe safety and security measures used in clinical trials.
Multilevel factors impacting clinical trial participation: An ASCO State of Cancer Care in America (SOCCA) analysis of oncology fellows’ perceptions of preparedness to conduct clinical research in practice and importance of clinical trial participation.
Authors: Subbiah Ishwaria M. , Schenkel Caroline , Kirkwood Margaret Kelsey , Peppercorn Jeffrey M. , Polite Blase N. , Waterhouse David Michael , Zon Robin , Levit Laura A.
Published: October 2023

110

Background: Despite cancer treatment advances from clinical trials, the proportion of those with cancer enrolling on oncology studies remains low, due to system-, patient-, and physician-level facilitators and barriers to participation. To better understand the upstream context impacting oncologists’ consideration of trials, we studied oncology fellows’ perceptions of trial participation and preparedness for clinical research. Methods: All year 1 (Y1), Y2, & Y3 fellows taking the 2023 ASCO Medical Oncology In-Training Exam (ITE) were invited to take a post-ITE optional survey. After consent, fellows answered whether they agree, disagree or are unsure of their preparedness by their fellowship program to address key elements of practice and research and their perceived importance of trial participation after training, ranging from Very Important, Important, Moderately, Slightly, or Not Important, the latter 3 ratings aggregated and labeled as ‘less important.’ Descriptive statistics and Chi-squared tests comparing responses by fellowship year are presented. Results: Overall, 97% of fellows (2184/2231) taking the 2023 ITE participated in this study and are included in this analysis; 32% were in Y1, 37% Y2, 30% Y3. When asked ‘my fellowship training program is adequately preparing me to address the following in my future,’ nearly one in four fellows felt unsure or disagreed that their program prepared them for (a) treating patients outside of an academic medical center (Y1 24%, Y2 24%, Y3 23%) or (b) conducting clinical research (Y1 26%, Y2 26%, Y3 28%). When asked ‘how important is it to you to have the opportunity to participate in clinical trials following completion of your training,’ nearly half of oncology fellows (Y1 49%, Y2 46%, Y3 40%, p.038) felt trial participation was ‘less important.’ When considering future practice setting, two out of 3 fellows (66%) planning a non-academic practice and one of 3 fellows (33%) planning an academic practice rated trial participation as ‘less important’ (p<.0001). When compared to fellows who reporting being unsure or unprepared by their programs to conduct clinical research, those who felt adequately prepared were more likely to rate trial participation as important/very important (57% vs 49%, p=.005). Conclusions: Our findings show that value of clinical trial participation is assigned early in oncologists’ careers during fellowship training. Addressing barriers to clinical trial participation calls for multilevel interventions that include efforts to identify and augment clinical research learning needs of oncology fellows and ensuring broad exposure during fellowship to successful and efficient conduct of cancer clinical trials.
Lung cancer screening in the prison population.
Authors: Kolandra Lakshmi , Bahgat Joseph , Bernstein Ethan , Petricca Lisa , Ibrahim Omar , Kumar Swarup
Published: October 2023

114

Background: The United States incarcerated population is large and aging resulting in greater incidence of cancer. Inmates are a vulnerable population with increased rates of tobacco use that can place them at risk of developing lung cancer. The goal of this study is to determine whether inmates within the Connecticut (CT) Department of Corrections (DOC) with a history of smoking are screened for lung cancer and to implement a process by which they may be screened. Methods: We conducted a retrospective chart review of patients within the CT DOC that have been diagnosed with a lung nodule or lung mass between the years 2018-2021. Each chart was reviewed to determine if these patients met the current United States Preventative Service Task Force (USPSTF) guidelines for lung cancer screening with low dose CT scan (LDCT). After identifying an opportunity for improvement, we then implemented a shared decision-making clinic to screen inmates. Patients were scheduled for LDCT if they met eligibility criteria and consented to CT scan. Results: 28 patients of charts reviewed were identified as eligible for LDCT screening from the years of 2018-2021. These results showed that 9 (32%) patients out of 28 had LDCT completed. 7 (25%) of these patients had biopsy proven lung cancer. 300 inmates residing within the CTDOC were found to have a significant smoking history. Thus far, 11 patients have been evaluated in our shared decision-making clinic. 7 patients met criteria for LDCT and underwent CT scan. All 7 patients require annual follow up for 3 years. 1 patient declined meeting with our providers. We will continue to offer screening to all eligible and consenting inmates. Conclusions: Through our study we have identified a need to improve screening for lung cancer in the DOC population. We have implemented a process by which inmates can be screened with help from our DOC, Pulmonology, and Radiology colleagues. We will continue the current process to screen and obtain consent for the 300 inmates identified as having a significant smoking history. To our best knowledge, this is the first study that demonstrates a sustainable workflow to screen DOC inmates for lung cancer.
Prevalence and timing of chronic obstructive pulmonary disease (COPD) diagnosis among patients newly diagnosed with lung cancer in the US.
Authors: Metwally Eman , Hinton Sharon Peacock , Lund Jennifer Leigh , Poole Charles , Drummond Brad , Thompson Caroline A.
Published: October 2023

118

Background: COPD is one of the most common comorbidities among patients with lung cancer, and an important determinant of their survival. While COPD is frequently under diagnosed in the general population, less is known about the occurrence of COPD underdiagnosis in patients with lung cancer. Objectives: 1) To estimate prevalence and under diagnosis of COPD among patients newly diagnosed with lung cancer. 2) To quantify the association between timing of COPD diagnosis and stage of lung cancer at diagnosis and whether this association is modified by sex, race, and socioeconomic status (SES). Methods: A secondary data analysis was conducted using the SEER-Medicare database. We included Medicare beneficiaries aged 66+years with primary invasive lung cancer diagnosed from 2008 to 2017 who were alive at the time of cancer diagnosis and had continuous Medicare coverage 12 months prior and 3 months after lung cancer diagnosis. Exposure: Comorbid COPD was determined using Medicare claims and classified as early COPD (evidence of COPD related healthcare utilization (HCU) >3 months before lung cancer diagnosis) versus late COPD (evidence of COPD related HCU only during the +/- 3 months from lung cancer diagnosis). Outcome: Early (localized) versus late (regional and distant) stage of lung cancer diagnosis. Statistical analysis: We used generalized linear models to estimate adjusted absolute (prevalence difference PD) and relative (prevalence ratio PR) association. Results: In a population of 185,405 Medicare beneficiaries with lung cancer, 131,230 (71%) had evidence of COPD. Compared to lung cancer patients without COPD, those with COPD were more likely to be younger, male, White, of lower SES, have more comorbidities, higher HCU, and be diagnosed with early stage lung cancer. Patients with early COPD diagnosis constitute 66,867 (51%) of patients with COPD and lung cancer. They were more likely to be older, female, Non-Hispanic White, of lower SES, and to have more comorbidities, acute exacerbation of COPD, and more early-stage lung cancer compared to patients with late COPD diagnosis. We observed a significant positive association between early COPD diagnosis and early-stage lung cancer diagnosis (PR= 1.27, 95% CI= 1.24 to 1.30; PD= 0.062, 95% CI= 0.057 to 0.066) in models adjusted for age, sex, race, SES, HCU, comorbidities, year of cancer diagnosis, SEER region, and histology. In subgroup analyses, this association was stronger for males, Non-Hispanic Black, American Indian Alaskan Native, and patients of lower SES. Conclusions: Approximately seven out of 10 patients with lung cancer have COPD, and late COPD diagnosis is common. Earlier COPD diagnosis is associated with diagnosis of lung cancer at earlier stages. These findings highlight the need for more structured screening of COPD among individuals at high risk for lung cancer.
Uptake of screening MRI in high risk patients without a personal history of breast cancer.
Authors: Boccuzzi Luciarita , Paul Shirlene , McPeek Chelsea , Stempel Lisa , Alvarado Rosalinda , Levy Mia Alyce ,   Mia Levy
Published: October 2023

133

Background: The American Cancer Society (ACS) recommends breast MRI in addition to annual screening mammogram for women who are high risk for breast cancer starting at age 30, regardless of breast density. This includes women with a lifetime risk of breast cancer of 20% or greater, according to breast cancer risk assessment tools. In this study, we evaluated the uptake of supplemental MRI screening in patients ages 25-75 classified as high risk (Tyrer Cuzick (TC) score greater than 20%), without a personal history of breast cancer (PHBC). Methods: Cancer risk assessment software was used to calculate a TC score. Data was extracted from the EMR of an academic center for patients ages 25-75 years old between 07/20/2020 and 07/29/2021 with a TC score of ≥ 20%. Factors such as age, ethnicity, race, insurance type, breast density, and whether patients had access to a High-Risk Breast Cancer (HRBC) provider were analyzed and a chi-squared test was used to determine whether there were significant differences in MRI supplemental uptake based on these subsets. Results: 1144 patients were identified as high risk, having a TC ≥ 20%. 27% (n=307) underwent supplemental MRI screening, while 73% (n=837) did not. 842 patients were classified as having dense breasts and 28% (n=237) of these patients underwent MRI. Of 635 patients with an MRI order, 36% (n=227) had access to a HRBC provider, while 64% (n=408) did not. Patients with a HRBC provider were more likely to fulfill their MRI order (88%, n=200), compared to patients without a HRBC provider (33%, n=135) (p<0.001). Conclusions: Various factors may be influencing whether high risk patients complete supplemental screening MRI. Patients with dense breasts and those with access to HRBC were more likely to undergo supplemental MRI screening. Patients who have not completed their recommended breast MRI may be faced with various challenges, such as, not having access to a HRBC provider. Identifying barriers to screening can help increase early rates of breast cancer detection in this high risk population of women.
Sociodemographic versus clinical factors associated with incomplete and prolonged courses of radiotherapy.
Authors: Barnes Justin Michael , Yang Joanna Chensi
Published: October 2023

139

Background: Radiotherapy is an important component of therapy for many patients with cancer. However, some patients have difficulty completing recommended courses of radiotherapy in a timely manner. Unfortunately, prolonged or incomplete courses of therapy are associated with higher rates of relapse and lower survival rates, particularly for head and neck and cervical cancers. However, the most important drivers of incomplete or prolonged treatment courses are unclear. Our objective was to quantify associations between sociodemographic and clinical factors and incomplete and prolonged treatment courses. Methods: We extracted data for all patients treated with radiotherapy at a large metropolitan academic institution from 2018 – 2022 from the radiotherapy treatment planning software and from the medical record. Incomplete radiotherapy courses were defined as lack of completion of all planned radiotherapy fractions based on the treating physician’s prescription. Prolonged radiotherapy courses were defined as prolonging treatment by more than 5 days and missing 5 or more fractions, a clinically meaningful delay that can impact cancer outcomes. The primary endpoint was a composite endpoint consisting of incomplete and prolonged radiotherapy courses. Multivariable logistic regression was utilized to quantify associations between incomplete and prolonged treatment courses with age, sex, distance to facility, ZIP code social deprivation index (SDI), insurance status, radiotherapy modality, number of radiotherapy fractions, and treatment site. Models were also adjusted for year-quarter. Results: A total of 9950 cases were included, including 352 (6.5%) and 642 (3.5%) incomplete and incomplete/prolonged radiotherapy courses, respectively. In multivariable logistic regression analyses, factors associated with increased risk of incomplete or prolonged radiotherapy courses included ZIP code SDI > 80 (8.8%, OR 1.43, 95% CI = 1.13-1.80, P=.003), Medicaid insurance (12%, OR 1.92, 1.47-2.50, P<.001), more than 5 fractions of radiotherapy (12.8%, 9.7%, 14.6%, and 13.1%, for 6-10, 11-20, 21-29, 30+ fractions, respectively; P<.001), and treatment site of female pelvis (23.9%, OR 3.27, 2.26-4.78, P<.001). Conclusions: Prolonged or incomplete radiotherapy courses were associated with disadvantaged neighborhoods, Medicaid insurance, higher number of radiotherapy fractions, and female pelvic cancers. Each of these factors is related to social determinants of health and time/financial burden of treatment, including female pelvic cancers (predominantly locally advanced cervical cancer, associated with lower socioeconomic status), underscoring the impact of social determinants of health on patient’s ability to undergo radiotherapy.
BRCA1/2 germline testing among eligible persons with breast cancer in Washington state: A retrospective study using state cancer registry and claims data.
Authors: Ramsey Scott David , Sun Qin , Fedorenko Catherine R. , Kreizenbeck Karma L. , Shankaran Veena
Published: October 2023

154

Background: Clinical practice guidelines have recommended germline testing certain groups of breast cancer patients (men, younger women, and triple negative) for pathogenic BRCA1/2 mutations since 1996. We linked cancer registry records with enrollment and claims records from public and commercial insurers in Washington state to assess factors associated with BRCA1/2 testing among eligible persons with breast cancer. Methods: The database consisted of Washington SEER and state cancer registry records linked with claims records from commercial insurers (Premera Blue Cross, Regence Blue Shield), Medicare, Medicaid, and the Washington State Employee Benefit Plan. Eligible patients were diagnosed with breast cancer between 2017-2019 and were age <= 50 female, any age male, or with triple negative cancer. Other inclusion criteria included first primary cancer, alive at least 3 months following diagnosis, and continuous insurance enrollment from 2 months prior to 24 months following diagnosis. We used multivariable logistic regression to examine factors associated with BRCA1/2 testing. In a secondary analysis, we examined whether receipt of testing was associated with bilateral mastectomy. Results: The study population included 1,358 women and 43 men (80.2% were non-Hispanic White, 4.1% non-Hispanic Black, 11.7% non-Hispanic Asian, and 4.9% Hispanic.) The insurance composition was as follows: 56% commercial, 15% Medicare, 19% Medicaid; 10% multiple insurers. Overall, 63% received BRCA1/2 testing. Factors that were significantly associated with testing are shown in the table. In the secondary regression model, the association between BRCA1/2 testing and bilateral mastectomy was positive (OR 1.45, 95% CI 1.07-1.98). Conclusions: Despite a trend towards more testing over time, BRCA1/2 germline testing remains underutilized among persons who are eligible for testing, with significant disparities among Medicaid and Medicare enrollees. Testing may influence management, but further study is required. Patients would benefit from more effective integration of clinical guidelines into practice.[Table: see text]
Evolving models of care for ambulatory systemic treatment.
Authors: Pardhan Aliya , Gallo-Hershberg Daniela , Shirodkar Apurva , Montgomery Nicole , Fedorowicz Nicole , Kandasamy Sharmilaa , Della Mora Lauren , Singh Simron , Forbes Leta Marie , Vu Kathy
Published: October 2023

155

Background: Increasing demand for systemic cancer treatment in Ontario, Canada, due to an aging population and therapeutic advances, is compounded by resource shortages and provider burnout heightened by the COVID-19 pandemic. This landscape has led to longer wait times, reduced services, poorer patient experiences, and widened health inequities, particularly impacting marginalized populations. In response, Ontario Health (Cancer Care Ontario) developed recommendations to optimize ambulatory systemic treatment delivery from various perspectives, including patients, providers, cancer programs, and organizations. Methods: Evidence-based recommendations were derived from a targeted literature review, current state surveys, and follow-up interviews across 16 Ontario treatment facilities. Feedback was gathered via focus groups involving patients, families, care partners, and providers. Key informants from cancer agencies in Canada and internationally were consulted through jurisdictional scans. Furthermore, focused discussions with First Nations, Inuit, Métis, urban Indigenous (FNIMUI) communities, Francophone populations, and other equity deserving groups informed the unique needs, experiences, and barriers to care of these groups. Results: Twenty-six recommendations that span various aspects of systemic treatment delivery, including referral processes, scheduling, role integration, patient education, patient and provider experiences, virtual care, and care transitions were developed. Priorities include evidence-based, person-centred care, timely access, effective collaboration, provider well-being, and technological innovation. Additionally, we highlight partnerships with FNIMUI communities, and other equity-deserving groups as strategies to address additional barriers to care. Conclusions: These recommendations strive to address challenges faced by healthcare providers and patients, ensure equitable access to care, and improve provider well-being. Engagement with FNIMUI communities and other equity-deserving groups influenced these recommendations, emphasizing the need for system-level oversight and investment to realize equitable and sustainable service delivery province-wide.
Demographic differences in receiving external beam vs brachytherapy radiation in primary ocular cancers.
Authors: Voth Caitlyn , Au Kristine , Silberstein Peter T. , Keirns Darby
Published: October 2023

163

Background: Primary ocular cancers are rare but may be lethal if not treated appropriately. Previously, enucleation was commonly recommended as treatment but has been associated with increased psychosocial disturbances. More recently, brachytherapy and external beam radiation therapy (EBRT) have been used instead due to similar survival outcomes and the opportunity to salvage the eye. Brachytherapy allows for more precise, high dose radiation to be localized to the tumor and minimizes exposure to nearby tissues and, thus, secondary complications. Due to this possible variance of outcomes between radiation therapies, it would be beneficial to examine the demographic differences of those who undergo each modality in the treatment of primary eye cancers. Methods: 2,783 patients diagnosed with a primary ocular cancer that underwent phase I treatment via either EBRT or brachytherapy were isolated using the National Cancer Database from the years 2016 – 2020. Multivariate binary logistic regression and descriptive statistics were used to compare the demographics associated with those who underwent EBRT vs brachytherapy. A p-value of < 0.05 was used to determine significance. Results: Private-insured and Medicare-insured patients were 224.9% and 155.2%, respectively, more likely than uninsured patients to receive brachytherapy. Patients in the third quartile for median household income were 28.4% less likely than those in the upper quartile to receive brachytherapy. Males were 40.2% less likely than females to receive brachytherapy. Compared to White patients, Black and Asian patients were less likely (81.6% and 83.8%) to undergo brachytherapy. Patients identifying as Hispanic/Spanish were 58.4% less likely than non-Hispanic/non-Spanish patients. There were no significant differences found when comparing Charlson-Deyo scores. Conclusions: Patients who are uninsured, in the third quartile for median household income, male, Black, Asian, or Hispanic/Spanish were less likely to undergo brachytherapy compared to EBRT. These findings illustrate that there are significant differences in the groups who undergo recommended radiation modalities for primary ocular cancers. Awareness of these disparities can help us understand the importance of ameliorating healthcare inequalities in the treatment of eye cancers.
Self-reported perceived discrimination and experiences of patients with cancer.
Authors: Arora Aakriti , Imo Brenda Umenita , Gautam Monika , Gallagher Christopher , Latif Hira
Published: October 2023

165

Background: Racial discrimination is a significant social determinant of health inequities. Ethnic disparities can indirectly result in different access to care, while healthcare provider ethnic bias can influence healthcare outcomes. National statistics show that Black patients have higher death rates when compared to those of other race and ethnicities. Our study aims to evaluate and compare self-reported and perceived discrimination in day-to-day life and healthcare experiences of patients who receive care at our cancer center. Methods: Cancer patients were surveyed in person at the Cancer Center at Medstar Washington Hospital Center between July 2022 and January 2023. The Everyday Discrimination Scale (EDS) by D.R. Williams and Discrimination in Medical Setting (DMS) questionnaire by M.E. Peek were used to collect data. Results: 100 patients following up at the clinic completed the paper survey. 74% were females and 26% males, 75% Black, 17% White and 8% Other Races (including Hispanic and Asian). The responses to the EDS and DMS were collected and coded as continuous variables, summed together, reported as medians, and compared across the various groups of interest. P-values between medians were reported using Kruskal Wallis test/Wilcoxon rank-sum test. Highest median scores on the EDS were found in Other Races, with a higher score representing higher self-perceived discrimination, followed by Black, and White (p<0.001). Lowest median scores on the DMS questionnaire were found in White, lower score representing lower self-perceived discrimination, followed by Other Races and Black (p<0.001). 30% of our total study population reported feeling that their quality of care was affected due to racial discrimination, out of which 83% were Black and 16% were Other Races, not including White (p= 0.006). Comparison of median scores for both the scales was not statistically different across age, gender, and cancer type. Conclusions: The results of our study demonstrate that self-reported and self- perceived racial discrimination extends to health care, and for some includes self-reported effects on the quality of health care received. Worse responses of the Other Races on the EDS and DMS scales could be explained by the low number of participants. Overall, the negative responses may have been affected by a variety of factors like varying stage of diagnosis, care received at other health-care centers, all of which would attribute to self-reported poorer experience regardless of race. There is a growing need to address these disparities to providing culturally sensitive care and addressing the root causes of systemic racism and inequality. This study is the first step in determining the day-to-day and healthcare experiences among patients at our center. We hope to follow with a prospective survey-based analysis of implicit bias among all healthcare workers.
Establishing purposeful oncology care disparities reduction strategies.
Authors: Elston Lafata Jennifer Elston , Benjamin Jenna , David Lori A. , Ray Emily Miller , Sanoff Hanna Kelly
Published: October 2023

166

Background: Quality thought leaders have noted the oneness of care quality and equity. Yet, quality improvement (QI) often ignores equity. We implemented a holistic approach to quality specifically designed to facilitate equity. We report the components of the approach and how it is being used to address disparities in unplanned acute care events (ACEs) among chemotherapy patients. Methods: We used the Institute for Health Improvement Whole System Quality framework to integrate care equity in an established quality program. We started by stratifying oncology dashboards by race, ethnicity, and language (REAL) as well as other factors (monitoring). We developed and implemented an Umbrella Action Plan Policy that specified an accountability structure to identify and address disparities (planning) and via goal setting (planning), prioritized, developed, and executed action plans to address disparities once identified (improvement). Results: In February 2023 a system-level senior leadership committee charged with priority setting cancer care quality initiatives approved the Umbrella Action Policy. This led to REAL-stratified, quarterly performance reports being shared with senior leadership who voted for this year’s annual goals to include identification and use of rapid cycle testing to eliminate ACE disparities. The organization-level goal engendered central QI coaching resources, established local entity QI teams within each System-affiliated entity with dedicated oncology program (N=6), and formed a learning collaborative across entities. One of each local QI team chose to focus on reducing race-related, language-related, and payor-related (Medicaid) disparities. The other organizations chose otherwise (e.g., age or gender). Teams are using two approaches to identify ACE root causes among target populations: (1) a structured chart abstraction form to search for, among other things, communication breakdowns, gaps in symptom management or other supportive care, and access barriers; and (2) a semi-structured interview guide to engage patients and caregivers for input and suggestions. In September, teams will work collaboratively to identify and execute small tests of change to alleviate identified drivers contributing to ACE disparities. Data from chart abstractions and patient engagement interviews will be shared along with results from tests of change tried to date. Conclusions: Facilitating the identification of disparities via REAL stratified dashboards, leadership teams setting expectations regarding gap closure, and allocation of resources to support local QI teams has focused the quality planning, monitoring, and, to some extent, improvement activities on care equity among marginalized populations. Prescriptively focusing local organization efforts may be needed for appropriate selection of target populations when wanting to infuse REAL equity in QI programming.
Association between social determinants of health and cancer treatment delay in an urban population.
Authors: Zhang Faye , Sheni Risha , Zhang Chenxin , Viswanathan Shankar , Fiori Kevin P , Mehta Vikas
Published: October 2023

167

Background: Delay in time to treatment initiation (TTI) has been shown to independently and adversely affect disease-specific mortality in patients with different cancers. Social Determinants of Health (SDoH) are increasingly recognized as significant contributors to patients’ disease management and health outcomes. Our academic center has developed and validated a 10-item SDoH screener that has been in place since 2018. We evaluated which self-reported social needs may be predictive of delayed TTI. Methods: This is a retrospective cohort study at an urban community-based academic center of patients diagnosed with breast, colorectal, endocrine and neuroendocrine, gastrointestinal, genitourinary, gynecologic, head and neck, hematologic, hepatobiliary, lung, and pancreatic cancer from August 2018 to September 2022. We identified patients who had completed an SDoH screening and had diagnosis and treatment data in the hospital’s cancer registry. Variables of interest included median household income (based on home zip code and US Census data), area deprivation index (ADI) (based on the Neighborhood Atlas from the University of Wisconsin), Charlson Comorbidity Index (CCI) score, marital status, smoking history, insurance status, tumor stage, and emergency department (ED) or inpatient admission 30 days before diagnosis. Factors associated with TTI delay, defined as TTI ≥ 45 days, were assessed using multivariable logistic regression. Results: Among 2,328 patients (66.6% female, 43.4% Hispanic, 35.7% Black, and 9.4% White), the median age was 65 (IQR, 56-73) and the median TTI was 25 days (IQR, 0-51 days). The multivariable models showed that patients with one or more self-reported unmet social needs experienced a statistically significant delay in TTI (odds ratio [OR], 1.68; 95% CI, 1.54-1.82). The disparities most strongly associated with delay were legal help, healthcare transportation, housing stability, and the need to provide care for others. Additionally, patients identified as non-Hispanic Black (OR, 1.44; 95% CI, 1.32-1.57) or Hispanic (OR, 1.47; 95% CI, 1.19-1.50) were more likely to have a delay compared to non-Hispanic White patients. A decreased likelihood for delayed TTI was found in those with ED (OR, 0.49; 95% CI, 0.44-0.54) or inpatient (OR, 0.54; 95% CI, 0.50-0.58) admission 30 days before diagnosis. Conclusions: Our data show that delays over 45 days are independently associated with unmet social needs. Additionally, ED or inpatient admissions within 30 days before diagnosis help increase care coordination and compliance, leading to improved TTI. These findings suggest that cancer patients who have unmet social needs are at higher risk of treatment delay and may benefit from interventions to mitigate needs, especially legal, transportation, and housing assistance.
Facility type as a prognostic factor? The role of academic centers in outcomes and treatment for patients with leiomyosarcoma.
Authors: Patel Jaikin , Braaten Marco , Silberstein Peter T.
Published: October 2023

185

Background: Leiomyosarcoma is a highly aggressive form of cancer that comprises roughly 10-20% of soft tissue sarcomas. It originates in smooth muscle tissue and its prognosis largely depends on how quickly it is detected – with surgical resection being potentially curative if the cancer is caught before it metastasizes. Previous studies have shown that patients from lower socioeconomic statuses with soft tissue sarcomas have worse survival rates; however, it appears that the relationship between leiomyosarcoma, specifically, and socioeconomic status has yet to be determined. Using the National Cancer Database, we aim to uncover this relationship and define the role of academic centers on the treatment and outcomes of these patients. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with leiomyosarcoma from 2004 to 2019 using the histology codes 8890 and 8891. Socioeconomic and treatment variables were identified as assigned by the Commission on Cancer Accreditation program. Survival data was computed using logrank testing and a Cox proportional hazards model. Data was analyzed using IBM SPSS Statistics for Windows, Version 27.0 software (IBM Corp., Armonk, NY) and statistical significance was set at α = 0.05. Results: Initial search revealed 16,573 patients to be included for analysis. 7,003 patients (42.4%) were treated at an academic facility. Patients treated at academic/research facilities experienced improved overall survival (76.78 months vs. 60.52 months; p<0.001), greater utilization of adjuvant chemotherapy (88.5 vs. 82.2%; p<0.001), and higher rates of complete resection (87 vs. 83.4%; p<0.001) compared with those treated at non-academic facilities. Furthermore, people traveled further for care at academic facilities (62.4 vs. 25.5 miles; p<0.001), and were more likely to be younger, in higher income groups (36.9 vs. 33.2%; p<0.001), Black, carry private insurance (44.9 vs 41.3%; p<0.001), and less likely to have Medicare (42.7 vs. 49.4%; p<0.001) compared with those at non-academic facilities. Extent of disease varied between facility type with patients at academic facilities presenting with higher rates of stages II and III disease, whereas those who presented to non-academic facilities had higher rates of stages I and IV disease. There were no differences observed between rates of palliative treatment, phase I radiation primary treatment volume, or tumor size between the two facility types. Conclusions: This analysis identifies various patient characteristics (e.g., income, race, insurance type) associated with seeking treatment at academic facilities for leiomyosarcoma, as well as the influence of facility type on patient outcomes with this cancer.
Gender equity education in oncology: A survey study of hematology-oncology fellowship program directors.
Authors: Hum Christina , Velazquez Manana Ana I. , Marshall Ariela Lucy
Published: October 2023

192

Background: Understanding gender equity (GE) as it pertains to patient care as well as the healthcare workforce is essential to the education of future physicians. However, the landscape of GE education in hematology-oncology (HO) fellowship programs is not well-characterized. The purpose of this study was to examine if and how current HO fellows receive training about GE for both patients and physicians. Furthermore, we aimed to identify barriers to providing such training and establish opportunities for educational initiatives regarding GE in HO. Methods: We conducted an online survey of program directors (PDs) of adult HO fellowship programs in the United States. We asked for PD perceptions of how important GE is for patients and physicians and whether their training programs currently offer GE training. For programs without such training, PDs were asked about reasons for lack of current training and level of interest in providing it in the future. Responses were recorded using Likert scales, multiple choice, and open-ended responses. Data were analyzed using descriptive statistics, and open-ended questions were analyzed with thematic analysis. Results: Of 172 PDs contacted, 57 PDs completed the survey (33.1%). Most PDs felt that training in GE issues is “somewhat important” or “very important” regarding patient care (n = 39, 68.4%) and the physician workforce (n = 45, 80.4%). However, most PDs reported that their program does not provide formal training in GE issues regarding patient care (n = 48, 84.2%) or the physician workforce (n = 44, 78.6%). Common reasons listed for lack of GE training include lack of resources (regarding patients: n = 28, 68.3% and regarding physicians: n = 24, 54.5%). Most PDs were interested in resources for patient and physician GE (n = 46, 93.9% and n = 39, 88.6%, respectively). Several programs were open to sharing their training materials for patient (n = 3, 44.4%) and physician GE (n = 8, 66.7%). Conclusions: While most HO PDs feel that GE training is important for patient care and the physician workforce, most reported their fellowship does not offer such training primarily due to lack of resources. Given the interest of many PDs for more educational GE resources, there are opportunities to share existing materials and create new resources to enhance the GE training for future HO physicians.[Table: see text]
Association of federal and state policies regulating short-term limited duration insurance (STLD) plans and later cancer stage at diagnosis.
Authors: Yang Nuo Nova Nova , Zhao Jingxuan , Barnes Justin Michael , Kirchhoff Anne C. , Chino Fumiko , Yabroff Robin , Han Xuesong
Published: October 2023

197

Background: Most short-term limited duration (STLD) insurance plans do not cover essential health services, such as cancer screenings, which may delay cancer diagnoses. STLD plans can disrupt individual insurance markets, leading to higher costs and delays in care for comprehensive plan enrollees. In October 2018, federal regulations extended the allowable duration of STLD plans to up to 36 months. States have taken varying approaches to expand, restrict, or eliminate the sale or terms of STLD plans, both prior to 2018 and following its enactment. Our study examined associations of state-level policies regarding STLD plans and late-stage cancer diagnosis before and after the 2018 change. Methods: We identified 1,289,366 adults aged 18-64 years newly diagnosed with cancer in 01/2016-02/2020 in 47 states and DC from the National Cancer Database, with a “washout” period +/- 3 months of the 2018 regulation. Patients were categorized into 4 groups according to their states’ STLD plans policies: (1) states prohibiting STLD plans prior to 2016; (2) states banning STLD plans or strict regulations leading insurers to stop offering STLD plans after 2018; (3) states restricting STLD plans; (4) states with no STLD regulation. We conducted difference-in-differences (DiD) analyses to evaluate changes in late-stage diagnoses (stages III/IV) pre- (01/2016-06/2018) and post- (01/2019-02/2020) STLD plan expansion between groups 2, 3, 4 vs group 1 for all cancers combined and 2 common cancers with effective screening tests: female breast and colorectal. We adjusted for age group, sex, race/ethnicity, rurality, area-level poverty, and state random effects to account for other state-level variations. Results: Percentages of late-stage diagnosis decreased since 2018 in all state groups (Table). Compared to patients in group 1 states (prohibited STLD plans prior to 2016), group 4 (no STLD regulations) had a net increase of 0.8 (95%CI = 0.2-1.3) percentage points (ppt) in late-stage diagnosis and group 3 (some STLD regulations) had a net increase of 0.9 (95%CI = 0.3-1.4) ppt in late-stage diagnoses (Table). Similar patterns were observed for female breast and colorectal cancers. Conclusions: The federal policy on STLD plan expansion was associated with an increase in late-stage cancer diagnoses, underscoring the importance of individual state policies banning or restricting STLD plans.[Table: see text]