bluuebunny/crossref_metadata_2025 huggingface dataset:
Racial disparities in obesity and comorbidities among women with early breast cancer.
Authors: Nyrop Kirsten A. , Deal Allison Mary , Muss Hyman B. , Damone Emily , Lorentsen Michael , Brenizer Tucker , Shachar Shlomit S.
Published: May 2020

e19061

Background: Both comorbidities and obesity (body mass index/BMI 30 or higher) are observed in women at the time of early breast cancer (EBC) diagnosis. This study investigates age and obesity and their association with disparities in comorbidities between black and white women at EBC diagnosis. Methods: This is a retrospective chart review of women with EBC (Stage I-III) treated at a single institution. Relative risk (RR) with 95% Confidence Interval (CI) for individual comorbidities are calculated for black compared to white patients, adjusted for age and BMI. Results: In a sample of 548 women, 26% are black and 74% are white. 18% of black patients vs 28% of white patients were age 65 or older (p = .01). 62% of black vs 33% of white patients had obesity (p < .0001). 63% of black vs 47% of white patients had 2 or more total comorbidities at diagnosis (p = .003). 33% of black vs 10% of white patients had 2 or more obesity-related comorbidities (p < .0001). 60% of black vs 32% of white patients had hypertension (p < .0001); 23% of black vs 6% of white patients had diabetes (p < .0001); and 28% of black vs 18% of white patients had high cholesterol (p = .02). In multivariable (MV) analysis adjusted for age and BMI, black women had 45% higher risk for hypertension [RR 1.45 (1.19-1.75), p = .0002)] and 44% higher risk for diabetes [RR 1.44 (1.02-5.86), p < .0001)] at EBC diagnosis. However, after adjustment, differences by race were no longer seen for > = 2 total comorbidities, > = 2 obesity-related comorbidities, heart disease, or thyroid disease. Conclusions: This study documents significant disparities between black and white women with EBC with regard to high rates of obesity, overall comorbidities and obesity-related comorbidities. Future research should assess the potential impact of weight management (avoiding weight gain) interventions in the first 2 years post diagnosis on improving OS and BCSS among patients with obesity and in reducing OS and BCSS disparities between black and white women.
Medical oncologists’ perceptions of clinical trials for underrepresented populations.
Authors: Perez Giselle Katiria , Park Elyse R. , Horick Nora K. , Mizrach Helen , Nipp Ryan David , Crute Sydney , Chabner Bruce Allan , Moy Beverly
Published: May 2020

e19062

Background: Ethnic/racial minorities and socioeconomically disadvantaged patients remain underrepresented in cancer clinical trials (CCT), challenging the accuracy and generalizability of findings. While oncologists’ recommendations influence trial participation, we know little about their perspectives on recommending CCT to underrepresented patients. Methods: From 9/16-5/19 we conducted a sequential mixed methods study to assess oncologists’ attitudes toward recommending underrepresented patients for CCT. We performed individual interviews with 17 oncologists, developed a survey instrument, and surveyed a randomly selected sample of 98 oncologists (from ASCO, NCORP, MGH; RR = 31.2%). Descriptive statistics summarized attitudes, practices and challenges with trial enrollment of underrepresented patients. Results: Content analysis of interviews (age = 46.9, female = 37.5%, white = 75.0%) revealed overall support for CCT. Indeed, 84.4% of survey respondents (age = 53.3, female = 31.3%, white = 78.6%) considered CCT as central to their professional identity. Yet, 37.5% agreed CCT placed undue burden on oncologists. Oncologists’ concerns around informed consent and perceived lack of clinical/personal equipoise discouraged recommending CCT participation to vulnerable patients. Interviews revealed that nearly all believed that patients with certain vulnerabilities (e.g., literacy, social, financial barriers) had needs that conflicted with CCT demands, increasing the potential for harm. Oncologists were less likely to recommend CCT to patients who do not reliably report side effects (91.2%), demonstrate difficulty comprehending the costs/benefits of CCT (88.7%), lack support (87.6%), live far away (76.3%), or face insurance obstacles (73.2%). Notably, 67.7% affirmed they presented trials with varying enthusiasm based on perceived patient challenges; 32.4% deemed it hard to justify enrolling patients if efficacious standard treatment options exist outside of trials. Oncologists desired navigation support (63.3%) to offset concerns and facilitate trial discussion/enrollment. Conclusions: Findings confirm that oncologists value CCT; however, they experience conflict when considering CCT for patients with pre-existing hardships. Time constraints interfere with oncologists’ ability to adequately address and overcome perceived challenges to participation. Our findings underscore the need for programs that integrate informational support with patient navigation to increase enrollment of underrepresented patients into CCT.
Development of a stop light tool using the bellarmine norton assessment tool (BNAT) for physical therapy referral.
Authors: Crandell Catherine Elizabeth , Wingard Christopher Jon , Quinn Sarah Elizabeth , Amin Kate Elise , Brownschidle Katie Marie , Dahm Donna , Huebler Lauren , Mayo Kelsey Lynn , Hamm John Turner
Published: May 2020

e19067

Background: Individuals with cancer experience fatigue, pain and decline in function. The Bellarmine Norton Assessment Tool (BNAT) was developed to give an objective measure identifying a person’s overall functional ability through a variety of physical assessments focused on mobility and strength. The purpose of this study was to develop a referral tool to provide health care professionals an easy determinant for physical therapy referrals. The referral tool was designed as a Red, Yellow, Green light for easy interpretation and use. Methods: The BNAT is composed of 1 self-reported physical activity question and 4 objective tests: 2-Minute Step Test (2MST); 30-Second Sit-to-Stand; Timed Arm Curl; and Timed Up and Go. A previously collected data set of BNAT scores was utilized to develop the referral tool with the poorest performance corresponding to Red and the best corresponding to Green. Three variations of normative scaling examined optimal distribution for classification. The first model averaged normative data of 70-74 age group of healthy individuals. No participants in our study achieved 50% of population norms. Therefore, the Green light represented 35% of the normative values, the Yellow light ranged from 15-34% and the Red light identified < 15%. A second model used frequency histograms for each BNAT elements. Groupings were made based on the natural break of the data to depict the Red, Yellow or Green light. A third approach combined normative and frequency distribution for each element as compared to the respective BNAT scores. The outcome assigned BNAT score of 1 and 2 to Red light, 3 to Yellow light and 4 and 5 to Green light. Except for the 2MST, these models were similar for the cutoff between color categories. The third model best fit the study population with respect to the individual’s total BNAT score. Results: Of the 161 subjects, 47 subjects (29%) fell into the Red category, 81 (50%) into Yellow and 33 (21%) into Green. Using this scaling system for the total BNAT score, 13 score combinations result in Red light, 6 scores for Yellow light and 6 scores for Green light. Regardless of the model, most individuals were assigned a Yellow light. Conclusions: The literature is void of functional cut off scores and normative distributive data for the oncology population. We defined a referral tool with scaling based off normative scores and functional assessments that reflect the distribution of oncology patients. The third model may be used as a simple referral tool among multiple health care professionals aiding in a referral for physical therapy.
Assessing social determinants of health in a safety-net oncology population: Use of an EHR-based screening and referral system.
Authors: Tsai Rebecca N. W. , Qureshi Muhammad M. , Losi Stephanie , Dyer Michael A. , Truong Minh Tam , Buitron de la Vega Pablo , Mak Kimberley S.
Published: May 2020

e19072

Background: Routine electronic health record (EHR)-based screening and resource referral to address social determinants of health (SDOH) have been established in adult primary care clinics and the emergency department of New England’s largest safety-net hospital. The burden of SDOH in safety-net oncology patients is less well-studied. This study aimed to understand the social needs of this vulnerable patient population and evaluate the need for implementation of SDOH screening in the oncology clinic. Methods: Patients with lung or head and neck cancer seen in consultation in the Department of Radiation Oncology at Boston Medical Center between 3/2019-1/2020 were identified. EHRs were reviewed for receipt of THRIVE, an EHR-based screening and referral model addressing SDOH. Associations between patient demographics and SDOH screening were evaluated. Results: A total of 104 head and neck (n = 53; 51%) and lung (n = 51; 49%) patients were identified. Median age was 65 years (interquartile range 57.5-72). The majority of patients were male (71.2%), and English-speaking (82%). Whites, Blacks, and Asians comprised 43%, 38%, and 3% of patients, respectively. Fifteen patients were Hispanic (14%). Patients were most likely to have private health insurance (n = 41; 39%), followed by joint Medicare-Medicaid plans including senior and community health plans for elderly (n = 27; 26%), Medicaid (n = 17; 16%), and Medicare (n = 17; 16%). 83 of 104 patients (79.8%) were screened for at least one SDOH domain, with 55 patients (66%) screened before presentation in radiation oncology clinic. Transportation to medical appointments (16%), food insecurity (14%), and inability affording medications (10%) were the most prevalent concerns among these oncology patients. Housing insecurity, utilities, caregiving, unemployment, and education were identified social concerns for 4-5% of patients. The majority of patients who had at least one social need requested resources to assist them (71%). Age, gender, race, language, and insurance status were not associated with receipt of the SDOH screener (p≥0.1). Conclusions: Safety-net oncology patients report significant social needs. Routine SDOH screening and resource referral should be considered in these vulnerable patients.
A knowledge, attitudes and practices survey for medical trainees about cancer in the LGBTQ community.
Authors: Taneja Alankrita , Stark Sabrina , Chokshi Bhavin , Alhusain Rashid
Published: May 2020

e19073

Background: The purpose of our study was to assess the extent of knowledge, attitudes and practices regarding cancer in the LGBTQ community among medical students and resident physicians at the Detroit Medical Centre/Wayne State University program. Methods: A 15 question validated survey was electronically provided to medical students and resident physicians. The survey included questions that assessed the knowledge, attitudes and practices regarding cancer in the LGBTQ community. Respondents selected a choice based on a 5 item rating scale that ranged from "strongly agree" to "strongly disagree." In addition, participant demographics including training level and gender/sexual identity were collected. Descriptive statistics (counts and percentages) were used to quantify survey responses. Results: A total of 110 responses were received. The respondents consisted of 77% medical students as well as 8.2% interns and 13.7% senior residents in the department of internal medicine. Five percent of the responders reported having rotations in Corktown Health Center, which is an LGBTQ clinic. Majority (82.7%) reported that they were heterosexual while the rest were homosexual, bisexual, pansexual or preferred not to say. In terms of knowledge, one third of the responders reported being well informed on the health needs of LGBTQ patients. While majority (82.1%) believed that LGBTQ patients avoid accessing healthcare, 7% of the respondents disagreed that transgender individuals are less likely to have health insurance. In terms of attitudes, majority (97%) agreed that the LGBTQ population has unique health risks. 82% of the responders believe that it is important to know the gender identity and the sexual orientation of the patients to provide the best care, however only 30% practiced actively inquiring about a patient’s sexual orientation when taking a history. One third of the responders assume that the patient is heterosexual upon first encounter. Ninety five percent of medical trainees agreed that formal education needs to be provided in medical school or as part of residency curriculum on LGBTQ health needs. Conclusions: Our survey shows that there is a gap in knowledge and practices of medical trainees about health needs of the LGBTQ population. Majority of the respondents believe that training about cancer in the LGBTQ population needs to be integrated into medical school or residency curriculum. Exclusion of LGBTQ- specific health needs from medical school and residency curricula contributes to cancer related health inequities faced by this population.
Disparities in use of immunotherapy for stage III and IV melanoma patients.
Authors: White Richard L. , Trufan Sally Jeanne , Gower Nicole Lee , Neelands Brittany , Amin Asim
Published: May 2020

e19087

Background: Approval of immune checkpoint inhibitors (ICIs), ipilimumab (ipi), nivolumab and pembrolizumab has significantly changed the outcome for patients with stage III and IV melanoma. Adoption of ICI based immunotherapy (IT) and utilization has not been studied. We sought to assess the utilization of ICI therapy and identify barriers that limit access. Methods: The National Cancer Database (2004-2016) was used to analyze stage III and IV melanoma patients separately using descriptive statistics, univariable and multivariable models to compare use of IT (yes/no) with sex, race, age, Charlson-Deyo score, insurance status, census median income, census education, distance to treating facility, year of diagnosis and facility type. Results: Of 15,373 stage III patients 2,555 (16.6%) received IT. Since approval of ipi for resected stage III disease, 20.8% received adjuvant treatment in 2015 and 28.2% in 2016 (Table). Multivariable analysis showed that older patients (OR 0.96 (0.96-0.97)), those treated at non-academic programs (community cancer (CC) (OR 0.69 (0.55-0.86)), comprehensive CC (OR 0.55 (0.49-0.70)), or integrated network cancer program (INCP) (OR 0.58 (0.49-0.70))), have government insurance (OR 0.80 (0.70-0.90)) or no insurance (OR 0.78 (0.64-0.94)) vs private insurance were significantly less likely to receive adjuvant IT. Of 21,718 stage IV patients, 3,098 (14.3%) received IT. Using multivariable analysis, patients with fewer co-morbidities (OR 1.4 (1.05-1.86)) diagnosed in 2011 or later (Table) were more likely to receive IT. Disparities were noted in older patients (OR 0.98 (0.97-0.98)), those treated at non-academic programs (CC program, OR 0.34 (0.28-0.41)), comprehensive CC program (OR 0.34 (0.30-0.38)), or INCP (OR 0.40 (0.34-0.46)), and low vs high education level (OR 0.75 (0.62-0.90)) as less likely to receive IT. Conclusions: Despite approval and significant impact of ICIs, many patients did not receive approved therapy. Variations in care depended on where patients received treatment, age, and education level. [Table: see text]
Clinicopathologic and molecular genetic comparison of primary uterine serous adenocarcinomas from African American and Caucasian women.
Authors: Wang Aifen , Chen Youguo , Holloway Robert W. , Pei Zhe , Yang Jinsong , Zhao Yingyan
Published: May 2020

e19092

Background: The study aimed to identify whether there were racial disparities in the clinicopathologic features and genetic mutation characteristics between African American (AA) and Caucasian women with uterine serous carcinoma. Methods: Clinicopathologic features, molecular genetic data of patients with uterine serous carcinoma were obtained from The Cancer Genome Atlas (TCGA), including age of diagnosis, body mass index (BMI), tumor grade, FIGO stage, myometrial invasion, lymph node involvement, overall survival and progression free survival. MLH1, MSH2, MSH6, PMS2, BRCA1, BRCA2, CHEK2, TP53 mutations were involved. A statistical analysis of these parameters was performed for AA and Caucasian women. Results: 44 AA and 97 Caucasian patients with uterine serous carcinoma were analyzed. There were no PMS2 and BRCA2mutations in tumors of African American patients. Compared to Caucasian patients, tumors from AA patients had no statistically significant differences in Lynch syndrome related genes ( MSH2, MSH6, PMS2) (4.5% versus 14.3%, p = 0.149) and HR pathway genes ( BRCA1, BRCA2, CHEK2) (9.1% versus 19.6%, p = 0.09). Tumors from AA patients had no statistically significant differences in alterations of the TP53 gene (79.5% versus 71.3%, p = 0.312). There were no statistically significant differences between the two groups regarding age at diagnosis, BMI, tumor histology, tumor grade, lymph node involvement, myometrial invasion, FIGO stage, overall survival or progression-free survival between the two groups ( p > 0.05). Conclusions: This study identified no statistically significant differences in clinicopathologic features and genetic mutations in AA and Caucasian women with uterine serous carcinomas. Especially, there were no differences in survival identified between two groups. Much larger database may be necessary to be analyzed in future. [Table: see text]
Nationwide analysis of healthcare burden and risk of mortality in cancer patients with deep venous thrombosis.
Authors: Ba Aqeel Sheeba Habeeb , Lingamaneni Prasanth , Farooq Muhammad Zain , Baral Binav , Banskota Shristi Upadhyay , Gupta Shweta
Published: May 2020

e19093

Background: Occurrence of venous thromboembolism is well known to have increased mortality in cancer patients with pulmonary embolism known to be the leading contributor. However, risk of mortality and healthcare burden with deep venous thrombosis (DVT) alone is not well elucidated, and primary prophylaxis is still controversial. We sought to evaluate risk of hospitalization, mortality, as well as, differences in resource utilization in patients with and without cancer, who were diagnosed in the emergency department (ED) with acute DVT alone. Methods: Adult patients diagnosed with acute DVT from January 2016 to December 2017 were identified from the Nationwide Emergency Department Samples (NEDS) database. Univariate and Multivariate logistic regression analysis was used to compare the risk of admission from the ED and inpatient mortality in DVT patients with cancer and those without. Secondary outcomes assessed were length of hospital stay (LOS), inpatient hospital charges, risk of GI bleed, and rates of inferior vena cava (IVC) filter placement and thrombolysis. Results: A total of 404,121 patients were diagnosed with acute DVT only, of which 8% had an underlying malignancy. Most common primary cancers were GI tract (20.1%), hematologic (16.5%) and lung (13.5%). Patients with cancer were older (mean age 66.4 vs 59.8 years, p<0.0001), with a slight male preponderance (51.8% vs 47.5%, p<0.0001). They were also more likely to be admitted from the ED (70.5% vs 39.1%, p<0.0001). Patients with malignancy had longer length of stay, higher hospital charges, higher mortality and rates of GI bleed (p<0.001 for all outcomes). On multivariable analysis, after adjusting for age, sex and comorbidities, patients with cancer were more likely to be admitted than those without cancer (OR 3.71, CI 3.41-4.04, p<0.001), had higher mortality (OR 3.09, CI 2.42-3.94, p<0.001) and rates of GI bleed (1.75, CI 1.45-2.12, p<0.001). Likely for this reason, patients with cancer were more likely to undergo IVC filter placement (15.2% vs 9.4%, p<0.0001) and less likely to receive thrombolysis (4.5% vs 7.4%, p<0.0001). Conclusions: Cancer patients with DVT presenting to ED had higher hospitalization rates with increased risk of mortality, GI bleed, IVC filter placement and decreased rates of thrombolysis than those without malignancy that was compounded by longer in-hospital LOS and healthcare costs. Further studies are needed to evaluate the need of prevention strategies for DVT that can help mitigate these factors in cancer patients.
The impact of therapeutic mediastinal radiation on stent healing in cancer patients: An optical coherence tomography study.
Authors: Graham Jordan , Aziz Moez , Donisan Teodora , Balanescu Dinu Valentin , Palaskas Nicolas , Lopez-Mattei Juan , Cilingiroglu Mehmet , Balanescu Serban Mihai , Ganim Nidal M , Lin Heather Y. , Marmagkiolis Konstantinos , Molony Donald A. , Durand Jean-Bernard , Iliescu Cezar
Published: May 2020

e19096

Background: Cancer is a prothrombotic and proinflammatory state. Understanding stent healing in cancer patients could modify the approach to antiplatelet regimen and facilitate cancer treatment. Mediastinal radiation therapy brings an additional layer of complexity to an already challenging clinical scenario in cancer patients undergoing percutaneous coronary intervention (PCI). We sought to compare stent healing patterns with and without a history of mediastinal radiation therapy using optical coherence tomography (OCT) data. Methods: All cancer patients that underwent PCI and follow-up OCT less than 12 months post-PCI between 2009-2018 were retrospectively identified from our institutional cardiac catheterization laboratory registry. Stent healing, which was defined by a combination of stent and strut coverage, apposition, expansion, in-stent restenosis, and neo-intimal hyperplasia, was compared among 2 groups of oncological PCI patients: those with and without a history of mediastinal radiation therapy. Differences among the two categories were assessed using linear-effect models. Results: There were 86 cancer patients who received PCI with follow-up OCT within 12 months. Of these, 22% received mediastinal radiation. There was no statistical difference in baseline characteristics (hypertension, dyslipidemia, diabetes, etc.) between the two studied groups. In the non-radiation group, 59% were late stage or advanced cancer patients, while 63% of patients in the radiation group were advanced cancer patients. Stent healing was similar among those who had received radiation therapy and those who had not (Table). Conclusions: A history of mediastinal radiation does not appear to affect early stent healing within 1 year of PCI. Given stent healing appears to be similar with or without radiation, dual anti-platelet therapy regimens may not need to change based on radiation exposure alone. Future studies should address the duration of dual antiplatelet regimens and long-term outcomes (i.e. in-stent restenosis) based on stent healing properties. [Table: see text]
Retrospective study of the evaluation and management of febrile neutropenia in cancer patients in a tertiary center.
Authors: Emmich Megan , Bhardwaj Prarthna V , Clark Jackson , Sridhar Arthi , Ali Fatima , Walia Ritika , Knee Alexander , Lagu Tara , Loh Kah Poh
Published: May 2020

e19100

Background: Febrile neutropenia is a medical emergency often managed by internists, but adherence to guidelines has not been well-described. We aimed to describe care and outcomes of a retrospective cohort of patients hospitalized with febrile neutropenia at a single tertiary care hospital. Methods: We included adults ≥18 years old who had a cancer diagnosis and required hospital admission for a principal diagnosis of fever and neutropenia (ANC < 500) from October 2015 - April 2019. We reviewed records to identify demographics, cancer diagnosis and stage, and outcomes, including death. Results: We included 193 patients; all were cared for by hospitalists. About half (52%) were classified as high risk [ < 21 Multinational Association of Supportive Care in Cancer (MASCC)score], but only 1 patient had a documented MASCC score in hospital progress notes. The majority of patients were female (55%) and white (84%). Twenty-three percent had a stage IV diagnosis. Most (89.1%) patients were within their first chemotherapy cycle, and 23% received GCSF. Approximately half (47%) had solid tumors; the remainder had hematologic malignancies. About one quarter (27%) had positive blood cultures (of these, 43.4 % were gram positive cocci (GPC); 49.1% were gram negative rods (GNR)). Most patients received empiric coverage for GPC and GNR: 82% received cefepime and 42% received empiric MRSA coverage. Few patients had cultures positive for resistant organisms such as MRSA (n = 3) or pseudomonas (n = 4). Hematology/Oncology was consulted for most (82%) cases. Inpatient mortality occurred in 12% of patients. Compared to those who survived, patients who died had lower MASCC score 13.9 (vs. 19.1) and were more likely to receive critical care therapies during hospitalization (70% vs. 14%). Few patients (n = 24, 12%) had documented goals of care (GOC) discussions. Conclusions: Although MASCC is predictive of outcomes, internists caring for patients with fever and neutropenia do not document this score. Hospitalist-focused education efforts about MASCC score could improve care. Few patients had documented GOC discussions. Oncologists should maintain good communication with internal medicine colleagues, who may be hesitant to address GOC in patients receiving chemotherapy.
Marital status and suicide as a competing cause of mortality among cancer survivors.
Authors: Osazuwa-Peters Nosayaba , Simpson Matthew C , Du Eric Y , Hong Scott A , Bukatko Aleksandr R , Adjei Boakye Eric , Varvares Mark A
Published: May 2020

e19113

Background: The risk of suicide among cancer survivors more than double that of the general population, highlighting the need to mitigating risk factors for suicide. While several studies have described marital status, a surrogate for social support, as associated with cancer mortality, it is inconclusive whether marital status impacts suicide as a competing cause of cancer mortality. We tested this hypothesis by describing the association of marital status and suicide among survivors of four cancer sites with the highest suicide mortality rates in the United States. Methods: Adult cancer patients were identified from the Surveillance, Epidemiology and End Results database from 2004 to 2016 for four index cancer sites previously identified with highest suicide mortality rates: pancreas, head and neck, lung/bronchus and stomach ( n = 800,798). Cumulative incidence curves stratified by marital status (divorced/separated, widowed, never unmarried, and married/partnered) estimated unadjusted probability of suicide (outcome of interest). A multivariable competing risk proportional hazards model yielded sub-distribution hazard ratios (sdHRs) and 95% confidence intervals (CI) to estimate the association of marital status with suicide for each cancer site, while controlling for clinical and nonclinical factors. Results: Half (50.7%) of the cohort were married/partnered, males (56.8%), and non-Hispanic whites (71.0%). Mean age at diagnosis was 67.3 years. Most patients (60.9%) had cancer in the lung/bronchus, 17.9% head and neck, 13.8% pancreas, and 8.3% stomach. Unadjusted probability of suicide was highest among head and neck cancer survivors (0.3%). In the fully adjusted model, mortality by suicide was more likely among divorced/separated patients vs. married/partnered patients across cancer sites (sdHRhead and neck = 1.81; 95% CI 1.38, 2.37; sdHRlung/bronchus = 1.68; 95% CI 1.28, 2.19; sdHRpancreas = 2.19; 95% CI 1.27, 3.78; and sdHRstomach = 2.38; 95% CI 1.17, 4.58). Additionally, for lung/bronchus cancer, patients who were never married patients were more likely to die by suicide than those married/partnered (sdHRlung/bronchus = 1.47; 95% CI 1.09, 1.98). Conclusions: Marital status is associated with suicide mortality among cancer survivors, and divorced/separated survivors may have greater suicide mortality risks, independent of cancer site. As overall probability of suicide remains low, these findings might help identify cancer survivors who may be candidates for ongoing surveillance and psychosocial support to mitigate suicide mortality risks.
Trends in the incidence and survival outcomes in patients with lung neuroendocrine neoplasms in the United States.
Authors: Gosain Rohit , Shah Shrunjal , Dasari Arvind , Halfdanarson Thorvardur Ragnar , Mukherjee Sarbajit
Published: May 2020

e19120

Background: The incidence and prevalence of Neuroendocrine Neoplasms (NENs) are rapidly rising. Epidemiologic trends have been reported for common NENs, but specific data for lung NENs has been lacking. Methods: We conducted a retrospective population-based analysis utilizing the Surveillance, Epidemiology, and End Results (SEER) database, and studied lung NENs patients from 1988 to 2015. Associated population data was utilized to report the annual age-adjusted incidence and overall survival trends. Trends in the incidence and survival of large-cell lung cancer (LCLC) and atypical carcinoid (AC) were reported from 2000-2015, while that for typical carcinoid (TC) and small cell lung cancer (SCLC) were reported from 1988-2015. Results: We examined a total of 115,995 lung NENs [103,980 – SCLC; 3,303 – LCLC; 8,146 – TC; 656 – AC]. The age-adjusted incidence rate revealed decline in SCLC from 8.6 in 1988 to 5.3 in 2015 per 100,000; while other NENs showed an increase: TC increased from 0.57 in 1988 to 0.77 in 2015 per 100,000, AC increased from 0.17 in 2001 to 0.22 in 2015 per 100,000, and lastly, LCLC increased from 0.35 in 2001 to 0.41 in 2015 per 100,000. On multivariable analyses, the median overall survival (OS) and disease-specific survival (DSS) rate varied significantly by stage, grade, age at diagnosis, histological type, insurance type, marital status, and race. The 5-year OS rate among SCLC and LCLC patients was 5% and 17%, respectively, consistent with their high-grade nature. On the other hand, TC and AC, representing low-grade neuroendocrine tumors, had good 5-year OS: 84% and 64%, respectively. Conclusions: The incidence of lung NENs is rising, possibly because of advanced radiological techniques. However, we have seen a downtrend in the incidence of SCLCs likely because of declining smoking habits. Such population-based studies are essential for resource allocation and to prioritize future research directions.
Brazilian medical waste program as an intent to reduce costs and air release of carcinogens.
Authors: Cesario Fabiane Kellem Oliveira , Fontoura Renata Pereira , Cruz Amanda , dos Santos Edivaldo Bazilio , Conceição Junior Amarildo , Said Nidah , Morais Poliana , Omena Brenda , Cotrim Gabriel , Antero Gabriel , Silvestrini Anderson , Andrade Rosangela ,   ASCO Authors' Group
Published: May 2020

e19128

Background: Hospital waste management is a current sustainability challenge. The proper waste separation is principally recommended in most protocols, despite not always performed. Potentially infectious, sharp and chemical residues must be properly incinerated. Incineration increases the cost of waste management and releases hazardous gases into the atmosphere, such as dioxins. Dioxins are extremely stable compounds with an estimated half-life of 7 to 9 years in humans. As an important compound of air pollution, they have been classified as a class I human carcinogen by the International Agency for Research on Cancer. The dioxin carcinogenicity evolves action on transcriptional activation and inhibition of apoptosis. A higher serum concentration of dioxins is found in individuals who live near incinerators or who consume food produced near them.Furthermore, studies showed a 3 to 4 times higher risk of developing cancer in inhabitants of the neighborhood of waste incinerators and an association of serum concentration of dioxins and mortality from different types of cancer. Some neoplasms related to this exposure are lung cancer, soft tissue sarcomas and Non-Hodgkin Lymphoma. Methods: We present the impact of adequate division of medical waste from an institution in the Federal District - Brazil with data collected for 8 years. The residues were separated into two groups, the first being formed of residues that should be incinerated (potentially infectious, sharps and chemicals); and the second for regular garbage, which could be recyclable or non-recyclable. Results: By training the team and establishing appropriate protocols for proper segregation of materials, we achieved a saving of 66% from what would have been incinerated waste, equivalent to 76 tons, of which 71.9 tons correspond to recyclable waste. Also, the incineration cost was five times higher than the adequate disposal of regular waste. If the waste separation protocol had not been implemented, the biohazardous and chemical material would have contaminated the rest of the residues, making incineration as a final destination mandatory for all the waste, resulting in the release of more gases after incineration and a 64% higher cost. Conclusions: Despite the barriers to the classification of residues such as non-standardization and inadequate training of hospital teams, this low-cost implementation procedures significantly reduces the cost of waste management and the air release of human carcinogens.
Usefulness of Charlson comorbidity index (CCI) to predict early mortality and overall survival (OS) in acute myeloid leukemia (AML).
Authors: Dhakal Prajwal , Shostrom Valerie , Al-Kadhimi Zaid , Maness Lori J. , Gundabolu Krishna , Bhatt Vijaya Raj
Published: May 2020

e19129

Background: Increasing age is associated with greater comorbidity burden. We hypothesized that comorbidity burden predicts 1-month mortality and OS in patients (pts) aged ≥60 y with AML. Methods: We utilized the National Cancer Data Base to identify pts aged≥60 y with AML diagnosed between 2004-2014. Pts were divided into 3 groups with CCI scores of 0, 1 and ≥2. Chi-square tests were used to examine the association between CCI and different variables. Logistic regression and cox proportional hazard models were used to determine predictors of 1-month mortality and OS, respectively. Results: Of 50,668 pts, 65% had CCI of 0, 24% CCI of 1 and 11% CCI of ≥2. 34% did not receive chemotherapy. 4% underwent upfront hematopoietic cell transplant (HCT). Pts with CCI of 0 were more likely to receive chemotherapy, especially multiagent chemotherapy (42% vs 39% vs 28%) and undergo HCT (4% vs 3% vs 1%). 1-month mortality was 24%, 34% and 45% for pts with CCI of 0, 1 and ≥2, respectively. In a multivariable analysis, 1-month mortality was worse with CCI of 1 (OR 1.5, 95% CI 1.4-1.6) or CCI of ≥2 (OR 2.3, 95% CI 2.2-2.5) vs CCI of 0. Lower CCI, younger age, male sex, white race, higher annual income, private insurance, multiagent chemotherapy, receipt of HCT, acute promyelocytic leukemia (APL) and diagnosis after 2009 were associated with improved OS (Table). Conclusions: In one of the largest real-world studies, we demonstrated that 1/3rd of newly diagnosed AML did not receive chemotherapy. Greater comorbidity, measured by higher CCI, was more common with increasing age, and correlated with lower likelihood of receiving chemotherapy. Higher CCI independently predicted worse early mortality and OS in older pts with AML. Trials are warranted to determine the effect of optimized comorbidity management and supportive care to reduce early mortality and improve OS. [Table: see text]
Performance of time to discontinuation and time to next treatment as proxy measures of progression-free survival, overall and by treatment group.
Authors: Walker Mark S. , Herms Lisa , Miller Paul J.E.
Published: May 2020

e19135

Background: Real-world data sources have historically provided limited information about the occurrence of disease progression. As a result, progression-free survival (PFS), a standard effectiveness outcome measure in oncology, has been estimated using proxies such as time-to-discontinuation (TTD) or time-to-next-treatment (TTNT). Curation of unstructured electronic medical record (EMR) data make it possible to calculate PFS from directly observed progression. The aim of this research was to compare TTD and TTNT as proxy indicators with PFS determined from direct statements regarding progression in the medical record and to compare effect sizes on treatment-based groups across these endpoints. This report cites findings from the metastatic breast cancer (mBC) setting. Methods: Previously curated EMR data were collected from Concerto’s Definitive Oncology Dataset for adult, female, hormone receptor-positive/human epidermal growth factor receptor-negative mBC patients diagnosed 2008 or later who received at least one line of systemic therapy. Patients were grouped based on any receipt vs. no receipt of an aromatase inhibitor (AI) in first line (1L). Kaplan-Meier and Cox regression methods were used to calculate PFS, TTD, and TTNT in 1L and OS from start of 1L. Results: The study included 378 patients, of which 138 (36.5%) were de novo stage IV or metastatic. The mean patient age was 60.3 years (SD 13.3), 57.1% were Caucasian, and 68.3% were postmenopausal. Conclusions: Estimates of TTD and TTNT aligned closely, suggesting that nearly all patients who discontinued initial therapy received subsequent treatment. Notably, TTNT and TTD were both meaningfully shorter than PFS, suggesting that their use as proxy indicators may systematically underestimate PFS. Further, analysis based on receipt of AI indicates that comparative effects on TTD or TTNT may produce quite different results than those for PFS and OS. [Table: see text]
Use of a dynamic disease progression model to estimate prevalence and prognosis for patients with urothelial carcinoma (UC) in the United States (US).
Authors: Fleming Sarah , Solo Kirk , Ke Xuehua , Shalaby Waleed , Siefker-Radtke Arlene O.
Published: May 2020

e19144

Background: Quantifying the distribution and prognosis of patients with UC as a function of disease stage may allow the impact of existing and novel therapies to be assessed in the real-world setting. We present a dynamic progression model that estimates the incidence, prevalence, and mortality of UC clinical state (CS) in the US. Methods: This UC dynamic progression model used US estimates of UC incidence and distribution of stage at diagnosis from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) database to establish new patients. Progression and mortality for each CS were based on published clinical trials and OPTUM claims data. The simulation started in 1990, introducing incident patient cohorts allocated across initial CSs (Table). Historical therapy distributions were applied for each year as additional incident UC cohorts were introduced into the model. This proprietary model built to annual point prevalence dynamically through historical incidence, progression and mortality. Results: Based on the progression model, point estimates of prevalence, incidence and annual mortality hazard are provided by stage of disease (Table). For all stages of UC, the model estimated a prevalence of 719,387 patients in 2019. For stage II/III and metastatic UC (mUC) disease, the model estimated that 5,205 and 12,499 patients will die in 2019, respectively. This combines to 17,704 which closely aligns with the SEER estimate of 17,670. Conclusions: This dynamic UC progression model provides estimates for incidence, prevalence, and mortality of UC by clinical state at diagnosis. Incorporating associated claims and clinical data with this model could estimate the benefits of newer therapies as they become available. [Table: see text]
Utilizing a novel four-drug regimen to reduce the incidence of infusion-related reactions for first-dose rituximab infusions: An institutional review of rituximab infusion-related reactions in lymphoma patients.
Authors: Bartels Trace , Moore Logan , Persky Daniel Oscar , Kumar Abhijeet , Abraham Ivo , McBride Ali
Published: May 2020

e19148

Background: Rituximab is a chimeric monoclonal anti-CD20 antibody utilized in the treatment of several disease states including B-cell non-Hodgkins Lymphoma. Infusion-related reactions (IRR) with rituximab occur with an incidence of up to 77% during the first infusion. The occurrence of an infusion reaction adds to the cost and time of rituximab administrations, especially with prolonged chair time and increased nursing and physician support, and decreased quality of life. The University of Arizona Cancer Center (AZCC) initiated a four-drug premedication regimen consisting of dexamethasone, famotidine, diphenhydramine, and acetaminophen. Our study examined the frequency of first-dose rituximab infusion reactions with our premedication regimen as compared to other published regimens. Methods: A retrospective chart review for all first-dose rituximab infusions was conducted for lymphoma patients treated with BR or RCHOP regimens from 11/2013 through 6/2019 at the AZCC. Data points collected included baseline patient demographics as well as rituximab infusion data. Results: In our study, the median age of the patient population was 64 years (range 22-89), 60.5% were males, and the average BSA was 2 m2 (range 1.39-3.04). The average rituximab dose was 750 mg (range 521-1140) and the average infusion time was 301 minutes (range 197-512). IRR with first time Rituximab was seen in 19 patients out of 81 total patients (23.5%). Of these IRR, 52.6% occurred in BR versus 47.4% in RCHOP. The most frequent IRR symptoms seen included flushing, itching, feeling hot, and tingling. The average infusion time for IRR patients was 334 minutes versus 284 minutes in patients not experiencing IRR. Grade 2 reactions were reported in 14 patients (73.7%) with grade 3 IRR’s reported in 5 patients (26.3%). Onset of IRR occurred on average during the first 61.6 minutes of the start of infusion (range 10-108 minutes). Conclusions: A novel four drug premedication regimen consisting of corticosteroids, antihistamines H2RA antatagonist and analgesic, resulted in a much lower rituximab infusion reaction rate (23.5%) than what has been previously reported in literature using standard premedications ( > 50%). The utilization of this four drug combination therapy provides the means to reduce first dose rituximab IRR in patients while maximizing patient care and increasing the number of patients who were able to receive Rapid Rituximab during their next cycle of chemotherapy.
Transitioning adriamycin ifosfamide mesna (AIM) chemotherapy in sarcoma patients to the outpatient setting: Evaluation of outpatient chemotherapy in an oncology care model setting.
Authors: Banh Cindy , Valsvik Kendall , Arredondo Alejandra , Notbohm Kassie , Kumar Abhijeet , Cranmer Lee D. , Kraft Andrew S. , Abraham Ivo , McBride Ali
Published: May 2020

e19149

Background: The combination of doxorubicin, ifosfamide and mesna (AIM) significantly improves outcomes among patients with advanced soft tissue sarcomas. The rising cost of inpatient care, alternative payment model changes and patient preferences has prompted institutions to consider shifting therapy to the outpatient setting. However, the safety and feasibility of outpatient AIM chemotherapy is not well established. The University of Arizona Cancer Center developed an Outpatient Program (OP) to facilitate administration of traditional inpatient chemotherapy regimens in the outpatient setting. We transitioned AIM based chemotherapy to the outpatient setting based on selective criteria and caregiver support. The transition to outpatient treatment could lead to large cost-savings implications under the oncology care model. Methods: The current retrospective analysis evaluated the safety and efficacy of outpatient AIM chemotherapy for sarcoma administered in the outpatient setting. An economic study evaluated AIM in the outpatient setting, address, cost of labs, chemotherapy and bed days saved from transitioning chemotherapy from the inpatient setting. Results: Twenty-one patients with soft-tissue sarcoma were treated with outpatient AIM, for a total of 83 cycles. The median age was 60 (27-73) with 6 females and 15 males being evaluated. The median number of cycles per patient was 3.9 (range, 1-6), an average of 4.68 days of infusion days per cycle. Notable side effects included three patients ifosfamide-induced neurologic syndrome and 2 with hematuria. Acute grade 3 and 4 hematological toxicities were observed in 16 and 15 of patients, respectively with 11 occurrences of febrile neutropenia in 9 patients. Of the 21 patients, 15 patients (71%) were hospitalized at least once and 9 patients (43%) were hospitalized due to neutropenic fever. Total bed days saved by transitioning AIM outpatient was 390, for a total hospital cost savings of $1,043,250. Current costs savings for laboratory, chemotherapy and patient assistance access is still being tabulated. Conclusions: The combination of ifosfamide and mesna as a continuous outpatient infusion is feasible and well-tolerated using proper selection of patient and caregiver evaluation. This new model of administration provides an opportunity to decrease cost of care, improve patient satisfaction and reduce utilization of healthcare resource for community and academic cancer center sites.
Implementation of 11 system-wide, disease-specific, multidisciplinary tumor boards connecting 24 hospitals in an integrated health care system.
Authors: Clayton Brook , Nielsen Craig , Jensen Jane , Tonkin Allison , Urie Paul , Yeatman Timothy Joseph , Barney Brandon M. , Van Meter Margaret Elizabeth McCormick , Lewis Mark Andrew , Miles Jodie , Zendejas Ivan , Avizonis Vilija N. , Dodson Mark W. , Low Clarke Alan , Gill David Michael , Hunter Grant Kirton , Bowles Tawnya Lynn , Hoda Daanish , Haslem Derrick S.
Published: May 2020

e19152

Background: Cancer treatment is becoming more complex, necessitating subspecialty expertise and multidisciplinary approaches to treatment planning. Simultaneously, there is increasing demand to provide care as close to home as possible. While tumor boards have long been an institutional backbone to providing high-quality multidisciplinary care in tertiary facilities, connecting several hospitals and dozens of cancer specialists in a large integrated healthcare system is unique and potentially transformational for smaller facilities and communities. Methods: Using highly-secure, network firewall-protected Cisco Telepresence and WebEx capabilities, 11 disease specific tumor boards (Breast, GI, Sarcoma, GU, Thoracic, Head/Neck, Melanoma, Neuro, Heme, Hepatobiliary, Gyn) were organized across Intermountain Healthcare’s 24 geographically and medically diverse hospitals spanning over 500 miles. Meetings for each of these disease-specific tumor boards have been held at least every 1-2 weeks, at set times and days since July 2019. Cases are submitted to the appropriate tumor board by individual providers from anywhere in the system. Submitted cases are reviewed by a designated subspeciality leader. Cases are either added to the system-wide agenda, or at times, the clinical decision can be resolved immediately. Included cases’ records including pathology, radiology and pertinent medical history are obtained for display and discussion. After each tumor board, recommendations and conclusions are recorded by nurse navigators for future review and consultation. Results: From July 2019 to February 2020, 1,598 patient cases were discussed. Just as relevant, 293 unique oncology providers (surgeons, medical oncologists, radiation oncologists, genetic counselors, nurse navigators, and therapists) participated in tumor board discussions. These deliberations provided insight, experience and recommendations directly related to patient care. Conclusions: Our system-wide, disease-specific, multi-disciplinary tumor boards are useful in connecting oncology providers and subspecialists. This effort has led to better collaboration, coordination and delivery of high-quality cancer care to patients throughout a large healthcare system that includes thousands of patients and dozens of cancer providers in smaller/rural communities. In addition, provider engagement has improved. Work is ongoing to prospectively evaluate the effects on treatment decisions and clinical outcomes.