bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the contribution of county characteristics to the rural mortality disparity in cancer.
Authors: Franks Jeffrey , Davis Elizabeth , Kenzik Kelly
Published: October 2023

173

Background: Rural disparities in cancer outcomes have been widely evaluated, but limited evidence is available to characterize what characteristics of rural environments contribute to the increased risk of poor outcomes. Therefore, we propose to estimate the mediating effects of county characteristics on the relationship between urban/rural status and mortality among patients with cancer, identify county profiles, and determine problematic county profiles alongside rural settings. Methods: Patients with cancers (known to be associated with rural disparities) between 2000 and 2016 were assessed using Surveillance, Epidemiology and End Results data. We then linked these data to the 2010 County Health Rankings (CHR) which ranks US counties into quartiles within their state based on measures of health: morbidity, mortality, health behaviors, physical environment, socioeconomic status, clinical care environment. We dichotomized each domain as least healthy (quartiles 3 and 4) and most healthy (quartiles 1 and 2). Rurality was defined using the 2010 Rural-Urban Commuting Codes. Using mediation analyses, we estimated 1) the direct contribution of rurality to five-year all-cause and cancer-specific mortality and 2) the contribution of the rural effect indirectly through each CHR domain. We then used latent class analysis to identify county groupings based on rankings. Using flexible parametric survival models, we estimated the hazard of mortality associated with class membership, rurality and the interaction between rurality and class. Results: Among the 757,655 patients representing 596 counties, 51% were female, the most frequent diagnoses were breast and prostate (21%, respectively), 52% were diagnosed with localized disease, and 54% were diagnosed between 55y and 65y. When setting the mediator at least healthy (quartiles 3 and 4) premature death, clinical care, and physical environment, the rural patients had 17.9% to 20.2% less survival time compared to those in rural counties. Of this, 4.1% to 12.6% of the total excess risk was mediated by these characteristics. Three county classes were identified: Class 1 (28%) had consistently poor rankings, Class 2 (32%) had moderate rankings but poor clinical care, and Class 3 (41%) had consistently high rankings except for physical environment. Patients living in rural-high risk counties (class 1 and 2) saw higher all-cause mortality than those in urban-lower risk counties (reference class 3; HR, 1.04, 95%CI 1.01-1.08 and 1.07, 95%CI, 1.03-1.11). Conclusions: County characteristics mediated the relationship between rurality and mortality among patients with cancer. Counties with poor rankings had increased mortality risks regardless of rurality; however, the poor rankings elevated the mortality risk for those in rural counties. Access to care and physical environment may be actionable points of intervention in the pathway from rurality to mortality.
Rural-urban disparities in breast cancer-related mortality in the United States (1999-2020).
Authors: Buzick Justin , Grewal Udhayvir Singh , Fleege Nicole Margo Grogan
Published: October 2023

181

Background: Breast cancer is the most commonly diagnosed cancer and the second most common cause of cancer death among women in the United States (U.S.). While racial and ethnic disparities in outcomes are known, large population-based data on rural and urban disparities in breast cancer-related mortality are lacking. Methods: We retrieved de-identified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) multiple causes of death database (years: 1999–2020) for females (aged 15 years and upwards) with “malignant neoplasm of breast” (ICD-10 C50) listed as “underlying cause of death”. We analyzed age-adjusted mortality rates (AAMRs) per 100,000 population and assessed temporal trends in the average percent change (APC) of AAMRs applying the simplest model with a maximum of 3 joinpoints (using Joinpoint regression program 4.9.1.0). We conducted nonparallel pairwise comparisons to assess differences in trends between large metropolitan, medium to small metropolitan and rural areas (per National Center for Health Statistics Urban-Rural Classification Scheme, 2016) using average annual percentage change difference (AAPCD). Results: A total of 909,467 breast-cancer related deaths were analyzed between 1999-2020. We noted a decline in breast cancer related AAMR overall and across large metropolitan, small to medium metropolitan and rural areas (table). However, the decline in AAMR was significantly higher among large metropolitan areas as compared to small to medium metropolitan (AAPCD -0.3371, 95% CI -0.61, -2.4187, p=0.02) and rural areas (AAPCD: -0.48, 95% CI -0.79, -3.12, p=0.002). No significant difference in AAMR trend in small to medium metropolitan and rural areas was noted (AAPCD -0.15, 95% CI -0.37, 0.08, p=0.19). Conclusions: We demonstrate disparities in decline in breast cancer related AAMR between urban and rural areas. A significantly higher decline in AAMR among large metropolitan areas compared to medium to small metropolitan and rural areas suggests discrepancy in access to cancer care among populations. Further work is needed to develop strategies aimed at ensuring equitable cancer care access for all patients with breast cancer regardless of their geographical location.[Table: see text]
Quality surgery for gastrointestinal cancers in the Deep South: Disparities in elements of the Enhanced Recovery Program.
Authors: Pisu Maria , Smith Burkely , Schoenberger Yu-Mei , Jones Bayley A , Wang Lingling , Ivankova Nataliya V. , Richman Joshua , Chu Daniel I
Published: October 2023

183

Background: Disparities in surgical outcomes exist for Black gastrointestinal cancer patients and may be due to the lower likelihood of undergoing quality surgery that minimizes adverse surgical outcomes. The Enhanced Recovery Program (ERP) has shown to improve perioperative outcomes through standardization of care and to reduce disparities in surgical outcomes in certain settings. The extent to which ERP is applied across patient groups is currently unclear, especially for patients in high poverty states of the Deep South. Methods: The ASCENDS study conducted a survey of colorectal, pancreatic, and esophageal cancer patients (stage 1-3, diagnosed within 5 years, had surgery) in Alabama and Mississippi. Survivors were recruited through the Alabama Statewide Cancer Registry and select hospitals in these states. Survey questions asked about selected ERP components including: 1) education and counseling about surgery, i.e., i) surgeon/other health care provider in surgery clinic gave instructions about getting ready for surgery, ii) instructions were definitely easy to understand; 2) carbohydrate drink before surgery (e.g., Sprite); 3) pain medication; 4) anti-thrombotic and antibiotic prophylaxis; 5) bladder catheter (removed day after surgery); 6) early mobilization (walking) and nutrition on day of surgery, and mobilization the day after surgery. Fisher Exact or Chi Square tests were performed to examine significant differences across White (W) and Black, Indigenous, or persons of color (BIPOC) respondents. Results: Of 272 survey respondents (mean age 63.17±11.57, range 23-92), 71.3% were W, 28.3% BIPOC, 55.5% women, 76.8% had colorectal,16.2% pancreatic, and 7% esophageal cancer, 58.8% were from rural areas, 33.8% had low health literacy, 46.7% had private insurance, 32.3% Medicaid or Medicare/Medicaid, and 21.7% Medicare. See Table 1. Conclusions: Overall, there were no disparities in ERP components as recalled by survey respondents. Low uptake of some of the ERP components is worrisome, although data from medical records is needed to confirm findings. Improvements may be needed to improve surgery outcomes for alI GI cancer patients in the Deep South.[Table: see text]
Disparities in cancer incidence and mortality for individuals incarcerated in Massachusetts (MA) state prisons compared to the general population.
Authors: Manz Christopher , Tramontano Angela , Wright Alexi A.
Published: October 2023

187

Background: More than 10 million people are incarcerated annually in the US. Incarcerated individuals are disproportionately affected by cancer disparities, yet receive healthcare while in prison which may offer opportunities for enhanced cancer screening and treatment. Little research has evaluated disparities in cancer incidence and survival among incarcerated patients. Methods: Name, birth date, and sex were obtained for individuals incarcerated in MA state prisons from 2010-2019 from the MA Department of Corrections and matched to MA state cancer registry data. Patients diagnosed with an incident cancer were classified as currently incarcerated (CI), formerly incarcerated (FI), or never incarcerated (NI) based upon incarceration status at diagnosis. We examined crude cancer incidence, standardized incidence ratios (SIR) and crude overall survival (OS) by incarceration status, and evaluated survival differences with Cox proportional hazards models adjusted for age, sex, race, ethnicity, diagnosis year and cancer type. Results: Of 416,267 cancers diagnosed in 2010-2019, 288 (0.1%) CI, 785 (0.2%) FI and 415,194 (99.7%) NI patients were diagnosed with cancer. Demographics differed by incarceration status (median age: 57 vs 54 vs 66 years for CI, FI and NI, respectively; males: 92.4% vs 71.6% vs 46.4%; and Whites: 69.8% vs 77.3% vs 89.4%; all P≤0.01). The most common cancers detected are in Table. Detection of screenable cancers were highest in CI and NI patients (51.4% and 51.0%) and lowest in FI patients (46.2%; p=0.03). However, of those diagnoses, 25.6% of CI and 22.6% of FI were diagnosed with Stage IV disease, compared with 16.4% of NI patients (p=<0.0001). Crude incidence per 100,000 patient years was 271.7 for CI, 267.9 for FI and 773.2 for NI patients. Compared to NI men, the SIR was 97.6 (95% CI 86.2-110.1) for CI men and 109.5 (95% CI 100.6-118.9) for FI men. Unadjusted 1-year all-cause OS was 68.1% for CI, 72.6% for FI and 76.5% for NI patients, while 5-year OS was 36.4% for CI, 53.2% for FI and 60.9% for NI patients (Table). In adjusted models, CI and FI patients had statistically worse OS, compared with NI (CI vs. NI: HR 2.17, 95% CI 1.84-2.56; FI vs. NI: HR 1.85, 95% CI 1.66-2.07). Conclusions: In MA, CI and NI patients are more likely than FI patients to have screenable cancers detected. However, CI and FI patients are more likely to be diagnosed with stage IV disease, and have worse all-cause OS, compared to NI patients. Research on cancer screening and treatment in prisons is needed to improve cancer outcomes for CI and FI patients.[Table: see text]
Prevalence of social risks among cancer patients in an integrated health system.
Authors: Ng Garett , Gill Simran , Glinsky Isabel , Frost Jennifer , Le Michele , Bocobo Omar
Published: October 2023

195

Background: Social risks can lead to adverse cancer outcomes, including poor quality of life and increased mortality. These risks also contribute to health disparities and inequities, deepening needs for social care and support of cancer patients. Kaiser Permanente (KP) evaluated its social determinants of health (SDOH) questionnaires to assess the prevalence of social risks among cancer patients and members to design solutions that would address their social support needs. Methods: KP uses standard and non-standard SDOH questionnaires across markets to screen pediatric and adult members for social risk factors such as financial strain, housing instability, and social isolation. Screening is built into KP’s electronic health record (EHR), where the survey is administered by clinical staff, call center agents, or patients when logged into KP.org. SDOH screening data was collected between January 2021 to September 2022 for this analysis. Electronic Medical Record (EHR) and claims data were used to identify KP members with care associated with a cancer diagnosis between September 2017 to September 2022. Benign neoplasm and basal/squamous cell diagnoses were excluded. Results: There were 608K patients identified with visits associated with a cancer diagnosis in the 5-year period. Of these 608K cancer patients, 18% (n=109,773) were screened for social risk using standard and non-standard SDOH surveys. For comparable results across KP markets, standard questionnaires yielded 39% (n=7,507) presenting at least one positive social risk factor out of 19,274 cancer patients screened. Financial strain and social isolation were the most prevalent factors. Members across all major health plan products screened positive for at least one risk. When stratified by product, 65% (n=825) of Medicaid members screened were the highest observed group with at least 1 social risk, and commercial members screened were the second highest (40%, n=2,700). Cancer patients’ positive social risks were consistent with the overall screened population at 38% (n=102,392). Conclusions: KP cancer members yielded a similar measure of social risks as the general screened population, and the prevalence of these risks across major health plan products signals a call to action. The top social needs surfaced from this analysis informed how KP can support members by designing solutions that will provide access and referrals to appropriate resources. Deploying standardized social needs screenings and integrating them with clinical workflows are critical success factors. KP is building screening tools in multiple languages and will offer additional screening modalities to broaden equitable access. Though wide evidence demonstrates social factors have a major impact on health and well-being, more research is required to understand their effects on disparities, other dimensions of inequity, and health outcomes among cancer patients and members.
Using standard-of-care screening to identify inequities in cancer-related financial hardship.
Authors: Williams Courtney , Liang Margaret Irene , Rocque Gabrielle Betty , Gidwani Risha , Caston Nicole E. , Pisu Maria
Published: October 2023

196

Background: Financial hardship is known as an “adverse event” for individuals with cancer. This study used data collected as part of routine care to understand the magnitude of and potential inequities in cancer-related financial hardship for patients with cancer receiving care in the Deep South. Methods: Universal financial hardship screening was piloted among oncology patients initiating treatment at University of Alabama at Birmingham from October 2020-May 2023. Financial hardship screening questions were added to a standard-of-care treatment planning survey administered by lay navigators. Questions included measures of (1) financial distress (Comprehensive Score for financial Toxicity [COST], scored 0-44; scores <26 indicate financial distress), and (2) financial difficulties affording one or more of 10 items. Proportions of screens completed and variations in financial hardship were calculated overall and by patient race and rurality. Results: Patients who completed treatment planning surveys (N=2,741) were an average 62 years old (SD 13), 18% Black, Indigenous, or persons of color (BIPOC), and 16% rural dwelling. Financial hardship screening was completed by the majority (90%) of patients with treatment planning surveys. Patients with a breast (23%), gynecologic (16%), or gastrointestinal (14%) cancer most commonly completed screening. Completion was similar by race and rurality. Screening identified 34% of patients were experiencing financial distress (mean COST 28, SD 11). However, 49% of BIPOC patients screened positive for financial distress compared to 30% of White patients. The most commonly reported financial difficulties were insurance or medical bills (reported by 32% of patients), upfront medical payments (29%), and medications (22%). Large differences in reported financial difficulties were seen comparing patients who were BIPOC and White (Table). Rural- and non-rural-dwelling patients reported similar proportions of financial difficulties. Conclusions: Most patients completed lay navigator-led financial hardship screening, which identified racial inequities in financial hardship even before treatment initiation. Efforts to collect patient economic data should support the design, implementation, and evaluation of patient-centered interventions to improve equity and reduce adverse cancer-related economic outcomes.[Table: see text]
Establishing an evidence-based cultural competency program with advanced practice providers in a community oncology setting.
Authors: Marti-Smith Marissa , Mikan Sabrina Q. , Broussard Stephanie Broadnax , Cone Kelly
Published: October 2023

199

Background: The United States continues to grow in both population and diversity. The trigger for this project was the dramatic increase in patient diversity in Texas and the lack of adequate cultural competency training for providers at a Texas Oncology clinic network. Clinicians must increase their self-awareness and knowledge to provide culturally competent care. The literature review found multiple educational modalities, across many health care disciplines, used by researchers to improve the cultural competency of health care providers. Methods: This project sought to improve satisfaction and adherence of patients over the age of 25 diagnosed with cancer by increasing provider cultural sensitivity and self-awareness of bias within 1 month of cultural competency training. The project sample was 14 advanced practice providers, 10 APRNs and 4 PAs. The educational plan for this project included an evidence-based course and a follow-up focus group to reinforce learning. Quantitative data were analyzed using the Cultural Competence Assessment tool to compare participants’ anonymous pre- and posteducation with the Wilcoxon signed-rank test. Qualitative data was obtained during focus groups. Results: The quantitative data indicated that cultural awareness and sensitivity increased following training, with median scores increasing from 6.09 to 6.55, p = 0.03. However, the data do not suggest that cultural competence and behavior changed after training, as median scores went from 3.96 to 4.23 after training, p = 0.06. Overall, the focus group participants agreed about improving self-awareness, identifying biases, improving patient experience by asking more open-ended questions, and being vulnerable. Conclusions: Despite the small sample size, the quantitative and qualitative data suggest that cultural awareness and sensitivity improved following the EBP course and focus group meetings. Cultural competency and behavior did not change according to the data. However, the project implications include improvement in provider knowledge and increased self-awareness, which promote individualized, culturally sensitive care.
Pembrolizumab vs chemotherapy in the first-line setting of PD-L1≥50% metastatic non-small cell lung cancer: A real-world cost-effectiveness analysis.
Authors: Lu Brandon , Parmar Ambika , Luo Jin , Chan Kelvin K.
Published: October 2023

21

Background: Despite the voiced concerns around the initial economic decision models for first-line pembrolizumab in PD-L1≥50% metastatic non-small cell lung cancer (mNSCLC), there has been a paucity of evidence on the anticipated cost-effectiveness of pembrolizumab in the real world. To resolve the uncertainties associated with the initial assessment, we evaluated the real-world cost-effectiveness of first line pembrolizumab versus platinum-based chemotherapy for mNSCLC patients with PD-L1≥50%. Methods: We retrospectively identified a population-based cohort of mNSCLC patients who received first-line pembrolizumab or platinum-based chemotherapy between April 1, 2013, and March 31, 2021, in Ontario, Canada. Employing a public payer’s perspective, all costs (in Canadian dollars) and effects were estimated over a 4-year horizon, adjusted for censoring and discounted at 1.5% yearly. The primary outcomes were incremental cost-effectiveness ratios (ICERs) for life-years gained (LYG) and quality-adjusted life year (QALY). To examine the sensitivity of the ICER to drug acquisition costs and discounting, we conducted a price reduction analysis and a scenario analysis of different discount rates. Results: Propensity-score matching resulted in a total of 1,142 pairs of matched mNSCLC patients. Pembrolizumab extended survival with an incremental effect of 0.37 LYG and 0.35 QALY, but at an incremental cost of $56,681; the resulting ICERs were $154,941/LYG and $163,039/QALY. Though the ICERs were not sensitive to discounting rate, 31% and 55% reductions to the price of pembrolizumab brought the ICER below $100,000/QALY and $50,000/QALY, respectively. Conclusions: In the real world, first-line pembrolizumab is not considered to be cost-effective for mNSCLC patients with PD-L1≥50%. Improvements in cost-effectiveness, however, may be achievable through price renegotiations for pembrolizumab.
Potential out-of-pocket savings from hematology/oncology drugs for commercially insured patients via Mark Cuban Cost Plus Drug Company.
Authors: Xiang Jenny Jing , Lei Xiudong , Li Meng , Giordano Sharon H. , Shih Ya-Chen Tina , Lin John Kent
Published: October 2023

22

Background: Prescription drug out-of-pocket (OOP) costs remain a major source of financial toxicity in hematology/oncology (heme/onc). Mark Cuban Cost Plus Drug Company (MCCPDC) sells generic drugs directly to patients, bypassing insurance. The purchase cost is equal to drug cost (manufacturing cost, 15% markup, $3 pharmacy fee) and $5 shipping fee. Research shows MCCPDC provides potential savings for Medicare beneficiaries, but its benefit for the commercially insured remains unknown. We assess OOP savings if the eight MCCPDC drugs with heme/onc indications were purchased directly from MCCPDC instead of commercial insurance. Methods: MCCPDC purchase costs were matched with equivalent drugs claims in IBM Marketscan (2021) based on name, strength, formulation, and amount dispensed, using claims with the most frequent days’ supply. Potential OOP savings were calculated by subtracting insurance claim OOP costs (copay + coinsurance + deductible) from MCCPDC purchase cost. Outcomes included % claims with cost savings and amount saved. Savings were calculated for brand-name drugs for which a MCCPDC generic may often be appropriately substituted. Results: Of 145,403 claims, 6.8-24.5% of generic antineoplastics approved post-1990 in MCCPDC and 26% of deferasirox claims would have OOP savings if purchased through MCCPDC, with median savings $63-$561 (Table). 14.8% of brand-name 2nd generation antiandrogen claims would save switching to abiraterone, with median (IQR) saving of $1045 (345, 2010). 43.2% of brand-name 1st/2nd generation BCR/ABL tyrosine kinase inhibitors (TKI) claims would save switching to imatinib, with median (IQR) saving of $116 (31, 1286). The share of newer generic antineoplastic claims with savings varied by insurance: high deductible health plan (HDHP) (28.1%), health maintenance organization (HMO) (23.5%), and preferred provider organization (PPO) (13.2%) (p<0.001). Conclusions: Some patients can save hundreds or thousands of dollars per fill by purchasing heme/onc drugs through MCCPDC instead of commercial insurance, with greater savings for HDHP/HMO and from brand-name antineoplastics to appropriately substitutable generics. MCCPDC is a new avenue to decrease financial toxicity. [Table: see text]
Self and proxy symptom reporting in patient-caregiver dyads coping with a primary brain tumor: The role of psychosocial function in rating agreement.
Authors: Whisenant Meagan , Snyder Stella , Weathers Shiao-Pei S. , Bruera Eduardo , Milbury Kathrin
Published: October 2023

223

Background: Patients with glioma experience high levels of symptom burden with often sudden performance declines. As such, family caregivers tend to report on the patient’s symptoms; yet previous research examining the validity of proxy symptom reporting points to inconsistent findings. While prior studies focused on identifying patient clinical variables that may be related to agreement, caregiver characteristics may also be important for accurately perceiving patient symptoms. We examined the associations between symptom agreement and patient and caregiver perceived illness communication, depressive symptoms, and QOL. Methods: As part of a behavioral intervention trial, baseline assessments were collected prior to randomization in 67 dyads. We report on patient symptom burden (MDASI-BT) and patient and caregiver depressive symptoms (CES-D), illness communication (CICS), and QOL (SF-36). Paired t-tests, difference scores and inter-correlations coefficients (ICCs) were used to test for agreement, accuracy and congruence in proxy symptom scores, respectively. Bivariate correlations were calculated to examine the association between psychosocial function variables and symptom agreement. Dyadic level associations between symptom agreement and QOL were examined using multi-level modeling. Results: Thirty-nine percent of patients (63% male; 93% non-Hispanic White; mean age=47 years; 84% Grade III-IV) and 49% of caregivers (79% female; 90% non-Hispanic White; mean age=51 years) endorsed clinical levels of depression. Clinically significant disagreement was found for all means scores of the MDASI-BT subscales except for GI symptoms and general symptoms. 22% of caregivers overestimated and 13% underestimated overall symptom severity and 32% overestimated and 21% underestimated symptom interference. ICCs of patient and caregiver proxy ratings were significant (except cognitive and GI subscales) ranging from small to moderate coefficients (.09 - .50). Patient illness communication was associated with agreement in overall symptom severity (r=-.27, p=.03) and affective symptom subscale (r=-.34, p<.01). Caregiver illness communication (r=-.33, p<.01) and depressive symptoms (r=.46, p<.0001) were associated with symptom interference agreement. Caregiver overestimation of patient symptom severity was significantly associated with poor caregiver physical QOL, while underestimation was significantly associated with poor patient physical and mental QOL and poor caregiver mental QOL. Conclusions: The psychosocial context of the family plays an important role in the accuracy of proxy symptom reporting. Moreover, inaccurately understanding patients' experience is related to poor QOL for both patients and caregivers, which points to important targets for symptom management interventions that involve family caregivers.
Defining the denominator for measuring quality of end-of-life care in children with cancer: Results of a nominal group technique.
Authors: Johnston Emily E. , Tefera Raba , Ananth Prasanna Janaki , Martinez Isaac , Porter Amy , Snaman Jennifer Malia , Thienprayoon Rachel , Asch Steven M , Bhatia Smita , O'Beirne Ronan
Published: October 2023

227

Background: National Quality Forum (NQF)-endorsed end-of-life (EOL) quality measures helped identify disparities in quality of EOL care in adults with cancer. In adults, those quality measures apply to all adults dying with cancer or those with Stage III or IV disease. Quality measures for EOL care for children with cancer were recently developed. However, identifying the denominator for EOL quality measures in children with cancer is more nuanced than in adults. Therefore, we utilized the Nominal Group Technique to determine to whom these EOL quality measures should be applied (i.e., the denominator). Methods: In a series of Nominal Groups, panelists answered the question: "Which children, diagnoses, conditions, or prognoses should be included when examining the quality of EOL care for children with cancer?" In each group, individuals first proposed answers to the group and then selected the 5 options they thought best answered the question. Five points were assigned to the statement that was the best answer, 4 the second best, etc. A team developed a framework of themes and subthemes based on the responses and coded each statement, with multiple meetings to develop consensus. Results: We conducted 5 separate Nominal Groups with a total of 44 participants. Most identified as female (88%) and Non-Hispanic White (86%). Seventy-nine percent were pediatric palliative care, pediatric oncology, pediatric critical care, or hospice clinicians, 40% researchers, and 12% bereaved parents. Responses fell into 5 themes: (1) Poor prognosis cancer (e.g. a child with a relapsed or refractory cancer); (2) Specific treatment scenarios (e.g. children who have no further curative treatment options available); (3) Certain populations (e.g. all adolescent and young adult patients); (4) Certain symptoms (e.g. respiratory depression related to brain malignancy); (5) Specific utilization scenarios (patients requiring two or more life-sustaining therapies). Poor prognosis cancer and specific treatment scenarios received the most points (320 points [49%] and 146.5 points [23%], respectively). Conclusions: Interprofessional Nominal Group participants created a framework for identifying children who should be included in EOL quality measures for children with cancer. This differs from similar work in adults in that it does not include all children with cancer or limit to patients with advanced disease. This framework will be a powerful tool for quality improvement, research, and clinical program development and is a critically important step to ensure all children with cancer receive high-quality EOL care.
Non-elective inpatient anti-cancer therapy for solid tumors: To treat or not to treat?
Authors: Shevlin Chloe
Published: October 2023

234

Background: Administration of anti-cancer therapy to hospitalized patients is associated with greater treatment-related complications and reduced quality of life. We designed and implemented a standardized process to review all non-elective systemic anti-cancer therapy in solid-tumor patients with the goal of reducing aggressive end of life care and improving quality. Methods: A multidisciplinary group of quality and safety, pharmacy, physician, and nursing leadership designed a workflow to standardize the review of all inpatient anti-cancer treatment requests for non-elective solid-tumor (NEST) patients. Our NEST process begins with a formal pharmacy and nursing review, which can flag a case for further physician review. The pharmacist reviews for adequate hematologic counts, hepatic function, creatinine clearance as well as any active infections requiring IV antibiotics. Then the nursing review assesses treatment plan parameters, patient’s performance status, recent vital signs, and other clinical concerns. If either review flags one or more criteria, the case then goes to physician review. The NEST escalation process includes two levels of physician review – a single reviewer and a committee. If the review determines that there are more potential benefits than risks associated with administering anti-cancer treatment, the treatment can be approved for inpatient administration. However, if the formal review estimates significantly greater risk than potential benefit, the treatment will not be approved for inpatient administration. Results: A total of 58 requests for inpatient anti-cancer therapy occurred between initial implementation (10/31/2022) through 3/31/2023. 82.8% (48/58) were reviewed by both pharmacy and nursing and 45.8% of those were approved without need to escalate. The remaining requests had baseline patient characteristics that triggered physician review - with 13 reviewed by a single physician and 3 requiring committee review. Of the cases requiring further review, 5 did not receive their requested therapy (either denied or the family decided to not pursue treatment). 36.2% (21/58) of NEST patients died within 60 days of process initiation, 22.4% (13/58) died within 30 days, and 13.8% (8/58) died within 10 days. These outcomes were more common in individuals where NEST was denied or inpatient treatment was not pursued (77.8% died within 60 days, 44.4% died within 10 days; note 2 patients discharged to hospice with no death date on record). Conclusions: We designed a formal review process for anti-cancer therapy to be administered in the inpatient setting to solid tumor patients. This multi-disciplinary review led to 15.5% of requests not being administered to patients. Ongoing continuous improvement work focuses on further developing review criteria, exploring options for hard stops prior to treatment administration and increasing earlier goals of care discussions.
Where do patients die when there is no hospice? Real-world data.
Authors: Kalapanida Despoina , Tsimpidakis Antonis , Labropoulos Stefanos V. , Rigakos Georgios , Vernadou Anastasia , Chatziyiasemi Lina , Myrodia Dimitra-Melia , Razis Evangelia
Published: October 2023

235

Background: The role of real-world data has been shown to be of vital importance in cancer clinical research in recent years. Furthermore, palliative and end of life care is rarely studied outside the real world setting. Lastly, Greece lacks any significant palliative care or services and the law does not recognize advance directives. Methods: We conducted a retrospective review of real world data derived from the medical files of the deceased patients of our group, in order to assess where patients in Greece die given the lack of hospice facilities. We routinely collect the cause and place of death for all patients as well as the source of the information of the patient's passing prospectively. We then retrospectively collected the date of diagnosis and cancer type. Results: Between 04/01/2019 and 01/30/2022, we collected information regarding the cause and place of death of patients that had been under clinical care in our oncology department. During this time period, 454 patient deaths occurred, of which 54.67% were male and 45.33% female. The median age of death was 63.85 years and the most frequent cause of death was disease progression (76,21%), with only 1,98% of our patients having lost their lives due to toxicity of anticancer treatment. Importantly, the majority of our patients were hospitalized at the time of death in contrast to 23.79% that passed away at home. Data regarding cancer type and overall survival since diagnosis are being processed. Conclusions: Because of the lack of specialized facilities providing end of life care in Greece, most of our patient choose or are forced to spend the last days of their life in general tertiary care hospitals, a situation which might be indicative of both the socio-economic characteristics of our country and the lack of awareness of the necessity of this healthcare infrastructure. Further analysis is pending regarding associated parameters.
Impact of early palliative care on healthcare utilization in patients with advanced lung cancer in the final year of life.
Authors: Knox Heater Natalie Knox , Tong Wendy , Meraz Jocelyn , Prieskorn Jessica , Szmuilowicz Eytan
Published: October 2023

239

Background: The benefits of early palliative care (PC) in advanced lung cancer are well established, including both increased quality of life and decreased hospital costs at end-of-life. We performed a quantitative and preliminary qualitative analysis on end-of-life healthcare utilization of patients with advanced lung cancer in their final year of life to explore the impact of early vs. late PC. Methods: We retrospectively reviewed claims and clinical data of 54 patients with advanced lung cancer who died between 2021 and 2022 under Northwestern Medicine’s Accountable Care Organization. We classified patients as having received PC if a diagnosis code (Z51.5) appeared in claims data or if the patient’s treatment team included a PC specialist. We identified patients as having received “early” PC if their first PC visit was 90 or more days before death. Statistical analysis was performed with Fisher exact tests. Results: Forty-three (80%) patients had a PC code on claims data, while 38 (70%) had a PC team member identified within the electronic medical record. Patients receiving PC were less likely to visit the emergency department in their last 6 months of life (71% vs. 94%, p = 0.03) and more likely to utilize hospice (53% vs. 44%, p = 0.27) compared to patients without PC. Patients receiving early vs. late PC were more likely to have initiated PC as an outpatient (67% vs. 31%, p = 0.02), more likely to utilize hospice (57% vs. 44%, p = 0.21), more likely to have shorter intensive care unit stays in their last month of life (average of 10 vs. 25 days), and significantly less likely to undergo systemic treatment in their last 30 days of life (24% vs. 56%, p = 0.02) or die in the hospital (29% vs. 56%, p = 0.04). From a preliminary qualitative review, patients receiving early PC may have engaged in increased communication about clinical prognosis and goals of care, while their PC teams provided more detailed documentation of conversations about end-of-life wishes and advanced directives. Conclusions: Our data demonstrate a difference in end-of-life healthcare utilization between patients who received early vs. late PC. Limitations of this study include its small sample size and the nature of retrospective cohort studies. Qualitative evaluation is ongoing to investigate the impact of early oncologist-driven goals of care discussions on end-of-life healthcare utilization as well as moderators of early palliative care’s positive impact.
Integrated supportive oncology program and outcomes for cancer patients at the end of life.
Authors: Rebman Jamie , Montague Rachel , Gill David Michael , Thota Ramya
Published: October 2023

240

Background: Patients with advanced cancer are often exposed to acute medical care that does not improve quality of life or restore health. Further, the cost of care during the terminal phase defined as the last 30 days of life is substantially higher with the vast majority related to acute care services. We established an integrated outpatient supportive oncology service to improve quality of life for patients with advanced cancer. The embedded program provides same day access, longitudinal symptom management, and advanced care planning services. Here, we looked at our institutional outcomes of those patients managed by the integrated supportive oncology program. Methods: A retrospective cohort analysis was performed on patients with metastatic cancer treated at Intermountain Medical Center who died between January 1, 2022 and December 31, 2022. The study population included patients who were seen in the integrated supportive oncology clinic. Hospitalizations, length of stay, and deaths in the hospital during the last 30 days of life were recorded. We used Medicare and commercial insurance claims data to calculate the cost of these end-of-life hospitalizations. Results: Of 164 patients with cancer who died in 2022, 111 (67%) received longitudinal care from the supportive oncology clinic. Hospitalization rate in the last 30 days of life was lower in the study population compared to the control cohort (26% vs 50%) as were in-hospital deaths (7% vs 19%). The median cost of an end-of-life hospitalization was $20,648. Conclusions: An integrated supportive oncology service decreases the rates of end of life hospitalizations and in-hospital deaths for patients with advanced cancer. This is associated with a cost savings.
Long-acting opioids as a trigger for palliative care consultation in pancreatic cancer.
Authors: Thakur Richa , King Daniel , Martins-Welch Diana
Published: October 2023

252

Background: Pancreatic cancer is associated with significant symptom burden, a poor prognosis, and a poor quality of life. Early involvement of palliative care alongside standard disease modifying treatment in metastatic pancreatic cancer has been associated with improved quality of life and improved symptom burden. Receipt of opioids has been shown to improve overall survival in patients with pancreatic cancer, while escalating opioid usage has been associated with higher risk of death. Given this dichotomy in prognosis, the utilization of a long-acting opioid for cancer-related pain should warrant a palliative care consultation. Methods: This is a retrospective study conducted under an IRB-approved protocol of patients who were diagnosed with pancreatic cancer between January 1, 2021 and May 30, 2023, and who had been prescribed a long-acting opioid for cancer-related pain at our institution. Data collection including patient demographics, opioid doses, hospice utilization, date of death, and aggressive interventions at end-of-life were collected via chart review. Descriptive statistics were calculated using means and medians. Statistical methods included percentage calculations of baseline characteristics. Time from initiation of long-acting opioid to death was measured. Results: Of 51 patients surveyed, 50 met eligibility criteria for our study. The median age was 66 years (Range 42-90). Stage at diagnosis included 6 resectable, 6 borderline resectable, 12 locally advanced, and 26 metastatic. Ten were able to undergo a surgical resection. 28% of patients died within 90 days of starting a long-acting opioid. 36% died within 180 days of starting a long-acting opioid. Access to palliative care services was associated with increased utilization of medical cannabis (P=0.00001) and documentation of MOLST (Medical Orders for Life Sustaining Treatment) forms (p=0.049). Access to palliative care consultation (p=0.0007) as well as access to medical cannabis (p=0.00001) was more likely at academic main site as opposed to satellite hospitals. Conclusions: The initiation of long-acting opioids in patients with advanced pancreatic cancer should be considered as a trigger for palliative care involvement as it portends a poorer prognosis. Furthermore, even at a single institution, there were disparities in access to specialty palliative care resources. Further research needs to be conducted to optimize timing of palliative care referrals in a resource limited environment.
Grief in the practice of oncology: Prevalence and impact.
Authors: Morgan Sarah , Berger Benjamin T , McGue Shannon R , Barlow Sara A , Pieper Carl F , Oswalt Cameron , Sutton Linda , Labriola Matthew , Galanos Anthony N.
Published: October 2023

253

Background: Oncology providers regularly face death and serious illness while shepherding patients through the cancer journey. International research shows that oncologists frequently experience grief and that grief is linked to compassion fatigue. Providing care for patients with terminal cancer has been linked to burnout, but the relationship between grief and burnout has not been explored. We sought to describe the prevalence of grief in oncology providers in the US and its link to burnout. Methods: We surveyed 255 Duke oncology providers, including in the Duke Cancer Network. Our survey included demographics, two questions about burnout, and an adaptation of the Traumatic Grief Inventory. Results: We received 128 responses, with 50% response rate. Our sample included 26% attendings, 12% fellows, and 62% advanced practice providers, with 78% of providers from the academic setting and 22% from the community. Of 123 participants who completed the grief inventory, 92 (94%) endorsed feelings of grief in the past year. Approximately half of participants endorsed burnout, and they attributed an average of 30.6% of their burnout to grief. Oncologists with personal grief, in academic settings, and <10 years in practice had higher grief scores trending toward statistical significance. Using logistic regression, we found that burden of grief predicted burnout in providers. For each increase in one point on the grief scale there was a 15% increase in odds of experiencing burnout (95% CI 7% - 22%). Conclusions: The prevalence of grief among US oncologists has not been studied. We found that the experience of professional grief is widespread among oncology providers, with 94% answering at least “sometimes” to any item on an adapted grief inventory. Moreover, we found grief to be an important predictor of burnout, suggesting a key opportunity for intervention in support of oncology providers. [Table: see text]
Frequency of malnutrition and anorexia-cachexia syndrome in patients with advanced cancer evaluated in an outpatient supportive care clinic.
Authors: Dev Rony , Bramati Patricia , Delgado Guay Marvin Omar , Azhar Ahsan , Tang Michael J , Tennison Jegy , Becerra Josue , Hui David , Bruera Eduardo
Published: October 2023

257

Background: Patients with cancer are at risk for malnutrition and the development of anorexia-cachexia syndrome, which is often under-treated. The objective of our study was to determine the frequency of these conditions in advanced cancer patients who were evaluated in an outpatient Supportive Care Clinic (SCC). Methods: Advanced cancer patients seen in SCC were prospectively enrolled to complete a cross-sectional one-time survey. We collected patient demographics, weight history and height, cancer history, the Functional Assessment of Anorexia Therapy – Anorexia/Cachexia Subscale (FAACT-A/CS) questionnaire, Edmonton Symptom Assessment Scale (ESAS), the Patient Generated Subjective Global Assessment – short form (PG-SGA SF), and a Body Image Scale (BIS) questionnaire. Malnutrition was indicated by a PG-SGA cut-off of ≥ 5, and loss of appetite, anorexia, was defined as either ESAS ≥ 3 or FAACT-ACS ≤ 37. Results: Of 165 cancer patients that were approached, 100 (61%) completed the prospective survey. The average (SD) age was 61.6 years old (11.5). The majority of patients were female gender (52%), Caucasian (75%), were married (80%), and the most common cancers were gastrointestinal (22%) and genitourinary (21%). At the time of the survey, 14% of patients were noted to have a BMI < 20, 60% of patients reported anorexia (ESAS ≥ 3), 53% patients screened positive for the FAACT-A/CS (≤ 37), 69% were malnourished (PGSGA ≥ 5), and 55% had body image dissatisfaction (BIS ≥ 4). Documented weight loss of >10% in the medical records was recorded in 59% of patients with an average (SD) of -12.8% (15.3). Patient self-reported weight loss of > 5% over 6 months and > 10% over a lifetime was noted in 56% and 62% of the patients, respectively. Conclusions: Advanced cancer patients seen in an outpatient SCC are at high risk of malnutrition and roughly 60% experience complications of anorexia-cachexia syndrome. Routine screening for malnutrition and weight loss should be incorporated into all Supportive Care encounters, and nutritional counseling and support should be offered to the majority of cancer patients.