bluuebunny/crossref_metadata_2025 huggingface dataset:
Mitigating provider burnout due to infusion center delays: Analysis of sustainability.
Authors: Sewaralthahab Sarah , Thorne Shaunika , King Linda , Goswami Debolina , Miller Carrie , Gallagher Christopher , Kaufman Laura , Veytsman Irina
Published: October 2020

235

Background: Physician burnout affects over 50% of physicians in the US and is related to the high workload and loss of anonymity. The result is physical exhaustion, moral distress, and increased rates of suicide. At our institution, burnout was identified in 42.1% of providers & 55.6% of staff surveyed using AMA/ASCO burnout questionnaires with treatment delays in the infusion center (IC) implicated as the biggest culprit. Methods: We tracked causes of delay in starting chemotherapy in the IC and utilizing Pareto Chart identified that over 80% of delays were due to missing chemotherapy orders on the day of IC appointment. Process flow charts for providers noted significant variations in practices. Retrospective chart review, 6/21/2019 to 8/30/ 2019, revealed that an average of 13.18% of patients scheduled to receive chemotherapy at the IC had missing orders on the day of the infusion, resulting in up to a 111-minute delay in starting chemotherapy. We set out to sustainably decrease the number of missing chemotherapy orders in the IC by 50%, decreasing the resultant stress on providers and IC nurses. Results: Four interventions were implemented over 2 plan-study-do-act (PDSA) cycles and resulted in decreasing the average number of missing orders on the day of IC appointment to 7% achieving our aim (Table). To ensure sustainability of results, we continued the interventions and maintained faculty engagement via periodic updates. Sustainability analysis revealed that the median number of patients with missing orders between 12/2/2019 and 2/28/2020 remained at 5% effectively achieving our goal. The effects of this intervention on physician/staff burnout will be reassessed after 1 year of intervention implementation using the same AMA/ASCO burnout questionnaires. Conclusions: Systematically standardizing a process achieves a sustainable impact, promotes a more effective workplace environment and decreases burnout on physicians and staff. [Table: see text]
An effectiveness-implementation hybrid trial for informatics-based cancer symptom management.
Authors: Smith Justin D. , Garcia Sofia F. , Penedo Frank J. , Scholtens Denise M. , Yanez Betina , Kircher Sheetal Mehta , Cella David
Published: October 2020

236

Background: Oncology outpatients can facesignificant cancer- and treatment-related symptoms that compromise health related quality of life and quality health care. Although the burden of symptoms on patients’ lives are well-known, most health care systems are not ideally set up to relieve them. Patients are not typically drawn into meaningful engagement with the health care team in ways that enable symptom self-management. As a result, opportunities for early identification and treatment are lost, causing avoidable human suffering and cost. The Northwestern University IMPACT (NU IMPACT) project aims to evaluate the effectiveness and implementation of an informatics-driven symptom monitoring and web-based self-management intervention. The project uses PROMIS measures, integrated into the EHR, to trigger response and intervention. This presentation describes the effectiveness-implementation hybrid trial design and measurement of implementation. Methods: NU IMPACT will test the effectiveness and implementation of a system-wide symptom management intervention, across six adult hematology/oncology and gynecologic oncology outpatient clinics at Northwestern Memorial HealthCare, using a cluster randomized pragmatic roll-out implementation trial with an embedded individual-level randomized clinical trial. This unique design allows for a fully-powered randomized trial to establish the efficacy of the intervention, as well as a randomized test of implementation. We are enrolling approximately 6,000 patients in pre-implementation and 6,000 in post-implementation, with half of the latter group randomly assigned to enhanced symptom management, and the other half to usual care. Results: Implementation process is guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) model with evaluation following the RE-AIM framework. Particular focus is paid to adoption at the clinic and provider levels, the extent to which the intervention achieves meaningful reach to cancer patients, and the potential for sustainment. Additionally, we are testing and validating a newly developed method for tracking and reporting dynamic changes to implementation strategies. Conclusions: Achieving the aims of the NU IMPACT project is a critical step in the advancement of informatics-driven symptom management interventions for cancer patients. The innovative implementation trial design and measurement approach will aid in the rapid translation of findings to other healthcare systems. Clinical trial information: NCT03988543 .
Increasing non-opioid pain management in the cancer patient presenting to the emergency department.
Authors: Wechsler Adriana , Vu Ngoc
Published: October 2020

237

Background: The opioid epidemic is claiming more than 115 lives daily in the US (1). Pain is commonly the chief complaint of cancer patients presenting to the emergency department (ED) and aggressively managed with opioids. A recent study of cancer patients presenting to the ED showed they were also at high risk for opioid misuse (2). Non-opioid analgesia is often avoided from concerns of masking fevers, intolerance due to nausea/vomiting, or bleeding risk in thrombocytopenia. Our aim was to identify opportunities to reduce opioid use while safely alleviating pain in patients presenting to the Emergency Department of a comprehensive cancer center. Methods: Following the PDSA model, baseline data on current opioid use was obtained and perceived barriers to non-opioid analgesia were identified through questionnaires. Comfort level with non-opioid analgesia in cancer patients and current pain management practice was also queried. Patients eligible for non-opioid analgesia (solid tumors, no fever, pain score < 7) were then identified through retrospective chart review and the prevalence of contraindications for non-opioid (renal/liver failure, thrombocytopenia, oral intolerance) and patient preference for opioids was calculated. This data and opportunities to use non-opioid analgesia was shared with providers in education sessions. Medication order panels were modified to provide easy access to oral and intravenous acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs). After two months the change in opioid prescribing was calculated. Results: Providers self-reported barriers to prescribing opioids as: low platelets, patient preference, and poor oral intake. Of 237 patients presenting to the MDA Emergency Department with complaints of pain between January 2018 and May 2018, 76 (32%) were eligible for non-opioid analgesia. Only 3 patients had absolute contraindications to both APAP or NSAIDs. After provider education, order entry simplification and prescribing guidance, the use of non-opioid analgesia rose from 3.9% to 9.4%. Patient satisfaction with pain control rose from 57.4 to 60.4 % following the intervention based on Press Ganey results. Conclusions: There is opportunity for non-opioid acute pain management in the solid tumor patients. Contraindications to non-opioid analgesia are uncommon. In the emergency department, safe pain relief can be provided by non-opioids such as NSAIDs and APAP.
Using the Risk Assessment Index to predict mortality and quality of life in breast and gynecologic cancer patients.
Authors: Ormond Ellen , Borrebach Jeffrey , Altieri Dunn Stefanie C , Bilderback Andrew , Van Londen G J. , Hall Daniel
Published: October 2020

239

Background: Cancer patients vary considerably in health status making it challenging to evaluate the risk of complications from cancer treatment. To aid oncologists in identifying patients with highest risk for adverse outcomes, we investigated the Risk Assessment Index (RAI), a validated tool used to assess frailty in patients prior to elective surgery. We assessed whether the RAI could serve to predict mortality, hospital utilization, and quality of life in cancer patients. Methods: Participants were breast and gynecological cancer patients treated at UPMC Magee Women’s Cancer Center who completed the RAI between July 2016 and December 2017. Patients completed patient reported outcomes (PROs) during each visit including the Short Form (SF)-12, Edmonton Symptom Assessment, anxiety and depression screens, and MD Anderson Symptom Inventory (MDASI) and were analyzed up to 180 days from the RAI date. Mortality was assessed at 90, 180, and 365-day intervals, and hospital utilization was assessed within 90-days of RAI. Results: There were 1,764 unique breast and gynecological cancer patients. Significant correlations between the RAI and mortality were observed for both groups with frail patients having higher rates of mortality at each interval. Frailty was associated with higher rates of hospitalization compared to non-frail patients (31% vs 20%, p = 0.05 & 50% vs 34%, p = 0.02 for breast and gynecologic patients, respectively). Frailty correlated with fair/poor ratings on the SF-12 for breast and gynecologic patients (r = 0.13, p = 0.01; r = 0.37 p < 0.001, respectively). On the Edmonton, frailty correlated with lower ratings of well-being in breast cancer patients (r = 0.11, p = 0.012) and higher symptom burden in gynecological patients (r = 0.23, p = 0.01). No correlations were observed between the RAI and anxiety or depression. For gynecologic patients, there were significant correlations between the RAI and MDASI with frail patients having higher rates of pain, fatigue, appetite, diarrhea, and memory. Conclusions: We demonstrated that the RAI is correlated with mortality, self-reported quality of life, and hospitalizations in breast and gynecologic cancer patients. Using this tool to risk-stratify patients may help to guide shared decision-making discussions and provide appropriate treatment and/or supportive services for this vulnerable population.
Use of a rapid access multidisciplinary bone metastases clinic to decrease financial toxicity for patients undergoing single-fraction palliative radiation.
Authors: Maldonado Jose Alberto , Kim Minsoo , Pandey Prasamsa , Todd Sarah , Christopherson Kaitlin Marie , Ning Matthew S. , Grosshans David R , Lin Lilie L. , Reddy Jay , Bird Justin E. , Satcher Robert L. , Lewis Valerae O. , Tang Chad , Koong Albert C. , Colbert Lauren Elizabeth
Published: October 2020

24

Background: A rapid access bone metastases clinic (RABC) was instituted at MD Anderson Cancer Center (MDACC) to allow outpatient consult, simulation and radiation treatment (RT) initiation in < 6 hours for patients with painful bone metastases. Patients underwent multidisciplinary evaluation with orthopedics and radiation oncology. One aspect of financial toxicity is distress due to out-of-pocket (OOP) cost associated with a treatment. We hypothesized the RABC would decrease financial toxicity for MDACC patients over traditional RT. Methods: RABC patients surveyed between April 2018 and January 2020 were included. Patients were asked to estimate OOP cost for RT (including travel and treatment cost) and perceived cost burden of treatment. Travel distance was hometown distance to MDACC. Subset analyses were performed for patients receiving single fraction (1fx) and 2-5 fractions (2-5fx). Estimated OOP cost (1fx: RABCN= 34, nonRABCN= 20; 2-5fx: RABCN= 4, nonRABCN= 22), perceived cost burden (1fx: RABCN= 32, nonRABCN= 27; 2-5fx: RABCN= 7, nonRABCN= 38) and travel distance (1fx: RABCN= 34, nonRABCN= 28; 2-5fx: RABCN= 7, nonRABCN= 38) were compared using a Mann-Whitney U Test. Travel distance was also compared to OOP cost. Patients treated with 6+ fractions were excluded. Results: Median estimated OOP cost was significantly lower for 1fx RABC patients vs. 1fx non-RABC patients ($450 [IQR $187.5-$1,050] vs. $2,000 [$625-$4,000]; p = 0.008), but there was no significant difference for 2-5fx ($1,900 vs. $1,375; p = 0.593). Overall patient satisfaction with cost burden was high regardless of treatment setting (1fx: 10 [8-10]; 2-5fx: 10 [8-10]). Median travel distance was not significantly different between clinics (1fx: 245 [39.8-351.5] vs. 262.5 [83-879.3], p = 0.3651; 2-5fx: 274 [36-1293] vs. 176 [25-626], p = 0.2721). Travel distance was directly correlated with out of pocket cost for single fraction (1fx: R2= 0.125, p = 0.0109; 2-5fx: R2= 0.037, p = 0.3433). Conclusions: The establishment of a RABC at MDACC significantly decreased financial toxicity for 1fx patients receiving palliative RT, but not in the 2-5fx cohort. Increased financial toxicity was associated with longer travel distance for 1fx palliative radiation. Implementation of a similar model in local community centers may decrease financial toxicity for patients receiving palliative radiation.
Using an integrated social-behavioral text message approach to improve screening mammography in African American women.
Authors: Dhahri Amina , Nyanin Paapa , Ntiri Shana
Published: October 2020

240

Background: The rate of breast cancer among Black and White women is nearly equivalent but the death rate is 40% higher for Blacks. This disparity is often attributed to lower screening mammography rates in Black women. The effectiveness of text messages on increasing screening mammography among Black women is not well known. Importantly, the themes that are most effective at promoting behavioral changes in Black women’s breast cancer screening practices through text message interventions have not been explored. An integrated social-behavioral approach was used to identify themes associated with Black women’s response to two types of text messaging: reminder and educational texts. Methods: A qualitative study was conducted in Metropolitan Baltimore with two focus groups among Black breast cancer survivors. Participants completed a demographic survey and indicated text messaging practices and preferences for future breast screening texts via survey. Participants provided feedback on a series of 17 educational and reminder text messages. Focus groups were digitally recorded and transcribed for analysis. Text message preferences were analyzed using a content analysis approach. Multiple themes were identified, discussed and recorded. Results: 17 participants had an average age of 60. All participants reported cell phone ownership and 82% of participants reported texting. 46% reported an interest in reminder text messages and 54% reported an interest in educational text messages. Four main themes were derived from participants’ responses the text message series: 1) access to cancer care surveillance, 2) social network support, 3) patient-centered approach, and 4) self-advocacy. Text messages that included themes of self-advocacy, social network support, and patient-centered approach generated positive responses and the text messages that included access to cancer care surveillance were perceived as demotivating. Educational text messages were perceived to be more motivating than reminder text messages. Conclusions: Breast cancer screening behaviors are affected by various demographic, social-behavioral, and socioeconomic factors. The findings from this study suggest that developing an educational text message content that incorporates social and behavioral themes focusing on the patient may be more beneficial to improve breast cancer screening rates in this population.
Investigating factors associated with postmastectomy emergency department visits: A population-based analysis.
Authors: Langer Steven , Quan May Lynn , Kong Shiying , Xu Yuan
Published: October 2020

241

Background: In 2016, a multi-pronged pathway was implemented in 13 hospitals across the province of Alberta, Canada to improve the mastectomy perioperative care experience focused on two objectives: 1) to increase same day surgery mastectomy rates and 2) decrease the number of unnecessary postoperative ED visits. The pathway successfully increased same day mastectomy rates from 1.7% to 47.8%, however the rate of postoperative ED visits remained high at 22-27%, a rate several-fold greater than described at other centers (3.1-12.8%) in spite of focused interventions at the patient and provider level to enhance perioperative support. Objective: To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada. Methods: Data was collected using the Discharge Abstract Database, and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy in the province of Alberta between 2004 and 2018. Patient demographics and operative variables including age, SES, Charlson comorbidities, date of surgery, surgery type (same-day vs. overnight) and health regions were collected. Primary outcome of interest was an ED visit within 30 days of mastectomy. Univariate and multivariate analyses were performed to identify independent predictors for post-operative ED visits. Results: A total of 18,076 patients had mastectomy during the study period, of which 4219 (23.3%) had an ED visit within 30 days of surgery. The most common causes of ED visits were infection, pain, and nausea/vomiting. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, having reconstruction, cerebrovascular disease, chronic pulmonary disease, peptic ulcer disease, diabetes, depression, and living rurally. There was a slight decrease in ED visits post-implementation of the perioperative pathway (21.6% vs. 23.7%) but it was not statistically significant in the multivariable analysis. Conclusions: Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. ED visits are associated with geographic location, specific comorbidities, and overnight stays. Currently, the majority of ED visits are manageable in non-emergent settings. Further investigations are necessary to discern whether additional perioperative interventions can curb the high ED visit rate.
Improving performance status documentation by hematology-oncology fellows.
Authors: Velazquez Manana Ana I. , Banerjee Rahul , Kennedy Vanessa Elaine , Dietrich August Reich , Lin Amy M. , Cinar Pelin
Published: October 2020

250

Background: Accurate performance status (PS) documentation is essential as poor PS is a strong predictor of treatment-related toxicity. At our institution, a baseline chart review revealed missing PS documentation in 28% of Fellow-seen new patient visits (NPV); PS documentation as unstructured text comprised the remainder. The lack of structured PS documentation represents a missed opportunity for accurate data in registries, trial registration, and supportive care referrals. Methods: To improve standardized documentation of PS for NPV, we designed a Fellow-led quality improvement (QI) initiative over the course of 2 PDSA cycles. Specifically, we developed and implemented a structured PS smart data element tool (SDET) into our electronic medical record (EMR). PDSA cycle 1 (7/2019–11/2019) included SDET implementation and publicity using flyers & emails. PDSA cycle 2 (12/2019–4/2020) incorporated individualized feedback to Fellows, biweekly email reminders, and outreach to attendings regarding our SDET. We calculated cumulative usage of our SDET for PS documentation during the 2019-2020 academic year among NPV seen by Fellows. Our aim was to assess and document PS in at least 50% of NPV seen in person. Results: During PDSA cycle 1, cumulative structured PS documentation increased from 8% to 31% (Table). Focus groups revealed that Fellows were not consistently incorporating our SDET into their note templates or were relying on attending-written templates. Over PDSA cycle 2, the cumulative structured PS documentation rate increased from 24% to 54%. Overall our cumulative documentation rate is 40%, in large part driven by cycle 1 because of a drop in NPVs and the transition to telehealth during the COVID-19 pandemic. Conclusions: Our Fellow-led QI intervention improved cumulative structured PS documentation from 8% to 40% using two rapid PDSA cycles. Our intervention highlights the importance of real-time data review and stakeholder feedback to identify ongoing challenges. Our third PDSA cycle will include expansion to all clinic providers (Fellows, attendings, and advanced-practice providers), as well as the incorporation of telehealth encounters and follow-up visits. We also hope to align our QI initiative with broader steps toward data interoperability via the ASCO-sponsored mCODE initiative. [Table: see text]
Standardization of cardiac monitoring practices in patients receiving cardiotoxic cancer therapy at an ambulatory oncology center.
Authors: DeLuna Hannah , Hensing Thomas A. , Brockstein Bruce , Pursnani Amit , Saha Poornima , Carro George W. , Feld Jamie , Mees Rachel , Birks Katie , Catsaros Kara , Velikov Dmitriy
Published: October 2020

251

Background: A significant number of cancer-directed therapies are associated with cardiotoxicity. This adverse effect is well-established in anthracyclines and anti-HER2 agents. At our ambulatory oncology practice, the recent availability of echocardiograms with strain imaging has prompted an evaluation of current practices for cardiotoxicity monitoring. A review of the electronic health record (EHR) in 2019 found that although our institution maintains high rates of baseline monitoring, follow-up monitoring is not standardized and not consistent between different practices. Methods: A multidisciplinary team was formed to conduct a quality improvement project with the aim of increasing the rate of follow-up monitoring in patients who receive anthracyclines or infusional anti-HER2 agents. A survey of providers identified the potential reasons that follow-up cardiac monitoring was not completed. A Pareto chart showed that lack of familiarity with clinical necessity and appropriate timing were the most common barriers to follow-up monitoring. Our first plan-do-study-act focused on addressing these barriers, and a pilot in breast cancer treatment plans was started. Cardiac monitoring orders were added to curative intent protocols containing doxorubicin, trastuzumab, or pertuzumab. Education was provided to physician and nursing teams regarding utility and timing of cardiotoxicity monitoring. Collaboration with the cardiology group ensured timely access and result turnaround time. Results: An initial review of the EHR was conducted to identify current trends in cardiac monitoring. The review showed that there was an increase in the use of echocardiograms with strain imaging for baseline and follow-up monitoring in our patients. From January to April 2020, there was a total of 102 echocardiogram orders which was a 23% increase compared to the same timeframe in the previous year. The majority (61%) of those echocardiogram orders included strain imaging compared to 8% in the previous year. Review of treatment plan utilization and appropriate timing of cardiac monitoring in breast cancer patients is ongoing. Conclusions: This quality improvement project suggests that efforts to standardize cardiac monitoring practices can be achieved through provider education and workflow modifications. Further long-term review of the EHR will be needed to determine whether the timing of follow-up monitoring is appropriate and to identify what changes to the intervention should be made.
Patient characteristics associated with time-to-consult for inpatient palliative radiotherapy.
Authors: Wang Jon X , Boreta Lauren , Yee Emily , Braunstein Steve E. , Hong Julian C.
Published: October 2020

27

Background: Delayed inpatient radiotherapy (RT) consultation can result in delayed treatment, extended hospitalization, and increased costs. There are limited data characterizing populations that may have longer time-to-consult (TTC). Methods: A single institutional electronic health record deidentified corporate data warehouse was used to identify adult inpatients with a consultation to radiation oncology between 2014-2019. TTC was defined as time from admission to placement of consultation. Multivariate linear regression was used to examine adjusted associations for factors including age, diagnosis, admission date, admitting service, and patient-reported sex, race and ethnicity to TTC. Continuous variables were normalized to generate standardized beta coefficients (B). Results: A total of 856 admissions with radiation oncology consult were identified. Median TTC was 21 hours (interquartile range [IQR] 5-69). Median age was 61 (IQR 49-68) and 51% of patients were male. Most patients were white (58%) and non-Hispanic or Latino (80%). The most common admission primary diagnoses were brain metastasis (14%), bone metastasis (10%), and primary brain neoplasm (9%), Most common admitting services were Neurosurgery (49%), Hospital Medicine (22%), Malignant Hematology (8%), and Gynecologic Oncology (8%). Primary brain neoplasms (vs brain metastases B = 64; P < .001), other non-metastatic diagnoses (vs brain metastases B = 45; P < .001) and admission on the malignant hematology service (vs neurosurgery; B = 37; P = .03) were associated with longer TTC. Patient demographic characteristics (age sex, race, ethnicity), and admission date did not have significant associations with TTC. Longer TTC was correlated with longer hospitalization (Pearson’s corr = 0.48). Conclusions: No clear demographic disparities in inpatient RT consultation were identified. Certain diagnoses and services were associated with longer TTC, potentially related to clinical practice. Increased TTC was associated with longer hospital length of stay.
Real-world patient pathway of care for diffuse large B-cell lymphoma (DLBCL).
Authors: Yang Fei , Zhang Ju , Abraham Anup , Xiao Yan , Hammer Richard D. , Prime Matthew Stewart
Published: October 2020

272

Background: Use of immunophenotyping and molecular diagnostics is the most important first step in the care process for DLBCL patients according to recommendations by the NCCN and the WHO. Process mining is a novel approach of statistical and graphical analytics and may provide insights on real-world patient pathway of care and guidelines-recommended diagnostic testing for appropriate DLBCL classification in clinical settings. Methods: This retrospective study included patients diagnosed with DLBCL between 01/01/2011 and 12/31/2019, using the Flatiron Health electronic health record-derived de-identified database. The database includes information on the date of diagnostic testing and corresponding results abstracted from pathology reports or clinical visit notes. This study included information on diagnostic testing by immunohistochemistry (IHC) and molecular diagnostics through fluorescence in situ hybridization (FISH) or karyotype for markers with a confirmed known result that can be used to classify cell of origin according to Hans algorithm and to identify double-/triple-hit lymphoma and double expressor lymphoma. We explored the application of process mining analytics to produce patient pathway graphs for visual investigation on the real-world care process for DLBCL patients, from initial diagnosis through diagnostic testing and line of therapy, until death or end of the study follow-up. Results: A total of 5387 patients (female 45%, mean age at diagnosis 66.4±13.6 years) were included. During a median follow-up of 19.2 months (IQR: 6.1-43.8), 4400 (82%) patients had evidence for IHC testing, 3205 (59%) had evidence for molecular testing, and few had information for next-generation sequencing (n = 91). Among those with evidence of diagnostic testing, 3721 (85%) and 1613 (50%) had the first test performed on the day (specimen collection date) of DLBCL diagnosis by IHC and molecular testing, respectively. During the study follow-up, most patients (n = 5005, 93%) started treatment within a median of 24 days (IQR: 14-36) and few participated in clinical trials (n = 131). When we stratified analysis by year of DLBCL diagnosis, patients with evidence of diagnostic testing increased from 67% (249/372) in 2011 to 86% (506/591) in 2019 for IHC and 50% (184/372) in 2011 to 67% (396/591) in 2019 for molecular testing, respectively. Conclusions: In DLBCL, use of recommended diagnostic testing appeared to increase from 2011 to 2019. Clinical insights generated using process mining could be used by institutions for benchmarking and for care pathway optimization.
Involvement of social work services in patients with advanced cancer in early-phase clinical trials (EP-CTs).
Authors: Johnson Andrew , Nipp Ryan David , Jimenez Rachel , Healy Megan , Capasso Virginia , McIntyre Casandra , Cashavelly Barbara J. , Juric Dejan , Lundquist Debra
Published: October 2020

28

Background: Early integration of supportive care in patients with advanced cancer has improved quality of life, symptom burden, and survival. Participants in EP-CTs often are highly pre-treated and the demands of participation can exacerbate financial and psychosocial concerns. Integration of social work services can address a broad scope of concerns including behavioral health, psychosocial needs, physical health, and financial concerns. Little data exists regarding the use of social work services in this patient population. Methods: We conducted a retrospective chart review of consecutive patients enrolled in EP-CTs at the MGH Cancer Center during 2017-2019. Information including sociodemographic data, clinical variables, and the use of social work services were captured from the electronic health record. We reviewed documentation in social work notes to determine reason for referral while participating on trial. Results: Of 426 EP-CT participants, 64% ( n = 272) received social work consultations at any time during their cancer course (consultations occurred a median of 23 months [range 0 – 444] following diagnosis). Compared to those who did not receive consultation, patients receiving consultation were younger (median age 60.5 years vs 65 years, p < .001) and more likely to have children (63% vs 46%, p < .001). More than half (59%, n = 159) of consultations occurred prior to EP-CT enrollment, while 14% (n = 39) were during patients’ time on EP-CT. The most common reasons for referral on trial included adjustment to illness (41%), limited patient resources (23%), and home/family support (15%). A quarter of referrals (27%, n = 74) were initiated after patients left the trial (27%, n = 74). There were no significant differences in demographic or clinical variables between those referred on EP-CT versus before or after EP-CT. For those who received social work consultation while on EP-CT, median time from date on treatment to consultation was 18 days (0 – 182 days) while median time on EP-CT was 55 days (2 – 576 days). Patients received a median of 2 visits (1 – 20) while on EP-CT. Physicians and research nurses were most likely to refer patients (31% vs 26%, respectively) while 10% of patients self-referred to social work. Conclusions: Over half of EP-CT participants received social work consultations during their cancer course. Most patients who received consultation on an EP-CT did so for psychosocial support. Future research should focus on determining how best to integrate social work into the care of EP-CT participants.
Utilization of anti-HER2 regimens among HER2-positive metastatic breast cancer patients.
Authors: Mehta Sandhya , Song Jinlin , Pavilack Melissa , Xie Jipan , Nie Xiaoyu , Vembusubramanian Mohini , Kwong Jackie
Published: October 2020

282

Background: HER2-positive (+) metastatic breast cancer (mBC) has a poor prognosis and many patients require multiple lines of HER2 targeted regimens. This study aims to examine the treatment sequencing of anti-HER2 regimens for HER2+ mBC among Medicare beneficiaries. Methods: A retrospective study was conducted using linked 1999-2016 Surveillance, Epidemiology, and End Results (SEER) cancer registries and Medicare claims. Adults patients who had mBC diagnosis, HER2+ status documented in SEER or claims of ≥1 anti-HER2 drug, continuous enrollment in Medicare from the date of mBC diagnosis until end of study period/death, and 2 anti-HER2 regimens with or without chemotherapy (Ch) or hormonal therapy (HT) were included. Discontinuation of anti-HER2 regimen was defined as the absence of claims for all anti-HER2 drugs for >60 days, or initiation of a different anti-HER2 drug. Re-initiation of the same regimen after >60 days was considered as a new regimen. The first two anti-HER2 regimens and subsequent therapies were summarized. Results: 804 patients with 2 anti-HER2 regimens were included. Trastuzumab (T) based regimen (defined as: T±Ch/HT; without other anti-HER2 drugs) was the most common 1st regimen (82%), followed by T+ pertuzumab (P) (14%) and lapatinib (L) (3%). For the 2nd regimen, T (52%) was most common, followed by T+P (18%), L (11%), trastuzumab emtansine (T-DM1) (11%) and T+L (7%). After a 2nd regimen, 578 (72%) initiated a subsequent therapy, with over half switching to non-targeted therapies [52%; HT alone (35%), Ch±HT (17%)] followed by T (17%), T-DM1 (12%) and T+P (7%). Among those with subsequent therapy, 2 T-based regimens followed by HT alone (21%) was the most common sequence. After the 1st regimen, 52% patients reused the same anti-HER2 drugs in the 2nd regimen, 21% added another anti-HER2 drug and 27% switched to a different anti-HER2 regimen. After the 2nd regimen, 14% reused anti-HER2 drugs and 6% added another anti-HER2 drug, 25% switched to a different anti-HER2 regimen; 15% reused anti-HER2 drugs from the 1st regimen. Conclusions: Trastuzumab based regimen was the mainstay of anti-HER2 drug regimens during the study timeframe. Despite availability of multiple anti-HER2 drugs, reuse of prior anti-HER2 drugs and switching to non-targeted therapies alone were common after using 2 anti-HER2 regimens. These findings underscore the unmet needs in later lines of therapy. Recently approved anti-HER2 agents may provide additional treatment options for pre-treated HER2+ metastatic breast cancer patients.
Real-world utilization of quality-of-life data: Perspectives from community oncology providers.
Authors: Feinberg Bruce A. , Kish Jonathan , Jeune-Smith Yolaine , Yeh Ting-Chun , Fortier Stephanie , Gajra Ajeet
Published: October 2020

286

Background: Quality of life (QoL) is commonly assessed in oncology clinical trials. However, it is unclear if oncology healthcare providers (HCPs) perceive value in these metrics or if they impact clinical practice. We sought to assess the real-world utilization of QoL data and barriers to its adoption among US community oncology providers. Methods: Medical oncologists/hematologists, and advanced practice providers (APPs) participated in a survey to assess their perceptions and the utility of QoL data for routine practice during a live meeting in September 2019. Responses were captured via a web-based premeeting survey and an audience response system during the live meeting. Participant characteristics and responses were summarized using descriptive statistics. Results: A total of 71 HCPs (51 physicians and 20 APPs) participated. Regarding perceptions of QoL in oncology, 50% of physicians and 32% of APPs reported aligning with the sentence “It is important to have QoL, but efficacy is obviously the most critical endpoint.” HCPs reported that QoL may outweigh overall survival (OS) in certain clinical scenarios, such as in end-of-life (81%), frail patients (67%), or metastatic tumors (62%). When selecting between two agents with similar efficacy, safety was the most important factor (78%), followed by QoL (40%). 64% of physicians utilized aggregate QoL data from registrational trials or real-world studies to keep informed about QoL of different treatments, while 69% of APPs relied on their personal or practice experiences. 85% of physicians and 84% of APPs responded that it is important to perform formal QoL assessments during routine patient visits. 88% of HCPs expected that QoL/patient-reported outcomes (PRO) collection will increase their workload. Patient burden (58%) and provider resources (43%) were other barriers for QoL/PRO collection. HCPs were largely split regarding their understanding of QoL versus PRO, with 34% reporting that PRO was a subset of QoL and 28% reporting that QoL was a subset of PRO. Conclusions: Efficacy and safety are prioritized as clinical endpoints among oncology HCPs; however, there are certain clinical scenarios where QoL may provide more impactful data for HCPs in managing patients. Barriers remain to successful collection of QoL, and there is a need for further education among HCPs regarding PROs and QoL.
Use of BRCA testing among patients diagnosed with pancreatic cancer: Analysis of commercial claims database in the United States.
Authors: Adeboyeje Gboyega , Shah Pooja , Corman Shelby , Kale Hrishikesh
Published: October 2020

291

Background: The role of BRCA testing to guide the course of pancreatic cancer treatment has evolved in the last couple of years. In December 2019, FDA approved the first PARP inhibitor for pancreatic cancer. However, little is known about the use of BRCA testing among pancreatic cancer patients. This study assessed the trend in the prevalence of BRCA testing and predictors of receiving a BRCA test among newly diagnosed pancreatic cancer patients. Methods: The study assessed 2012-2018, Optum Clinformatics Datamart database. Patients newly diagnosed with pancreatic cancer, continuously enrolled in a health plan for ≥6 months before and after diagnosis were included in the study. Claims for BRCA testing were identified after diagnosis using HCPCS, ICD-9/10 procedure, and LOINC codes. The prevalence of BRCA testing was calculated for patients diagnosed in each year from 2012-2017. Multivariable logistic regression was used to assess predictors of BRCA testing controlling for sociodemographic and clinical factors. Results: From a total of 5,339 pancreatic cancer patients included, 293 (5.5%) patients received a BRCA test. The prevalence of BRCA testing increased from 1.2% in 2012 to 7.7% in 2017. Of patients receiving a BRCA test, 198 (67.6%) were tested within 1 year of diagnosis. The median time to receive a BRCA test from diagnosis was 158 days (mean: 269.1 days). Results from logistic regression indicated that younger age at diagnosis (eg.18-44 years versus ≥75 years, odds ratio [OR] = 3.24), diagnosis in recent years (eg. 2017 versus 2012, OR = 6.86), presence of metastasis (OR = 1.86), family history of cancer (OR = 2.26), plan type (point of service versus health maintenance organization, OR = 2.31) and Charlson comorbidity index score (0 vs ≥3, OR = 1.87) significantly (p < 0.05) increased odds for receiving BRCA test. The odds for the BRCA test did not vary statistically significantly by gender (female, OR = 1.25), insurance type (commercial versus Medicare Advantage, OR = 0.90), and census region (eg. Northeast versus West, OR = 1.03). Conclusions: The prevalence of BRCA testing among pancreatic cancer patients was low but increased steadily over time. Several demographic and clinical factors were associated with the use of BRCA testing among pancreatic cancer patients.
Optimization of the triage nurse's time by decreasing time spent on non-nursing functions.
Authors: Pugh Jennifer , Shah Dhaval , Ladics Lee Ann , Wade Elizabeth
Published: October 2020

293

Background: Triage nurses are an essential part of the multidisciplinary management of the oncology patient. Because of the nature of their role, they spend a significant amount of time performing non-nursing functions, resulting in a delay in patient care and decreased job satisfaction. This study will examine whether implementing a central phone triage system and commensurate process improvements in a large oncology practice will decrease the amount of time that the triage nurses spend on non-nursing functions. Methods: Nine triage nurses at our practice participated in a survey to obtain baseline data. The survey focused on data regarding the non-nursing issues that are encountered during the work day. We then developed a survey for the nurses to determine how much time per 8-hour work day, was spent on the identified non-nursing functions. A new telephone operator system was evaluated for suitability and then implemented. With the new system, the central operator answers all phone calls coming into the practice, and directs them to appropriate department via a messaging system, thus eliminating phone calls to the triage nurses’ direct extensions. Two months after the implementation of this new system, we recollected data to measure the time spent on the previously identified non-nursing functions. A job satisfaction survey was collected pre- and post-study. Results: The initial data collected showed that triage nurses spent approximately 60 minutes per day on non-nursing functions. These functions included the following: the amount of time listening to and taking off patient messages, pre-cert issues, order clarifications and social work issues. The data collected after implementing a new telephone system showed that this time dropped to approximately 12 minutes per day, a 78% reduction in non-nursing calls received by nurses. Additionally, there was a 7% increase in the triage nurse job satisfaction. Conclusions: After implementing a new telephone operator system, the nurses at this large oncology practice were able to better optimize their time taking care of patient related nursing functions. This improved their work flow, increased their time performing direct patient care related functions, and increased their overall job satisfaction. During this process, we also learned the importance of taking triage nurses input to improve their job function. Further research is recommended to better define the role of the phone triage nurse with the multidisciplinary care team of complex hematology/oncology patients.
Impact of immune assessment on patterns of care in stage II colon cancer.
Authors: Barzi Afsaneh , Poage Graham M. , Catteau Aurelie , Vernerey Dewi
Published: October 2020

295

Background: Approximately 25% of patients with colon cancer are diagnosed at stage II. Recommendations for adjuvant chemotherapy and follow-up for these patients are risk-based, however the benefit of therapy is not supported by consistent, robust evidence and there are physical and financial harms associated with adjuvant treatments. Immunoscore is a novel paradigm for risk refinement through measurement of the immune response to the tumor. However, the impact of this tool on physician recommendations for clinical management has yet to be defined. Methods: Medical oncologists were presented with 10 patient profiles (real-life, de-identified stage II cases submitted for clinical Immunoscore testing) and queried for their recommendations (adjuvant chemotherapy and frequency of surveillance) via an online survey. Next, they took part in a live meeting where the Immunoscore data were introduced and completed the same patient survey, but this time with the Immunoscore classification (High or Low) assigned. A physician was counted as influenced by immune response assessment when there was at least one therapeutic modification (chemotherapy decision or surveillance de-intensification) after an Immunoscore test result was provided. We hypothesized that a rate of practice change of 30% (H1) would be considered an impactful result, while 10% would not be impactful (H0). According to A’Hern’s design with a one-sided alpha of 5% and 80% power, 25 physicians needed to be included to test the hypothesis. If 6 or more practice changes (≥ 24%) were observed, the study would be considered positive. Results: Twenty-five physicians were enrolled, representing a range of practice settings from academic medical centers, to high-volume hospital networks, to private community practices; all physicians had experience in treating stage II colon cancer. On average, physicians elected to change their chemotherapy and/or surveillance recommendations 56% of the time, therefore the objective of the study was reached. All but one physician (96%) changed their recommendations for at least one case, while 92% (23/25) changed their preference for chemotherapy in at least 1 case. The rate of change for chemotherapy prescription was 36% per patient case (range: 7-13 changes). Altered surveillance strategies were infrequently observed when chemotherapy recommendations changed. Conclusions: In this physician survey of real-world stage II colon cancer cases, Immunoscore classification significantly impacted decision-making. This impact can translate into a significant reduction in non-value care.
Utilization of a clinical pathways decision support (CPDS) tool to guide myeloid growth factor usage in metastatic cancer.
Authors: Dang Jeff , Chau Sang , Delaisla Jessy , Hertler Andrew Allan
Published: October 2020

302

Background: Myeloid growth factors (MGF) are used to prevent and treat febrile neutropenia caused by immunosuppressive therapy. In the curative setting, the use of a full dose-intensity chemotherapy plus an MGF are recommended based on the febrile neutropenic risk levels, as maintaining the full dose intensity has been shown to increase the chance of cure. In the metastatic setting, instead of administering an MGF to maintain dose-intensity, decreasing the dose and/or delaying the chemotherapy to allow recovery of the neutrophils is a reasonable alternative. This is supported by the American Society of Clinical Oncology (ASCO) where a review did not find data to support the use of MGFs to maintain dose-intensity in the treatment of metastatic cancer. In addition, no improvements in disease-free or overall survival were reported for any common cancer with the use of MGFs. New Century Health’s goal is to proactively educate and promote appropriate utilization of MGFs in the metastatic setting by incorporating several non-invasive questions into a Clinical Pathways Decision Support (CPDS) tool that aligns with ASCO’s recommendation (e.g. has a dose reduction/delay been attempted?). Methods: For a Medicare population, approved treatment requests involving the use of chemotherapy in metastatic cancer in the baseline period (baseline: January 2019 to May 2019, n = 606) were compared to requests approved in the implementation period (intervention: June 2019 to November 2019, n = 615). Two states were included in the analyses: Arizona (baseline: n = 200, intervention: n = 237) and Florida (baseline: n = 442, intervention: n = 422). Chi-square ( χ2) tests were performed to evaluate differences in requests during the baseline period as compared to the intervention period. Results: In Arizona, Florida, and total sample, treatment requests for MGF in metastatic cancer were lower in the intervention period as compared to the baseline period (Arizona: 21.52% vs. 28.50%, Florida: 18.48% vs. 23.98%, and total sample: 18.86% vs. 25.25%). In the total sample, the findings suggest that treatment requests for MGF in metastatic cancer were significantly lower in the intervention period as compared to the baseline period (χ2 = 7.25, p = .007). Conclusions: ASCO recommendations were incorporated into a CPDS tool to help align prescribing behavior. Real world data was used to help evaluate whether this change led a reduction in the utilization of MGFs in metastatic cancer. These findings suggest that such approaches can help guide providers to best practice.