bluuebunny/crossref_metadata_2025 huggingface dataset:
Transitions in care for ER patients with a suspected cancer diagnosis.
Authors: Roy Megan , Rummel Margaret , Miller Eleanor , Fanslau Katie L. , Gambino Patricia , Hemmert Keith
Published: September 2022

117

Background: The oncology nurse navigators (ONNs) at Penn Medicine’s Abramson Cancer Center (ACC) observed that patients seen in the Emergency Room (ER) and found to have a suspicion of cancer were being told to call a medical oncologist. The oncologist in the ACC are highly specialized and since the patient has not had a confirmed cancer diagnosis, they were being told they couldn’t schedule an appointment. Some patients waited for the ACC to call them to schedule. When this didn’t happen they would call the ACC a week later. These barriers led to delays in care, poor patient experience, and a financial loss for the health system. The ONNs identified this as an opportunity to change the process to improve patient care. Methods: The initiative formally began in June 2021 when the ONNs reached out to the ER leadership to collaborate on a quality improvement project to streamline the process from ER visit to oncology work up and diagnosis. Direct referral to oncology nurse navigation from the ER facilitates timely navigation assessment and coordination of care. The Plan Do Study Act (PDSA) methodology was utilized. A “Consult to Nurse Navigation” order was built into the electronic medical record (EMR) for ER providers to directly refer patients to the navigation team. The ONNs contacted the patient within one business day to assess next steps. The ONNs scheduled the patient with the appropriate oncology specialist. The ONNs follows the patient through the diagnostic phase of care and assists with decreasing barriers to care. Data collection is ongoing to assess the impact of the interventions. Results: The EMR consult to ONNs went live April 2022. It includes 3 hospital ERs in the health system with diverse populations that often have limited access to health care. To date, 90% were appropriate referrals and triaged to cancer specialists for diagnostic workup and treatment. 90% had insurance accepted by the health system. Patients with unacceptable insurance plans were referred to ER social work and financial advocates. 70% were diagnosed with cancer and began treatment. Conclusions: ONNs are vital in identifying and removing barriers to care. The ONN team’s clinical knowledge, assessment skills, and expertise of the Penn health system have closed a gap in care while increasing patient satisfaction, patient retention, and downstream revenue. The ONNs leadership has directly enhanced the diagnostic process and timeliness to care for patients newly effected by cancer.
Lessons learned from a lung cancer screening patient navigation program at a safety-net hospital system.
Authors: Semlow Andrea R , Natchimuthu Vijaya Subbu , Lee Simon Craddock , Gerber David E , Zhu Hong , Hamann Heidi A. , Browning Travis , Santini Noel O. , Lee Jessica L.
Published: September 2022

121

Background: As part of a CPRIT prevention services grant led by UTSW, Parkland Health adapted a patient navigation model previously piloted in 2017 to optimize low-dose computed tomography (LDCT) imaging for lung cancer screening and evidence-based tobacco cessation services. Methods: Non-clinical patient navigators (PN) contacted patients with a LDCT order to discuss their lung scan and smoking cessation options via telephone encounters. The PN has three planned touchpoints to assess patient knowledge, identify barriers, and refer to appropriate resources. Program evaluation data has been collected monthly for enrolled patients (n = 460) from August 2021-June 2022 via REDCap and EPIC. Navigation excluded patients who were incarcerated, had no phone number listed in medical record, or patients opted out of the program on intake. Results: Of the LDCT-eligible patients, PNs were able to complete two or more navigation calls with 55.62% of patients assigned. 77% of patients completed their first LDCT, compared to 80% in the initial trial. The most common barriers to screening completion included transportation (n = 38), insurance coverage (n = 22), and cost (n = 9). Of the navigated patients who were active smokers (75%), 33% scheduled at least one smoking cessation-related visit. Some patients unresponsive to conversations about quitting, were responsive to language around “reducing” tobacco use. Conclusions: Disproportionately under- and uninsured, Parkland Health patients face a variety of barriers to screening. As a result, PN staff must balance reaching all patients with a LDCT order and spending additional time navigating patients with complex barriers. To address these barriers, the PN program facilitates coordination of patients between primary care providers, radiology operations, smoking cessation clinics, patient financial services, lung diagnostic clinic, and social work. For example, patients can schedule a smoking cessation visit directly with our PN instead of being referred. As Parkland has a decentralized LCS program model, having embedded non-clinical PNs within existing roles in the cancer center, like medical practice assistants, increases continuity of care. These individuals have the benefit from day-to-day knowledge of downstream services that bolster their ability to connect patients to external services to address barriers.
COVID-19 impact on multiple myeloma prescribing patterns.
Authors: Shah Dipti , McAuliff Kelly , Pittos Elias , McCarthy Amanda , Cavers William , Grover Rashmi , Feczko Lucia , Avalos-Reyes Elisea , Johnson Kjel Andrew
Published: September 2022

123

Background: COVID-19 has impacted several areas of oncology patient care, most notably the reduction of patient visits for treatments. Standard treatment of multiple myeloma (MM) involves a combination of intravenous (IV) and oral therapies. The purpose of this study is to assess the impact COVID-19 had on IV and oral medication prescribing patterns pre and during the COVID-19 pandemic among MM patients. Methods: This is a retrospective review of adult MM patients insured by a large commercial and Medicare health plan in the United States who started a new IV or oral MM agent during the study period. To assess the impact of COVID-19 on IV and oral medication prescribing patterns, we compareda pre-COVID period (March 1-August 31, 2019) to a COVID period (March 1-August 31, 2020). We utilized medical and pharmacy claims to identify patients and calculated new therapy starts per newly diagnosed patient (defined as the number of patients starting a new IV or oral medication for MM divided by the total number of patients with a first indication date of MM within the study timeframe). We compared rates using a Chi-square test; p-values ≤ 0.05 were considered statistically significant. Results: 1,754 patients were enrolled in the study; there were no significant differences in demographic characteristics pre and during COVID-19 between the two groups with respect to age (67.05 vs. 66.64; p = 0.45), gender (p = 0.80), insurance plan type (p = 0.17), geographical region (p = 0.26) and medication (p = 0.59). During COVID-19, the number of newly diagnosed MM patients decreased by 22% (9,657 to 7,560) and the total number of new therapy starts decreased by 11% (930 to 824). When looking at rates of new therapy starts per newly diagnosed patient, both IV (11%; p = 0.03) and oral (51%; p = 0.03) medication rates significantly increased. Additionally, there were significant increases in new therapy start rates by region in the Northeast for oral (157%; p < 0.01) and West for IV (32%; p = 0.02) medications. There were no significant differences in new start rates by insurance plan type (all p > 0.08). Conclusions: While the total count of new therapy starts, a proxy for new diagnoses, decreased during COVID-19, the rate of new starts for both IV and oral therapies for patients diagnosed with MM significantly increased. These increased start rates may be explained by a remarkable 22% drop in the total number of newly diagnosed MM patients during COVID-19. As the pandemic continues, further study is warranted to understand how COVID-19 may impact IV vs. oral usage in MM.[Table: see text]
Real-world racial disparities in EGFR testing and third-generation EGFR TKI use among U.S. patients with stage IV NSCLC.
Authors: Sacchi Elizabeth , Li You , Miller Vincent A. , Curtis Melissa D. , Ali Siraj Mahamed
Published: September 2022

124

Background: Biomarker testing for EGFR mutations (EGFRm) is recommended for all newly diagnosed patients with metastatic NSCLC. Third-generation EGFR TKIs are the recommended standard-of-care therapy for patients with EGFRm+ NSCLC regardless of race, although EGFRm occur more frequently in Asian patients (Table). We investigated the association between race, EGFR testing and receipt of subsequent first-line (1L) treatment with the third-generation EGFR TKI, osimertinib. Methods: This retrospective, observational study used the nationwide Flatiron Health EHR-derived de-identified database. Adults with an initial diagnosis of stage IV NSCLC who initiated systemic 1L therapy between Apr 2018 (osimertinib approval) and Feb 2022 (data cutoff date) were eligible. Two cohorts were defined: those eligible for EGFR testing, and those EGFRm+ patients eligible for 1L osimertinib. Multivariable logistic regression was used to investigate odds of 1) EGFR testing, and 2) 1L osimertinib use, by race. Random-effects logistic regression was used as a sensitivity analysis to evaluate the impact of inter-practice variation on each outcome. Confidence intervals (CI) were calculated at 95%. Results: 9,505 patients were eligible for EGFR testing. After adjustment, Asian patients were nearly twice as likely to be tested (adjusted odds ratio [aOR]: 1.93, CI: 1.33 – 2.89, p = 0.0001), while Black patients were 25% less likely to receive testing (aOR: 0.75, CI: 0.62 – 0.90, p = 0.002), both relative to White patients. Including a random factor of practice attenuated the effect of race for Asian patients (aOR: 1.74, CI: 1.15 – 2.64, p = 0.0009) as well as Black patients (aOR: 0.8, CI: 0.65-0.97, p = 0.021). Of these patients, 1,247 were confirmed EGFRm+ and were thus eligible for 1L osimertinib. Asian patients were marginally more likely to receive 1L osimertinib, even after adjustment ( aOR: 1.51, CI: 0.958 – 2.43, p =.082). The inclusion of a random factor of practice diminished the marginal effect of race ( aOR: 1.46, CI: 0.90 – 2.36, p = 0.1). Conclusions: Retrospective analyses using real-world data revealed differences across races in EGFR testing among patients with stage IV NSCLC, suggesting disparities in quality of care. Racial disparities were also observed in 1L osimertinib use among patients with EGFRm+. Sensitivity analyses suggest that these disparities may partially be attributed to differences in care between practices. Future studies are warranted to further characterize this unexpected race-based difference in biomarker testing and treatment initiation. This work highlights the need for investigations of racial disparities in access to both biomarker testing and effective treatment options across precision oncology.[Table: see text]
Creating a single point of referral and standardized care pathway for patients with melanoma to improve access to care.
Authors: Rubin Fitzgerald Sydney , Hanson Bailey , Loehrer Andrew Phillip
Published: September 2022

127

Background: Access to care is often a challenge for healthcare organizations  especially as pressures on time increase and workforce availability decreases  and is often complex to solve. In this quality improvement (QI) initiative, a team from a rural academic medical center deployed the Lean Six Sigma approach to develop a two-pronged method that reduced the median time to first visit for new melanoma patients. Methods: The project team deployed the Define, Measure, Analyze, Improve, and Control (DMAIC) processes to address access for melanoma patients after the healthcare organization set a goal that 55% of new specialty care patients be seen within 10 days. Define: Concern was raised by the melanoma clinical care team that the lack of a well-defined and standardized referral workflow for melanoma patients could delay patient care. Measure: Data from the electronic medical record (EMR) indicated that only 31% of incoming referrals were seen within 10 days, and the median number of days to first visit was 15, or 50% over the organizational standard. Analyze: Analysis found considerable waste in the existing referral system. First, untrained staff made referral and routing decisions, meaning patients could potentially be seen by inappropriate departments based on the assessment of those not specialized in melanoma care and treatment. This led to the second area of waste: rework. Every referral had to be reviewed by multiple staff in several departments to ensure the referral made was appropriate based on the characteristics of disease. This was a very labor-intensive processes that allowed too many patients to slip through the cracks of the system. Improve: Two interventions were deployed to address the identified waste. First, a centralized referral point for all melanomas monitored by the Program Coordinator. Second, a referral questionnaire developed by an interdisciplinary team to guide where routine cases should be referred. Early results show that the interventions had marked impact on the time to first appointment for all referrals, whether originating inside of the organization or out. After the intervention 54% of newly referred patients were seen within 10 days. Results: Control: A standard report was built to support the project team in monthly monitoring of the KPI, days from referral to patient seen. The report is monitored by a dedicated Program Coordinator who can escalate any issues during regular interdisciplinary care team meetings. Conclusions: Improvements in access can be achieved by adopting standard work that is targeted to reduce waste in the referral workflow. The model developed by this QI initiative is easily replicable and may be especially useful for interdisciplinary teams who provide care to complex diseases.[Table: see text]
Prevalence of social risks among oncology patients in an integrated health care delivery system.
Authors: Kumar Deepika , Zamani Constanza , Martin Ernesto , Kolevska Tatjana , Payne Jessica , Sheehan Tammy Rene , Gordon Nancy P. , Egorova Olga , Kroenke Candyce , Neeman Elad , Liu Raymond
Published: September 2022

128

Background: Social risks and needs can affect oncology treatment and outcomes, and some may be amenable to intervention before or during treatment. We surveyed Kaiser Permanente Northern California (KPNC) oncology patients to estimate prevalence of social risks among cancer patients. Methods: Adults undergoing treatment at KPNC infusion centers between 11/2021 – 05/2022 completed a print questionnaire that included questions about recent (past 3 month) financial strains, living, relationship, and transportation situation, and different aspects of social support. Results: A total of 767 patients completed surveys in English. Respondents were 63% female, median age 63y, and majority White (61% White, 19% Asian, 11% Latino, 7% Black) and college-educated (28% some college, 45% ≥ bachelor’s degree). About 20% lived alone, 35% were not in a committed relationship, 13% reported they did not usually get the social or emotional support they needed, and 3% often felt lonely or socially isolated. Approximately 24% said they had no one to help them with daily activities (shopping, cooking, transportation, etc.), 8% reported need for more help with daily activities, and 8% indicated that lack of transportation made it hard to get to medical appointments. Patients with no one to help them were more likely to indicate needing more help (14% vs. 6%). Additionally, while undergoing treatment, 6% were also acting as a primary caregiver to someone who was frail, chronically ill, or had a disability. Approximately 18% had experienced at last one recent financial strain, including trouble paying for medical/dental needs (9%), debts (8%), utilities (6%), food (5%), housing (3%), phone/internet (3%), or transportation (2%). Conclusions: Many patients lack adequate emotional and instrumental social support and may also be experiencing difficulties paying for recommended or essential medical and dental needs while undergoing cancer treatment. These findings highlight the importance of incorporating social risk screening into the oncology intake process so that this information is available to the oncology team for care planning and referral to institutional and community resources. In this way, the oncology care team may be able to improve social support and reduce financial and other barriers that may impact patient participation in treatment and treatment outcomes.
Real-world variability in use of bone-modifying drugs for multiple myeloma by payer type.
Authors: Soni SOPHIA Monica Monica , Hertler Andrew Allan
Published: September 2022

129

Background: The use of bone-modifying agents (BMAs) in multiple myeloma is gold standard. Benefits include prevention of skeletal-related events, reduction in bone pain, and improved progression-free survival. Guidelines recommend that patients with active multiple myeloma receive a BMA for up to two years. Unfortunately, real-world data has shown undertreatment with delays in initiation, interruptions in dosing, and premature discontinuation. These gaps are more pronounced for Black patients. The objective of this study was to describe real-world BMA treatment patterns across different payer types: Medicaid, Medicare, and Commercial/Exchange. Methods: This was a retrospective observational study using oncology prior authorization data from multiple payers in the New Century Health (NCH) database. NCH is specialty risk management company who supported over 107,000 oncology patients in 2021. All patients with a diagnosis of multiple myeloma, as indicated by the treating provider’s office, were included who had a prior authorization request for anti-cancer therapy between January 1, 2021, and December 31, 2021. Use of BMA was defined as having ≥1 authorization request for zoledronic acid or denosumab any time in the prior 24 months. BMA use was also evaluated by payer: Medicaid, Medicare, or Commercial/Exchange. Results: A total of 4774 patients were identified as having active multiple myeloma from January 1, 2021, to December 31, 2021. Fifty-nine percent (59.6%) of patients had at least one authorization request for a BMA submitted by their treating provider any time in the preceding 24 months. While most of the identified patients had Medicare, when request for BMA was disaggregated by payer, meaningful differences were found. For patients with commercial or exchange coverage, 64.6% (281/435) had a BMA requested; for patients with Medicare coverage, 60.1% (2339/3890) had a BMA requested. However, for patients with Medicaid, only 51% (229/449) had a BMA requested. Conclusions: Like other studies, our findings highlight underuse of BMAs in multiple myeloma. Differences in request for BMA across payer types suggests variability in adherence to guidelines may be based on patient insurance. To achieve equitable outcomes, including for patients of lower socioeconomic status, targeted efforts must be put in place to ensure receipt of guideline-directed therapy. A strength of this study is the large population and diversity of patients from practices in 41 states with multiple payer types. However, our analysis is limited by several unknown factors such as patient contraindication to or declination of BMA in past that are not captured in the NCH database. This retrospective study, using a large real-world oncology database, highlights that many patients with multiple myeloma may not be receiving guideline-based BMA therapy and that there are meaningful differences depending on patient insurance type.
Access to treatment among patients with advanced kidney cancer in Mexico.
Authors: Salazar-Mejía Carlos Eduardo , Piñeiro-Martínez Antonio , Juárez-Villarreal Angela Leticia , Jara-Rios Arianna Elizabeth , Ibarra-Alaniz Ana Patricia , Wimer-Castillo Blanca Otilia , Hernandez-Barajas David , Vidal-Gutiérrez Oscar , Gómez-Guerra Lauro , Zayas-Villanueva Omar Alejandro
Published: September 2022

130

Background: The socioeconomic status of patients diagnosed with metastatic renal cell carcinoma (mRCC) in developing countries could in many cases limit their access to the best available therapeutic options. We aimed to describe the clinical characteristics and access to treatment of Mexican patients with mRCC. Methods: We performed a retrospective analysis of all patients with a histopathologically confirmed diagnosis of renal cell carcinoma who were treated at an oncology referral center in Northeast Mexico over a 5-year period. Results: We included 233 patients in the analysis, of whom 63% were men. The mean age at diagnosis was 58.2 years; 87% of the tumors were histopathologically classified as clear cell carcinoma. Regarding laterality, 54% of the tumors originated from the right kidney. The distribution of cases by clinical stage (CS) was as follows: CS I 15%, CS II 8%, CS III 17%, CS IV 60%. All of the included patients had government health insurance coverage; however, specific treatment for renal cell cancer was not included in this coverage. In terms of access to first-line systemic management in the 139 patients with advanced kidney cancer who were candidates for treatment, 29% received treatment with a single-drug tyrosine kinase inhibitor (TKI), 4% were treated with combined or single-drug immunotherapy (IO), and 12% were treated with TKI combined with IO. All but one patient who was treated with a single drug or a combination of IO received these drugs in the context of a clinical trial. Fifty-five percent of patients with advanced disease did not have access to standard first-line therapy. The rate of loss to medical follow-up was 69% of cases. Conclusions: Despite the proven oncological benefit of the latest generation of therapies based on IO/IO or IO/TKI for mRCC, access to first-line standard management is still poor in our country, even with single agent TKI. Public health programs should be implemented to expand therapeutic options for this group of patients.
Evaluation of facilitators and barriers of timely breast cancer care in North Carolina (NC): A qualitative study.
Authors: Gaddy Jacquelyne Janean , Teal Randall , Bell Emily Fox , Wheeler Stephanie B. , Reeder-Hayes Katherine Elizabeth
Published: September 2022

134

Background: Early detection and timely treatment of breast cancer using multi-disciplinary therapies often contributes to a goal of curative intent along with improved overall outcomes. In prior studies, Black women compared to non-Black women are at a higher chance of treatment delay (> 60 days) in NC. The care team factors that contribute to these treatment delays are unclear. Methods: This qualitative study utilized content analysis. The 30 participants included community stakeholders involved in breast cancer care delivery, including breast cancer clinicians and community resource providers. Participants were selected through purposive sampling. Three Area Health Education Centers (AHEC) regions (Northwest, Charlotte, and Area L) that represent the diversity of the state of NC were selected as sites for data collection. Each participant completed a one-time semi-structured interview which was audio-recorded and transcribed. Inductively derived codes were created from the previously established interview guide leading to the production of the codebook with each code conceptually defined. Transcripts were coded by 7 coders through the method of consensus coding leading to the identification of emergent themes. Code reports were generated from each code leading to the production of a narrative summary. Results: All participants identified perceived both facilitators and barriers to the timely initiation of breast cancer treatment. Barriers fell into several categories: geographical, financial, healthcare system related, and patient related (non-financial). Most barriers were perceived as more common among Black patients. Additionally, participants emphasized incidents of historical racism in medical care that limited Black patients from having trust in the healthcare system. Facilitators identified included: outreach through community partners, healthcare navigation, supportive healthcare providers, provision of social support services, transportation, integrative services, and raising the overall quality of cancer care. Conclusions: Despite the diversity of participants regarding region, years of employment, and role, stakeholders identified important common themes when reviewing the perceived facilitators and barriers of breast cancer care delivery. Perceived barriers were largely related to patients’ social determinants of health, and participants perceived that Black patients had more adverse social determinants impacting their care timeliness, highlighting that structural racism contributes to delayed cancer care delivery. Future initiatives aimed at improving the delivery of timely breast cancer care must focus on evaluating marginalized communities’ overall access to adequate care along with effective community engagement to build a higher level of trust from such patients and target the social determinants of health.
Falling off the treatment wagon: Barriers to cancer treatment and care for people experiencing health and social inequities.
Authors: Bourgeois Amber , Mollison Ashley , Horrill Tara C , Lambert Leah , Stajduhar Kelli
Published: September 2022

135

Background: A key pillar of Canada’s healthcare system is universal access, yet significant barriers to cancer services remain for those impacted by health and social inequities (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing health and social inequities within a Canadian context. Methods: We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 hours of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. Results: Our analysis identified four themes presenting as ‘modifiable’ barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) health literacy and ‘missing the window’ for shared decision making (3) invisibility of the social/structural determinants of health (4) navigating a complex and fractured system. These inter-related themes point to how people impacted by health and social inequities are at times ‘dropped’ out of the cancer system and therefore unable to access cancer treatment. Conclusions: Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publicly funded health care system. Identifying people with social and health inequities and approaches to delivering cancer services are explicitly equity-oriented are urgently needed.
Association of prevalent social risks with treatment initiation among patients with cancer.
Authors: Velazquez Manana Ana I. , Dickerson John F. , Banegas Matthew P.
Published: September 2022

137

Background: Social risks are adverse conditions that may serve as barriers to health care and lead to poor health outcomes. Among individuals with cancer, social risks like financial hardship have been associated with delayed treatment and increased mortality. However, little is known about the association of multiple prevalent social risks with cancer treatment initiation. In this study, we assessed the prevalence of social risks at time of cancer diagnosis and their association with treatment initiation. Methods: Data from patients aged ≥18, enrolled at Kaiser Permanente Northwest, diagnosed with cancer between June 1, 2017-December 31, 2019 and screened for social risks within 90 days pre-cancer diagnosis (baseline) were included. Baseline social risks included financial hardship, food insecurity, housing instability, and transportation difficulties. Cox proportional hazards regression models were used to assess the outcome of time to treatment initiation. Patients were censored at disenrollment or end of the study observation (February 29, 2020). Separate models were used to measure associations of any baseline social risks and time-to-treatment, each individual social risk, and a combined model with all 4 social risk variables. Confounding was controlled propensity score overlap weighting, estimated as a function of age at diagnosis, sex, race/ethnicity, Elixhauser comorbidity index, education, household income, NDI, cancer type, stage, and days from social risk assessment to cancer diagnosis. Results: Among the 549 patients, 49% were female and the mean age was 66 years (SD = 14). 105 (19%) patients reported any baseline social risk. The most common prevalent social risk was financial hardship (12.8%), followed by housing instability (9.1%), food insecurity (6.4%), and transportation difficulties (5.7%). In separate adjusted models, presence of any baseline social risk was associated with lower risk of treatment initiation (HR = 0.69, p = 0.040) and financial hardship was associated with lower risk of treatment initiation (HR = 0.63, p = 0.032). Conclusions: This study provides evidence that social risks at the time of cancer diagnosis are associated with lower risk of treatment initiation. Among individual social risks, financial hardship was a major barrier to initiation of cancer treatment. Our findings highlight the importance of screening for and addressing social risks at time of cancer diagnosis to reduce the risk of poor cancer care and subsequent health outcomes.
The impact of geography on receipt of cancer treatment in Montana.
Authors: Hensold Jack Oliver , Zimmerman Heather , Merrill Janette K. , Nagarajan Sumitha , Ng Diane , Grubbs Stephen S.
Published: September 2022

140

Background: The challenges of cancer patients in rural areas are well-documented. Most rural hospitals do not deliver on-site cancer care services and lack infrastructure, specialty physicians and oncology-trained support personnel (i.e., nurses, advanced practice providers, and pharmacists) to deliver infusion services. Because of this, cancer patients travel long distances to receive treatment. Travel distance is associated with an increased financial burden and worse outcomes with cancer, including later stage at diagnosis, less timely receipt of chemotherapy, and delay or declination of treatment. According to America’s Health Rankings, high geographic disparity within the state of Montana remains a significant challenge to overall health. Chronic understaffing of oncologists further exacerbates the geographic barrier to cancer care. Methods: To assess the impact of these combined access barriers to cancer treatment, we utilized 5 year cumulative data (2014-2018) from the Montana tumor registry database to assess the impact of geographic disparity on cancer care for patients in Montana. Results: Overall 19.2% of Montanans did not receive treatment following a cancer diagnosis. This is similar to the percentage of cancer patients in Delaware that did not receive treatment (19.1%). Although the population of Delaware is similar to Montana, it is 1.3% of the size. While this suggests that distance may not impact the receipt of treatment for cancer, further analysis of treatment data for Montana by county demonstrated broad discrepancies in the receipt of treatment: No treatment ranged from 12.5% to 30.3%. When mapped geographically the counties with the highest percentage of “no treatment” were distant from the 8 Commission on Cancer-approved cancer centers within the state. A similar county-by-county analysis demonstrated no apparent relationship of “no treatment” with either socioeconomic deprivation or lack of insurance. Distance from Commission on Cancer-approved centers also correlated with traveling out of state to receive care. Conclusions: This analysis provides insight into the impact of geographic barriers on cancer treatment in Montana and identifies remote sites that could benefit from robust outreach and care services to improve cancer care delivery.
Addressing social determinants of health for colorectal cancer in the African American population: STAT (Screen, Trust, Access, Treat) phase I study.
Authors: Coe Emily , Induni Marta , Royal Diane , Shurney Dexter
Published: September 2022

143

Background: Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer deaths among African Americans, who have the highest CRC rates compared to other racial/ethnic groups, in the United States. STAT (Screen, Trust, Access, Treat) is a three-phase study assessing attitudes and perceptions related to disparities in CRC screening, treatment and clinical trial participation in the African American population. STAT Phase I surveyed attitudes/perceptions among health care providers (HCPs) and Phase II is ongoing to survey African American patients with CRC; in Phase III, data collected from Phases I/II will be used to design and test multiple interventions to reduce CRC disparities among African Americans. Here we present findings from STAT Phase I. Methods: Using non-probability and convenience sampling methodology, a survey link was exposed to over 3,000 HCPs through partnering non-profit health care organizations. The 20-item survey evaluated practitioner views on strategies for overcoming social determinants of health (SDOH), improving CRC outcomes among African Americans, and barriers/motivators for clinical trial enrolment. Results: Respondents (n = 109) comprised oncologists (53%), primary care providers (29%), gastroenterologists (2%), and representatives from other specialties (16%). They were predominantly White/Caucasian (65%); 22% were Asian/Asian American, 11% were African American/Black, and 6% were Hispanic/Latino. To overcome SDOH disparities, most HCPs used translation/interpreter services (83%), offered patients information in multiple languages (76%), and asked them to repeat back care instructions (73%); however, fewer offered provisions such as SDOH assessments (50%), access to financial assistance (66%), and transportation services (45%). Most HCPs agreed or strongly agreed they were prepared to care for patients from cultures differing from their own (91%), with health beliefs conflicting with Western medicine (71%), and with limited health literacy (83%). Increased community-based education (85%), community access to stool-based cancer screening tests (71%), and improved access to primary care physicians (69%) were viewed by HCPs as the favoured approaches to improve CRC outcomes among African Americans. Lack of awareness (43%) was reported as the predominant barrier to clinical trial enrolment, and HCPs agreed or strongly agreed that a patient eligibility screening system (86%) or clinical trial alert system (73%) would be a motivator to engage in clinical trials. Conclusions: Results from STAT Phase I reveal opportunities for HCPs to overcome inequities due to SDOH. Together with ongoing/planned research in STAT Phases II and III, these findings could inform strategies to reduce existing disparities in CRC care and improve outcomes for the African American population.
Racial/ethnic disparities in surgery access and outcome among non-metastatic HCC with an emphasis on Asian Americans.
Authors: Wang Qian , Corbett Virginia , Zhang Yaning , Jiang Changchuan , Boffetta Paolo , Schwartz Myron E. , Sung Max W.
Published: September 2022

145

Background: Hepatocellular carcinoma (HCC) has the highest incidence and mortality in Asia. Though the incidence in the US has been decreasing, Asian Americans (AA) continues to face a significant burden from HCC. We aim to examine disparities in patients with non-metastatic HCC in receiving surgery and outcome, with an emphasis on AA ethnic subgroups. Methods: Patients diagnosed with localized or regional HCC were extracted from SEER 17 (1989-2019). Race was categorized into non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, Alaska Indian/American Native (AI/AN) and 12 AA subgroups. Multivariate logistic regression and Cox regression models were used to calculate the odds of receiving surgery and overall mortality, respectively. Results: Among the total of 71,552 patients with non-metastatic HCC (Table), after accounting for multiple comparison, Chinese and Japanese were significantly more likely to receive surgery while NHB, Hispanics, AI/AN, and Laotians were less likely to receive surgery compared to NHWs. Among those who received surgery, Chinese, Korean and other APIs had improved survival while NHB and Samoan had significantly increased overall mortality than NHWs. Conclusions: Although prior studies have combined AAs into a single group, considerable heterogeneity exists amongst AA ethnic subgroups. Further studies are needed to evaluate if socioeconomic status, cultural background, health behaviors, tumor biology, and health care access may underline these disparities and to help identify potential inventions to improve outcomes in this growing but heterogenous population.[Table: see text]
Clinical and nonclinical factors associated with a complete family history in a statewide quality improvement consortium.
Authors: Weiner Shayna , Liu Manlan , Rizzo Elizabeth , Griggs Jennifer J.
Published: September 2022

149

Background: A complete family history is critical in identifying cancer patients who should be referred to genetic counseling and testing. Despite the importance of a detailed family history, defined as any cancer diagnoses in first- or second-degree relatives and their age at diagnosis, only about one third of cancer patients have a complete family history documented in their medical record. The Michigan Oncology Quality Consortium (MOQC), a physician-led consortium of oncology practices across the state of Michigan, selected documentation of a complete family history in oncology patients as a quality measure. The purpose of this study was to identify clinical and non-clinical factors associated with the quality of the family history. Methods: Beginning in 2020, MOQC began collecting completeness of documentation of cancer family history from the medical oncology records of patients with invasive cancer from MOQC practices twice per year in the Quality Oncology Practice Initiative (QOPI) database. QOPI data from 2020 and 2021 were combined for analyses. A multivariate model was built to determine the clinical and non-clinical factors, including age, sex, race, ethnicity, and cancer diagnosis, associated with documentation of a complete family history. Results: Between January 2020 and December 2021, 10,800 patients’ records were abstracted. Of these, 30% had a complete family history documented in their medical record. Factors independently and significantly associated with not having a complete family history included increasing age and Black race. Patients with breast cancer (AOR 1.94, 95% CI 1.72, 2.19) and colorectal cancer (AOR 1.2, 95% CI 1.05, 1.37) were more likely to have a complete family history than all others. Patients with prostate, pancreas, or endometrial cancer—all of which are associated with cancer syndromes—were no more likely than other patients to have a complete family history. Sex and ethnicity were not significantly associated with documentation of a complete family history. Conclusions: Patients may qualify for genetic testing based on family history alone. It is therefore crucial that clinicians know a patient’s complete family history to identify those patients eligible for genetic risk assessment. We have identified gaps in the quality of the family history with increasing age, in Black patients, and, except for breast and colorectal cancer, in patients with cancers associated with an inherited susceptibility. Our findings highlight an opportunity to improve care.[Table: see text]
Survival of the Hmong population diagnosed with colorectal cancer in the United States.
Authors: Walker Margaret , LoConte Noelle K. , Lor Kajua B. , Hampton John M. , Schiefelbein Andrea M , Lor Kha , Bui Molinna , Vidri Roberto J.
Published: September 2022

152

Background: The Hmong people constitute an Asian-American subgroup, accounting for 0.1% of the United States (US) population. Originating from Laos and Vietnam, Hmong individuals fought as secret soldiers for the US during the Vietnam War and later immigrated to the US, with the largest settlements in Minnesota, Wisconsin, and California. The Hmong population has faced various health disparities in the domains of mental health, chronic disease, and cancer. This study seeks to investigate trends in colorectal cancer (CRC) survival in the US Hmong population. Methods: Cases of colon and rectal adenocarcinoma diagnosed between 2004-2017 were identified within the National Cancer Database. Summary statistics of demographic, clinical, socioeconomic, and treatment variables were calculated. Multiple Cox proportional hazard models were constructed using sets of demographic, clinical, socioeconomic, and treatment variables to identify factors associated with overall survival (OS) within the Hmong population diagnosed with CRC. Results: One hundred and twenty (0.01%) Hmong individuals were identified within a total of 881,243 CRC cases. Their average age at diagnosis was 58.9 years, compared 68.7 years for Non-Hispanic White (NHW) individuals (p < 0.01). Over half of Hmong individuals (52.5%) were diagnosed with Stage III or VI disease (NHW, 42.5%, p < 0.03), and they more frequently resided in the lowest median income quartile (p < 0.01), the lowest high school degree achievement quartile (p < 0.01), and had higher rates of Medicaid coverage (p < 0.01) compared to NHWs. When adjusting only for age, sex, stage, and Charlson-Deyo comorbidity score, Hmong individuals had a greater hazard of death compared to their NHW counterparts (HR 1.43, p < 0.01). However, in a multivariable model accounting for all variables suspected to be associated with CRC outcomes, OS was similar between these groups (HR 1.01, p < 0.93). Conclusions: Hmong individuals diagnosed with CRC appear to have similar overall survival to Non-Hispanic Whites despite belonging to lower socioeconomic groups, being diagnosed at a younger age and with a higher proportion of Stage III/VI disease. This may point to a robust response to treatment and resilience within the Hmong community. Future efforts will focus on disseminating this information and developing community-based approaches for health screening and prevention.
Survival outcomes by insurance status for patients with cancer ages 18-64 and 65 or older treated in clinical trials.
Authors: Unger Joseph M. , Moseley Anna , Vaidya Riha , Xiao Hong , LeBlanc Michael Leo , Hershman Dawn L.
Published: September 2022

154

Background: Prior studies using cancer population data have shown that patients with Medicaid or no insurance (M/NI) have worse survival outcomes than other patients, likely due to differences in access to care, staging, and treatments received. However, little research has examined the relationship between patient insurance status and outcomes for patients enrolled to cancer clinical trials, who have uniform access to protocol guided treatment and are uniformly staged and treated. Methods: We examined survival outcomes for patients enrolled to phase III or large phase II clinical treatment trials conducted by the SWOG Cancer Research Network between 1992-2019. We compared patients with M/NI to all other patients with known insurance. Patients with military/VA insurance were excluded. Multivariable Cox regression frailty models were used, with cancer cohort as a random effect and covariate adjustment for age, race, and sex. We also adjusted for clinical risk by deriving a composite prognostic score based on key cancer-specific clinical risk factors. Separate analyses were conducted for those < 65 years vs. those 65 or older. Overall, progression-free, and cancer-specific survival outcomes were analyzed. Results: In total, 29,423 patients from 51 trials comprising 27 cancer-specific cohorts were examined. Overall, 31.1% of patients were ≥ 65 years, 64.0% were female, 9.6% were Black, and 11.6% had M/NI. For all three survival outcomes, patients with M/NI had statistically significantly worse outcomes in patients under the age of 65, including a 24% increased risk of death (HR = 1.24, 95% CI, 1.16-1.32, p <.001), a 12% increased risk of progression (HR = 1.12, 95% CI, 1.06-1.18, p <.001) and a 19% increased risk of cancer-specific death (HR = 1.19, 95% CI, 1.11-1.27, p <.001). Consistent findings were observed when comparing patients with Medicaid to all other patients, and separately, when comparing patients with no insurance to all other patients. In contrast, in those 65 or older, there was no statistically significant difference in overall, progression-free, or cancer-specific survival between patients whose insurance included Medicaid (i.e., dual eligible) vs. those with Medicare alone or Medicare plus private insurance. Conclusions: Access to protocol-guided therapy ameliorates much but not all of the insurance-related disparities in outcomes previously observed using cancer population databases. For those < 65 years, despite receipt of treatment in a clinical trial, remaining disparities for those with M/NI may be due to limited access to supportive services, worse access to post-protocol therapy, or management of non-cancer related conditions. In contrast, these factors are less likely to be relevant for individuals 65 or older receiving Medicare. These findings suggest that an individual’s health insurance can meaningfully impact cancer outcomes over the longer term.