bluuebunny/crossref_metadata_2025 huggingface dataset:
Differences in self-reported health-related quality of life in heterosexual and sexual minority women surviving cancer: 2013 to 2018 national health interview survey.
Authors: Hutchcraft Megan Leigh Gleason , Patterson Joanne G , Teferra Andreas A , Montemorano Lauren , Backes Floor Jenniskens
Published: May 2020

e19038

Background: Health related quality of life (HRQoL) is associated with excess morbidity and mortality after cancer diagnosis. While a growing body of research indicates that sexual minority women (lesbian and bisexual women; SMW) experience greater risk for cancer diagnoses and cancer-related mortality, there is a paucity of evidence describing HRQoL in this population. This is a critical omission as assessment of sexual orientation differences in HRQoL may inform clinical interventions to improve health and survival of SMW after cancer diagnosis. This study examined associations between sexual orientation and HRQoL domains among female cancer survivors. Methods: Data from the 2013-2018 National Health Interview Survey (NHIS) was pooled. HRQoL was defined using individual indices across physical health, mental health, social, and financial domains. The association between sexual orientation and individual indices of HRQoL was assessed using weighted multivariable logistic regression analyses. Results: The sample included 97909 heterosexual, 1424 lesbian, and 1235 bisexual women who reported a cancer diagnosis. Sexual minority women were more likely to be college graduates (p < 0.001) and employed (p < 0.001); however, they had higher rates of being uninsured (p = 0.01) than their heterosexual counterparts. Reproductive cancers—including breast, ovarian, cervical, and uterine—accounted for 51% of cancer diagnoses in heterosexual women and 57.2% in SMW (p = 0.06). Sexual minority and heterosexual women had more similarities than differences in individual indices of HRQoL; however, several pertinent differences were noted. Specifically, SMW had higher odds of moderate (OR 1.46 [1.01-2.13]) and severe psychological distress (OR 2.10 [1.17-3.77]); chronic health conditions, including COPD (OR 1.72 [1.06-2.80]) and heart disease (OR 1.93 [1.32-2.83]); financial concerns about retirement (OR 1.36 [1.01-1.83]); food insecurity (OR 2.13 [1.23-3.68]), and severe food insecurity (OR 2.44 [1.28-4.67]). Conclusions: Sexual minority women with cancer diagnoses report worse indices of HRQoL. Poorer HRQoL may influence excess morbidity and mortality evidenced in these populations; however, future longitudinal studies are needed to assess prospective risk. Given our results, implementing interventions in the cancer setting to identify sexual minority patients in need of physical and mental health and financial services may reduce disparities.
Psychological distress, social function and financial burden of cancer patients receiving treatment in an African setting.
Authors: Tolani Musliu Adetola , Abur Peter Pase , Daniyan Muhammad , Nwabuoku Stanley Emeka , Mustapha Aisha , Bashiru Mutiu
Published: May 2020

e19048

Background: The improvement in the quality of cancer treatment is key to increasing survival. However, the functional well-being of these patients is equally important. This study aimed to assess the degree of psychological distress, social function and financial burden in patients undergoing cancer treatment in our center. Methods: A cross-sectional study was designed to prospectively recruit patients in our teaching hospital between December 2019 to February 2020. Those with cancer, aged 18 years and above, who had surgery, chemotherapy and (or) radiotherapy for treatment were included while those who had not commenced cancer treatment were excluded. Information on their clinicopathologic characteristics was obtained. The degree of psychological distress was assessed using a distress thermometer (DT) based on an 11-point scale. Social function was assessed using validated SCARF social functioning index (SSFI) (Cronbach's alpha = 0.818) which has 4-domains, each with scores ranging from 0 (very poor) to 4 (very good). Financial burden (FB) was assessed on a 5-point Likert scale. SPSS was used for data analysis with p < 0.05 considered significant. Results: Seventy-two patients were analyzed with a mean age of 50.3 ± 13.7 years and male to female ratio of 0.8:1.0. The median time from diagnosis was 6.0 (2.5 – 16.0) months and 51 (70.8%) were on palliative treatment. The median psychological distress score was 6.0 (4.0 – 8.0) while the mean SSFI score was 12.0 ± 3.3. Relationship with immediate family (3.4 ± 0.7) had a significantly higher sub-score than two other domains (occupational role: 2.3 ± 1.4, p < 0.001; self-concern/care: 3.0 ± 1.0, p < 0.001). Fifty patients (69.4%) had heavy or extreme financial burden with 34 (47.2%) admitting to income reduction since onset of therapy. Female sex (p < 0.001, 95% CI: 1.246 – 3.597), higher ECOG score (p = 0.033, 95% CI: 0.061 – 1.383) and palliative treatment (p = 0.038, 95% CI: 0.084 – 2.768) were independent predictors of psychological distress. Conclusions: Despite the marked psychological distress and huge financial burden in patients receiving cancer treatment in this setting, they still maintained a relatively normal status in most of the social function domains.
Disparities in advanced stage breast cancer: The socioeconomic and geographic contributions.
Authors: Clemons Kelli , Forehand William , Xu Hongyan , Zhang Li Fang , Raval Priyanka
Published: May 2020

e19055

Background: Socioeconomic disparities in healthcare have been well documented in America, with cancer being a critical area. One in four deaths are caused by cancer, and the effects on different communities are not equal. Clinical observations suggest that poorer socioeconomic circumstances lead to more frequent, later stage diagnoses and worse outcomes. The aim of this project was to quantify the sociodemographic and geographic contributions to disparities in advanced, metastatic breast cancer within the Augusta population and surrounding areas. Methods: Records of patients managed for breast cancer at the Georgia Cancer Center between Jan 2009- Jun 2019 were reviewed. 80 patients who presented with early stage breast cancer (clinical stage I) without positive lymph nodes were compared with 80 patients who presented with advanced, metastatic disease (clinical stage III-IV). Their race, breast cancer characteristics, insurance status, geographic proximity to a mammography site or major healthcare facility, and time interval between diagnosis and treatment were compared. Results: Results show that 73.75% early stage patients had private insurance, while 41.25% late stage patients had private insurance (p value < 0.0001). The early stage patients were 4.0 times more likely to have private insurance than late stage patients. Results also show that 25.0% of late stage patients had annual mammography screenings, while 77.78% of early stage patients had regular screening for mammograms (p value < 0.0001). The late stage patients were 1/10 as likely to have regular screening for mammogram as early stage patients. 80.6% of patients that received regular mammograms had private insurance, while the remaining 19.4% of those patients had public insurance. No statistical difference was shown in late and early stage presentation based on HER2 and/or triple negative (ER-, PR-, HER2-) status. Conclusions: There is a significant outcome of advanced, metastatic breast cancer in patients that do not have private insurance and in those that do not receive regular mammograms. Our findings support the importance of investing resources into alleviating differences in various socioeconomic populations as they relate to the amount and quality of cancer healthcare available. While the incidence of mortality in breast cancer is decreasing nationwide, disparities in morbidity and mortality will most likely continue unless there is an aggressive effort towards addressing said differences.
The comparative effectiveness of biologic agents among non-hispanic black (NHB) patients with metastatic colorectal cancer (mCRC): Preliminary results of a SEER-medicare analysis.
Authors: Goel Sanjay , Negassa Abdissa , Acuna-Villaorduna Ana
Published: May 2020

e19059

Background: Biologic agents (bevacizumab, cetuximab, panitumumab) have improved the overall survival (OS) of patients with mCRC. However, clinical trials are plagued by low representation of NHB patients, and a disproportionately high (>90%) accrual of non-Hispanic whites (NHW). As a result, the real world benefit among NHB patients in unknown. Comparative effectiveness research is an approach for effectively addressing this drawback. Methods: Utilizing the SEER-Medicare linked database, we identified 5,728 patients with mCRC diagnosed between 2004 and 2011 who received chemotherapy (CT; oxaliplatin, irinotecan, 5-FU, capecitabine) alone or chemotherapy with a biologic agent (CBT). OS was examined using the Kaplan-Meier method and a weighted semi-parametric accelerated failure time model. A propensity score model approach was undertaken to further account for potential treatment selection bias. Results: Overall, 88% were NHW and 12% NHB patients. The median age at diagnosis was 73 and 70 years and exposure to biologics was 71.2% and 71.4%, respectively. NHB patients had more women, were single, had lower median incomes, better differentiated tumors, less rectal primary cancers, more right sided tumors, and a worse Charleson co morbidity index. There was no difference in the receipt of 1 (72%) vs > 2 (28%) lines of therapy. The median OS was 11 and 12 months (m) in the CT-alone group, and 21 and 22 m in CBT group, among NHW and NHB, respectively. Based on an unadjusted analysis, receipt of biologics, younger age, left sided primary, well/moderate differentiation, being married, more lines of CT, and lower prevalence of co-morbidity were associated with improved OS. We also performed multiple imputations to properly account for the missing data. Among NHW, median OS was 21 vs 11 m in the CBT and CT groups, respectively (effect 1.47, 95% CI 1.36-1.60, p = 0.0000). Among NHB, median OS was 22 vs 12 m in the CBT and CT groups, respectively (effect 1.48, 95% CI 1.23-1.88, p = 0.0000). All comparisons maintained significance when adjusted for multiple comparisons. We found no interaction between biologics and race (p = 0.8743). On subgroup analysis, those patients receiving both classes of biologics (anti EGFR and anti VEGF) had the best outcome. Conclusions: In this cohort of older patients, CBT was associated with longer survival, regardless of race. Clinicians should offer CBT therapy to all patients to maximize their clinical benefit, factoring in clinical variables, but not their race.
A single institution study on the demographics and response rates of Hispanic women with HER2+ disease.
Authors: Cholankeril Michelle , Smith Keia
Published: May 2020

e19069

Background: Hispanics have 20% lower incidence of breast cancer than the general US population. Despite this, breast cancer is the leading neoplasm seen in Hispanics and is a significant cause of their mortality. Our study reports the incidence and outcome of HER2 breast cancer, use of a neoadjuvant regimen, and surgery type in the Hispanic population at our urban institution. Methods: This study reports on 37 women that were diagnosed with HER2+, non-metastatic breast cancer from 2015-2019. We report this as a single institution, community program that provides equal access healthcare and delivery. Our data was investigated and compiled using our facility’s cancer registry. The patient sample included 20(54%) Hispanics, 13(35%) African Americans, 3(8.0%) Caucasians and 1(3%) Asian. Of the 20 Hispanic women, 85% were Estrogen Receptor (ER) positive and 48% were Progesterone Receptor (PR) positive. Eleven (55%) of the 20 Hispanic patients(pts) received neoadjuvant chemotherapy (NAC), which included regimens containing Trastuzamab (H) with or without Pertuzumab(P). Our remaining 9 pts receiving adjuvant therapy were investigated for response as well. Results: Our Hispanic pts receiving NAC had an overall complete response rate of 45% and a partial response rate of 55%. There appeared to be no significant difference in response rate in Hispanic women between the HP group versus H. NAC pts had fewer partial mastectomies performed than those not receiving NAC. Hispanic NAC patients were found to have significantly more sentinel lymph node dissections (SLND) 7(88%) versus axillary lymph node dissections 1(16%) compared to other ethnicities receiving NAC. Non NAC Hispanic patients had 56% sentinel lymph node dissections, compared to 44% complete axillary dissections. Conclusions: The results indicate that there is a significant Hispanic population at our facility that harbor the HER2 oncogene. These pts seem to have a promising response to the NAC regimen in regards to SLND. We hope to have a larger patient sample through a multi-institution study, with statistical analysis to support our current findings. More studies should be performed on Hispanic women with HER2 disease, as data with this subset of population is lacking. The NAC regimen should be greatly considered and implemented in the treatment in those looking to downstage axillary disease. We hope to further investigate treatment options for Hispanic pts to gain greater pathological responses, leading to improved progression free and disease free survival that match that of other ethnic groups.
Using implementation science to examine impact of a social responsibility agenda on addressing cancer health disparities in Ceará, Brazil.
Authors: Rocha Hermano Alexandre Lima , Dankwa-Mullan Irene , Meneleu Pedro , Juaçaba Caio Figueiredo , Solomon Metasebya , Boni Debora , Lopes Silvia Helena de Souza , de Souza Silvia Elaine Miranda , Ximenes Mylena Silvia , Thé Rebeca Rodrigues , Lacerda Leandro Freire , Oliveira Erick Siqueira Campos de , Clark Cheryl , Felix Winnie , Arriaga Yull Edwin , Silva Marcelo Gurgel Carlos da , Jackson Gretchen Purcell , Juaçaba Sergio Ferreira
Published: May 2020

e19071

Background: Programs to address disparities in cancer care outcomes in resource-limited settings require attention to social determinants of health (SDoH) to achieve successful clinical care implementation. The Instituto de Câncer do Ceará, the largest cancer center in northeastern Brazil, has implemented a Social Responsibility Agenda (SRA) to guide equitable cancer care delivery. This goal of this study was to develop a framework for an implementation science (IS) study evaluating the longitudinal impact of the SRA on cancer outcomes. Methods: We outlined a mixed-methods and participatory study incorporating a process model, the Consolidated Framework for Implementation Research (CFIR) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) evaluation framework. A list of constructs and links to measurement tools associated with IS models were identified to guide the study phases. Results: We established a logic model to guide in evaluating the health and economic impact of the SRA. We identified >30 constructs and measures across domains of IS models. The table shows a driver diagram to inform the framework. Conclusions: Understanding determinants, key drivers and change concepts are important initial steps in an ongoing evaluation of the impact of evidence based SDoH interventions to address cancer disparities. [Table: see text]
Cancer clinical trial consent forms: A readability analysis.
Authors: Roy Mohana , Schapira Lidia
Published: May 2020

e19075

Background: The National Cancer Institute (NCI) provides a template for cancer clinical trial consent forms and recommends a reading grade level of eight grade or lower for such forms. This recommendation aligns with the goal of making clinical trials accessible to more patients. Methods: We surveyed clinical trial leaders at a large tertiary academic cancer center, to provide consent forms for active or recently closed, interventional cancer clinical trials (as of 2019). We requested forms that were preferably from multi-center trials and those perceived to have the highest accruals. We received 26 consent forms representing nine disease groups. Results: The average Flesh-Kincaid reading grade level was 11.2 (reflecting a 11th grade reading level), and no single form met the 8th grade reading level mark. The grade levels were assessed with three additional readability analyses (SMOG, FORCAST, and Raygor, see Table). The average Flesch reading ease was 50.7, rated as “fairly difficult”, with a scale of 0-100 (100 =“very easy” to read). The general HIPAA consent followed similar patterns, with a reading level of 10.9 and a reading ease of 49.2. There was an average of 18-20 words used per sentence. The reading levels and ease did not significantly vary with disease group or phase of trial. Conclusions: The overall readability level of cancer clinical trial forms, at our center, still require at least at least a 10th grade reading level. These forms may be difficult to understand for those with lower English proficiency and/or health literacy. We recommend a basic readability screen of such forms, and use of shorter sentences and simplified writing structure, to aid in comprehension. Flesh-Kincaid: uses word and sentence length; SMOG: used particularly for health messaging; FORCAST: used for functional literacy (number of single syllable words); Raygor: uses number of sentences and letters per hundred words [Table: see text]
Investigating potential disparities in clinical trial eligibility, offers and enrollment at an NCI-designated comprehensive cancer center.
Authors: Patel Monica Arun , Brinley F. John , Shah Jennifer Lobo , Abrahamse Paul , Veenstra Christine M , Schott Anne F.
Published: May 2020

e19076

Background: Although many prior studies have demonstrated the existence of disparities in cancer clinical trial enrollment, few studies have explored clinical trial eligibility criteria and offers as potential drivers of disparities in enrollment. Methods: We identified patients age 18-96 with gastrointestinal (GI) cancers who were seen as new patients at the University of Michigan in 2016. Primary outcomes were: 1) Eligibility for; 2) Offer of; and 3) Enrollment in, a clinical trial. All 28 clinical trials available in 2016 for patients with GI cancers were considered. We assessed individual patient eligibility for any trial by exhaustive review of the electronic medical record (EMR). We determined trial offers and patient enrollment in a trial by EMR review, including notes by clinicians and research coordinators. Independent variables included clinical and non-clinical patient-related factors (such as age, race, and gender) as well as provider-related factors. We assessed associations between patient- and provider-related factors and our primary outcomes, using multivariable regression. Results: Of 827 patients, 40% were female, 18% were age ≥75, 7% were Black, and 2% were Asian. 155 (19%) patients were potentially eligible for an open clinical trial. Among patients potentially eligible for a trial, 83 (54%) had documentation of a trial being offered and 46 (30%) enrolled. After adjustment, age < 75, lower Charlson comorbidity index, not having a second primary cancer, hepatobiliary primary, and higher disease stage were associated with a higher odds of clinical trial eligibility (all P < 0.05). Having ≥1 child, lower Charlson comorbidity index, hepatobiliary primary, and higher disease stage were associated with a higher odds of being offered a clinical trial (all P < 0.05). Hepatobiliary primary and higher disease stage were associated with a higher odds of enrollment (all P < 0.05). Conclusions: We found that patients age 75 or over were less likely to be eligible for a clinical trial, but did not find significant disparities in eligibility by other non-clinical factors such as gender and race. Only 54% of patients potentially eligible for a trial had documentation of a trial being offered; this varied by number of children, but not by any other non-clinical factors. We found no significant associations between non-clinical factors and enrollment. Future work is needed to ensure that eligibility criteria for clinical trials reflect the overall patient population, and that trials are offered to eligible patients.
Changes in black-white disparity in receipt of guideline concordant treatment for women with early-stage breast tumors.
Authors: Nadeem Hasan , Romley John , Warren-Andersen Shaneda
Published: May 2020

e19089

Background: Racial disparities are well documented in the treatment of women with breast cancer. Whereas clinical treatment guidelines are established for early stage breast tumors, disparities in guideline-concordant (GC) treatment may influence variation in breast cancer outcomes. As such, we investigated differences in the receipt of GC treatment for black and white women with early-stage breast cancer between 2008 and 2016. Methods: We evaluated the Surveillance, Epidemiology, and End Results Registry (SEER) Incidence database for black and white women aged 20-64 years with stage I / stage II breast tumors. Primary analyses investigated associations between race and receipt of GC treatment in three chronological periods. Potential driving factors for trends in receipt of guideline-concordant treatment were also assessed. Results: Among 145,561 women diagnosed with early stage breast tumors, overall receipt of GC care decreased from 84.58% in 2008 to 83.89% in 2016. In period 1 (2008-2010), there was a prominent disparity between black and white women (81.89% black vs 86.24% white; p < 0.001). By period 3 (2014-2016), GC care increased for black women (84.29%) but decreased for white women (84.82%), eliminating the disparity (p = 0.276). Multivariate logistic regression on changes in the black-white disparity across the study period showed increased receipt of GC treatment for black women relative to white women in period 2 (2011-2013, odds ratio [OR], 1.202; 95% confidence interval [CI], 1.075 – 1.344) and period 3 (OR, 1.376; 95% CI, 1.212 – 1.505). For black women undergoing breast conserving surgery, administration of radiation therapy increased from 44.01% in period 1 to 50.64% in period 3 (p < 0.001) and was a prominent driver for increased GC care. Conclusions: Overall receipt of guideline-concordant treatment decreased from 2008-2016. Black women experienced a substantial increase in receipt of guideline-concordant care in period 2 (2011-2013) and period 3 (2014-2016) relative to white women. Delivery and completion of radiation therapy with breast conserving surgery increased the likelihood of receipt of guideline-concordant treatment.
Addressing rural disparities in cancer care via telehealth.
Authors: Heifetz Laurence J. , Koppel Ahrin B. , Kaime Elaine M , Palmer Daphne , Semrad Thomas John , Lara Primo , Bold Richard J.
Published: May 2020

e19090

Background: Patients in rural areas have reduced access to high-quality cancer care, which contributes to rural-urban disparities in cancer mortality. Telehealth technologies can connect providers across rural and urban communities. Methods: In 2006, one author (LH) established an oncology program in Truckee, CA, a rural community with a single critical access hospital without oncology services. The program joined with 4 other facilities comprising the UC Davis Cancer Care Network, a central element being daily participation in structured virtual tumor boards addressing the four sites (colorectal, prostate, lung, & breast) that compromise ~80% of all cancer diagnoses. Remote telemedicine clinics outside the primary catchment area were also established to serve the mountain communities of Quincy, Portola, Loyalton, and South Lake Tahoe, CA. We assessed the reach and quality of the cancer program through referrals, in-migration, clinical trial accruals and accreditations. Results: The combination of virtual tumor boards and telehealth clinics associated with growth of the program to 3 medical oncologists, 1 radiation oncologist and expansion into a 20,000 ft2 facility. Total new patient visits, the percent of patients coming from zip codes outside of the primary catchment area, clinical trial enrollments, and quality accreditations steadily increased (Table). The program is accredited by the Commission on Cancer with commendation, ASTRO’s APEX, ASCO’s QOPI and CancerLinq programs, and is a G02Foundation for Lung Cancer Community Center of Excellence. Conclusions: We termed the knowledge dissemination that occurs through a telehealth connected rural oncology program involving a Comprehensive Cancer Center partner and disseminated rural telemedicine nodes a “synaptic knowledge network.” In this implementation, it enhanced the reach and quality of care as measured by volume, in-migration, clinical trial activity, and national quality accreditations. Application of synaptic knowledge networks to other rural sites is a promising strategy to reduce rural-urban disparities in cancer care. [Table: see text]
Outcomes of Pneumocystis juroveci pneumonia complicating treatment of solid tumors.
Authors: Dean Andrew Peter , Rolston Amy , Kelly Geena , Seeley-Rogers Madeleine , Ong Shaun
Published: May 2020

e19104

Background: Pneumocystis Juroveci Pneumonia (PJP) is a life threatening infection by an opportunistic pathogen historically affecting those with HIV and patients with immunosuppression from multiple lines of cytotoxic therapy, with mortality rates often > 50%. We previously reported data showing that PJP can affect patients early in the course of treatment, even during 1st line treatment. We analysed our outcomes from PJP occurring in these patients. Methods: Electronic database records were searched to identify PJP, chemotherapy, lines of therapy and survival. Results: 12 patients were identified who contracted PJP whilst undergoing chemotherapy for solid tumours, 4 during first line therapy and 5 during second line therapy. Age ranged from 33 to 84. 3 of 12 patients died within 1 week of diagnosis, one during first line therapy with erlotinib, 1 after 5 lines of chemotherapy and 1 after 7 lines of chemotherapy. 1 patient who survived had received 10 lines of therapy. Those who survived the initial infection had received between 1 and 10 lines of therapy and survival ranged from 2 to 25 months with a median survival of 11.5 months. Patients contracting PJP during 1-3 lines of therapy had the highest likelihood of survival with median survival of 11 months. Conclusions: PJP had a mortality rate in our series of 25% and was not exclusive to those with multiple lines of chemotherapy. Early recognition of infection resulted in good outcomes with ultimate prognosis being related to underlying malignancy rather than PJP.
Impact of oligometastatic disease on survival in ER positive breast cancer: A population-based analysis.
Authors: LeVasseur Nathalie , Willemsma Kaylie , Lohrisch Caroline A. , Lalani Nafisha , Chia Stephen K. L. , Liu Mitchell , Gelmon Karen A.
Published: May 2020

e19109

Background: Estrogen positive (ER) advanced breast cancers (ABC) are associated with a longer survival compared to other subtypes. However, clinical equipoise remains for the management of oligometastatic disease. While recent phase I and II data support the use of metastasis-directed therapy, breast cancer patients remain underrepresented and real-world outcomes for breast cancer patients with directed treatment for oligometastases is lacking. Methods: The BC Cancer Breast Cancer Outcomes Unit (BCOU) database was utilized to identify patients with ER positive breast cancer referred to BC Cancer from 2005-2014 with documented metastases. Baseline clinical, pathological and treatment data were compiled. Overall survival (OS) was compared between the group with oligometastatic disease(OM) (defined as < = 5 foci of metastases) and the group with non-oligometastatic disease (defined as > = 6 foci of metastases) using Kaplan-Meier survival curves. Key secondary endpoints included metastasis-directed treatment impact, based on the site of metastasis, local control (LC) and distant failure (DF) rate. Results: A total of 938 patients met the inclusion criteria. Of these, 191 (20.4%) had OM and 747 (79.6%) had widespread disease at 1st diagnosis of ABC. The groups were well balanced for clinical characteristics (all p > 0.05), with a median age of 59yrs (23-99). 84% were ductal carcinomas, 14% were also HER2 positive. Sites of oligometastases were bone (66.5%), liver (12.0%), brain (8.4%) and lung (5.8%). Median follow-up was 7.4 yrs. Median OS was 24 mo (95% CI 20.2, 27.8) for patients with OM and 11 mo (9.5, 12.5) for those with widespread disease (p < 0.0001). In the OM group, 114 (59.7%) of patients received metastasis-directed treatment, whereas 77 (40.3%) did not. Treatment modalities included radiation in 53.4% of patients, surgery in 8.9% of patients and stereotactic body radiotherapy (SBRT) in 3.7%. Median OS was 24 mo (18.3, 29.7) for patients who received metastasis-directed treatment and 23 mo (17.5, 28.5) for those who did not (p = 0.954). Patients with bone-only metastases had a median OS of 27mo with directed treatment and 25mo without directed-treatment (p = 0.334). Conclusions: Oligometastatic state was associated with a significantly better OS. Metastasis-directed treatment was associated with a non-significant OS difference in patients with bone-only metastases in a real world cohort. However, the impact of modern systemic treatment and SBRT methods are evolving. Large prospective randomized studies of this approach merit further study.
Quality of life (QOL), financial burden, and perception of care in patients enrolled on clinical trials (CTs).
Authors: Sidana Surbhi , Allmer Cristine , Larson Melissa C. , Dueck Amylou C. , Yost Kathleen J. , Warsame Rahma M. , Thanarajasingam Gita , Cerhan James Robert , Paludo Jonas , Rajkumar S. Vincent , Habermann Thomas Matthew , Nowakowski Grzegorz S. , Lin Yi , Gertz Morie A. , Witzig Thomas E. , Dispenzieri Angela , Gonsalves Wilson I. , Ansell Stephen M. , Thompson Carrie A. , Kumar Shaji
Published: May 2020

e19112

Background: We sought to study the longitudinal QOL, financial burden and perception of care (PoC) in patients with multiple myeloma (MM) or lymphoma (LYM) enrolled on CTs vs. those receiving standard care (Non-CT). Methods: QOL was evaluated using the FACT-G questionnaire (baseline, 1, 2, 3, 6 & 12 months). Financial burden was evaluated using 10 questions adapted from the MEPS survey and PoC was evaluated using 6 questions adapted from the CAHPS survey (baseline, 3, 6 & 12 months). Results: 35 (28%) of 123 enrolled patients were treated on CTs. Demographics, QOL and financial burden are shown in the Table. Baseline QOL scores were similar in CT vs non-CT groups. Age, gender and self-reported performance status were significantly associated with baseline QOL, while lines of therapy & cancer type were not. There were no significant differences in change in QOL vs. baseline in patients treated on CTs vs. non-CTs at 1, 2, 3, 6 and 12 months from baseline, including the total FACT-G score and the subdomains of functional, physical, emotional and social well-being. Within each group, there was a decline in QOL over the first 3 months, specifically physical WB, which gradually returned to baseline. Baseline answers to financial burden questions were similar, except patients on CTs reported less need for taking extended time-off from work (22% vs. 46%, p = 0.02). The only statistically significant difference in individual Qs over 1 year was ‘worry about having to pay large medical bills’ at the 6-month timepoint (CT: 0%, non-CT: 52%, p = 0.01). Using a composite score from 4 MEPS questions, financial burden over time was lower in the CT group, though the differences were not statistically significant. There were no significant differences in PoC at baseline, 3, 6 and 12 months in the two groups based on answers to each of the six questions adapted from the CAHPS survey. Conclusions: Over 1 year, patients on CTs experienced a similar QOL and perceived their care to be similar as non-CT patients. Financial burden was lower in the CT group, though differences were not statistically significant. [Table: see text]
The use of a chatbot based on artificial intelligence to collect patients reported outcomes in oncology practice. A pilot study with real-world data.
Authors: Murad Junior Munir , Nascimento Arthur , De Castro Alexandre Fonseca , Paiva Lilian , Fernandes Amandio S. , Lodi Luiz Adelmo
Published: May 2020

e19119

Background: There is growing interest in enhancing symptoms monitoring during routine cancer care using patient-reported outcomes (PROs). The quality of evidence that demonstrates clinical benefits of this type of assistance is also increasing. However, the best method for this approach is evolving and there are many barriers to implement these tools in the real world scenario. We aim to describe a pilot study about a chatbot with artificial intelligence developed to collect PROs and to optimize adherence to systemic cancer treatment. Methods: This is a case series that reports the first patients in a private oncology clinic in Belo Horizonte, Southeast Brazil who consecutively underwent regular conversations with a chatbot based on artificial intelligence. Data was collected from February the 23th to December the 3rd 2019. The virtual assistant interacted with the patient in four different ways, being the first three of these an active search from the chatbot: a) search for adverse events, b) adherence to oral treatment c) screening for depression d) spontaneous patient demand (not an active search). Results: Interaction with the chatbot was offered to 193 patients. A total of 107 patients were included. Of these 74% were female, 55% older than 60 years and 22% had at least 7 years education.194 protocols of treatment were analysed, 66% of these being chemotherapy regimens and 23% hormone therapy. Oral drugs corresponded to 23% of the protocols. The main adverse events reported were fatigue 20%, nausea 13%, pain 11%, diarrhea 10%, lack of appetite 6%. Adverse effects were classified by patients as grade III or IV approximately 24% of the time. For patient safety the system runs a script twice a day to detect any adverse effect and send it to the service attended. A total of 3883 dialogues were initiated, the majority of which (3772) was carried out by the machine. Only 3% of the dialogues were spontaneously initiated by the patients. Once the conversation started, adherence was considerably satisfactory since engagement was 73% for questions about adherence to oral medications and 76% of people reported at least one adverse event. Conclusions: An initial barrier must be surpassed since the chatbot was offered to 193 patients and 86 (44%) did not register for use. Once the contact started, we understand that the use of AI is promising since the engagement rates were very good. It is important to highlight the potential capacity for early identification of symptoms since most dialogues were initiated by the virtual assistant.
Adoption patterns of an electronic patient-reported outcomes tool in oncology.
Authors: Polubriaginof Fernanda CG , Parekh Priti K , Akella Naga Ravi Shankar , Stetson Peter D.
Published: May 2020

e19127

Background: Patient-reported outcomes (PROs) are critical for the delivery of patient-centric care. Previous research has shown that the use of PROs can impact clinical outcomes in Oncology. Despite these benefits, PROs have not been widely implemented as part of standard of care. Significant barriers exist for its adoption including lack of integration between PRO tools and electronic health record systems (EHRs). We developed MSK Engage, a home-grown PRO tool integrated with the EHR and embedded within MSK's patient portal (MyMSK). It was launched in late 2015 and it is currently used enterprise-wide for both standard of care and research purposes. The purpose of this study was to describe the usage patterns of PROs in a real-world setting. Methods: We conducted a retrospective analysis of patients that have been assigned at least one MSK Engage survey instrument between 2015 and 2019. Patient demographic information was extracted from the EHR system. Usage patterns including the number of survey instruments assigned and completed were extracted from MSK Engage. Survey completion rates were stratified by patient demographic information and number of assigned surveys. We performed univariate and multivariate analyses to identify factors associated with survey completion rates. Results: During the study period, 57 survey instruments were implemented, with the majority being used for standard of care (41 for standard of care only, 9 for research protocols, 6 for standard of care and research, and one for a quality improvement initiative). In total, 246,638 patients were assigned 557,559 surveys. Of those, 146,505 patients completed a total of 265,174 surveys, with a median completion time of 3 minutes. Among the patients that were assigned a survey, 73.7% were women. Women in our sample were older than men, with median age 52 and 47 years old, respectively. Men were more likely to complete the assigned surveys with 61.2% completion rate among men and 43.3% among women (p < 0.001). On multivariate analysis, men were less likely to miss surveys than women (odds ratio [OR], 0.49; 95% CI, 0.48-0.49). We also identified a significant correlation between the survey completion rate and number of assigned surveys, demonstrating that assigning a large number of surveys for each patient can lead to a reduced survey response. Conclusions: Providers have quickly adopted MSK Engage demonstrating that it is feasible to incorporate PROs as part of standard of care. Patients are willing to answer PROs; however, it is important to mindful when assigning surveys to avoid negative effects of survey burden.
Overcoming difficult conversations: Training medical professionals to discuss mental health with cancer survivors.
Authors: Roberts Shelby , Macchi Marti , Hodges Samaha , Goldman Ron , Patton John
Published: May 2020

e19155

Background: Cancer survivors have overcome a significant health challenge, and now face the physical, social and emotional effects of surviving cancer. These psychosocial side-effects are often not addressed in the clinic due to time constraints, false perceptions of reimbursement and discomfort toward the subject from both the patient and medial professional. The National Association of Chronic Disease Directors, along with the Centers for Disease Control and Prevention and Kognito Solutions have developed a series of conversation simulations led by virtual human, digital characters to help medical professionals practice these patient interactions. Methods: The simulation was developed after an extensive literature review and interviews with cancer survivors and 12 professionals in oncology and primary care. Scripts were developed that included hundreds of conversation pathways for providers to choose from. Scripts were tested by subject matter experts in clinical psychology, oncology and survivorship. Three video interviews with survivors were included along with a didactic teaching segment to provide instruction to medical professionals participating in the simulation. Results: The resulting learning experience is a self-guided conversation pathway where the medical professional chooses responses to the virtual cancer survivor’s questions guiding the survivor toward a discussion focused on distress. The simulation offers feedback and suggests conversational improvements throughout the process. The simulation is now complete and freely available online. Full rollout and dissemination including CME credits will begin in March. To date,197 distinct users have engaged in the simulation. Users self-reported the simulation was high quality and resulted in them listening more, asking more open-ended questions, and discussing mental health issues routinely with patients. Conclusions: This innovative approach to learning offers an interactive and highly engaging way to practice difficult discussions with patients. Increasing the quality and frequency of mental health screenings with cancer survivors will empower survivors and improve their adherence to other health behaviors reducing the risk of recurrence. Increased use of the simulation after the national rollout will allow a more robust evaluation of future impact on patient mental health and changes in medical practice.
Assessing oncology patients’ perceptions of treatment goals.
Authors: Ngo Phuong , Dong Brian , Souders Lisa , Mull Jetta , Hegazi Mohamed M. , Wu Xiaoyong , Rai Shesh , Redman Rebecca A.
Published: May 2020

e19160

Background: Metastatic disease is generally treated with palliative intent, but a patient’s perception of this is highly variable and dependent upon multiple factors. Our study evaluated our patients’ understanding of their treatment goal and sought to identify factors affecting it. Methods: This was a prospective study of 111 consecutive patients with stage IV solid tumor malignancies at a single institution. Patients were given a survey during a routine follow up visit. Requested information included primary site of malignancy, stage, duration of treatment, whether they think the treatment is curative, and whether they think the treatment will help them live longer and/or relieve cancer-related symptoms. Patients also provided basic demographic information such as age, gender, marital status, race and education level. Their answers regarding cancer type, stage and length of treatment were compared with their medical records. Characteristics were compared to survey responses using Pearson’s chi-square test and Fisher’s exact test. Results: Median age was 62 years with 58.6% females. Sixty-five percent of patients were married and 55.9% had college education or higher. The primary malignancies consisted of breast, gastrointestinal, genitourinary, lung, sarcoma and skin. Sixty percent were metastatic at diagnosis, 27% of patients had received adjuvant therapy, and 49.5% of patients received two or more lines of therapy in the metastatic setting. Of all patients, 91.9% correctly identified their primary cancer but only 77.5% knew it was stage IV. Only 22.5% of patients knew their treatment was not curative while 32.4% believed it was and 45% did-not-know. Seventy-three percent thought treatment would help them feel better and 85.6% believed it would help them live longer. Lines of therapy received significantly affected whether a patient thought treatment would help alleviate symptoms. Cancer type was significantly associated with whether a patient believed treatment to be curative. Marriage, age, race and education did not significantly affect patients’ answers. Conclusions: Less than one-third of our patients receiving treatment with palliative intent reported that his/her treatment was not curative. Factors influencing a patient’s perception of treatment goals are many and include those specific to the patient, their cancer and their providers. Ongoing studies will focus on identifying more barriers affecting a patients’ perceived treatment intent and will explore possible solutions to overcoming them.
Development and evaluation of patient reported outcomes-based performance measures during chemotherapy.
Authors: Urick Benjamin , Stover Angela M. , Deal Allison Mary , Jansen Jennifer , Chiang Anne C. , Cleeland Charles S. , Zylla Dylan M. , Basch Ethan M.
Published: May 2020

e19175

Background: As value-based oncology care models become increasingly common, there is need for reliable and valid patient-reported outcome performance measures (PRO-PMs) to assess quality of symptom control at practices. We propose a method for combining PRO items across multiple symptoms into a single reliable and valid summary PRO-PM metric. Methods: Symptom surveys were administered to 607 patients at 6 cancer centers, between 5-15 days after starting a chemotherapy cycle. Twelve symptoms were elicited, each scored from 0-4, with higher scores indicating greater severity. Summary PRO-PM metrics were generated by summing scores for symptoms. A 3-item short form (score range 0-12) included nausea, diarrhea, and pain. A 12-item long form (score range 0-48) included short form items plus neuropathy, dyspnea, vomiting, fatigue, constipation, anxiety, sadness, insomnia, and appetite. PRO-PM summary item scores were dichotomized into high and low symptom burden categories. Cut points for dichotomization were compared based on reliability, validity, and prevalence. Reliability was defined as the average of practice-specific signal-to-noise ratios, with an optimal score ≥0.7. Practice-level validity was defined as the Pearson correlation between the proportion of patients with high symptom burden and low self-reported physical functioning. Patient-level validity was estimated as the relative risk (RR) of low physical functioning for patients with high vs. low symptom burden. For prevalence, measures were required to have > 5% or < 95% of patients with high symptom burden. Optimal cut-points were identified via a scatter plot comparing measure reliability and validity. Results: Optimal cut-points were identified for both summary PRO-PM metrics. For the short form, a cut-point at ≥5 had a reliability of 0.56, correlation of 0.14, RR of 2.56, and prevalence of 24.5%. For the long form, a cut point at ≥22 had reliability of 0.54, correlation of 0.56, RR of 2.61, and prevalence of 8.5%. Conclusions: Summary PRO-PM metrics can be generated from multiple PRO symptom items, with optimal cut-point scores determined by comparing reliability and validity. Reliability scores approached but did not meet the recommended 0.7 threshold due to sample size, therefore additional data are currently being collected to further support these cut points.
Utilization of a cardio-oncology clinic: A single center experience.
Authors: Doukas Peter , Khan Sadiya S , Akhter Nausheen
Published: May 2020

e19192

Background: Many systemic anti-cancer therapies (chemotherapy, immunotherapy and radiation) have known cardiac toxicities. The field of cardio-oncology aims to optimize the cardiac health of cancer patients. Our goal was to evaluate baseline clinical characteristics, referral patterns and the rate of adverse cardiac outcomes in patients referred to a single cardio-oncology clinic at a tertiary care academic center. Methods: We performed a retrospective review of 100 consecutive patients who established care at a cardio-oncology clinic between 2011-2019. Baseline clinical data was collected from the initial presentation. Interventions and subsequent adverse cardiac events that occurred within a 6-24 month follow-up period were recorded. Fisher’s exact test was used to compare the measured variables. Results: Of the 100 patients, the median age was 63 years old and 69% were women. The most common reasons for referral were echocardiographic changes in systolic function or symptomatic congestive heart failure (HF) (54%; 54/100). Of patients who received anti-cancer therapy, only 18% (17/95) were referred for a pre-treatment cardiac evaluation. The rate of new HF diagnoses or worsening HF symptoms, defined by decreased NYHA class or HF-related hospitalizations, was 6% in the cancer treatment naïve group and 12% in the group that was not (p=0.68). Anti-cancer therapy was stopped or changed in 6 patients who were diagnosed with HF at any point. Conclusions: Our study provides insight into referral practices, interventions and outcomes at a single cardio-oncology clinic at a tertiary care academic center. Patients were often referred after the initiation of anti-cancer therapy, with the majority already experiencing a decline in systolic function. There was a higher rate of new HF events in patients who had already been treated with anti-cancer therapy before their first cardio-oncology visit. This may suggest the need for a change in referral practices to optimize cardiac health, specifically a shift in cardio-oncology evaluation prior to initiation of anti-cancer therapy. [Table: see text]