bluuebunny/crossref_metadata_2025 huggingface dataset:
The use of surgical & interventional procedures for the diagnosis and treatment of pediatric tumors: An example from an upper middle income country.
Authors: Kutluk M. Tezer , Çakmakkaya Kübra , Ahmed Fahad , Akıncı Devrim , Ekinci Saniye , Oğuz Berna , Haliloğlu Mithat , Orhan Diclehan , Akyüz Canan
Published: May 2020

e19022

Background: The burden of pediatric cancer is more than 300.000 cases per year in children aged 0-19 years globally. Turkey faces almost 4000 cases per yr in the same age group. The survival rates exceeded 80% in high income countries although it is still a challenge in LMICs at different level of low survivals. The availability, accessibility & affordability of advanced techniques such as interventional procedures are major challenges for successful treatment of pediatric cancers in LMICs. Methods: 279 sequentially diagnosed cancer in children aged 0-18 years in a single institution in 2018 were included. Tumors were classified according to the ICCC-3. Leukemias were not included. The types of interventional & surgical procedures used for diagnosis were recorded. The distribution of procedures according to the type of malignancies were examined & descriptive characteristics of patients were compared. Results: The median age was 58/12yrs, M/F=153/126. The most common tumors were CNS tumors followed by lymphomas & neuroblastoma. Among all, surgery was performed in 189 (67.8) children whereas 45 (16.1%) patients were diagnosed by interventional radiology procedures. Radiological diagnosis was made in 42 (15.1%) children. Conclusions: Early diagnosis & access to best available care is the most essential part of the pediatric cancer control. Current global initiatives have a focus on how to improve the survival in LMICs. Here we report the use of surgery vs interventional radiological procedures for the diagnosis of pediatric tumors. The efficient & timely use of the diagnostic procedures save the patients lives in a cost effective ways with less morbidity & mortality. Since there is limited data from the LMICs, we suggest to the pediatric oncology community to do more detailed evidenced based research for the diagnosis pediatric cancers. [Table: see text]
Association of socioeconomic status and molecular testing in stage IV colorectal cancer.
Authors: Punekar Salman Rafi , Griffin Megan Marie , Masri Lena , Makarov Danil V. , Sherman Scott , Becker Daniel Jacob
Published: May 2020

e19023

Background: The use of EGFR monoclonal antibodies extends life for patients with advanced colorectal cancers (CRC) whose tumors exhibit wild type KRAS. Research suggests that KRAS testing is underused, denying patients access to targeted therapy. We sought to study the role of socioeconomic factors in the application of KRAS testing. Methods: We identified subjects with stage IV colorectal adenocarcinoma diagnosed between 2010 and 2015 in the Surveillance Epidemiology and End Results (SEER) database. We identified clinical and demographic characteristics, including diagnosis year, race, ethnicity, sex, age, geography, median household income (MHI), insurance coverage, tumor grade, and tumor location. We used multivariable logistic regression models to evaluate associations between these factors and the rate of KRAS testing. We constructed Cox proportional hazard models to assess the impact of KRAS testing on survival. Results: We identified 37,676 patients with stage IV CRC, 31.1% of whom were tested for KRAS mutations. The rate of KRAS testing varied from 23.2% to 56.5% across geographic regions. Patients were more likely to be tested if they were younger (OR 5.10 for age 20-29 vs 80+, 95% CI 3.99-6.54, p < 0.0001), diagnosed more recently (OR 1.92 for 2015 vs 2010, 95% CI 1.77-2.08, p < 0.0001), or lived in an area of high MHI (OR 1.24 for MHI of > $69,311 vs < $49,265, 95% CI 1.14-1.35, p < 0.0001). Patients were less likely to be tested if they had Medicaid (OR 0.83, 95% CI 0.77-0.88, p < 0.0001), were unmarried (OR 0.78, 95% CI 0.75-0.82, p < 0.0001), or had rectal cancer (OR 0.79, 95% CI 0.74-0.84, p < 0.0001). The risk of death was decreased in patients who received KRAS testing (HR 0.77, 95% CI 0.75-0.80, p < 0.0001). The median survival for patients who were tested was 20 months (95% CI 20-21), vs 11 months (95% CI 10-11) for patients not tested (p < 0.001). Conclusions: We found a low rate of KRAS testing overall in CRC patients diagnosed between 2010 and 2015. Testing rates increased over the study period, but, even as of 2015, the majority of patients did not have KRAS testing.We found thatpatients with Medicaid and those who lived in areas of lowest income were less likely to have KRAS testing. Prior studies reported that Medicaid was associated with lower utilization of KRAS testing, but ours represents a more contemporary cohort and is the first to evaluate Medicaid and MHI simultaneously. Ideally Medicaid insurance would increase access to molecular testing for patients with limited resources, but our model suggests that income-based disparities persist despite Medicaid insurance.
Implementation science of district cancer care delivery model (Pendharkar model).
Authors: Pendharkar Dinesh , Tripathi Chandramauli
Published: May 2020

e19024

Background: Health care systems are fighting with issues related to multiple elements of access to care. The problems include non availability of physical facilities and qualified human resource. Here we report successful intervention results of a scalable, replicable, cancer care model starting with two and expanding to nearly 198 districts, using standard processes. This has brought specialised cancer care to government run general district hospitals using existing human resource, through empowerment of alternate oncology workforce, capacity building, decentralisation, and task sharing with impactful outcome. Methods: Government run general district hospitals were involved to train one physician and nurse in principles of oncology care over one month period, followed by constant 24 x7 support and continued training etc. (techno-mentoring). Administrative changes enabled creation of identity of nodal cancer units and organised process of cancer drug delivery. Results: The implementation process was experimented in two hospitals and later on extended to nearly 198 hospitals, over a period of six years (Table). Majority of states have formulated the innovation as state run district cancer care program with published operational guidelines. The state governments designated physicians as nodal cancer officers and created their identity with physical allocation of space and providing cancer drug formulary. The physicians are assisting cancer patients from diagnosis up to end of life care including chemotherapy, palliative care. More then 45000 patients have availed services. Few thousand chemotherapy sessions have been performed by alternate oncology workforce. Drug availability is maintained through routine government supplies by adding anticancer drugs to list of essential medicines. Satisfaction survey conducted amongst patients, has proved its usefulness, acceptability. Conclusions: Impactful implementation at scale is feasible for cancer care delivery, using existing physical infrastructure and empowerment of alternate oncology workforce, through this model. It can ideally serve areas with no access to cancer care, including LMIC. [Table: see text]
Emergency room presentation of lung cancer as a highly practical prognostic marker for consideration in clinical trials: A SEER database analysis.
Authors: Mushtaq Rao Rashid , Yekkaluri Sruthi , Meyer Elisabeth , Camidge D. Ross
Published: May 2020

e19032

Background: Multiple factors influencing lung cancer prognosis could be used for stratification in randomized intervention trials which are either observer-dependent (performance status) or poorly available (education/comorbidity index). In this study we explored the independence of ER presentation of lung cancer (an objective variable) as a prognostic factor. Methods: We performed a study using patients from the Surveillance, Epidemiology, and End Results-Medicare linked database, aged 66 years or older and diagnosed with lung cancer between 2007 and 2015. ER presentation was defined as ER visit ≤30 days prior to the earliest diagnostic procedure. Factors associated with ER versus non-ER presentation and the impact of ER presentation on overall survival (OS) and Cancer specific survival (CSS) were assessed. Results: Between 2007 and 2015, a total of 75,798 lung cancer patients met study criteria. 37% of small cell lung cancer (SCLC) and 28% non-small cell lung cancer (NSCLC) patients had ER presentation. For both histologies, in univariate Chi-Square analysis ER presentation was affected (p < 0.05) by sex, race, marital status, census tract poverty and education levels, number of comorbidities, geographic region, and cancer stage, but not by age (except with NSCLC) or rural/urban commute. Multivariable Logistic Regression showed that for both histologies, stage IV, Black or Hispanic race/ethnicity, East or mid-West region, ≥2 comorbidities, unmarried, and tract poverty level ≥ median were independent risk factors associated with ER presentation (odds ratio > 1). For NSCLC, year of diagnosis ≥2009, female, age ≥75, South region, tract education level > median; for SCLC, year of diagnosis ≥2012 and age 70-74 were also significantly associated with ER-presentation. ER versus non-ER presentation was associated with lower 1-yr OS in NSCLC (43% vs 61% HR 1.79, 95% CI 1.68, 1.77; p < 0.0001) and SCLC (33% vs 43% HR 1.32, 95% CI 1.25, 1.40; p < 0.0001). After adjusting for histology, year of diagnosis, age, sex, race, marital status, region, poverty level, education level, number of comorbidities, and stage in a multivariable Cox model, ER presentation remained an independent poor prognostic marker (HR for OS 1.34, 95% CI 1.31, 1.37; p < 0.0001; HR for CSS 1.32, 95% CI 1.29, 1.36; p < 0.0001). Conclusions: ER presentation of lung cancer is an independent, objective, highly practical poor prognostic risk factor which should be considered for patient stratification and data analyses within interventional clinical trials.
Outcomes in minority patients (pt) with aggressive B cell lymphoma (BCL) if optimally managed with equal access to care and nurse navigation (NN).
Authors: Hu Bei , Chen Tommy , Boselli Danielle , Pye Lisa , Bose Rupali , Raghavan Derek , Symanowski James Thomas , Blackley Kris , Moyo Tamara Kay , Jacobs Ryan , Park Steven , Soni Amy , Avalos Belinda , Copelan Edward Alan , Ghosh Nilanjan
Published: May 2020

e19040

Background: Aggressive BCL is curable but previous studies have shown that minorities have inferior survival, partly due to socioeconomic barriers and poor access to care. NN programs are designed to reduce barriers to care via various methods. We present disease characteristics, treatment, and outcomes of Caucasian (C) & non-Caucasian (NC) pts with aggressive BCL at Levine Cancer Institute which has an active NN program. Methods: We collected demographic, insurance, disease characteristics, treatment, and outcomes for pts with aggressive BCL [diffuse large B cell lymphoma (DLBCL), primary mediastinal B cell lymphoma (PMBCL), or high grade B cell lymphoma (HGL)] between Jan 2016 and Jun 2019. Race (C or NC) was self-reported. NN encounters were characterized as low intensity (basic needs) or high (moderate/high needs). OS and PFS were calculated using Kaplan Meier. Demographics were compared using Fisher's Exact tests. Results: 204 pts (186 = DLBCL, 14 = PMBCL, 4 = HGL) were included (NC = 47; C = 157). NC were younger at diagnosis (median age 56 vs 62 yrs, p = 0.03) and more likely to be uninsured/Medicaid (26% vs 4%, p < 0.0001). There were no significant differences in prognostic scores (44% vs 50% R-IPI score 3-5, p = 0.5), incidence of double hit (11% vs 13%, p = 0.8), frontline rituximab/anthracycline containing chemotherapy (98% vs 96%, p = 0.9), and incidence of relapsed/refractory (R/R) disease (40% vs 37%, p = 0.7) for NC compared to C. For R/R BCL, similar % of pts underwent hematopoietic stem cell transplant (SCT) (32% NC vs 28% C, p = 0.8) or CAR-T cell therapy (16% NC vs 19% C, p = 0.9). Enrollment in clinical trials was comparable (17% NC vs 14% C, p = 0.6). The % of pts receiving NN was similar (81% NC, 87% C, p = 0.4) but NC had higher intensity NN encounters (42% vs 21%, p = 0.01). With median follow up of 35 mo, OS and PFS were comparable between both groups. The 2 yr OS was 81% for NC and 76% for C, p = 0.3; 2 yr PFS was 62% for NC and 64% for C, p = 0.8. Conclusions: We show equivalent survival between Caucasian and non-Caucasian pts with aggressive BCL. Disease biology and treatment patterns--including access to SCT, CAR-T and clinical trials--were similar in both groups. Differences in insurance coverage favored Caucasians. Similar proportion of pts in both groups received nurse navigation, but non-Caucasian pts had higher intensity navigation needs. Providing equal access to care and availability of an active nurse navigation program may overcome racial heath disparities. This study has implications for national health policy.
The effect of locality of residence (LOR) and socioeconomic status (SES) on mortality in patients with squamous cell carcinoma of the head and neck (HNSCC): 20-year experience at the UPMC Hillman Cancer Center.
Authors: Taylor Janielle , Shuai Yongli , Robertson Linda , Normolle Daniel Paul , Ferris Robert L , Bear Todd , Nilsen Marci Lee , Johnson Jonas T. , Kubik Mark , Sridharan Shaum , Duvvuri Umamaheswar , Wang Eric , Skinner Heath Devin , Clump David Anthony , Ohr James , Snyderman Carl , Chiosea Simion I. , Gish-Johnson Rachelle , Kim Seungwon , Zandberg Dan Paul
Published: May 2020

e19043

Background: As cancer centers expand, evaluation of potential disparities in outcomes amongst the catchment area is critically important. We examined the effect of LOR and SES on overall survival (OS) in HNSCC patients treated at HCC, which spans 29 counties in western Pennsylvania with diverse socioeconomic profiles across urban and rural localities. Methods: Retrospective review included patients with primary HNSCC (excluding M1 and recurrent disease) treated at HCC 1997-2018. Using Rural-Urban Commuting Area codes, LOR was classified as urban/suburban or rural according to ZIP code. SES was defined by medium income level (low, moderate (Mod), middle (Mid), Upper) via Federal Financial Institutions Examination Council geocoded census tract data. Kaplan-Meier methods and Cox regression models were used to evaluate OS. Results: 3512 patients were identified. Median age was 61, 72.7% male, 93.2% White, 18% HPV +, 75.5% urban/suburban, and by SES: 4% Low, 21% Mod, 46% Mid, and 19% Upper. Primary site included 35.2% oral cavity, 28.4% oropharynx, 28.1% larynx, 8.3% other, stage was majority III/IVa (61%), 66% had surgery and 54% received multimodality treatment (tx). While median OS differed significantly by race (Black: 5.8 vs. White: 7.3 years, p = 0.0457) and SES (Low: 4.1 vs. Mod: 5.3 vs. Mid: 7.3 vs. Upper: 9.1 years, p < 0.0001), there was no difference by LOR (rural: 7.7 vs. urban/suburban: 7.2 years, p = 0.99). Multivariable Cox Regression showed lower SES was associated with a higher risk of death [(Low vs. Upper, HR: 1.416, 95% CI: 1.023-1.959) (Mod vs. Upper, HR:1.443, 95% CI: 1.214 – 1.716), p = 0.0004], adjusting for LOR and factors associated with OS in univariate analysis (age, smoking status, primary site, staging, tx, HPV status, race, and enrollment on clinical trial). The effect of LOR, race, and enrollment on clinical trial were not significant in multivariate analysis. Conclusions: SES was independently associated with OS in HNSCC patients treated at HCC, while LOR was not associated with OS. The lack of difference by LOR may be partially explained by HCC’s efforts to increase access to care throughout the catchment area by establishing community sites. However, a focus on improving outcomes for lower SES HNSCC patients is needed.
Identification of transgender people with cancer in electronic health records (EHR): Recommendations based on CancerLinQ observations.
Authors: Alpert Ash , Bruinooge Suanna S. , Dizon Don S. , Koronkowski Becky , Garrett-Mayer Elizabeth , Meersman Stephen C. , Miller Robert S. , Potter Danielle , Komatsoulis George Anthony
Published: May 2020

e19046

Background: Data regarding people who are gender minorities are not well-captured in oncology practices or large cohorts. Given this, collection of cancer prevalence and outcomes data, which are necessary to understand disparities in this population, are significantly hampered. Real-world data may be the most readily available source to explore outcomes in transgender populations. A database of EHR data on people with cancer, CancerLinQ is housed by the American Society of Clinical Oncology and collected from nation-wide practices and multiple EHRs. Methods: In order to identify people with cancer who may be transgender within CancerLinQ, we used three criteria: 1. ICD 9/10 diagnosis (Dx) code indicating likely transgender or non-binary gender conforming status 2. Male gender and Dx of cervical, endometrial, ovarian, or Fallopian tube cancers 3. Female gender and Dx of prostate, testicular, or penile cancers . We reviewed medical records for gender, cancer diagnosis, Dx indicating transgender identity and surgical history of transition-related surgeries, in other words surgeries that align bodies with identities and constructed a de-identified dataset of people who met one of the three criteria listed above. People without evidence of transgender identity were assigned as: (1) likely Dx error, because the person had either (a) no cancer, (b) an alternate cancer Dx consistent with sex assigned at birth, or (c) a cancer not listed in the above criteria (e.g. lung); or (2) likely error in gender data, if the cancer Dx was confirmed, but gender data was not; or (3) unknown. Results: Of ~1.3 million records in CancerLinQ at time of case selection, 557 matched inclusion criteria and 242 were abstracted. 76% of patients with ICD9/10 gender related Dx codes had evidence confirming transgender identity. By contrast, only 2% and 3% of the people identified by criteria 2 and 3 had evidence of transgender identity, respectively. Conclusions: Given the need for data regarding transgender people with cancer and the deficiencies of current data resources, a national concerted effort is needed to broaden terminology in EHRs to include whether people are transgender or not as routine and required data elements, provided by patients at their discretion. [Table: see text]
Impact of age on racial disparity in early stage breast cancer in the United States.
Authors: Bhandari Shruti , Kumar Rohit , Ngo Phuong , Mudra Sarah , Murray Drew Carl Drennan , Riley Elizabeth Carloss , Boone Stephanie D.
Published: May 2020

e19058

Background: Racial disparities persists in women with early stage breast cancer and is most pronounced in Black (B) compared to White (W) women even when controlled for stage and biological subtype. Little is known about the impact of age on racial disparities. Our study evaluates the magnitude of a racial disparity in mortality across age strata in a real-world population. Methods: We identified stage I-III female breast cancer patients between 2010 – 2015 from the National Cancer Database. Hazard ratios (HR) and 95% Confidence Intervals (CI) for all-cause mortality were estimated using multivariable Cox Proportional Hazards regression, adjusted for clinical and demographic factors. The mortality risk for B and Other (O) race was compared to W across four age groups. To determine the significance in excess risk of mortality, the magnitude of disparity of each age group was compared to the > 60y age group. Results: A total of 679,327 patients were included. W comprised the largest percentage across all age groups. However, the percentage of W increased with age, while the percentage of B decreased with age (p < 0.001). The risk of mortality was significantly higher for B relative to W across all age groups ≤60y. When compared to > 60y, the magnitude of effect of age on risk of dying was significantly different (p < 0.0001) (Table). Conversely, the risk of mortality was significantly reduced for O race compared to W, with similar magnitude of effect across all ages. Conclusions: Even after adjusting for known risk factors of racial disparity such as insurance, biologic subtype and stage, the B to W racial disparity in mortality decreased with age (most pronounced in younger age) and appeared to diminish among women > 60 years of age. In contrast, the risk of dying in O race remained constant. Reasons are unclear and may be due to unmeasured socioecomomic or biologic factors that cannot be controlled for in this dataset. Regardless, identifying factors associated with worsened outcomes in younger age groups in B women should be the direction of future studies. [Table: see text]
Socioeconomic status, race, and mortality disparities in insured patients in southern California.
Authors: Cooper Robert Michael , Haque Reina , Schottinger Joanne E.
Published: May 2020

e19060

Background: One known factor related to increased mortality is lack of health insurance coverage. To eliminate this variable we evaluated overall mortality by socioeconomic status (SES) in an insured southern California population diagnosed with cancer accounting for confounding factors including race/ethnicity. Methods: We identified adults diagnosed with eight common cancers from 2009-2014 from the California Cancer Registry and followed them through 2017. We calculated person-year mortality rates by SES and race/ethnicity. Adjusted hazard ratios for the association between all-cause mortality and SES were estimated using Cox proportional hazards models accounting for covariates (race/ethnicity, demographics, stage, treatments). Results: A total of 164,197 adults were diagnosed with cancers of the breast, prostate, lung, colon, melanoma, uterus, kidney and bladder; total of numbers of deaths was N=41,727. Compared to subjects in the highest SES quintile, we found an increased overall mortality risk in each of the lower SES quintiles. In multivariable models, mortality risk was 16% to 37% greater in the lower SES groups versus the highest SES group. Conclusions: After multivariable adjustment that accounted for race/ethnicity, cancer treatments and tumor factors, insured individuals in lower SES groups had a significantly higher overall mortality risk compared those in the highest SES group. [Table: see text]
Implementation of a triage system in the Alerta Rosa breast cancer navigation program.
Authors: Villarreal-Garza Cynthia , Tamez-Salazar Jaime , Mireles-Aguilar Teresa , De la Garza-Ramos Cynthia , García-García Marisol , Ferrigno Ana Sofia , Platas Alejandra
Published: May 2020

e19064

Background: Alerta Rosa is a navigation program in Nuevo Leon, Mexico that aims to reduce delays in breast cancer (BC) diagnosis and treatment initiation irrespective of healthcare coverage. Via a call center, a navigator registers each patient’s initial concern and schedules a medical evaluation. This study aimed to assess the implementation of a triage system to guide appointment prioritization for undiagnosed BC patients with abnormal breast findings or imaging studies. Methods: Women that contacted Alerta Rosa were stratified according to their clinical characteristics into three priority groups. Asymptomatic women seeking check-up information were classified as low-priority (“Green”), those with nonspecific symptoms (e.g. mastalgia) or indeterminate image studies (BIRADS 0) as intermediate-priority (“Yellow”), and patients with suspicious symptoms (i.e. palpable mass, nipple retraction or bloody discharge), abnormal image studies (BIRADS 3-5) or an established BC diagnosis as high-priority (“Red”) for an appointment. The triage system’s ability to detect undiagnosed BC was evaluated against the number of patients per category in whom BC was later confirmed. Differences in time from initial contact to first medical evaluation were explored with an independent t-test. Results: From December 2017 to 2019, 561 women with a median age of 44 years (range: 8-89) contacted Alerta Rosa. 369 (66%) reported breast symptoms, 92 (16%) sought check-up information, 68 (12%) had an indeterminate/abnormal image study and 32 (6%) had received a BC diagnosis and wanted a second opinion. Accordingly, 16% of patients were classified as “Green”, 25% “Yellow” and 59% “Red”. The median time from stratification to medical evaluation was 4 days for the “Red” group and 7 days for those in other categories ( p= 0.003). A total of 558 appointments were scheduled, of which 441 (79%) were attended. Excluding those who had received a prior BC diagnosis, 20/299 patients from the “Red” group had BC confirmed (6.7%) compared to 1/138 patient from the “Yellow” (0.7%) and none from the “Green” categories. Therefore, the “Red” category achieved a sensitivity of 95.2% (CI95%: 76.2-99.9%) and specificity of 53.8% (CI95%: 49.3-58.3%) for BC. Conclusions: The triage system adequately identified women with different probabilities of having BC. Thus, the implementation of a stratification system could help identify high risk patients in limited-resource settings where screening programs are ineffective and efforts to prioritize access to medical attention is crucial to achieve early-stage diagnoses.
Beyond patient-level barriers: Evaluation of rural residency and area-level deprivation and clinical trial (CT) participation.
Authors: Unger Joseph M. , Moseley Anna , Osarogiagbon Raymond U. , Doolittle Gary C. , Hershman Dawn L.
Published: May 2020

e19068

Background: Residents of rural and socioeconomically deprived areas have worse cancer outcomes and are less likely to participate in CTs. It is unknown whether these area-level attributes predict CT participation after accounting for individual sociodemographic variables. Methods: We combined data from two SWOG national survey studies. S0316, a multi-center prospective survey, was combined with data from a large web-based survey. Both studies examined CT treatment decision making from diagnosis in patients with common cancers. Zip codes of residences were classified as rural or urban using Rural-Urban Continuum Codes (urban, 1-3, vs. rural, 4-9) and a 3-level ordinal variable (urban, 1-3, vs. rural, 4-7, vs. very rural, 8-9). We identified socioeconomically deprived areas (SDAs) as those with an Area Deprivation Index (ADI) in the upper quartile. We also examined areas by ADI quartile. Multivariable logistic regression was used to evaluate the association of rural residency and area-level socioeconomic deprivation with CT participation after adjusting for important individual-level factors (age, sex, race/ethnicity, income, and education), stratified by study and cancer type. Results: Among 7080 patients, 1299 (18.5%) were from rural areas, 653 (9.4%) were from SDAs; and 715 (10.1%) participated in a CT. Patients had breast (56.1%), prostate (21.8%), lung (13.6%), and colorectal (8.4%) cancer. In univariate analysis, rural patients were 23% less likely to participate in a CT (OR=0.77, 95% CI: 0.62-0.95, p=.016); in multivariate analysis, results were similar (OR=0.80, 95% CI: 0.64-0.99, p=.037). Very rural residents were 34% less likely to participate than urban patients (OR=0.66, 95% CI, 0.55-0.80, ordinal p=.031). There was no statistically significant association between residence in SDAs and CT participation (p>.30). Rural patients were more likely to have >1 comorbid conditions (45.4% vs. 39.5%, p=.001), to be concerned about how to pay for their care (40.6% vs. 32.4%, p<.0001), and to travel farther for care (median 50.0 vs. 12.0 miles, p<.0001). Conclusions: Our findings are the first to show that rural residents are less likely to participate in CTs even after accounting for confounding individual factors. These results agree with prior observations that rural patients must travel longer distances for care, including for CT care. Reducing the travel burden for rural cancer patients could improve their CT participation and the generalizability of CT results to all patients.
Prostate cancer screening patterns among LGBT populations.
Authors: Ma Sung Jun , Oladeru Oluwadamilola Temilade , Miccio Joseph , Wang Katy , Attwood Kristopher , Singh Anurag K , Haas-Kogan Daphne A. , Neira Paula M
Published: May 2020

e19077

Background: More than 10 million Americans identify themselves as lesbian, gay, bisexual, and transgender (LGBT), and the majority of male-to-female (MTF) transgender individuals still have prostates even after surgical transitions. Guidelines on prostate specific antigen (PSA) screening for LGBT populations are limited, and informed and shared decision making are encouraged by various organizations. However, patterns of care for PSA screening in LGBT populations remains unclear. To address this knowledge gap, we conducted a cross sectional study to evaluate self-reported PSA screening and decision making among LGBT populations. Methods: The Behavioral Risk Factor Surveillance System database was queried for LGBT adults from 2014-2016 and 2018. Those with prior prostate cancer were excluded. Multivariable logistic regression was performed to evaluate the association of LGBT status with PSA screening, informed and shared decision making, after adjusting for demographic characteristics and survey weights. Results: A total of 164,370 participants were eligible for PSA screening (n = 156,548 for cisgender [CG]+straight, n = 156 for MTF+straight, n = 33 for MTF+gay, n = 52 for MTF+bisexual, n = 51 for MTF+other sexual orientation [SO], n = 3354 for CG+gay, n = 1641 for CG+bisexual, n = 2535 for CG+other SO), representing a weighted estimate of 1.2 million LGBT populations. When compared to CG+straight, CG+gay/bisexual cohorts were more likely to undergo PSA screening within the past 2 years (CG+gay: OR 1.08, p < 0.001; CG+bisexual: OR 1.06, p < 0.001), have ever received PSA screening (CG+gay: OR 1.30, p < 0.001; CG+bisexual: OR 1.12, p < 0.001), and be recommended for PSA screening by their physicians (CG+gay and bisexual: OR 1.16, p < 0.001). All other cohorts were less likely to do so (all OR < 1, p < 0.05). MTF+gay and CG+gay participants were more likely to make informed decision (MTF+gay: OR 3.13, p < 0.001; CG+gay: OR 1.09, p < 0.001), while all other cohorts were less likely to do so (all OR < 1, p < 0.05). CG+gay participants were also more likely to share decision (OR 2.51, p < 0.001), while there were no associations for all other cohorts (all p > 0.05). Conclusions: Select gay populations were more likely to undertake PSA screening recommended by their physicians and participate in informed and shared decision making. However, other LGBT populations were less likely to make informed decisions, and transgender participants were less likely to undergo PSA screening. Further research efforts are needed to improve informed and shared decision making for PSA screening in such underserved population.
The impact of affordable care act on the treatment disparities for stage-IV colorectal cancer: A contemporary analysis.
Authors: Jayakrishnan Thejus Thayyil , Bakalov Veli , Chahine Zena , Finley Gene Grant , Monga Dulabh K. , Wegner Rodney E.
Published: May 2020

e19082

Background: Patients with advanced cancers are among the most vulnerable group of patients. We sought to analyze the impact of Affordable Care Act on the interaction of socioeconomic factors with treatment enrollement and survival in patients with metastatic colorectal cancers. Methods: We queried the National Cancer Database (NCDB) for patients with Stage-IV colon (C-Ca) and rectal cancers (R-Ca) diagnosed from 2004-2015 and excluded those who did not receive any therapies within 6 months of diagnosis. Enrollment rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy (denominator) and used to calculate incident-rate ratios that was further analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER, < 1 indicating lower enrollment rate). Multivariate Cox-proportional hazard model was performed for survival analysis and reported as calculate Hazard Ratios (HR). Results: We identified 59,211 C-Ca and 4,818 R-Ca for the analysis. Median ages were 64 years vs. 60 years and included 52% vs. 60% males respectively. For C-Ca enrollment to primary therapies were significantly associated (p-value < 0.05) with gender, race, insurance status, educational status and treatment facility. HR < 1 was associated with high-income vs. low-income group- 0.90(0.87-0.94),p-value < 0.005. The HR for non-Hispanic Blacks (NHB) vs. Whites (NHW) improved from 1.1(1.03-1.11),p-value < 0.005 to no-significant difference post-ACA. For R-Ca, the enrollment rates were favorable for NHB vs. NHW and ER improved from 1.15(1.0-1.32),p-value = 0.054) to 1.29(1.06-1.58),p-value = 0.013 post-ACA. Despite this, the HR for mortality were unfavorable - 1.19(1.06-1.33),p-value = 0.003 that persisted through the post-ACA period. The HR was favorable for the insured group in both cancer groups (0.84 for R-Ca,0.86 for C-Ca). Conclusions: Socioeconomic factors influence outcomes for this vulnerable group of patients in terms of enrollment to therapies and survival. The Affordable Care Act appears to have had a positive impact overall but more needs to be done including broadening insurance coverage.
Application of neo-bioscore to a real-world cohort: Potential implications for patient selection, for escalation, and de-escalation of therapy.
Authors: Simmons Christine E. , Willems Kaylie , Chia Stephen K. L. , Tesch Megan , Kespe Kaitlyn , LeVasseur Nathalie
Published: May 2020

e19094

Background: Recent studies have demonstrated that escalation of therapy for patients with residual disease after neoadjuvant therapy for breast cancer may result in better long-term outcomes. However, refining patient selection based on prognosis has not been widely adopted. The Neo-Bioscore is a validated independent prognostic tool that can be readily applied clinically. The utility of this tool to predict the expected magnitude of benefit from escalation of therapy for ER+, HER2+ and TNBC disease has not yet been explored. Methods: A retrospective review of prospectively collected data from May 2012-May 2019 of patients treated with neoadjuvant chemotherapy followed by surgery was undertaken. The Neo-Bioscore was calculated for each patient. Kaplan-Meier method was used to generate disease-specific survival (DSS) curves, and 5-year DSS rates were estimated. These estimates were compared to those predicted by the original validation cohort. The potential benefit of further adjuvant therapy was extrapolated from data available in the published literature. Results: A total of 471 patients were included in this study; all were women, and the median age was 56 (range 24-88). 324 had residual disease at the time of surgery (68%). Median follow up from diagnosis was 4.4 years. 5-year DSS for each Neo-Bioscore category is seen in the Table below. This correlated with the predicted DSS with a correlation coefficient of X. For patients with residual disease, utilization of adjuvant capecitabine for those with ER+ or TNBC and utilization of adjuvant TDM-1 for those with Her2+ disease would have minimal impact on DSS in those with Neo-Bioscore of 0-2, modest benefit for those with Neo-Bioscore of 3-4, and would be of high benefit for those with Neo-Bioscore of 5 or higher. Conclusions: Neo-Bioscore is a tool that can be readily applied to a real-world cohort without additional pathological information, with good correlation to the predicted outcomes in validation studies. The impact and utility of the Neo-Bioscore to stratify patients for selection of adjuvant therapy will need to be validated, but may help better inform treatment in resource constrained environments. [Table: see text]
Rising incidence of clostridium difficile infection and associated clinical outcomes in hospitalized cancer patients: A national perspective.
Authors: Dalal Shivani , Patel Krunalkumar , Radadiya Dhruvil , Patel Kirtenkumar
Published: May 2020

e19095

Background: Cancer patients are more prone to Clostridium difficile infection (CDI). Several factors such as increased exposure to antibiotics (either in the form of prophylaxis or treatment), being on chemotherapy, and frequent exposure to healthcare settings are responsible for this. Rate of CDI in these patients ranges from 10-20%. Here, we performed a retrospective analysis using the national inpatient sample to study the trend and to see whether CDI leads to poor outcomes in these patients. Methods: We have used National Inpatient Sample database from the year 2009 to 2015 to identify hospitalized adult patients with cancer using ICD-9 CM codes. Similarly, We also identified patients with concurrent CDI amongst all cancer patients. Our primary aims were to study the trend of CDI and associated outcomes in from of mortality, cost of hospitalization and length of stay. Incidence of CDI per 10,000 discharges in those patients over the study period was assessed. Outcomes related to CDI in cancer patients were compared with those without CDI. Categorical and continuous variables were compared between matched cohorts using Chi-square and Student’s t-test, respectively. Statistical significance level was set at < 0.05. All analyses were performed with the use of SAS (version 9.4). Results: Total of 6,035,966 cancer patients was identified over the study period. Out of which, 57,167 (0.9%) had concurrent CDI. Age, sex and race were comparable in both the groups. Incidence of CDI increased from 89 cases to 101 cases per 10,000 cancer patients (p-trend: < 0.05). Inpatient mortality was significantly higher in cancer patients with CDI compared to without CDI(12.1% vs 4.7%, p < 0.0001). Cost of hospitalization was almost 3 times higher ($36,243 vs $12,910, p < 0.0001).Median length of stay was almost four-fold longer (16 days vs 4 days, p < 0.0001). Patients with Medicare and Medicaid had higher percentages of CDI cases while patients with private insurance had lower percentages. Conclusions: Incidence of CDI in cancer patients is on the rise. CDI lead to higher mortality, cost of hospitalization, and length of stay in cancer patients. Preventive strategies in form of judicious use of antibiotics and prompt identification with treatment may help with reducing mortality and associated healthcare burden.
Patient-reported diarrhea impact on physical functioning and quality of life in clinical trial data submitted to the U.S. Food and Drug Administration.
Authors: Chen Ting-Yu , King-Kallimanis Bellinda , Merzoug Lyna , Fiero Mallorie , Gao Jennifer J , Beaver Julia A. , Bhatnagar Vishal , Kluetz Paul Gustav
Published: May 2020

e19105

Background: Patient-reported outcomes can provide symptom and function data that complement standard oncology endpoints. Frequently, trials will conclude there was no clinically meaningful detriment to health-related quality of life (HRQL) or function, even when notable toxicity is observed. It is possible that mean change from baseline analyses obscures meaningful change in subgroups experiencing symptomatic toxicity. In this study, we explore how patients’ response to a diarrhea item related to physical function (PF) and HRQL in trials submitted to US FDA. Methods: We analyzed 3 randomized, double-blind breast cancer trials (early to late line metastatic) where diarrhea was a more common AE-symptom in the treatment arm, but there was not a large detriment in the mean change from baseline for HRQL and PF. Trials included the EORTC Quality of Life Questionnaire (QLQ-C30), which captures patient-reported HRQL, symptoms, and functioning. Higher scores (range 0-100) indicate better functioning and HRQL. Symptoms were measured with a 4-point scale; not at all to very much. Descriptive statistics were used to analyze diarrhea, PF, and HRQL over time. Results: Patients reporting very much diarrhea at month 3 had worse PF and HRQL compared to patients reporting no diarrhea . The range of difference between patients who reported very much diarrhea and those with none was 8-18 points for PF across trials. For HRQL scores, the range was 13–17 points worse. This trend was also seen in the control arm and at other times. Conclusions: In this set of breast cancer trials with differences in diarrhea by arm, reporting “no meaningful difference in PF or HRQL between the arms” is insufficient and potentially misleading. A more informative interpretation is that an exploratory analysis of HRQL and PF did not show in the investigational arm; there was a greater proportion of patients reporting diarrhea on the treatment arm; and patients reporting more frequent diarrhea reported lower HRQL and PF compared to patients with no diarrhea, regardless of arm. [Table: see text]
Patterns and determinants of chemotherapy-associated Clostridium difficile infection among cancer patients in the United States: A population-based study.
Authors: Nadpara Pramit
Published: May 2020

e19111

Background: Elderly cancer patients comprise a population that is vulnerable for Clostridium difficile infection (CDI). In addition to the frequent hospitalizations, the administration of chemotherapeutic agents has been associated with the development of CDI. The objective of this study was to identify the patterns and determinants of chemotherapy-associated CDI (Chemo-CDI), in a nationwide sample of elderly patients. Methods: We used NCI’s Surveillance, Epidemiology, and End Results registry linked Medicare (SEER-Medicare) 2007-2012 files. We included patients’ aged ≥65 year, with diagnosis of lung/breast/ovarian/colorectal/prostate cancer, or lymphoma/multiple myeloma/leukemia during 2008-2011. We excluded those not receiving chemotherapy, with non-continuous Medicare enrollment, or HMO enrollment. Chemotherapy receipt was identified using appropriate ICD-9/HCPCS/CPT codes. Incidence of CDI following chemotherapy were determined by identifying any claim with primary/secondary diagnosis of CDI during the two-month follow-up period. Recurrent Chemo-CDI was identified by presence of any claim that was > 2 weeks and ≤8 weeks from the index CDI diagnosis date. Covariates including antibodies/proton pump inhibitors usage were captured and included in the analysis. Chi-square tests, and hierarchical generalized logistic models were conducted to identify determinants of Chemo-CDI. Results: We identified 41,470 elderly patients with lung/breast/ovarian/colorectal/prostate cancer, or lymphoma/multiple myeloma/leukemia diagnosis during the study years. While few (266) patients developed Chemo-CDI within one year of diagnosis, more than 50% (136) of those patients developed recurrent Chemo-CDI. Patient characteristics were not associated with risk of developing Chemo-CDI, however, significant differences were observed in antibiotics/proton pump inhibitors exposure across all cancer types (p < 0.001). Treatment for Chemo-CDI mostly comprised of Metronidazole and oral Vancomycin. Conclusions: While the incidence of Chemo-CDI is lower among patients receiving chemotherapy, the rate of recurrent Chemo-CDI was significantly higher. Strategies to prevent CDI recurrence in this population are therefore warranted. Future studies should also explore the association between increased disease burden and comorbidity, and the risk of developing Chemo-CDI.
Mental distress among adolescent and young adult (AYA) and adult cancer survivors.
Authors: Adjei Boakye Eric , Polednik Katherine M. , Sharma Arun , Molina Yamile , Pham Vy , Deshields Teresa L. , Osazuwa-Peters Nosayaba
Published: May 2020

e19116

Background: Mental distress is associated with poor treatment adherence and adverse psychosocial outcomes, and cancer survivors, especially adolescent and young adults (AYA), may experience greater distress than older adults and the general population. We tested this hypothesis by examining the association between AYA vs. adult cancer survivors vs. the general population without a history of cancer, and mental distress. Methods: Using the 2014-2017 National Health Interview Surveys, 2,516 AYA cancer survivors (aged 15 – 39 years) were identified. We then used propensity score matching (matched on sociodemographics, comorbidities, smoking status and visit to mental health professional in past year) to create 2,516 older cancer survivors (aged ≥ 40 years); and 2,516 adults without cancer (general population) as the comparison groups. Mental distress (outcome of interest) was measured using the validated Kessler nonspecific mental/psychological distress (K6) scale. The 6-item K6 scale examines how frequently within the past 30 days an individual felt nervous, hopeless, restless or fidgety, worthless, sad, and that everything was an effort. Responses were summed to yield a score ranging between 0 and 24 and classified as none/low (0≤K6 < 5), moderate (5≤K6 < 13), and severe (K6≥13) mental distress. Two separate weighted multinomial logistic regression models estimated the odds of mental distress in study population (AYA vs. adult cancer survivors; and AYA vs. general population), adjusting for known covariates. Results: Mental distress was more prevalent among AYAs than adult cancer survivors (moderate: 24.0% vs 18.3%; and severe: 5.7% vs 4.2% [ P= .0002]); and the general population (moderate: 24.3% vs 16.7%; and severe: 6.1% vs 5.3% [ P< .0001]). Similarly, prevalence was higher among adult cancer survivors than the general population (moderate: 16.8% vs 13.6%; and severe: 3.2% vs 2.7% [ P= .0002]). In the multivariable multinomial analyses, AYAs had greater odds of mental distress (aORmoderate = 1.44; 95% CI 1.09, 1.89; and aORsevere = 1.77; 95% CI 1.21, 2.58) vs. adult cancer survivors. AYAs also had greater odds of mental distress vs. the general population (aORmoderate = 1.39; 95% CI 1.08, 1.79), but no significant difference in severe distress. Conclusions: About 1-in-4 AYA cancer survivors report some mental distress, and distress is more prevalent among this younger age group than older adults with cancer and the general population. Psychosocial care may be especially needed in this younger population to mitigate adverse psychosocial outcomes.