bluuebunny/crossref_metadata_2025 huggingface dataset:
The impact of oral oncology drugs in the era of value-based care.
Authors: Garey Jody S. , Indurlal Puneeth , Thomas Hope Ives , Dave Neal , Doshi Gury K. , Escudier Susan Marie
Published: September 2024

15

Background:
Oncology drug expenditures are a significant contributor to increasing total cost of care (TCOC). Oral oncolytics (OO), such as small molecule inhibitors (CDK 4/6 inhibitors, tyrosine kinase inhibitors, etc.), and immunomodulators, have revolutionized the treatment landscape for many cancers. We evaluated the patterns of OO use and spend for Medicare patients over time at a large community oncology practice participating in the Center for Medicare and Medicaid Innovation (CMMI)’s Value-based care (VBC) Program, the Oncology Care Model (OCM), with a focus on the seven cancers that are part of a successor model, the Enhancing Oncology Model.
Methods:
Using CMMI claims for attributed 6-month OCM episodes, we evaluated drug use and expenditures by performance period (PP) from July 2016 – June 2022 (11 PPs), with an emphasis on OO drugs. We used Part D expenditures as a proxy for OO.
Results:
From 2016-22, average TCOC per PP increased by 15.5% in the 7 EOM diagnoses (breast, lung, colon, prostate cancer, myeloma, lymphoma, and chronic leukemia). Average drug expenditures per PP grew 33% percent and represented 71% of total cost by PP11, up from 61% in PP1. Average expenditures per episode increased by 11.7% for Part B and 82.6% for Part D drugs (p<0.01). Increase in Part D drug expenditures was partly due to an increase in the number of unique oral drugs which grew by 32% over the evaluation period. The greatest increases in Part D drug expenditures occurred in breast cancer (87%) and lymphoma (153.7%). Table reports average OO expenditures per PP, percent change from PP1 to PP11, and the change in the % Part D drugs contributed to TCOC.
Conclusions:
Increases in drug expenditures represent the greatest impact on TCOC for cancer patients. OO medicines have an increasing role in the treatment landscape and represent a growing focus in VBC models. Utilization and cost of OO medication have a significant bearing on VBC performance.

Diagnosis
Avg. OO Expenditures PP1
Avg. OO Expenditures PP11
Avg. OO Expenditures Change
Contribution of OO to TCOC Change from PP1 - 11

Breast
$4,208
$7,869
87.0%
9.9%

Leukemia
$25,334
$41,128
62.3%
19.9%

CRC
$1,206
$2,158
78.9%
3.1%

Lung
$3,650
$3,625
-0.7%
-2.5%

Lymphoma
$4,193
$10,637
153.7%
13.0%

Myeloma
$25,109
$39,298
56.5%
6.7%

Prostate
$18,815
$20,114
6.9%
3.2%

Total
$8,291
$15,140
82.6%
10.8%
Association of county-level medical debt and survival among individuals newly diagnosed with cancer in the United States.
Authors: Han Xuesong , Yang Nova Nova , Hu Xin , Fan Qinjin , Zhao Jingxuan , Braga Breno , Jiang Changchuan , Yabroff Robin
Published: September 2024

156

Background:
Individuals diagnosed with cancer often bear significant health care costs and productivity loss, with over half incurring cancer-related medical debt. Medical debt is increasingly recognized as a social determinant of health care and health outcomes. Using newly available nationwide county-level medical debt information from 2011 to 2019 linked with national cancer registry data, we examined the association of county-level medical debt with survival among individuals newly diagnosed with cancer in the US.
Methods:
Individuals aged ≥18 years with newly diagnosed first primary cancer in 2011-2019 were identified from the National Cancer Database, which was linked with credit bureau data on county-level percentage of adults with medical debt in collections based on patients’ year of diagnosis. Patients were followed from diagnosis through December 31, 2019. Hazard Ratios (HR) and were derived from Cox proportional hazard models to estimate the associations of county-level medical debt quartiles with overall survival, adjusting for year of diagnosis, age, sex, race and ethnicity, insurance status, comorbidity score, metropolitan status, county-level social deprivation index and medically underserved area designation, and state of residency. Stratified analyses were conducted by cancer type and sociodemographic and clinical factors.
Results:
A total of 7,558,658 individuals newly diagnosed with cancer were identified, with a median county-level medical debt of 18%, ranging from 0% to 56%. County-level medical debt decreased since 2015. The highest percentage of county-level medical debts was found among patients racialized as non-Hispanic Black, uninsured, and living in medically underserved areas. In adjusted analyses, patients living in counties with the highest quartile of medical debt had 17% increased risks of death compared with those living in counties with the lowest quartile of medical debt (HR=1.17, 95%CI=1.16-1.18), with a statistically significant dose-response relationship for the higher quartiles (P-trend<.0001). The pattern was consistently seen across cancer types as well as socioeconomic and clinical groups.
Conclusions:
County-level medical debt was strongly associated with worse survival among individuals newly diagnosed with cancer, consistent across socioeconomics and clinical subgroups. Policies preventing and relieving medical debt maybe effective ways to improve cancer outcomes at population level.

Hazard ratios for risk of death associated with county-level medical debt by cancer site and stage at diagnosis.

County-Level Share of Population with Medical Debt
Q1
Q2
Q3
Q4

All cancers
1
1.08
1.13
1.17

Female breast
1
1.10
1.13
1.16

Prostate
1
1.06
1.11
1.13

Lung
1
1.06
1.10
1.12

Colon and rectum
1
1.07
1.11
1.14

Stage I-III
1
1.09
1.14
1.19

Stage IV
1
1.07
1.11
1.13

All
P
for trend <.0001.
Increasing access to biomarker-driven treatment for lung cancer in Alabama: The Alabama Access initiative.
Authors: Dickson-Gavney Beth , Modi Mahir , Vyas Abhinav , Ismail Ahmed , Basu Roy Upal Kunal , McNeeley Ellen , Harada Shuko , Mackinnon Craig , Fish-Steagall Ann Ann , Driss Meriam , Boumber Yanis , Khalil Maya , Desai Aakash
Published: September 2024

159

Background:
Lung cancer is the leading cause of cancer death in Alabama, with an estimated 2,550 deaths in 2024. Non-small cell lung cancer (NSCLC) represents 85% of these cases. Despite national guidelines recommending comprehensive biomarker testing (CBT) for metastatic NSCLC, significant disparities persist in the utilization of CBT and targeted therapies among Alabama residents.
Methods:
In March 2024, we launched the "Alabama Access" initiative – a partnership between the LUNGevity Foundation and the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham – to foster academic and community oncology partnerships to increase access to biomarker-driven treatments. We used a population health science and geospatial mapping approach to visualize oncology practices serving counties with Alabama's highest lung cancer burden. Practices in Walker, Dothan, Marengo, Morgan, Jackson, Marshall, and Montgomery counties were identified as the highest priority based on annual mortality rates. Key interventions will include virtual molecular tumor boards and oncology navigation to facilitate the integration of resources and expertise and ensure that patients in nonacademic practices benefit from the latest advances in precision oncology. After roll-out, we will collect feasibility and acceptability data around program integration.
Results:
Our analysis revealed that 62.0% of the state’s population resides in Primary Care Health Professional Shortage Areas (HPSAs), and 58 out of 67 counties are classified as Medically Underserved Areas. The poverty rate in 89.6% of counties surpasses the national average, contributing to higher lung cancer incidence and mortality rates, with 62.0% of cases diagnosed at advanced stages. The state also shows a higher smoking prevalence, affecting 97.0% of counties compared to national figures. We will present practice-level testing data, including barriers to CBT.
Conclusions:
This pilot aims to mitigate disparities in CBT through enhanced collaboration between academic and community oncology settings. Integrating molecular navigation into community practices will be pivotal in disseminating program information and collecting data on current testing practices to improve overall lung cancer care quality in Alabama.
Healthcare spending and out-of-pocket burden for working-aged adults after a cancer diagnosis.
Authors: Zhao Jingxuan , Parsons Helen M. , Perraillon Marcelo C. , Clark Roxanne , Greenwald Samuel , Bradley Cathy J. , Yabroff Robin
Published: September 2024

16

Background:
The cost of cancer care rose dramatically over the past decades, increasing the financial burden on patients. However, current estimates of healthcare spending and out-of-pocket burden rely heavily on data from older populations that may not reflect contemporary treatment patterns in working-aged adults or variation in type of insurance coverage.
Methods:
We used the 2012-2021 Colorado Central Cancer Registry linked to the All-Payer Claims Database to identify adults aged 22-63 years newly diagnosed with invasive cancer who were consecutively enrolled on the same insurance type or the month of diagnosis and 6 months after (or until death). We used quantile regression to adjust spending by age and sex and report median insurer reimbursements for medical care and pharmacy costs and out-of-pocket spending (copays, deductibles, coinsurance) for the most common insurance and cancer types.
Results:
Among 31,179 individuals newly diagnosed with cancer, the median total spending six months after diagnosis across all cancers ranged from 59,022 for those insured by private non-health maintenance organization (HMO) plans to 26,887 for those enrolled on Medicaid and 19,152 for those on Medicare Advantage (MA) plans (Table). The majority of spending was for medical care. Among individuals insured by private non-HMO plans, those with lymphoma had the highest total median spending at 130,408, followed by lung (94,207), breast ($87,830), and leukemia ($82,445). Although total spending was markedly lower among those insured by Medicaid, among this group, individuals with leukemia ($50,399) and lymphoma (48,747) experienced the highest median spending. Out-of-pocket spending was substantially higher for those insured by private non-HMO plans (3,582 or approximately 511/month) across all cancer types, and highest for lymphomas (3,966) and lung ($3,455) cancers.
Conclusions:
Total healthcare spending in the 6 months after a cancer diagnosis is considerable in the working-age population, with a high out-of-pocket burden for patients with private non-HMO coverage.

Median spending in 6 months after cancer diagnosis (in 2021 dollars), adjusted for age and sex.

Medical Care Plan Payments*
Pharmacy Plan Payments*
Out of Pocket Spending*
Total Spending*

Overall(n=31,793)
Dual Medicaid/Medicare
$24,081
$1,793
$19
$28,806

Medicaid
$23,415
$641
$13
$26,887

Medicare TM
$20,698
$797
$3,275
$27,028

Medicare MA
$14,227
$570
$2,069
$19,152

Private non-HMO
$51,196
$274
$3,582
$59,022

Private HMO
$36,414
$219
$2,622
$42,916

Median costs significantly different across all payers, p<0.05.
Implementing a genetic testing station in a safety net setting for equitable genetic testing and counseling.
Authors: Dixit Niharika , Friedlander Terence W. , Velazquez Manana Ana I. , DeBoer Rebecca Jane , Trejo Evelin , Leung Ivan C. , Frick Miya , Tong Barry , Gordon Kelly , Lee Robin , Couey Paul , Kabra Sabina , Joseph Galen
Published: September 2024

167

Background:
Genetic testing (GT) in patients with hereditary cancers has significant implications for treatment options and risk reduction among family members. Recent GT guidelines have expanded the eligibility criteria with limited genetic counseling staff. Patients who are from marginalized groups, are under or uninsured, or have limited English proficiency continue to experience disparities in GT, underscoring the need for innovations in care delivery.
Methods:
From March 2021 to June 2023, we conducted a single-arm intervention study of a point-of-care genetic testing station (GTS) in a safety net hospital. Patients who met NCCN criteria for GT were eligible. We compared this group to a historical cohort who received GT either in person or via telehealth in the preceding two years and non- GTS cohort. The GTS intervention consisted of (1) screening of clinic schedules for eligible patients, (2) GT video-based education in English, Spanish, and Cantonese, (3) consent and collection of blood or saliva samples by a genetic counseling assistant, and (4) telehealth-based post-test counseling with a genetic counselor (GC). The historical cohort underwent GT in a traditional model: (1) oncologist-initiated electronic referral, (2) pretest counseling with a GC, (3) GT if appropriate, and (4) post-test counseling to review and discuss results. Our primary outcomes were completion of GT and time to result delivery. We evaluated all associations with the Chi-square test for categorical variables.
Results:
We enrolled a total of 256 participants, 26% were Asian, 18% were Black, 30% were Hispanic/Latinx, 13% were Non-Hispanic White, and 2% were Native Hawaiian/Pacific Islander. The most common languages were English 48%, Spanish 28%, Cantonese 20%, and Other 4%. 251 (98%) of GTS participants completed GT, and 241 (95%) completed the post-test GC visit, compared to the Non-GTS cohort (79%, p<0.001), pre-GTS cohort (85%, p<0.001) with traditional GT model with in-person at 122 (95%) and telehealth (72%). The median time to result delivery was 35 days (IQR 27 - 52) for the GTS cohort, 56 days for non-GTS cohort, 97 days for pre-GTS telehealth (IQR 24.7 - 111), and 21 days ( IQR 14-31) days for in-person.
Conclusions:
GTS resulted in more patients completing GT and promptly receiving their results with telehealth genetic counseling. As GT eligibility criteria broaden, innovative interventions, workflows, and tailored educational resources for diverse populations are needed to ensure equitable access to GT.
Patients’ understanding of treatment decisions: Impact on major quality metrics and patient informed decision-making at end of life.
Authors: Sweeney Ann , Crocker Eric , Candelario Elise , Tarpley Trish , Skelton Matthew Rama , Elia Giovanni
Published: September 2024

170

Background:
Blue Ridge Cancer Care (BRCC) is a community oncology practice in rural Virginia and West Virginia. BRCC is an ASCO-certified practice and participates in multiple value-based care programs to ensure a quality improvement and patient-centered approach. BRCC serves regions with low health literacy (LHL) which impacts a patient’s ability to self-manage their disease, make informed health-related decisions, and navigate the health system. The top indicators of LHL are being over 65 years old, having less than any college education, and being insured by Medicare or Medicaid which is 63% of BRCC’s patient population.
Methods:
BRCC conducted a retrospective analysis of our 2023 end-of-life (EOL) quality measures and 1,682 unique National Comprehensive Cancer Network (NCCN) Distress Tool & Problem List assessments. We then matched the results with each patient’s demographics and disease course. Additional research revealed that LHL levels have the greatest impact on patients engaging in their care and ability to make informed decisions at end of life.
Results:
21% of patients reported concerns with understanding treatment decisions (n=353) and they had vastly different outcomes compared to patients that did not have concerns (n=1329). A chi-square test was performed to examine the relation between these events, all outcomes were found to be statistically significant. Detailed outcomes are shown (Table).
Conclusions:
In our review, patients reporting concerns with or understanding treatment decisions had more aggressive EOL care and used more resources from health care systems. BRCC plans to deepen our understanding of this population by using an evidence-based tool that assess a patient’s understanding of their disease severity, perceived curability, and treatment options to identify gaps in a patient’s prognostic understanding and enhance communication between the care team and better support patients informed decision-making at EOL.

Population Reported
Concerns with/understanding Treatment Decisions = 21%
No Concerns with Treatment Decisions = 79%

> 3 Emergency department visits in 1 year
19%
8%

Chemotherapy in the last 14 days of life
38%
19%

Enrolled in Hospice
14%
54%
Medical students' knowledge and attitudes towards breast cancer screening strategies for the transgender population.
Authors: Cruz-Zermeño Mayte , Seidman Sorsby Alec , Barragan-Carrillo Regina , Chavarri Guerra Yanin
Published: September 2024

179

Background:
Transgender patients (TP) are less likely to seek medical attention, including breast cancer screening (BCS) . Approximately half of TP perceive healthcare workers as uneducated, and face intersecting disparities when accessing healthcare. Despite an increased risk of BC while hormonal gender reassignment treatment, only 0.6% adhere to BCS recommendations. Most medical schools do not include transgender health training in their curricula, leading to an inadequacy in preparing professionals to deliver comprehensive high-quality care. Our group previously demonstrated an important gap in knowledge from specialists on BCS in TP (Barragan-Carrillo et. al. ASCO, 2022). We seek to evaluate the state of knowledge of BCS in TP in Medical Students.
Methods:
We conducted a validated 14-item online survey exploring the knowledge and attitudes of medical students regarding BCS strategies in TP. 6 questions assessed attitudes and 8 knowledge. Participants were invited in July 2022 through social media to complete the survey. Descriptive statistics were employed for data analysis and chi square was used to asses for associations between demographic data with knowledge.
Results:
104 participants completed the survey, 75 (72.1%) identified as female, 28 (26.9%) as men, and 1 (1%) as transgender. 17 (16.3%) self-identified as a sexual minority. Median age was 22 (range 18-30) years. 69 (66.3%) were enrolled in private institutions, and 35 (33.7%) in public. Most (65%) were 4
th
-7
th
year, and 36 (35%) 1
st
-3
rd
year students. 32 (30.7%) expressed confidence in their knowledge to address BCS needs for TP. 15% considered medical schools provide good understanding of transgender health needs,86%) believe understanding these needs should be mandatory in in the medical school curricula, and 103 (99.0%) stated they would benefit from more training the subject. Regarding knowledge evaluation, the average score was 46.7% (SD 19.3), with only 11.5% identifying the correct age to start BCS and only 22% the correct interval for it. Only 9 students (8.6%) had a score higher than 75%, and 0 participants got a score of 100%. On chi-square testing we did not find any associations between demographics and knowledge.
Conclusions:
Most medical students believe they lack capacity to address transgender health issues and would benefit from additional education and training. Our findings support that the current medical school curricular do not support sufficient training on this subject, and bolster the need for a more inclusive curricula. The described deficiencies in future physicians’ knowledge emphasize the importance of incorporating these topics into academia.
Increased biosimilar options in oncology and impact on administrative burden caused by drug switches: Implications of step therapy.
Authors: Poole Stacey , Blakely L. Johnetta , Schleicher Stephen Matthew , Dickson Natalie R.
Published: September 2024

18

Background:
Within drug classes, some payers require a particular drug to be tried and failed first, before reimbursing other drugs within the same drug . This is called a step-edit. These step edits are mandated despite physician or patient preference. With the increased utilization of biosimilar drugs, the instances of step edits have dramatically increased. With the increase of step edits the administrative burden of inventory management, authorizations, appeals and regimen maintenance has significantly increased. The extent of the increased step therapy requirements and associated costs are unclear.
Methods:
Drug conversions due to step edit requirements were tracked for twelve months and compared to the same twelve-month period the prior year at Tennessee Oncology, a large community-based practice. Ten drug classes containing biosimilar options were reviewed for ten different payers. The review monitored the addition of biosimilar drug options within the various drug classes and the number of patients that required a switch to an alternate therapy, solely due to payer step edits. A per patient cost was calculated by evaluating the time spent per patient to obtain an authorization, manage inventory, appeal denials and revise regimens.
Results:
July-Dec 2022, 83 patients required drug conversions due to payer step edits. This included eight payers within the ten drug classes. Each drug class had an average of 3 therapies. July -Dec 2023, over 500 patients were converted due to payer step edits. Each drug class had an average of eight step therapy choices. The cost of conversion, per patient, was an average of $76.00. If extrapolated, $76,000 in 2023 compared to 12,616 in 2022. It was noted that not all required drug switches resulted in the least costly drug being mandated by the payer. There were cases where the practice was required to switch from a less costly drug to a more costly drug due to a payer step edit.
Conclusions:
There was a six-fold increase in the number of patients requiring a step-edit year over year. This increased the administrative burden of drug management while costing practices over $75 per switch each . Step edit drug classes and drug choices have also grown exponentially highlighting the fact that the step therapy trend continues to grow and become more complex. Physician practices bear the financial burden of the payer UM requirements and patients are placed in the middle.

2022 vs 2023 required drug switches due to step edits.

Payer
Drug Classes Requiring Step Therapy 2022
Drug Classes Requiring Step Therapy 2023
Total Drug Agents With Step Edits 2022
Total Drug Agents With Step Edits 2023

Payer 1
0
1
0
6

Payer 2
7
9
14
49

Payer 3
0
1
0
6

Payer 4
0
9
0
49

Payer 5
2
9
3
49

Payer 6
2
9
4
49

Payer 7
4
10
12
53

Payer 8
3
10
10
50

Payer 9
7
9
9
49

Payer 10
6
9
18
49

Total
31
76
70
409
Building partnerships to improve clinical trial accrual in rural and Native American communities through community health educator interventions.
Authors: Barbosa Carroll Cibele , Smith Ashley , Crowe Nona , Dahlke Allison , LoConte Noelle K. , Traynor Anne M. , Bailey Howard Harry , Ward Earlise
Published: September 2024

180

Background:
Rural populations and racial minorities are often underrepresented in cancer clinical trials. The low representation is determined by multilevel factors, including lack of geographic access to facilities in rural locations and mistrust in the medical and scientific community. Presented here are partial results of an educational intervention to improve clinical trials-related knowledge among rural residents and racial minorities.
Methods:
The Center to Reduce Cancer Health Disparities (CRCHD) from the National Cancer Institute (NCI) developed the study materials, that were available in English or Spanish, to be utilized according to participants' preferences. The University of Wisconsin Carbone Cancer Center implemented this intervention in northern Wisconsin, which consisted of a baseline questionnaire, a recorded educational intervention, and a post-educational questionnaire. The chosen community is largely rural and Native American. The questionnaires consisted of 11-knowledge- and 6-intention-related questions. After being screened by the rural Community Health Educator (CHE), subjects self-administered the intervention online or received the intervention from the CHE during tribal or other educational group events in rural communities.
Results:
Between January and May 2024, 62 participants started the intervention. Participants’ mean age was 45.1 (±15.36) years, 64.5% (40/62) were female, and 53.2% (33/62) self-identified as American Indian/ Alaska Native. All resided in rural community, defined as Rural-Urban Continuum Codes 7 or 8. Three participants did not respond to the post-educational questionnaire, and one skipped its intentions section. Although the two questions about informed consent presented the highest percent of correct answers post-intervention, the median total knowledge score pre and post-intervention remained the same (p>0.05). Post-intervention, participants more often agreed it is important for minority groups to participate in clinical trials, reported being likely to search for a clinical trial they might be eligible for, join a clinical trial, and talk to family/friends about joining a clinical trial (p<0.05).
Conclusions:
The CHE successfully engaged rural community members to participate in the intervention. In addition, the intervention facilitated building trust and partnerships for future cancer-related community driven work.
Understanding the extent of caregiver involvement and needs in treatment-impacting activities.
Authors: Runfola Stacey , Videtti Laura , Clauer Julie Saliba
Published: September 2024

187

Background:
Caregivers are known to be a significant part of patient care; however, the extent of their role is commonly underestimated and they often feel ‘invisible’. COLONTOWN (CT) is a virtual colorectal cancer community providing peer support and evidence-based education for both caregivers and patients. As such, we sought to understand caregivers’ involvement related to treatment decision making and care delivery, and related gaps in support.
Methods:
Our online anonymous survey was posted in May 2024 to members of CT’s international caregiver community, who may be more active in their patients’ care than typical of the broader CRC population. It included 33 questions on caregiving responsibilities, effect of cancer on other life activities, impacts, support received/needed and 13 demographic questions. We identified a subset of 9 questions specifically related to treatment that are reported here.
Results:
All data was self-reported based on their patient’s time in active treatment. Of 359 respondents, 88% were female and 86% significant others/spouses. Their patients were 90% Stage IV and 85% in the US with 17 other countries represented. Caregivers nearly always participate in and often have primary responsibility in treatment-impacting activities (Table). This includes researching treatment options, where among the 69% in a primary role 31% have complete responsibility, managing side effects, and recording and reporting symptoms. 88% were always or usually at appointments and/or otherwise in direct contact with the care providers. Caregivers' roles, however, are not always recognized by their patient’s care team. Only 6% felt completely supported and 21% felt completely respected by their patient’s care team. 66% felt “Enhanced communication and collaboration with healthcare providers” would aid in their role in patient care. 56% indicated “more education resources for caregivers” are needed.
Conclusions:
Caregivers report assuming primary responsibility in many critical activities in patient treatment. The gap in recognizing this dynamic contributes to the challenges of caregiving. CT embraces the vital role of caregivers by offering dedicated caregiver resources and engaging them as equal partners in development and offering of all programs . Acknowledgement of the depth of the caregiver role is needed and more caregiver support should become a standard component of the patient’s care plan. Any shared decision-making processes and education should appropriately recognize and include caregivers as critical stakeholders as requested by their patient.

Caregivers’ reported role in treatment-impacting caregiving activities.

Activity
Primary Role %
Split Evenly %
Support Role %
No Role %

Researching treatment options
69
13
17
1

Researching/managing side effects
64
21
14
1

Symptom reporting
47
24
23
6

Coordinating care
44
27
25
4
‘ALERT’, a machine learning predictive model to identify six-month mortality in patients with advanced cancer: Perception of the utility and acceptability among patients.
Authors: Augustin Marsha , Krishnamurthy Nithya , Besculides Melanie , Mazor Melissa , Gorbenko Ksenia O. , Morillo Jose , Vargas Marcos , Smith Cardinale B.
Published: September 2024

189

Background:
Machine learning (ML) models can predict mortality and guide end-of-life (EOL) care for patients with advanced solid cancers. Early advanced care planning (ACP) leads to more goal-concordant care, yet many patients, especially from minoritized groups, do not engage in serious illness conversations (SIC). Reasons for delay include inability of oncologists to identify patients at high short-term mortality risk, and uncertainties about prognosis. While ML may improve prognosis accuracy, research on its use and impact on racial biases affecting SIC is limited. This study aims to evaluate the acceptability of deploying a ML model to predict 6-month mortality among patients with advanced solid cancers.
Methods:
In order to inform the implementation of ‘ALERT,’ a predictive mortality model into a clinical alert system, we conducted one-on-one semi-structured interviews with patients with advanced solid cancer receiving care at a single institution (N=26). Interviews were recorded, transcribed verbatim, coded, and themes were reviewed by a team of interdisciplinary investigators.
Results:
Benefits and challenges to guide the future implementation of ALERT were identified. Patient-perceived benefits were: 1) EOL Planning: preparing family members (e.g., financial, emotional); 2) Emotional Freedom: knowledge would give freedom to live out life more carefree due to limited time left; 3) Medical Autonomy: the treatment could be worse than the actual disease, if at any point it was not helping, knowing allows individuals to make the decision to stop. Challenges identified were: 1) Loss of Control: “when you don’t know [the outcome], you just keep moving, you just keep pushing”- knowing can result in a loss of control patients may desire for their course of treatment 2) Emotional Impact: knowledge of mortality could lead to grief among patients and families leading to distress around acceptability; 3) Faith: mortality prediction can be seen “playing God,” many patients believed when their time comes, it will happen and a ML tool cannot accurately predict when that time will be.
Conclusions:
Patients expressed equal balance of acceptability and resistance of ALERT for themselves and their families. This resulted in the difference of preferences regarding whether or not the knowledge this tool could provide would be helpful. This could lead to clinicians taking a patient-centered approach where the delivery of results using ALERT can be based on patient preference. The findings underscore the complexity of implementing ALERT, balancing significant benefits with notable challenges. These insights will guide the refinement of ALERT, ensuring it supports patient care while ensuring ALERT’s benefits are maximized and challenges are overcome.
Assessing outcomes for patients receiving chemotherapy in the intensive care unit.
Authors: Holmes Aaron N. , Ippoliti Cindy , Hayward Bradley , Lief Lindsay , Berlin David , Garcia Christine A.
Published: September 2024

190

Background:
Despite the low in-hospital mortality rate (9%) for Intensive Care Unit (ICU) stays in the US, outcomes for patients with cancer undergoing chemotherapy in the ICU remains unclear. We aimed to assess survival in patients with cancer (liquid, solid tumor and allogeneic stem cell transplant (alloSCT) receiving chemotherapy at our institution and identify patient characteristics for enhanced chemotherapy stewardship.
Methods:
We analyzed pharmacy data for patients with confirmed malignancies who received chemotherapy while admitted to the ICU at our institution from 1/1/21 to 12/31/23, excluding non-cancer patients and those on home oral regimens. Primary endpoints included 14-day, 30-day, and 90-day survival. Secondary analyses examined survival differences by age, ECOG performance status, and treatment history. Survival differences among patient subtypes were evaluated using Z-tests.
Results:
We identified 74 unique patients who received chemotherapy for cancer. 54 had liquid tumors, 5 were post-alloSCT, and 15 had solid tumors. The 90-day survival rate was 47% overall: 46% for the liquid tumor group, 80% for the alloSCT group, and 40% for the solid tumor group. When further stratified by tumor type, higher 90-day survival was variable; see Table 1 for details). In patients with lung cancer, 90-day survival was worse for non-small cell lung cancer without tumor mutations (0%, n=2) than those with targetable mutations (50%, n=4) or small cell lung cancer (33%, n=3). An ECOG performance status of 3-4 showed poorer 90-day survival in liquid tumors (23%) compared to ECOG 1-2 (74%; 95% CI 0.26 , 0.76). Solid tumors showed no significant ECOG differences (50%, 40%). Treatment-naive status showed higher 90-day survival in liquid tumors (59%) compared to treatment-resistant tumors (18%; 95% CI 0.17, 0.65), but not in solid tumors (50%, 20%).
Conclusions:
Our findings suggest generally unfavorable 90-day outcomes for ICU chemotherapy patients, especially those aged over 75, with multiple therapy lines, or ECOG status 3-4. Survival rates varied significantly across tumor types. We are currently broadening our study to include all solid tumor cancer patients. While this is a limited sample, this underscores the need for careful chemotherapy stewardship and advanced care planning in ICU settings.

90-day survival of solid and liquid tumor patients receiving chemotherapy in the ICU by select cancer diagnoses.

Cancer Diagnosis
n
90-Day Survival (%)

AML
20
45

DLBCL
16
33

APML
6
83

Multiple myeloma
5
60

Other liquid tumors
1

11
45

Lung cancer
9
44

Germ cell tumor
2
100

Hormone-sensitive breast cancer
1
100

Other solid tumors
2

3
0

1
T-cell lymphoma, ALL, CNS lymphoma, Castleman, MPN, and plasmablastic lymphoma. Note, patients with allogenic stem cell transplants not included.

2
Carcinoma of unknown primary, colon adenocarcinoma, multiple solid tumors.
Early integration of palliative care and oncology (EIPCO): A low-maintenance, easy-to-implement program to address palliative care shortages in oncology.
Authors: Hu Xiaoyi Sean , DeNofrio Jan , Ramchandran Kavitha
Published: September 2024

192

Background:
With demand for palliative care rising and increasing cancer survival rates, there is an urgent need to train future healthcare professionals in palliative care principles, especially for oncology. Prior work has focused on adding modules or rotations to medical school curriculums. However, this approach provides insufficient or late exposure to specific trainees, such as undergraduate and medical students that are less aware of palliative care. Here, we report on the successful development and implementation of a program that educates early trainees in palliative care and oncology topics while immediately benefiting patients and healthcare teams.
Methods:
The pilot version of the EIPCO (Early Integration of Palliative Care and Oncology) program was initiated at Stanford in 2021 by a single medical student and faculty advisor. Recruited medical, graduate, and undergraduate student trainees first complete an online, didactic course as a self-paced, safe introduction to palliative care and oncology. A member of EIPCO leadership (officer) then interviews trainees one-on-one to discuss course takeaways, remaining questions, and what follow-up opportunities are most relevant for each trainee. Next, EIPCO facilitates trainee boarding into their respective opportunities, such as shadowing, volunteering, talks, or research projects, to stimulate further learning and excitement. Involved trainees may then also apply to become officers. EIPCO was reliably maintained and expanded by a small team, even when all officers had significant time constraints.
Results:
EIPCO was received positively by trainees, especially for providing access to rare opportunities where they could directly help patients. Trainees reported the most interest in shadowing (88% of trainees, e.g. inpatient or at tumor boards), providing companionship (96% of trainees, e.g. spiritual care visits or for actively dying patients), and helping patients complete advanced care directives (85% of trainees). These experiences solidified crucial concepts and cultivated interest in palliative care and oncology. Resources have also been developed for the flexible implementation of EIPCO at other institutions.
Conclusions:
EIPCO serves as a low-maintenance and easy-to-implement model to address a growing need in medical education. EIPCO benefits healthcare teams and patients while exposing early trainees to how palliative and cancer care can be integrated. Further work has begun to expand the program to other institutions to enhance training on a broader scale.
Clinician engagement strategies to increase palliative care access in a multi-site community oncology practice.
Authors: Basenese Tina Marie , Sabates Cailee , Johnson Sally , Ronnen Ellen A.
Published: September 2024

196

Background:
Despite nearly 20 years since PC was recognized as a medical subspecialty, and ACS, ASCO and NCCN’s recommendations for early involvement, many oncologists continue to categorize PC synonymously with hospice and therefore refer to palliative medicine specialists very late in the disease trajectory, if at all. Each year, more oncology and PC researchers study and report the life changing impact of early PC for patients living with stage III and IV “advanced cancer” (AC). While mandating PC would have its challenges, creating workflows to encourage providers to change their behavior and attitude regarding PC, while empowering other clinical team members to directly refer, should result in patients and families receiving earlier PC services.
Methods:
The study included a pre-intervention period (9/1/2023 - 12/31/2023), and an intervention period (1/1/2024 - 4/30/2024). Pre-intervention referral data was collected from OncoEMR, OneAnalytics and Social Work reports. PC referrals were requested for both oncology and hematology patients, regardless of diagnosis date or stage. During the intervention period, 6 strategies were designed to increase PC referrals and were deployed equally in all 8 oncology/hematology offices. Strategies included 1) weekly MD/APP huddles with one of the goals to discuss the palliative care needs of all patients, 2) self-directed referrals from nursing, 3) self-directed referrals from social work, 4) APP referrals for advance care planning, 5) proactive chart reviews by PC APNs and direct PC referral suggestions to MD/APPs for AC patients, and 6) hardwiring timely scheduling of PC referrals. The primary end point is the percent of unique cancer (UC) patients who had a PC referral; the secondary end point is the percent of referred AC patients with early PC referral as defined by referral within 8 weeks of diagnosis.
Results:
During the pre-intervention period, of the 8,551 UC patients, 154 (1.8%) received PC referrals as compared to 227 (2.8%) of the 8,055 UC patients during the intervention period, yielding a 56% increase in the intervention period. In the pre-intervention period, 24 (14%) of the 177 newly diagnosed AC patients received early PC referrals compared to 32 (21%) of the 153 newly diagnosed AC patients in the intervention period, giving rise to a 50% increase.
Conclusions:
Strategies to increase PC referrals in a community oncology practice increased overall referrals as well as earlier referrals in newly diagnosed AC patients. As the interventions mature, the total number of PC referrals and a shift toward earlier referrals will likely be seen. Future goals will include assessing patient and family comfort with their treatment plan with PC versus without PC, as well as assessing providers' perceived value of PC over time. With attitude and behavior change, practice culture change is anticipated amid PC becoming the standard of care for all AC patients.
Integrating diabetes care into an oncology practice: A patient-centric model of care delivery at a safety-net health system.
Authors: Gunasekaran Uma , Sadeghi Navid
Published: September 2024

2

Background:
Oncologic treatments can disrupt glycemic control in people with diabetes and induce dysglycemia in individuals without diabetes through the use of steroids and/or targeted therapies. Severe hyperglycemia can result in delay/interruption of oncologic care and emergency department (ED) utilization. Here we report on an integrated model of diabetes care at a safety-net system, where patients commonly use the ED for their care.
Methods:
Parkland Health is an academic-affiliated safety-net system, primarily providing care for the un-/under-insured patients in Dallas County. An advanced nurse practitioner specializing in diabetes care (DM-ANP), supervised by an endocrinologist, was embedded in oncology clinics. Patients were referred to the DM-ANP by their oncology provider, or through an automated process if they had a recent hemoglobin A1c >8.0% or a random blood sugar > 250mg/dL. Patient education was provided by a trained nurse educator. Nutrition consult was available through an oncology dietitian. An acute hyperglycemia management protocol was developed to manage patients in the infusion center and prevent unnecessary ED visits.
Results:
Between March 2021 and March of 2024, the DM-ANP provided 4,276 visits to 797 distinct patients (average, 1425 visits per year). Breast cancer was the most common malignancy among patients seen in the integrated clinic. DM-ANP visits were coupled with oncology visits (clinic or infusion) or via telehealth, thereby increasing access and decreasing number of days patients had to come to clinic to receive care. Telehealth visit rate was highest in 2021 (27.5%) reflecting the impact of the pandemic, and subsequently dropped to 10.1% in 2023. Patients who were seen by the DM-ANP had an overall lower number of ED visits. Comparing prior vs post establishing care with the DM-ANP, the total number of ED visits by patients with diabetes significantly reduced in 2021-2022 (2021: 970 vs. 241, p <0.01; 2022: 796 vs. 501, p<0.01) before equilibrating in 2023-2024; (2023: 426 vs. 468, p=0.24). On average, patients had 1.2 less ED visits after receiving care from the DM-ANP. Since in-person visits were coupled with other oncology visits, the no-show rate for DM-ANP mirrored the rates for oncology clinics/infusion visits.
Conclusions:
Integrating diabetes/glycemic management into our oncology practice provided a patient-centric model of care delivery, improved visit adherence compared to an off-site model, reduced the time-toxicity by having fewer clinic visit days. Future directions include comparing oncologic outcomes in patients who had DM-ANP management to those who were managed by primary care.
Surviving is just the beginning: Exposing unmet needs of cancer survivors through a patient-informed lens.
Authors: Payan Michelle , Muñoz Rebecca J. , Schear Rebekkah , Richardson Robin
Published: September 2024

214

Background:
Despite advancements in survivorship care over the past two decades, cancer survivors continue to grapple with unmet needs that impact their quality of life. While survivorship care plans and clinical interventions have made progress in addressing physical health concerns, a substantial gap remains in delivering comprehensive biopsychosocial support. For the growing population of cancer survivors, varied degrees of toxicity and trauma persist. Research shows only 40% of survivors feel their healthcare providers adequately support their transition to post-treatment care (1).
Methods:
We conducted a qualitative study among survivors of varying Dx, grouped into 3 cohorts, with a two-pronged approach: semi-structured focus groups using “Experience Group” methodology identified domains of care gaps; followed by in-person, human-design workshops mapping perceived gaps in care based on lived experiences. We held 4 Experience Groups; posing open-ended questions (i.e., “what was a good day like w/ cancer?”) to 21 participants. A trained facilitator guided discussion based on emerging patterns in conversation. We utilized an inductive approach: data gathered from groups was used to define & develop codes to categorize responses from in-person workshops into domains & subdomains for care gaps. We held 3, 3-hour workshops in 9 months. Survivors were asked to explore “challenges or unmet needs in extended and long term survivorship.” We collected 628 qualitative data points from 24 total participants.
Results:
Participants identified 66 discreet unmet needs across 7 predominant domains: psychological/emotional, physical health and safety, social/relational, practical, education/information, financial, and existential/spiritual. Most common themes among cohorts included: 1) Mental health concerns: managing anxiety, depression, and existential dread. 2) Physical health: managing long-term effects, daily functioning, and quality of life. 3) Social health: building and maintaining support networks, caregiver support and healthy relationships. Second most common themes included: practical day-to-day concerns, financial and sexual health.Notably, young adult survivors expressed heightened financial and existential concerns.
Conclusions:
While these data exemplify common themes in current literature, they also point to the deep gap between clinical survivorship care plans and real-life support. These findings, while specific to Central Texas, hold implications for survivorship care nationally: increasing awareness and timely use of interdisciplinary interventions delivered outside the clinical setting are needed to comprehensively address the diverse needs of survivors. 1. NCCS, 2022.