bluuebunny/crossref_metadata_2025 huggingface dataset:
The impact of a digital solution on tumor board preparation time for nurse navigators.
Authors: Fowler Donna , Sheets Lincoln R , Prime Matthew S , Siadimas Athanasios , Levy Yariv Z , Hammer Richard D
Published: May 2019

e18020

Background: A multidisciplinary tumor board (MTB) provides an interdisciplinary approach for decision-making in cancer care. Oncology nurse navigators (NN) have been introduced to facilitate patient access to services and resources, and to improve continuity and coordination of care. Little is known about how digital technologies support this role. Methods: A prospective IRB approved cohort study was undertaken to evaluate NN time preparation for MTBs before and after the implementation of the NAVIFY Tumor Board (NTB) solution at University of Missouri Health Care (MU). Data was collected using a digital time-tracking application. The NTB manual version was implemented via a phased roll-out (Hematology – Apr 9, 2018; Breast May 18, 2018; Gastrointestinal Jul 11, 2018). Subsequently, the integrated version was introduced (Oct 4, 2018). Results: Time preparation for 101 MTBs (828 cases) were evaluated throughout 2018 (35 Breast; 213 cases / 32 GI; 302 cases / 34 Hematology; 313 cases). Data showed NN meeting preparation time decreased for each MTB after the introduction of NTB; further time saving was achieved with NTB integrated version (Table 1). For the Breast MTB there was statistical significance between time preparation pre- & post-NTB (p-value = 0.011) but not between the manual and integrated versions (p-value = 0.118). For the Gastrointestinal MTB, there was no statistical significance between pre- & post-NTB (p-value = 0.214). For Hematology MTB there was statistical significance between the change from the NTB manual version vs. integration (p-value = 0.004). Note before NTB implementation Hematology MTB was not supported by NN. Conclusions: Introduction of the NTB reduced time spent by NNs preparing for 3 different MTBs, EMR integration delivered further time-savings. No discernable learning curve was observed suggesting user-training was sufficient and NTB was easy to learn. A reduction in variance (SD & IQR) for time preparation across all MTBs was seen. This suggests the NTB solution standardized the process for MTB preparation. Less time spent preparing for MTBs gives NNs more time to support patients.
Bone marrow donation perceptions among healthcare workers: A follow-up study at University of Cincinnati Medical Center.
Authors: Roof Logan , Chaudhary Rekha T.
Published: May 2019

e18032

Background: It has been well-documented that there is a severe lack of participants enrolled in the National Bone Marrow Donor registry. Even those who are registered often decline to donate at a critical juncture in the donation process due to a wide variety of misconceptions. Health care professionals should be among the most educated about the bone marrow donation process as they will often be giving advice to potential donors. Methods: We conducted an anonymous online survey of medical students, residents, fellows, and attending physicians at the University of Cincinnati Medical Center to determine the common misconceptions surrounding bone marrow donation. Results: There were a total of 187 participants (73% medical students, 23% residents/fellows, 4% attending physicians). Fifty-one percent were already bone marrow donors, while 49% were not. Forty percent of respondents believe bone marrow biopsy is necessary for donation and 10% believe CT scans are done prior to donation. Twenty-eight percent responded that bone marrow is extracted under general anesthesia, 43% responded that it is extracted not under general anesthesia, 5% responded that it is extracted via central intravenous line, and 24% responded that it is extracted via peripheral intravenous line. Thirty percent responded that they are not bone marrow donors because bone marrow donation is painful, 12% because it involves surgery, 2% because it weakens the donor, 13% because it involves a lengthy recovery process, 3% because donors have to pay for donation, 1% because of ethnic/religious/cultural beliefs, while 39% have not had the opportunity to donate but would or are planning on it. Conclusions: The majority of allogeneic transplants are performed with peripherally collected bone marrow stem cells, however, most potential donors including health care professionals do not know this. We conclude that a great deal of education surrounding bone marrow donation is still needed among healthcare workers today. Educating health care workers is of the utmost importance as they will impart this knowledge to those considering donation. Future aims of this project are to develop an educational curriculum to address the most common misconceptions, particularly in medical students, as they are in the age group most targeted in bone marrow donation and they will be the future generation of physicians to educate patients on the process.
Characterization of temporal relationships of comorbidities developed following cancer diagnoses in veterans.
Authors: Hong Julian C. , Hauser Elizabeth R. , Redding Thomas S. , Sims Kellie J. , Gellad Ziad F , O'Leary Meghan , Madison Ashton , Qin Xuejun , Weiss David G. , Bullard A Jasmine , Williams Christina D. , Sullivan Brian , Lieberman David A. , Provenzale Dawn T.
Published: May 2019

e18049

Background: Understanding patient trajectories and common sequences of comorbidity accrual among those newly diagnosed with cancer is critical for precision approaches to care and prevention. The Veterans Affairs (VA) Cooperative Studies Program (CSP) #380 cohort includes 3,121 healthy asymptomatic veterans who underwent screening colonoscopy and were followed for at least ten years. The current analysis leverages computational approaches to characterize the temporal relationships of diagnoses in CSP #380 participants following diagnosis of colorectal or other cancers. Methods: Patients enrolled in CSP #380 with at least 5 years of linked electronic health record data from the VA Corporate Data Warehouse (October 1999-December 2015) were included. Cancer diagnoses and their most common subsequent new diagnoses were identified per patient by the first instance of each three-digit ICD-9 diagnosis affecting at least 50 patients. Pairwise chronological relative risks (RR) between subsequent diagnoses were represented as a directed network graph, which maps the probability of developing a diagnosis following a prior diagnosis. Results: A total of 2,210 patients were included. The most common cancer diagnoses were prostate (436), thoracic (169), bladder (120), colon (72), and kidney cancers (65). Most first diagnoses following a cancer diagnosis were related to progressive cancer or acute/subacute treatment toxicity. For prostate cancer, comorbidities with greatest RR were carcinoma in situ (RR 6.85), unspecified (NOS) metastases (2.75), and urethral stricture (2.53). For lung cancer, they were metastases of respiratory and digestive sites (12.24), lymph nodes (6.47), and NOS (5.68), pneumothorax and air leak (4.16), and convalescence and palliative care (3.07). In bladder cancer, they were carcinoma in situ (9.00), cystitis (6.78), kidney or other urinary cancer (6.19), attention to artificial openings (3.40), and urethral stricture (2.78). These and other results were visualized with network graphs. Conclusions: Computational techniques can identify and visualize future health concerns following cancer diagnoses. In this cohort of initially healthy and asymptomatic veterans on a prospective screening colonoscopy study, most subsequent diagnoses were related to cancer or toxicities of therapy, as might be expected in an aging cohort. Future work may focus on streamlining in-clinic identification of potential high likelihood comorbidities.
Target versus non-target lesions in determining disease progression: Analysis of 581 patients.
Authors: Raskin Stephen , Klang Eyal , Kharizman Tehila , Konen Eli , Berger Raanan , Amitai Michal
Published: May 2019

e18053

Background: RECIST, among methodologies designed to provide an objective assessment of tumor response to therapy, is based on the measurement of Target Lesions (TLs) and classification of response according to an objective scale of beneficial response or progressive disease (PD). The “PD point” (the time-point at which RECIST 1.1 first classifies the trial as PD) is a common end-point in clinical trials and is defined as that point when the objective response rate is > 20%. However, RECIST also allows for the subjective assessment of non-TL lesions (NTLs) and new lesions (NLs) to determine the PD point. We sought to determine which of these parameters was most influential in determining PD. Methods: We evaluated the formal RECIST 1.1 assessments for consecutive patient enrollments in randomized clinical trials prepared by two senior radiologists at our institution from 2013 through 2018. Data was evaluated at the “PD point.” Results: There were 1260 patients, with 4499 CT or MRI scans. Of these, 581 trials concluded with PD. There were seven groups (+/-/-, -/+/-, -/-/+ . . . +/+/+) according to the status of TLs, NTLs, and NLs at the PD point. In 538 patients (92.6%), TLs were unnecessary in determining the PD point. Two-thirds of these had objective response rates of < 40%. Measurable and non-measurable NTLs were equally responsible for PD, and the strongest determinant of PD was the unequivocal appearance of new lesions. Conclusions: In this study, subjective parameters, as defined by RECIST 1.1, were far more likely to result in a determination of PD than objective ones. These findings may have relevance for considering the value of RECIST 1.1 as a scientific standard for therapeutic efficacy as well as in the design of new methodologies for the assessment of tumor response.
Real-world efficacy of bone modifying agents (BMAs) in patients with breast cancer (BC) treated in an academic health system: Use of the “green button.
Authors: Karimi Yasmin , Gombar Saurabh , Dean Latanya , Hansen Jennifer , Callahan Alison , Jung Ken , Divi Vasu , Blayney Douglas W.
Published: May 2019

e18054

Background: BC patients (pts) have a high incidence of bone metastases (mets) and associated morbidity. BMAs – zoledronic acid (ZA) and denosumab (Den) – reduce bone met related skeletal related events (SREs). ASCO guidelines do not recommend one over another, and survival and real-world outcome data to guide point-of-care decision-making is lacking. We used the previously developed “Green Button” informatics consult service, designed to rapidly test hypotheses when no applicable published data is available to guide treatment choices (Longhurst et al Health Affairs 2014), to compare BMA efficacy in BC patients. Methods: Patients treated for BC at Stanford HealthCare between 2009 - 2018, receiving standard of care cancer and BMA therapy, as determined by their oncologists, were identified who had > 2 electronic health records (EHRs) documenting BMA administration, and had either ICD9 174 or ICD10 C50 diagnostic codes. Pts were grouped into Den only, ZA only, or both. Two outcomes were analyzed: 1) SREs as a composite outcome of pathologic fracture (1st ICD10 M84.5); spinal cord compression (1st ICD10 M47.1 or G95.2), radiation therapy (1st CPT 77300) or hypercalcemia (calcium ≥10.5); and 2) death. Effects were compared relative to baseline treatment with ZA; we show results of log rank tests for differences in survival outcomes. Three analyses were performed: 1) Unadjusted analysis; 2) Basic matching analysis accounting for length of medical record, age, sex and year of treatment; 3) Propensity score matching using all available data; all prior to index treatment with either Den or ZA. Results: 802 patients had ≥ 2 records of BMA administration. Comparison of Den only and ZA only pts is shown in the table below. Median ages and length of medical record were balanced in all groups. Conclusions: This preliminary retrospective analysis of unsupervised BMA use suggests that Den is superior to ZA for the outcomes of interest; confirmatory analyses are underway.[Table: see text]
Remote patient monitoring using smart phone derived patient reported outcomes and Fitbit data to enable longitudinal predictive modeling in prostate cancer: Feasibility results and lessons on platform development.
Authors: Laccetti Andrew L. , Slack Tidwell Rebecca , Sheth Nipa P , Logothetis Christopher , VanAlstine Michael
Published: May 2019

e18068

Background: Wearable activity trackers and frequent interrogation of remote patient reported outcomes (PROs) have the potential to revolutionize oncology clinical trial design, therapeutic sequencing and patient (pt) safety. Established feasibility and novel systems of data processing are necessary to substantiate value for these methods. Methods: Expanding upon our clinical research data platform, Prometheus, we have developed a HIPPA compliant, remote pt monitoring system capable of collecting minute-by-minute step count and heart rate (via Fitbit) in addition to smart phone derived symptom surveys. To pilot this program, a cohort of metastatic castration resistant prostate cancer (mCRPC) pts participated in continuous Fitbit monitoring and thrice weekly NCI-PRO-CTCAE survey for 26 weeks. Pre-specified interim feasibility results were examined with a focus on pt characteristics, treatment and compliance. Qualitative assessment of barriers to pt enrollment and device use was performed. Results: 15 mCRPC pts completed our pilot program: mean age 63.1 years (range 48-79), pre-treatment PSA 33.2 ng/mL (range 0.3 – 499.9), 80.0% stage M1b, ECOG 0 or 1. All pts were treated per protocol NCT02703623: abiraterone/prednisone/apalutamide for 8 weeks followed by continuation of therapy (5 pts), cabazitaxel/carboplatin (6 pts) or addition of ipilimumab (2 pts). 33.3% of pts reported grade 3 clinician interpreted adverse events. 14 pts had data available for compliance analysis. Mean Fitbit compliance was 62.6% (STD 35.5%) with rates trending down over the study duration (week 1 vs 26 = 86.7% vs 33.3%; p= 0.002; R2= 0.716). Mean smart phone derived NCI-PRO-CTCAE survey completion rate was 37.1%. Barriers to pt enrollment included slow Fitbit app download times, incompatible smart phones and the need for extensive device use education/counseling. Barriers to data collection were missed survey text prompts and inconsistent use of Bluetooth. Conclusions: MD Anderson’s novel, home-grown, remote pt monitoring platform, utilizing Fitbit and smart phone derived PROs, is feasible in function and pt use. Automated compliance checks, streamlined enrollment and pt education are critical to future application. This foundational work will facilitate longitudinal signal variation benchmarked against standard monitoring methods, ultimately aiming to improve outcomes and support of discovery through enriched access to pt experience.
Emergency oncology: The situation of acute general hospital in Japan.
Authors: Onishi Yoshitaka , Miyakawa Takashi , Minematsu Mari , Natsuaki Shimpei , Ogawa Masari , Nagata Toshinori
Published: May 2019

e18069

Background: The need for supportive and palliative care services for cancer patients is well established. Our hospital is acute general hospital with 602 beds, 20 ICU beds, radiation unit, chemotherapy unit and with emergency department(ED) 24hours and 365 days open, locates close to one of the national cancer center. In this situation, we have many acutely unwell patients with newly diagnosed cancer in emergency department(emergency oncology). Methods: We reviewed the records of the patients with newly diagnosis of cancer and treated by surgery, radiation and or chemotherapy and of the patients transfered by ambulance at ED in 2017, 2018 and 2019, retrospectively and consecutively. Results: In this three years, we have 1626 patients with first diagnosis of cancer, 268 patients visited after clinic-hour and 130 patients needed ambulance with critical symptoms. Of those, 145 had gastro-intestinal, 34 hepato-billiary, 25 urological, 24 lung, 16 gynecology, 9 breast and 23 other cancer. During this period, total 30027 patients were transported by ambulance to our ED. Conclusions: Although there are many cancer centers in Japan, there are only one unit in Japan.(National Cancer Center Hospital(Tokyo) )that provide urgent care to cancer patients. In this situation, acute hospitals have to have a role for emergency oncology. We need varying models of emergency and acute care development (e.g., acute cancer net-work system, regionalization, education for the physicians and patients, organize the emergency oncology unit in acute hospital or cancer center) with cooperation of oncologist and non-oncology emergency physicians in Japan as they are trying and developing in the USA and UK.
ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.
Authors: Hung Kin Wai (Tony) , Banerjee Natasha
Published: May 2019

e18071

Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.
Electronic but overly eclectic: Disciplined EHR data management is needed to automate MIPS reporting.
Authors: Schorer Anna E. , Koskimaki Jacob , Miller Robert S. , Rubinstein Wendy S. , Bernstam Elmer Victor , Krauss John C. , Moldwin Richard , Venepalli Neeta K. , Chen James Lin
Published: May 2019

e18074

Background: Physician reimbursement for care delivered to Medicare beneficiaries fundamentally changed with the 2015 MACRA legislation, requiring eligible clinicians to report quality measures in the Merit-Based Incentive Payment System (MIPS). To determine whether structured data in electronic health records (EHRs) were adequate to report MIPS results, EHR data ingested by ASCO’s CancerLinQ (CLQ) was analyzed. Methods: Nineteen MIPS measures specified for medical oncology, including 8 shared by other specialties, were retrieved from qpp.cms.gov and systematically evaluated to determine data elements necessary to satisfy each measure. The existence of corresponding data fields and completion of these fields with clinical data was analyzed according to EHR implementation in de-identified and aggregated CLQ data. Results: Five clinician informaticists reviewed the 19 oncology MIPS measures, and identified a consensus list of 52 discrete EHR data elements (DEs) that would be needed. CLQ-processed data from 4 commercial EHR systems implemented at 47 CLQ practices found structured data fields for 84% (43 of 52) of the DE, but fewer than half (46%) of these fields were ever populated and only 32% (17 of 52) of DE were recorded for > 20% of cases. Only 3-5 of 19 MIPS measures could be reliably reported based on data element availability by most practices in this sample set. There were minimal differences between the EHRs ability to encode MIPS DE. Elements most likely to be encoded were those for registration (birthdate, gender), billing (diagnosis, meds), vital signs and smoking status, while those seldom or never encoded related to care plans (tobacco, alcohol, pain management). Other DE rarely encoded were patient events occurring outside the oncology practice (receipt/completion of consultations, dates of hospice enrollment and death), which would be dependent on data exchange between work units and practice entities or, more likely, re-entry by oncology practices. Conclusions: Only a minority of DE required to satisfy MIPS criteria are available as discrete data fields in current EHRs, limiting automated reporting efforts. Improved data quality and completeness is needed to satisfy mandated reporting.
Development of a digital immunohistochemistry records’ management system at the Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya.
Authors: Patel Kirtika Tushar , Bhamra Ashwinder Singh , Kibet Kibor Keitany , Busakhala Naftali Wisindi , Asirwa Fredrick Chite
Published: May 2019

e18075

Background: Cancer diagnosis using immunohistochemistry (IHC) is important for quality care of patients. The utility of IHC services in management of cancer patients in low- middle income countries (LMIC) has gained popularity. Paper-based IHC records storage systems have made it cumbersome to retrieve records and thus impair the management of quality care for patients. We describe here the setup of a digitised records’ management system (RMS) in a LMIC which is user friendly, easy to access, prone to minimal errors and aid in research. Methods: A spreadsheet with blank templates containing key fields was designed and populated along the process until all records to the date of completion of data collection were recorded from January 2012 to November 2017. The complete reported tests were clustered into categories based on the diagnoses reached and frequencies for each cluster were derived. Information collected included patient identifiers, gross, histology, and immunohistochemical markers tested and the diagnosis. A provision is also made to store pictures of stained slides on the RMS. Results: Using RMS, a total of 948 immunohistochemistry staining was performed between January 2012 and November 2017; 677 of these have been reported, 200 were controls and 71 were repeats. Testing for breast cancer was the most common investigation performed (39.9% [n = 270]). Anti-LANA tests for Kaposi Sarcoma closely followed at 15.1% (102), followed by Non-Hodgkin’s lymphoma at 13.4% (n = 91). The RMS brings up the IHC test to be performed after HE diagnosis is entered, helping the technician to prepare and plan for IHC staining. Conclusions: The RMS has made it easier for clinicians taking care of patients to get results and provide quality care. This system is helpful in answering research questions and data analysis. Models such as these are especially useful in LMIC as they can assist technicians to perform IHC as they await the consultant pathologist. RMS will also help incorporation of IHC in telemedicine, aiding transmission of photographs taken by mobile phones in remote setups to pathologists in distant places.
An analysis of growth patterns of targeted therapies (TTs) using keywords from ASCO annual meeting abstracts.
Authors: Gong Yutao , Schneider Julie A , Blumenthal Gideon Michael
Published: May 2019

e18084

Background: The number of TTs approved to treat cancer patients has increased dramatically in the past decades. We analyzed how frequently 27 oncology targets (and associated therapies) appeared in ASCO meeting abstracts since 2005 to explore if future drug development patterns could be predicted. Methods: We obtained abstracts from the ASCO Center for Research & Analytics. We used keyword abstraction to calculate the percentage of abstracts referencing 27 specific target/drug combinations each year, and we categorized them into high (HV), medium (MV), and low volume (LV) groups based on percentage in 2018. Results: Table shows data since 2012 for the HV group. The percentages of MV (BCR/ABL, CDK4/6, CD20, MEK, CTLA4, iMID, PARP, PI3K, proteasome inhibitors) and LV (BCL2, BTK, CD19, CD30, CD38, HDAC, IDH1, IDH2, and NTRK) in 2018 were less than 1.7%. The HV group was associated with more FDA-approved therapies (41) than the MV (23) and LV (13) groups. The HV and MV groups are likely enriched for more mature targets, as the median date of relevant drug approvals is earlier (11/2012 and 4/2013, respectively) than the LV group (4/2016). Growth patterns are consistent with key regulatory milestones. The number of abstracts with PD-1/PD-L1-related keywords has grown more rapidly than any other drug/target combination. This growth begins soon before FDA approvals for a diversity of relevant indications. Continued growth likely reflects ongoing clinical trials of several other PD-1/PD-L1 inhibitors and combinations. We identified similar growth trends for other targets just prior to key regulatory approvals. Conclusions: Our analysis revealed interesting growth patterns for key oncology target/drug combinations. Future work will explore whether we can extend the analysis to help predict the evolution of development programs for new targets. [Table: see text]
Assessing real-world outcomes in precision oncology by linking clinical genomic testing to electronic medical records.
Authors: Datta Debajyoti , Goldstein Theodore , Butte Atul
Published: May 2019

e18091

Background: With an ever-widening array of targeted therapies for cancer patients, clinical genomic testing has expanded rapidly in recent years. Tumor molecular profiling by next-generation sequencing is now considered a cornerstone of precision oncology, with the potential to offer patients with advanced cancers new therapeutic options. However, the overall impact of this testing remains unclear, and evidence demonstrating improvement in patient outcomes is lacking. The objective of this study is to assess the utility of clinical sequencing on the management of cancer patients. Methods: We present the development of a database that combines results of tumor mutation profiling using various next-generation sequencing panels (both external commercial tests and our institution’s internal sequencing panel), with a variety of data points from a de-identified representation of our institution’s electronic medical record (EMR). Assembling this data from different sources into a common relational database permits efficient retrospective analysis of real-world outcomes in patients with advanced cancers. Results: This study included over 3000 patients seen at UCSF Comprehensive Cancer Center since 2013. With this linked data set we analyzed the rate at which tumor molecular profiling affected clinical decision making, identified barriers to the efficient use of testing, and assessed for disparities in utilization. For example, by measuring patient survival relative to the clinical intervention of genomic testing for the subset of patients with a date of death recorded in our EMR, we found that a small fraction of patients died before results returned and any action could be taken, especially in cases of pancreatic cancer. Conclusions: We demonstrate that a common relational database combining clinical sequencing results with real-world EMR data provides insights into the optimal clinical use of tumor molecular profiling. This provides new opportunities for advancing precision oncology initiatives and improving patient care, such as identifying which cancer patients should get genomic testing and efficiently matching patients to clinical trials.
Generating real-world evidence: Using automated data extraction to replace manual chart review.
Authors: Law Jennifer H. , Pettengell Christopher , Le Lisa W , Aviv Steven , DeMarco Patricia , Merritt David C. , Lau Sally CM , Sacher Adrian G. , Leighl Natasha B.
Published: May 2019

e18096

Background: Real world evidence is a valuable resource to help guide clinical care beyond evidence generated from clinical trials, for example safety and effectiveness of novel treatments in special populations. Administrative databases often lack sufficient clinical detail to address gaps in the improvement of patient management and quality of care. Detailed clinical data collection and curation are resource intensive, limiting the ability to generate and maintain large informative cancer databases. Darwen, novel technology developed by Pentavere, enables the automation of data abstraction from unstructured hospital electronic medical records and may eliminate the need for manual chart review. Methods: Health records were identified through an institutional cancer registry from patients with stage IIIB/IV lung cancer (NSCLC or SCLC) diagnosed and treated at the Princess Margaret Cancer Centre between 01/01/2015 and 31/12/2017. Cases underwent automated data extraction including demographics, comorbidities, treatment, concurrent medications and outcomes until 30/06/2018. Agreement with data fields extracted using manual data collection in an external validation set of patients is planned. Results: Of 1210 patients identified, 538 were eligible for analysis. From automated data abstraction, 9.9% were reported to have SCLC, 67.5% adenocarcinoma, 11.2% squamous carcinoma, 28% EGFR mutations, 5.8% ALK fusions and 9.3% tumour PDL1 > = 50%. Of the 304 (56.5%) that received systemic therapy, initial treatment was chemotherapy for 55.6%, targeted therapy in 34.2% and immunotherapy in 10.2%. Additional outcome data and agreement with manually curated data fields will be presented. Conclusions: Automated software to extract clinical data is a powerful new tool to generate and maintain databases that yield high quality real world clinical evidence. This is a critical next step to improve clinical decision making, inform evidence-based practice and improve quality of cancer care.
Visualizing real-world outcomes through the lens of a molecular tumor board: Persona-typing pancreatic cancers for clinical decision support.
Authors: Petricoin Emanuel , Barg Daniel , de Arbeloa Patricia Miren , Pishvaian Michael J. , Blais Edik Matthew
Published: May 2019

e18100

Background: Despite the molecular diversity of pancreatic adenocarcinoma, standard therapy options remain largely molecularly-untailored except in the context of DNA damage response alterations such as BRCA mutations, NTRK fusions, or microsatellite instability. Methods: To broaden the utility of molecular profiling, we analyzed real-world outcomes and established 12 molecularly-driven clusters, or “persona types” (PTs), across a cohort of 1280 pancreatic cancers with CLIA-grade genomic/proteomic data (commercially available NGS/IHC panels). Patients were consented into Perthera’s precision oncology platform via referrals from advocacy programs and hospital partnerships for case review by a molecular tumor board (MTB). Persona types were generated using unsupervised k-means clustering of molecularly-tailored therapy recommendations formulated by the MTB. Progression-free survival was documented across all lines of therapy. Results: Personas based on multi-omic profiles and expert-driven recommendations were representative of molecular phenotypes reported in previous studies (e.g. DNA damage response deficiencies, BRAF mutations, other non-KRAS-drivers, SWI/SNF alterations, squamous-associated genes, cell cycle regulators, etc.). To streamline the exploration of real-world outcomes, we developed an interactive dashboard that enables users to compare PFS survival curves across Personas for various therapies such as gemcitabine/nab-paclitaxel, FOLFIRINOX, other standard regimens, immunotherapy, PARP inhibitors, RAF/MEK/ERK inhibitors, and more. Persona types associated with increased/decreased sensitivity to several classes of agents were identified (e.g. PD-1/L1 inhibitors in a persona enriched for cell cycle dysregulation, PARP inhibitors in a persona enriched for BRCA mutations). Conclusions: Empowering oncologists with personalized insights into real-world outcomes may promote investigator-initiated trials and augment clinical decision support, particularly when choosing between standard of care regimens or when exploring potential clinical trial options.
Socioeconomic disparities among uninsured cancer patients: A free clinic study.
Authors: MacDonald Madeline , Lu Yuanyuan , Song Ethan , Ayoubi Noura , Robinson Katherine , Todd Amber , Mirza Abu-Sayeef
Published: May 2019

e18110

Background: Cancer is the second leading cause of death in the United States and approximately 38.4% of Americans will be diagnosed with cancer during their lifetime. Cancer treatment and follow-up care is expensive and uninsured individuals may face barriers to receiving necessary treatments. Minorities may encounter additional barriers to accessing healthcare. There is limited research about socioeconomic disparities in uninsured cancer patients seen at free clinics in the United States. Methods: A retrospective chart review was conducted to collect chronic disease parameters from electronic medical records and paper charts at nine free clinics in the Tampa Bay area in Florida. Demographics were compared between cancer patients and the non-cancer population via chi-square test or independent samples t-test. Results: Between January 2016 and December 2017, 9127 uninsured patients were seen at nine free clinics. 2137 patients were excluded from the study because there was no cancer data in their charts. Of the patients included in the study, 221 (3.2%) had a current or past diagnoses of cancer. Cancer patients were more likely to be female (n = 145, 65.9), p = 0.048, compared to non-cancer patients. Cancer patients were more likely to be Caucasian (n = 106, 89.1%), p < 0.001 compared to non-cancer patients (n = 2489, 69.3%). Cancer patients were less likely to be African American compared to non-cancer patients (n = 6, 5.0% vs. n = 754, 21%), p < 0.001. Cancer patients were significantly older than non-cancer patients (M = 54.1, SD = 12.0) vs. (M = 41.0, SD = 16.7), p < 0.001. Patients who had cancer were more likely to be unemployed compared to non-cancer patients (n = 78, 54.9% vs. n = 1685, 46.6%), p = 0.050. Conclusions: The study revealed that uninsured cancer patients are more likely to be unemployed, female, of older age, and Caucasian compared to non-cancer patients. It appears that uninsured African Americans are not utilizing free clinics for their healthcare and may be lost to follow-up. A variety of factors may have contributed to these disparities in this vulnerable population including lack of transportation, lack of awareness of free resources in the area, and more. This study increases awareness of disparities in uninsured, cancer patients.
Impact of dual anti-HER2 therapy on pathologic complete response rate in breast cancer in a minority-enriched population.
Authors: Li Jenny Jing , Li Hsiao Ching , Gao Ang , Syed Samira K. , Unni Nisha , Sadeghi Navid
Published: May 2019

e18111

Background: The addition of pertuzumab (P) to a neoadjuvant trastuzumab (H) plus chemotherapy combination has been shown to significantly improve the pathologic complete response rate (pCR) in localized HER2+ breast cancer; however, minorities have been under-represented in these trials. Racial/ethnic disparities have also been shown to affect outcomes of cancer treatment. This study is aimed to assess the impact of neoadjuvant dual HER2-blockade in an unselected minority-enriched population. Methods: A retrospective chart review was conducted of women with stage I to III HER2+ breast cancer who received neoadjuvant treatment between 2007 and 2017 at an academic institution and its affiliated safety net health system. Data on stage, chemotherapy, race/ethnicity, site of therapy (academic vs safety net hospital), and hormone receptor status were collected. All patients underwent surgery after completion of neoadjuvant chemotherapy. pCR was defined as ypT0/is, ypN0. Chi-squared test and univariate/multivariate logistic regression were used for statistical analysis. Results: The study population included 261 women with the following race/ethnic distribution: 37.7% Non-Hispanic Whites, 34.6% Hispanics, 20.6% Blacks, and 7% other racial/ethnic origin. Ninety-five patients (36%) received chemotherapy-H vs 166 patients (64%) received chemotherapy-HP. Patients at the safety net health system had higher stage at diagnosis compared to the academic site. Site of care and race/ethnicity did not impact the choice of neoadjuvant treatment. The pCR rate was significantly higher for the chemotherapy-HP group (55.4%) compared to the chemotherapy-H group (34.7%) (p = 0.001). There was no association between race/ethnicity, or site of treatment (academic vs safety net), and the probability of achieving pCR. Multivariate analysis showed only dual anti-HER2 therapy (OR: 2.67, CI: 1.55-4.59, p = 0.0004) and hormone-receptor negative status (OR: 2.18, CI: 1.30-3.67, p = 0.0031) to correlate with pCR. Conclusions: Neoadjuvant dual anti-HER2 therapy was more likely to result in a pCR in our minority enriched population. Our data also suggests the combination of chemotherapy-HP confers similar benefit irrespective of race/ethnicity or site of care.
Contextualizing place and health in rural America: Cancer information seeking across four categories of an urban/rural continuum.
Authors: Lopez Gilberto , Mattie Heather , Culakova Eva , Lin Po-Ju , Kamen Charles Stewart , Janelsins Michelle Christine , Morrow Gary R.
Published: May 2019

e18124

Background: Cancer is the second leading cause of death in the United States. Despite decreases in cancer mortality overall, rural populations continue to have higher prevalence and slower reduction of cancer death rates. As a preventive approach to combat cancer, the National Cancer Institute continues to prioritize providing the public with health information. Yet, little is known about cancer information-seeking across rural America. Methods: Using Rural-Urban Commuting Area Codes (RUCAs), from the 2018 Health Information National Trends Survey (HINTS-5) database we analyze the odds of looking for information about cancer across four geo-political contexts (n = 2,625): urban, large-rural, small-rural, and isolated-rural areas, thus giving us a potentially more detailed understanding of place and health across the urban-rural continuum. Using an established social determinants framework, a series of logistic regression models were fitted to estimate odds ratios (OR) and 95% confidence intervals (CIs). Results: Across all models, those living in large rural towns had about 1.5 times the odds of looking for cancer information compared to urban-dwellers (p < 0.05) while those living in remote rural areas had about 0.5 times the odds (p < 0.05). There was no difference for those living in small rural towns. Additionally, gender, race/ethnicity, marital status, education, housing status, and internet availability were independently associated with information-seeking (p < 0.05). Conclusions: In this study, compared to urban-dwellers, those living in large rural towns appeared to have increased odds of looking for cancer information while those living in isolated rural areas had decreased odds. Understanding this relationship between place and health has implication for the allocation of resources and the design of interventions aimed at increasing information about cancer.
Impact of the Affordable Care Act on insurance for adolescents and young adults with cancer.
Authors: Winestone Lena , Hochman Lauren , Sharpe James , Alvarez Elysia Marie , Becker Laura , Chow Eric Jessen , Fish Jonathan D. , Reiter Joseph , Ginsberg Jill P. , Silber Jeffrey H.
Published: May 2019

e18125

Background: The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed young adults to remain on their parents' health insurance until age 26 years (y), whereas pre-DCP the cut-off varied, but was most often 18 y. Our objective was to compare rates of insurance disenrollment among patients with cancer who were DCP-eligible compared to those who were not. Methods: A retrospective cohort from the OptumLabs Data Warehouse, which includes claims data for privately insured enrollees in a large US health plan, was used. Patients born between 1982-93 diagnosed with cancer between 2000-15 were included. In the Recent Cohort, patients who turned 19 in 2010-12 (who were always eligible to stay on parents’ insurance) were matched to patients who turned 19 in 2007-09 (who were not protected by the DCP when they turned 19). Sensitivity analyses paired patients in an Earlier Cohort, who turned 19 (in 2001-03 and 2004-06), none of whom were eligible for the DCP when they turned 19. Patients were matched on cancer type, diagnosis date, and additional clinical characteristics. Using a time to loss of coverage analysis (defined as > 90 d interruption in insurance enrollment), hazard ratios (HR) were calculated using Cox proportional hazards models. Difference-in-difference between pairs from the Recent and Earlier cohorts was evaluated. Results: Of the 3,013 patients who turned 19 in 2010-12, 2,829 were matched. Median time to disenrollment was 26 months (m) compared to 22 m among patients who turned 19 in 2007-09 (HR 0.88, 95% CI 0.81-0.95, p = 0.0009). In the 4,489 pairs of patients who turned 19 between 2001-06, median time to disenrollment was 20 m among both the younger and older patients in the pair (p = 0.047). In grouped analyses, the difference-in-difference between the Recent and Earlier sets of pairs displayed a 14% reduction in the hazard for losing coverage (p < 0.0001), favoring those who turned 19 after DCP became available. Conclusions: In pediatric cancer patients and survivors, a vulnerable population that needs continuous insurance coverage, these data suggest that the DCP of the ACA lowers the insurance drop-out rate.
Association of state Medicaid expansion with timeliness of cancer care delivery.
Authors: Takvorian Samuel U , Bekelman Justin E. , Mamtani Ronac , Shulman Lawrence N. , Werner Rachel M.
Published: May 2019

e18126

Background: The Affordable Care Act (ACA) expanded Medicaid eligibility to nonelderly adults with incomes at or below 138% of the federal poverty level in participating states. Medicaid expansion has been associated with earlier cancer stage at diagnosis; however, its impact on cancer treatment is unknown. Methods: We assembled retrospective cohorts of adult nonelderly patients (ages 40-64) with newly diagnosed breast, colon and lung cancer from January 2011 to December 2015, using data from the National Cancer Database (NCDB). We conducted a quasi-experimental, difference-in-differences analysis to compare Medicaid expansion and non-expansion states on timeliness of cancer therapy, stage at diagnosis, and insurance status for the years before (2011-2013) and after ACA Medicaid expansion (2014-2015). Results: There were 466,314 patients in expansion states (mean age, 54.7 years; 81.5% women) and 487,958 patients in non-expansion states (mean age, 54.9 years; 78.5% women). In expansion states relative to non-expansion states, there was no significant difference in the proportion of patients initiating cancer therapy within 30 days (adjusted difference-in-difference (DID) estimate -0.1%; 95% CI -0.8 to +0.7%, p = 0.868) or within 90 days of diagnosis (adjusted DID estimate -0.1%; 95% CI -0.3 to +0.1%, p = 0.501), before and after expansion. Among those with early-stage cancers undergoing definitive therapy, there was similarly no significant difference in time to treatment. Relative to non-expansion states, the proportion of early stage cancer diagnoses increased more (adjusted DID estimate +0.7%; 95% CI +0.3 to +1.2%, p = 0.002), and the proportion of advanced stage cancers decreased more (adjusted DID estimate -0.4%; 95% CI -0.7 to -0.1%, p = 0.008) in expansion states. The proportion uninsured at diagnosis decreased more in expansion states (adjusted DID estimate -0.8%; 95% CI -1.2 to -0.4%, p < 0.001). Conclusions: Among nonelderly patients with common cancers, ACA Medicaid expansion was associated with an increase in the proportion of cancers diagnosed at early stage, a decrease in the proportion of cancers diagnosed at advanced stage, and a decrease in the proportion of uninsured. There was no significant effect on the timeliness of treatment.
Which social measures relate to cancer screening & healthy behaviors?
Authors: Fei Kezhen , Cruz Daliz , Lin Jenny J. , Yagnik Radhi , Gallagher Emily , Bickell Nina A.
Published: May 2019

e18142

Background: Much of cancer health services research relies on administrative data, yet, there have been calls for more granular racial & social disparities data. Subjective SES (sSES) is associated with health status & behaviors, independent of objective SES (oSES) measures like income, education and race. We assessed the relationship between breast cancer patients’ oSES and sSES with their cancer screening and health behaviors. Methods: Data are part of a large prospective study evaluating the role of insulin resistance in women with newly diagnosed breast cancer. Patients were asked to place where they stand in their communities on the MacArthur Scale of Subjective Social Status ladder (sSES). oSES measures include race, income & education. We assessed diet, activity, breast & pap screening. Group comparisons used chi-square and t-tests as appropriate. We ran logistic multivariate models with age, race, insurance, comorbidity & income. Results: Of 1035 breast cancer patients with an average age of 58±12 yrs, 81% were White and 19% Black, 63% graduated college, 47%W & 16%B women reported an income of > $100,000/yr. The median sSES = 8; 20% had high sSES ( > 8). There were no racial differences observed in sSES (high sSES: 22% B vs 20% W; p = 0.7). More patients with high sSES graduated college (76% vs 61%, p = 0.0002) & had income > $100K/yr (62% vs 36%, p < .0001) than patients with lower sSES. Of the oSES, women with higher income were more likely to undergo both cancer screenings as compared to patients with lower income. College education did not impact cancer screenings. Black women were less likely to get pap smears. Patients with high as compared to low sSES had higher cancer screening rates and healthy behaviors. Conclusions: Income and sSES are positively associated with cancer screening and health behaviors; education & race are associated with activity & diet. Race is associated with pap screening.[Table: see text]