bluuebunny/crossref_metadata_2025 huggingface dataset:
Identifying visual sensitive areas: an evaluation of view corridors to support nature-culture heritage conservation in Chiang Mai historic city
Authors: Sukwai Janjira , Mishima Nobuo , Srinurak Nattasit
Published: September 2022

The visual integrity of mountains contributing to cultural landscapes as nature-culture attributes is often obscured by the vertical intrusive built environment, especially in buffer areas of protected heritage zones. Therefore, this study argued that even low/medium-rise buildings that inappropriately appear in the horizontal visual plane could be a factor increasing sensitivity to this panoramic view.

An integrative tool – visual sensitivity assessment – consists of Viewshed and Skyline analysis considering the pedestrian’s visual limitation in identifying the sensitive areas of the mountain view corridor in the historic city of Chiang Mai. The visible mountain areas (VMAs) were determined as a baseline, and their relationship with the visible building areas (VBAs) was then examined using statistical correlation to define a strong negative relationship as the visual sensitive areas in five zones. The results showed that the buffer zone was found to have more areas with visual sensitivity values, but this varies depending on the characteristics of buildings and the assessment from the view corridor. Meanwhile, in height-restricted areas, such as historic area zone 5, there are some concerns about the visual intrusion, which necessitates continuous monitoring using the assessment result as a guideline.

Incorporating the results into implementation could support cultural landscape conservation in Chiang Mai city. The method is applicable in historic cities with similar settings to produce the baseline for the built environment that is harmonious with the cultural and historical characteristics of the city and with respect to its broader setting.
Financial toxicity of front-line platinum etoposide plus atezolizumab versus durvalumab in extensive-stage small-cell (ES-SCLC) lung cancer.
Authors: Harrison Bradley , Keith Nicole , Verbyla Allison , Mileham Kathryn Finch
Published: September 2022

23

Background: With the continued advent of new therapeutics, burgeoning costs and financial toxicity are more frequently a complication in comprehensive cancer care. At Levine Cancer Institute (LCI), a multidisciplinary Financial Toxicity Tumor Board has driven $55-60 million in cost savings for patients annually, and presented patient cases can serve as a continual impetus for iterative quality improvement and cost-savings research. One such example highlights the augmented risk of financial toxicity resultant from increasing utilization of front-line chemoimmunotherapy (chemo-IO) in ES-SCLC. Both atezolizumab and durvalumab in concert with platinum-etoposide chemotherapy separately portend an overall survival benefit. Retrospective analyses have failed to demonstrate a PFS or OS advantage between the two regimens. Amidst comparable efficacy, we sought to ascertain institutional variance in cost profiles and financial toxicity. Methods: Billing and demographic data for patients with ES-SCLC who received chemo-IO with durvalumab or atezolizumab in an LCI hospital-based outpatient infusion center were queried. Treatment dates encompassed October 1, 2019 through April 30, 2022. Patient costs were compared and exploratory analyses were performed related to patient demographics, patient geography (with financial characteristics per Census data) and bad debt proportions. Results: 211 patients received chemo-IO with atezolizumab, and 108 patients received chemo-IO with durvalumab. Medicare (+/- supplementary insurance), Medicare Advantage, and commercial insurance constituted 85% of payors. Institutional covenants restrict publication of commercial and supplementary insurance data; for compliance and generalizability, reported is the Medicare-only population. Medicare allowables of $6791 and $8429 were utilized per dose of atezolizumab 1200 mg and durvalumab 1500 mg, respectively. Amidst 20% patient responsibility with Medicare, durvalumab patient cost was $327.60 higher per cycle. Incorporating observed mean number of cycles of 5.20 for atezolizumab and 5.31 for durvalumab, an average course of durvalumab was $1836.56 more expensive. Assessing the entire population, 24% of patients in both groups met criteria for bad debt; however, mean quantity of bad debt was 62% higher with durvalumab ($8988.77) than with atezolizumab ($5555.11). Bad debt was disproportionately congregated in lower income zip codes (data to be displayed pictorally). Conclusions: Chemo-IO with durvalumab was $1834.56 more expensive per treatment course in ES-SCLC, with 62% increase in quantity of bad debt relative to atezolizumab. Future directions may focus on institutional interventions to mitigate financial toxicity related to therapy choice and geographic allocation of resources, as well as the assessment of cost variance in other solid tumors.
The use of adjuvant chemotherapy in resected stage IB-IIIA non–small cell lung cancer (NSCLC) and comparison to the TriNetX database.
Authors: Shameem Ayesha , Jubelirer Steven , Annie Frank , Welch Christine A.
Published: September 2022

29

Background: Adjuvant cisplatin-based chemotherapy (AC) is the standard of care for completely resected stage IB (tumor size > 4cm), II, and IIIA non small cell lung cancer (NSCLC) patients. Several randomized clinical trials have shown varying levels of survival benefit for patients treated with AC compared to surgery alone. Methods: A retrospective study was performed regarding the use of adjuvant chemotherapy comparing Charleston Area Medical Center (CAMC) patients to those in the TriNetX database in the years 1998-2017. Inclusion criteria were patients > 18 years of age, completely resected (R0), stage IB (tumor size > 4 cm) through stage IIIA (R0) NSCLC. SAS 9.3 was used for data analysis. Results: The populations included two hundred and thirty-six (CAMC) and 4,364 (TriNetX) patients. The CAMC population was 98% Caucasian, 63% male with an average age of 65±10 years. The TriNetX population was 66% Caucasian, 57% male with an average age of 67±10 years. The 5-year overall survival (OS) in the CAMC database between chemotherapy and non-chemotherapy groups was not statistically significant (49.5% vs 49.8%, p = 0.8, respectively). In the TriNetX database, the 5-year OS for the chemotherapy group was significantly higher compared to the non-chemotherapy groups (61.2% vs 54.0%, p < 0.05, respectively). Cox proportional hazards model was used to determine the factors influencing 5-year OS in the CAMC population. Results showed that patients >65 years of age were 2.2 times (95% CI: 1.53-3.2) more likely to be dead in 5-years. With each increase in stage patients were 1.3 times (95% CI: 1.0-1.8) more likely to be dead in 5-years. Moreover, patients without coronary artery disease were 1.7 times (95% CI: 1.2-2.4) more likely to be dead in 5-years. Conclusions: Regardless of treatment, about half of CAMC patients were alive at 5 years, while a higher OS was seen in the TriNetX chemotherapy group. Regression analysis of the CAMC population showed that chemotherapy was not a significant variable in 5-year OS. Differences in survival between CAMC and TriNetX could be due to the large number of comorbidities in the CAMC population, patient refusal to chemotherapy, particularly those >65 years, and incomplete planned dose due to side effects of adjuvant chemotherapy. We conclude that several barriers may impact the use of adjuvant chemotherapy in non-trial settings in the CAMC population.
Implementation of an innovative multidisciplinary survivorship clinic: The OWLS (Oncology, Wellness, Lifestyle and Survivorship) experience.
Authors: Duffy Christine Mary , Higel-Mcgovern Camille , Dizon Don S.
Published: September 2022

34

Background: Cancer survivors have complex medical and psychosocial needs and report difficulty accessing specialty care for short and long-term effects of treatment. We created an innovative multi-specialty survivorship clinic to address the medical and psychosocial consequences of cancer and to promote wellness and healthy lifestyle changes. Methods: The “Oncology, Wellness, Lifestyle and Survivorship” (OWLS) clinic was implemented 12/2020 for breast and gyn cancer survivors and extended to all cancer types in 111/2021. Patients complete pre and post-clinic survey to their medical and psychosocial concerns. OWLS is led by an internist and NP expert in survivorship with nurse navigator, physical activity coach, massage therapist on-site. A multidisciplinary team of providers experienced in survivorship care from hem/onc, cardiology, pulmonary, rheumatology, nephrology, dermatology, endocrinology, neurology, psychiatry, sexual health, physical therapy, nutrition, and lifestyle medicine meet monthly to create a comprehensive care management plan presented to survivors at their follow up visit and shared with their PCP and oncologist. Results: The OWLS team has seen 91 patients as of May 2022 and had 12 MDC meetings. Mean survivor age was 50 and the majority were white (80%) had breast cancer(76%) with non-metastatic disease 80%. Most frequent referrals were nutrition, physical therapy, gastroenterology and sexual health. At 6 mos f/u survey almost all were v.satisfied/satisfied with care. All OWLS MDC providers rated it as valuable. Conclusions: The OWLS clinic is an innovate, multi-specialty program that provides a comprehensive survivorship plan for cancer survivors at any stage of their disease. Areas for future growth include extending onsite services, expanding the number of male survivors serviced, and increasing outreach to non-white, non-commercially insured patients.[Table: see text]
Impacts on breast cancer screening by targeting high-risk individuals through the utilization of allied health members in rural India.
Authors: Menakuru Sasmith
Published: September 2022

38

Background: Currently, screening in rural India is done in most instances by utilizing mobile detection units that the government of India sets up to reduce the barrier of accessibility. These screening camps infrequently occur and manage to screen around 100-150 people a day. Screening even with a positive result is ultimately useless without follow-up care. Breast cancer, which is often diagnosed late in presentation, is widely screened for by utilizing mobile mammography screening units. The authors propose that instead of recruiting patients randomly, patients should be chosen prior to the set-up of camps by using accredited social health workers (ASHAs), community health leaders (CHL), and other allied health professionals (AHP) based on risk factors. Methods: Mobile health screening camps were deployed in rural Andhra Pradesh, India, where for 2 screening sessions, females were recruited either a day before or just before set up. These results were compared to another 2 screening sessions where females were recruited for 2 weeks prior to being set up by ASHAs, CHLs, and other AHPs. They recruited patients at risk of breast cancer, including those with a family history, who were smokers, who felt a lump on self-examination, who had a prior history of cancer, and those with a BMI over 25. They explained about mammography, the need for them to be screened, and the need for follow-up care. Both data sets were compared to check for positivity rates on mammography and establishment of the initial follow-up appointment. Results: It was found that the screening camps where recruitment took place on the same day or the day before had a more significant number of patients who were recruited to get screened. In total, 267 people were screened that day. Out of those 267, mammography was positive in 21 patients; however, only 1 of those 21 patients established care at a follow-up visit. In the screening camps where ASHAs, CHL, and other AHPs were recruited to recruit patients based on high-risk factors, a total of 138 people were screened. Of those 138 people, 37 people had positive findings on mammography. Out of the 37 people, 29 patients established follow-up care. It was found that due to the decreased number of mammograms performed, the overall cost went down even with the need to allocate funding for recruitment. Conclusions: This study showed that it is beneficial to establish the recruitment process before setting up mammography camps by utilizing ASHAs, CHLs, and other AHPs to screen for high-risk individuals. Despite a more significant number of patients screened using the current widely utilized method of randomly recruiting patients in India, the follow-up rates were poor. By targeting high-risk women for mammography, the follow-up rates improve, and the overall cost of the screening camp decreases.
Strategic team engagement for successful documentation of pain management.
Authors: Bates Christine , Crum Erin , Brooks Donald J. , Andres Grant
Published: September 2022

53

Background: Pain is experienced by a majority of cancer patients, often having a significant negative impact on their quality of life. Effective documentation of pain scores and plan of care provide care teams with data for decision-making to improve pain management. In Q2 of 2021 documentation deficiencies were identified. Process improvement interventions were initiated through the remainder of 2021 to support clinical teams. Methods: Over the course of twelve months our practice sought to improve documentation of pain management through a multi-pronged approach. Execution began with initiation of the Quality and Safety Committee early in 2021 to engage key stakeholders. Our Chain of Command Project identified strategic members of the administrative and clinical leadership teams at the individual clinic level who initiated monthly meetings to promote quality awareness and engagement. Quality measures associated with pain management, MIPS 143 and 144, were examined with assistance from our Value Based Care Transformation Team. Monthly provider scorecard distribution commenced Q2 to identify documentation inconsistencies related to pain management. Providers, medical assistants, and scribes were provided education and training related to appropriate pain management documentation workflows. Follow up audits were performed by the Quality team. In Q3 and Q4 the Quality team collaborated with Human Resources to identify new employees and facilitate education on quality metric capture within a month of hire. Results: The data above is a representation of all clinics and patients treated. The interventions resulted in improved metrics from 2020 to 2022 YTD: MIPS 143 +5.5%, MIPS 144 +27.3%, and PIMSH4 +6.3%. Conclusions: Effective change management occurred from the top down with additional engagement of administrative and clinical members. Analysis of the internal structure and deficiencies was needed with implementation of metric training. Data transparency helped with engagement and managing documentation of MIPS 143 and 144. Next steps include leveraging the current documentation processes to improve PIMSH4, ultimately improving the quality of life for patients.[Table: see text]
Associations of delays in care due to transportation barriers and care utilization, and cause-specific mortality risk among the U.S. adults with a cancer history.
Authors: Jiang Changchuan , Deng Lei , Perimbeti Stuthi , Wang Qian , Yabroff K. Robin Robin , Han Xuesong
Published: September 2022

70

Background: Cancer survivors have greater comorbidity burden, health care use, and mortality risk than individuals without a cancer history. Cancer survivors are also more likely to experience transportation barriers to care in the US. This study examines associations between transportation barriers and cancer survivors' care utilization and outcomes in a nationally representative sample. Methods: We identified cohorts of cancer survivors (n = 28,606) and adults without a cancer history (n = 469,860) from the 2000-2018 National Health Interview Survey (NHIS) linked to the recently released NHIS Mortality Files. Transportation barriers were measured as medical care delays during the past 12 months due to lack of transportation. Outcomes included lack of routine place for care, emergency room (ER) use during the past 12 months, all-cause, and cancer-specific mortality. Their association with transportation barriers was estimated using weighted multivariable logistic, and Cox’s proportional hazards regressions, respectively. Models were adjusted for age, sex, race, educational attainment, comorbidities, region, year of survey, and functional limitations, as well as time since cancer diagnosis, and cancer types (breast, colorectal, prostate, and others). Health insurance coverage was added sequentially to models. Results: 2.8% of cancer survivors and 1.7% of adults without cancer history reported delays in care due to transportation barriers. Cancer survivors with transportation barriers had the strongest associations with lack of routine place for care and ER use; followed by survivors without transportation barriers; and adults without a cancer history with and without transportation barriers (Table). Similarly, transportation barriers were associated with the highest risk of all-cause and cancer-specific mortality risk among cancer survivors. Further adjustment for health insurance reduced the magnitude of association between transportation barriers and mortality. Conclusions: Cancer survivors who delayed care due to lack of transportation were more likely to use the ER. They also had the highest risks of all-cause and cancer-specific mortality. Efforts are needed to mitigate transportation barriers in the rapidly growing but vulnerable cancer survivor community.[Table: see text]
Association of the Affordable Care Act Medicaid expansion and receipt of palliative care among individuals newly diagnosed with advanced stage cancers.
Authors: Han Xuesong , Shi Kewei , Zhao Jingxuan , Nogueira Leticia M , Parikh Ravi Bharat , Jemal Ahmedin , Yabroff K. Robin Robin
Published: September 2022

73

Background: Receipt of palliative care is a guideline-based practice but is low among patients with advanced cancer is low in the U.S. Lack of insurance is a major barrier to accessing palliative care. It is unknown, however, whether Medicaid expansion under the Affordable Care Act (ACA) and the associated increase in insurance coverage among individuals diagnosed with cancer has led to increased palliative care. We use a nationwide dataset to examine the association between Medicaid expansion and receipt of palliative care among individuals newly diagnosed with advanced stage cancers. Methods: Individuals aged 18-64 years with newly diagnosed stage-IV solid cancers pre- (2010-2013) and post- (2014-2019) ACA Medicaid expansion were identified from the National Cancer Database. We used difference-in-differences (DD) analyses to estimate the association between Medicaid expansion and changes in receipt of palliative care as part of first-line therapy, adjusting for age group, sex, race/ethnicity, area-level poverty, metropolitan status, comorbidity, facility type, palliative care specialist availability, diagnosis year and state of residence. Stratified analyses were conducted by cancer type and sociodemographic factors. Results: A total of 685,781 individuals diagnosed with stage IV cancers were included from Medicaid expansion (N = 439,142) and non-expansion (N = 246,639) states. The percentage of eligible patients who received palliative care as part of first-line therapy increased from 17.0% pre-ACA to 18.9% post-ACA in Medicaid expansion states and from 15.7% to 16.7% in non-expansion states, resulting in a net increase (DD) of 1.4 (95%CI = 1.0-1.8) percentage points in expansion states after adjusting for sociodemographic and clinical factors. The increase in receipt of palliative care in expansion states compared to non-expansion states was greater for patients with advanced pancreatic (DD = 2.5; 95%CI = 0.8-4.3), colorectal (DD = 2.2; 95%CI = 1.1-3.3), female breast (DD = 1.9; 95%CI = 0.1-3.7), lung (DD = 1.6; 95%CI = 0.7-2.5), oral cavity and pharynx (DD = 1.1;95%CI = 0.5-1.6) cancers, and non-Hodgkin lymphoma (DD = 0.9; 95%CI = 0.2-1.5). The improvement in receipt of palliative care was larger among individuals aged 55-64 years, non-Hispanic White patients, and patients residing in middle-income areas and nonmetropolitan areas. Conclusions: Among individuals newly diagnosed with stage-IV cancer, Medicaid expansion was associated with increases in receipt of palliative care, although overall use was low. Furthermore, the increase varied by cancer type and sociodemographic factors. Improving access to insurance can facilitate access to guideline-based palliative care.
Palliative care utilization and trends among patients with metastatic breast cancer: A SEER-Medicare analysis.
Authors: Giap Fantine , Hong Young-Rock , Xie Zhigang , Li Yujia , Guo Yi , Bradley Julie Ann , Oladeru Oluwadamilola Temilade
Published: September 2022

75

Background: Receiving palliative care (PC) is associated with improving quality of life in patients with cancer. Despite its clinical benefits, limited data is available regarding PC utilization among the metastatic breast cancer population. Examining the trends and current patterns of PC provide an opportunity for improved effective implementation of PC in management of patients with breast cancer. Methods: SEER-Medicare linked data was queried to identify patients with metastatic breast cancer aged > 65 years between 2006 and 2017. PC utilization since diagnosis was identified using ICD-9 code V66.7 or ICD-10 Z51.5. Descriptive statistics were used to summarize patient characteristics by the receipt of PC. Multivariable logistic regression was estimated to identify predictors of PC use. Trends in PC utilization were then compared by patient race/ethnicity, residential region, and census poverty rate. Results: Of 11,245 patients with metastatic breast cancer diagnosed between 2006 and 2017 (median survival, 17.9 months), 1,756 (15.6%) received PC (median time from diagnosis to PC, 18.5 months). During the study period, PC use increased significantly from 2.5% in 2006-2007 to 28.1% in 2016-2017 (P trend <.001). Patients with metastatic breast cancer who received PC were more likely to be younger (20.6% among 65-69 years old vs. 11.9% among 80+), living in the West census region (17.2% vs. 14.1% in South), urban areas (16.8% vs. 8.2% in rural), and low poverty rate (16.1% with < 5% poverty level vs. 12.9% with > 20%) (P all <.05). There was no significant difference observed by race or ethnicity (P >.05). Conclusions: There was a significant increase in PC utilization among patients with metastatic breast cancer aged > 65 years between 2006 and 2017. However, its utilization rate remains suboptimal, with geographic, age and income disparities in PC use.
Clinical trial participation in a majority-minority, NCI-designated cancer center.
Authors: Bailey Ryan , Mazo- Canola Marcela , Ko Heidi Chwan , Diaz Duque Adolfo Enrique
Published: September 2022

86

Background: Substantial racial and ethnic disparities exist in clinical trial enrollment. Because oncology has rapidly evolved into a field rife with therapies aimed at specific biologic differences in patients, disparities in the standard of care and treatment outcomes have arisen, mainly in minorities such as Hispanics, African Americans, and Native Americans/Alaskan Natives. These disparities are due mainly to the limited understanding of tumor biology in underrepresented groups. The lack of representation in clinical trial enrollment represents both a grave oversight in oncology and an opportunity to increase treatment options for underserved groups significantly. Methods: Retrospective single-institution analysis including patients enrolled in clinical trials between 2014 and 2018. We use a Negative Binomial generalized linear model to measure the racial and ethnic disparities in Mays Cancer Center's clinical trials accruals from 2014 to 2018. Results: 4724 patients with various tumor types were enrolled in clinical trials at the mays cancer center: Using a Negative Binomial generalized linear model, we discover that clinical trial enrollment is distinct in Blacks (ecoefficient = 0.22, p = 1.38e-09) and Asians (ecoefficient = 0.08, p = 3.03e-20) when compared to Whites. Hispanics and Non-Hispanics do not differ in clinical trial enrollments (ecoefficient = 0.77, p = 1.34e-01). Both Hispanic and Non-Hispanic Asians are greatly underrepresented; Non-Hispanic whites are overrepresented. Hispanics of all races are overrepresented in breast cancer trials as compared with Non-Hispanics (p = 6.89e-18). The inverse is true for genitourinary trials, with Non-Hispanics being overrepresented as compared to Hispanics (p = 9.78e-46). Conclusions: Hispanics were disproportionately enrolled in breast cancer trials, and Non-Hispanics were disproportionately enrolled in GU trials. Mays Cancer Center outperforms similar institutions in the enrollment of Hispanics, yet despite this, Hispanics are still somewhat underrepresented in our trials. Asians broadly are underrepresented in MCC enrollments.
Race in a molecular tumor board compared to cancer registry population.
Authors: Randall Jamie , Wang Hongkun , Cannon Timothy Lewis , Winer Arthur , Wadlow Raymond Couric
Published: September 2022

103

Background: Disparities in cancer care due to race and ethnicity are prevalent in both the care patients receive and patient outcomes. The evaluation of next generation sequencing (NGS) results from patients with advanced cancer by a molecular tumor board (MTB) has become standard practice in many institutions for the identification of additional treatment options and targeted therapies. We sought to compare the racial distribution of patients evaluated by our MTB with our institutional cancer registry (CR). Methods: We tabulated the racial distribution of 560 MTB patients chosen for presentation in a bimonthly case conference based on physician request or clinical interest from more than 2,500 NGS reports of patients with advanced cancer from 2016 through 2020. Self-identified race from patients with stage 4 cancer within our institutional CR from the same time interval was compared to the MTB population from each year using the Chi-Squared test. The Cochran-Mantel-Haenszel test was used to analyze the relationship between race and MTB/CR after controlling for year. Race categories were defined as Asian, Black/African-American (AA), White/Caucasian, and other. Results: We identified 4,151 CR patients with stage 4 cancer from 2016 through 2020, 573 of whom identified as Black/AA (13.8%). Of the 560 MTB patients, 55 were Black/AA (9.8%). When controlling for year, Black/AA patients were less frequently included in the MTB compared to the CR (p = 0.0128). Conclusions: Black/AA patients with advanced cancer are under-represented in our MTB. Larger studies are warranted to examine underlying causes of this discrepancy including implicit bias, generalizability of this finding to other minorities and institutions, and potential remedies to ensure equitable access to state-of-the-art cancer care.[Table: see text]
Quality initiative to improve lung cancer screening in a Veterans Affairs medical center.
Authors: Miotke Laura , York Audrey , Bowles Alicia , Lewis-Williams Farrah , Beck Emily
Published: September 2022

108

Background: In 2013 the US Preventative Services Task Force recommended lung cancer screening (LCS) with low-dose CT (LDCT) scans in high-risk populations. Eight VA Medical Centers (VAMC) successfully piloted LCS in a demonstration project and several additional VA sites have since launched LCS programs, including the Salt Lake City VAMC. These systems utilize the “Clinical Reminder System” (CRS) in the electronic medical record to enroll patients into the LCS program which allows LDCTs to be tracked by a nurse coordinator. As these programs are relatively new, improvements and shared knowledge is imperative to optimizing the success of LCS programs. Methods: Our intervention was to change the radiology ordering menu to encourage providers to order LDCTs through the CRS, thus enrolling patients in the LCS program. We examined the percentage of LDCTs performed within the LCS screening program as our process measure. We then chose three outcome measures based on recommendations proposed by a national cancer roundtable: 1) Percentage of Lung-RADS 1 or 2 diagnoses with follow-up within 15 months, 2) Percentage of Lung-RADS 3 diagnoses with follow-up within 8 months and 3) Percentage of Lung-RADS 4 diagnoses with follow-up within 18 weeks. We compared outcome measures between LDCTs performed within the LCS program and those performed outside of the program. Results: We compared a total of 492 LDCTs during a pre-intervention six-month period to the 544 LDCTs performed in the first 6 months after our intervention. Pre-intervention, 54% of LDCTs were performed through the LCS program, compared to 79% post-intervention (p < 0.001). The percentage of Lung-RADS 1 or 2 scans with appropriate follow-up time was significantly better within the LCS program (70%), compared to scans performed outside the program (49%, p < 0.001). There was no statistical difference in follow-up of Lung-RADS 3 or 4 scans. Conclusions: Through this work we learned the CRS is non-intuitive and used with variable comfort within the VAMC. As such, a simple intervention guiding ordering providers from the radiology ordering menu to the CRS was effective in increasing enrollment and adherence to follow up in a VA system LCS program. LCS is complex compared to other cancer screening programs. Many primary care providers and radiologists alike are uncomfortable managing these patients. As such, enrollment in a standardized LCS program and early involvement of a multi-disciplinary team is imperative. Not only did we demonstrate this with our outcome measures, but while examining the system we uncovered many inappropriate follow-up scans, biopsies, and oncology consults that contribute to waste. As lung cancer screening programs continue to evolve, quality improvement projects such as this will help improve lung cancer care and outcomes.
Uptake of second-line anticancer therapy after first-line pembrolizumab in patients with stage IV non–small cell lung cancer with PD-L1 > 50%: Comparison between clinical trials and the real world.
Authors: Rittberg Rebekah , Jones Lauren , Leung Bonnie , Shokoohi Aria , Ionescu D N , Pender Alexandra , Yuan Ren , Wong Selina K. , Al-Hashami Zamzam Salam , Wang Ying , Ho Cheryl
Published: September 2022

126

Background: In KEYNOTE-024 single agent pembrolizumab was compared to platinum-based chemotherapy in advanced non-small cell lung cancer (NSCLC) with PDL1 >50%. Patients treated with pembrolizumab had an improved progression free survival and overall survival (OS). In KEYNOTE-024, 53% of patients treated with pembrolizumab received second line anticancer therapy with a median OS of 26.3 months. The objective of this study is to characterize real-world NSCLC patients who received second line therapy after pembrolizumab. Methods: A retrospective study of stage IV NSCLC patients with PDL1 >50% referred to BC Cancer between 2018-2021 treated with first line pembrolizumab. Patient demographics, treatment received, and outcomes were collected retrospectively. Baseline characteristics were compared using descriptive statistics. Univariate and multivariate analysis was completed. Kaplan-Meier curves was used to calculate OS and compared using the log rank test. Results: Between 2018-2021, 718 Stage IV NSCLC patients received at least 1 cycle of pembrolizumab. Median duration on treatment was 4.4 months and follow up duration was 16.0 months. 567 (80%) had disease progression of which only 21% (n = 119) received second line systemic therapy. Within the subset with disease progression, median duration on treatment was 3.0 months and follow up duration was 11.7 months. Patients who received second line therapy were younger (p < 0.001), better baseline ECOG PS (p < 0.001) and had longer duration on first line pembrolizumab (p < 0.001). There was no difference in sex (p = 0.519), smoking status (p = 0.416) or histology (p = 0.136). In the multivariate model including age (OR 0.95), baseline ECOG PS (PS 0-1, OR 2.59) and duration on pembrolizumab (OR 1.05) each independently impacted receipt of second line therapy, Table. Median OS from date of diagnosis was 9.6 (IQR 8.4-10.9) months in patients who did not receive additional therapy after progression and 25.3 (IQR 22.5-28.1) months in patients who received subsequent therapy, (p < 0.001). Conclusions: In our stage IV NSCLC population, we found that only 21% of patients received second line systemic therapy despite it being associated with improved OS. Compared to KEYNOTE-024, this real-world population found that 60% less patients received second line systemic therapy. Although differences exist between a clinical and non-clinical trial population, these findings suggest significantly undertreating our stage IV NSCLC patients requiring increased rates of offering second line therapy.[Table: see text]
Patterns of molecular testing and targeted therapy use among privately insured patients with cancer.
Authors: Qin Xuanzi , Dusetzina Stacie B
Published: September 2022

133

Background: Despite increased molecular testing (MT) for cancers with actionable biomarkers, the NCCN guidelines only recommend comprehensive MT for newly diagnosed patients with metastatic non-small cell lung cancer (mNSCLC). Methods: We used IBM MarketScan Claims to examine MT and Tx use among privately insured patients < 65 yrs. We identified 101,456 patients with new colorectal, lung, breast, ovary, or prostate cancers or melanoma between 2017-2019. We used procedure codes to identify MT receipt within 6 months after the cancer diagnosis. We divided MTs into three categories: single-gene, panel, or unspecified MTs (tests without a uniquely assigned procedure code). We also identified the use of targeted therapy in the year after the cancer diagnosis. Results: Among 101,456 patients, 14,657 (14.4%) received MT, and 8,166 (8.0%) received targeted therapy. Use patterns varied across cancers (Table). Patients with breast, colorectal, or ovary cancers were more likely to receive MT. Patients with lung cancer were most likely to receive panel tests. Patients with breast cancer were most likely to receive single-gene tests. Patients with lung cancer were the most likely to receive targeted therapy, with or without MT. Median days from diagnosis to MT was the shortest for lung cancer and the longest for prostate cancer. Median days from diagnosis to targeted therapy was the shortest for lung cancer and the longest for ovary cancer. Conclusions: We observed higher uptake of MT among individuals with lung cancer, consistent with recent guidelines. However, the high use of single-gene tests among patients with lung cancer, the receipt of targeted therapy without MT among patients with breast or lung cancers, and the use of multiple types of MT might suggest poor quality of care. Moreover, despite multiple actionable biomarkers, the uptake of MT was low in other cancers. Patients with other cancers might not benefit from the advances of cancer precision medicine due to the lack of clear guidelines.[Table: see text]
Predictive factors for cancer treatment delay in an underserved urban population.
Authors: Sheni Risha , Qin Jiyue , Viswanathan Shankar , Castellucci Enrico , Mehta Vikas
Published: September 2022

136

Background: Incremental delays in time to treatment initiation (TTI) have been shown to cause a proportional, independent increased risk of disease specific mortality for breast cancer, colorectal cancer (CRC), head and neck (HNC), non-small cell lung cancer (NSCLC) and pancreatic cancer. Delays can partly be attributed to increasingly complex workup with modern imaging, genomic and multidisciplinary/multimodality treatments. However, studies suggest delays are associated with racial and socioeconomic disparities, implicating a target for addressing inequity. Given Montefiore Medical Center (MMC) serves a racially diverse, socioeconomically challenged population, we sought to evaluate associations between patient factors and TTI to identify those associated with delay. Methods: Retrospective cohort study at an urban community-based academic center of patients diagnosed with or referred for curative intent treatment of breast cancer, CRC, HNC, NSCLC and pancreatic cancer at MMC from January 2019 to December 2021. Variables of interest included tumor stage, primary treatment modality, median household income, Charlson Comorbidity Index (CCI) score, tobacco use, insurance type, language preference and inpatient (IP) admission or emergency room visit 30 days prior to diagnosis. Results: A total of 2543 patients (F = 1755, M = 788) were identified (mean age 63.4 ± 13.4). The median TTI was 25 days (6, 44 IQR). Factors associated with TTI delay were assessed using logistic regression (Table). Patients who were treated outpatient, and not admitted 30 days prior to diagnosis, experienced increased delay for CRC (OR 2.82) and NSCLC (2.11). Higher CCI score was associated with delay for HNC (2.63) and NSCLC (1.75). For breast cancer, uninsured and Spanish-speaking patients (1.79) were subjected to increased TTI. Conclusions: This study identifies predictors and opportunities for addressing delay and health inequity while improving survival. IP admission 30 days before diagnosis was associated with timely TTI for CRC and NSCLC. Other factors predictive of delay included CCI score in HNC and NSCLC, and insurance type and preferred language in breast cancer.[Table: see text]
Overall survival by race and ethnicity among men with metastatic castration-resistant prostate cancer (mCRPC) in the U.S. Medicare population.
Authors: Freedland Stephen J. , Davis Matthew , Epstein Andrew J. , Arondekar Bhakti , Ivanova Jasmina I.
Published: September 2022

144

Background: Previous studies reported mixed findings about racial and ethnic disparities in overall survival (OS) in mCRPC. This study describes OS by race and ethnicity among men with mCRPC in the US Medicare population. Methods: Men newly diagnosed with mCRPC were identified in Medicare fee-for-service claims during 1/1/2014–6/30/2019. Adult men were required to have a diagnosis of prostate cancer, metastasis diagnosis, castration-resistance using a published claims-based algorithm, and continuous insurance coverage for ≥1 year before and ≥6 months after index mCRPC diagnosis unless patients died. OS from mCRPC diagnosis and from start of first-line (1L) therapy for mCRPC for White (W), Black (B), Hispanic (H), and Asian (A) men were estimated using Kaplan-Meier analysis and Cox proportional hazards models adjusting for patient characteristics and 1L mCRPC therapy type or no treatment. Results: Among 14,780 men with mCRPC in this study, 75% were W, 14% were B, 6% were H, 3% were A, and 3% were of other or unknown race. Mean age at mCRPC diagnosis was 76 years among W men; B men had similar age while H and A men were slightly older than W men (Table). B, H, and A men had higher Quan-Charlson Comorbidity Index (CCI) than W men. Median follow-up after mCRPC diagnosis was 17 months. Similar proportions of W, H and A men (78%, 78%, and 79%, respectively) and lower proportion of B men (75%) initiated 1L life-prolonging therapy after mCRPC diagnosis. Among treated men, higher proportions of B, H, and A men (71%, 74%, and 73%, respectively) initiated 1L therapy with novel hormonal therapy than W men (64%). Median OS after mCRPC diagnosis was 26.0, 22.3, 22.9, and 24.2 months among W, B, H, and A men, respectively. Median OS after initiation of 1L mCRPC therapy was 23.8, 21.1, 19.9, and 24.1 months among W, B, H, and A men, respectively. After adjusting for patient characteristics and 1L treatment, OS was not different for B and H men relative to W men, while A men had lower risk of death. (Table). Conclusions: This study found no statistically significant differences in overall survival in mCRPC for B and H men and lower risk of death for A men relative to W men after adjusting for patient characteristics and treatment in the US Medicare population.[Table: see text]
Association of race, ethnicity, and socioeconomic characteristics as predictors of cachexia risk and survival in stage IV non–small cell lung cancer (NSCLC).
Authors: Olaechea Santiago , Liu Alison , Sarver Brandon , Alvarez Christian , Gilmore L Anne , Infante Rodney E , Iyengar Puneeth
Published: September 2022

151

Background: Cachexia, seen in more than a third of patients with non-small cell lung cancer (NSCLC), directly leads to functional and survival detriments. As screening and interventions for cachexia and NSCLC improve, deficits of healthcare access and quality among patients disadvantaged by race and socioeconomic factors must be addressed. Methods: Through retrospective and prospective data collection, we established a cohort of 957 patients diagnosed with stage IV NSCLC between 2014-2020 in Dallas, Texas. Presence of cachexia at diagnosis was determined using consensus criteria for substantial (5% for BMI≥20 and 2% for BMI < 20) unintentional weight loss in the 6 months leading to diagnosis. Analyses including multivariate logistic regression and log-rank testing evaluated for significant associations of variables with cachexia incidence and survival. Results: Black race and Hispanic ethnicity independently associated with more than a 70% increased risk of cachexia at NSCLC diagnosis (Table; P < 0.05). Inclusion of private insurance status as a covariate diminished this finding for Hispanic patients only. Black patients presented at younger ages than White patients (Kruskal-Wallis P =0.0012; T-test P = 0.0002), with an average difference of 3 years. Cachexia at diagnosis was a major predictor of survival, highlighting the importance of addressing differential cachexia risk across race/ethnicity. Conclusions: The elevated cachexia risk observed for Black patients independent of insurance status reveals broader causative factors of disparity. A lack of private insurance may be a primary contributor in Hispanic cachexia prevalence. Targeting these differences could mitigate survival detriments linked to cachexia in minority groups. Supported contributors in broader NSCLC outcome inequities include poor representation in trials substantiating USPSTF guidelines as well as preventable barriers to primary and preventative care. Our interpretation of NSCLC outcome disparity in the context of cachexia demonstrates further consequences of these deficits. Moreover, our findings suggest novel targets for health policy by highlighting the prevalence of undiagnosed unintentional weight loss in minority populations with late-stage NSCLC.[Table: see text]
Harnessing academic-community partnerships to improve colorectal cancer screening rates in medically underserved communities.
Authors: LoConte Noelle K. , Antoine Allison , Corbett A. Michelle , Stehman Carrie , Frazer David , Ticku Abhishek , Williams Aronica , Sprecher Elissa , Kos Allison
Published: September 2022

166

Background: Colorectal cancer continues to be very common, and a widening racial disparity has been demonstrated. Wisconsin’s Comprehensive Cancer Control Program which is a program of the University of Wisconsin Carbone Cancer Center partnered with nine Federally Qualified Health Centers (FQHCs) on this five-year program to increase colorectal cancer (CRC) screening. Methods: This project was funded by the CDC and was a partner of a state’s comprehensive cancer control program and a variety of community health centers. Activities included clinical and environmental assessment and baseline data review of CRC screening, identification of a CRC screening team at each clinic, selection and implementation and evaluation of a panel of evidence-based interventions (EBI) per the The Community Guide to Preventive Services. Ongoing implementation data tracking and monitoring strategies were used to create opportunities for data-informed decisions at each clinic. Results: FIT kits were the preferred CRC screening modality. The preferred EBI were patient reminder systems, provider reminders, reducing structural barriers, professional education, EMR improvements and small media. Screening rates for CRC increased by 17% over the course of the project with a peak weighted average of screening at 51.8% for eligible average risk adults, which was up from a baseline of 34.8%. Over 9,000 take-home stool kits were distributed, and a 60.7% completion rate was achieved. The positivity rate for the FIT kits across all centers was 7.6%. A subset of the patients with a positive FIT (n = 97) were reviewed and 53.7% (n = 51) did not have a documented colonoscopy in their electronic medical record. Conclusions: This project of an academic-community partnership was successful in increasing CRC screening in medically underserved communities in Wisconsin. The positivity rate in this high needs population was higher than expected based on prior publications. Further efforts should focus on decreasing the gap between positive FIT testing and completion colonoscopy.[Table: see text]
Preliminary findings from a consensus building process to update financial advocacy services guidelines.
Authors: Mangir Christina , Harvey Allison , Santiago Angie , Schneider Lori , Doherty Meredith , Boehmer Leigh , Kajdic Hodzic Rifeta , Lucas Lorna
Published: September 2022

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Background: In 2018, the Association of Community Cancer Centers (ACCC) developed the Financial Advocacy Services Guidelines to support cancer programs and practices with proactively addressing patients’ financial concerns along the cancer care continuum. Since then, research on financial hardship has expanded and the field of financial advocacy has continued to grow and evolve, necessitating new guidelines. Methods: To assess the current landscape of cancer financial advocacy interventions, ACCC conducted a literature scan of articles published between 2016 and 2021 using key words including financial advocacy, navigation, toxicity, oncology, and cancer. In May 2022, ACCC convened a multidisciplinary group of 49 national experts to begin developing new guidelines through a consensus-based Delphi process. To identify changes and additions to the 2018 guidelines, the panel completed a brief qualitative survey that asked which services are most important to include as a part of financial advocacy programs and necessary resources for effective delivery. Responses were compiled in a document and grouped by similarity using a rapid qualitative analysis approach. Results: The literature scan yielded a total of 55 articles. Several key recommendations emerged including the need to further integrate financial advocacy into care planning services, more training across team members to address financial toxicity, and ensuring services are accessible and equitable. Additional areas for research were ways to leverage technology to enhance services, when and how to screen for financial distress, and the development of care models. From the survey, responses clustered in the following domains and sub-domains: Financial Advocacy Services and Functions (Benefits Verification, Pre-Authorization, & Insurance Optimization; Financial Distress Screening; Patient Communication & Education; Financial Assistance); Program Management Functions (Staffing/Roles & Responsibilities, Staff Training, Infrastructure & Information Exchange, Monitoring & Evaluation); and Stakeholder Management Functions. Conclusions: Early input from the panel illuminated numerous areas for defining new guidelines to increase comprehensiveness, incorporate an explicit focus on health equity, and begin to tease out minimal and optimal services and program components and structure. The information from the literature scan and survey are being used by ACCC and a guidelines task force of field experts to draft new financial advocacy services guidelines, which will then go through at least two rounds of rating by the Delphi panel in order to find areas of consensus. ACCC will also hold a series of roundtables with patient advocacy, commercial, and pharmaceutical stakeholders to allow an opportunity to comment on the guidelines as well. The finalized guidelines are expected to be released before June 2023.