bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality of end-of-life care for veterans with metastatic cancer and advanced chronic kidney disease.
Authors: Grant Shakira Jeanene , Richards Claire A , Burwick Nicholas , Hebert Paul L , O'Hare Ann A
Published: May 2019

e18281

Background: Patients with cancer receive less aggressive interventions and higher quality end-of-life care than those with advanced chronic kidney disease (ACKD). However, the relationship between ACKD and cancer and patterns and quality of end-of-life care is poorly understood. Methods: Among a retrospective cohort of all patients with ACKD (estimated glomerular filtration rate < 20 mL/min/1.73m2) who died in Veterans Affairs facilities between 2009-2015 ( N = 9993), we compared dialysis treatment patterns, end-of-life care and family rated quality of care among those who did and did not have a diagnosis of metastatic cancer during the year before death. Data sources included Veterans Affairs clinical and administrative data, Medicare claims, and the United States Renal Data System registry. Family ratings of end-of-life care were based on responses to the Bereaved Family Survey (BFS). We fit logistic regression models and converted the coefficients to predicted probabilities Results: Overall, 1,237(12.4%) patients had a diagnostic code for metastatic cancer during the year before death. These patients were less likely than other patients to have been treated with dialysis before death. In analyses adjusted for patient characteristics and dialysis receipt, patients with metastatic cancer were less likely than other patients to receive intensive procedures (predicted probability: 18.2% vs. 36.2%) and to be admitted to the intensive care unit (ICU) within 30 days of death (30.7% vs. 50.1 %), or die in the ICU (16.2% vs. 33%). These patients were also more likely to receive a palliative care consultation within 90 days of death (46.6% vs. 37%) and to have hospice services at the time of death (55.3% vs. 33.4 %). Family-rated overall quality of care was higher for those with metastatic cancer (59.6% vs. 54.1%). Family members of patients with metastatic cancer also provided more favorable ratings for five individual BFS items including provider listening, informational, emotional support before death and pain control. All comparisons were statistically significant (i.e., P < 0.05). Conclusions: Within a national cohort of US Veterans with ACKD, the presence of metastatic cancer was associated with less dialysis utilization, less intensive medical care, and significantly higher bereaved family ratings of end-of-life care.
Implementing physician education to increase lung cancer screening compliance.
Authors: Olazagasti Coral , Sampat Devi , Rothman Adam , Seetharamu Nagashree , Steiger David
Published: May 2019

e18282

Background: Lung cancer is the leading cause of cancer-related deaths worldwide. The USPSTF recommends annual low-dose CT chest (LDCT) for lung cancer screening in adults who meet the appropriate criteria: age 55-80, current smokers or former smokers who quit within 15years, with a 30 pack-year smoking history. Even with these recommendations, screening rates in these patients remain low. We created a study to assess compliance in an outpatient Internal Medicine clinic to assess the barriers for obtaining LDCT. We hypothesized that by providing an educational program, overall compliance would increase. Methods: The study was divided in two arms: a pre-intervention arm and a post-intervention assessment. Initially, 35 physicians completed a questionnaire on their attitudes to LDCT screening and their reasons for not screening high risk patients. We created a lung cancer screening education program, which consisted of lectures provided to physicians. Following the lectures, consecutive patient visits were reviewed to assess compliance with screening. Results: In the first arm, 678 visits were reviewed. 115 patients met USPSTF criteria of whom only 26% underwent screening with LDCT. The most common reasons for not ordering LDCT scans in patients meeting criteria included: poor knowledge of criteria (22%), failure to determine if patients qualified (13%), patient refusal (8%). Following the education, 208 patients out of the 955 visits reviewed met USPSTF criteria, of which 78% underwent LDCT. Our study showed how after education, physicians were ten times more likely to screen patients for lung cancer (Odds ratio 9.98, 95% CI 5.87-16.94, p < 0.0001). Conclusions: We confirmed there was suboptimal adherence to established LDCT lung cancer screening guidelines, mainly due to unfamiliarity with the screening criteria. By providing educational lectures, compliance improved significantly. We concluded that educating physicians about lung cancer screening guidelines increased LDCT screening tenfold, and therefore benefit patients that are at high risk for developing lung cancer.
Impact of sarcopenia for patients with localized muscle invasive bladder cancer treated by neoadjuvant cisplatin based chemotherapy and radical cystectomy.
Authors: Billon Emilien , Regnier Pierre , De Luca Valeria , Brunelle Serge , Walz Jochen , Dermeche Slimane , Guerin Mathilde , Vicier Cecile , Maubon Thomas , Rybikowski Stanislas , Branger Nicolas , Fakhfakh Sami , Pignot Geraldine , Gravis Gwenaelle
Published: May 2019

e18286

Background: Several studies suggested the prognostic importance of sarcopenia in survival or treatment complications in cancer. The concept of cancer prehabilitation before surgery is gaining wide recognition. The aim of our study was to assess the impact of sarcopenia on chemotherapy toxicities and survival in patients with localized muscle invasive bladder cancer (MIBC). Methods: Between January 2012 and December 2017, patients who underwent neoadjuvant platinum-based chemotherapy (NAC) followed by radical cystectomy (RC) for cT2-T4 N0 M0 MIBC were retrospectively selected, from a single institution cohort. Using CT scan: before NAC, after NAC and after cystectomy, sarcopenia was defined according to the Lumbar Skeletal Muscle Index (SMI) in L3 assessed by two observers blinded to patients’ status. Results: 82 patients were selected, 62 men (75.6%) and 20 women (24.4%), with a median age of 64.5 years (31 to 80). 35 were considered severe sarcopenic (SMI < 35cm2/m2 for women and SMI < 50 cm2/m2 for men) before NAC. The characteristics between severe and non-severe sarcopenic patients were not significantly different except for weight (71.7 vs 81.1kg, p = 0.006) and BMI (24.0 vs 28.4kg/m2, p = 8.0x10-6). Sarcopenia pre-chemotherapy was significantly associated with nausea (p = 0.003), hypokalemia (p = 0.023) and with platinum dose-intensity during NAC (p = 0.007) but was not significantly associated with overall survival (OS) or disease-free survival (DFS). Sarcopenia post-cystectomy was correlated with the OS (HR = 0.94, CI95% [0.89-0.99], p = 0.01), but not DFS. In multivariate analysis, factors associated with OS were post cystectomy sarcopenia (p = 0.038), pN status (p = 0.001) and glomerular filtration rate (p = 0.045). Conclusions: For localized MIBC, sarcopenic status before platinum based NAC could predict some chemotherapy toxicities. After radical cystectomy, sarcopenia is an independent prognostic factor for OS. Improve patients care by prehabilitation during NAC and before surgery, using physical, nutritional and psycho-social supports, could decrease chemotherapy toxicities and improve survival particularly for sarcopenic patients.
Interest and use of alternative/holistic therapies amongst cancer patients at a large urban safety-net hospital.
Authors: Posnik Bartlomiej , Thekkekara Romy Jose , Bharadwaj Sushma , Yim Barbara , Gupta Shweta
Published: May 2019

e18289

Background: Patient interest in alternative/holistic therapies during cancer treatment is common in oncology. Studies have shown that 1 in 3 cancer patients in Europe turn to alternative therapies in combination with conventional medicine. Observational studies have shown some benefit of herbal medications in treating chemotherapy-associated complications; however, there remains skepticism in clinical practice. This study was undertaken to evaluate the interest and use of alternative treatments amongst cancer patients at a large urban safety-net hospital. Methods: An anonymous optional survey was offered in a random fashion to malignant hematology/oncology patients at Cook County Hospital in downtown Chicago. Results: One hundred seventy patients completed the survey comprised of 51% men, 78% being over age 50, and 67% with a high school or higher level of education. Responses included 35% African Americans, 34% Hispanics, and 25% Caucasians. At the time of the survey 16% of patients were currently using alternative treatments, while another 12% were planning to. Eighty-seven percent stated that they believed alternative treatments were very/somewhat beneficial, 77% expressed being very/somewhat interested in their use, and 77% stated they were very/somewhat likely to use such treatments. The treatments of interest included herbal supplements/oils in 40%, meditation/prayer in 29%, and cleanses/diets in 26%. Media and internet were the primary sources of information for 41% patients, while 36% heard about these treatments from family/friends. Although 51% of patients described having some safety concerns of such therapies, 77% had not discussed with their doctor. Conclusions: Our data showed that 28% of patients were either already taking or planning to take alternative/holistic therapies in conjunction with conventional medicine for their cancer care. Data also shows that an even larger number of patients are interested in such options and perceive them to be beneficial; however, there is a general reluctance to discuss it with the treating physician. The use of complementary therapies needs to be more openly discussed in order to better guide patients and assure safety.[Table: see text]
Quality of life and tumor location in patients with desmoid tumors: Data from the desmoid tumor research foundation natural history study.
Authors: Mercier Kelly A , Hernandez Lynne , Boulanger Vanessa , Seebald Allison , Rossov Suzanne , Milligan Kelsey
Published: May 2019

e18291

Background: Desmoid tumors (DTs) are sarcoma, known to invade surrounding tissues, compromising organ function and complications. As few as 5 per 1 million people are diagnosed with DTs annually, which may be an underestimate of the actual affected population due to difficulty in correctly diagnosing the disease. To improve awareness of DTs and better inform treatment development, DTRF, in partnership with the NORD, launched the DTRF patient registry and natural history study. Here, we describe patient demographics, tumor location, and QOL in registry patients. Methods: The registry launched September 2017 and contains 15 surveys covering diagnostics, disease, treatment, care management, and quality of life. As of January 2019, 357 patients have completed 2,371 surveys. Results: Registry participants are mostly white (88%, 313/357), female (81%, 277/343), and reside in 27 countries with 80% (285/357) US-based. Median age at diagnosis is 33 and the time from onset of symptoms to diagnosis was more than 1 year for 54% (189/352). DT location was reported for 119 respondents at time of data collection. Most prevalent locations were joint /extremities (39%, 47/119), intra-abdominal (24%, 28/119), and chest wall (24%, 29/119). Multiple locations were indicated for 22% (26/119). QOL reported as very good or excellent ranged from 28% to 60%, depending on DT location. Conclusions: Patients with DTs have varied QOL and tumor locations. Data collection through the study is ongoing. [Table: see text]
Implementation of the Quality Training Program in Spain.
Authors: Lopez Rafael , Anton Antonio , Aranda Enrique , Carrato Alfredo , Constenla Manuel , Cruz Juan Jesús , Díaz-Rubio Eduardo , Feyjoo Margarita , García Foncillas Jesús , Gascon Pedro , Guillem Vicente , Lugo Ilse , Camps Carlos
Published: May 2019

e18296

Background: The ECO Foundation is a collaboration of experts representing the major Spanish hospitals in the pursuit of excellence in cancer treatment. Since 2015, ECO has been collaborating with ASCO (American Society of Clinical Oncology) in quality initiatives in cancer care, like the QOPI (Quality Oncology Practice Initiative) program and the QOPI Certification Program (QCP). The Quality Training Program (QTP) is a 6-month program with 3 in-person learning sessions that prepares oncology teams to design implement and lead successful quality improvement activities in their practices. In 2018, ECO reached a new agreement with ASCO to implement this program in Spain. Methods: The QTP was developed in Spain by the ECO Foundation in collaboration with ASCO, following the same methodology and contents of ASCO’s program. The first session was carried out on October 2018, with 12 Spanish teams participating with diverse quality improvement projects. The program counted with ASCO and ECO faculty, constituted by experts in the quality and oncology field. Results: The QTP Spanish teams counted with 2-3 representatives from their hospitals. Each team develop an improvement project, following the methodology of the course, including a problem statement, process map, cause and effect diagram, diagnostic data, aim statement, measures, baseline data, priority/pay-off matrix of possible changes/interventions, change data, next steps/plan for sustainability, among others. The projects were mainly focused on the waiting time reduction in the Emergency Area, the waiting time reduction for cancer patients from the visit to the oncologist until treatment administration, burnout reduction on oncology professionals, improvement of the identification and management of complications for cancer patients receiving immunotherapy, improvement of the uniformity in the medical records registry, among others. QTP participants will present the results of their projects on the third and last session of the program, on April 2019. Conclusions: The quality improvement approach followed in the QTP allows Spanish teams and the ECO Foundation to enhance the goal of a quality-oriented health care system. ECO will continue pursuing excellence and quality with further initiatives like the QOPI program, the QCP and the QTP.
Quantifying febrile neutropenia rates using electronic medical records in a large integrated delivery network.
Authors: Budlong Holly , Lin Chia-Wei , Aasen Joanie , Malard Johnson Darcy , Mason Elyssa , Caloyeras John , Conley Erin , Belani Rajesh , Rao Arpit
Published: May 2019

e18298

Background: Febrile neutropenia (FN) is a key driver of morbidity and mortality in oncology patients receiving myelotoxic chemotherapy. Identification and prophylaxis per guidelines can result in a substantial reduction of FN risk and is a key oncology quality of care measure. This project evaluated the feasibility of using electronic medical records (EMR) to quantify FN rates and characterize patients at risk for FN. Methods: Search algorithm was used in EMR to identify patients initiating oncologic care between 1/1/2016 and 12/1/2017 at the Masonic Cancer Clinic, University of Minnesota—Fairview Health System, for a lymphoid, gastrointestinal, breast, female genital, or thoracic malignancy. FN event was identified using a diagnosis of neutropenia (ICD-10: D70.x) with associated fever (ICD-10: R50.2-R50.9) or infection (ICD-10: A40.x, A41.x, B95.0-B95.8, B96.0-B96.8, T80.21-T80.29) during the myelotoxic chemotherapy course. FN rates were evaluated overall and by cancer type, disease status, prior chemotherapy use, select comorbidities, age, curative or palliative intent, and treatment plan FN risk. Results: A total of 1,123 patients receiving 1,663 myelotoxic chemotherapy plans were identified. Patients were predominately female (60%) with a mean age of 61 years (SD: 14.1). A total of 66 patients experienced 79 FN events. Of these events, 70 (88.6%) resulted in a hospitalization. The FN rate during the study period was 5.9% (95% CI: 2.3%-10.2%). Factors associated with the highest FN rates were: lymphoid malignancy (9.9%), non-metastatic disease (7.2%), no prior chemotherapy (6.5%), ≥ 3 comorbidities. Conclusions: Our findings indicate it is feasible to estimate FN rates using a search algorithm with a known FN definition in the EMR of a large integrated delivery network. While additional analyses are planned to account for concomitant patient characteristics to fully understand the occurrence of FN, the current project nevertheless demonstrates the ability of estimating FN rates to both measure care quality and allow pursuing quality improvement (QI) initiatives for appropriate FN prophylaxis. The results also have the potential to serve as a benchmark for similar QI projects in other large healthcare systems.
Factors associated with physician attitude and management of financial toxicity.
Authors: Fischer Katrina , Walling Anne Margaret , Glaspy John A.
Published: May 2019

e18300

Background: Little is known about the attitudes and knowledge of oncologists who discuss financial toxicity with patients compared with those who do not. We assessed perceptions of the oncologists’ role in discussing out of pocket (OOP) costs and financial stress (FS) to inform quality improvement strategies in the management of financial toxicity. Methods: We surveyed 45 practicing medical oncologists at a large academic medical center in 2019 using Likert scale responses. Questions covered three domains; self-perceived knowledge of financial issues related to care, practice of cost discussions with patients, and perceived ability to navigate toward solutions related to FS. Results: Fifty-three percent of oncologists felt comfortable discussing OOP costs, but only 42.5% discussed FS with patients. Over half (55%) lacked confidence they could help patients experiencing FS from treatment. These providers were less likely to ask about FS than those who were confident (r0.416, p0.004). Perceived knowledge among many was low: 48% felt they had little to no knowledge of OOP treatment costs, 33-37% had little to no understanding of how private or public insurance covers treatment respectively, and 60% reported low knowledge of point of care (POC) resources. Those who ask patients about FS reported higher perceived knowledge of insurance (public r0.47, p < 0.001, private r0.452, p 0.002) and POC resources (r0.392, p 0.007), but not more knowledge of OOP cost. Three factors were associated with increased confidence in the ability to help patients; higher knowledge of POC resources (r 0.379, p 0.01); having changed a treatment because of cost within the past year (r 0.395, p 0.047), and years in practice (r 0.329, p 0.047). Conclusions: Many oncologists lack confidence that they can help patients with financial issues, particularly early on in their career. Providers who lack confidence that they can help their patients appear less likely to ask patients about financial stress. Those who do ask about financial stress report higher self-perceived knowledge of insurance coverage and POC resources. This suggests that quality improvement efforts aimed at improving education and resources for providers to help navigate financial toxicity are needed.
Adherence of oral targeted agents in patients with B-cell malignancies.
Authors: Samples Laura S. , Banjanin Dora M. , Kim Booyeon , Graf Solomon A.
Published: May 2019

e18301

Background: Oral targeted agents (OTAs) are rapidly changing the management of B-cell malignancies (BCM) and introducing challenges in prescribing practices and communication between patients, their clinicians, and pharmacists. Emerging data suggests dose interruptions impair OTA efficacy in BCM. However, infrastructure to ensure best practices may be outstripped by increasing OTA use in some clinics. We evaluated adherence to OTAs for BCMs at the Veterans Affairs Puget Sound Health Care System to identify opportunities for quality improvement in prescribing practices and patient education. Methods: Consecutive patients treated with OTAs for BCMs from 2014 to 2018 were examined by detailed chart review and included if they used an OTA uninterrupted for ≥ 30 days. OTA adherence was assessed by 1) identification of medication gaps ≥ 8 days not attributable to medication toxicity or disease progression and 2) ReComp, a validated electronic pharmacy refill adherence algorithm in which a value of 1 corresponds with perfect adherence and deviations from 1 correlate linearly with either over- or under- supply. Logistic regression modeling assessed for independent predictors of adherence. Results: Fifty patients were evaluated and 39 met inclusion criteria. They were prescribed 42 unique OTAs, including ibrutinib, venetoclax, idelalsib, and acalabrutinib over a total of 33,655 days, with a median duration of 420 days (range 60 to 1687). Twenty-three patients (59%) had at least one medication adherence gap ≥ 8 days. Five patients (13%) had ≥ 3 eight-day gaps. The study population had a mean ReComp value of 1.02 (median 0.99, standard deviation 0.15). Medication over-supply was identified in 46% and a quarter of patients were adherent < 93% of the time. No statistically significant correlations were identified between either measure of adherence and examined factors related to socio-demographics and comorbidities. Conclusions: In our institution, a significant percentage of patients prescribed OTAs for BCMs experienced suboptimal adherence. These data identify opportunities to improve disease-related outcomes and costs. Initiatives to improve education and automated monitoring of OTA refills are under evaluation.
Understanding cancer care coordination: Opening the black box.
Authors: Canavan Maureen , Sedghi Tannaz , Gross Cary Philip , Lane Stacey , Bogdan Jeanette , Adelson Kerin B.
Published: May 2019

e18310

Background: Cancer care is complex, requiring multidisciplinary care over time and settings. Our implementation strategy for participation in CMS’ Oncology Care Model included the development of a new care management program to provide elderly patients with cancer support and continuity between inpatient and outpatient care with the goal of reducing acute care utilization. With no published models of care coordination in cancer, we launched this program using nurses experience to risk stratify and manage the needs of nearly 2500 patients. To optimize their work, we sought to understand the activity breakdown of their working time and to identify areas that can be managed more efficiently. Methods: Care coordinators are nurses responsible for completing the Institute of Medicine (IOM) care plan, stratifying patients by risk and comorbidity and administering weekly symptom assessment scales to those at high risk for disease and treatment complications. We created, pilot tested and refined a data collection tool that care coordinators could self-report the time they spent in activities of direct and indirect patient care. We performed a desk audit to measure the amount of time that oncology care coordinators spend on various activities and to explore differences in academic center versus care center care coordinators. A total of seven care coordinators self-reported activity specific time for 5 working days. Data were analyzed to assess variation in the proportion of activity time by care coordinator, site of care and day of the week using anova and t-test for the difference in mean activity time. Results: Care coordinators spent the majority of their time in indirect patient care (58%) with the highest percentage of their time specifically on charting/documentation (28%) while only 42% of their time included activities that were direct patient care. We observed no significant difference in the proportion of time spent in direct versus indirect patient care across care coordinators (p = 0.47, day of the week (p = 0.35) or by location of care (p = 0.68). Conclusions: A minority of care coordinators time is spent on providing direct patient care and substantial time is spent on indirect activities including charting and documentation. The efficiency of the care coordination model may be improved by transferring tasks that do not require the clinical expertise of these nurses.
A digital oncology patient-reported outcomes platform: Building innovative electronic patient symptom assessments in epic mychart to improve the quality of life and survival of patients with advanced cancer.
Authors: Anand Sidharth , Walling Anne Margaret , DAmbruoso Sarah F. , Wenger Neil , Singer Jennifer , Glaspy John A.
Published: May 2019

e18312

Background: Establishing a system to monitor patient reported outcomes (“PRO”) has been demonstrated to be essential for a well-functioning cancer system. Studies have shown that routine collection of PROs allows providers to address medical issues earlier and impacts a patient’s overall survival. Unmet needs for symptom management are prevalent in the cancer population, especially patients with advanced cancer. Approximately 35% of UCLA Hematology-Oncology patients with advanced cancer in 2016 presented to Emergency Rooms for symptom-related complaints such as nausea, pain, constipation, dehydration, and fatigue. We hypothesize that the creation of an electronic PRO platform through EPIC MyChart will ensure patients receive timely evaluation of their symptoms, resulting in improved quality of life, and decreased ER and hospital utilization. Methods: We developed an innovative PRO platform through Epic MyChart along with a Best Practice Advisory alert system to identify patients at risk for worsening symptoms, ER visits, and inpatient admissions. We then built an electronic version of the Edmonson Symptoms Assessment System, which providers can push to patients through Epic MyChart, with results stored within the Flowsheets section of Epic. We also built a passive alert using Epic’s Best Practice Advisory (“BPA”) system, to notify providers when a patient’s MyChart ESAS Assessment Scores have exceeded a defined threshold. Results: Preliminary data from surveys sent to a series of advanced cancer patients seen in an outpatient palliative oncology clinic over 1 month, demonstrated a 100% response rate (6/7) surveys completed when sent one week prior to patient’s being seeing in clinic, and 17% response rate (1/6) when sent two to three weeks prior to clinic visit. The average total ESAS score reported was 40, with average individual score of 4/10 for any given symptom. Conclusions: We will implement this electronic PRO platform in multiple oncology clinics at UCLA, and measure provider and patient satisfaction, completion rates, and monitor outcomes such as ED visits and inpatient admissions. We hope this system will lead to an overall survival benefit. This project demonstrates the potential of developing innovative PRO platforms through Epic MyChart and the importance of clinical workflows in the implementation process.
Survey to evaluate quality of cancer patient care: A questionnaire based analysis in a tertiary hospital.
Authors: Ackula Haritha , Ning Ying , Jindal Vishal , Patil Shekhar , Siddiqui Ahmad Daniyal
Published: May 2019

e18320

Background: As the burden of cancer is on the rise, there is a need to understand the logistics in caring for cancer patients. Internists and nurses are integral part of cancer care team, alongside oncologists. Our aim was to assess their knowledge, attitude and practice in order to identify areas of strength and limitation to help devise opportunities to enhance care. Methods: A close ended cross-sectional survey was conducted among internal medicine physicians, residents and nurses. We developed 36 questions broadly based on cancer-care and distributed them randomly. Additionally, subjects were asked to list factors limiting their ability to provide effective care. We semi quantitatively graded the depth of awareness amongst participants. A total of 95 health care providers were included in the final analysis. Results: Only 62% of participants were accurate in knowledge based questions. About 57% believed all cancer patients benefit from less aggressive treatment and considered chemotherapy side-effects to be the most common cause of hospitalization. Total of 94% reported effective care coordination by visiting nurses, primary care providers in outpatient settings decrease readmissions. Seventy percent thought a dedicated inpatient service run by Oncologists would be better for cancer patient care, with 96% preferring co-management. Around 80% felt they were better able to manage decompensated heart failure and fulminant liver disease than oncological emergencies like neutropenic fever. All the attendings (100%) were comfortable discussing new cancer diagnosis compared to 65% residents and 60% nurses. However 58% of them would like the health care proxy to be involved in all goals of care decisions, irrespective of patient’s capacity. Conclusions: Surprisingly, the baseline knowledge about cancer-care is suboptimal and there is a significant gap in expected versus real cancer-care delivery. Most commonly encountered factors hindering patient-care were lack of awareness of cancer illness trajectories and unclear goals of care with inter-provider disparities/gaps in understanding them. Initiatives such as targeted education, shared care plan and engaging patients at every step is crucial.
Predictors of death for patients treated with palliative intent radiation using prospective databases.
Authors: Agrawal Namita , McClelland Shearwood , Shiue Kevin , Bartlett Gregory , Zellars Richard C. , Watson Gordon A , Tim Lautenschlaeger , Ellsworth Susannah G.
Published: May 2019

e18325

Background: Radiation therapy (RT) effectively palliates pain and other symptoms due to cancer and is frequently offered to patients with metastatic disease. Standard palliative RT schedules range from one to ≥10 fractions; however, prognostic variables related to survival following palliative RT are not well studied. A better understanding of prognostic factors in this setting will assist in selecting appropriate palliative RT regimens for patients with short life expectancies. Methods: Prospectively maintained institutional databases tracking morbidity and mortality and outcomes of a departmental peer review process were used to identify patients who received palliative RT between April 2015 - December 2018. Cox proportional hazards model was used to identify factors correlated with overall survival (OS) and mortality within 30 days (30DM) after completing palliative RT, including age, sex, admission status (inpatient versus outpatient), Karnofsky Performance Status (KPS), treated site and primary site. Results: Of 421 patients, 389 received palliative RT; 30DM rate was 25.7% (n = 100). Median age was 61, median KPS was 70, and 196 patients (50.4%) were female. The most common primary sites were thorax (N = 121, 31.1%) and genitourinary tract (N = 60, 15.4%), while the most commonly treated sites were brain (N = 136, 35.0%) and bone (N = 71, 18.3%). KPS and treatment site were strong independent predictors of both OS and 30DM. Patients with KPS < 70 had an HR 2.61 (95% CI 1.54 – 4.43, p < 0.0001) for 30DM and an HR of 2.22 (95% CI 1.57 – 3.13, p < 0.0001) for death at any time after RT. Treatment site was also independently associated with OS and 30DM (p = 0.01 and p = 0.03, respectively). Median OS durations (95%CI) were: abdomen/pelvis not reached, bone 340 days (133.9-546.1), spine 207 days (28.0 – 386.0), head and neck 184 days (55.2 – 312.8), brain 104 days (34.3 – 173.7) and thorax 76 days (10.3 – 141.7). Age, sex, admission status and primary site were not correlated with OS or 30DM. Conclusions: RT can effectively palliate distressing symptoms related to primary or metastatic cancers. However, early mortality is common following palliative RT and is associated with poor performance status and treated site. Hypofractionated RT courses should be considered in patients with such risk factors to reduce the burden of prolonged therapy on patients and their families at the end of life.
Pneumocystis jiroveci pneumonia during first and second-line chemotherapy for solid tumours.
Authors: Shaughnessy Emma , Armstrong Kevin , Rogers-Seeley Madeline , Das Adarsh , Higgs Domenic , Dean Andrew Peter
Published: May 2019

e18330

Background: Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection, historically associated with individuals with advanced immunodeficiency, sustained temozolamide chemotherapy and in those who have undergone multiple lines of chemotherapy. PJP is now increasingly being recognised in patients undergoing first-line chemotherapy. This is a retrospective study of ten cases of PJP at our institution amongst patients undergoing first or second-line chemotherapy for solid tumours. Methods: An electronic database search was conducted, looking at cases of PJP diagnosed in our institution over a five year period. Ten patients with a history of PJP were identified. These patients’ pharmacy records, pathology, imaging and laboratory results were examined. Results: All identified patients developed PJP whilst undergoing first-line (70%) or second-line (30%) chemotherapy for solid tumours. These included metastatic cancers such as: pancreatic adenocarcinoma (50%), lung cancer (20%), prostate adenocarcinoma (10%), gastric adenocarcinoma (10%); and colon adenocarcinoma (10%). Eight of ten patients were lymphopenic, with lymphocytes counts of 0.1 - 0.5 (reference range 1.0 - 4.0 x 109/L). One patient had a recorded CD4 count of 114 (reference range 500-1500). On the basis of clinical context, ground-glass changes on CT and/or a positive sputum PCR for PJP, each patient was treated with intravenous high-dose trimethoprim/sulfamethoxazole until they were clinically stable. Patients were then switched on to a life-long prophylactic dose. Four patients required intensive care for management of respiratory failure. Nine out of ten patients recovered well without any long-term sequelae and one patient died. Conclusions: PJP is being diagnosed more frequently than previously thought in those receiving first and second-line chemotherapy. Limited research has been conducted into the potential benefit of prescribing trimethoprim/sulfamethoxazole prophylaxis to patients commencing chemotherapy. Monitoring of CD4 count prior to each chemotherapy cycle could provide guidance to oncologists regarding when to commence prophylactic treatment as a means to reducing patients diagnosed with PJP.
Mobile short message service (SMS) alerts for reducing the toxicity and improving protocol compliance during cancer chemotherapy: A randomized controlled trial.
Authors: Chawla Tanuj , Mallath Mohandas K.
Published: May 2019

e18331

Background: Text message-based interventions has been used to facilitate patient care and enhance compliance in clinical oncology. This trial assessed the benefit of text message in reducing emergency room visits and other outcomes related to toxicity and expenses during cytotoxic chemotherapy. Methods: The study was funded by an International Innovation Grant from ASCO. This single center randomised controlled trial was done after approval from our Institutional Review Board. Briefly patients due to take 3-weekly chemotherapy for stomach/gastroesophageal cancer, colorectal cancer, breast cancer and lymphoma were enrolled. Randomization (1:1) was stratified by site and type of chemotherapy. Patients in standard care arm (STD) were given verbal and/or written instructions at the start of each chemotherapy cycle. The interventional (SMS) arm received periodic text messages in addition to the standard care on early warning signs of toxicity at regular intervals during each chemotherapy cycle. Participants were evaluated at the baseline and then followed up for 3 cycles (adjuvant setting) or 4 cycles (palliative setting). Primary endpoint was emergency room (ER) visits. Secondary endpoints included Suspected Unexpected Serious Adverse Reactions (SUSARs), delayed chemotherapy cycles, dose reductions, total cost of care and out of pocket expenditure. The study was designed with a sample size of 400 subjects with an interim analysis planned when 190 patients were randomized. Results: From May 2015 to June 2016, 191 patients were randomized and 189 completed the study [97 in SMS arm and 92 in STD arm]. The median age was 51 years (Range: 23-69) and male:female was 1:2. The relative risk (RR) for ER visit compared to STD arm was 1.09 (95% CI: 0.86-1.38; p = 0.46). The RR for SUSARs was 1.04 (95% CI: 0.99-1.09; p = 0.2); the RR for dose delay was 1.06 (95% CI: 0.9-1.26; p = 0.44) and the RR for dose reduction and 1.16 (95% CI: 1-1.33; p = 0.03). This study was closed prematurely for futility. Conclusions: Text (SMS) message-based patient education during cancer chemotherapy does not to reduce ER visits, SUSARs or cost of care. Clinical trial information: CTRI/2015/02/005491.
Implementation and evaluation of video-based tumor board conferencing in Haiti.
Authors: Lormil Joarly Kerwick , Bhangdia Kayleigh , Svoboda Ludmila , Pierre Viergela , Buswell Lori , Greenberg Lauren , Damuse Ruth , Triedman Scott Andrew , Fadelu Temidayo
Published: May 2019

e18333

Background: Lack of local oncology specialists remains a challenge in delivering cancer care in low-resource areas. Since 2013, Dana-Farber Cancer Institute has partnered with Zanmi Lasante, a Haitian non-profit to support the oncology department at University Hospital Mirebalais, a tertiary government hospital. In an effort to build local capacity, the partnership established weekly remote tumor boards between US oncologists and Haitian clinicians. For five years, the tumor boards were conducted by phone; they were limited by inconsistent participant engagement and suboptimal sound quality. The goal of the project was to enhance the tumor boards by implementing a video-based system, and to evaluate its feasibility and acceptance. Methods: We conducted a baseline mixed-methods assessment of satisfaction among tumor board participants. We trained participants on the new video-platform (ZOOM) and implemented its use. We conducted weekly surveys over an 18-week period, using a Likert 1-5 scale to assess call quality and satisfaction with discussion. We collected general information about cases and call logistics. Lastly, we conducted a post-implementation survey. Two-sample T-test was used to examine changes in satisfaction scores. Results: Over the study period, 12 calls occurred; six calls were cancelled –due holidays (2), lack of cases (4). A total of 32 cases were presented, an average of 2.67/call. The cases by cancer type were: 75% breast, 9.38% gynecologic, 9.38%, hematologic, and 6.26% others. Baseline overall satisfaction ranking from 11 participants (response rate-RR 78.6%) was 3.18, while post-implementation from 8 participants (RR 66.7%) was 4.24, P-value= 0.0025. Summary of Weekly Calls (Averages). Conclusions: There was improved call quality and overall satisfaction with transitioning to video-based tumor boards. During longer video calls with didactics, Haiti participants noted lower call quality and satisfaction, likely due to low internet-bandwidth. Videoconference tumor boards are feasible in low resource settings.[Table: see text]
Experience and impacts of remote telepathology consultation in improving cancer patients’ diagnosis and management in China.
Authors: He Gang , Yan Mingfei , Wu Qingqing , Wang Ying , Zhang Yujie , Lu Jing Amanda , Wu Jiejun , Li Xiaomei , Zhao Songqing , Gu Ping , Iqbal Jameel , Zhang Yue Hua
Published: May 2019

e18337

Background: Over the past 4 years, we have conducted over 30 telepathology consultation cases from China covering a wide spectrum of cancers. Through our experience, we realized that the diagnostic accuracy and report integrity from Chinese pathologists is lower than US standards. which brings great concern about diagnosis, treatment and prognosis of cancer patients in China. Methods: Consultation cases were submitted by Chinese patients, their family members or physicians. Specifically, all clinical reports were sent for consultation including imaging studies, laboratory tests, pathology reports, and histology slides for review which covered a wide spectrum of malignant neoplasms, including lung, esophagus, stomach, colon, ovary, breast, prostate, neuroendocrine, melanoma, head/neck, and soft tissue sarcoma; for most cases (27/30) additional immunostaining or molecular tests were performed. All cases and reports were analyzed at top pathology institutions in the United States, including Memorial Sloan Kettering Cancer Center, Johns Hopkins Hospital, or Brigham Women’s Hospital/Beth Israel Medical Center. Following the review of the original materials, final diagnostic reports between the Chinese and US medical centers were compared for major discrepancies in diagnosis. Results: All consulted cases had major discrepancies in diagnosis (100%). Specifically, 75% of cases had improper cancer classifications or grading, 2 cases had improper quality control in immunostains rendering interpretation questionable; 3 cases lacked appropriate molecular tests; finally, 29/30 (97%) of cases lacked cancer staging based on CAP/AJCC/UICC TNM classification of cancer report protocols. Conclusions: Our consultation experiences demonstrated great discrepancies in malignant neoplasm diagnosis and reports among pathologists between the US and China. These findings raise concerns for Chinese patient’s clinical management and prognoses; moreover, they might help explain the observed difference in cancer patient's total 5-year survival between China and USA (40% vs 70%). These findings emphasize the importance of providing support and consultations for pathologists in China, especially those who practice in non-metropolitan, small county or rural local hospitals which lack updated information, technical and academic supports.
Economic benefits of adaptive abiraterone therapy for advanced prostate cancer.
Authors: Mason Neil Thomas , Burkett Jason M , Nelson Ryan , Pow-Sang Julio M. , Gatenby Robert A , Kubal Timothy Edward , Peabody John Williamson , Letson Douglas D. , McLeod Howard L. , Zhang Jingsong
Published: May 2019

e18343

Background: We recently completed a study showing that adaptive abiraterone therapy (AT) led to more than a doubling of the time to radiographic progression (TTP) compared to continuous therapy (CT) in patients with metastatic castration resistant prostate cancer (mCRPC), [Nat Commun. 2017; 1816]. This study compared the cost of care in the AT cohort versus the standard of care CT cohort. Methods: We conducted a retrospective economic analysis of mCRPC patients receiving intermittent AT compared to patients receiving CT abiraterone. The study followed the adaptive therapy trial protocol (NCT02415621). The primary endpoints were costs of care per patient per year and cost per treatment month. We used itemized billing data and standardized to Medicare reimbursement rates to determine the pharmacy, lab, and imaging costs. Results: Patients receiving adaptive abiraterone therapy (N = 15) had a mean annual cost of care of $80,668 compared to a mean annual cost of care of $132,631 for CT patients. The cost of treatment per month was $6,713 for the AT versus $11,088 for the CT. The economic benefits persisted even after taking into account the cost of abiraterone (Table). Conclusions: The reduction in cost of care in patients with mCRPC with nearly an additional year of TTP from adaptive abiraterone therapy demonstrates the potential value of novel precision medicine approaches. If confirmed by other, larger scale studies, AT may provide significant economic value from far more effective therapy. [Table: see text]
Proper dosage of primary pegylated G-CSF prophylactic use for breast cancer patients receiving adjuvant or neo-adjuvant chemotherapy.
Authors: Yu Liang , Lei Xin , Lin Ying
Published: May 2019

e18354

Background: Myelosuppression during chemotherapy can lead to life-threatening infections, dose reductions, treatment delays, as well as prolonged hospitalizations, early morbidity, and early mortality. According to NCCN guideline, Pegfilgrastim 6mg per cycle is recommended for breast cancer patients receiving chemotherapy, and dosage modification based on body weight is not required. However, primary PEGylated G-CSF prophylaxis comes with significant extra cost, which has a great impact on health care resources, especially for patients without insurance coverage. Methods: We analyzed clinical data of patients, weighing between 45 and 65 kilogram, received a single subcutaneous PEGylated recombinant human G-CSF injection at fixed doses of either 3 mg or 6 mg per chemotherapy cycle approximately 24 hours after completion of each cycle of chemotherapy. Data for this retrospective study were obtained from Thyroid and Breast Surgical Department of the First Affiliated Hospital of Sun Yat-sen University between July 1, 2017, and October 31, 2017. Results: 41 cycles in 33 patients were included in 3mg PEGylated G-CSF group, and 46 cycles in 39 patients were included in 6mg PEGylated G-CSF group. Among chemotherapy cycles, the incidence of neutropenic event was19.5%and 2.2% in 3mg PEGylated G-CSF group and 6mg PEGylated G-CSF group, respectively. No patients experienced dose reductions or treatment delays in both groups. Using single-factor Logistic Regression Analysis, we found that dose of PEGylated G-CSF(3mg vs 6mg) was significantly associated with occurrence of neutropenic event(p = 0.028). Multi-factor Logistic Regression Analysis also showed that dose of PEGylated G-CSFwas significantly associated with occurrence of neutropenic event (p = 0.031). Conclusions: Our study showed that dose of prophylactic PEGylated G-CSF was significantly associated with occurrence of neutropenic events. So adequate dose of PEGylated G-CSF is important to reduce chemotherapy induced neutropenic events and to guarantee the quality of chemotherapy in patients with breast cancer.
Economic analysis of ceritinib used as second-line versus third-line treatment for patients with ALK-rearranged non-small-cell lung cancer.
Authors: Wu Bin , Li Hongchao
Published: May 2019

e18355

Background: Targeted therapy with ceritinib notably improves survival in patients with advanced non–small-cell lung cancer (NSCLC) harboring anaplastic lymphoma kinase (ALK) rearrangement tumors after the failure of chemotherapy and crizotinib. However, the economic outcome of ceritinib used as the second-line versus third-line treatment is still unclear. Methods: A mathematical model was constructed to project 21-day patient transitions. The clinical data were primarily extracted from the ASCEND-5 trial. The health resource consumption data were estimated from the perspective of the Chinese health care system. The cost, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER) was measured in a 10-year time horizon. Sensitivity analyses were conducted to test the impact of uncertainties. Results: Comparing with the 3rd-line strategy, ceritinib 2nd-line strategy achieved the comparable life years and additional 0.06 QALYs with the less cost of $6,694 (Table), which suggested that ceritinib used as 2nd-line treatment is a dominant strategy. The utility of disease-free survival and the cost of ceritinib were the factors that had the considerable impact on the model outcomes. Conclusions: These results indicate that ceritinib used in 2nd-line setting is a more favorable treatment option than in the 3rd-line setting. [Table: see text]