bluuebunny/crossref_metadata_2025 huggingface dataset:
End-of-life chemotherapy and palliative care utilization among patients with breast cancer treated at a safety-net system.
Authors: Bell Lauren , Li Hsiao Ching , Syed Samira K. , Delgado Ramos Glenda Maria , Unni Nisha , Sadeghi Navid
Published: October 2023

241

Background: End-of-life chemotherapy (EOL-C) is associated with a decline in quality of life and increased cost of care. Despite these findings and recommendations of professional and national organizations, EOL-C remains a common practice. Studies have suggested that early referral to palliative care may reduce the likelihood of receiving chemotherapy within the last 30 days of life. We sought to describe the palliative care referral pattern and cancer-directed agent administration at end-of-life among breast cancer patients at a safety-net health system. Methods: Parkland Health (PH) is the safety-net system in Dallas County and is affiliated with the University of Texas Southwestern Simmons Comprehensive Cancer Center. After Institutional Review Board approval, we retrospectively identified patients who died from metastatic breast cancer at PH between 2017 and 2021. Data on demographics, disease and treatment characteristics, and palliative care referral/evaluation were obtained by chart review. EOL-C was defined as planned or administered treatment with cytotoxic agents, immunotherapy, and/or targeted agents (oral or intravenous) within the last 30-days of life. Results: Between 2017 and 2021, 109 patients died from metastatic breast cancer at PH. Median age at diagnosis and death were 52 and 55, respectively. Most patients belonged to racial and ethnic minorities: 41.3% Hispanic, 41.3% Black. Breast cancer was hormone receptor positive/HER2 negative in 53, HER2-positive in 29, and triple negative in 27 patients. Thirty-three patients (30.3%) received or were planned to receive EOL-C: 15 IV (11 administered, 4 planned) and 18 PO. An additional 3 patients received clinic administered non-chemotherapy treatments (leuprolide, fulvestrant, zoledronic acid). Rate of EOL-C was 33.3% (15) in Hispanics and 26.7% (12) among Black patients. Majority of patients were referred to palliative care (79, 72.5%), however, only 46 (42.2%) completed a visit. In the EOL-C group, 84.8% (28) of patients were referred to palliative care and 42.4% (14) completed a visit. Median time between palliative care referral and death was 509 days among patients who completed a visit vs. 53 days in those who did not. Conclusions: Compared to other studies, we observed a higher rate of EOL-C in our patient population. In addition, less than half of the patients in our study completed a palliative care visit before death. Late palliative care referral, timely access, understanding the benefit of the service, low health literacy, language barrier, cultural considerations, and physicians’ perception are likely contributors to pattern of care. As our next step, we plan to study systemic barriers that impact access to and utilization of palliative care service among cancer patients at our safety-net system.
Impact of hospice enrollment timing on overall survival and quality of life indicators in patients with pancreatic ductal adenocarcinoma (PDAC).
Authors: Paredes Rodrigo , Banegas Marcela , Sucre Santiago , Ponce Cristina , Peters Mary Linton Bounetheau
Published: October 2023

243

Background: This study aimed to examine the effects of hospice enrollment timing on survival and end-of-life quality of life indicators for pancreatic ductal adenocarcinoma (PDAC) patients. Methods: A retrospective chart review of 152 patients with biopsy-proven PDAC from August 2009 to December 2022 at a single center was conducted. Patients were categorized based on hospice enrollment timing: Early-Hospice (EH) (≥ 60 days before death), Late-hospice (LH) (< 60 days), and No Hospice (NH). Parameters assessed included overall survival (OS), palliative care service interaction, treatment lines, time from last chemotherapy treatment to death, hospital utilization after last chemotherapy treatment, documentation of advance care directives (ACD), and place of death. Statistical analysis was performed using Chi-squared test with Yates' continuity correction and Kruskal-Wallis test. The time-to-event endpoint was estimated using the Kaplan-Meier method. Results: Analysis of 152 patients showed that hospice enrollment timing did not significantly influence OS in PDAC patients (p=0.6). Median OS for EH (n=10), LH (n=84), and NH (n=58) groups were 10.1 months, 15.7 months, and 12.5 months, respectively. Subgroup analysis of patients with unresectable tumors at diagnosis (EH [n=7], LH [n=61], and NH [n=40]) showed no statistically significant difference in survival (9.19 vs. 12.22 vs. 9.08, p=0.08). The time from first interaction with the Palliative Care team to death was not different between groups. However, patients in EH had a notably longer median duration between their last chemotherapy session and death compared to LH and NH (201 vs. 43 vs. 31.5 days, p<0.01), as well as fewer days hospitalized after the last chemotherapy session (0.5 vs. 5 vs 8 days, p=0.02). Hospice enrollees had a substantially higher rate of documented ACD, and were far more likely to die at home. Conclusions: Although the timing of hospice enrollment did not significantly impact overall survival in PDAC patients, it played a significant role in influencing end-of-life quality of life indicators. Interaction with the palliative care team did not vary across groups, implying that hospice referral by oncology is acceptable and effective. However, documentation of ACDs for non-hospice enrollees was very low, a clear area for improvement.[Table: see text]
Hospital utilization in patients with advanced-stage cancer who refused anti-cancer treatment.
Authors: Akpoviroro Ogheneyoma , Sauers Nathan Kyle , Akpoviroro Oghenetejiro Princess , Uwandu Queeneth , Castagne Myriam , Rodrigues Elga , Mirza Wasique , Bolden Brian
Published: October 2023

246

Background: We sought to describe hospital utilization (HU) in patients with advanced-stage cancer who refused treatment and to determine if palliative medicine referral was associated with any changes in HU. Methods: We performed a retrospective chart review of patients diagnosed with advanced-stage malignancies, aged 18-75 years, between 01/01/ 2010 and 12/31/2015, who refused any form of therapy. HU was measured as a sum of emergency department (ED) visits, ED-to-inpatient admissions, and direct inpatient admissions. Results: The study population was composed of 508 patients. The mean age was 63.1 years (standard deviation (σ) 8.1); females composed 39.6% (201/508). HU prevalence was 61.8% (314/508). In female patients, HU occurred in 60.2% (121/201), compared 62.9% (193/307) in male patients (p=0.545). Palliative medicine referral occurred in 17.7% (90/508). When HU was evaluated according to palliative medicine referral, 68.9% (62/90) of patients who were referred to palliative medicine had HU, compared with 60.3% (252/418) who were not referred to palliative medicine (p=0.128). The mean number of hospital visits (NHV) in the population was 1.0 (SD 1.3). In palliative medicine-referred patients, the mean NHV was 1.1 (SD 1.2), and 1.0 (SD 1.3) in patients not referred to palliative medicine (p=0.435). In the total population, ICU admissions occurred in 17.1% (87/508). In patients referred to palliative medicine, ICU admissions occurred in 11.1% (10/90). In patients not referred to palliative medicine, 18.4% (77/418) had ICU admissions (p=0.095). In the total population, the average number of ICU admissions was 0.2 (SD 0.4). In palliative medicine-referred patients, the average number of ICU admissions was 0.1 (SD 0.4). In patients not referred to palliative medicine, the average number of ICU admissions was 0.2 (SD 0.4); p=0.141. Conclusions: Hospital utilization occurred in approximately 60% of patients with advanced-stage cancer who did not accept treatment. Sex was not associated with hospital utilization. The average number of hospital visits remained consistent, whether patients were referred to palliative medicine or not. While a slightly higher prevalence of ICU admissions was observed in patients who were not referred to palliative medicine, this difference did not reach statistical significance, and the number of ICU admissions was comparable regardless of palliative medicine referral. Of note, we did not evaluate if early palliative medicine referral influenced HU compared with later palliative medicine referral.
Can we skip the simulation step for radiation treatment planning in patients with symptomatic bone metastases?
Authors: WANG Tingyu , Liu Tian , Chao Ming , Sheu Ren-Dih , Tam James , Dharmarajan Kavita Vyas
Published: October 2023

255

Background: Patients with bone metastases may require urgent radiation treatment (RT) due to severe pain, neurologic or other symptoms. Conventional approaches typically involve a 3-step process: initial consultation, followed several days later by a planning CT (pCT) simulation and dosimetric planning, and finally RT delivery. The time frame from consultation to RT can be up to 2 weeks, overly lengthy for severely symptomatic patients. We explored the viability of using diagnostic CT (dCT) imaging, usually available to radiation oncologists at the time of consultation, for RT planning - with the ultimate goal of removing the simulation step to reduce the interval from consultation to RT. In this initial phase of the project, we set out to compare differences in key dosimetric parameters from dCT- and pCT- generated RT plans. Methods: We retrospectively reviewed patients (n=28) treated for bone metastases at a single academic institution from 2020-2023. We utilized rigid image registration to transfer physician contours from pCT images to dCT images to account for changes in patient positioning. Beam arrangements, energies, and administered monitor units were also transferred from the pCT to the dCT for accurate dose calculation. We calculated RT dose coverage of each target metastasis using “V100”, or the percentage of the target lesion receiving 100% of the RT prescription dose. Correspondingly, the “V95” and the maximum point dose (“hotspot”) in patients were also calculated. Results: Out of 28 patients, 24 were treated to single and 4 to multiple (2-4) bone metastases. We excluded patients who had no dCT (n=7) or whose body positioning on the dCT (e.g. arms) created obstructions for beam arrangements (n=2). Eventually, 24 clinical plans made from 19 patients’ pCTs were migrated to their dCTs to generate comparable dosimetric plans. For all 24 dCT-based plans (12 spines and 12 extremities), the mean full dose coverage V100 decreased by 7.14% ± 15.89%. Overall, the plans had 91.14% ± 18.6% for V95 to PTV. Hotspots rose by 2.75% ± 3.61%. Two cases were observed to have full-dose-coverage drop over 40%: one was caused by patient’s outline change induced by different couches used for diagnosis and simulation, and the other one had an initial coverage of 57.6% for V100 in the original clinical plan. The remaining plans had a drop of 3.14% ± 8.37% on V100, and 96.1% ± 8.2% for V95. Conclusions: It was feasible to generate radiation treatment plans for bone metastases with good tumor coverage using dCT imaging. Patient selection plays a crucial role in dCT-based treatment planning, as the dose distribution is highly sensitive to anatomical variations resulting from patient positioning. This treatment planning approach circumvents the simulation step and would reduce patients' wait time for RT, thereby enabling more rapid access to RT for patients suffering with symptoms from bone metastases.
Assessing the utilization of palliative care services in the management of patients with metastatic pancreatic adenocarcinoma.
Authors: Gandhi Sonal , Moss Drew , Sheppard Richard Stephen , Omore Ibrahim , Wu Linda , Cohen Deirdre J. , Smith Cardinale B.
Published: October 2023

256

Background: Pancreatic Cancer is known to be associated with poor survival outcomes and high symptom burden. Integration of early palliative care has been associated with improved end of life care, including reduced hospitalizations and emergency room visits. We conducted a retrospective study to determine the utilization rates of specialist palliative care in patients diagnosed with metastatic pancreatic cancer at an academic teaching hospital and summarize the impact on end-of-life care. Methods: A database of patients diagnosed with metastatic pancreatic cancer on index presentation from 2011 and 2022 was analyzed for utilization of specialist palliative care. Patients who transitioned cancer care to other centers and those who were lost to follow-up were excluded. Data on patient demographics, treatment course, and end-of-life care were collected, and descriptive statistics were used to summarize the data. Results: In our study, 168 patients met the inclusion criteria. The average age of diagnosis was 66 years with a diverse ethnic composition, including White (35.7%), African American (26.8%), and Hispanic (15.5%) patients. Among the cohort, 126 out of 168 (75%) patients were seen by palliative care at least once, with 79 (62.7%) of them initially seen during one of the hospitalizations, and 47 (37.3%) were seen by palliative care outpatient for the first time. The median duration between pancreatic cancer diagnosis and first encounter with palliative care was 145 days (IQR 305 days). No significant differences were found in terms of age, race, sex, ethnicity or insurance type between patients who received palliative care and those who did not. The median time from consultation to death was 57 days and 36.5% patients received palliative care only within one month of their death. Patients who received palliative care were more likely to have a DNR/DNI code status (86.7% vs. 13.3%, p < 0.001) and were more likely to be enrolled in hospice care (86.3% vs. 13.7%, p < 0.001). Conclusions: Early involvement of specialist palliative care in management of patients with metastatic pancreatic cancer may lead to optimization of health care services with earlier hospice referrals and comfort directed care at the end of life. Further research is warranted to explore the impact of palliative care on patient outcomes, quality of life, and the potential benefits of aligning treatment decisions with patients' end-of-life preferences.
EHR-based process to reduce no-shows at the outpatient supportive care clinic at a tertiary cancer center.
Authors: Admane Sonal , Bansal Anjuly , Joy Manju P , Kheirkhah Parviz , Castro Debra , Edwards Tonya , Pangemanan Imelda , Stewart Holly A. , Dalal Shalini , Haider Ali , Amaram-Davila Jaya Sheela , Reddy Akhila , Bruera Eduardo
Published: October 2023

263

Background: No-Shows are pervasive across healthcare systems and are associated with interrupted clinical workflows, increased cost, healthcare utilization, and increased morbidity, and mortality. In palliative care, patients who miss their appointments are more likely to have uncontrolled symptoms, frequent Emergency Room visits, and unplanned hospitalization. There is an ongoing need to reduce no-shows to improve patient outcomes. Methods: The aim of this quality improvement (QI) project, launched in September 2022 at the outpatient supportive care center (SCC) at the University of Texas MD Anderson Cancer Center, was to reduce overall no-shows by process improvement in the targeted areas. We developed a process map and Ishikawa diagram to outline workflow and reasons for no-shows. Based on the results of a previous study from our center, 8% of no-shows were due to hospitalization. We used the Plan Do Study Act (PDSA) tool. We developed an electronic query for the Electronic Health Record (EHR) to identify hospitalized patients with an upcoming appointment at SCC in the next 10 days. We redesigned the clinical workflow to generate a daily list of such appointments which were canceled and replaced by patients on the waitlist. We assessed overall no-show rate and rate specific to hospitalizations for our center monthly for eight months. This QI project was approved by the Quality Improvement Assurance Board at the University of Texas MD Anderson Cancer Center. Results: Overall no-show rate was 12% before intervention (BI) and decreased to 8% after intervention (AI), measured at 8 months. No-show rate due to hospitalizations decreased from 9% BI to 2% AI. Telehealth visits had a lower rate of no-shows (5.9%) than in person visits (10.4%). No-show rates did not differ based on days of the week (median 7.4%, SD 0.3%), and the type of visit - consult vs. follow-up (8% vs. 7%). Conclusions: Clinical workflow redesign using EHR at our SCC decreased no-shows due to hospitalization, thereby reducing overall no-show rate by 33% of the original. However, most no-shows are due to reasons other than hospital stays, and more research is needed to identify these patient and system level factors.
BE-A-PAL: Behavioral economics and automated analytics to improve palliative care among patients with advanced cancer.
Authors: Mudumbi Sandhya , Bilbrey Larry Edward , Ferrell William , Johnson Nicole , Steckel Jenna , Schleicher Stephen Matthew , Dickson Natalie R. , Bekelman Justin E. , Parikh Ravi Bharat
Published: October 2023

268

Background: Patients with advanced solid malignancies often experience high symptom burden and aggressive end-of-life care. Early specialist palliative care (PC) can improve symptom management, mood, and quality of life. However, many patients do not receive PC before they die, with clinician inertia and difficulty identifying high-risk patients being barriers to initiating PC referrals. Methods: In a 2-arm pragmatic randomized clinical trial among patients with stage 3 or 4 lung or non-colorectal gastrointestinal malignancies, oncology clinics were randomly assigned to intervention or usual practice. In the intervention arm, oncologists received automated algorithm-based default notifications prompting specialty PC referral. The control arm received usual care, in which oncologists could refer to PC at their discretion. The algorithm was adapted from NCCN guidelines, identified high-risk patients based on prognosis or symptom/psychosocial burden, and was integrated into the EHR. Oncologists were alerted weekly about eligible patients and had the option to opt-out of PC referral. If there was no response or agreement, a PC coordinator introduced and offered a PC visit to the patient. The primary outcome was a completed PC visit within three months of identification among high-risk patients. We report descriptive results from an interim analysis of the trial. Results: 15 practices (7 clinics and 32 physicians in intervention; 8 clinics and 31 physicians in control) and 567 patients (299 intervention; 268 control) were randomized. Rates of completed early PC visits were 46.4% (139/299) the intervention arm and 11.2% (30/268) in the control arm. The opt-out rate in the intervention arm was 10.7%. Among clinicians who did not opt-out, 79% of their patients agreed to an initial PC visit. Adjusted analyses and demographic data will be completed and available by September 2023. Conclusions: Algorithm-based default PC referrals meaningfully increased utilization of specialty PC within a community oncology practice. Targeting high-risk patients using guideline-based risk stratification prevented overwhelming PC capacity. Further analyses will assess the impact of the intervention on end-of-life care, acute care utilization, patient-reported outcomes, and explore clinician perspectives. Clinical trial information: NCT05590962 .
Perceptions of palliative care knowledge among Hispanics in the United States: An analysis of the Health Information National Trends Survey data.
Authors: Kedia Sapna , Rose Brandon Edward , Kareff Samuel A. , Rodriguez Estelamari , Mahmood Asos
Published: October 2023

270

Background: Patient knowledge of palliative care (PC) has been demonstrated to improve the quality of end-of-life care. Current evidence indicates decreased knowledge of PC and decreased utilization of services such as hospice and advanced directives among Latinos in the US. Hispanic Americans make up 18.9 % of the US population, however, categories of Latino and Hispanic are broad and encompass different ethnic groups, each with unique cultures and experiences. Previous research has demonstrated different ethnicities have differing perspectives on end-of-life care. In this study, we aim to investigate variations in knowledge of PC between different Latino ethnic subgroups in the US. Methods: We employed data from the National Cancer Institute’s Health Information National Trends Survey (HINTS5–Cycle 2; 2018) for a nationally-representative sample of 3,504 adults (aged ≥18 years). Lack of knowledge of PC was assessed by respondents’ selecting “I’ve never heard of it” when asked, “How would you describe your level of knowledge about palliative care?” We performed a binomial regression assessing knowledge of PC and comparing this answer choice between Hispanic and non-Hispanic respondents as well as a Wilcoxon-Mann-Whitney test to compare among Hispanic subgroups. Results: Of all 3,504 survey respondents, 13.07% self-identified as Hispanic, and 65.2% stated they had never heard of palliative care. In the ethnic subgroups analyzed, 173 (79.4%) Mexicans, 33 (71.7%) Puerto Ricans, and 11 (55%) Cubans reported they had never heard of PC compared to 689 (62.2%) of non-Hispanics. We used a binomial regression to compare this response in Hispanics vs. non-Hispanics and found a significant difference in PC knowledge between Hispanics and non-Hispanics (p < 0.001), with an OR of 0.469 between the lack of PC knowledge answer choice and selecting Hispanic (95% CI 0.37-0.6). A Wilcoxon-Mann-Whitney comparing PC knowledge by subgroups found a significant difference between non-Hispanics and Mexicans (p< 0.001) but no differences between Hispanic sub-groups. Conclusions: Hispanics had lower levels of knowledge of PC than non-Hispanics. When stratified by Hispanic subgroups, only Mexicans had significantly lower PC knowledge than non-Hispanics. This calls for further research into why this ethnic group has lower knowledge of PC and what potential moderating factors could affect this association. Additionally, we need more studies on US Hispanics’ level of PC knowledge to assess if the trends seen between Hispanic subgroups in this survey are replicated.
Knowledge of palliative care and barriers to access among outpatients with cancer.
Authors: Schlichte Lindsay , Hildenbrand Jordan , Wolf Steven , Herring Kris W. , Troy Jesse D , LeBlanc Thomas William
Published: October 2023

271

Background: Integrated specialist palliative care (PC) is known to improve outcomes among ambulatory patients with cancer, yet it remains underutilized for this population. It is known that PC is poorly understood among the public, however very little is known about what ambulatory patients with cancer understand about PC or what barriers to access exist. Methods: Outpatients undergoing cancer treatment completed a survey evaluating their familiarity and knowledge of PC (Palliative Care Knowledge Scale; PaCKS), feelings towards PC (before and after reading a standardized definition of PC), barriers to PC, prognostic awareness, and health literacy. We examined variables associated with participants’ familiarity with PC and current interest in receiving PC by fitting logistic regression models. To determine if there was a difference in patients’ feelings toward PC before and after reading the standardized definition, a Chi-Squared test was conducted. All other responses were summarized descriptively. Results: Of 151 participants, 58.9% reported familiarity with palliative care. The average PaCKs score was 11.9 (standard deviation 1.4), and 46.4% of patients received a perfect score, indicating high knowledge of PC overall. Only time since diagnosis (> 1 year vs < 1 year) was associated with significantly increased odds of being familiar with PC (OR 2.93; 95% CI 1.37-6.25). After reading the standardized definition of PC, participants reported feeling significantly less anxious and more reassured; however, more participants were interested in receiving PC in the future compared to at the time of survey completion (74.2% vs 44.4%, respectively). Patients with stage III or IV cancer had significantly increased odds of having interest in receiving PC at the time of study completion compared to patients with stage I or II (OR 2.66; 95% CI: 1.05, 6.76). Having an aggressive cancer was not associated with interest in receiving PC at the time of study completion. Logistic barriers (additional travel or time at the hospital) were commonly reported barriers to attending palliative care appointments. Conclusions: Outpatients with cancer who are being treated at a large academic cancer center have higher familiarity and knowledge of PC than the average American adult. Despite this, anxiety surrounding PC and hesitations regarding early integration of PC persist. Therefore, factors outside of knowledge may be perpetuating the delayed or lack of involvement with PC in oncology. Future work must seek to overcome these barriers to PC integration in outpatient cancer care.
Total and treatment-related costs of care associated with in patients with metastatic renal cell carcinoma receiving targeted or immune therapy.
Authors: Rahman Syed N. , Long Jessica B. , Westvold Sarah J. , Wheeler Stephanie B. , Spees Lisa P. , Leapman Michael , Hurwitz Michael E. , McManus Hannah Dzimitrowicz , Gross Cary Philip , Dinan Michaela Ann
Published: October 2023

28

Background: Oral anticancer agents (OAA) and immunotherapy (IO) as initial treatments in metastatic renal cell carcinoma (mRCC) have yielded substantial improvements in disease control and survival but may increase costs. OAA monotherapy has decreased in recent years and use of IOs has increased dramatically, however, their impact on costs in patients with mRCC has not been examined at the population level. Methods: Retrospective cohort study of Medicare beneficiaries over age 65 diagnosed with mRCC from 2015 through 2019, who were enrolled in Medicare Part D for at least 1 year after diagnosis and received OAA or IO within a year of diagnosis. We summarized Medicare payments and out-of-pocket (OOP) responsibility in the year following diagnosis stratified by type of initial treatment and cost component (Treatment, Inpatient, and Outpatient). Dollar amounts were adjusted to 2019 using the Urban All Consumers Price Index. We used multivariate generalized linear models with a gamma distribution to assess the relationship between demographic and treatment variables and costs. All reported differences were significant with p < 0.001. Results: The study sample included 6183 patients. Initial therapy was an OAA in 3630 patients (59%), IO in 2034 patients (33%), and combined OAA+IO in 519 patients (8%). Total mean Medicare payments were substantially higher in patients receiving combination therapy (OAA+IO $149,200) vs. monotherapy with IO ($104,800) or OAAs ($109,900). Direct treatment costs composed at least half of all costs for all patients, including those undergoing first line OAA (56%), IO (50%), or combination OAA+IO (69%) therapy. Costs increased over the study period, with metastatic diagnosis in 2019 vs. 2015 being associated with roughly 33% higher costs [aCRR1.33(1.26-1.40)]. Older age (≥ 81 vs age 66-70 [aCRR 0.74 (0.71-0.77)] and female sex [aCRR 0.93(0.90-0.95] were associated with lower total payments. Total OOP responsibility was higher for individuals who received IO ($18,500) compared to an OAA ($12,200). Those receiving OAA+IO had the highest OOP costs ($21,800). OAA+IO combination therapy was also associated with higher total Medicare payments compared to OAA [adjusted Cost Relative Ratio (aCRR) 1.36 (95% CI; 1.29-1.43)]. Conclusions: Direct costs of treatment are the primary drivers of costs in patients with mRCC initiating therapy during the first year of diagnosis, with half or more of total costs derived from treatment. OOP responsibility remained relatively steady from 2015 to 2019, while total costs to Medicare increased by a third. The recently passed Inflation Reduction Act may impact future total costs in patients with mRCC given the substantial contribution of direct treatment costs to overall costs in this population.
Frequency and characteristics of integrative oncology (IO) consults in patients with cancer receiving inpatient rehabilitation.
Authors: Gupta Ekta , Lopez Gabriel , Fu Jack Brian , Narayanan Santhosshi , Tennison Jegy , Bruera Eduardo
Published: October 2023

285

Background: IO interventions may provide patients with cancer with relief of physical, psychological, and social distress related to their disease and its treatments. Little is known about the frequency and predictors of IO referral for symptom management in cancer rehabilitation inpatients. Methods: This descriptive retrospective review identified the frequency and characteristics of cancer rehabilitation inpatients referred to IO from 5/2016-8/2019. Results: Out of 1196 inpatient rehabilitation admissions, 100 (8.4%) were referred to IO during the study period. Admission AMPAC 6-click scores were 15 (+/-6) for total mobility and 16 (+/-4) for activities of daily living (equates to a ˃ 50% degree of functional impairment). 35% had brain/spine cancer, 20% hematologic; 67% advanced/metastatic cancer. Top reasons for consultation to IO included: pain (73%), integrative approach (41%), relaxation (38%), stress/anxiety (33%), fatigue (27%), sleep disturbance (23%), spirituality (9%), neuropathy (8%), and nausea/vomiting (7%). Out of the 100 patients referred, 13 did not receive any intervention due to thrombocytopenia, leukopenia, or treatment not completed during hospitalization. Recommendations included: massage therapy (81/100) mostly for pain (94%) and fatigue (11%); acupuncture (53/100) for pain (70%), fatigue (32%), nausea/vomiting (16%), sleep (11%), stress/anxiety (8%), and chemotherapy induced peripheral neuropathy (6%); music therapy (14/100) for anxiety (57%), mood/depression (36%), rehabilitation support (29%), pain (21%), social interaction (14%), and other reasons such as fatigue, motivation (36%); and yoga (2/100) for stress/anxiety. A majority of patients referred to IO received at least one intervention: massage therapy (n=69), acupuncture (n=39), or music therapy (n=11). Conclusions: This exploratory study shows that a small percentage of cancer rehabilitation inpatients were referred to IO. Most patients did receive one or more IO interventions, with pain as the most common indication. Larger trials are needed to characterize the effects of IO on inpatient rehabilitation.
Bereaved parents’ perspectives on financial toxicity at end-of-life for children with cancer.
Authors: Alexander Ariel , Martinez Isaac , Tefera Raba , Beauchemin Melissa P , Lawhon Valerie , Nichols Ashley , Rosenberg Abby R. , Bhatia Smita , Johnston Emily E.
Published: October 2023

287

Background: Families of children with cancer often experience financial toxicity. However, little is known about families’ experiences with financial toxicity at end-of-life (EOL). Therefore, we qualitatively explored bereaved families’ experiences related to financial toxicity. Methods: We performed a secondary analysis of semi-structured interviews of bereaved parents about their perspectives on high-quality EOL care. The interviews were conducted with bereaved parents in California and Alabama whose child (0-21 years at the time of death) died of cancer ≥6 months before the interview. Quotes related to financial experiences were identified and then grouped thematically. Results: Fifty-five parents, representing forty-eight children were interviewed. Twenty-eight parents (51%) were recruited in California and twenty-seven (49%) in Alabama. The majority of participants were non-Hispanic White (29; 52%), fourteen (25%) were Hispanic, and twelve (22%) were Black. The most common cancer diagnoses were non-central nervous system solid tumors (18, 38%). Children died at a mean age of 11 years (SD=6 years) and a median of 4 years (IQR=2-8 years) prior to the interview. Almost all families (52, 95%) discussed themes related to financial toxicity. Parents identified transportation, housing, other basic needs, funeral costs, and medical costs as contributors to financial toxicity at EOL. Barriers to financial wellness included battling insurance companies, insufficient financial support from the hospital, and the cumulative financial toxicity of treatment. Many parents discussed how the hospital and community served as facilitators of financial wellness by connecting them with resources and providing financial support. In some cases, finances prevented families from accessing services such as hospice care mental health support; financial constraints also affected EOL decisions. Conclusions: Almost all families discussed themes related to financial toxicity, despite not being specifically asked about financial toxicity. In particular, families were financially impacted by basic needs, medical bills, and funeral costs at the end of their child’s life. They identified numerous community and hospital-based barriers and facilitators of financial wellness. It is critical that pediatric oncology programs routinely screen for financial hardship at EOL (and into bereavement). Further research is also needed on how best to support these families’ financial struggles at this challenging time.
RRx-001 potentially reduces financial toxicity for patients and caregivers in head and neck cancer.
Authors: Reid Tony R. , Abrouk Nacer A. , Oronsky Bryan , Caroen Scott , Sonis Stephen T.
Published: October 2023

31

Background: Of all the toxicities that result from the treatment of head and neck cancer, perhaps the most insidious is financial burden or “out-of-pocket (OOP) expenses” for patients and their caregivers otherwise known as financial toxicity (FT) which is associated with decreased treatment adherence and poor clinical outcomes. A huge unmet need is interventions and strategies to mitigate this problem. Methods: PREVLAR was a Phase 2 study that randomized 53 head and neck cancer patients 1:1 to receive four doses of RRx-001 prior to the start of intensity modulated radiation therapy (IMRT) in 2.0-2.2 Gy fractions/weekday to a cumulative radiation dose of up to 72 Gy plus cisplatin administered either weekly (40 mg/m2) or tri-weekly (100 mg/m2) vs. cisplatin plus IMRT alone (control). The primary outcome was the incidence of severe oral mucositis. Adverse events were evaluated using NCTCAEv5 criteria. Results: The RRx-001 pre-treatment paradigm with four doses (“four before and no more”) dramatically reduced the incidence and duration of severe oral mucositis and associated grade 3-4 adverse events. These anti-toxicity effects translated to a shorter duration of hospitalization, less narcotic use, and less feeding tube placements. Extrapolating from cost estimates in the literature, we project a per patient total cost savings estimate of $12,500 - $22,500 with RRx-001 use based on an average 30% reduction in Grade 3-4 adverse events, a 50% reduction in hospital stay duration, and a 50% reduction in feeding tube placement. Conclusions: The RRx-001 “four before and no more” pre-treatment dosing regimen is not only convenient for patients and their caregivers but also reduces several toxicities including, most likely, financial toxicity. This is likely to bolster its adoption once RRx-001 becomes part of the medical armamentarium for the treatment of SOM. We plan more rigorously to test the effect of RRx-001 on financial toxicity in an upcoming Phase 2b trial in head and neck cancer called KEVLARx, n = 216. Clinical trial information: NCT03515538 .
Intervention to improve patient self-management and satisfaction in breast and lung cancers using the 4R Oncology model: Results by cancer, race and deprivation index.
Authors: Weldon Christine B. , Trosman Julia R. , Linehan Elizabeth Shurell , Gordon Nancy P. , Hennings Marti , James Henie , Abbe Thea , Katzel Jed Abraham , Ng Chun Fai , Tomita Megumi , Velotta Jeffrey B. , Sakoda Lori C. , Beringer Kimberly , Ravelo Arliene , Zhu Zheng , Rapkin Bruce , Liu Raymond
Published: October 2023

326

Background: Patient self-management (pSM) is important for optimal cancer care, health equity and mitigation of clinician shortage (Howell 2021, Alfano 2022). 4R Oncology is an intervention fostering pSM and team-based care with a novel Care Sequence plan. 4R (Right Info / Care / Patient / Time) has been shown to improve pSM in breast cancer (Trosman 2021) but has not been studied for impact in other cancers or whether impact is affected by race or neighborhood deprivation index (NDI). 4R effect on patient satisfaction with care – important in care quality and reimbursement – is also unknown. We examined 4R impact on pSM and satisfaction in lung and breast cancers and whether it was influenced by race and NDI. Study took place at 3 centers of a large health system Oct 2020 - Dec 2021. Methods: Surveys of patient: 4R cohort who received 4R plans (N=192) and historical control who received care pre-4R (N=103). Cohorts included breast cancer stages 0-3 and all lung cancer stages. Results: Survey response: 53% (control), 42% (4R). 4R significantly improved 4 of 5 pSM metrics from control to 4R cohort in each cancer (table). Satisfaction with care improved in 3 of 5 metrics in lung and 2 metrics in breast cancer. pSM significantly improved in all metrics from control to 4R cohort for non-White patients, and in 2 of 5 metrics for White non-Hispanics. Satisfaction significantly increased in 3 metrics in both race groups. NDI did not affect 4R impact: both higher and lower NDI groups benefited similarly in all metrics from control to 4R cohorts (data not shown). Conclusions: 4R is effective in improving patient self-management and satisfaction with care across different cancers. Non-White patients derived more self-management benefit than White non-Hispanic, indicating that 4R may help address racial disparities. Deprivation index results suggest that 4R benefits both lower and higher socioeconomic status patients. Further model refinement should address remaining gaps along relevant metrics.[Table: see text]
Harmonization of patient-reported outcome measurement across four academic medical centers: Multi-site clinician focus group results from the Carolinas Collaborative Initiative.
Authors: Ernster Alayna E , Chung Arlene E. , Stover Angela M. , LeBlanc Thomas William , Topaloglu Umit , Zafar Yousuf , Zullig Leah L. , Smeltzer Philip A. , Golden Shannon L. , Gibbs Sydney-Evelyn L. , Sohl Stephanie Jean , Basch Ethan , Wagner Lynne I.
Published: October 2023

336

Background: Use of patient-reported outcomes (PROs) to monitor symptoms in cancer care demonstrates clinical benefit, but implementation of PROs across healthcare settings remains low. We conducted focus groups (FGs) with stakeholders from four academic medical centers (AMCs) to identify perceived barriers and facilitators to implementing PROs in routine care. Methods: Stakeholders were recruited to participate in FGs and asked to identify barriers and facilitators of future PRO implementation in their respective healthcare setting. Transcripts were coded and synthesized via thematic content analysis. Results: Seventy stakeholders participated in one of 14 FGs (leadership groups, n = 5; nurse groups, n = 4; physician groups, n = 5) stratified by role and site. The mean FG size was 5 (range = 2 to 14). Three overarching domains were identified: Workflow, Training and Implementation, and Data-Driven Action. Table 1 shows the relative frequency of notable codes associated with each domain across FGs aggregated by stakeholder role. Themes within each domain are: Workflow: current workflow dynamics inhibit PRO implementation (code = Workflow, Table 1); more resources are necessary to adjust clinical workflow and the EMR to facilitate administration and clinicians’ ability to respond to concerning symptoms (code = Resources needed, Table 1). Training and Implementation: clinicians may be unaware of the utility of PROs; training about the clinical relevance of PROs may help facilitate integration (code = Training needs, Table 1). Data-Driven Action: data derived from PROs must be interpretable and actionable to promote sustained utility (code = How to display PROs, Table 1). Tailored measures for specific clinical populations are needed, along with information on clinically significant scores, meaningful change thresholds, predictive value, and whether integration of PROs improves healthcare quality. Conclusions: Similar barriers to PRO implementation were identified across four AMCs. Infrastructure is needed in each AMC to help clinics integrate PROs. Resources to address workflow inefficiencies, EMR integration, clinician training, and follow-up support may help facilitate integration. Academic medical centers must also ensure that data derived from PROs are relevant and actionable.[Table: see text]
Mixed methods study of the feasibility and acceptability of remote monitoring of lung cancer patient-reported outcomes.
Authors: Mody Gita N , Medley Chaely , Deal Allison Mary , Weiss Jared , Pecot Chad Victor , Lee Carrie B. , Gentry Amanda , O'Leary Meghan C. , Shrestha Sachita , Chen Hemda , Novak Lara , Weiner Ashley , Patel Shetal Arvind , Stover Angela M.
Published: October 2023

341

Background: Symptom monitoring using electronic patient-reported outcome (ePRO) systems during cancer care has been shown to provide clinical benefits and is now recommended for routine care. Integrating existing ePRO platforms into practices may lower costs and logistical barriers to use. The purpose of this study was to assess the feasibility and acceptability of a mobile app (Moovcare) for care of patients with lung cancer. Methods: In this single-site study, patients on treatment for lung cancer were recruited for 6 months of ePRO monitoring using Moovcare, an application originally designed for patients undergoing surveillance. Patients reported symptoms weekly via a survey delivered to their email address. Providers received email alerts for concerning symptoms and accessed graphical reports displaying responses over time. Providers were asked to complete an interview after 6 months of experience using Moovcare. Feasibility was assessed by the % of surveys completed per patient. Clinician acceptability was evaluated using semi-structured interviews. Results: 90 patients were recruited to participate and 46/90 (51.1%) were enrolled. 41/46 (89%) completed at least 1 survey. Patients were a mean 61.5 years of age. The majority were female (61.0%), White (73.2%), and had advanced NSCLC (92.7%). Nearly half (43.9%) had completed at least college level education. Most reported daily internet (87.8%) and email (63.4%) use. Survey completion rates are in Table 1. Alerts occurred in 78.0% of participants, with a mean of 4.2 alerts (SD=4.7) per patient. Alerts were closed by providers in a mean 2.7 days (SD=3.9). 3/7 providers participated in alert management, all of whom participated in interviews. These providers felt there was potential value for Moovcare to monitor symptoms but did find enrolled patients were already proactive about contacting the clinic for symptom management. Most interviewed providers (66.0%; 2/3) would like to use the system again and would recommend the system to others. EMR integration was strongly desired to improve workflow. Conclusions: ePRO survey completion and alert management using an existing web-based application were feasible for lung cancer patients and their providers. While concerning symptoms were commonly experienced by patients, provider perceptions of alert utility were low. Adjusting alert criteria to increase the frequency of actionable alerts and using strategies to increase ePRO use in patients with low participation levels may increase the utility of ePROs. EMR integration may improve acceptability to providers. Clinical trial information: NCT05011890 .[Table: see text]
An innovative approach to “off pathway prescribing” to improve pathway adherence and practice collegiality utilizing a peer-reviewed process and scorecards.
Authors: Skelton Matthew Rama , Mock Joseph , Meyer Susan , Tarpley Trish , Peterson Christopher , Sweeney Ann Marie , McCorkindale Debra , Alvarez Autumn
Published: October 2023

37

Background: Blue Ridge Cancer Care (BRCC), part of the US Oncology Network, utilizes Value Pathways, a refinement of the NCCN Guidelines that highlights evidence-based treatment options based on efficacy, toxicity, and evaluation of financial impact to patients and payors. Adherence to evidence-based and cost-effective treatment guidelines are a significant aspect of oncology care. BRCC implemented a monthly meeting that improved patient care and provider adherence to Value Pathways guidelines and increased the understanding of financial toxicity related to various therapies. Incremental cost-effectiveness ratio (ICER) was introduced as a tool to help estimate therapy value. Methods: Monthly virtual/in-person meetings involved the two divisions (9 locations) and included two alternating formats. 1) Journal Club focused on new pathway regimens. 2) Pathways Round Table established open discussions between providers focused on peer review of “off-pathway” treatment decisions. Provider scorecards were shared monthly on individual provider pathway adherence rates. Surveys were conducted prior to and after the interventions to assess knowledge of guidelines, financial toxicity, and overall satisfaction. Results: We compared provider pathways adherence rates from 2018 - 2023 and surveyed providers on the impact of these meetings. Oncologist adherence to Value Pathways prescribing compliance increased 7.5% from 2018 to 2023 with an average of 2400 cancer treatment regimens entered per year. Conclusions: The Journal Club and Pathways Round Table meetings plus scorecards improved pathway adherence, collegiality among providers, normalized financial toxicity discussions with patients, and was considered valuable by most providers. [Table: see text]