bluuebunny/crossref_metadata_2025 huggingface dataset:
Retirement behavior of cancer survivors and the role of employer-sponsored health insurance.
Authors: Bradley Cathy J , Owsley Kelsey
Published: September 2022

222

Background: Workers who rely on employment for health insurance may choose to continue working following a serious health condition, potentially harming their health in retirement. In this study, we examine the influence of retiree and employment-contingent insurance on retirement behavior and health of workers diagnosed with cancer. Methods: This longitudinal cohort study used 2000-2018 Health and Retirement Study data to examine changes in employment, weekly hours worked, and health status measures following a cancer diagnosis by health insurance status. We selected respondents who reported a new cancer diagnosis (n = 354) and a matched, non-cancer sample (n = 1,770 respondents), restricting both samples to those employed and younger than age 63. Results: Women with cancer and retiree health insurance were 21.0 percentage points less likely to work (95% CI: –38.5 to –3.5; p < 0.05) relative to women with employer health insurance, but no retiree insurance. Employed women with cancer but no health insurance increased weekly hours worked by 32% relative to similar non-cancer controls. Men and women with a new cancer diagnosis and without health insurance were also less likely to work (p < 0.05). Respondents with employer-based health insurance reported better subsequent health status than respondents without health insurance from their employer. Conclusions: Cancer survivors with both employer insurance and retiree health insurance are able to leave the workforce earlier, and report better health status when they stop working following a cancer diagnosis.
Surviving colorectal cancer: A study of information needs and health-related quality of life.
Authors: Gerido Lynette Hammond , Abrahamse Paul , Tocco Rachel , Braun Thomas , Hawley Sarah T. , Veenstra Christine M
Published: September 2022

223

Background: Colorectal cancer (CRC) is a life changing process, which impacts survivors’ health-related quality of life (HRQoL). CRC survivors face new uncertainties and have specific information needs. While advances in CRC treatment have increased the number of survivors, little is known about how information needs differ across groups of survivors, or whether information deficits influence HRQoL. Methods: In 2019-2020 we surveyed patients who, in 2014-18, underwent resection of Stage III colorectal cancer and were seen at a community oncology practice, an academic cancer center, or reported to Georgia SEER (51% RR). Patients were asked questions about survivorship, including their need for additional information (NAI) about CRC follow-up care. HRQoL was measured using PROMIS—29+2 Profile v2.1. Patients also self-reported their race and their belief about whether they were cancer free. Associations between patients’ NAI and covariates (including race and belief in being cancer free) were assessed with logistic regression, while associations between HRQoL scores and covariates were assessed with one-way analysis of variance (ANOVA). We used linear regression to assess relationships between NAI and HRQoL. Results: Data from 380 patients were included in these analyses. 44% were > age 65, 84% white, 22% had < high school education, and 32% had a household income of less than $60,000. 55% indicated a need for more information about CRC follow-up care. 90% believed that they were currently cancer free. Black CRC survivors were significantly more likely to report an information need compared to White patients (OR 2.446, 95% CI 1.147-5.217; p = 0.02). Patients who believed they were currently cancer-free were significantly less likely to report an information need compared to patients who did not believe they were cancer-free (OR 0.357, 95% CI 0.169-0.750; p < 0.01). Having a need for additional information was significantly associated with worse HRQoL (difference in mean HRQoL score -0.26, standard error 0.19; p < 0.01). Conclusions: Black CRC survivors were 2.4 times more likely to have an information need than White survivors. Survivors who believed they were currently cancer-free were 35% less likely to have an information need than those who did not share the same belief. Having an information need was associated with worse HRQoL. Tailored survivorship communications and patient education related to managing recurrence risk may help improve HRQoL among CRC survivors.
Stakeholder evaluation of a supportive care needs assessment tool for adolescent and young adult (AYA) cancer survivors.
Authors: Kwekkeboom Kristine L , Montgomery Kitty , Evered Jane , Norslien Kirsten , Parkes Amanda Marie , Phelps Kat , Tierney Susan , Lee-Miller Cathy
Published: September 2022

224

Background: The survivorship needs of Adolescents and Young Adults (AYA) with cancer are complex and differ from other age groups. Evidence suggests that AYA cancer survivors are unaware of and underutilize supportive care services both during and after treatment. Recently, the Needs Assessment & Service Bridge (NA-SB) tool was developed to screen AYAs’ survivorship needs and facilitate delivery of appropriate services. We engaged a stakeholder group of YA cancer survivors from the Midwest United States to provide feedback regarding NA-SB content and administration. Methods: We used a descriptive focus group design. We recruited 10 YA cancer survivors, aged 20-38, of diverse sex, race, rural/urban residence, and on/off active therapy. We held five 90-minute virtual stakeholder group meetings. Before the first meeting, stakeholders reviewed the 57 NA-SB items. The PI and a trained facilitator co-led the meetings, asking participants about the utility of the NA-SB, item content, response options, and administration. Meetings were recorded and transcripts were analyzed deductively, organizing comments by the 9 NA-SB domains. Results: Stakeholders endorsed all original NA-SB items, modified 4 items, and identified 18 new items (Table). Stakeholders recommended that YA patients initially complete the NA-SB in-person shortly after treatment begins, and again electronically at clinical milestones. They suggested using a screening question for each domain, allowing patients to skip items not relevant for them. Conclusions: The stakeholder-engaged process resulted in a modified NA-SB and recommendations for administration that reflect the needs of our Midwestern YA cancer survivor population. Prior to implementation, we will integrate recommendations from clinician experts and align available resources with NA-SB domains.[Table: see text]
Continued outpatient oncology care for cancer survivors by antineoplastic medication use: Identifying opportunities for stratified survivorship care.
Authors: Birken Sarah A , Peluso Alexandra , Wagi Cheyenne , Shalowitz David I , Isom Scott , Bell Ronny A. , Strom Carla , Dharod Ajay , Bundy Richa , Weaver Kathryn E.
Published: September 2022

226

Background: Cancer survivors may be more likely to receive preventive care services when they see both oncologists and PCPs; however, some oncology visits may not be necessary, straining limited subspecialty resources. In this study, we quantified outpatient primary and oncology care utilization in the years surrounding cancer diagnosis. We further characterized the proportion of survivors with oncology visits in the absence of ongoing antineoplastic use, as we hypothesized these survivors might be appropriate for need- and risk-stratified survivorship care, a model successful outside the US. Methods: We conducted a retrospective review of the electronic health records of survivors in an academic health center diagnosed with breast, colorectal, or uterine cancer between 1/1/14 and 9/1/19. We excluded survivors who died during the study period, had a PCP outside of our health system, or had recurrent cancers. Descriptive statistics described survivors’ provider visits up to 4 years before and 8 years after diagnosis with their most recent cancer. We then stratified our results by current antineoplastic prescription. Results: Our sample included 1,929 survivors (75.0% white, 20.1% Black, 5.0% other; 86.2% female; cancer type: 59.4% breast, 26.7% colorectal, 13.8% uterine). In the first-year post-diagnosis, 94.6% of survivors had an oncology provider visit; the figure declined to 55.8% by year 8. The percentage of survivors with PCP visits increased from 41% 3-4 years pre-diagnosis to 66% in year 1 and remained at > 50% 8 years post-diagnosis. More than 50% of survivors saw both PCPs and oncologists through 5 years post-diagnosis. Survivors were slightly more likely to have an oncology visit if they were on antineoplastics; 5+ years after diagnosis, >50% of survivors not on antineoplastics had oncology visits. Conclusions: A slight majority of 5+ year survivors, regardless of antineoplastic use, continue to have oncology visits and may be candidates for discontinuing oncology care. Work is needed to develop and test interventions to facilitate need- and risk-stratified survivorship care focused on transitioning longer-term survivors not on antineoplastics to PCPs.
Understanding adult survivors of childhood cancers: An analysis of a survivorship transitions clinic.
Authors: Hentzen Stijn , Alsman Kyla , O'Neal Alicia , Adams Taylor , Calhoun Elizabeth , Lowry Becky N.
Published: September 2022

227

Background: As the prevalence of patients with cancer increases and improvements to treatment continue, the population of childhood cancer survivors (CCS) will see remarkable growth in coming years. Care for CCS requires collaboration between oncologists and primary care practitioners (PCPs). Long term follow up calls for unique attention to survivorship guidelines, the late effects of treatment, and the risk of secondary malignancies. To meet these needs, the cancer center at the University of Kansas Health System partnered with internal medicine to establish a primary care based STC. This study aimed to describe and analyze the population of cancer survivors in this clinic. Methods: After obtaining IRB approval, a retrospective chart review was completed for patients established in the STC between 2014 and 2022. Subjects were de-identified and analysis was performed using Microsoft Excel. Results: The 261 patients were 57% (150) female and had an average age of 12 (2 months - 41 years) at the time of cancer diagnosis and an average age of 28 (18 – 61 years) at the time of of clinic establishment. Patients were from 9 states, 47 counties, and 139 unique zipcodes. We identified 42 different cancers among the patients with ALL (24.5%) and Hodgkin’s Lymphoma (19.2%) most common. We found that 244 (93.5%) received chemotherapy, 138 (52.9%) received radiation, and 41 (15.7%) underwent bone marrow transplant. Secondary cancers were diagnosed in 30 (11.5%) of the patients with breast (23.3%) and thyroid (23.3%) malignancies most common. Three of these patients had two secondary malignancies. Conclusions: Our CCS population was clinically diverse in malignancy and treatment regimen. Nearly half of the patients received therapy in combination, adding to the complexity of late effects risks and care monitoring. This is emphasized by the prevalence of secondary malignancies which enforces the need for close follow up and adherence to survivorship guidelines. We found that despite the young age of cancer diagnosis, many of the patients established care in our clinic well into adulthood which is concerning for a gap in survivorship care as patients transition from treatment to follow up. Finally, the wide catchment area of this clinic is unique and shows the success of rural survivorship care at a tertiary medical center.
Mental health symptom severity and health care utilization in adolescent and young adult cancer survivors.
Authors: Baclig Nikita V. , Comulada W. Scott , Ganz Patricia A.
Published: September 2022

229

Background: Adolescent and Young Adult (AYA) cancer survivors experience psychological sequelae, yet causal pathways between AYA cancer, mood disorders, and mental healthcare remain unclear. The 2019 National Health Interview Survey (NHIS) applies the Patient Health Questionnaire-8 item (PHQ8) and Generalized Anxiety Disorder-7 item (GAD7), providing validated evaluation of mental health (MH) in a national sample. We investigated how AYA cancer history affects MH symptoms and MH care utilization. Methods: Descriptive statistics evaluated depression (PHQ8), anxiety (GAD7), use of MH medications, and receipt of psychotherapy in three groups: adults with AYA cancer history, adults with Older Adult (OA) cancer history, and cancer-free adults. Structural Equation Modeling (SEM) was used to estimate cancer survivorship impact on medication use and receipt of therapy (total effects), as well as direct/indirect effects through depression and anxiety (mediated effects). Results: AYA cancer survivors had higher mean PHQ8 (3.64, 2.80, 2.43, p < 0.001) and GAD7 (3.05, 1.90, 2.05, p < 0.001) compared to OA survivors and cancer-free adults. They reported more medication use for MH (24.8%, 21.0%, 15.2%, p < 0.001), and received therapy more often (14.0%, 8.6%, 9.5%, p = 0.001). Total effects models showed AYA survivors were more likely to have received therapy (OR 1.55, 95% CI 1.20-2.00) and to have taken medications (OR 1.84, 95% CI 1.49-2.28) compared to cancer-free adults. Mediated models examined indirect (mediated by MH symptoms) and direct (residual) pathways. All indirect partial paths (regressor to mediator or mediator to outcome) showed large, significant effects (p < 0.001), except for regression of GAD7 on OA survivors. Direct paths showed large, significant effects of AYA and OA survivorship on medication use, but small nonsignificant effects on therapy. Indirect full paths (regressor to outcome through mediators) demonstrated smaller effects than direct pathways, but overall larger effects for AYA survivors than OA survivors. Conclusions: AYA survivors experience worse MH symptoms and are more likely to utilize MH care than OA survivors and cancer-free adults. Effects of cancer survivorship on MH care utilization were mediated through MH symptom severity. Mediated effects were larger for AYA survivors than OA survivors.[Table: see text]
The painting of a patient: Provider representations of patient fitness and preferences in multi-disciplinary tumor board meetings.
Authors: Henderson Nicole , Andrews Courtney J. , Pywell Cameron , Zubkoff Lisa , Rose J. Bart , Williams Grant Richard , Rocque Gabrielle Betty
Published: September 2022

246

Background: Pancreatic cancer treatment can involve multiple treatment modalities (e.g. chemotherapy, surgery, radiation) that vary greatly in intensity and timing. The most intense treatments are associated with substantial toxicity and only recommended for medically ‘fit’ patients regardless of age. Despite evidence-based guidelines demonstrating the benefit of including the geriatric assessment (GA) and patient preferences, these may not be formally included in multidisciplinary tumor boards (MDTBs) where treatment decisions are often made. Methods: This qualitative study evaluated MDTB meetings at a single institution between November 2021 and February 2022 for inclusion of fitness and patient preferences. Discussions of patients with stage I-IV pancreatic cancer were identified for inclusion. These recordings were transcribed and analyzed using NVivo for recurring themes and exemplary quotes regarding how providers characterize patients’ fitness and present their preferences to the board. Results: Thirteen MDTB meetings including 50 individuals with stage I-IV pancreatic cancer were included. Descriptions of patient fitness largely consisted of the presentation of common demographic traits such as age and gender. Additional context, primarily focused on occupation, comorbidities, and patient attitudes, was provided when demographic information did not align with perceived fitness level; for example “He’s 60 years old. He’s actually very strong. He used to, or he does, work in landscaping”. There was no formal inclusion of GA data. Explicit references to patient preferences or agentive decision-making only occurred in 19 cases; 11 referring to the patient’s (non-)interest in clinical trials, 3 denying additional testing (tone suggesting non-compliance), and 7 specifically referring to treatment type preference (e.g. surgery vs. chemotherapy). Conclusions: At present, MDTB treatment discussions primarily rely on shared understandings of the cultural significance and meaning of various demographic traits and rarely reference patient-reported preferences or fitness when determining the best pathway for patient care. Further work is needed to understand how to better formally incorporate fitness and preferences into decision-making.
Patient-reported satisfaction with care and care coordination: Results from an online survey conducted in Manitoba, Canada during the COVID-19 pandemic.
Authors: Thiessen Maclean Harvey , Decker Kathleen , Park Jason , Soriano Andrea
Published: September 2022

258

Background: In Manitoba, Canada, changes to cancer care delivery implemented in response to the COVID19 pandemic included, but were not limited to, restrictions on informal caregiver accompaniment for ambulatory care appointments and implementation of physician care administered over the telephone. These changes were predicted to negatively impact the patient experience, specifically patient satisfaction with care and perceived care coordination. To assess this, a survey of patients on active treatment was conducted. Methods: After ethics approval, a SurveyMonkey survey was conducted of cancer patients receiving radiation and IV treatment at one of the 24 cancer treatment sites across Manitoba. The survey collected demographics, disease characteristics, functional status and responses to validated questionnaires addressing satisfaction with care (PSCC), and care coordination (CCQP, including communication (CCQPcomm) and navigation (CCQPnav) subscales). Mean differences of PSCC and CCQP scores (including subscales) were compared using t-test for dichotomous patient characteristics and ANOVA followed by post-hoc pairwise t-tests for non-dichotomous categorical patient characteristics with statistically significant ANOVA results. Results: Between July 2020 and February 2022, 203 responses were collected. The 154 respondents with complete responses for either PSCC, CCQP or both were included in this analysis. Median age of respondents was 64.6 (SD = 11.7). Sex was balanced (male = 47%, female = 52.3%, other/prefer not to say = 0.7%). Breast (26.1%), hematological (13.7%), and prostate (13.1%) cancers were the most common. PSCC and CCQP scores did not differ by marital status, treatment site, disease type, or treatment intent (i.e., curative versus non-curative). Individuals with lower functional status (i.e., ECOG > 1) were identified to have lower mean scores for CCQP and CCQPcomm. Patients < 59 years had lower mean PSCC scores compared to those 59 – 69, and 70+. See Table for comparison of CCPQ and PSCC scores by age and functional status. Conclusions: Young patients and those with decreased functional status were identified to have statistically significant lower mean scores for PREMs reflecting satisfaction and coordination of care. Further work to identify meaningful strategies to improve the patient experience for these two patient groups is needed.[Table: see text]
Racial/ethnic disparities in patient care experiences among prostate cancer survivors: A SEER-CAHPS study.
Authors: Pandit Ambrish , Li Chenghui
Published: September 2022

291

Background: To evaluate racial/ethnic disparities in patient care experiences (PCEs) among prostate cancer (PCa) survivors. Methods: This retrospective study used 2007-2015 National Cancer Institute Surveillance, Epidemiology and End Results registry data linked to Consumer Assessment of Healthcare Providers and Systems surveys. First survey ≥6 months post-PCa diagnosis was analyzed. We performed linear regression modelling to evaluate the association of race/ethnicity (non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, non-Hispanic Asian (NHA), and other races) with PCE composite measures (getting needed care, doctor communication, getting care quickly, getting needed prescription drugs, customer service), and rating measures (primary physician, specialist, health plan, and overall care) adjusting for demographic and clinical covariates. Results: Among 7453 PCa survivors, NHAs (vs. NHWs) reported disparities in more PCE measures than any other racial/ethnic minority; reported lower scores for customer (ß = -7.58; p = 0.003), getting needed prescription drugs (ß = -3.08; p = 0.020) and specialist rating (ß = -2.32; p = 0.021) besides lower scores for getting care quickly. NHBs scored better on doctor communication (ß = 1.96; p = 0.006) and primary physician rating (ß = 1.28; p = 0.047) than NHWs. No statistically significant differences were found between other races and NHWs. Conclusions: Racial/ethnic minority PCa survivors reported worse experiences than NHW survivors on several PCE measures. Further research is needed to understand reasons behind these disparities and their influence on healthcare utilization and health outcomes among PCa survivors.
Reducing same-day cancellations of precious CT simulation slots: A quality improvement project.
Authors: Ng Ivy , Lai Michelle , Ng Jessie , Beltran Richerlyn Quindara , Teng Kie Yin , Wei Wei , Lee Chia Ching , Pastores Kathleen Viloria , Chiau Ye Lin , Chuah Jyy Yin , Leong Cheng Nang , Poon Keah How , Ho Francis
Published: September 2022

301

Background: CT simulation (CTsim) is a prerequisite step in radiotherapy treatment. Each successfully completed CTsim brings a patient a step closer to receiving their radiotherapy. A non-attempt or unsuccessful attempt (both reflected as cancellations) also delays radiotherapy for another patient. Baseline data revealed that 33% of CTsim appointments were cancelled, of which 47% occurred on the same day. Cancellations made on the same day provides little reaction time for slots to be allocated to another patient and leads to inefficiency in resource utilisation. This project aims to reduce the cancellations occurring on the same day from 15.5% to 10% within 6 months at National University Cancer Institute radiotherapy center at Tan Tock Seng Hospital. Methods: A cause-and-effect diagram was constructed to identify reasons attributing to existing same-day cancellations. Multi-voting and Pareto analysis were conducted to identify 3 main root causes. Interventions were introduced and then tested using the Plan-Do-Study-Act approach. Run chart was used to monitor the proportion of same-day cancellations over the total number of CTsim appointments. Results: Three root causes identified were 1) no workflow to check on patient’s adequacy of preparation leading up to CTsim 2) no workflow to identify potential non-attendance 3) no take-home information detailing CTsim process. Interventions introduced included establishing workflow to assess adequacy of patients’ preparation required for successful CTsim and integrating a screening phone call to confirm patient’s attendance two days prior to CTsim appointment day and handing out information sheet detailing instructions for CTsim respectively. We achieved our target in our fourth month and sustained the results for 2 further months. Mean was 5% in the last three months. This reduction of same-day cancellation improves efficiency in resource utilisation and reduces delay in access to radiotherapy. Conclusions: Using quality improvement tools, we have successfully reduced the same-day cancellations of our precious CT simulation slots from 15.5% to 5%.
I-DO GOC: Improving documentation in oncology with goals of care.
Authors: Martinez Francisco , Hauser Karen , Aller Ashley , Shirazi Aida , Lin Amy Ying Ju , Lim Peggy T , Jones Tyler , Whitehead Hannah , Risbud Amita , Yen Sue May , Liu Raymond , Katzel Jed Abraham
Published: September 2022

314

Background: Goals of Care (GOC) discussions are part of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early GOC discussions are associated with better quality of life, reduced use of futile medical care, and enhanced goal-concordant care. In order to increase GOC documentation within the electronic medical record (EMR), the Kaiser Permanente San Francisco medical oncology practice began an ASCO Quality Training Program initiative in January 2022 to increase oncologist discussion and documentation of GOC in advanced cancer patients. Methods: Baseline data on the frequency of GOC discussions was obtained through a structured chart review with a historical cohort of stage IV or recurrent cancer patients > 18 years old between 1/1/2020-6/1/2020. The project aimed to improve accessible GOC documentation from a baseline of 0% to a goal of 25% among stage IV or recurrent cancer patients seen by an oncologist between 1/2022 and 5/14/2022. Patients with hematologic malignancies were excluded. Oncologists were instructed to use a templated GOC automated phrase (Smartphrase) that consolidated content into a visible, centralized EMR location. The frequency of GOC Smartphrase usage among oncologists was tracked monthly through a customized dashboard. Plan-Do-Study-Act cycles included education on GOC documentation and monthly feedback for oncologists on performance. Results: Review of the 2020 historical cohort revealed no structured or accessible GOC documentation by oncologists. During the intervention period, 300 Stage IV and recurrent cancer patients were eligible for GOC documentation. The median age of the intervention group was 70 years, with the most common types of cancers represented: Prostate (21%), Breast (19%), and Lung (17%). Our study cohort included a diverse population: White (45%), Asian (36%), Black/African American (11%), and Hispanic (7%). Between 1/1/2022 to 5/14/22, 142 (47%) patients had at least one documented GOC conversation, exceeding the target of 25%. 100% of these structured conversations were viewable in the designated area in the EMR. Conclusions: Our ASCO Quality Training Program initiative successfully increased oncologists' overall number of GOC conversations and made those conversations more easily accessible to the entire care team. Our process for standardizing the documentation of GOC conversations was based on the use of a Smartphrase that helped organize the collected information within the EMR. During the study period, we increased the documented GOC rate from 0% to 47%. This can improve patient and physician satisfaction, as well as improve goal concordant care for patients with advanced cancer. Further efforts will be focused on sustaining these initial gains in GOC documentation and on promoting their broader use across our organization.
Association of patients' primary language, race, and location of care with decision-making for personalized breast cancer risk assessment.
Authors: Rutkowski Angela , Paul Shirlene , Lieberenz Jordan , Stempel Lisa , Alvarado Rosalinda , Levy Mia Alyce
Published: September 2022

331

Background: Personalized breast cancer risk assessment (CRA) and genetic counseling/testing for women have been shown to improve interventional and clinical outcomes. However, despite CRA being routinely offered to all women at our institution, not all women choose to opt into the program. This study evaluated the demographic distribution of patients that opted out of the CRA to identify potential components influencing this substantial decision. Methods: Our medical center, located in four urban and suburban locations, piloted a clinical framework to provide CRA to all women between the ages of 25 and 75 with a qualifying mammogram. In this single institution retrospective study, we analyzed differences among patients who opted out of the program between July 20, 2020and July 19, 2021. Data elements extracted from the electronic medical record include race, primary language, location of care, and decision to partake in CRA. Overall Chi-square tests and all pairwise comparisons with Bonferroni correction were used to statistically determine the impact of various demographics on opting out. Results: 18726 women met criteria for inclusion and 2717 (14.5%) declined CRA. Within their respective racial groups, 122 (17.6%) Asian, 1175 (16.3%) Black, 455 (14.2%) Hispanic, 112 (15%) Other, and 853 (12.4%) White opted out. Within their identified primary language, 2370 (13.7%) English, 231 (23.1%) Spanish, 35 (19.7%) Bilingual, and 81 (35.2%) Other opted out. Based on their setting of care, 837 (16.8%) Location A, 1436 (14.2%) Location B, 270 (13.8%) Location C, and 174 (10.6%) Location D opted out. The differences between demographics and opting out were statistically significant for all analyses (p <.0001). Results shown in Table below. Conclusions: The main variables mediating the decision to opt out of CRA are a non-English primary language, non-White race, and location of care, potentially due to inadequate interpretation services, barriers to education, and staffing shortages. Thus, these women are less likely to receive genetic counseling/testing or supplemental screening. Our study is the first to investigate the factors contributing to the uptake of risk assessment. Further study is needed to determine the clinical impact of this striking disparity.[Table: see text]
Adaptation of a financial toxicity intervention for scale-up to diverse contexts: Core functions of Lessening the Impact of Financial Toxicity (LIFT).
Authors: Birken Sarah A , Wheeler Stephanie B. , Wagi Cheyenne , Manning Michelle L. , Strom Carla , Bell Ronny A. , Gellin Mindy , Padilla Neda , Rogers Cindy , Rodriguez-O'Donnell Julia , Rosenstein Donald L.
Published: September 2022

345

Background: Rural and non-English speaking populations experience a disproportionate burden of financial toxicity and access to services for their cancer care. Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, clarifies costs, and develops strategies to cope with costs. LIFT was successful in reducing financial toxicity in preliminary studies among English-speaking patients with high levels of FT in a single large academic cancer center. To benefit diverse patients with FT in cancer programs across the US, there is a need to adapt LIFT. Adapting LIFT requires distinguishing between its core functions— the components of LIFT key to its effectiveness and implementation, and its forms— the activities that comprise LIFT, facilitate its implementation, and may be adapted to accommodate new populations and contexts. We completed the first stage of adaptation, identifying LIFT core functions. Methods: We conducted interviews with individuals responsible for LIFT’s design and implementation. Interview questions were based on Kirk’s methods for identifying core functions and were recorded and transcribed verbatim. Using a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts and identified themes related to how LIFT engaged cancer program staff in FN (implementation core functions) and decreased FT (intervention core functions). Results: Eight interview participants filled various roles in designing and implementing LIFT (e.g., P.I.s; FNs). LIFT intervention core functions include a systematic way of cataloging knowledge, resources, and tracking patient information; using patient-specific needs to guide access to resources; ongoing, dynamic assistance and strong one-on-one relationships between navigators and patients; and removing common barriers to accessing resources. Conclusions: We identified core functions key to LIFT’s effectiveness and implementation. Next steps include identifying systematic differences between LIFT’s original context and population and new ones. Successfully adapting LIFT has the potential to extend its benefits to diverse patients in cancer programs throughout the US, such as Spanish-speaking patients served by rural community cancer programs.
Spreading routine serious illness conversations at a single cancer center using a multidisciplinary and patient-family advisory approach.
Authors: Wasp Garrett Thomas , Guo Karen , Wilson Matthew , Vergo Maxwell Thomas , Willaims Andy , Perry James J. , Holthoff Megan M. , Buus-Frank Madge E. , Cullinan Amelia M.
Published: September 2022

367

Background: ASCO Guidelines recommend oncologists conduct serious illness conservations (SIC) for all patients with advanced cancer. We describe the spreading of a multidisciplinary and patient-family advisor (PFA) quality improvement (QI) initiative to conduct routine SIC at a NCI-designated comprehensive cancer center. Methods: This single center study describes the second phase of a learning health system initiative to conduct routine SIC for all seriously ill patients with cancer. Prior work completed included defining patient eligibility (e.g. two-year surprise question), and deploying a SIC template in the electronic health record (EHR) to capture SIC in a centralized location. Phase II can be categorized into three steps: a) increasing communication coach and PFA capacity; b) refining EHR tools to automate tracking and reporting of outcomes; and c) adoption of the Model for Improvement as the QI methodology to guide testing and implementation. For the first three months, each team engaged in preparatory work including: process mapping, key driver diagram development, and SIC Guide training. In the last six months, each team met weekly to set their own team goals, conducted iterative PDSAs, and reviewed run charts of their performance. Patient-level data on SIC documentation was collected through automated EHR tools and provided to the teams on a weekly basis. Results: Over nine months (3/1/2021 to 12/31/21), four teams screened 510 patients with cancer, identified 272 (53%) patients as eligible for SIC, and 178 (65%) of those eligible had a documented SIC from a baseline of 0%. The breakdown of this combined SIC patient count by clinician author is as follows: team A 40 (22%); team B 45 (25%); team C 9 (5%); team D 14 (8%) and specialty palliative care 70 (39%). Each team set modest, initial SIC documentation goals (range 5-15%), and attainment of first SIC documentation goal varied (range 2 to 4 months). We retained all clinician team members during the study period, but 2 out of 3 PFAs left by study period end. Noted challenges with PFA recruitment and retention included: lengthy recruitment, integration into clinical teams, and resistance to change by teams. Conclusions: The multidisciplinary approach, inclusive of specialty palliative care, increased SIC documentation. PFA involvement, as implemented, met with challenges and yielded mixed results. Additional follow-up will be required to assess if gains can be sustained and/or increased.
Electronic Frailty Index: A risk stratification tool for survival and health care outcomes in veterans with colorectal cancer.
Authors: Zhu Huili , Razjouyan Javad , Yarlagadda Sudha , Naik Aanand , Sada Yvonne H
Published: September 2022

375

Background: Frailty reflects decreased physiologic reserve and subsequent increased vulnerability to stress. Frailty has been associated with poor health outcomes in patients with cancer, however traditional frailty indices are time consuming and not widely implemented in clinical oncology practice. An electronic frailty index (EFI) derived from electronic medical records (EMR) is an objective and standardized approach to frailty that can be automated. Little is known about the association between EFI and survival and healthcare utilization outcomes in patients with colorectal cancer (CRC). Methods: We used VA administrative files from 2016 – 2020 and the VA Central Cancer Registry to identify a cohort of patients diagnosed with CRC. EFI was calculated based on the Veterans Affairs-FI (VA-FI), a validated 31-item cumulative deficit FI, to define three groups: robust (≤0.1), prefrail (0.1-0.2), and frail (> 0.2). We conducted Cox proportional hazard analyses to evaluate survival. We performed logistic regression to examine prolonged length of stay (LOS) ≥ median (11 days) during all-cause hospitalization and emergency department (ED) visits within one year after diagnosis. All models were adjusted for age, gender, race, Charlson comorbidity index, and stage. Confidence intervals (CI) were calculated as 95%. Results: Of 6,043 CRC patients (age: 69.7 ± 10.6 years), 45.6% were robust, 34.5% were prefrail, and 19.9% were frail. The cohort included 22.9% rectal cancer and 77.1% colon cancer cases, distributed across stages I (29.2%), II (25.0%), III (25.2%), and IV (20.6%). Increased risk of death was found in prefrail (adjusted hazard ratio [aHR] 1.21; CI 1.10-1.32) and frail (aHR 1.90; CI 1.71-2.11) patients when compared to robust patients. Increased odds of one-year ED visits were identified in prefrail (adjusted odds ratio [aOR] 1.18; CI 1.06 – 1.35) and frail (aOR, 1.66, CI 1.43-1.94) patients. Frailty status was associated with increased odds of one-year hospitalization of prolonged LOS among prefrail (aOR 1.38; CI 1.11-1.70) and frail patients (aOR 1.79; 95% CI 1.39-2.30). Conclusions: EFI was significantly associated with survival and healthcare utilization among patients with CRC, independent of stage. Frail patients had nearly 80% increased likelihood of prolonged hospitalization. EFI has the potential to be an automated and objective decision support tool at the point of care for risk assessment prior to CRC treatment-related stressors, such as surgery or chemotherapy. Future work is needed to develop a cancer specific EFI with dynamic variables that can be followed prospectively, as well as evaluating barriers to implementation within the EMR to guide treatment decisions and improve the quality of cancer care.
A pilot study to increase cascade genetic risk education and testing in families with hereditary cancer syndromes.
Authors: Katz Steven , Hawley Sarah T. , Tocco Rachel , Kurian Allison W.
Published: September 2022

378

Background: There is great need to build and evaluate tools and strategies to improve cascade genetic risk evaluation in families at high risk for hereditary cancer. The Genetic Information and Family Testing (GIFT) Trial is a population-based intervention that will examine features of a virtual platform that provides genetic risk education (GRE) and low-cost genetic testing (GT) to relatives of 5000 adult patients diagnosed with cancer in 2018-19 in Georgia and California and who tested positive for a clinically actionable germline pathogenic variant (PV). We present findings of a pilot study that informed the GIFT Trial protocol and platform features. Methods: We surveyed 277 women diagnosed with breast cancer in 2017, reported to the Georgia SEER registry, and who tested positive for a clinically actionable PV in a cancer-associated gene. We then invited respondent patients to enroll in the intervention phase which provided online GRE, human pretest genetic navigator support, and an offer of low-cost GT through Color Health, Inc. to all untested 1st or 2nd degree relatives. Respondent patients were eligible for the intervention if they reported a PV on genetic testing and had at least one relative who had not received GT. Enrolled patients invited relatives through the platform by providing email addresses. Family clusters were block randomized to free vs $50 test costs at the time of the initial patient invitation. Results: 125 of 277 patients (45.2%) returned surveys: median age was 51 and 22% were African American. The most common PV reported by patients were BRCA2 (25.7%), BRCA1 (19.5%), CHEK2 (20.4%), ATM (8.8%) and PALB2 (7.1%). Disclosure of genetic test results to relatives was quite high: 83.6% of patients reported that they discussed results with all their daughters vs 69.4% with sons; 78.1% discussed their results with all sisters vs 61.8% with all brothers. The median number of patient-reported untested relatives in a family was 9 (25th-75th percentile: 4-14). Most respondents were eligible for the trial offer (113 of 125, 90.4%). Overall, results were similar between the free test arm and $50 test arm: In the free testing arm, 20 patient participants invited 28 relatives; 12 relatives enrolled, and all 12 relatives ordered testing. In the $50 arm, 16 patient participants invited 38 relatives of whom 18 enrolled and all 18 ordered testing. For the 66 relatives invited by the patient participants: 47 (71.2%) were first degree (8 parents, 22 siblings, and 17 children) and about half of the relatives were men (47.0%). Conclusions: Breast cancer patients with PVs make substantial efforts to communicate with family members about genetic risk but most relatives do not receive GT. Our study findings suggest that a low-cost online navigator-supported intervention can directly engage relatives to increase cascade genetic risk education and testing with little difference in uptake by test cost arms.
Patient preferences for telehealth versus in-person oncology visits.
Authors: Kumar Deepika , Gordon Nancy P. , Neeman Elad , Zamani Constanza , Sheehan Tammy Rene , Martin Ernesto , Payne Jessica , Egorova Olga , Kolevska Tatjana , Liu Raymond
Published: September 2022

386

Background: The COVID-19 pandemic led to rapid adoption of telehealth (video or phone) visit modalities for oncology encounters not requiring in-person visits. We surveyed oncology patients regarding preferences for in-person versus telehealth modalities for different types of clinical encounters. Methods: We surveyed adults who were undergoing treatment at Kaiser Permanente Northern California infusion centers between 11/2021 – 05/2022 using a self-administered questionnaire. Patients were asked about modality preferences for 6 types of clinical discussions, overall advantages and disadvantages of telehealth versus in-person encounters, and barriers to video visit use. Results: A total of 757 patients who completed surveys in English answered questions about visit modality preferences for different types of discussions with their oncologist. Respondents were 63% female, median age 63y, and majority White (61% White, 19% Asian, 11% Latino, 7% Black) and college-educated (28% some college, 45% ≥ bachelor’s degree). For the first post-diagnosis discussion, most patients preferred in-person (IP) visits (83%), followed by video visits (27%) and phone visits (18%). For follow-up visits during treatment, patients preferred IP (52%), video (50%) and phone (37%) visits. For discussions of bad news and sensitive topics, IP visits were preferred by 68% and 62%, video visits by 44% and 48%, and phone visits by 32% and 41%, respectively. Good news could come at IP (49%), video (52%) or phone (49%) visits. Approximately 20% of patients had no overall preference for IP versus telehealth visits. However, 58% of patients felt more personally connected with their doctor at IP visits. Patients also had more confidence in IP examinations (73%) and felt IP was easier for showing things (67%) and talking (51%) to the doctor. Patients felt telehealth visits saved them time (72%), reduced infection exposure (64%) and travel issues (45%), were cheaper (38%), and enabled inclusion of more people (28%). Of 24% of patients who felt video visits would be hard, 51% cited poor internet, 41% lack of an adequate device, and 28% difficulty signing on. Conclusions: The majority of oncology patients consider telehealth visits acceptable for most types of clinical discussions, with the exception of the first post-diagnosis visit. Only one-fourth of patients indicated potentially modifiable barriers to video visits. Our results support use of telehealth visits for most types of oncology encounters.
Comorbidities among patients with breast cancer during COVID-19: Agreement between patient-reported data and electronic medical records.
Authors: Maculaitis Martine C. , Liu Xianchen , Thompson Jeffrey A. , Berk Alexandra , Massa Angelina , Weiss Marisa C. , Li Benjamin , Kurosky Samantha K. , McRoy Lynn
Published: September 2022

409

Background: Comorbidities are a major cause of complications in cancer patients and can increase the risk of severe illness from coronavirus disease 2019 (COV). Yet, in real-world studies of cancer patients, comorbidities are often not well captured in electronic medical records (EMR); self-reported comorbidities may be limited by recall error. Combining and comparing self-reported and EMR data may help identify key data gaps in comorbidity diagnosis. We aimed to estimate self-reported and EMR-documented comorbidities and examine agreement between these data sources in US patients with early-stage (eBC) or metastatic (mBC) breast cancer. Methods: From March 30 to July 6, 2021, patients (aged ≥18 years) who self-reported a BC diagnosis (no current Stage 0 or ductal carcinoma in situ) and provided consent were recruited via Ciitizen, a patient-mediated health records and real-world evidence platform, and patient advocacy groups to complete a cross-sectional online survey. EMR data from Invitaes Ciitizen platform, covering November 1, 2019-September 28, 2021, were collected. The datasets were then linked; in preliminary assessment, depression (DEP), anxiety (ANX), and COV were the only comorbidities sufficiently populated to enable agreement analysis. DEP, ANX, and COV prevalence rates in EMR and survey data were computed. Agreement between data sources was estimated using Cohens kappa. Results: Overall, 542 patients in the linked sample were included in the analyses. A majority was female (99%), aged ≥50 years (52%), and diagnosed with mBC (53%). Patients were similarly distributed by US geographic region. DEP, ANX, and COV prevalence rates were 40%, 50%, and 6% in EMR and 20%, 16% and 10% in survey, respectively (Table). The kappa values for agreement were.5 (DEP),.3 (ANX), and.8 (COV). Conclusions: Mental health conditions and COV were prevalent in BC patients during the pandemic. It is important for oncologists to consider that DEP and ANX are often underreported among patients with BC. Agreement between data sources was low for mental health conditions. Self-report and EMR data may thus provide complementary information on comorbidities.[Table: see text]