bluuebunny/crossref_metadata_2025 huggingface dataset:
Timing of postoperative radiation therapy and survival in resected salivary gland cancers: Long-term results from a single institution.
Authors: Romine Perrin , Voutsinas Jenna M. , Wu Vicky , Tratt Micah , Liao Jay Justin , Parvathaneni Upendra , Barber Brittany , Dillon Jasjit , Timoshchuk Mari-Alina , Futran Neal D. , Houlton Jeffrey , Laramore George E. , Martins Renato G. , Eaton Keith D. , Rodriguez Cristina P.
Published: June 2021

e18052

Background: Timely administration of postoperative radiation therapy (PORT) impacts oncologic outcomes in resected squamous cell carcinomas of the head and neck. Salivary gland cancers (SGCs) are uncommon, and timing of PORT has not been extensively explored. We aimed to determine if the interval between surgery and PORT impacts outcomes in SGCs. Methods: We retrospectively identified patients with SGCs who underwent curative intent surgical resection followed by adjuvant PORT at our tertiary referral center. Demographic, tumor, and treatment data were collected. Patients with non-oncologic resections and/or delay of > 6 months to radiation start were excluded. Locoregional control (LRC), relapse free survival (RFS), and overall survival (OS) were estimated using the Kaplan Meier method. A multivariate analysis explored the association between demographics, tumor characteristics, and PORT timing with oncologic outcomes using a stepwise Cox proportional hazards model. Results: Between 1/1/1997 and 12/31/2017 180 eligible patients were identified. Patient characteristics are described in Table. The median time to PORT start was 61 (range 8-121) days, 169 (93.9%) of patients received neutron beam PORT. With a median follow up of 8.2 years in surviving patients, the 5-year OS and LRC estimates were 73% and 67%, respectively. In a multivariate analysis, only nodal involvement, histologic grade, and age at diagnosis were associated with OS, while nodal involvement, tumor size, and age at time of diagnosis were associated with LCR and RFS. Time to PORT start or completion was not statistically associated with survival outcomes on multivariate analysis. Conclusions: SGC patients who underwent surgery in our tertiary institution received PORT within a median of 61 days after surgery. With long term follow up, PORT timing in this retrospective series was not associated with worse oncologic outcomes, and support timely administration of PORT with 3 months of surgical resection. Further work is necessary to assess generalizability of these results.[Table: see text]
Enrollment disparities in cancer clinical trials leading to FDA approvals between 2008 and 2020.
Authors: Nguyen Ryan Huu-Tuan , Silva Yomaira , Gadi Vijayakrishna K.
Published: June 2021

e18501

Background: Cancer clinical trials based in the United States (US) have lacked adequate representation of racial and ethnic minorities, the elderly, and women. Pivotal clinical trials leading to United States Food and Drug Administration (FDA) approval are often multi-national trials and may also lack generalizability to underrepresented populations in the United States. We determined the racial, ethnic, age, and sex enrollment in pivotal trials relative to the US cancer population. Methods: We reviewed the FDA’s Drug Approvals and Databases for novel and new use drug approvals for breast, colorectal, lung, and prostate cancer indications from 2008 through 2020. Drugs@FDA was searched for drug approval summaries and FDA labels to identify clinical trials used to justify clinical efficacy that led to FDA approval. For eligible trials, enrollment data were obtained from FDA approval summaries, FDA labels, ClinicalTrials.gov, and corresponding journal manuscripts. Enrollment Fraction (EF) was calculated as enrollment in identified clinical trials divided by 2017 SEER cancer prevalence. All data sources were publicly available. Results: From 2008 through 2020, 60 drugs received novel or new use drug approval for breast, colorectal, lung, or prostate cancer indications based on 66 clinical trials with a total enrollment of 36,830. North America accounted for 9,259 (31%) enrollees of the 73% of trials reporting location of enrollment. Racial demographics were reported in 78% of manuscripts, 66% of ClinicalTrials.gov pages, and 98% of FDA labels or approval summaries. Compared with a 0.4% enrollment fraction among White patients, lower enrollment fractions were noted in Hispanic (0.2%, odds ratio [OR] vs White, 0.46; 95% confidence interval [CI], 0.43 to 0.49, P< 0.001) and Black (0.1%, OR 0.29; 95% CI 0.28 to 0.31, P< 0.001) patients. Elderly patients (age ≥ 65 years) were less likely than younger patients to be enrollees (EF 0.3% vs 0.9%, OR 0.27; 95% CI 0.26 to 0.27, P< 0.001) despite accounting for 61.3% of cancer prevalence. For colorectal and lung cancer trials, females were less likely than males (EF 0.7% vs 1.1%, OR 0.66; 95% CI 0.63 to 0.68, P< 0.001) to be enrolled. Conclusions: Black, Hispanic, elderly, and female patients were less likely to enroll in cancer clinical trials leading to FDA approvals from 2008 to 2020. Race and geographic enrollment data were inconsistently reported in journal manuscripts and ClinicalTrials.gov. The lack of appropriate representation of specific patient populations in these key clinical trials limits their generalizability. Future efforts must be made to ensure equitable access, representation, and reporting of enrollees that adequately represent the US population of patients with cancer.
The impact of demographics and Medicare payments on quality of external beam radiotherapy for bone metastases in U.S. hospitals.
Authors: Mladkova Nikol , Dharmarajan Kavita Vyas
Published: June 2021

e18504

Background: External Beam Radiotherapy (EBRT) has a well-established role in palliation of metastatic bone disease, yet the adherence to evidence based palliative EBRT doses and fractionation schemes is not universal across United States outpatient treatment facilities. We aimed to explore potential disparities in palliative EBRT quality in relation to Medicare visit payments and population demographics. Methods: Centers for Medicare & Medicaid Services (CMS) EBRT for Bone Metastases process measure score for 2018 included in the Hospital Outpatient Quality Reporting Program (Hospital OQR) was available for a total of 824 facilities across the US. The score represents the percentage of evaluated patients that received an acceptable palliative dose/fractionation regimen. Radiation Oncology Office Visit Costs per zip code for new and established patients were obtained from CMS. Demographics (percentage of total population representing males, females, 5 years or younger, under 18 years, 65 or older, white, black or African American, Latino) were obtained from US census. Linear regression analysis was carried out with score representing the dependent variable. Results: The median score was 95% (range 5-100%), average 88.86%. In the final multivariate model, the score was significantly positively associated with the percentage of white population (p = 0.04) and negatively associated with the percentage of population under 18 (p = 0.03), and there was a trend toward association with the mode of Medicare pricing for a new patient visit (p = 0.06). Of note, the percentage of population under 18 was positively correlated with percentage of Latino population (p = 3.155e-09) but not black population (p = 0.9.) There was no association with gender, or with the percentage of those patients who were very young (under 5) or over the age of 65 years. Conclusions: The quality of palliative EBRT in US outpatient facilities is associated with demographic diversity of a given area, with predominantly nondiverse neighborhoods generally receiving higher quality EBRT-based palliative care. Additionally, it appears to be negatively affected by Medicare payments. This data suggests that disparities in healthcare quality are directly mediated by race and partially by geography.
Racial disparities among women who develop invasive secondary breast cancer.
Authors: Taparra Kekoa , Fukui Jami Aya , Killeen Jeffrey , Sumida Kenneth N. M. , Loo Lenora , Hernandez Brenda Y
Published: June 2021

e18523

Background: Noninvasive breast cancers ( e.g. ductal and lobular carcinoma in situ) are highly treatable nonobligate precursors to invasive breast cancers. However, even after treatment, some women develop second breast cancers (SBCs), increasing their mortality risk. Prognosticators may inform treatment recommendations for women at higher risk of SBC. In this study, risk factors for SBC were evaluated using deidentified data from the Hawaiʻi Tumor Registry (HTR), an NCI SEER registry. The HTR covers a uniquely multiethnic, statewide population allowing for elucidation of disparities in understudied U.S. populations. Methods: Women initially diagnosed between 1973-2017 with noninvasive (ductal and lobular) breast cancer were identified. Patient demographics, cancer characteristics, and treatment information were collected. Univariate (UVA) and multivariate (MVA) logistic regression analyses were used to identify factors associated with SBC, defined as a breast cancer diagnosis > 6 months after their prior cancer. Results: Of 7,057 women diagnosed with a first noninvasive breast cancer, 696 (10%) developed SBC. Invasive ipsilateral (iiSBC) and invasive contralateral (icSBC) disease represented 9% and 20% of patients who developed SBC, respectively. The five most prevalent ethnic groups were Chinese, Filipino, Japanese, Native Hawaiian, and White. When adjusting for confounders, women who developed iiSBC were more likely to be Native Hawaiian (odds ratio [OR] = 3.20, 95% CI = 2.07-4.94) or Filipino (OR = 1.72, 95%CI = 1.02-2.91) when compared to Whites; diagnosed between 1990-1999 (OR = 2.06, 95%CI = 1.27-3.34); and not have undergone surgical treatment (OR = 2.93, 95%CI = 1.42-6.04). Women who developed iiSBC were less likely to be > 50 years old (OR = 0.67, 95%CI = 0.49-0.90); diagnosed between 2010-2017 (OR = 0.18, 95%CI = 0.09-0.35); received lumpectomy with radiation therapy (OR = 0.54, 95%CI = 0.35-0.72); and undergone mastectomy (OR = 0.48, 95%CI = 0.32-0.72). Women who developed an icSBC were more likely to be Native Hawaiian (OR = 1.58, 95%CI = 1.06-2.35) or Filipino (OR = 1.60, 95%CI = 1.06-2.42). These women were also less likely to have been diagnosed between 2010-2017 (OR = 0.30, 95%CI = 0.17-0.53). On a subset analysis separating all patients with SBC by first course treatment type, there were no statistically significant differences for treatment type based on race/ethnicity. Conclusions: Overall, in this observational study, Native Hawaiian women, Filipino women, and younger women had increased odds of developing invasive SBC. This study highlights racial disparities in SBC development risk that was not previously appreciated among disaggregated groups of Pacific Islanders and Asian women when compared to White women. This may help oncologists understand the risk of developing SBC in these understudied populations.
Bridging the gap by providing access to oncology care to rural communities: A hybrid delivery model combining in-person visits with Telehealth.
Authors: Rariy Chevon , Truesdale Lynn , Ahn Eugene R. , Gershenhorn Bruce G. , Easthon Katie , Garoutte Bethany , Govorchin Pete , Schink Julian C.
Published: June 2021

e18528

Background: Americans who live in rural areas experience unique barriers to access healthcare such as limited transportation, shortages in oncology providers, limited access to advanced services which contribute to poor health outcomes. The current COVID-19 pandemic has provided a catalyst for rapid adoption of telehealth. A regional cancer center has established a novel rural health partnership program that utilizes a hybrid model of on-site visits and telehealth to increase access to advanced oncology care for patients in rural communities. Here we describe the collaboration and benefits of this model. Methods: The rural health hybrid delivery model utilizes a combination of in-person and telehealth visits to provide immediate access to the regional center’s oncology care team and specialized services such as advanced surgeries, radiation, precision medicine, and clinical trials. Speed to care was built into the model as a key feature, offering initial appointments within 3 business days from the time of the referral, wherein treatment plans are developed facilitating immediate start. The model is a collaborative partnership, ensuring a coordinated care process driven by the regional oncologists working in coordination with the local provider to meet the needs of the patient. The patient is able to decrease transportation time, cost, and obtain care closer to their support system by keeping the patient in their community for basic needs. For more complex requirements, on-site visits are coordinated. This allows access to the regional center’s specialty oncology care services not available locally, while keeping the patient engaged with their local provider, which increases service utilization and expands the patient base. Leveraging telehealth visits at the local hospital ensures access to adequate broadband and technology capabilities to facilitate continuity of patient care. Results: This model provides the patient with timely access to specialty cancer care in their local community. Partnerships with two rural health systems were implemented in July and November 2020. 14 patients are enrolled in the program to date with a 100% retention rate. The turnaround time from treatment plan to treatment is 6 business days. There was a total of 62 oncology telehealth appointments, reducing patient travel by 12,705 driving miles, 310 travel hours, saving $7,380 in travel costs and accommodation. Conclusions: Telehealth provides a bridge to the rural health access gap, and advances health equity by offering specialized care to patients in their local communities. Improving access to best practice treatment strategies for all cancer patients moves us closer to resolving disparities in outcomes. Applications of this hybrid model of care to other rural sites is a promising strategy to reduce rural-urban disparities in cancer care.
Mapping geographical disparities in population-level patient-reported quality of life following prostate cancer management.
Authors: Koo Kendrick , Papa Nathan , Evans Melanie , Jefford Michael , IJzerman Maarten J. , Millar Jeremy Laurence
Published: June 2021

e18531

Background: Prostate cancer patients generally have good survival outcomes, but some survivors have poor functional outcomes with persisting symptoms and poor quality of life (QoL). Socio-economic status (SES), access to specialist care and place of residence (including rural, remote areas) are associated with poor survival. These variables may also impact survivorship outcomes, including QoL. This study aimed to identify and visualise geographical disparities in QoL outcomes for prostate cancer survivors. Methods: We extracted complete data for 7690 patients, including patient-reported EPIC-26 QoL questionnaire results (12 months post-treatment), from the Prostate Cancer Outcomes Registry–Victoria (PCOR-VIC), a population-based clinical quality outcomes registry. Patient-matched geographic coordinates were obtained through the Victorian Cancer Registry. Scores from each of the 5 EPIC-26 functional domains were visualised using geospatial maps and correlated to the Index of Relative Socio-economic Advantage and Disadvantage (IRSAD) and geographical remoteness. A composite score condensing all 5 domains into a single number (range 5 – 20) was created for succinct visualisation of functional outcomes. We analysed hotspots using the Getis-Ord Gi* statistic. Results: Scores in all 5 functional domains were positively correlated to IRSAD, which remained an independent predictor of low functional score when controlling for age, disease stage, treatment modality and geographical remoteness (p < 0.001 for all). Geographical remoteness predicted low functional score in all domains (p < 0.05) except Urinary Irritative but was not statistically significant when adjusted for IRSAD. The constructed composite score was significantly correlated to IRSAD and remoteness in a univariate model (p < 0.001). In a multivariate model, remoteness was not an independent predictor of outcome, but the composite score rose by 0.13 for each IRSAD decile (p < 0.001), with patients in the bottom decile of IRSAD more likely to have composite scores below median ( < 14) than those in the top decile (OR 1.8 CI 1.4-2.2 p < 0.001). The composite score allowed visualisation of functional outcomes in a single figure and identification of geographic hotspots with poor outcome. Conclusions: Systematic collection of long-term patient-reported outcomes is feasible. Geographical disparities in QoL outcome following prostate cancer treatment correlated with SES and remoteness, and we note the relative importance of SES over remoteness. A single composite score for EPIC-26 showed face-validity. Our results will allow targeted efforts to further understand the drivers of these findings and improve equity in survivorship outcomes for prostate cancer survivors. The methods developed in this study can be extended and re-deployed to evaluate outcomes in other jurisdictions and cancer types.
Age-based disparities in clinical trials supporting FDA approval of therapies for solid tumors.
Authors: Gajra Ajeet , Zettler Marjorie E.
Published: June 2021

e18534

Background: Cancer of any site is most frequently diagnosed among adults age 65 years and older, however older adults have historically been under-represented in clinical trials for oncology drugs (difference in median age [DMA] −6.49 years among clinical trials for breast, prostate, lung and colorectal cancer from 1994-2015 [Ludmir et al, JAMA Oncology 2019]). Representation in registrational trials, which are the basis for drug approval and inform the prescribing information, is of particular importance as age‐related differences may affect response and toxicity. We conducted an analysis of the trials supporting recent Food and Drug Administration approvals of new therapies for the treatment of solid tumors to assess the median age of participants and compare it to the median age of patients in the real world for each malignancy. Methods: Prescribing information for novel therapies that received primary approval for solid tumor indications between 2015 and 2019 was reviewed, and the median age in the evaluable population of the supporting clinical trials was abstracted. Median age estimates among adults for each indication in the general population were obtained from the Surveillance, Epidemiology and End Results database or the published literature. The DMA was calculated for each trial by subtracting the median age in the real-world population from the median age in the trial. Characteristics of trial protocols were obtained from approval packages accessed in the Drugs@FDA database. Data are presented using descriptive statistics. Results: A total of 35 solid tumor drugs were approved based on 38 trials, with 15859 patients in the evaluable populations. Less than half of the trials were phase 3 (16; 42%) or were randomized with a control group (18; 47%). On average, the median age of the trial participants was 2.6 years younger than the median age of the disease populations (95% CI: -1.4, -3.9 years; p < 0.01). For indications with > 1 trial, those with the greatest disparities were in melanoma (mean DMA -6.5), urothelial carcinoma (-5.8), and lung cancer (-4.1). The DMA among phase 3 trials was -1.8, vs. -3.2 among phase 1 and 2 trials. None of the protocols for the trials specified upper age limits, however 23 (61%) required an ECOG performance status (PS) ≤1, and all trials had eligibility restrictions related to organ function or comorbidities. Conclusions: In this contemporary analysis of registrational trials across all solid tumor indications, we found that the median age of clinical trial participants was nearly 3 years younger than their real-world counterparts. No trial protocols had upper age limits, however most restricted PS, organ impairment or the presence of comorbidities, which may have impacted older patients’ eligibility to participate. Although inclusion of older adults in clinical trials appears to have improved in recent years, changes to trial design may help to ensure adequate representation.
Association of rurality and race with surgical treatment and outcomes for nonmetastatic colon cancer.
Authors: Ramkumar Niveditta , Colla Carrie , Wong Sandra L. , Wang Qianfei , Brooks Gabriel A.
Published: June 2021

e18536

Background: Rural cancer patients face limited access to care due to greater travel distance and lack of specialty cancer care. Little is known about the intersection of rurality with well-documented racial disparities in colon cancer treatment and outcomes. Methods: We used fee-for-service Medicare claims to study patients age 65+ diagnosed with incident colon cancer without evidence of metastases who underwent cancer-directed surgery between 04/01/2016 and 09/30/2018. The primary exposure was rurality of patient’s residence categorized as metropolitan (metro), micropolitan, and small town/rural. Outcomes were non-elective surgery (emergency department visit or transfer within 2 days of surgery), receipt of minimally invasive surgery (laparoscopic or robotic), 90-day surgical complications, and 90-day mortality. Logistic regression adjusted for patient demographics, cancer side (right vs left), comorbidities, and Area Deprivation Index. We assessed effect modification by race/ethnicity. Results: Of 57,710 patients with incident non-metastatic colon cancer, 37,691 (65%) underwent surgery. In this surgical cohort, small town/rural and micropolitan residents were more likely to be older, white, and Medicare-Medicaid dual-eligible than metro residents. After risk adjustment, patients in small town/rural areas had higher odds of non-elective surgery (OR=1.24, 95% CI:1.13-1.36) and lower odds of minimally invasive surgery (OR=0.75, 95% CI:0.71-0.80) than patients living in metro areas. Similar results were seen for micropolitan areas. The association between rurality and 90-day outcomes differed by race/ethnicity (p-interaction=0.001 for surgical complications and mortality, see Table). Hispanics and other races had higher odds of 90-day surgical complications in non-metro versus metro areas but there was no notable difference for white patients. Likewise, compared to metro areas, racial/ethnic minorities had higher odds of 90-day mortality in small town/rural areas but white patients had lower odds. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and worse outcomes, especially among non-white patients. The compounded effect of sociodemographic factors should be further studied to develop targeted policies and improve care for rural cancer patients.[Table: see text]
Neighborhood area-level social determinants and receipt of mammography screening in an area with high deprivation: A retrospective cohort study.
Authors: Dhahri Amina , Azargoon Sam , Buchongo Portia , Chicas Tatiana , Singh Amrik , Meshkat Razavi Gity , Gopakumar Smitha , Chhabra Gurdeep Singh
Published: June 2021

e18550

Background: Early detection through screening mammography has been shown to decrease breast cancer mortality. Screening mammography rates remains low among racial/ethnic minorities and patients with socioeconomic deprivation (SED). Most studies evaluating the role of area-level social determinants of health and breast cancer screening have included only a small number of variables; in this study, a comprehensive and granular measure of socioeconomic deprivation (SED) which included 17 variables was used to determine an association with screening mammogram completion. Methods: A retrospective cohort study was conducted at an academic hospital system between 2014-2020 to identify asymptomatic female patients who received screening mammogram referrals in their primary care clinic after they were deemed eligible per screening guidelines. Patients were assessed for mammogram completion at their annual visits. SED was evaluated using the area deprivation index (ADI), a measure of 17 variables including education, housing, and income at the census block group level. Other covariates analyzed were insurance status, age, and race. Chi-square test, Kruskal-Wallis test and a multivariate logistic regression model were used for statistical analysis. Results: 856 women were referred for screening mammography. 324 (38%) underwent mammogram. Patients with high, moderate, and low SED comprised 69 (8%), 287 (34%) and 500 (58%) of the cohort, respectively. In multivariable analysis, SED and race were not associated with higher screening rates. Uninsured and self-pay patients had the lowest odds of screening mammography completion (AOR 0.22; 95% 0.08, 0.60) and Medicare patients had decreased odds of mammogram completion relative to privately insured patients (AOR 0.64; 95% CI 0.43, 0.97). Older age was associated with a slightly higher odds of mammography completion (AOR 1.02; 95% CI 1.00, 1.04). Conclusions: The receipt of screening mammography was low among all patients relative to previously published rates. Uninsured/self-pay status was the strongest indicator for completion of mammography. Additional research is needed to understand the barriers that may influence mammography completion in this population with high socioeconomic deprivation.

Multivariate Logistic Regression Estimates for Associations Between Mammogram Completion and SED category.[Table: see text]
Racial, ethnic, and socioeconomic disparities in diagnosis, treatment, and survival of patients with breast cancer.
Authors: Azin Arash , Tahmasebi Houman , Brar Amanpreet , Azin Sam , Ko Gary T. , Covelli Andrea , Cil Tulin D.
Published: June 2021

e18551

Background: Racial disparities in breast cancer are well established. However, there is a paucity of literature assessing the interaction of patient, socioeconomic, and community factors on outcomes. The objective of this study was to determine the influence of race/ ethnicity, socioeconomic status (SES), and insurance status on disease presentation, access to care, and survival in breast cancer. Methods: A retrospective analysis was performed of Non-Hispanic Black (NHB), Non-Hispanic White (NHW), and Hispanic patients with non-metastatic breast cancer in the SEER cancer registry between 2007 and 2016. Multivariable binary logistic regression and Cox regression analyses were conducted. Results: A total of 382,975 patients were identified; 289,074 (75.5%) NHW, 45,821 (12.0%) NHB, and 48,080 (12.6%) Hispanic patients. On multivariate analysis (see table), NHB (OR 1.18, 95%CI: 1.15-1.20) and Hispanic (OR 1.20, 95%CI: 1.17-1.22) patients were more likely to present with higher stage disease than NHW patients. There was an increased likelihood of not undergoing primary resection in NHB (OR 1.56, 95%CI: 1.49-1.65) and Hispanic (OR 1.41, 95%CI: 1.34-1.48) patients compared to NHWs. Similarly, NHB and Hispanic patients had increased odds of not undergoing breast reconstruction following mastectomy (OR 1.07, 95%CI: 1.03-1.11 and OR 1.60, 95%CI 1.54-1.66, respectively). NHB patients had increased hazard for all-cause mortality (HR: 1.13, 95%CI 1.10-1.16) and breast cancer-specific mortality (HR: 1.20, 95%CI 1.16-1.24). All-cause mortality increased across SES categories (lower SES: HR 1.33, 95%CI 1.30-1.37, middle SES: HR 1.20, 95%CI 1.17-1.23) in NHBs. Conclusions: This population-based analysis confirms worse disease presentation, access to surgical therapy, and survival across racial, ethnic, and socioeconomic factors. These disparities were compounded across worsening SES, suggesting structural racism may partly account for our findings.[Table: see text]
The impact of COVID-19 on patients with cancer: A qualitative study.
Authors: Kumar Dhanya , Khateeb Sana , Patel Manali I.
Published: June 2021

e18559

Background: The SARS‐CoV‐2/COVID‐19 pandemic greatly impacted the health of many patients with cancer. We conducted in-depth interviews with patients across the United States to better understand the effect of the COVID-19 pandemic on their cancer care, emotional and mental health, and to solicit suggestions for how health care providers could mitigate these concerns. Methods: We contacted respondents from the Impact of COVID-19 on Cancer parent study. The parent study used a snowball sampling approach to survey patients nationally regarding cancer delays between April 2020 and October 2020. We invited all respondents who volunteered for future studies to participate in a 40-minute interview regarding their experiences and suggestions for how health care providers could mitigate COVID19-related concerns. Interviews were conducted between August 2020 and October 2020, recorded, transcribed and analyzed using qualitative thematic content analysis. Results: A total of 34 participants were contacted and consented to participate in this study. Four overarching themes were identified: (1) significant concern regarding infection risk; (2) concerns regarding care changes, such as delays, worsening cancer outcomes; (3) concern regarding loss of employment, health insurance, and transportation on cancer treatment, affordability, and prognosis; and (4) worsening emotional and mental health due to social isolation. Suggestions for the clinical team included: 1) specific and direct guidance from health care providers on how to mitigate infection risk; 2) screening for and access to mental health services; 3) continuation of cancer treatment, surveillance, and clinical trials without delays and 4) allowing caregivers to attend appointments. Conclusions: In this national qualitative study of patients with cancer, participants identified that COVID-19 and modifications to their cancer care worsened their emotional and mental health with growing concerns about the impact of the virus and socioeconomic status on their cancer outcomes. Specific suggestions for health care providers, such as anticipatory guidance, access to mental health services, and expanded visitation should be considered to improve patient experiences with care during the pandemic.
The timeliness of lung cancer care: A systematic review of systematic/scoping reviews on risk factors and interventions.
Authors: Zhang Jianrong , Oberoi Jasmeen , Karnchanachari Napin , Druce Paige , IJzerman Maarten J. , Emery Jon D.
Published: June 2021

e18575

Background: Lung cancer is the leading cause of cancer death worldwide, and over half of lung cancer cases are diagnosed with advanced stage, indicating an urgent need to improve the timeliness of lung cancer services. In this systematic review of systematic and scoping reviews, we summarize the current evidence of risk factors and interventions on diagnostic and treatment intervals. Methods: Eligible articles were published systematic or scoping reviews and meta-analyses that used systematic searching to investigate risk factors for longer time intervals or interventions aimed to reduce time intervals in original studies on lung cancer, based on at least one interval involving the date of diagnosis as the start or end point. Articles were searched via PubMed, Embase, Web of Science, and the Cochrane Library; the date range of the search was from database inception to 6 August 2020 (PROSPERO identifier: CRD42020203530). Results: A total of 16 systematic/scoping reviews published in 2002-2020 were included (10 on risk factors and 9 on interventions). According to these reviews, we found that risk factors had intersected impacts on the increase of diagnostic and treatment intervals. However, these factors could be summarized based on tumor, patient, healthcare provider and healthcare system levels as: (tumor level) adenocarcinoma, small size; (patient level) living in a rural area, lower education level, lower-income level, longer travel distance, non-specific symptom, non-white race (in the USA), fear and lack of knowledge about lung cancer; (healthcare provider level) low index of suspicion, multiple consultations for diagnosis, missed diagnosis; (healthcare system level) long waiting time for hospitalization, health system’s incapacity to treat all patients, high cost, inaccessibility or lack of diagnostic tools/investigations, poor organization and management of health services. To reduce time intervals, these reviews indicated that effective interventions include multidisciplinary teams or clinics, lung-specific clinics, nurse navigation or other care coordination program. In these reviews, we found that the types of time intervals used in original studies were poorly reported. Conclusions: Therisk factors identified from the current reviews indicate disparities in timely access to lung cancer services, as well as potential for improvements to reduce waiting time at the patient, healthcare provider and healthcare system levels. To reduce waiting time, effective interventions suggested from the current reviews should be considered for implementation.
Association of social support with overall survival and health care utilization in patients with aggressive hematologic malignancies.
Authors: Markovitz Netana H. , Gray Tamryn , Bhatt Sunil Mahesh , Nipp Ryan David , Ufere Nneka , Rice Julia , Reynolds Matthew J. , Lavoie Mitchell W. , Topping Carlisle E. W. , Clay Madison A. , Lindvall Charlotta , El-Jawahri Areej , Johnson Patrick Connor
Published: June 2021

e18582

Background: Social support plays a crucial role for patients with aggressive hematologic malignancies as they navigate their illness course. We examined associations of social support with overall survival and health care utilization in this population. Methods: We conducted a cross sectional secondary analysis using data from a prospective longitudinal cohort study of 251 hospitalized patients with aggressive hematologic malignancies at Massachusetts General Hospital from 2014 through 2017. We utilized Natural Language Processing (NLP) to identify extent of patients’ social support (limited versus adequate as defined by NLP-aided chart review of the Electronic Health Record (EHR)). We used multivariable regression models to examine associations of social support with: 1) overall survival; 2) death or readmission within 90 days of discharge from index hospitalization; 3) time to readmission within 90 days; and 4) index hospitalization length of stay. Results: Patients had a median age of 64 (range: 19-93) years, and most were white (89.6%), male (68.9%), and married (65.3%). A plurality of patients had leukemia (42.2%) followed by lymphoma (37.9%) and myelodysplastic syndrome/myeloproliferative neoplasm (19.9%). Using NLP, we identified that 8.8% (22/251) of patients had limited social support. In multivariable analyses, limited social support was associated with worse overall survival (HR = 2.00, p = 0.042) and higher likelihood of death or readmission within 90 days of discharge (OR = 3.11, P = 0.043), but not with time to readmission within 90 days, or index hospital length of stay. Conclusions: In this cohort of hospitalized patients with aggressive hematologic malignancies, we found associations of limited social support with lower overall survival and higher likelihood of death or readmission within 90 days of hospital discharge. These findings underscore the utility of NLP for evaluating extent of social support and the need for larger studies evaluating social support in patients with aggressive hematologic malignancies.
Nutritional status and outcomes of veterans undergoing curative surgery for colorectal cancer.
Authors: Mitbander Urvashi , Frankel Timothy , Dobrosotskaya Irina Y.
Published: June 2021

e18585

Background: Malnutrition is highly prevalent within the cancer population. Malnourishment has various negative surgical and oncologic impacts. The Veterans Health Administration (VHA) provides comprehensive care to patients in a single-payer system allowing for capture of peri-operative data and the opportunity for focused pre-operative (pre-op) interventions to improve outcomes. We sought to study the effect of pre-op weight and albumin on post-operative (post-op) complications in a contemporaneous group of veterans with colorectal cancer (CRC) at a tertiary care Veterans Affairs (VA) hospital. Methods: This is a retrospective review of 105 patients with colorectal malignancies treated with curative intent surgery at the VA Ann Arbor Healthcare System between January 2015 and January 2020. Patients with distant metastatic disease, neoadjuvant therapy, non-adenocarcinoma histology, or those receiving majority of care outside of the VHA were excluded. We examined BMI trends from one year prior to one year post surgery, rates of nutrition consults, and post-op complications defined as abnormal clinical developments such as, but not limited to, infection and delayed wound healing. Fisher’s exact test was used for analysis. Results: At time of CRC diagnosis, the mean age was 70.3 ± 9.1 and the median stage was T2N0. Surgical resections were 65% (n = 68) laparoscopic. Pre-op weight loss from 6 months prior to diagnosis to time of surgery was observed in the majority of patients (n = 47, 64%). Significant weight loss, defined as ≥3% weight reduction, was seen in 45% (n = 33) of patients. A quarter of patients were identified to have a low pre-op albumin of less than 3.5 (n = 25, 25%). Significant weight loss and low pre-op albumin were each independently associated with increased post-op complications (p < 0.01). Post-op weight loss was seen in 81% (n = 73) and 69% (n = 48) of patients at 30- and 60-days post-op, respectively, and was not associated with post-op complications. Inpatient post-op nutrition consultation was performed in 96% (n = 101) of patients; nutritional supplements were recommended in only 23% (n = 23) of cases. In patients with significant weight loss, pre-op nutrition evaluation was performed in 15% (n = 5) of cases and post-op outpatient nutrition follow up occurred in 18% (n = 6) of cases. Conclusions: 45% of patients had ≥3% weight loss 6 months prior to diagnosis of CRC and 25% of patients had low albumin levels. These led to greater post-operative complications. An intensive nutrition pre-habilitation program to address weight loss and low albumin prior to surgery for CRC is needed and may reduce associated complications.
Practice patterns of platinum chemotherapy use in a population-based cohort of women with nonmetastatic triple-negative breast cancer.
Authors: King Tess , Fedorenko Catherine R. , Li Li , Yung Rachel Lynn
Published: June 2021

e18590

Background: The use of platinum agents (PT) in neoadjuvant chemotherapy (CTX) for triple negative breast cancer (TNBC) has been debated in research and practice guidelines. In high risk patients, the addition of PT to standard anthracycline and taxane regimens improves pathological complete response without definitive evidence of survival benefit (Korde JCO 2021). Due to PT’s toxicities and unclear benefit in early stage breast cancer, this study aimed to elucidate the real world practice patterns of PT use and overuse in breast cancer patients. Methods: The cohort was defined as women with stage I-III TNBC (ER, PR, and Her2 negative) who received curative intent surgery between 2011-2018. We utilized the Hutchinson Institute for Cancer Outcomes Research (HICOR) database, which links enrollment and claims records from commercial and public health insurance plans with clinical information from Washington state cancer registries (Manohar JACR 2020). We hypothesized there was overuse of PT CTX in this cohort. Overuse was defined as PT use in stage I, in the adjuvant period (NCCN 2020), and in nonstandard CTX regimens (PT use without taxane and anthracycline (NCCN 2020)). Results: Of the 910 women in the cohort, average age was 63, 90% were white, 682 (75%) received CTX, and 36% had commercial insurance, versus 53% with public insurance (Medicare 45%, Medicaid 8%). Of those receiving CTX, 39% received neoadjuvant and 67% adjuvant. Of those receiving CTX, 85 (13%) received PT, and 28 (4%) received PT without anthracycline. Of those receiving PT, 20% had stage I disease, and of those receiving adjuvant CTX, 43 (9%) received PT in the adjuvant period. Conclusions: We found there was overuse and nonstandard use of PT in this real world data. This overuse was demonstrated by the fact that 20% of women receiving PT had low risk stage I disease, and 9% of women receiving adjuvant CTX received PT in the adjuvant period. Additionally, there was nonstandard use, with 4% of women getting CTX receiving PT without anthracycline. Next steps in this research are to evaluate factors influencing overuse and nonstandard use, as well as complication rates with PT use and overuse.[Table: see text]
An institutional evaluation of the safety and efficacy of same-day administration of pegfilgrastim in patients receiving chemotherapy for lung cancer.
Authors: Vraney Jamie , AlRawashdh Neda , Choi Briana , Abraham Ivo , McBride Ali
Published: June 2021

e18591

Background: Pegfilgrastim is recommended to be administered 24 hours after myelosuppressive chemotherapy (CTX) as prophylaxis for chemotherapy-induced (febrile) neutropenia (CIN/FN). Recent studies have yielded equivocal data on same day versus next day administration of pegfilgrastim. There has been limited real world evidence addressing lung cancer (LC) patients and the use of same day pegfilgrastim. We evaluated our own institutional data on the safety of same day pegfilgrastim administration in LC patients. Methods: A retrospective chart review was performed by searching electronic health records using ICD-9 and ICD-10 codes corresponding with a lung cancer diagnosis between November 1, 2013 and August 31, 2018 at The University of Arizona Cancer Center (UACC). Patients included in the study were 18 years of age or older, diagnosed with biopsy-confirmed lung cancer, treated at UACC, and receiving chemotherapy and pegfilgrastim on the same day. The outcomes of interest included FN incidence after the first cycle and across all cycles of CTX, CIN grade 3/4 and CTX dose delays or hospitalizations due to CIN/FN after first cycle and across all cycles of CTX. Results: 1,181 patient records were reviewed and 114 patients met the inclusion criteria; 87 (76%) patients had non-small cell LC and 27 (24%) patients had small cell LC. The median age was 68 years, 52% of patients had cancer stage of 3 to 4, and 63% of patients had 0-1 ECOG status. The FN risk assessment was mild in 72% of patients. The mean (SD) of baseline absolute neutrophil count was 5.68 (3.09). In total 384 CTX cycles were received. The table shows the results of all intended outcomes. One patient experienced FN after the first cycle of CTX of irinotecan and 5 patients developed 6 FN episodes across all cycles; 2 patients were on carboplatin etoposide; 1 patient on cisplatin etoposide; 1 patient on vinorelbine and 1 patient was on pemetrexed and then on irinotecan CTX when the two FN episodes were developed. Conclusions: This study showing that same day administration of pegfilgrastim was as effective as next day administration in LC patients, without warranting any concerns for febrile neutropenia or delayed engraftment. Utilization of same day pegfilgrastim, in light of biosimilars and COVID, provides a unique opportunity for cancer care without concerns for FN as stated in previous studies.[Table: see text]
Association of systemic anticancer therapy with an increased risk of death in hospitalized COVID-19 positive oncology patients.
Authors: Hermel David Jacob , Spierling Bagsic Samantha R. , Bhangoo Munveer Singh , Bollin Kathryn Blount , Mason James R. , Saven Alan , Sigal Darren
Published: June 2021

e18594

Background: Malignancy is thought to be an independent risk factor for increased COVID-19 morbidity and mortality. However, neoplastic diseases encompass a heterogenous group of pathologic processes, and further stratification of those patients prone to severe disease is necessary. We sought to identify predictors of poor COVID-19 outcomes among hospitalized patients with malignancy. Methods: We retrospectively reviewed all patients with a diagnosis of hematologic and solid tumor malignancy within the regional Scripps Health hospital system in San Diego County from March 1, 2020 to January 5, 2021 with a PCR confirmed diagnosis of COVID-19. Cancer diagnoses were confirmed via manual chart review; in situ non-melanoma skin cancers were excluded. Only hospitalizations greater than one day were included in the analysis and readmissions were excluded. Outcomes of interest included admission to the ICU, intubation during hospitalization, and death. Associations between outcomes of interest and tumor types, metastatic disease (with or without lung involvement) and those receiving active systemic anticancer therapy (treatment within 3 months of admission) were determined using univariable logistic regression analyses. The study was approved by the Scripps Health Institutional Review Board. Systemic anticancer therapy included cytotoxic chemotherapy, immunomodulators, immune checkpoint inhibitors, and other targeted therapies. Results: Among a total of 2,771 hospitalized patients, 204 (7.36%) met inclusion criteria. The average age was 72.7 years, 48.5% were male, 33.3% were Hispanic and the average BMI was 27.5. The majority of patients (82.8%) had solid tumors, with the most prevalent being breast carcinoma (17.6%) and prostate carcinoma (17.2%). Overall, 21.9% had metastatic disease and 16% had lung involvement. 17.2% had been receiving active cancer systemic treatment. On univariate analysis, patients who were actively receiving treatment had an increased rate of death (37.1% vs 18.9%, OR: 2.5 (1.1-5.5) p= .021). Among patients receiving systemic anticancer therapy, 48.6% received cytotoxic chemotherapy, 5.7% immune checkpoint inhibitors, 22.9% immunomodulators, 17.1% molecularly targeted agents and 2.7% other agents. Moreover, there was a trend towards increased mortality in those with lung involvement (33.3% vs 17.6%, OR: 2.3 (0.9-5.7) p= .067) and those with hematologic malignancy (31.4% vs 20.1%, OR: 0.5 (0.2-1.3) p = 0.146). Conclusions: Among patients hospitalized with a diagnosis of cancer, systemic anticancer therapy was associated with a significantly increased odds of death. Other factors potentially increasing risk of death include hematologic malignancy and solid tumors with lung involvement. Further validation of these findings in a larger sample could impact therapeutic decision making during the COVID-19 pandemic.