bluuebunny/crossref_metadata_2025 huggingface dataset:
Management and treatment of patients (pts) with stage III unresected non-small cell lung cancer (NSCLC) at UPMC: A quality initiative by Integra Connect PrecisionQ.
Authors: Petro Daniel P. , Gart Mike , Blanc Simon , Vasudevan Anupama , Li John , Fares Marielle , Choksi Rushir J.
Published: October 2023

579

Background: In 2019, the University of Pittsburgh Medical Center (UPMC) and Integra Connect (IC) initiated a QI to improve immunotherapy (IO) use post CRT. Baseline analysis assessed scanning and treatment patterns post-CRT and duration of treatment (DOT) with durvalumab (durva). Drawing on this analysis, IC and UPMC conducted a focus group to address gaps in care and initiated improvements. This real-world study aims to assess the change in IO use post-CRT, the time to scan (TTS), time to treatment (TTT), DOT compared to baseline. The DOT of durva was compared between pts initiated <14 days of CRT and those who started ≥14 days. Methods: From the UPMC and IC real-world databases, we identified 555 pts with stage 3 unresectable NSCLC for manual chart abstraction. Pts received CRT between 2/16/2018 and 12/31/2021. TTS was calculated from the last day of CRT to the 1st scan and the TTT obtained from the last day of CRT to the 1st durva dose. The baseline period was from 2/16/2018 to 8/31/2020 and the post-intervention stage from 9/1/2020 to 12/31/2021 based on CRT start date. Pts were excluded if they had no scan data, a 1st scan ≥90 days post CRT (TTS analyses), a duration of zero days (DOT analyses) or a TTT >120 days (TTT analyses). At least 1 yr of follow up was required for DOT comparisons. Descriptive analyses were used. A two-tailed 2 sample z-test was used for proportions and the nonparametric Wilcoxon rank sum test was used for TTS, TTT and DOT comparisons. Results: The baseline pts were 46% female with an average age of 67.7 years; post-intervention patients were 47% female with an average age of 69.4 years. The rate of durva use post CRT in pts who did not progress increased from 66% (n =128/194) at baseline to 83% (n =96/116) post intervention (p < 0.01). The baseline median TTS decreased from 22.5 days (n=174) to 20 days (n=121) post intervention (p <0.05), and median TTT decreased from 35 days (n=121) to 28 days (n=90) (p < 0.05). The median DOT increased from 6 (n=127) to 8.2 months (n=76) (p >0.05). During the study period, 8% (n =17/223) of pts started durva < 14 days post CRT and 92% started ≥14 days (n =206/223). The median DOT in the < 14 days group was 10.8 months versus 6.2 months in ≥14 days (p >0.05). Median overall survival (OS) was 36.5 months in the <14 days vs. 27.8 months in the ≥14 days group (p > 0.05). Conclusions: NSCLC QIs are effective tools to improve IO utilization, TTT, and DOT in eligible pts. Practices that assess clinical performance can identify gaps in care and act. In this Stage III study, a superior OS, though lacking statistical significance, was seen in the group that started IO <14 days post CRT compared to ≥14 days. Further studies with larger sample size are needed to validate these findings.
Integrated oncology operational dashboard for clinical and operational quality improvement.
Authors: Sanyal Amit , Couture Lauren , Cropp Brett F. , Taylor Evie , Bianchi Michael J. , Remick Scot C.
Published: October 2023

588

Background: MaineHealth Cancer Care Network, comprised of nine member and two affiliate cancer centers, provides care to more than 70% of analytic cancer cases in largely rural south-central Maine and eastern New Hampshire. To drive high quality and performance and harmonize care across the network, an integrated operational dashboard was created. Methods: A team of clinicians, operational leaders and business intelligence analysts identified improvement goals across clinical and operational domains. Using a Microsoft Power BI platform, an integrated dashboard with extracts from various non-interoperable data sources were migrated together to illustrate all relevant metrics. Divided into five pages, the Summary page allowed for a high level visualization of financial improvement metrics across the service line. The Growth page included trends of template utilization, provider access, encounter and financial statistics. The Service Excellence page measured diagnosis to treatment times, new patient volumes, timely chart completion rates and provider net promoter scores. Lastly, the Innovation and Transformation page measured clinical trial accruals, use of Epic TNM staging (Epic Systems, Verona, WI), Clinical Pathways (Elsevier, Amsterdam, NL) and use of NCCN distress thermometer for patient assessment. All data was searchable based on chosen fiscal years, practice locations and provider names with automated monthly data refreshes. Dashboard access to clinical and operational staff with monthly reviews drove performance improvement. Results: Since creation in January 2023, dashboard has been leveraged to improve structured Epic TNM staging by medical oncology providers from 46.9% in FY22 to 53.4% in FY23. Time to treatment data has helped identify process bottlenecks. Provider productivity metrics have been used to launch a compensation reform program incorporating production based incentives and improve patient access. Information transparency has improved team engagement and ownership. Conclusions: High quality cancer care delivery requires equal attention to clinical and operational metrics. In most organizations, this data is siloed across disparate software platforms with limited visibility and access to care team members, impeding quality initiatives. Implementation of the system-wide integrated quality dashboard has led to tangible improvements in care delivery and provider engagement. Additional work to incorporate provider well-being data is underway.
Pan-sarcoma database (PSDB): A model-view-controller framework application utilizing REDCap, shiny, and R to create a continuous pipeline of sarcoma data that can inform the care of current patients.
Authors: Rose Brandon Edward , Barreto Coelho Priscila , Bialick Steven , Patel Pooja , Statz-Geary Kurt , Nunez Osvaldo , Dhir Aditi , Kang Alina , Thornton Mason , Jonczak Emily , D'Amato Gina Z. , Trent Jonathan C.
Published: October 2023

589

Background: Sarcomas are a rare group of mesenchymal malignancies arising soft tissue and bone, often requiring multidisciplinary care. The Pan-Sarcoma Database (PSDB) is an innovative open-source research application developed to efficiently collect and manage data on sarcoma patients to create a reliable research pipeline by funneling data from multiple sources. This process can be customized to fit other institutions and can be used to explore disparities and improve quality for cancer patients. We will share our data structure, process, and code as an adaptable framework for other multidisciplinary research groups with overlapping patients. Methods: The Model-View-Controller (MVC) framework is a software design pattern used by many modern applications. In this framework, "model" is the database, including the structure and metadata; "view" is the user interface software; "controller" is the coding language used to handle user input, update the model, and interact with the viewer. PSDB uses REDCap, shiny, and R, respectively. We integrated relational database concepts in our design, such as normalization, and utilized standards from Clinical Data Interchange Standards Consortium (CDISC). The database is comprised of 290 data fields to capture demographics, survival data, initial HPI, pathology, stage, grade, detailed location, detailed progression history, and associated treatment data. Results: We captured data from 28,380 candidate sarcoma patients from 2010 to present, including 3,291 confirmed cases, with 751 cases reviewed to date, merging data from multiple databases, pathology, and prior projects. Currently, 30.6% of our cases are metastatic at diagnosis; 57.7% are High grade, 28.9% are Intermediate grade, and 8.9% low grade; the median age at diagnosis is 55; 93.5% of reviewed cases received systemic therapy and 73.1% received radiation. By capturing key data and organizing an open-source code base in R mapped to our “model”, we produced updating tables, statistics, time-to-endpoint analyses, and other modifiable outputs to identify outcome disparities. Conclusions: The PSDB successfully addresses the unique data challenges faced in sarcoma research group. The use of the MVC framework with REDCap, shiny, and R, enabled the creation of an application that is secure, user-friendly, and adaptable, supporting collaborative research efforts. This project also emphasizes the importance of employing appropriate tools for data management and encourages similar initiatives to enhance collaboration and benefit both research teams and the patients they study. Furthermore, because it is open-source it can be used and modified by other research teams to improve the quality of care for cancer patients.
Understanding inpatient mortality and 30-day mortality at a comprehensive cancer center.
Authors: Soucise Allison , Shekher Rohil , Faller Julia , Keppel Daniel , Anthony Greta , Chowdhry Varun
Published: October 2023

59

Background: Inpatient mortality quality metric for hospital settings. We sought to review instances of inpatient mortality as part of continuing quality improvement (QI) in our pursuit of the Triple Aim of Health care to improve individual and population health, while reducing unnecessary physical harm, psychological harm, and costs. Methods: An interdisciplinary institutional mortality review committee (MRC) was assembled to review all instances of inpatient mortality or 30-day hospital mortality (hospital mortalities). Individual team members reviewed pertinent clinical information, and appropriate instances were discussed during monthly meetings. The purpose is to review the details of the hospitalization and make determinations if any learning opportunities or process improvements were present. Study data were collected and managed using REDCap electronic data capture tools. Approval from the IRB was obtained to conduct this retrospective analysis. Results: Between January 2022 and April 2023, a total of 430 instances of hospital mortalities were identified and reviewed. Of the 421 patients for which data was available, 294 deaths were classified as “Anticipated” while 127 were classified as “Unanticipated”. Out of the 421 patients, 189 (44.9%) were classified as having an improvement opportunity. There was no association between anticipated vs unanticipated death and opportunity for improvement χ2,(1, n=421) =0, p=.998. However, we noted a significant inverse association with prior goals of care conversation and learning opportunity χ2,(3, n=421) =77.2, p<0.001. During the period of this initiative, we have noted an upward trend in the percentage of patients who had a GOC conversation from 83% to 96%. Improvement opportunities and hospital mortalities related to hospital acquired infections, direct surgical complications, and misdiagnosis were rare. Conclusions: Regarding hospital mortality, opportunities for improvement were largely centered around goals of care conversations and advanced care planning. There is a suggestion that MRC may have contributed to the increase in documented Goals of Care conversations. We believe that an MRC can contribute towards a cultural shift to promote Advanced Care Planning. Initiatives to improve goals of care conservations early in a patient’s disease course may have the potential to reduce inpatient mortality and reduce the physical, psychological, and financial toll of disease.
Value of care by reducing treatment terminations during radiation therapy.
Authors: Nosrati Jason Daniel , Ma Daniel , Bloom Beatrice , Hwang Jamie , Herman Joseph M. , Potters Louis , Chen William Chun-Ying
Published: October 2023

6

Background: Disruptions in cancer care adversely affect patient clinical outcomes, particularly when a patient does not complete the prescribed course of treatment. Adverse outcomes include decreased overall survival and earlier/increased disease relapse or progression requiring additional salvage, palliative, and/or supportive therapies. We have reported on the incidence of treatment terminations (TT) in a large multi-center academic radiation medicine department. This study addresses the healthcare expenditure toward sub-optimal treatment associated with TT. Methods: TT of patients undergoing radiation treatment between 1/2013 and 1/2023 were prospectively tracked as part of departmental quality and safety monitoring. A TT was defined as the discontinuation of therapy at any point following informed consent and treatment simulation. The rate of TT was calculated as a percentage of all new patients who start radiation treatments. Cost of care was estimated using mean values from the 2023 Medicare Part B Fee schedule for New York, accounting for consultation, simulation and planning, treatment delivery, and weekly physician and physics treatment checks prior to TT. Cuts to the Medicare Physician Fee Schedule, Medicare reimbursement, and stagnant Medicare Conversion Factor relative to inflation over the 10 years were not accounted for. Results: There were a total of 1,467 TTs out of 28,707 planned treatment courses (5.1%). The average expenditure prior to TT was $8,584 per patient. Aggregated over the past decade, $12.59 million represents an underestimate of healthcare spend toward these situations at one institution. The rate of TT decreased from 9.3% in 2013 to 3.3% in 2022. As discussed separately, this TT rate was reduced via prospective analysis as part of our ongoing department quality and safety program, with incremental changes to pre-treatment evaluation, on-treatment management, and scheduling processes. Assuming stagnant clinical volume, this translates into decreased spend of $1.48 million annually toward incomplete (sub-optimal) treatments. Conclusions: Radiation TTs reflect major deviations from the original care plan. By understanding reasons for TT, we have more effectively selected optimal treatment paradigms and supported patients proactively through their treatment course. Avoiding divergence from intended cancer care decreases adverse outcomes, thereby improving value of the treatment course.
Social determinants of physicians’ treatment recommendation in early glottic cancer.
Authors: McGuire Dehra , Kilpatrick Kayla W , Kuchibhatla Maragatha , Cohen Seth M , Osazuwa-Peters Nosayaba
Published: October 2023

65

Background: Glottic cancer is often diagnosed early due to its deleterious effects on the voice. National cancer treatment guidelines recommend larynx preserving treatment, either surgery or radiation, since both modalities have similar rates of local control and recurrence. Without any survival advantage for either treatment modality, physicians may make treatment recommendations based on other clinical or nonclinical factors. Methods: Using the National Cancer Database, a national hospital-based cancer registry data, this retrospective cohort analysis included adult patients, aged 18 years and older, with clinically confirmed diagnosis of early-stage (T1 and T2) glottic cancer between 2004 and 2017 (n = 27,632). The outcome of interest was physicians’ treatment recommendation of surgery or radiation therapy. Main measures included social determinants of health variables, including race/ethnicity, urban/rural status, health insurance status, and income. We further adjusted for covariates, including age and gender. Logistic regression analysis estimated odds of physicians’ recommendation of radiation versus Surgery, based on social determinants of health factors and adjusting for all covariates in the model. Results: More patients received recommendation for radiation treatment vs surgery (78% vs 22%). Female patients were less likely to receive a recommendation of radiation (aOR = 0.90; 95% CI 0.82, 0.98), while Black patients had increased odds of being recommended radiation compared to White patients (aOR = 1.16, 95% CI 1.04, 1.29). Both facility type and location, and patients’ urban vs. rural status were all associated with treatment recommendation, and individuals residing in rural areas had 32% increased odds of being recommendation radiation treatment vs surgery (aOR = 1.32; 95% CI 1.06, 1.64). Conclusions: Radiation treatment is prevalent in early-glottic cancer care, and we found an association between social determinants of health and physician recommendation of treatment. Further research should examine concordance of patient treatment preference vs physician recommendation.
Tailored doses, tailored savings: Optimizing dosing strategies of immune checkpoint inhibitors.
Authors: Desai Aakash , Jensen Chelsee , Soefje Scott A. , Das Devika Govind , Hussaini S. M. Qasim , Sridhar Arthi
Published: October 2023

68

Background: While immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, their high cost and limited global supply pose major challenges. Optimizing ICI dosing to achieve a minimum effective dose that has shown to maintain clinical benefit may be a potential solution with significant savings to the health system. We investigated potential savings in Medicare that could be attained from alternative ICI dosing. Methods: We conducted a literature review including original Phase 1/2 trials describing the minimal effective dose of three commonly used ICIs: Pembrolizumab (P), Nivolumab (N) and Atezolizumab (A). Alternate dosing strategies based on existing data for Pembrolizumab (2 mg/kg), Nivolumab (1 mg/kg) and Atezolizumab (4 mg/kg) were proposed. Publicly available CMS data on Medicare Part B expenditure for these therapies was utilized to obtain average cost per dosage unit, mg/dosage unit, and number of Medicare beneficiaries between 2018-2021. Average cost per dose and total cost per ICI was calculated based on current FDA approved dosing and alternate dosing strategies. Results: The average wholesale cost per fixed dose for P (200 mg), N (480 mg), and A were $9,242.00, $12,460.80, and $8,616.00, respectively. Implementing the proposed alternate dosing strategies led to a substantial reduction in drug costs: P ($7,393.60), N ($2,076.80), and A ($2,297.60). The ensuing cost savings were calculated based on the annual number of Medicare beneficiaries. From 2018-2021, the average total savings were estimated to be $95,545,182 for Pembrolizumab, $294,734,264 for Nivolumab, and $62,937,582 for Atezolizumab (Table). The cumulative average total cost savings from 2018-2021 exceeded $453 million. Conclusions: We demonstrate potential savings in Medicare with implementation of an alternative ICI dosing strategy. Our study underscores an urgent need to better understand clinical efficacy and cost savings from a patient perspective, and feasibility from a regulatory standpoint. This perspective may hold considerable global implications, providing a roadmap for cost-effective care in the domain of immunotherapy. [Table: see text]
Time trends of Part D drug expenses and Part D risk adjustment in the Oncology Care Model at a community oncology network.
Authors: Indurlal Puneeth , Wilfong Lalan S. , Thomas Hope Ives , Staggs Stuart George
Published: October 2023

72

Background: The Oncology Care Model (OCM) was a 6-year Medicare value-based care (VBC) program that rewarded practices for providing high-quality cancer care to Medicare beneficiaries receiving system anti-cancer therapy, while decreasing Total Cost of Care (TCOC) compared to a benchmark price. TCOC in the model was driven by drug expenses and included both physician-administered (Part B) and prescription (Part D) medications. The past decade has seen several novel oral anti-cancer drugs revolutionize cancer treatment. The impact of the shift to oral anti-cancer drugs, the associated costs, and risk adjustments in the OCM is studied here. Methods: Using Medicare episodes data for 15 practices in The US Oncology Network (The Network) participating in the OCM, we evaluated the time trends of Part D drug expenses between July 2016 and June 2022, assessed the risk adjustment for episodes with and without Part D, and studied impacts on TCOC & benchmark prices. Results: Mean per episode spending at The Network practices increased 16.4% (3.4% CAGR) driven by a mean Part D expense per episode increase of 59% (8% CAGR) from 2016 ($5,532) to 2022 ($8,796) for OCM beneficiaries. Much of the increase was led by the approval of new oral cancer medications, cost increases on legacy oral medications, and expanded indications for oral medications in various cancer diagnoses. Mean Part D expenses increased 46.5% for Multiple Myeloma, 68.7% for Chronic Leukemia, and 124.2% for Breast Cancers. The OCM risk adjustment methodology used to determine baseline and benchmark prices includes a Part D risk adjuster that applies to patients with Part D coverage (with and without low-income subsidy eligibility) during the episode. The Part D risk adjuster increased the episode benchmark on an average by 5.1% ($2,112) (range between 2.9% ($850) in 2016, and 6.1% ($2,500) in 2022)), less than the actual increased Part D episode expenses. 81.4% of episodes in the OCM had Part D coverage that ranges between practices: 66% to 88.6%. Variation in Part D coverage between practices translates to variable impact of Part D risk adjustment in the OCM. Conclusions: Novel drugs, cost increases and newer indications for oral anti-cancer medications have translated into higher Part D spending for patients with cancer. Part D risk adjusters alone did not proportionately adjust benchmarks for increased Part D spending, disproportionately affecting those practices with higher Part D coverage. A modified risk adjustment approach for Part D is needed in TCOC VBC programs to account for variations in Part D coverage and increases in Part D expenses.
Engagement of patients with advanced cancer (EPAC) randomized clinical trial: Long-term effects on survival and healthcare use.
Authors: Patel Manali I. , Agrawal Madhuri , Blayney Douglas W. , Asch Steven M , Bundorf M. Kate , Milstein Arnold
Published: October 2023

76

Background: The Engagement of Patients with Advanced Cancer (EPAC) randomized Veterans with newly diagnosed stage 3 or 4 cancer or recurrent disease to usual care (control) or usual care with 6-month community health worker (CHW) support (intervention) to engage Veterans in end-of-life (EOL) goals of care discussions. At 6- and 15-months follow-up, the intervention tripled goals of care documentation (primary), doubled hospice (secondary), and reduced end-of-life (EOL) acute care use (secondary) and total costs (secondary). This post-hoc analysis after 10 years from study initiation evaluates effects on overall survival (OS) and EOL healthcare use and costs. Methods: We abstracted dates of death, emergency department (ED), hospitalization, palliative care (PC), hospice use, and costs within and outside Veterans Affairs (VA) using electronic health record and claims before data cut-off on February 1, 2023 for all EPAC participants. We compared OS using Kaplan Meier and log-rank, risk of death using Cox-proportional hazard models, ED, hospitalization, PC, hospice use and costs in the last 30 days of life using Logistic Regression, and incidence rate ratios of ED and hospitalizations using Poisson regression. Results: Among 213 participants, there were no imbalances in demographic or clinical characteristics. 165 (77.4%) were White, 211 (99%) males, 80 (37.6%) had lung cancer, and 118 (55.3%) had stage 4 disease. Median follow-up was 298 days (range 12-3438). Intervention group participants had greater OS (log rank p=0.03), 25% reduction in risk of death, lower acute care use, greater PC and hospice, and lower total costs (p<0.001) than control group participants. Conclusions: The CHW-led intervention significantly improved OS and maintained robust effects on EOL healthcare use and costs. Results support integration of CHWs into care to improve clinical outcomes. Clinical trial information: NCT02966509 .[Table: see text]
Rapid care transition: Implementation of an undiagnosed cancer clinic.
Authors: Triglianos Tammy , Sorah Jonathan D , Cao Felicia , Bunch Joshua , Collichio Frances A. , Allard Melanie , Medley Chaely , Basch Ethan , Sanoff Hanna Kelly
Published: October 2023

80

Background: There is a critical need to address potential delays in care for patients (pts) with new, undiagnosed cancer in academic medical centers that operate on a subspecialty clinic model. To bridge this gap, we established an Undiagnosed Cancer Clinic (UCC) staffed by oncology physicians and advanced practice providers (APP) to provide rapid access to specialty-led diagnostic work-up, symptom management, and disease education with the transition to subspecialists at a final diagnosis. Methods: A referral process was created, and specified provider template allocation (2 slots/week increased to 5) with a goal of referral to visit time <3 business days. A nurse navigator facilitates diagnostic procedures and helps overcome barriers to care. We collected data on time from referral to UCC visit, demographics, diagnosis, and symptoms managed. Results: Prior to the UCC, median wait time for undiagnosed pts at our institution was 17 days (range 7-49) over a 4-month historical cohort (n=14). In the first 9 months of the UCC, 52 patients were seen, with a decrease in median wait time to 5 business days (range 1-21); when excluding 13 pts who requested delays or were hospitalized, wait time was 3 business days (range 1-7). Referrals increased over time from 1 to 8 per month, most from primary care providers (PCP) (31%) and emergency department (ED) (25%). Demographics include race: 65% White, 25% Black/African American, 10% Other; ethnicity: 13% Hispanic; language: 90% English, 8% Spanish, and 2% Other. The most common cancers diagnosed were gastrointestinal (35%), lymphoma (12%), genitourinary (8%), and breast (8%); 79% of solid tumor pts had metastatic disease. No cancer was identified in 15%. 58% had at least one ED visit before UCC visit, and 8% between UCC visit and establishing care with a subspecialty team. Symptoms requiring intervention were present in 63% at the time of visit, including pain, nausea, vomiting, diarrhea, and constipation. 8% of those diagnosed were referred to hospice. Conclusions: The UCC is a high-value means of specialty-led care to work up a presumed cancer diagnosis while offering symptom management and patient-centered goals of care. A team of oncology providers and clinical navigation team decreased wait time and increased access in an outpatient setting, had a low rate of ED visits following UCC-established care, and provided support and coordination of care with the ability to address barriers for marginalized communities. We are actively partnering with EDs and PCPs to expand the reach of our UCC to a broader population.
“If we don’t speak the language, we aren’t offered the same opportunities”: Qualitative perspectives of palliative care coordination for women of color living with metastatic breast cancer.
Authors: Krishnamurthy Nithya , Smith Cardinale B. , Lin Jenny J. , Odom James Nicholas , Mazor Melissa
Published: October 2023

88

Background: Black and Latina women with metastatic breast cancer (MBC) experience more severe distress, unaddressed symptom burden, and discordant provider communication relative to White women. Adequate care coordination has the potential to mitigate disparities in care access and outcomes, yet little is known regarding palliative care (PC) coordination experiences in women living with MBC. Methods: We conducted a qualitative thematic analysis of transcribed interviews of Black and Latina women with MBC (N=20) and interdisciplinary care providers (N=20). Participants were recruited from urban PC and oncology clinics, federally qualified health centers, and community organizations. Transcripts were reviewed and analyzed by a team of investigators, community scientists and community advisory board members. Themes were identified with inductive coding. Results: Barriers and facilitators of PC coordination were identified. Barriers included a) lack of communication between oncology, PC, and primary care teams, b) limited understanding and stigma surrounding PC among patients and non-PC providers, c) language and health literacy-related communication challenges, and d) racism and marginalization, including implicit bias and lack of diverse racial/ethnic representation in the supportive care workforce. Facilitators of PC coordination included a) patient-to-patient referrals, b) support groups breaking cultural stigma on topics including self-advocacy and PC, c) referrals from trusted providers, and d) community organization’s abilities to overcome challenges related to social determinants of health with logistical and financial support. Respondents reported barriers of quality PC coordination resulted in significant gaps in management of psychosocial and physical symptoms, including mental health, lymphedema, sexual health, cognitive health, and pain. Conclusions: Care coordination and patient reported PC outcomes are heavily influenced by social determinants of health and stigma surrounding PC. Patients and providers value patient-to-patient referrals, support groups, and community organizations in improving care coordination and early PC access. The results from this study will inform the design of ACCESS, a community navigator-led intervention for Black and Latina women with MBC focusing on acceptance of early PC and linkage to community and clinical resources.
Advance care planning among older cancer survivors in the United States.
Authors: Zhou Weijiao , Cho Youmin , Shang Shaomei
Published: October 2023

91

Background: The goal of advance care planning (ACP) is to ensure that end-of-life (EOL) care is consistent with patient wishes and preferences. The ACP is particularly relevant to older adults with cancer due to their high risk of mortality. However, it remains unclear whether older cancer survivors have a higher rate of ACP engagement than general older adults. Methods: We used data from the National Health and Aging Trends Study (NHATS) Round 8, a nationally representative study of adults aged ³65. This cross-sectional analysis included 4,666 participants (1,568 cancer survivors), representing 33.93 million older Americans in 2018. The ACP was defined as having any of the three self-reported elements of ACP: EOL discussion, durable power of attorney (DPOA), or living will/advance directive. Cancer survivors were identified by self-reported cancer in Round 8 or prior rounds. Covariates were self-reported, including age, sex, race, marital status, education level, income, number of comorbidities, number of limitations in activities of daily living (ADL) and probable/possible dementia. We used logistic regressions to examine the association of cancer diagnosis and ACP engagement, adjusting for covariates and complex survey design and weights. Results: Older cancer survivors reported a higher rate of ACP engagement (80.10% vs 73.39), EOL discussion (66.94% vs 60.92%), DPOA (58.56% vs 51.02%) and living will/advance directive (63.34% vs 52.81%), compared to older adults without cancer. However, in adjusted logistic models, there was not significant difference between the two groups in ACP engagement (adjusted OR=1.12, 95% CI: 0.93, 1.36, P=0.22), EOL discussion (adjusted OR=1.08, 95% CI: 0.91, 1.29, P=0.37), DPOA (adjusted OR=1.07, 95% CI: 0.90, 1.28, P= 0.42) or living will/advance directive (adjusted OR=1.20, 95% CI: 1.00, 1.45, P=0.05). The oldest old (>80 years), women, White people, single/not married, with higher education, income, comorbidities and ADL limitations were more likely to engage in ACP (all P<0.01). The associations were similar across models that explored the individual elements of ACP. Conclusions: Despite the high mortality risk, older cancer survivors are not more likely to engage in ACP than the general older adults. About 20% of US older cancer survivors have not engaged in any form of ACP. Hospital, clinic and community strategies to introduce and encourage ACP among older cancer survivors are needed, especially for those minority populations.
As bleak as it sounds? Analyzing trends in oncology clinical trial initiation in the United Kingdom from 2013 to 2022.
Authors: Hadfield Matthew James , VanHelene Alex , Warner Jeremy Lyle , Lythgoe Mark
Published: October 2023

93

Background: Clinical trials, especially phase 3 randomized clinical trials (RCTs), inform the standard of care in oncology, and their availability is the first step in ensuring opportunities for patient participation.A recent study by the Association of the British Pharmaceutical Industry showed a sharp decline in industry-sponsored clinical trials being performed in the United Kingdom (UK) over the past 5 years. In this study we sought to focus on UK participation in phase 3 RCTs of systemic anti-cancer therapy, both industry- and non-industry-sponsored, to evaluate if this decline applies more broadly to all phase 3 RCTs in the UK, especially within the context of Brexit in 2020. Methods: Data were identified and downloaded from ClinicalTrials.gov (CT.gov), a registry of privately and publicly funded clinical studies conducted globally, on March 14, 2023. Completed and recruiting trials with a start date on or after January 1, 2013, were identified using the keywords “neoplasms” and “cancer” and limited to “Phase 3”. Trials of supportive interventions or purely loco-regional interventions e.g., surgery, were excluded, as were randomized phase 2 trials. Eligible trials were categorized by year of commencement, participating countries, and the primary sponsor (e.g., industry or non-industry, including academic and cooperative groups). Results: 2345 of 3849 identified trials met the study eligibility criteria. The number of studies open in the UK increased from 48 in 2013 to 77 in 2021 but decreased to 49 in 2022. The number of UK trial sites included 383 in 2013 and decreased to 259 in 2022. Industry sponsored studies remained steady each year from 2017 to 2021 from 71 to 74 followed by a decline to 45 in 2022. In the European Union, excluding the UK, the number of open studies was 93 in 2013 and increased to 127 in 2021, but dropped to 93 in 2022. Combined trials in the US and Canada increased from 67 in 2013 to 105 in 2022. Conclusions: Clinical trials offer patients an avenue to experimental drugs and therapeutic combinations. Previous reports have raised concern that the UK has had precipitous drops in clinical trial initiation and enrollment secondary to the evolving regulatory landscape driven by concern about changes to the regulatory process and disharmonization due to Brexit. Our study highlights a reduction in clinical trials in the UK, however, this is consistent with declines in trial initiation across the EU, suggesting other factors (e.g., COVID-19) may be contributing factors. Paradoxically, trial initiation in the US and Canada increased over the same timeframe.[Table: see text]
Making “Women's News”: French Feminists of la Femme nouvelle (1934–36) and the Newsreel Magazine Actualités féminines
Authors: Sidhu Maya
Published: October 2023

This article demonstrates how the interwar French suffragist organization la Femme nouvelle used the platform of the newsreel to make political claims through its collaboration with Pathé’s newsreel magazine Actualités féminines or Women's News. Through the filming of their political actions and educational segments edited together in their newsreel compilation film, Le film de la Femme nouvelle (dir. la Femme nouvelle, France, 1935), the suffragists, led by Louise Weiss, frame themselves as essential workers, fearless political actors, and perfect housewives. These contradictions reveal a strategic manipulation of their gender identity to obtain the vote at all costs. Newsreel making provided the feminists an avenue for political claimsmaking beyond electoral politics. These filmed accounts of their actions give the spectator a sense of being present at the event, which is missing from written accounts of la Femme nouvelle's history. Through this aesthetic liveness, achieved through camera placement and staging in crowd scenes, the suffragists were able to portray themselves as vital political actors. One such filmed protest from 12 May 1935 provides a compelling account of their filmmaking practice, in which the activists march on la place de la Bastille in chains, then break their chains and put them in a bonfire. The French Revolution, referenced by this action, was a popular analogy for the Left, as seen in the film La marseillaise (dir. Jean Renoir, France, 1937). Le film de la Femme nouvelle is significant because it allows for an alternate, feminist history of political filmmaking in the period.
Calculating Couples: Computing Intimacy and 1980s Romance Software
Authors: Hilu Reem
Published: October 2023

In the 1980s, as the market for computing in the home was still emerging, a category of software arose that promised computer-mediated experiences of romance and sex. These programs, which this essay is calling “romance software,” drew on popular psychological and therapeutic discourses to offer couples advice for more satisfying relationships while also managing their interactions with the computer as an intimate or romantic activity. This essay argues that romance software employed the then novel home computer as a tool that could help mediate relational and communication ideals and bolster the heterosexual couple in the context of changing expectations for relationships in the 1980s. Romance software attempted to instantiate computing intimacy — referring not only to the application of computational methods to the management of relationships but also to the romantic or erotic experience of a couple using computers together. Although they amounted to a minor subset of the software introduced during the decade, these programs envisioned computing in the home as a technology to mediate companionate relationships. Romance software demonstrates that some software companies in the 1980s conceived of personal computer users not only as abstracted masculine individuals but rather addressed users within their roles in companionate relationships, in this case as part of a couple. These programs proposed methods through which computing could be used to assist in creating better relationships for couples that had adopted computers into their homes.
Educational Pasts, Enduring Colonial Presents
Authors: Boggs Abigail
Published: October 2023

Taking Indigenous sovereignty as at once axiomatic and constitutively strategic, this article argues that it is necessary to expand the chronology and disrupt the geographic certitude through which the history and present of US higher education and its internationalization are conventionally understood. Colleges and universities in the British colonies and what became the United States, including Harvard, William & Mary, and Dartmouth, were founded and funded with the intention that they would function as a vital technology through which the nation-state and white Christian culture would reproduce and secure themselves, their possessions, and their futures. This project was to be accomplished through the assimilation and at times incorporation of people, often youth, from polities understood as fundamentally other from that of their instructors and benefactors. Assessments of the extent to which such projects were effectuated vary, but it is well established that contemporary universities and colleges are conceptually and financially rooted in colonial educational projects that targeted Indigenous students for incorporation and assimilation. In an era when many of these same institutions are making substantial, if inadequate, efforts to contend with their historical origins, it is necessary to move beyond acknowledgment of these histories and contend, instead, with how such projects materially and epistemologically underwrite the basic functions of the most well-resourced and prestigious higher education institutions of the present.
Presentism, Spectacle, Unreality
Authors: Connolly Brian
Published: October 2023

This essay engages the dismissal of presentism and identity politics by the former president of the American Historical Association. In doing so, the essay argues that his essay shares a rhetorical style with other intellectuals and politicians that can aptly be called the spectacle of transgression. The essay argues that this spectacle works to obscure the material conditions of higher education in general and of history in particular.
Un-resolving frozen shoulder: Are we really treating it?
Authors: Wagan Abrar Ahmed , Surahyo Paras
Published: October 2023

Objective: To perform ultrasound examination in un-resolving frozen shoulder disorder, in Pakistani cohort visiting rheumatology clinic.

Methods: This cross sectional study was carried out at Department of Rheumatology, Indus Medical College Tando Mohhamad Khan, from 16th March 2022 to 30th October 2022. Patients diagnosed as unilateral frozen shoulder on clinical grounds and received intra-articular injection (s) in last six months, never been investigated, still persisting with pain and restricted range of shoulder motion were enrolled. After the demographic details and shoulder examination, ultrasound examination of both shoulder joints was performed by senior musculoskeletal radiologist, to know the exact diagnosis.

Results: In 138 cases on ultrasound examination following injuries were noted: rotator cuff tendinopathy (RCT) (61%), adhesive capsulitis (21%), mixed lesion (rotator cuff tendinopathy and adhesive capsulitis) (14%). In age group < 50 years rotator cuff tendinopathy was the major lesion, while in cases >50 years age group: adhesive capsulitis (AC) was predominant lesion (p-0.05).Rotator cuff tendinopathy had significant association with supraspinatus tears (p<0.5).

Conclusion: In Un-resolving frozen shoulder pain, ultrasound examination of involved joint helps in reaching the exact cause which may differ from the existing diagnosis and guides to further management.

doi: https://doi.org/10.12669/pjms.40.1.7440

How to cite this: Wagan AA, Surahyo P. Un-resolving frozen shoulder: Are we really treating it? Pak J Med Sci. 2024;40(1):---------.  doi: https://doi.org/10.12669/pjms.40.1.7440

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Value of serum CRP and IL-6 Assays combined with Pancreatitis activity scoring system for assessing the severity of patients with acute pancreatitis
Authors: Xu Fang , Hu Xin , Li Shu-ling
Published: October 2023

Objective: To evaluate the accuracy of serum CRP and IL-6 assays combined with the pancreatitis activity scoring system (PASS) in assessing the severity of patients with acute pancreatitis (AP).

Methods: This was a retrospective study of 223 patients with AP admitted to Baoding Lianchi District People’s Hospital between February 2021 and 2023. They were classified into three categories: mild AP (MAP), moderate severe AP (MSAP) and severe AP (SAP). The differences, accuracy and sensitivity of the individual assays, and the three in combination, were compared and analysed in the three groups.

Results: PASS scores, IL-6 and CRP levels were significantly higher in the SAP and MSAP groups compared to those in the MAP group, with statistically significant differences between the three groups. Multi-factorial logistic regression analysis suggested that PASS, IL-6 and CRP were correlated indicators of AP severity. The combination of the three assays was higher than that of the PASS score, IL-6 and CRP alone, suggesting optimal diagnostic efficacy when the three assays were combined. Moreover, the levels of PASS score, IL-6 and CRP showed a positive correlation with the degree of disease severity.

Conclusions: The serum CRP, IL-6 and PASS scores were significantly elevated in AP patients and showed a positive correlation with disease severity, all of which are beneficial for the diagnosis of AP. PASS is superior to CRP and IL-6 in the assessment of AP. The combination of the three assays can achieve a far superior diagnostic efficacy to that of the individual index assays.

doi: https://doi.org/10.12669/pjms.40.1.7550

How to cite this: Xu F, Hu X, Li S. Value of serum CRP and IL-6 Assays combined with Pancreatitis activity scoring system for assessing the severity of patients with acute pancreatitis. Pak J Med Sci. 2024;40(1):---------. doi: https://doi.org/10.12669/pjms.40.1.7550

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel
Authors: Bakhtiar Nighat , Nasir Dr. Irfan-ul-Islam , Dr. Muhammad Fahd Shah  , Dr. Ihtisham-Ulah  , Dr. Shahid Khattak  , Dr. Aamir Ali Syed  , Dr. Osama Shakeel
Published: October 2023

Background & Objective: To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.

Methods: This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system.

Results: A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months.

Conclusion: For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

doi: https://doi.org/10.12669/pjms.40.1.7619

How to cite this: Bakhtiar N, Nasir I, Shah MF, Ihtisham-Ulah, Shakeel O, Khattak S, et al. Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel. Pak J Med Sci. 2024;40(1):---------. doi: https://doi.org/10.12669/pjms.40.1.7619

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.