bluuebunny/crossref_metadata_2025 huggingface dataset:
Uptake and effectiveness of checkpoint inhibitor therapy among trial-ineligible patients with advanced solid malignancies.
Authors: Parikh Ravi Bharat , Min Eun Jeong , Wileyto E. Paul , Riaz Fauzia , Gross Cary Philip , Cohen Roger B. , Hubbard Rebecca A. , Long Qi , Mamtani Ronac
Published: June 2021

e18595

Background: Immune checkpoint inhibitors (ICIs) are part of standard of care in many advanced solid malignancies. Patients (pts) with poor performance status or organ dysfunction have been usually ineligible in pivotal clinical trials of ICIs. Methods: In this retrospective cohort study, we assessed ICI uptake and effectiveness among 34,131 pts diagnosed with advanced non-targetable non-small cell lung (NSCLC), urothelial cell (UCC), renal cell (RCC), or hepatocellular (HCC) carcinoma between January 1, 2014 and December 31, 2019. Pts were identified from the Flatiron Health electronic health record-derived database, consisting of pts receiving care in 280 mostly community oncology practices in the US. 9,318 (27.3%) pts were trial-ineligible based on ECOG performance status ≥ 2 or liver (total bilirubin ≥ 3 mg/dL) or kidney (eGFR < 30 ml/min/1.73m2) dysfunction. The association between trial-ineligibility and ICI monotherapy uptake was assessed using inverse probability weighted logistic regression. We hypothesized that there would be no differences in overall survival between ICI and non-ICI therapies in the trial-ineligible cohort. To test this hypothesis, we used inverse probability of treatment weighted survival analyses. Because we observed non-proportional hazards, we report 12- and 36-month restricted mean survival times (RMSTs) and time-varying hazard ratios < and ≥ 6 months. Results: Between 2014-2019, the proportion of pts who received ICI monotherapy rose from 0% to 30.2% among trial-ineligible pts and from 0.1% to 19.4% among trial-eligible pts. Trial-ineligible pts received ICI monotherapy more frequently than trial-eligible pts (22.5% vs 12.7%, adjusted odds ratio [aOR] relative to non-ICI therapy 1.8, 95% CI 1.7-1.9). Among trial-ineligible pts, there were no OS differences between ICI monotherapy, ICI combination therapy, and non-ICI therapy at 12 months (RMST 7.8 vs. 7.7 vs. 8.1 mos) or 36 months (15.0 vs. 13.9 vs. 14.4 mos). Relative to non-ICI therapy, ICI monotherapy was associated with early mortality (adjusted hazard ratio [aHR] within 6 months 1.19) but late benefit (aHR after 6 months 0.80) in trial-ineligible pts (Table). Conclusions: Trial-ineligible pts with advanced malignancies preferentially receive first-line ICI, despite the lack of a survival benefit and possible early mortality associated with ICI use. Positive results for ICI in phase III trials may not translate to this vulnerable population. [Table: see text]
Thirty-day readmission after percutaneous coronary intervention with drug eluting stent in patients with active malignancy.
Authors: Macchi Hugo , Salazar Miguel , Del Cid Fratti Juan , Upadhyay Shristi , Baral Binav , Shrivastava Trilok , Gauto Estefania , Cattoni Juan Adolfo
Published: June 2021

e18601

Background: Reducing the 30-day readmission is one of the quality performance measures upon which hospitals are being evaluated. Readmissions represent a significant economic burden to the patients and the health care system. Index admission for myocardial infarctions requiring PCI with a concurrent diagnosis of malignancy represents a critical part of the population due to the association between cancer and the pro-thrombotic state that renders them at high risk of readmission. By harnessing the power of large datasets such as the NRD (National Readmission Database), we sought to find associations that, together, could aid in the development of better public and private policies that would make patient care more efficient. Methods: We conducted a retrospective study of the 2017 National Readmission Database (NRD) of adult patients readmitted within 30 days after an index admission for myocardial infarction requiring PCI with a concurrent diagnosis of malignancy. We aimed to identify the 30-day readmission rate, mortality, healthcare-related utilization resources, and independent readmission predictors. Results: A total of 8,350 patients with malignancy underwent PCI. The 30-day readmission rate was 17.8%. The main causes for readmission were sepsis, ventricular fibrillation, recurrent STEMI. Compared to initial admissions, readmitted patients were less likely to require mechanical ventilation (7.3% vs. 5.2%; P = 0.05), intra-aortic balloon pump placement (4.1 vs 0.4; P < 0.01), IMPELLA device use (4.0 vs 0.3; P < 0.01), less had private insurance (16.2% vs 12.9%; P = 0.02), less developed shock (7.7% vs 3.2%; P < 0.01), & less had major bleeding (2.0% vs 0.1%; P < 0.01). Readmission was associated with lower in-hospital mortality rate (1.5% vs. 0.1%; P < 0.01), but more likely to require hemodialysis (4.3% vs 6.6%; P < 0.01), & have venous thromboembolism (VTE) (1.9% vs 3.2%; P < 0.01). The total health care in-hospital economic burden of readmission was $937 million in total charges for patients and $224 million in total costs for hospitals. Independent predictors of readmission were female gender, the disposition to a short-term hospital or skilled nursing facility, prolonged length of stay, inpatient hemodialysis, and VTE episodes. Conclusions: Readmissions after PCI in patients with malignancy are associated with a lower in-hospital mortality rate but pose a high health care burden. We identified potential risk factors that, if targeted, could lead to a reduction in readmissions after PCI in cancer patients, & therefore decrease health care costs.
Association of Memorial Sloan Kettering-Frailty Index with the postoperative intensive and specialized advanced care units admission among older adults with cancer.
Authors: Donoghue Timothy J , Tin Amy L. , Shahrokni Armin
Published: June 2021

e18606

Background: Understanding factors associated with poor surgical outcomes of older adults with cancer is necessary in identifying high risk patients and finding ways to mitigate poor outcomes following surgery. In this study, we evaluated whether frailty is associated with intensive postoperative healthcare utilization for this vulnerable population. Methods: This was a single hospital, retrospective cohort study, using the Memorial Sloan Kettering Frailty Index (MSK-FI) to define frailty, with higher MSK-FI corresponding to increased frailty. Multivariable logistic regression with random intercept models were used to assess the association between frailty and 30-day postoperative Intensive Care Unit (ICU) admission, and Specialized Advanced Care Unit (SACU) admission, separately. Covariates included surgical department, age, sex, surgical stress score, preoperative albumin level, and whether patients took a Beers criteria medication prior to surgery. Results: We identified 4417 patients over the age of 65 undergoing elective surgery between January 2015 and December 2018 at our institution and had a length of stay of at least one day. A quarter of patients had an MSK-FI score of 3 or greater. Among our patients, 3.8% (95% CI 3.2%, 4.4%), and 5.4% (95% CI 4.8%, 6.1%) were admitted to the ICU, and the SACU, respectively. We found evidence of an association between greater frailty and increased risk of ICU admission (OR per one-point increase in MSK-FI 1.44; 95% CI 1.31, 1.59; p-value < 0.001), and SACU admission (OR per one point increase in MSK-FI 1.46; 95% CI 1.33, 1.60; p-value < 0.001). For example, for a patient with an MSK-FI score of 2, the predicted risk of ICU admission is 2.2% and SACU admission is 1.1%, compared to 4.5% and 2.2%, respectively, for a patient with an MSK-FI score of 4, when all continuous covariates are set to the mean and the categorical covariates are set to the mode. Conclusions: Frailty based on the MSK-FI is associated with intensive postoperative care utilization in this population of older adults with cancer. Future studies should assess the impact of this information on surgery decision making for this vulnerable population.
Mortality in adult patients with solid or hematological cancers and SARS-CoV-2 infection with a specific focus on lung and breast malignancies: A systematic review and meta-analysis.
Authors: Tagliamento Marco , Agostinetto Elisa , Bruzzone Marco , Ceppi Marcello , Saini Kamal S. , de Azambuja Evandro , Punie Kevin , Westphalen Benedikt , Morgan Gilberto , Pronzato Paolo , Del Mastro Lucia , Poggio Francesca , Lambertini Matteo
Published: June 2021

e18608

Background: Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and a diagnosis of cancer are at high risk of severe symptomatic disease (COVID-19) and death. We performed a systematic review and meta-analysis of published studies, to estimate the case-fatality rate (CFR) of patients with solid or hematological tumors and SARS-CoV-2 infection. Methods: A systematic search of PubMed library up to 31 January, 2021, was performed in order to identify publications reporting the CFR among adult patients with solid or hematological tumors and SARS-CoV-2 infection. CFR was defined as the rate of deaths among SARS-CoV-2-positive cancer patients. Moreover, we separately assessed the CFR among patients with lung and breast cancer. Studies with at least 10 patients were included. The CFR was assessed through a random effect model, and 95% confidence intervals (CI) were calculated. The Higgins I2 index was computed to assess the heterogeneity between studies. Results: The systematic search of the literaturereturned 1,727studies. 1,551 were excluded on the basis of the title, 29 based on the abstract, and 3 were duplicates. A total of 144 studies were selected, including 35,725 patients with solid or hematological tumors and SARS-CoV-2 infection. In total, 46 and 32 studies reported the CFR among COVID-19 patients with lung (total N = 1,555) and breast (total N = 1.398) cancer, respectively. Overall, the CFR was 25.5% (95% CI 23.1%-28.1%, Egger test p < 0.001). A sensitivity analysis, after excluding studies with less than 100 patients, showed a CFR of 22.1% (95% CI 19.4%-25.2%). The CFR among patients with lung cancer and SARS-CoV2 infection was 33.4% (95% CI 28.1%-39.6%) when including all studies and 26.3% (95% CI 17.6%-39.2%) at the sensitivity analysis after excluding studies with less than 100 patients. The CFR among patients with breast cancer and SARS-CoV2 infection was 13.7% (95% CI 9.1%-20.7%) when including all studies and 13.0% (95% CI 7.6%-22.1%) at the sensitivity analysis after excluding studies with less than 100 patients. Conclusions: One year after the outbreak of the pandemic, this large meta-analysis reports the impact of SARS-CoV-2 infection in patients with cancer. This population experienced a high probability of mortality, with a comparatively higher CFR in patients with lung cancer, and a comparatively lower CFR in patients with breast cancer. Patients with an underlying diagnosis of cancer require special attention with aggressive preventive measures that also include early access to COVID-19 vaccination.
Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic.
Authors: Parikh Divya Ahuja , Ragavan Meera Vimala , Srinivas Sandy , Garrigues Sarah , Rosenthal Eben Lloyd , Patel Manali I.
Published: June 2021

e18609

Background: The COVID-19 pandemic prompted rapid changes in cancer care delivery. We sought to examine oncology provider perspectives on clinical decisions and care delivery during the pandemic and to compare provider views early versus late in the pandemic. Methods: We invited oncology providers, including attendings, trainees and advanced practice providers, to complete a cross-sectional online survey using a variety of outreach methods including social media (Twitter), email contacts, word of mouth and provider list-serves. We surveyed providers at two time points during the pandemic when the number of COVID-19 cases was rising in the United States, early (March 2020) and late (January 2021). The survey responses were analyzed using descriptive statistics and Chi-squared tests to evaluate differences in early versus late provider responses. Results: A total of 132 providers completed the survey and most were white (n = 73/132, 55%) and younger than 49 years (n = 88/132, 67%). Respondents were attendings in medical, surgical or radiation oncology (n = 61/132, 46%), advanced practice providers (n = 48/132, 36%) and oncology fellows (n = 16/132, 12%) who predominantly practiced in an academic medical center (n = 120/132, 91%). The majority of providers agreed patients with cancer are at higher risk than other patients to be affected by COVID-19 (n = 121/132, 92%). However, there was a significant difference in the proportion of early versus late providers who thought delays in cancer care were needed. Early in the pandemic, providers were more likely to recommend delays in curative surgery or radiation for early-stage cancer (p < 0.001), delays in adjuvant chemotherapy after curative surgery (p = 0.002), or delays in surveillance imaging for metastatic cancer (p < 0.001). The majority of providers early in the pandemic responded that “reducing risk of a complication from a COVID-19 infection to patients with cancer” was the primary reason for recommending delays in care (n = 52/76, 68%). Late in the pandemic, however, providers were more likely to agree that “any practice change would have a negative impact on patient outcomes” (p = 0.003). At both time points, the majority of providers agreed with the need for other care delivery changes, including screening patients for infectious symptoms (n = 128/132, 98%) and the use of telemedicine (n = 114/132, 86%) during the pandemic. Conclusions: We found significant differences in provider perspectives of delays in cancer care early versus late in the pandemic which reflects the swiftly evolving oncology practice during the COVID-19 pandemic. Future studies are needed to determine the impact of changes in treatment and care delivery on outcomes for patients with cancer.
Neoadjuvant chemotherapy and disease recurrence after curative-intent surgery in patients with pancreatic adenocarcinoma: A single-center retrospective review.
Authors: Alhamad Khaled , Alrifai Nada , Attah Abraham Attah , Shankar Karthik , Alnimer Lynna , Samhouri Yazan , Jayakrishnan Thejus Thayyil , Srinivasamaharaj Srividya , Monga Dulabh K.
Published: June 2021

e18610

Background: Early stage pancreatic ductal adenocarcinoma (PDAC) account for up to 30% of newly diagnosed patients. Until recently, the mainstay of treatment remained curative-intent surgery followed by adjuvant chemotherapy. More recently, the incorporation of neoadjuvant therapy (NAT) has demonstrated clinical benefit. The two commonly used regimens are 5-Fluorouracil, Leucovorin, Oxaliplatin and Irinotecan (FOLFIRINOX), or Gemcitabine and nab-Paclitaxel. Limited data is available to differentiate outcomes between the 2 common NAT regimens. We conducted a retrospective review to assess the rates of disease recurrence and progression after neoadjuvant chemotherapy and to identify any associations that may predict early recurrence. Methods: A retrospective review was conducted of all patients diagnosed with PDAC from 2017-2019 at Allegheny General Hospital. Data analysis was completed using IBM SPSS v23. Disease recurrence or progression was assessed radiologically, and time to progression was calculated as time (months) since diagnosis to evidence of radiological progression. Results: Out of 171 patients reviewed, 56 were deemed resectable or borderline resectable and underwent curative-intent surgery and were included in the analysis. Median age was 68, and 12 (41%) were male. Majority of the patients were white (90%). 29 (52%) patients received neoadjuvant chemotherapy: 16 (55%) received FOLFIRINOX, 12 (41%) received Gemcitabine with nab-Paclitaxel, and 1 received another regimen. 9 patients out of 16 (56%) that received FOLFIRINOX progressed, and 5 out of 12 patients (42%) who received Gemcitabine with nab-Paclitaxel progressed. Patterns of progression in those that received FOLFIRINOX: 1 (11%) within 6 months, 4 (44%) between 6-12 months, and 4 (44%) after 12 months. Of those that received Gemcitabine with nab-Paclitaxel, 2 (40%) progressed within 6 months, 1 (20%) progressed between 6-12 months, and 2 (40%) progressed after 12 months. On multivariate analysis, no association was identified to predict progression. Conclusions: There was no significant difference in disease progression rates among patients that received neoadjuvant FOLFIRINOX versus Gemcitabine and nab-Paclitaxel (42% vs. 56%; p = 0.46). No predictive associations were identified in patients with disease recurrence. Study limitations include a low sample size and retrospective analysis. Further, larger scale studies are warranted to better assess the difference in rates of progression after neoadjuvant FOLFIRINOX versus Gemcitabine and nab-Paclitaxel.[Table: see text]
Prevalence of sarcopenia in patients with gastroesophageal and lung malignancies undergoing surgical resection and its impact on immediate postoperative outcomes: A prospective observational study.
Authors: Gunasekar Sudhakar , Deo SVS , Kumar Sunil , Dhamija Ekta , Bhoriwal Sandeep Kumar
Published: June 2021

e18617

Background: The study evaluated the prevalence & impact of sarcopenia in gastroesophageal cancer (GC) & lung cancer (LC) patients undergoing resection. Methods: An observational prospective study was conducted in department of surgical oncology, AIIMS, New Delhi. All patients aged under 65 years with resectable GC & LC were included. Skeletal muscle index (SMI) using cross-sectional CT images at the level of L3 & Hand grip strength (dynamometer) were used to assess sarcopenia. Random benign patients with CT images were used as control group. Patients were categorized into sarcopenic and non-sarcopenic and outcome parameters were compared. Results: In the study population (n = 66), GC & LC constituted 44 (66.67%) & 22(33.33%) respectively. Mean age was 53.4 years. The prevalence of sarcopenia based on the combined method (CT imaging & handgrip strength) was 57.58%, CT based sarcopenia was 33.34% & handgrip strength-based sarcopenia was 43.93%. Mild and moderate sarcopenia was seen in 37.88% (n = 25) & 19.7 % (n = 13) respectively. Among patients with GC, prevalence of sarcopenia was 59.09% by combined method, 36.36% and 43.18% by CT based method alone & handgrip strength-based method alone respectively. Among LC prevalence of sarcopenia was 54.54% by combined method, 27.27% and 45.45% by CT based & handgrip-based method. The concordance between CT muscle mass & grip strength was 62.12%. Most female patients had weak handgrip strength despite having normal SMI. In control group (n = 44) mean age was 54.5 years, the prevalence of CT based sarcopenia was 34.09%. Weight loss history & BMI correlated with the degree of sarcopenia. Out of 66 patients 13% (n = 9) patients were unresectable. Moderate sarcopenia group had more statistically significant (P -0.02) unresectable disease compared to mild and non-sarcopenic groups. In postoperative period, sarcopenic group (64.51% vs 38.36 %) had more grade 2 complications though statistically insignificant. There was no difference in hospital stay between the two groups. In patients with GC , postoperative respiratory complication occurred in 11.53% (n = 3) of sarcopenic patients and 5.5%(n = 1) of non-sarcopenic patients, anastomotic leak occurred in 7.69% (n = 2) of sarcopenic patients and 5.5% (n = 1) of nonsarcopenic patients. Conclusions: The prevalence of sarcopenia is higher in patients with gastroesophageal cancer compared to lung cancer. The important factors that affect the sarcopenia include age and body mass index and weight loss history. The study has showed a trend towards increased post-operative complications and increased unresectable cases in patients with mild to moderate sarcopenia. Further larger studies are required to validate if sarcopenia can be used as an adjunct to predict resectability and post-operative outcomes.
Clinical outcomes in HER2-positive and triple-negative breast cancer: Assessing racial disparities.
Authors: Sarma Maithreyi , Ronghe Ashwini , Nasir Samar , Kapoor Ankita , Attwood Kristopher , Gandhi Shipra
Published: June 2021

e18624

Background: Triple negative breast cancer (TNBC) & HER2 positive breast cancer (Her2BC), are aggressive breast cancer subtypes. Both are associated with higher mortality in Non-Hispanic Black (NHB) compared to Non-Hispanic White women (NHW). Factors attributed to this racial disparity include socioeconomic status, insurance status, diagnosis(dx)/ treatment delays & comorbidities. We examined the association between race & clinical outcomes (pathological complete response, pCR; recurrence free survival, RFS & overall survival, OS) in patients (pts) dxed with TNBC/Her2BC treated with neoadjuvant chemotherapy (NAC) at Roswell Park Comprehensive Cancer Center. Methods: Pts dxed with Stage I-III TNBC/Her2BC who received NAC from 2000-2018 were included. pCR was defined as absence of residual invasive cancer in the breast & lymph nodes after NAC. Association of race with pCR & survival outcomes was evaluated using logistic & Cox regression models, respectively. Multivariate (MV) models were used to evaluate the association between race & pCR or survival while controlling for relevant confounders including age, BMI, insurance, comorbidities, clinical stage, grade & time from dx to chemotherapy(chemo)/surgery. Analysis was conducted using SAS v9.4 at a significance level of 0.05. Results: 174 TNBC (49 NHB, 125 NHW) & 80 Her2BC (13 NHB, 67 NHW) pts were analyzed. Among TNBC pts, NHB pts had higher baseline BMI(34.3 vs 28.6 kg/m2; p<0.001), higher incidence of hypertension (HTN) (45% vs. 24%; p<0.01), diabetes mellitus (20% vs 8%; p<0.05) & higher Medicare/Medicaid use (M/M) (55% vs. 28%; p<0.01). Among Her2BC pts, NHB pts had higher incidence of HTN (54% vs 25%; p<0.05). There was no statistically significant difference in mean chemo relative dose intensity by race. Among TNBC pts, those with pCR were younger (47 vs 53 yrs; p=0.002) & had more grade 3 tumors (96% vs 80.5%; p<0.05) at dx compared to pts without pCR. Similarly, among Her2BC pts, those with pCR had more grade 3 tumors (64% vs 36%; p<0.05) at dx compared to pts without pCR. Among TNBC pts, advanced age, higher clinical stage & longer time from dx to surgery were associated with worse RFS & OS (p<0.05). Among Her2BC pts, M/M use & advanced clinical stage were associated with worse RFS & OS (p<0.05). There were no significant associations between race & pCR/RFS/OS on MV analysis (table below). Conclusions: Similar outcomes were noted between races for TNBC/Her2BC pts treated at a single academic center in Buffalo, NY. Given the known genetic diversity of African American ancestry in the US, further studies investigating the interplay between race, geography & clinical outcomes are warranted.[Table: see text]
Differences in transitions of care among cancer patients with and without venous thromboembolism (VTE) events.
Authors: Nathan Cinduja
Published: June 2021

e18636

Background: Transitions of care are an important part of medical care, as they provide opportunities to address patient concerns, refine goals to match current needs and prevent unforeseen complications and comorbidities. One such common and prevalent comorbidity amongst cancer patients is venous thromboembolism (VTE) events. Common VTE events include the occurrence of pulmonary embolism (PE), deep vein thrombosis (DVT) or both at the time of diagnosis or any time thereafter. It is estimated that approximately 4–20% of cancer patients will experience a VTE. Cancer patients developing VTE is a serious concern as it can adversely affect the patients’ quality of life and reduce overall survival rates and prognosis. Methods: This study is designed as a case control study. The subject group consists of 87 cancer patients who had one or several VTE events after their cancer diagnosis. Patients were selected from the UVM Medical Center electronic health record database. The goal of this project was to quantify and compare the average number of transitions of care in cancer patients with and without venous thromboembolism (VTE) events. This was achieved by reviewing the patients charts three months following a VTE event and evaluating whether these patients had a greater number of transitions compared to the three months prior to their VTE event. Transitions of care in our study were defined as office visits, ED visits, and inpatient admissions related to their VTE. Results: Initial evaluation of the results showed that there were more transitions of care amongst cancer patients with a VTE than without. Preliminary data of the 87 patients shows that patients who developed a VTE event after their cancer diagnosis had on average 1.3 more transitions of care within the three months following their VTE event compared to cancer patients without a VTE event. A t test will be used to determine whether the difference between the means (number of transitions of care) of the two groups (cancer patients with VTE and those without VTE) is significant. Conclusions: The implications of having greater transitions of care amongst cancer patients with VTE events are profound. Having more transitions of care exemplifies better implementation, patient care and involvement of health care teams given a history of VTE. Furthermore, the results of this study will provide further insight on ways to improve clinical outcomes and oncology patient care given a history of VTE.
Improving end of life care with advance care planning in a rural cancer center.
Authors: Barnhart Jacquelyn , Wells Stacy , Harris Tasha , Symington Banu
Published: June 2021

e18637

Background: We discovered four out of five Medical Oncology patients admitted to the hospital December 2019 and January 2020 were discharged to hospice and died within a week. None of those patients had advance directives. In November and December 2019, all oncology patient charts were reviewed and only 7% (12/174) had advance directives. We believe an established advance directive could have helped avoid unnecessary hospitalization, improved end of life care and reduced wasteful health care costs. This led to the question: Would process changes in a rural cancer center lead to an increase in completion and documentation of Advance Directives, thereby providing more patient goal congruent care? Methods: Data collection and process mapping was performed revealing current processes and overall barriers. This was analyzed and countermeasures were developed leading to process changes and interventions. The interventions included assigning dedicated staff to “own” the advance directives education, follow up and completion, training and certification of staff, and education of the entire Cancer Center on the new process and interventions. The new process included a standardized order set to cue a referral to the dedicated staff, standardized patient education and follow up and documentation consistencies. Results: The initial data collection revealed an advance directive completion rate of 7% in new oncology patients. Process inconsistencies and communication deficiencies, with redundant screening and no follow up, created significant barriers to advance directives. Repeat data collection after creating a position for dedicated staff to educate patients and help with advance directive completion revealed a completion and documentation rate of 6% and thus, was insufficient to lead to change. When a consistent process with formal communication to the dedicated staff was implemented, improvements were noted. Our most recent data collection revealed a 36% completion and documentation rate in advance directives. Conclusions: Lack of effective advance directive programs potentially lead to end of life care incongruent with patients’ wishes and wasteful of health care resources. An advance directive ensures that if a patient is unable to clearly communicate their wishes, these wishes are still honored. In addition, the advance directive can help avoid unnecessary hospitalizations, improve end of life care and reduce wasteful health care costs. As a rural cancer center with a limited service area, we are challenged with a small sample size. Practice will be needed to ensure consistency and efficacy of the current interventions in order to support continued improvement in completion and documentation rates of advance directives. This project will be expanded to address advance directives for all patients.
Descriptive study of the therapeutic aggressiveness in oncology patients in the hospital area of Huelva.
Authors: Amor Urbano María , Sánchez Escudero Laura , Palomo Rodríguez Rocío , Inoriza Angel , Camacho Pizarro Tomás , Bayo Juan L.
Published: June 2021

e18645

Background: The therapeutic aggressiveness (TA) criteria or Earle criteria (EC) (Table) explore indicators that reflect the quality of end-of-life cancer patients (pts). They are considered the gold standard to evaluate TA. The aim of our study is to analyze TA by applying EC in deceased cancer patients (pts) in the hospital area of Huelva. Methods: Observational and descriptive study of deceased cancer pts in the area of Juan Ramón Jiménez (HJRJ) and Vázquez Díaz (HVD) hospitals (2017– 2019). We used the IBM SPSS Statistics 22 program to analyze the overuse of oncology therapies (OT) and invasive therapies near death, as well as underutilization of hospice services (HS). Results: 922 pts were classified according to the type of tumor. The most prevalent was lung-pleural cancer (LC) 27%, followed by colorectal cancer (CRC) 17.7%. 25.3% died in an acute care unit of the HJRJ, 48.7% in the hospice care unit (HCU) of the HVD and 26% at home with follow-up by HCU. 70.3% received OT in the last month of life. 11% started a new treatment and 17% received it in the last 14 days of life. 75.8% of the pts were included in the HCU before death. Of these, 4.3% were included in the 72 hours before death. 18.5% of pts went to the Emergency Service more than once in the last month of life. We also analyzed the previous data according to the type of tumor (Table). Conclusions: Our study reflects an overuse of oncology therapies near death. This produces a greater use of resources, such as assistance to the Emergency Service or aggressive actions to alleviate the adverse effects secondary to the treatments. There is a greater TA in pts with head and neck cancer (HNC). These pts usually initially show malnutrition, comorbidities (heart disease, liver disease) and a borderline performance status before starting the treatment. Our data show that the rise of new therapeutic options in LC and breast cancer generated an overuse of treatment near the end-of-life.[Table: see text]
Insomnia in cancer patients.
Authors: Ashraf Sara , Jafri Mohammad Ali Syed , Alsharedi Mohamed Farouq
Published: June 2021

e18651

Background: Insomnia is a prevalent, debilitating problem that is faced by a growing number of patients with cancer. These patients are at higher risk of excessive fatigue, anxiety, depression, less immunity and poor adherence to treatment. A recommendation by the National Comprehensive Cancer Network (NCCN) Guidelines is to routinely screen patients for sleeps issues. We sought to analyze the screening for insomnia and its management at a cancer center in Appalachia. We also evaluated referrals for cognitive behavioral therapy, which is recommended as first line therapy in patients with chronic insomnia by the American College of Physicians (ACP). Methods: We performed an anonymous survey related to sleep at our cancer center which included 312 patients diagnosed with a solid tumor malignancy divided into early stage (stage I or II) or advanced stage (stage III or IV). Three questions were directly from NCCN guidelines screening for sleep disturbances in patients with cancer. We also added questions regarding if the patients’ medical oncologists ever asked about or addressed their sleep difficulties and if any treatment was offered. The institutional review board of the cancer center approved this study. Results: Our results showed that 67.9% (212 patients) reported either having difficulty falling asleep, staying asleep, or waking up too early. 14.7% (46 patients) reported excessive sleepiness, while 64.7% (202 patients) reported that someone else told them that they snore frequently or stop breathing while sleeping. Of the patients who reported difficulty with sleep, only 4.7% (10 patients) reported that their medical oncologist ever addressed it, with 7 patients being started on medication. No patients were referred for cognitive behavioral therapy. Patients with advanced stage disease were four times more likely to report disturbances with sleep than early stage disease. Conclusions: Patients with cancer have difficulty with sleep, which profoundly affects their quality of life and may negatively impact their response to treatment. We wanted to use this survey to see how we can improve efforts to routinely screen patients and identify those in need of assistance and therapy. Routine screening and initiation of treatment must be implemented nationwide in all cancer centers. We aim to start referrals for cognitive behavioral therapy and continue to address patients’ sleep disturbances on a routine basis.
Availability, reading level, quality, and accessibility of online cancer center smoking cessation materials.
Authors: Littman Dalia , Chino Fumiko
Published: June 2021

e18662

Background: Smoking cessation after a cancer diagnosis improves cancer outcomes. Therefore, it is important for cancer centers to provide educational resources to encourage patients to quit smoking. The NIH recommends that patient reading materials be written at a grade 6-7 reading level to maximize comprehension. As smokers on average have lower educational attainment than the general population, they may have particular difficulty comprehending smoking cessation materials written at advanced grade levels. Methods: This study evaluated the reading level of online resources via textual analysis of smoking cessation webpages associated with 63 NCI-Designated Cancer Centers or their affiliated medical centers or universities. Reading level was assessed using the WebFx Readability Test Tool. Differences in grade level were calculated by Mood’s Median Test. Content was evaluated for the quality of information, including textual analysis of print-out pamphlets. Non-English content and ease of navigation to webpages was documented. Results: Availability: Of 63 cancer centers, 42 (67%) had smoking cessation webpages. Among centers that did not have their own webpages, 14 had smoking cessation webpages hosted by affiliated medical centers and the remaining 7 had webpages hosted by affiliated universities. Reading Level: The median grade level for online smoking cessation materials was 9 (interquartile range IQR 8-10). There was no significant difference in grade level based on cancer center region, ranking, or whether the webpage was hosted by the cancer center, medical center or university. 17 webpages (27%) had print out pamphlets available, which had a median reading level of 8.5 (IQR 7-10). Information Quality: 27 webpages (43%) explicitly stated that smoking cessation improves cancer outcomes, 15 (24%) included details about smoking cessation medications, 16 (25%) provided information on behavioral counseling, and 14 (22%) described the risks/benefits of e-cigarette use. Only 4 (6%) had information on all four topics, while 21 (33%) did not have information on any of these four topics. Accessibility: Only 3 webpages (5%) were available in multiple languages. 12 webpages (19%) were inaccessible by search from the homepage with common terms (i.e. smoking, quit smoking, tobacco, etc). 38 webpages (60%) required 3 or more clicks to reach from the center homepage. Conclusions: Online smoking cessation materials at leading cancer centers exceed recommended reading levels, which can inhibit comprehension for patients trying to quit smoking. These webpages do not routinely include information on cancer outcomes or on evidence-based medications and behavioral change interventions to assist patients in quitting. Given the survival benefit found in cancer patients who quit smoking, it is imperative that educational materials from cancer centers maximize comprehension and accessibility.
Mobile and comprehensive assessment of patient-reported outcomes (PRO) in routine inpatient cancer care: A three-arm randomized controlled feasibility study.
Authors: Salm Hanna , Hentschel Leopold , Kramer Michael , Pink Daniel , Schuler Markus K
Published: June 2021

e18664

Background: Most of the work on PRO has been done in outpatient setting. However, cancer patients might even suffer from more severe problems when admitted to hospital for anticancer therapy. The question whether and how patients’ well-being changes during the course of the hospital stay and if electronically assessed PRO (ePRO) will bring benefit to patients and physicians remains unanswered. Implementing such a tool into routine clinical care can be considered as an additional challenge.The objectives of this study were to implement a multidimensional ePRO system to improve patient-physician interaction in inpatient cancer care and test its feasibility. A comprehensive set of PRO measures that would broadly assess the patient’s situation was developed by a multidisciplinary expert team. Before study initiation, semi-structured interviews with patients were carried out to optimize visualization and user experience. The tool included a rapid response ePRO system with a patient-tailored graphical feedback for physicians. The effect of the mobile tool on quality of life (QoL), symptom burden and patients’ satisfaction with care were explored. Methods: The study is an interventional, three-arm and multicenter inpatient trial. A self-administered questionnaire based on validated PRO-measures was applied and completed at admission, one week after and at discharge. Group A (intervention arm) and B received tablet versions while group C (control) completed the questionnaire on paper. Additional to the mere assessment of electronic patient reported outcome, results from group A were presented graphically to the treating physicians. Standardized instruments included measures of QoL (EORTC QLQ-C30), patients’ satisfaction with care (IN-PATSAT32) and adverse events (PRO-CTCAE). A feasibility questionnaire was administered to arm A and B. Results: N = 185 patients (mean age 63.5, 44.3% female) were recruited in oncology wards. 62% of patients were treated for oncological disease (33% with stage IV disease) and 37% for hematological disease. Feasibility questions revealed that the majority of patients preferred the electronic tool and believed that the tool was of high value for individualized patient care. Among others, symptom burden and global QoL did not significantly change during hospital stay. Satisfaction with care was significantly lower ( p = 0.047) in the intervention group (mean 3.55) versus the control group (mean 3.77) with scores ranging from 0-5. Conclusions: Results indicate that the intervention is feasible. Some of the results are counterintuitive and could possibly be influenced by a lack of physician compliance due to a busy daily routine. Moreover, the optimal interval and composition of questionnaires has yet to be determined in inpatient setting.
Optimizing blood product utilization: A whole lot to gain and nothing to lose!
Authors: Binder Adam F , Loos Katy , Peedin Alexis , Karp Julie , Gergis Usama , Wilde Lindsay
Published: June 2021

e18669

Background: Transfusion stewardship is a vital part of managing patients with hematologic malignancies (HM). Blood products are limited resources and blood product transfusion (txn) is costly and poses complications. Randomized trials in different clinical settings have shown that a conservative txn strategy is not inferior to more liberal txn strategy. As a result, the AABB and ASCO have recommended following a conservative txn strategy in patients with cancer (hemoglobin (hg) <7-8g/dL and platelets (plt) <10K in stable non-bleeding patients). Here we report our early outpatient institution’s experience implementing a contemporary txn approach in patients with HM. Methods: We formed a multi-disciplinary team to analyze blood product utilization. Overutilization was defined as orders for multi-units, packed red blood cells (pRBC) for hg >8 or plt for plt >10K in stable non-bleeding patients. Patients’ charts were audited during the baseline period to understand practice patterns. Data were collected using Qlik database. The baseline period (May 1, 2019-Feb 29, 2020) was compared to the intervention period (March 1 – December 31, 2020). A root cause analysis was performed. When possible 2-sided paired T-test was performed. If not possible, descriptive statistics were performed. Three interventions were developed and implemented sequentially: March 2020 – Blood bank began real-time review of blood products overutilization. May 2020 – Electronic Medical Record txn order set was revised to reflect recommended best practices. October 2020 –Txn guidelines revised for patients with HM. Results: During the study period, there were 3,227 pRBC and 2,817 plt transfused units in the outpatient setting. Monthly pRBC txn decreased from (mean(SD)) 168.5 (16.6) to 154.2(16.4) (p value: 0.14). Monthly plt txn decreased from 166.5 (26.5) to 115.2 (26.2) (p value: 0.001). Rates of multi-unit orders decreased significantly. Average monthly multi-unit orders decreased for pRBC (pre-48.6(5.9);post-24.3(7.6);p value 0.00007) and plts (pre-67.4(11.8);post-21.3(23.3);p value: 0.0002). Average hb at time of txn in the pre- and post-intervention period was 7.47 and 7.22. The percentage of txn in which the indication for txn was hb <7, 7-8, >8 changed from 34.6% to 56.3%, 52.6% to 32.8%, and 12.8% to 10.9% respectively. There was no significant increase in admissions for bleeding or increase in number of outpatient visits during the study period. Conclusions: Over 10-months, we significantly reduced outpatient blood product. Robust quality improvement methodology, engaging key stakeholders, and changing the culture of outpatient management were keys to success. To date, we have not seen any unintended consequences of these changes. These results are encouraging, as outpatient transfusion stewardship is thought to be harder given concerns about patients not being monitored as closely as in the inpatient setting.
Development of evidence-based clinical pathways for an outpatient oncology acute care clinic.
Authors: Simon Shayna , Charania Sadaf , Devlin Judy , Brucker Edie , Hong Christine , Bazzell Angela F. , Nair Kavitha , Sweetenham John W.
Published: June 2021

e18676

Background: Oncology patients frequently experience acute physical symptoms related to cancer and its treatment. Management of symptoms is best accomplished using evidence-based clinical care. When implementing an advanced practice provider (APP)-led oncology acute care clinic, evidence-based clinical pathways were developed to ensure standardization among treating providers. Methods: The top ten emergency department admitting diagnoses for oncology patients identified by the Centers for Medicare and Medicaid Services provided the foundation for development of the clinical pathways. Relevant primary literature, National Comprehensive Cancer Center Network guidelines, and American Society of Clinical Oncology guidelines were reviewed for development of outpatient oncology acute care clinical pathways. The information was cross-referenced with institutional data to confirm applicability to the patient population. A multidisciplinary team including nursing, pharmacy, laboratory services, radiology, information technology, and administrative staff reviewed the workflow to ensure best processes. The pathways were reviewed by oncologists, APPs and pharmacists before finalization. Results: Nine evidence-based clinical pathways were developed by August 1, 2020. From August to December 2020, 165 patient visits took place in the outpatient oncology acute care clinic. Gastrointestinal manifestations (25%), hypovolemia/weakness (25%), and infections (17%) were the most frequently encountered symptoms. Evidence-based clinical pathways were followed for patients with a chief complaint with an associated algorithm (N=124). Conclusions: Implementation of clinical pathways facilitate best practice standardization when ordering labs, tests, and medications while enhancing the acceptance of the new service. The pathways will be reviewed and updated by a multidisciplinary team every 3 months to ensure current evidence-based practices. Semi-annual pathway audits have been implemented to evaluate utilization and optimize patient outcomes, as well as determine areas of improvement and growth. Areas of opportunity identified during the first pathway audit included creating pathways for cardiac disorders, mouth disorders, and infections unrelated to neutropenia. Additionally, order set integration to automate the clinical pathway process in the electronic medical record is in progress.[Table: see text]
COVID-19 and cancer care: Embedding high-value changes into practice.
Authors: Milch Vivienne , Der Vartanian Carolyn , Austen Melissa , Wang Rhona , Woods Candice-Brooke , Liu Lillian , Ackland Stephen P. , Anderiesz Cleola , Keefe Dorothy Mary Kate
Published: June 2021

e18685

Background: Health systems pressures during the COVID-19 pandemic have driven adoption of innovative models of cancer care which optimise resources and protect patients and staff. High-value changes should be identified and retained to improve resilience of cancer care. Methods: Cancer Australia reviewed the literature and consulted with oncology health professionals, cancer control experts and consumers to examine elements of cancer care that changed during the pandemic. Strategies that support high-value care and improve cancer outcomes were identified. Results: The pandemic highlighted models of care which minimise risk of infection for cancer patients, whilst optimising outcomes. Of the numerous cancer care elements that we examined, this abstract focuses on key enhancements in digital health and treatment practices. Digital health helped maintain quality and continuity of cancer care during the pandemic. Use of telehealth (for clinical and supportive care), e-prescribing, and e-ordering of investigations increased, supported by national health system funding. Shared care between care settings was facilitated by rapid uptake of telehealth, e-health records, virtual multidisciplinary team meetings and secure messaging. Treatment modifications included hypofractionated radiotherapy, transitioning to oral chemotherapy where possible, and home-based palliative care. Lower thresholds adopted for use of G-CSF with chemotherapy to reduce risk of febrile neutropenia, aimed to decrease hospital admission rates. It is important to address barriers to uptake of these high value changes. For digital health, variations in patient access to telehealth and digital health literacy can be reduced through technical and coordination support (tailored to people with diverse needs and backgrounds), with telehealth consultations offered in safe, accessible clinical or community settings. Administrative and technical burdens in health service settings can be mitigated through sustainable IT infrastructure, standardised processes for appointments, and improving staff digital health capabilities. Patient anxiety regarding changes in care plans can be mitigated through transparent, accessible, and culturally appropriate communication, documentation and shared decision-making. Clinician uncertainty in calculating risks and benefits in treatment modifications can be addressed through evidence-based standardised care procedures and risk-stratification protocols. Conclusions: Many modifications to cancer care made during the pandemic can have long-term benefits and should become standard care, including enhancements in digital health and treatment practices. Strategies have been identified which enable these changes and address barriers to uptake at the system-, service-, practitioner-, and patient-level. Efforts to embed high value changes are required across the cancer control sector.