bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of intraoperative imprint cytology with frozen section for lymph node metastasis in patients with head and neck cancer.
Authors: Neduvanchery Saheer
Published: May 2020

e18548

Background: Intraoperative evaluation of lymph nodal metastasis in head and neck carcinoma assumes importance in deciding the extent of lymph node dissection. Frozen section is the most commonly employed technique. But it requires significant investment in terms of resources, time and personnel. Intraoperative imprint cytology is a rapid, reliable and an inexpensive alternative. So we conducted a prospective diagnostic test accuracy study to assess the diagnostic accuracy of intraoperative imprint cytology and frozen section for lymph node metastasis in Head and neck Cancer when compared to Gold standard, which is the final Histopathology. Methods: All patients presenting with squamous cell carcinoma of head and neck with clinically N0 neck undergoing surgery as primary treatment were included in the study. For patients undergoing surgery, neck nodal tissue were sent for intraoperative assessment of clinically suspicious nodes. Intraoperative assessment was done by imprint cytology and frozen section and was reviewed and reported by two independent pathologist. The sensitivity, specificity and accuracy of imprint cytology and frozen section were calculated with reference to the final histopathology report. Time duration for reporting were also calcuted for both. Results: Total 34 patients with clinically N0 neck were included in the study and 85 slides were examined for frozen section and imprint cytology. Occult nodal metastasis was found in 16 patients (47.06%). The mean time duration for reporting for frozen was 41.18 ±3.62 minutes where as for imprint cytology it was 18.12 ±2.01 minutes. The concordance rate between the frozen section and imprint cytology was 94.12%. The sensitivity of frozen section was 100 % where as for imprint cytology it was 85.7 %( p = 0.00). The specificity was 98.6 % for frozen section and 95.8 % for imprint cytology (p = 0. 27). The positive predictive value was 93.3 % and 80 % for frozen section and imprint cytology respectively (p = 0.01). The negative predictive value was 100% for frozen section and 97.1% for imprint cytology (p = 0.12). The accuracy for frozen section was 98.8 % where as for imprint cytology it was 94.1%(p = 0.09). Conclusions: Imprint cytology provides a cheaper, accurate, reliable and a rapid alternative for frozen section for intraoperative assessment of neck nodes in squamous cell carcinoma of head and neck and it assumes importance in resource driven countries like India.
Correlation of pathologic tumor grade with survival in oral cavity squamous cell carcinoma.
Authors: Anderson Eric , Luu Michael , Lu Diana J. , Nguyen Anthony Tuan , Mallen-St. Clair Jon , Scher Kevin , Mita Alain C. , Ho Allen S. , Zumsteg Zachary Stephan
Published: May 2020

e18557

Background: Pathologic tumor grade is a well-established prognostic risk factor that impacts staging and standard-of-care treatment decisions across multiple cancer types. However, the significance of tumor grade in cancers of the head and neck is less certain. Even in oral cavity squamous cell carcinoma (OCSCC), the head and neck cancer subsite with largest body of literature regarding the predictive value of tumor grade is, the prognostic significance of tumor grade remains controversial. Thus, we sought to better elucidate the prognostic importance of tumor grade in OCSCC. Methods: Patients with OCSCC diagnosed from 2004-2015 and undergoing primary surgery with or without adjuvant treatment in the National Cancer Data Base (NCDB) were identified. Overall survival (OS) was estimated using the Kaplan-Meier method with and without propensity score matching (PSM). Univariate and multivariable survival analyses were performed using Cox regression. Analyses were adjusted for multiple clinicopathologic factors, including age, sex, comorbidity status, year of diagnosis, pathologic staging, margin status, number of lymph nodes (LN) examined/positive, extranodal extension (ENE), lymphovascular invasion (LVI), adjuvant radiation, and concomitant chemotherapy. Results: Median follow-up was 40.7 months. Of 13,941 patients with OCSCC, 2,883 had low-grade tumors, 8,716 had intermediate-grade tumors, and 2,342 had high-grade tumors. Higher tumor grade was strongly associated with decreased survival. Specifically, five year OS was 62.7%, 52.8%, and 42.5% in low-grade (LG), intermediate-grade (IG), and high-grade (HG) OCSCC, respectively (p-value < 0.001). In PSM cohorts, OCSCC patients with high-grade had significantly worse 5 year OS (47.7% vs. 57.7%, p < 0.001) in comparison to those with LG OCSCC. Similarly, patients with IG tumors has worse 5-year OS (55.6% vs. 60.3%, p = 0.001) than patients with LG tumors in PSM cohorts. In multivariable analysis, both HG (HR 1.38, 95% CI 1.25-1.52, p < 0.001) and IG (HR 1.17, 95% CI 1.08-1.26, p < 0.001) OCSCC was associated with worse survival than what was observed in LG tumors. The magnitude of the independent effect of tumor grade in multivariable analysis was greater than or equal to what was observed with other well-established prognostic factors like margin positivity (HR 1.34), ENE (HR 1.35), and LVI (HR 1.18). Conclusions: Pathologic tumor grade is a strong predictor of survival among patients with OCSCC. Tumor grade should be considered when making therapeutic recommendations for OCSCC.
Delayed PET/CT scanning in locally advanced squamous cell carcinoma of the head and neck (SCCHN) receiving definitive chemoradiation: Outcomes and management of “incidental” findings.
Authors: Alluri Sunitha , Yunes Michael J , Cassells Lucinda J , Kaufman Seth , Napier Thomas , Mertens Wilson C.
Published: May 2020

e18558

Background: Comparative PET/CT scanning 3-4 months after chemoradiation is often used to determine the need for salvage therapy, but approaches to managing incidental findings prior to, and incomplete response after, therapy vary. Methods: PET/CT scans before and 3-4 months after completion of definitive combined modality therapy for locally-advanced head and neck cancer (AJCC7 stage III-IVB) from 2008-14 were evaluated for FDG-avid masses and abnormal metabolic activity outside of the expected area of involvement, response to treatment and subsequent management. Results: Of 78 eligible patients, 72 had follow-up scans. Scans prior to therapy demonstrated abnormal FDG uptake in non-enlarged cervical lymph nodes in 17 (22%) and were upstaged. Pre-treatment scans revealed FDG-avid uptake outside of expected involvement in 23 patients (9 lung [ < 1.5 cm or ground glass], 4 GI, 3 bone [without CT correlate], 3 lymph nodes, 1 prostate, 1 thyroid, 3 other; 3 had multiple sites). Lung (2), bone (1) and thyroid (1) lesions were biopsied prior to therapy; on post treatment scans 20/23 demonstrated resolution while 2 had lung resections for new primaries (1 died). After therapy, 43/72 (60%) patients had a complete response (CR) without other abnormal uptake; 10/72 (14%) obtained a CR in treated areas, but developed metastases; 19/72 (26%) had persistent uptake, of whom 10 (14%) were shown to have persistent disease; 11 biopsies, 7 further PET/CT, 18 other imaging, 3 LN dissections (1 malignant) and two other salvage surgeries were performed. CR patients had a 3-year overall survival (OS) of 94%; OS was similar regardless of pre-treatment uptake. Conclusions: Minor FDG uptake outside of the head and neck on initial scanning is frequent and most of these will resolve. Persistent uptake is common 3-4 months after therapy but only half of these are persistent cancer. Patients with a normal PET/CT scan after therapy have excellent survival.
Differential immune pathways in classic and mixed variants of anaplastic thyroid cancer.
Authors: Young Hannah J , Pharaon Rebecca , Bonjoc Kimberley-Jane C. , Ally Feras , Yin Holly , Kang Robert , Gernon Thomas , Maghami Ellie , Chaudhry Ammar
Published: May 2020

e18579

Background: Patients with anaplastic thyroid cancer (ATC) have poor outcomes due to treatment resistance with an estimated 5-year survival rate of 7%. Although “classic” ATC can arise de novo from follicular thyroid cells, it can also arise in association with papillary thyroid carcinoma (PTC), as a “mixed” histology. The immunologic and molecular differences between these histological subtypes have not been well-characterized. We aimed to investigate the differences in immune signatures in these histological subtypes to assess immune pathway differences in the classic ATC and mixed ATC/PTC tumor microenvironment. Methods: Classic ATC and mixed ATC/PTC cases (N = 12) from 1998 to 2018 with viable formalin-fixed paraffin-embedded (FFPE) tissue were identified and selected by a board-certified pathologist. 4 samples exhibited both PTC and ATC components while 8 were classic ATC cases, as confirmed by a pathologist. In the 4 mixed ATC/PTC histology specimens, 3 were identified to contain greater than 80% ATC involvement while the fourth was characterized as 40% ATC and 60% PTC. The NanoString Immune Profiling panel contains more than 770 genes. It was performed with extracted RNA to evaluate and compare the gene expression of classic ATC versus mixed ATC/PTC. Results: Majority of patients (N = 11) developed metastatic disease, a common feature of ATC, and are currently deceased (N = 10). The NanoString panel identified several differentially expressed immune pathways in the mixed ATC/PTC in comparison to the classic ATC group. There is upregulation of CD3 (p < 0.01) and CD8 (p < 0.01) transcripts in the mixed ATC/PTC group, but not CD4 transcripts (p > 0.05). Additionally, we found that genes associated with B cell and T cell function were significantly upregulated in the mixed ATC group, including CD27 (p < 0.01), CD28 (p < 0.05), BTLA (p < 0.01), CTLA4 (p < 0.01), LAG3 (p < 0.05), and TIGIT(p < 0.01). We did not observe any significant differences in the expression of PD1 (p > 0.05) or MR1 (p > 0.05) between classic ATC and mixed ATC variants. Conclusions: Our study demonstrates a significant difference in the immune landscape between classic and mixed variants of ATC. Our results indicate there may be an increase in immune cell infiltration and tumor inflammation in the mixed ATC variant, which suggests patients with the mixed ATC variant may show a positive response to immunotherapy.
Investigation of triple negative breast cancer rates in women diagnosed with breast cancer in Trinidad and Tobago.
Authors: Parkinson Gerneiva , Cooper Arianne , Alleyne-Mike Kellie
Published: May 2020

e19005

Background: According to the WHO/PAHO, Trinidad and Tobago (T&T) has the 2nd highest breast cancer mortality rate in the Caribbean region. In T&T, citizens of African descent make up about 36.8% of the T&T population, with 24.8% being of East Indian ancestry, and 32.4% identifying as having mixed heritage. In the United States, it has been showed that African American women, despite being diagnosed less often, have an earlier onset of breast cancer with less favorable clinical outcomes. One of the factors studied has been the higher frequency of triple negative breast cancer (TNBC) in African American women particularly when these patients are diagnosed at a younger age. Notably, a large proportion of breast cancer cases in T&T appear to occur at a young age, with nearly 36% of them being diagnosed under the age of 50. However, breast cancer tumor phenotypes have not been well studied. Therefore, we sought to investigate the distribution of tumor hormone receptor markers in the T&T breast cancer population. Methods: At the National Radiotherapy Center, T&T’s main oncology unit, we investigated breast cancer patients born in T&T using paper chart reviews. We collected information about their demographics, personal breast cancer diagnosis, tumor hormone receptor status and germline genetic testing results. Results: So far, we reviewed 90 patient charts, and in our sample, 33.3% (30/90) had TNBC. This is higher than the rates in the US where TNBC accounts for 10-20% of breast cancer patients, and of those TNBC cases, 10.6% have BRCA 1 or BRCA 2 mutations. In our T&T sample, of those with TNBC, 23.3% (7/30) had a HBOC mutation (5 BRCA, 1 TP53 and 1 PTEN). Average diagnosis age of TNBC cases reported in our sample was 45.7 years. In our sample, 52.2% (47/90) identified as having African ancestry, 37.8% (34/90) identified as having East Indian ancestry and 10% (9/90) identified as Mixed. Of the patients with TNBC, 63.3% (19/30) were of African ancestry, 30.0% (9/30) were of East Indian ancestry and 6.7% (2/30) identified as Mixed. Conclusions: Therefore, our sample results suggest that there is a significant portion of the breast cancer cases being TNBC in the T&T population, particularly in citizens with African ancestry. As we continue to finalize the incoming data, we hope to draw associations between tumor pathology, clinical presentation and genetic profiles. However, these initial results demonstrate the need to study tumor pathology within the T&T population, as this could lead to improved clinical and screening guidelines specific to T&T citizens.
Outcomes of a lung cancer screening program in a Hispanic urban population: The University of Miami experience.
Authors: Gawri Kunal , Charles Marie Jeannette Jeanette , MacIntyre Jessica , Torrents Sophie , Torres Tisdrey , Villamizar Nestor , Nguyen Dao M. , Yechieli Raphael , Dawar Richa , Lopes Gilberto , Rodriguez Estelamari
Published: May 2020

e19011

Background: The National Lung Screening Trial (NLST) revealed a 20% reduction in lung cancer (LC) mortality when low-dose computed tomography (LDCT) was utilized for LC screening vs chest radiography. NLST participants were predominantly Non-Hispanic Whites, with only 1.8% Hispanics. The goal of our study was to investigate the attributes of a LC screening program in a largely Hispanic urban population and compare with NLST. Methods: We performed a retrospective analysis of 421 consecutive cases who underwent LDCT screening from 2016-2019 at University of Miami (UM), with similar inclusion criteria as the NLST. Demographic characteristics, smoking status, lung RADS, LC detection and compliance were examined & compared with NLST cohort using summary statistics and χ2 tests for categorical variables. Results: Demographic and smoking characteristics of the UM cohort didn’t resemble those of NLST LDCT cohort. UM cohort had a different racial and ethnic profile, with a higher percentage of Hispanics (47.3% vs 1.8%) and African Americans (15% vs 4.5%) in the UM cohort vs NLST cohort respectively (p < 0.001). UM cohort generally had lesser smoking intensity, and significantly fewer active smokers when compared to the NSLT cohort; 38.5% vs 48.1% respectively. The proportion of positive LDCT screens (Lung-RADS Class 3 or 4) in the UM cohort (14.1%) was almost similar to the NLST cohort (13.7%) (p = 0.81). The UM cohort had a higher LC detection rate (3.3%) than the NLST cohort (1.1%) (p < 0.001). In keeping with goals of screening, both cohorts had 50% or more LC cases detected at an early curable stage. Overall patient adherence to screening guidelines was more than 90% in NLST cohort; whereas almost a quarter of referred patients in UM cohort didn’t show for their initial decision-making visit and only 45% completed two or more scans. Conclusions: Our LDCT screening program was based in a Hispanic urban location (UM) with 47.3% Hispanics. Compared to NLST LDCT arm, the UM cohort had fewer active smokers, lighter smoking history, a more diverse population, somewhat higher LC detection rate, weaker adherence to screening related visits. More data is needed to understand obstacles to compliance with screening in minority populations.
Pain in cancer: The patient experience in Spain.
Authors: Garcia-Foncillas Jesus , Anton Antonio , Caballero Fernando , Feyjoo Margarita , Gomez De Liano Lista Alfonso , Guillem Vicente , Monge Diana , Camps Carlos
Published: May 2020

e19021

Background: For patients, pain management can be a therapeutic objective that is just as important as oncological treatment. The aim was to analyze the illness experience of a group of oncological patients with pain associated to cancer and episodes of breakthrough cancer pain (BTcP), as well as their opinions on the care received. Methods: This study is an initiative of the ECO Foundation (Oncology Excellence and Quality Foundation), undertaken with the methodological support of Francisco de Vitoria University. Descriptive, transversal, multicenter and ecological study. 47 oncologists participated. Each of them invited 6 patients that met the participation selection criteria (one patient every day for 6 consultation days). An anonymous patient questionnaire was used, produced by the Scientific Committee, so they could provide their personal opinions and scores on their oncological pain (categorical variables). The doctor was in charge of transcribing the aggregated data compiled by means of an online survey. Statistical package: version 21.0 IBM SPSS-Windows. Results: The 47 oncologists collected information from 275 patients whose average age was 62.4. 46.5% were women. Clinical profile of the patient: The most frequent location of the primary tumor was the lung (28%), followed by breast (15.3%) and the intestine/colon (13.1%). Almost half of the patients (46.2%) suffered from maximum intensity pain of 8 points or higher (on a scale of 0 to 10) within the last 24 hours. Despite this, 8 out of 10 patients reported that they are satisfied or very satisfied with their pain treatment. 43% of patients were worried about the possibility of addiction or side-effects as a result of the treatment. However, 95% expressed satisfaction with the information offered by their doctor regarding analgesic treatment. More than half of patients gave the impact of their pain on their general activity, mood, everyday work and enjoyment of life a score of ≥7 out of 10 (10 = completely impacted). Conclusions: Although the patient satisfaction level regarding the doctors’ pain management was high, there seems to be room for improvement in terms of pain control and the impact of pain on each patient’s life.
Characteristics and factors affecting mortality of patients admitted for chemotherapy in the United States during the year 2017.
Authors: Mariam Roy Arya , Konda Manojna , Goel Akshay , Verma Rashmi
Published: May 2020

e19025

Background: Over the past two decades, there has been a tremendous increase in the chemotherapy options available to cancer patients. In terms of overall, progression-free survival, and temporary suppression of cancer-related symptoms, chemotherapy has shown beneficial effects. However, the side effects of chemotherapy are sometimes life threatening which affects an individual’s physical health, emotional state and quality of life. There is a considerable increase in the prevention, early identification and timely management of toxicities associated with chemotherapy; however, chemotherapy-related deaths still occur. Methods: We conducted a retrospective analysis of the National Inpatient Sample Database for the year 2017. Patients who were admitted for the administration of chemotherapy are identified using ICD- 10 codes. The epidemiology, the role of insurance providers in the treatment outcome were studied. Results: A total of 29,018 hospitalizations for the administration of chemotherapy were there in 2017. The median age of patients who received chemotherapy was 48. The overall mortality related to chemotherapy admissions was 0.80% (n = 233). The mortality of females who were admitted for chemotherapy did not vary much when compared to males admitted for chemotherapy (0.89% vs 0.73%, p = 0.132). It was found that admissions for chemotherapy during weekend had 85 % higher odds of dying as compared to admission during weekdays (1.6% vs 0.76%, OR = 1.85, p = 0.001, CI = 1.16 – 2.95). Patients who were admitted electively for chemotherapy were 74% less likely to die in hospital when compared to those who were admitted emergently for chemotherapy (1.4 % vs 0.49% OR = 0.36, p = 0.001, CI = 0.266 – 0.49). Interestingly, patients who had Medicare and Medicaid had higher mortality than those who had private insurance and self-pay when admitted for chemotherapy (2.08 % vs 0.58% vs 0.36%, p = 0.00). Those who had private insurance were 60% less likely to die in hospital while admitted for chemotherapy. The average length of stay for chemotherapy admissions were 5.92 ± 7.9%. Conclusions: Medicare and Medicaid patients, weekend admissions and emergent admissions were more likely to die in hospital while admitted for chemotherapy. Further studies are needed to reveal the disparities in the mortality of chemotherapy admissions, based on the socioeconomic status and the insurance payers.
Health disparity in Central Valley of California: Higher incidence of breast cancer in Asian population.
Authors: Sodavarapu Soujanya , Hatter Kate , Goyal Megha , Ramdass Prakash , Sayedi Majed , Obad Nashwan , Gill Amandeep Singh , Vyas Dinesh
Published: May 2020

e19029

Background: California has the most immigrants of any state in the U.S., with approximately a quarter of the residents being foreign-born. The impact of migration on breast cancer incidences over time has not yet been characterized in the Northern Central Valley. This provides a unique opportunity to study the influence of migration, socioeconomic gradient, and racial identity on the incidence of breast cancer in San Joaquin County. Methods: This study was a retrospective, single-institution study that compared the socio-demographic variables and clinical characteristics of the patients who had a history of breast cancer in a teaching central valley hospital. We reviewed all charts with a breast cancer diagnosis from 2014-2019. We compared age, demographics, socioeconomic status comorbidities, pathology, treatment, and outcomes. Appropriate statistics have been used to analyze the data. Results: A retrospective chart review of all patients with a diagnosis of breast cancer from 2014-2019 at a central valley teaching hospital. 33.5% were white, 17.2% African American, 26.6% Hispanic, and 22.6% were Asian. Migrated Asian women are having three times increased incidence in central California compared to their peers in Asian. Additionally, those of lower socioeconomic status were more often affected (61.9% vs. 30.4% of middle-class status) in our population. Demographics and comorbidities were studied. Smoking was seen in 23.2% of patients, alcohol in 16.3%, hypertension in 43.6%, Diabetes in 18.9%, lung disease in 11.7%, and Kidney disease in 6.9%. 23.8% of the patients had a family history of cancer. Screening was only done in 41% of patients, and the distribution of race was as follows: white 10.6%, African American 7.7%, Hispanic 8.9%, Asian 8.9%. It was found that infiltrating ductal carcinoma was seen in 54.8% of patients, of which 16.1% were white, 10% African American, 15.5% Hispanic, and 13.2% were Asian. Triple-negative breast cancer was seen in 14.9% in our patient population. We further reviewed treatment methods, including chemotherapy, radiation, and surgery, as well as recurrence rates. Conclusions: We suggest that screening has to be more concentrated in all communities. The fact that the Asian population in the Central Valley shows higher rates of breast cancer could be due to epigenetic, western lifestyle, and environmental factors. Higher awareness and willingness as a subgroup may be contributing as well or there may be an actual increase; this requires further investigation, and we will present further subgroup analysis at presentation.
The effect on financial toxicity and well-being of cancer trial patients through the reimbursement of ancillary costs by the lazarex care program (LCP).
Authors: Dornsife Dana , Johnson Robert G.
Published: May 2020

e19030

Background: Financial toxicity is a significant issue for many cancer patients (pts) and an even greater concern for pts considering a cancer clinical trial (CT) given the potential issues of distance to the trial site, additional trips to the cancer center, etc. Lazarex Cancer Foundation (LCF) has developed an efficient mechanism to quickly evaluate pts who are economically challenged and often underserved and to efficiently reimburse the non-clinical expenses (i.e. travel, lodging). Reimbursement (RI) of ancillary CT expenses can help to remove this important barrier and effect CT enrollment, retention, and diversity. Methods: Data was retrospectively reviewed from the LCP for years 2015 to 2019, and assessed for age, gender, race/ethnicity, household income (HI), type of assistance, and compared with trends from the prior 5 years. In addition, information was obtained concerning whether the RI was an important determinant in the decision to enroll or remain enrolled, the impact of RI on the pts’ well-being, and the ease/difficulty of the application and RI process. Results: During this period, 2,911 pts were approved for RI: 45% male, 55% female; 12.2% Latino/Hispanic, 7.6% black/African-American, 3.8% Asian/Pacific Islander, 72% white, and 4.3% multi-ethnic/other. The median HI was $35,000-$49,000 with 32% of the HI at less than $25,000, and 17% less than $15,000. RI expenses were distributed: 37% airfare, 37% lodging, and 26% ground transportation. There were increases in the % of minority pts and decreases in the median HI when compared with the five years prior. Questionnaires with 65% return rate of active pts indicated that 38% of pts stated that RI contributed to their positive CT decision, 92% of pts indicated RI had a significant impact (moderate to extremely high) on their sense of well-being with 82% in the high to extremely high category. 96% reported the application as not difficult to easy and only 4% noted the RI process itself as difficult. Conclusions: Accumulating data indicates that the socioeconomic financial toxicities are a significant root cause of inequitable access to CT. RI for pts upon whom the costs of participation place an undue burden, decreases their vulnerability, increases their well-being, and helps protect their rights to equal treatment. The LCF with more than ten years of experience with pt RI is currently expanding its efforts into targeted major cancer centers where all eligible pts will be enabled: the IMPACT (Improving Patient Access to Cancer Clinical Trials) Program.
Screening for health literacy at an urban academic cancer center.
Authors: Leader Amy , Waldman Lauren , Yocavitch Liana , Shimada Ayako , Cammy Rebecca , Garber Gregory D. , Worster Brooke
Published: May 2020

e19034

Background: Low health literacy is more prevalent among older adults and minority populations, and it has been linked to excess health care utilization and poor health outcomes in cancer patients. Screening for health literacy may improve communication and care, such that discussions and information can be tailored to patient need. The purpose of this study was to describe health literacy levels and correlates among patients at an urban, NCI-designated cancer center. Methods: In September 2019, we began health literacy screening for each newly diagnosed, English-speaking cancer patient. Patients were categorized as having low, medium, or high health literacy using the BRIEF health literacy screener; results are visible in the EMR. For this analysis, we included patient age, gender, insurance type, race/ethnicity, and socio-economic status (SES), which was calculated using an Area Deprivation Index (ADI) ranging from 0 (no deprivation) to 100 (extreme deprivation). Data was summarized using descriptive statistics; ANOVA and Chi-squared tests investigated associations between patient’s health literacy levels and potential correlates. Results: Among 284 patients, 68%, (n = 195) were Caucasian, 25% (n = 70) were African American and 7%, (n = 19) identified as Hispanic, Asian American or some other race. Seventy-five percent (n = 211) were male; the mean age was 63 years (SD: 12). The mean ADI was 42 (SD: 28), indicating a low to moderate SES. Seventy percent (n = 200) had a high health literacy score, 20% (n = 57) had a medium score, and 10% (n = 27) had a low health literacy score. Only a patient’s race/ethnicity and the ADI were significantly associated with their health literacy score. Seventy-seven percent of Caucasian patients had high health literacy scores compared to 59% of African American patients and 48% patients of Hispanic, Asian or some other origin (P < .001). Patients with low health literacy had an ADI score (65.1) that was almost double the score of patients with high health literacy scores (38.5) (p < .001). Conclusions: Roughly one-third of patients seen at this urban cancer center did not have a high health literacy score. Socio-economic status was a stronger correlate to health literacy than patient age, marital status, or insurance type. EMRs should capture a patient’s SES in some manner, as this is strongly associated with health literacy.
Patient-reported physical and mental health of socioeconomically disadvantaged cancer patients.
Authors: Gehr Aaron , Lu Yan , Tanna Bhavna , Narra Kalyani , Ghabach Bassam , Ojha Rohit P.
Published: May 2020

e19041

Background: Patient-reported outcomes (PROs) are extensively described for cancer patients with access to care, but little information is available about PROs for socioeconomically disadvantaged cancer patients with barriers to care. Therefore, we aimed to compare patient-reported mental and physical health between newly diagnosed cancer patients at an urban safety-net cancer center and the general population. Methods: We used data collected during implementation of a quality improvement pilot initiative to integrate PROs into clinical care at the JPS Oncology and Infusion Center (Fort Worth, TX), which is a Comprehensive Community Cancer Program. The Patient-Reported Outcomes Measurement Information System (PROMIS) 10-item Global Health Survey was used to ascertain mental, physical, and social health for newly diagnosed cancer patients between August and December 2019. Our outcomes of interest were the mental and physical health subdomains. We computed T-scores, where a score of 50 represents the mean for the U.S. general population with a standard deviation (SD) of 10. We defined severely impaired health as subdomain scores ≥2 SDs below the mean. In addition, we estimated standardized morbidity ratios (SMR) and corresponding 95% confidence limits (CL) to compare the observed number of patients with severe impairment of mental or physical health with the expected number of patients with severe impairment. For example, an SMR = 1.0 implies that the observed number of severely impaired individuals in the study population is equal to the expected number in the general population. Results: Our study population comprised 59 patients, of whom 73% were aged < 65 years, 51% were female, and 54% were racial/ethnic minorities. Breast (21%) and lung (21%) cancers were the most common diagnoses. The frequency of severely impaired physical health for our population was 4.4 times higher than the general population (SMR = 4.4, 95% CL: 1.6, 9.6), whereas no patients in our study population reported severely impaired mental health (SMR = 0, 95% CL: 0, 2.2). Conclusions: Our results suggest that socioeconomically disadvantaged cancer patients have substantially impaired physical health but not mental health at diagnosis. These findings may be useful for raising awareness about the importance of systematically ascertaining PROs and using the results to allocate resources for delivering care to safety-net cancer patients.
Real-world biomarker testing practices in cancer treatment in a lower-middle income country in Southeast Asia.
Authors: Catedral Lance Isidore Garcenila , Tan Harold Nathan , Chua Alfredo Viray , Sacdalan Danielle Benedict Leoncio , Sacdalan Dennis
Published: May 2020

e19042

Background: Several factors affect how medical oncologists in the Philippines, a lower middle income country, incorporate biomarkers in real-world practice. This study described patterns of use of biomarker testing for the management of breast, colorectal, and lung cancers among medical oncologists in the Philippines, where treatment is largely out-of-pocket. Methods: A cross-sectional survey was performed among practicing medical oncologists in the Philippines from November to December 2019. Responses were compiled and summarized using descriptive statistics. Results: A total of 127 responses (about 40% of medical oncologists in the country) were collected. Respondents were both consultants and fellows-in-training who, on the average, had been in oncology practice for 6.64 years (SD 7.37). Majority of respondents were affiliated with private hospitals and/or clinics (62.20%), but 40.94% of medical oncologists worked in academic medical centers. If clinically indicated and if cost did not play a role, 96% of respondents would order ER, PR and HER2neu testing for breast cancer. A quarter of respondents would include Ki-67 testing. In actual practice, 97% of the respondents reported ordering for ER/PR and 93% for HER2neu testing. For lung cancer, respondents would use EGFR (97.76%), PD-L1 (88.19%), ALK (80.31%), ROS1 (58.27%), and BRAF (33.07%). In actual practice, EGFR was the most frequently ordered biomarker (67.72%). 44.80% of medical oncologists had never used ROS1. For colorectal cancer, the respondents would use KRAS (98.43%), NRAS (81.89%), MMR/MSI (82.25%), and BRAF (63.78%), but these were only sometimes used. 59.84% of medical oncologists had never used BRAF. The strongest factor that drove medical oncologists to test for biomarkers was adherence to clinical practice guidelines (96%), with most respondents using international guidelines from the United States and Europe (61.4%). The largest barrier to biomarker use in the Philippines was financial constraints (94.5%), followed by the patients’ unwillingness to be tested (59.1%), and unavailability of tests in the areas of practice (58.27%). Conclusions: Medical oncologists in the Philippines would use biomarkers in the management of breast, colorectal, and lung cancers if these were clinically indicated and if cost did not play a role. Biomarker use was largely driven by American and European clinical practice guidelines. Financial difficulties by patients, who often had to resort to out-of-pocket payments for their treatment, formed the largest barrier to biomarker use.
Population-based analysis of guideline adherence for patients with rectal cancer in California.
Authors: Del Rosario Michael , Chang Jenny , Ziogas Argyrios , Clair Kiran , Bristow Robert E. , Tanjasiri Sora Park , Zell Jason A.
Published: May 2020

e19045

Background: The goal of oncology-specific evidence-based treatment guidelines is to improve cancer care. We sought to analyze adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines for rectal cancer in the state of California and the associated impacts on survival. Methods: Patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004 and December 31, 2017 with follow-up through November 30, 2018 were identified in the California Cancer Registry. Patient characteristics such as age, race, insurance status, socioeconomic status (SES), marital status, and tumor stage were identified. In addition, based on available data our investigators determined whether patients received NCCN guideline-adherent care. Odds ratios (OR) and 95% confidence intervals (CI) were used for logistic regression to analyze patients receiving NCCN adherent care. Disease specific-survival analysis was calculated using Cox regression model. Results: A total of 30,118 patients identified with diagnosis of rectal cancer in California, 16,442 (54.6%) of whom did not receive guideline-adherent care. Disease specific-survival was worse for those who did not receive NCCN adherent care with hazard ratio (HR) 1.52 (95% CI 1.41 - 1.63, p < 0.0001). Compared to Caucasians as a referent group, Asians (in aggregate) were more likely to receive guideline adherent care and had better disease specific survival with adjusted HR 0.88 (95% CI 0.80 -0.97, p = 0.008). Also compared to Caucasians, Hispanics were more likely to receive guideline adherent care and had better disease specific survival HR 0.90 (95% CI 0.83 – 0.98, p < 0.015). As compared to managed care insured patients, uninsured patients were least likely to receive care and were observed to have worse disease specific survival adjusted HR 1.34 (95% CI 1.18 – 1.54, p < 0.0001). Patients with Medicaid were also significantly associated with lower survival HR 1.39 (95% CI 1.26 – 1.53, p < 0.0001) – and the CIs indicate Medicaid and uninsured were not statistically different from each other. Comparing to patients with highest SES as a referent group, patients with lowest SES were least likely to receive guideline adherent care and also were observed to have worse disease-specific survival with HR 1.22 (95% CI 1.09 – 1.36, p < 0.0004). Conclusions: In this population-based analysis of rectal cancer patients in California, guideline-adherent care was associated with improved survival.
Esophageal cancer: How far is close enough?
Authors: Elliott Leighton Andrew , Vadakara Joseph
Published: May 2020

e19049

Background: According to Surveillance, Epidemiology, and End Results (SEER) data, 5-year survival of esophageal cancer (EC) improved from 4.1% to almost 20% from 1975 to 2016, however, this is still poor compared to other cancers. Chitti et al describe temporal changes in EC mortality by geographic region across the United States (U.S.) and concluded that disparities exist. Other studies described survival disparities for rural communities specific to small cell lung carcinoma, cervical cancer, and breast cancer. Hung et al determined that 1 in 5 rural Americans lived > 60 miles from a medical oncologist. Studies performed outside of the U.S. described no difference in survival with travel distance. No studies on this topic have focused on gastrointestinal malignancy. Our study aimed to associated travel distance with travel time to a medical oncology treatment center as time can vary greatly with similar distances. We focused specifically on esophageal cancer considering its high mortality rate and significant effect on quality of life. Methods: We performed a descriptive analysis of a retrospective cohort (January 2008 – August 2019) of all individuals diagnosed with esophageal cancer using data from the institutional Oncology Tumor Registry, a regional cancer registry, and the electronic health records (EHR) of patients throughout a rural integrated health system in Pennsylvania. We geocoded home addresses using Google Maps Geocoding application programming interface (API) and the average driving distance and time to the nearest medical oncology treatment center was calculated using the Google Maps Distance Matrix API. Travel time compared to cancer stage was also assessed. Addresses listed over 100 miles were evaluated for documentation accuracy via the EHR. Results: A total of 1157 adult patients diagnosed with esophageal cancer was evaluated; of these, 433 had a documented outpatient chemotherapy infusion site visit. The mean travel distance to a medical oncology treatment center was 19.8 miles with a median of 16 miles; this correlated with a mean travel time of 28.2 minutes. Seventy-five percent of the population lived within 26 miles of an outpatient oncology center. The maximum distance traveled was 139 miles, which was confirmed via EHR chart review. Conclusions: This study shows that a rural population may not necessarily experience disparity in travel distance and time to a medical oncology treatment center. This was an exploratory study and further analysis will be needed to see if there was any statistically significant difference in survival based on distances when stratified by stage, age, treatment modality, etc.
A comparative study on costs of cancer and access to medicines in Europe.
Authors: Wilking Nils Erik , Brådvik Gunnar , Lindgren Peter , Svedman Christer , Jönsson Bengt , Hofmarcher Thomas
Published: May 2020

e19051

Background: Cancer care is evolving rapidly, and costs and value of new treatments are often causing headlines without being discussed in a larger context. This study estimates the cost of cancer and access to medicines in Europe in 2018 and extends a previous analysis for 1995–2014. Methods: Cancer-specific health expenditure for 31 countries (EU-27 plus Iceland, Norway, Switzerland, and the UK) were derived from national estimates. Data on cancer drug sales were obtained from IQVIA. The productivity loss from premature mortality was estimated from data from Eurostat and the WHO. Estimates of the productivity loss from morbidity and informal care costs were based on previous studies. Results: The total cost of cancer was €199 billion in 2018. Total costs ranged from €160 per capita in Romania to €578 in Switzerland (after adjustment for price differentials). Health expenditure on cancer care was €103 billion, of which €32 billion was spent on cancer drugs. Informal care costs were €26 billion. The total productivity loss was €70 billion, composed of €50 billion from premature mortality and €20 billion from morbidity. Between 1995 and 2018, cancer incidence increased by 50 percent from 2.1 million to 3.1 million cases in Europe. Cancer mortality increased only by 20 percent. Health spending on cancer care doubled from €52 billion to €103 billion (in 2018 prices and exchange rates), whereas the share of cancer care on the total health expenditure remained stable at around 4 to 7 percent. A shift from treatment in inpatient care to ambulatory care has probably saved costs. Expenditure on cancer medicines more than tripled from €10 billion to €32 billion between 2005 and 2018 (excluding confidential rebates). Productivity loss from premature mortality decreased over time, linked to mortality reductions in working-age patients. Conclusions: There are large country differences in spending on cancer care and outcomes in Europe. Access to new cancer medicines is low or very low in certain parts of Europe. Inequalities are mainly related to countries’ economic strength and not to the disease burden of cancer.
The complex comorbidities of uninsured cancer patients.
Authors: Shah Shreni , MacDonald Madeline , Lu Yuanyuan , Pabbathi Smitha , Mirza Abu-Sayeef
Published: May 2020

e19054

Background: Uninsured patients diagnosed with cancer receive fewer screenings, frequently present with later-stage cancer, and are often unable to access standard-of-care treatment when compared to insured patients. We previously performed a study demonstrating that uninsured patients with cancer histories have higher levels of comorbidity. However, there is limited data on long-term studies describing comorbid chronic conditions among uninsured cancer patients. Here we examine socioeconomic factors and comorbid chronic conditions in uninsured patients with a cancer history over a period of three years. Methods: A retrospective chart review was conducted from 10 free clinics around the Tampa Bay region. Patients with any documented history of cancer who utilized a free clinic between 2016 and 2018 were included. Patients with no documentation of cancer history were excluded. Demographics, chronic disease parameters, and Charlson Comorbidity Index (CCI) scores were extracted and analyzed. Results: Between 2016 – 2018, a total of 17,003 uninsured patients were treated at 10 free clinics. Of these patients, 455 (2.7%) had a documented history of cancer, 9021 (53.1%) had no history of cancer, and 7527 (44.3%) had no documentation of cancer in their charts. Cancer patients were mostly women (305, 67.0%) and the average age was 55.2 years. Patients with cancer had significantly higher CCI scores compared to patients without cancer in 2016 (3.0 [2.0 SD] versus 0.94 [1.2 SD]), 2017 (2.71 [2.38 SD] versus 0.93 [1.26 SD]), and 2018 (3.27 [2.22 SD] versus 1.08 [1.26 SD]), p < 0.001. Patients with a cancer history were also more likely to be current drinkers (16.9% versus 13.0%) or smokers (17.8% versus 11.0%) compared to patients without a history of cancer. Conclusions: The results demonstrate that uninsured cancer patients consistently have higher levels of chronic disease and comorbidity compared to uninsured patients without a cancer diagnosis. This study increases awareness of the disease burden and mortality risk specific to uninsured cancer survivors which could inform free clinics and volunteer providers to better address the needs of this vulnerable population.
Gynecologic oncology, gender and relevant leadership in academic medicine.
Authors: Temkin Sarah Madhu , Rubinsak Lisa , Benoit Michelle F. , Chandavarkar Uma , Hong Linda , Berry Laurel K , Heisler Christine A , Rimel BJ , McGuire William P.
Published: May 2020

e19056

Background: Within academic medicine, there has been increasing attention to diversity and inclusion. We sought to characterize gynecologic oncologist (GO) faculty inclusion, with attention to gender in relevant academic leadership roles. Methods: Using the American Association of Medical Colleges list of accredited schools of medicine academic institutions were identified. Observational data was obtained through institutional websites in 2019. Results: Of 154 accredited medical schools, 144 contain a department of obstetrics and gynecology (OBG) with a chair; 103 a GO division with a director; 98 a clinical cancer center with a director. GO divisions included an average of 3.1 faculty. 55% of GO faculty were women, compared to 66% of OBG faculty (p < 0.01). 38% of the GO division directors were women which was an under-representation (p < 0.01). GOs made up 10% of OBG faculty and 15.4% of OBG chairs (NS). Women GOs made up 7.9% of women OBG faculty and 8 (5.6%) women GOs were OBG chairs (NS). 9.9% of GO faculty (11.6% of women GO faculty) report to women GOs at the chair level. OBG departments with a GO chair were more likely to have a woman GO division director (68.4 vs 31.7%, p < 0.01), and GO fellowship (59.1 vs 32%, p < 0.01). The majority (59%) of cancer centers directors were medical oncologists (see Table). 2 (2%) of cancer center directors were GOs; 1 at an NCI designated cancer center. Neither GO directors were women. Incidence to leadership and mortality to leadership ratios were calculated compared to expected rates by SEER 2019. By these measures GOs were underrepresented in cancer center leadership (p < 0.01, p < 0.01). Conclusions: Despite representative leadership of GO and women GO within in OBG leadership, most GOs report to non-oncologists at the department chair level. Potential benefits of GO leadership within OBG departments were identified. The practice of gynecologic oncology includes complex medical and surgical cancer care making these physicians uniquely qualified for cancer center, but representation of GOs in cancer center leadership is low and women GO were absent from cancer center director positions. Without inclusion of GO in cancer center leadership, existing inequities in clinical care, research and funding for gynecologic malignancies may be amplified. [Table: see text]