bluuebunny/crossref_metadata_2025 huggingface dataset:
Mutation-specific costs of advanced non-small cell lung cancer treatment.
Authors: Tan Juanyi , Yang Szu-Chun , Dinan Michaela Ann , Chiang Anne C. , Gross Cary Philip , Wang Shi-Yi
Published: October 2023

14

Background: Novel immunotherapy and targeted therapies prolong survival, but are associated with substantial costs for patients with advanced non-small cell lung cancer (NSCLC). Because biomarker results can strongly impact treatment options, we explored the relation between biomarker results and NSCLC treatment costs. Methods: Using the Flatiron Health database, we conducted a retrospective cohort study to investigate the association between biomarker test results and medication costs in patients with newly diagnosed advanced NSCLC between 2011 and 2020. To be included, patients had to receive at least one biomarker testing. Patients with two or more actionable gene alterations, without structured/treatment data, or who participated in clinical trials were excluded. Patients with negative actionable gene alterations and no definitive PD-L1 results served as the reference group. We linked medication records to Medicare Spending by Drug Dashboard to calculate the first-year cost. We applied a coarsened exact matching approach to estimate the cost difference compared to the matched reference group. Results: A total of 32,008 patients with advanced NSCLC were identified. The mean first-year medication costs in the overall cohort increased from $29,283 in 2011 to $46,062 in 2020. The unadjusted mean first-year costs varied substantially, from $27,703 for patients with ALK+ NSCLC to $51,047 for patients with RET+ NSCLC ($34,520 for the reference group; details in Table). After coarsened exact matching, the mean medication costs for patients with MET+, RET+, BRAF+, PD-L1≥1%, or PD-L1<1% advanced NSCLC were significantly higher than that for the reference group, whereas patients with ALK+ or EGFR+ tumor had significantly lower mean medication costs than the reference group. There was no significant difference in costs between patients with NTRK+ or ROS1+ tumor and the reference group. Conclusions: Our economic evaluation found that medication costs for advanced NSCLC increased substantially over time and differed by biomarker status, highlighting the importance of using more accurate cost estimates in cost-effectiveness analysis of novel therapies to guide value-based practices. [Table: see text]
Implementation of an academic-community partnership model for equitable access to precision oncology decision support in rural community cancer centers.
Authors: Kumar Anivarya , Owen Jennifer R , Sloat Nicholette , Maynard Elizabeth , Hill Vanessa , Hubbard Christopher , McKinney Matthew , Sutton Linda , McCall Shannon J. , Datto Michael , Ramaker Ryne , Green Michelle , Strickler John H. , Caughey Bennett Adam
Published: October 2023

141

Background: Comprehensive genomic profiling (CGP) is an essential tool for selecting cancer therapies and matching patients to clinical trials, however patients in rural community cancer centers are less likely to receive CGP. We developed an academic-community partnership model to expand Duke’s Molecular Tumor Board (MTB) clinical decision-making and trial-matching services to Duke Cancer Network (DCN), a series of affiliated community cancer centers across rural North Carolina. Methods: The Duke Precision Cancer Medicine Initiative created a Molecular Registry of Tumors database to aggregate CGP results from multiple vendors and enable review by a multidisciplinary MTB. Patients treated at DCN sites had their CGP results and relevant clinical data reviewed by the Duke MTB. After review, clinical recommendations were communicated in a standardized note and returned to DCN providers within one week. One year into implementation, DCN providers were anonymously surveyed to identify persistent barriers to utilization of CGP. Results: Between Jan 2022 and June 2023, 96 patients were consented, enrolled, and reviewed by Duke MTB. 29.2% were Black, 19.8% were Native American, and 5 .2% were of Hispanic ethnicity. 57.3% patients were found to have an actionable genomic biomarker. Of these, 14 of 22 (63.6%) received matched FDA-approved therapies and 0 of 17 (0%) with molecular criteria for a clinical trial at Duke successfully enrolled at time of submission. 85% DCN providers reported comfort ordering CGP and 45% reported comfort interpreting the results. Most frequently reported major barriers to clinical trial participation included distance (70%), lack of transportation (55%), and lack of local trials (50%). Conclusions: Our implementation of a novel academic-community partnership serves as a sustainable and reproducible model to expand access to MTB services. Further research and interventions are necessary to mitigate persistent urban versus rural barriers to utilizing CGP, especially those in clinical trial enrollment. By providing MTB support to historically underserved communities and a framework to identify salient barriers in the process, our model can be adopted by academic cancer centers nationally, contributing to improved and equitable outcomes in oncology.[Table: see text]
Access to radiotherapy in Hispanic and Latinx populations in the United States: An update.
Authors: Verdini Nicholas Peter , Santos Patricia Mae Garcia , Vicioso Yorleny M. , Rivera Amanda , Perez Carmen Ana , McClelland Shearwood
Published: October 2023

142

Background: Radiation therapy (RT) is a mainstay of oncology care and has been shown to optimize outcomes for patients in many settings. Disparities in access to RT therefore represent substandard care. The Hispanic/Latinx population has consistently faced disparities in oncology access and outcomes, with cancer being the leading cause of death in the Hispanic American population. In this study, we aim to evaluate recent research in RT disparities among the Hispanic/Latinx population in the United States since the seminal analysis from 2017 (PMID: 29904731). Methods: A PubMed literature search was conducted for articles published from January 2017 through March 2023. Four term combinations were utilized, including: (1) “Hispanic” and “Radiotherapy” and “Disparities”, (2) “Latino” and “Radiotherapy” and “Hispanic”, (3) “Hispanic” and “Radiation” and “Disparities”, and (4) “Latino” and “Radiation” and “Disparities.” All articles returned from each search were documented and duplicates were removed. Following the initial search, research studies qualifying for inclusion included studies taking place in the United States, examination of radiation oncology care, and examination of health disparities in the Hispanic/Latinx population. Articles meeting criteria were then organized by disparity type that they address. Results: Our initial PubMed search returned 245 articles. Of these articles, 60 met inclusion criteria and spanned 5 disparity-types: (1) Time to Treatment Initiation & Completion, (2) Receipt of Treatment and Guideline-Concordant Care, (3) Geography, (4) RT Clinical Trial Access and (5) Insurance and Treatment Center Type. The most common disparity evaluated (n=23 studies) was receipt of treatment and guideline-concordant care, showing that the Hispanic/Latinx population was found to be less likely to receive any treatment. Another commonly identified disparity (n=10 studies) was the time to treatment initiation and completion, which highlighted that compared to the Non-Hispanic White population, the Hispanic/Latinx population had greater times to initiating RT and decreased likelihood of timely completion. Additionally, the Hispanic/Latinx population faced disparities in RT access due to geography (n=4 studies), RT clinical trial access (n=3 studies), insurance and treatment center access (n=5 studies). Conclusions: Disparities in radiotherapy access and quality care remain prominent for the Hispanic/Latinx population, despite increasing interest in health care disparities research. This population faces disparities in access via a multitude of barriers. Continued health care disparities research with tangible intervention is needed in radiation oncology in order to properly understand and address this problem.
A population-based study of health care system factors associated with receipt of treatment and treatment intent in stage III non-small cell lung cancer.
Authors: Thibodeau Stephane , Nguyen Paul , Robinson Andrew George , Ynoe de Moraes Fabio , Pantarotto Jason R. , Hanna Timothy P.
Published: October 2023

146

Background: Stage III non-small cell lung cancer (NSCLC) is a disease with a spectrum of anatomic extent, patient health status, and treatment approaches. When health care quality is optimal, receipt of treatment and its intent should be independent of health system factors. We investigated whether modifiable health care system-level factors are associated with receipt of treatment and treatment intent in stage III NSCLC. Methods: This was a population-based, retrospective cohort study using health administrative data covering nearly the whole population of Ontario, Canada (15 million) from 2010-2018 for people with AJCC 7 or 8 stage III NSCLC aged ≥20 years. System factors were: treatment era, diagnostic interval, health region of residence, travel distance, and volume of advanced radiotherapy and systemic therapy. The health region is responsible for administering regional cancer care. The relative risk (RR) of (1) any treatment versus no treatment, and (2) palliative-intent versus curative-intent treatment was determined, using multivariable Poisson regression models. We adjusted for patient, disease, and treatment factors, including age, sex, rurality, income quintile, substage, comorbidity, histology, and use of PET imaging. Results: 7,093 people with stage III NSCLC diagnosed between 2010 and 2018 were identified. There were differences between groups in patient, disease, and treatment factors. For example, factors associated with no treatment include advanced age (e.g. adjusted RR [95% confidence interval]: 80+ vs. 20-64, 0.83 [0.80-0.87]), greater Elixhauser comorbidity score (e.g. 3+ vs. 0, 0.88 [0.84-0.92]), dementia (RR: 0.78 [0.70-0.87]), palliative care consultation (RR: 0.92 [0.89-0.94]) and geriatrics consultation (RR: 0.82 [0.71-0.95]) (all p<0.05). On multivariable stepwise analysis adjusting for these factors, no system factors were associated with receipt of treatment versus no treatment. For those treated, patient, disease, and treatment factors associated with palliative intent were similar. Over time, there was increasing utilization of immunotherapy and advanced radiotherapy (e.g., VMAT, IMRT) (treatment eras: 2010-2012 vs. 2013-2015 vs. 2016-2018). The major system factor associated with palliative intent treatment amongst those treated was health region of residence (RR: ranges from 0.88 to 1.67, p<0.001), which remained after stratifying analysis by treatment era. Conclusions: Even with increasing adoption of advanced radiotherapy and systemic therapy over time, health region of residence emerged as the major health system-level factor associated with choice of treatment intent for stage III NSCLC after adjusting for patient, disease, and treatment factors. Our study suggests possible opportunities to improve care outcomes by addressing unexplained regional variation in care.
Treatment (tx) patterns and real-world outcomes among patients (pt) with mantle cell lymphoma (MCL) in the Flatiron database.
Authors: Shah Gunjan L. , Subbiah Krishnaveni , Garrison Sean , Gu Tao , Patwardhan Pallavi
Published: October 2023

152

Background: Despite the increasing number of tx options for MCL, data on novel agents and associated OS are scarce. We assessed the tx patterns and estimated OS by line of therapy (LOT) among pts with MCL in the United States (US). Methods: This retrospective observational study using the Flatiron Health database included pts aged ≥ 18 y at initial MCL diagnosis who received first-line (1L) systemic tx for MCL during the index period (01/01/2011–03/31/2022) on the date of 1L tx initiation. Pts who had < 1 mo of data after the index date, received clinical study drug during the study period, or had other primary cancer diagnoses or active primary malignancies were excluded. Time to next tx (TTNT) was calculated from LOT start date to next LOT start date. OS was estimated using Kaplan-Meier methodology. Results: Of 4846 pts diagnosed with MCL, 2072 met all eligibility criteria and were included in the final cohort. The median age was 69 y; pts were mostly male (71%), from the Southern US (43%), had commercial health plan insurance (47%), and had stage IV disease at diagnosis (64%). The median length of follow-up from index was 27.4 mo. The most common 1L tx was bendamustine + rituximab (29%) and ibrutinib was the most common second-line (2L) and third-line or later (3L+) tx (25.5% and 10.5%, respectively); only 17% received a stem cell transplant. Median TTNT and OS were similar across subgroups (Table). Median time to start of LOT, TTNT, and OS for subgroups of pts who (1) received ≥ 2 LOTs, including an alkylating agent, Bruton tyrosine kinase inhibitor, and CD20-targeting agent (TRANSCEND NHL 001, MCL cohort eligibility criteria; n = 508); (2) received second-line or later (2L+) tx (n = 859); and (3) received 3L+ tx (n = 363) are shown in the Table. Conclusions: Bendamustine + rituximab and ibrutinib were the most common tx in 1L and 2L/3L+, respectively, among pts receiving approved tx. For all pts/subgroups,median TTNT was longest for the 1L LOT; median OS was longest from 1L start date. Diminishing TTNT and OS in subsequent LOTs after 1L tx provide benchmarks for future tx.[Table: see text]
Discrimination, medical mistrust, and delaying cancer screenings and other medical care.
Authors: Fiala Mark Aaron
Published: October 2023

159

Background: Mistrust in the health care system can delay one from seeking needed care and lead to worse health outcomes. For racial/ethnic minorities, medical mistrust may be rooted in past experience of discrimination during clinical encounters. However, few studies have analyzed the relationships between discrimination, medical mistrust, and delaying care, such as cancer screenings. Methods: The study utilized the 2022 Health Information National Trends Survey (HINTS) data, a nationally representative study about knowledge of and attitudes toward cancer- and health-related information. Medical mistrust was assessed by one question “How much do you trust the health care system.” Those reporting “not at all” or “a little” opposed to “somewhat” and “very” were considered to have medical mistrust. Results: Overall, 15% were considered to have medical mistrust. 14% of participants who identified as a racial/ethnic minority reported feeling discriminated against when getting medical care. Participants reporting prior discrimination were 286% (p <0.001) more likely to report medical mistrust after controlling for age, education, income, and race and ethnicity. Interestingly, after controlling for prior discrimination, African American or Black participants were 33% (p = 0.001) less likely to report medical mistrust than their White peers. Overall, 33% of participants reported delaying needed medical care in the past year and 22% reported not being interested in having a cancer screening test in the next year. Participants reporting prior discrimination were 170% (p < 0.001) more likely to report delaying care and those reporting medical mistrust were 83% (p < 0.001) more likely after controlling for age, education, income, race and ethnicity, and insurance coverage. Participants reporting medical mistrust were 37% (p < 0.001) less likely to report being interested in having a cancer screening test after controlling for covariates. There was no independent association between prior discrimination and interest in cancer screenings (p = 0.286). Conclusions: Perceived discrimination during clinical encounters is a mechanism for medical mistrust and medical mistrust is associated with delaying needed care including cancer screenings. Decreasing discrimination may improve trust and reduce disparities in health outcomes.
Using a disparities dashboard to identify racial/ethnic differences in breast cancer treatment: Implications for improving cancer care delivery.
Authors: Edmonds Megan C. , Agarawl Parul , Balija Tara , Bickell Nina A.
Published: October 2023

161

Background: Delays in the initiation of breast cancer treatment (e.g., surgery, chemotherapy, adjuvant endocrine therapy) contributes to breast cancer survival disparities. Yet, the use of a cancer dashboard to assess and inform real time assessments of the timing of surgery and systemic treatment by race/ethnicity is unclear. The purpose of this study is to investigate whether a cancer disparities dashboard can be used to assess racial/ethnic differences in the initiation of first line of treatment and timeliness of breast cancer surgery. Methods: A disparities dashboard was built using data from the tumor registry and the electronic medical record’s Data Warehouse. Key fields assessing patient race/ethnicity, cancer stage, receptor status, surgery type, treatments received and dates of surgery. This retrospective analysis included women diagnosed with a new primary breast cancer who underwent definitive surgery at Mount Sinai Hospital (2010-2020). We defined delays as >8 weeks to treatment initiation, and delay to breast surgery as > 6 weeks from diagnosis. Chi-square and t tests were used to assess independent variables (e.g., stage, age) by race/ethnicity. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and delays to initiation of first treatment and surgical delays. Results: Of 8,403 women identified (46.5% non-Hispanic White, 17.7% Black, 16.9% Hispanic), 64.5% had stage I cancer, 80.8% had estrogen receptor cancer. 18.5% of the sample had delays to initial treatment and 42.6% experienced delays to surgery. After adjusting for stage, age and receptor status Black patients compared to non-Hispanic White patients had the greatest likelihood of delayed initial treatment (OR: 3.03; 95% CI:2.6-3.5) or surgery delays (OR:2.45; 95% CI:2.1-2.8). With regards to clinical/sociodemographic factors younger patients (22-39 vs. 40-64; p<0.001), mastectomy surgery type (; p=0.031), higher stage (stage 3 vs.1; p<0.0001), HER2 and TNBC receptor status (vs. ER; p<0.0001),) were more likely to experience surgery delays. Conclusions: Breast cancer treatment delays were more common among minoritized patients compared to White counterparts. A Disparities Dashboard can be used to assess differences in care. These data can be used to inform quality initiatives to improve cancer care delivery for at-risk patient populations who experience worse cancer outcomes.
Sociodemographic differences in treatment and survival for patients who receive genomic tumor testing in a rural state.
Authors: DiBiase Jessica , Scharnetzki Elizabeth , Rueter Jens , Jacobs Elizabeth , Anderson Eric
Published: October 2023

170

Background: New cancer technologies like genomic tumor testing (GTT) make targeted treatments and improved outcomes possible. However, access to technologies like GTT is often inequitably skewed such that it is most available to urban and socially advantaged individuals, which may contribute to cancer disparities in disadvantaged groups. This study aims to assess the impact of differential resource allocation by examining whether patient rurality, education, or income are associated with whether patients receive genome matched treatment (GMT) and their survival. Methods: Patients with cancer ( n=1,258) enrolled in the Maine Cancer Genomics Initiative, which provided free GTT across a rural state Demographic and clinical data was collected from surveys and electronic medical records. We used multivariable logistic regression models to examine whether receipt of GMT differs by patient rurality, education, and income. Kaplan-Meier survival (KM) curves and multivariable Cox proportional hazards regression were conducted to explore the relationship between 12-month mortality and rurality, education, and income. We fit both unadjusted and adjusted (age, gender, physical quality of life, cancer stage and type) models. Results: After completing GTT, ~16% of patients received at least one GMT. Rurality, education, or income did not predict receipt of GMT. 41.4% of the lower educational level group versus 32.2% of the higher education group died within 365 days of enrollment (unadjusted HR: 1.37; 95% CI: 1.12 to 1.68; p=0.002). This difference was driven by patients who did not receive GMT, where those in the lower education group had increased mortality (unadjusted HR: 1.43, 95% CI: 1.15 to 1.78, p=0.001). For patients who received GMT, there was no difference in mortality between the education groups (unadjusted HR: 1.03, 95% CI: 0.58 to 1.83, p=0.9). No significant differences in mortality were observed for rurality or income. Conclusions: Lower educational attainment was associated with worse survival for patients who did not receive GMT. Education and specialized health care are differentially available to those in urban and rural areas and can cause health disparities. Sustaining initiatives that provide access to novel technologies is critical to address cancer disparities. To account for the intersection of social and psychological factors on cancer disparities, future analyses will include patients’ perceptions of GTT.
Addressing cancer health disparities with a quality dashboard.
Authors: Sato-DiLorenzo Aya , Zhang Kevin Juan , Celmen Melis , Zerillo Jessica Ann
Published: October 2023

171

Background: Equity is lacking in cancer care. In 2021, the cancer center at our academic medical center established a quality dashboard with relevant performance measures. We aimed to evaluate our care in various domains of healthcare quality; however, no measures of equity were displayed. In 2023, we stratified our performance measures according to various population groups and evaluated group differences. In the next phase of this quality improvement cycle, we added the stratified results to the quality dashboard to display these group differences and prioritize equity. Methods: We identified performance measures that could be stratified by population groups, such as race, ethnicity, insurance type, and primary spoken language. Three measures, mortality index (MI), length of stay (LOS) index, and 30-day readmission rate, were calculated using a third-party program for the fiscal year 2022. Additionally, we stratified 2021 and 2022 data on patient satisfaction, assessed by the proportion of patients selecting the top answer to the likelihood of recommending the practice, by race and language. Each performance measure was color-coded in a quality dashboard according to the institution-set benchmarks (goals) and thresholds (satisfactory performance). Values better than or equal to the benchmark were displayed in green, between the benchmark and threshold in yellow, and worse than the threshold in red. Values worse than the benchmark were considered opportunities for improvement. Results: Population group differences are now captured on our quality dashboard. For the stratified MI results, white and Asian patient populations met the threshold, while the black patient population did not. Latinx patients did not meet the MI threshold, while the non-Latinx patient population did. Patients with Medicaid did not meet the MI, LOS, or readmission thresholds. Regarding patient satisfaction, the white patient population and those whose primary language was English met the benchmark, while the non-white patient population and the non-English speaking group did not. Conclusions: The quality dashboard, with the addition of measures stratified by sociodemographic factors, highlights signs of cancer health disparities at our institution. Leadership can use this tool to target resources to specific areas where disparities exist. The next steps include understanding contributing factors and setting appropriate benchmarks for future quality improvement work. Finally, we must understand the needs of other population groups facing cancer health disparities but not represented in the data, including the sexual and gender minority population.
Measuring substance use disorder (SUD) in commercial and Medicaid insured patients with cancer in Washington state.
Authors: Li Li , Fedorenko Catherine R. , Kreizenbeck Karma L. , Shankaran Veena , Ramsey Scott David
Published: October 2023

177

Background: Studies have shown that SUDs not only impact cancer risk, treatment, and survivorship but also increase ED and hospital use. We sought to characterize SUD within Medicaid enrollees diagnosed with cancer in Washington state, hypothesizing thatMedicaid enrollees were more likely to be diagnosed with SUDs than commercial enrollees, and that patients with an SUD experienced higher rates of emergency department (ED) visits or inpatient (IP) stays during initial cancer treatment. Methods: We linked Washington State cancer registry records with claims data from two large commercial insurers and Medicaid. Eligibility criteria included patients under 65 diagnosed with a solid tumor between 2013-2021 who started systemic therapy within 6 months of diagnosis. SUD diagnoses were identified using codes from CMS’s hierarchical condition category for SUD in the 6 months following diagnosis. Chi-square tests were used to compare demographic characteristics of those with and without a SUD diagnosis. Multivariate logistic regressions were used to evaluate the association between SUD and likelihood of at least one ED visit or IP stay, after controlling for payer, sex, race, ethnicity, age, marital status, stage, cancer group, area deprivation index, and diagnosis year. Results: Among the 10,709 patients (6,680 Commercial, 3,718 Medicaid, 311 Multiple) who received systemic therapy, 7.2% had a SUD diagnosis. SUD patients were less likely to be Asian and more likely to be male, living without a partner, diagnosed at a later cancer stage, and living in more deprived areas. Medicaid patients had significantly higher rates of SUD than commercial-insured patients (14.3% vs 3.3%). Overall, 46.6% of cancer patients had an ED visit or IP stay. Patients with SUD had greater use of ED or IP visits than patients without SUD (70.1% and 44.8%, respectively). In the first 6 months of systemic therapy patients with SUD were significantly more likely to visit the ED or be admitted to IP (OR 2.12, 95% CI 1.79 - 2.50) than cancer patients without SUD. Conclusions: More than 1 in 7 Medicaid cancer patients in WA state has an identified SUD. SUD is associated with significant excess risk for ED/IP admissions during treatment. Accurate identification of SUD in patients is necessary prior to strategies aimed at mitigation of unplanned ED visits and hospitalizations during cancer care. Further research is needed on interventions that effectively reduce the risk during treatment.[Table: see text]
Racial and ethnic disparities in post–liver transplant survival among patients with hepatocellular carcinoma in the United States.
Authors: Grewal Udhayvir Singh , Chandar Apoorva K , Al Armashi Abdul Rahman , Alkrekshi Akram , Gaddam Shiva Jashwanth , Garikipati Subhash C
Published: October 2023

178

Background: Liver transplantation (LT) is a potentially curative treatment option for some patients with early-stage hepatocellular carcinoma (HCC). Racial and ethnic disparities in diagnosis and overall outcomes for HCC are well known. However, real-world data on disparities in post-LT survival among patients with HCC are lacking. Methods: We used TriNetX, a national database comprising approximately 74 million patients across 54 health care organizations in the United States, to retrospectively identify patients who had an ICD-10 diagnosis of HCC (ICD-10 C22.0, C22.8) and underwent LT (CPT codes 47135, 47140, 47140, 47141, 47142) from 2012-2022. We retrieved data on baseline characteristics and compared them across racial and ethnic subgroups; Caucasians, African Americans (AA) and other minorities (Hispanics/Asians). We studied post-LT outcomes using survival at 1 year, 3 years and 5 years. Results: A total of 2,901 patients with HCC underwent LT over the study period, out of which, majority were Caucasians (2403/2901, 84.8%), followed by AA (267/2901, 9.2%) Hispanic/Asian (231/2901, 7.9%). At baseline, AA patients had higher prevalence of viral hepatitis B (10.1% vs 5.7%, p=0.004), hepatitis C (72.7% vs 47.1%, p<0.001) and lower prevalence of alcoholic liver disease (36.3% vs 45.5%, p=0.004) as compared to Caucasian patients. Hispanic/Asian patients had lower prevalence of alcoholic liver disease (37.7% vs 45.5%, p=0.02), nicotine dependence (13.4% vs 21.3%, p=0.004) and higher prevalence of viral hepatitis B (24.7% vs 5.7%, p<0.001) as compared to Caucasian patients. We found no differences post-LT survival at 1 year (92.9% vs 91.6%, p=0.60), 3 years (77.6% vs 80.5%, p=0.48) and 5 years (71.0% vs 72.3%, p=0.46) between AA and Caucasian patients. While post-LT survival at 1 year was lower among Hispanic/Asian patients (88.5% vs 94.3%, p=0.04), we found no difference in post-LT survival at 3 years (82.5% vs 85.4%, p=0.27) and 5 years (75.8% vs 75.7%, p=0.55) when compared to Caucasians. Conclusions: We present real-world data demonstrating the under-representation of racial minorities in the cohort of patients with HCC receiving LT in the US. We found no differences in post-LT survival (except higher early mortality among Hispanic/Asian patients), across racial/ethnic groups. These results show that stringent implementation of policies aimed at ensuring equitable access to LT may contribute to bridging disparities in overall outcomes in HCC.
Overall survival differences in small intestine adenocarcinoma patients treated at academic vs non-academic facilities: A national perspective.
Authors: Bine Christopher Reese , Nielsen Eric G. , Czaplicki Alec , Lee Aron , Silberstein Peter T.
Published: October 2023

180

Background: Adenocarcinoma is a malignancy of glands lining organs in the human body. It is commonly found in the breast, lung, pancreas and throughout the digestive track. Prior research shows that common treatments include a combination of surgery, chemotherapy, and radiation. It also demonstrates that socioeconomic factors (such as income, insurance status, facility type) impact a patients’ survival. Thus, using the National Cancer Database (NCDB), this study aimed to evaluate the differential survival of patients treated at Academic or Non-Academic facilities for small intestine adenocarcinoma. Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with small intestine adenocarcinoma from 2004 to 2019 using the histology code 8140 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, ANOVA, Chi-Square, and Cox Proportional Hazards tests were performed. Data was analyzed using SPSS version 27 and statistical significance was set at α = 0.05. Results: Of the 20,791 patients queried, 38% were treated at an academic/research facility (AF). Patients treated at an AF had an improved median survival compared to a non-academic facility (NA) (58 months versus 47 months; p < 0.001). After controlling for income level, age, sex, race, adjuvant therapy and surgery, patients treated at an AF was associated with an independent decrease in hazard (HR=0.85, p<0.001). AF patients disproportionately presented with a lower stage, had fewer lymph node metastases, had lower comorbidity scores, were more likely to receive chemotherapy, were more likely to receive surgery and come from a higher income bracket (p<0.001). They were also more likely to have no residual tumor after surgery, have private insurance and receive palliative care (p<0.001). There were no significant differences in grade/differentiation at presentation, 30-day surgical readmission rates, or phases of radiation treatment between patients treated at AF and NA. Conclusions: Patients treated at AF survived longer than patients treated at NA. While patients treated at AF were more likely to receive chemotherapy and surgery, controlling for those factors and others still resulted in a decreased hazard. It is a concerning finding that confirms prior research and underscores the need for further research to alleviate health care disparities.
Political environment and overall survival after cancer diagnosis in the United States (US).
Authors: Hussaini S. M. Qasim , Blackford Amanda L.
Published: October 2023

184

Background: Political environment in the US is closely tied to state and national-level budgetary spending as well as laws and regulations that influence health. It is unclear if survival gains in cancer care differ by county political voting status. We investigated survival trends based on county level presidential voting patterns. Methods: A 5% sample of individuals diagnosed with cancer from 2001 to 2017 in the SEER-Medicare Program was linked to county level data on US presidential elections over the same period. Using the total number of votes in each party, county political environment was classified as either Democratic or Republican for the four years that followed a presidential election. Cox proportional hazards models estimated changes in survival over time, and differences by political party were assessed with interaction analysis. To account for the association between follow-up time and year of diagnosis, overall survival was censored at 3 years for individuals diagnosed in 2015 or earlier. Results: Of 100,755 individuals in our cohort from 2001-2017, 66439 (65.9%) resided in Democratic and 34316 (34.1%) in Republican counties with similar median age at diagnosis and distribution of regional/distant disease. Democratic counties had more urban-located residents (93% vs 70%). 1-year survival in both Democratic and Republican counties increased from 2001 (77% for both) to 2017 (81% Democratic, 80% Republican). 3-year survival increased in Democratic (62% in 2001 to 66% in 2015) but not in Republican counties (65% in 2001 and 2015). Compared to the 2000 election cycle, patients residing in Democratic counties had an 11% decreased risk of death (Hazard Ratio (HR) = 0.89) after the 2008 election cycle while Republican counties did not see these improvements during the same time period (Table; interaction P = 0.02). Among White patients, survival improved (HR = 0.89 for 2016 election cycle compared to 2000) in Democratic counties, but not in Republican counties (HR = 0.99 for same years, P = 0.02). However, among Black patients, survival improved in both Democratic (HR = 0.89) and Republican counties (HR = 0.89) for the same years (P = 0.87). Conclusions: Survival after cancer diagnosis in Republican voting counties has concerningly lagged behind that of Democratic voting counties following the 2008 elections coinciding with the passage of the Affordable Care Act. Our study sheds light on the sharp contrast between political policy and legislation, and rural-urban divide driving outcomes in these areas.[Table: see text]
Role of social determinants of health on cancer knowledge among parents of children with newly diagnosed cancer.
Authors: Aristizabal Paula , Nataraj Shilpa , Thornburg Courtney D
Published: October 2023

189

Background: It is critical for parents of children with cancer to be knowledgeable regarding their child’s diagnosis to effectively navigate their child’s cancer care. Research investigating the role of Social Determinants of Health (SDoH) on cancer knowledge is scarce. Methods: We prospectively assessed levels of disease knowledge among parents of children with newly diagnosed cancer (past 3 months) and associations with SDoH. Our outcome measure was level of parental cancer knowledge on cancer type, stage/risk stratification, if enrolled in a therapeutic clinical trial or receiving standard of care treatment, and name of protocol if applicable (score 0-100% correct answers). Socio-demographics included parental age, sex, race/ethnicity, English proficiency, marital status, education attainment, insurance type, and employment status. Health literacy (HL) was measured using the Newest Vital Sign (NVS). Results: 182 English or Spanish-speaking parents completed surveys. 67% of participants were female (n=112) and 47% Hispanic (n=96). On average, parents answered 40% of questions correctly on the cancer knowledge survey (SD+/-19). In univariate analysis, lower cancer knowledge was associated with limited HL (p=0.003), unmarried status (p=0.015), lower education attainment [high-school or less] (p=0.048), and public insurance (p=0.006). In adjusted multivariate analysis, limited HL remained significantly associated with lower knowledge (p=0.036). Moreover, parents with limited HL were 77% less likely to know if their child was receiving treatment enrolled in a clinical trial or standard of care treatment (OR=0.13, p<0.001, 95%CI=0.065-0.403). Conclusions: Parents of children with newly diagnosed cancer scored overall low on the baseline knowledge test. Limited HL was significantly associated with lower cancer baseline knowledge after adjusting for SDoH. Our findings underscore the importance of identifying parents with limited HL to effectively increase their cancer knowledge by providing targeted education and support. Future research should assess how parental cancer knowledge affects clinical outcomes and include interventions, particularly tailored to individuals with limited HL.
Trends of cancer drug cost increases and impact of generic and biosimilar drug launches.
Authors: Indurlal Puneeth , Wilfong Lalan S. , Garey Jody S. , Busby Leslie T. , Feinberg Erica
Published: October 2023

19

Background: Drug cost increases are key contributors to cancer care spending in the US. These increases often outpace consumer price index (CPI) inflation, and impact patient access, outcomes, and cost sharing. We analyzed pricing trends and impacts of lower cost generic or biosimilar alternative (LCA) drug launches for key cancer drugs. Methods: Using Medicare Part B drug (Part B) administration & Part D drug (Part D) dispense data for 15 practices in The US Oncology Network, we obtained the unit cost to Medicare for top 30 drugs by total spend over a 6-year period (July 2016 – June 2022). Evaluating cost change patterns in Part B and Part D, we compared trends before and after LCA launches. Results: Over a 6-year period, mean drug costs increased by 12.3% (range: -41.8% to 39%) for Part B and 46.2% (range: -67.5% to 278.2%) for Part D. The largest increases were for Protein-bound Paclitaxel (Part B) (39%) and Ibrutinib (Part D) (278.2%). Many increases exceeded CPI inflation (23.2%) over the same period. Part B/Part D drugs with LCA launches had decreases of -11%/-39%. Non-LCA Part B/Part D drugs increased 21%/ 67%. Prior to LCA launches, Part B/Part D LCA drugs had a mean increase of 22%. After LCA launches, a mean decrease of 36% was observed. Conclusions: Part D drugs have 3.75 times higher increases versus Part B and often outpace CPI inflation. LCAs for branded drugs bend cost increase trends. The impacts of evergreening drug patents and potential shifting of drug coverage from Part B to Part D on costs are ripe for evaluation. The inflation-based rebate and Part D coverage changes in the Inflation Reduction Act (IRA) need to be monitored for its impact on cancer drug cost trends, access, affordability, and financial toxicity for patients. [Table: see text]
Self-reported health-related social needs screening for new adult patients in an ambulatory oncology setting.
Authors: Manni Michael , Barwick Paige , Zhang Sunyi , Black Brittany , Moles Hana , Lakhani Hakim , Siegel Jocelyn H. , Hassett Michael J. , McCleary Nadine Jackson
Published: October 2023

194

Background: Health-related social needs (HRSN) are strongly associated with patient health outcomes, making screening for HRSN a critical component to providing patient-centered oncology care. In April 2023, the Dana-Farber Cancer Institute (DFCI) Patient Reported Data (PRD) Program led the deployment of an EHR-integrated HRSN screening tool. Embedded within our New Patient Intake Questionnaire, the screening supports early identification of and response to needs, informs care planning and delivery, and aims to improves outcomes. Methods: PRD, in collaboration with DFCI’s Patient & Family Advisory Council and others, elected to use an HRSN screening tool deployed across the Mass General Brigham healthcare system (with which DFCI shares an EHR). HRSNs assessed include transportation, housing security, food security, medication costs, utility costs, family and childcare, education, and employment. New adult oncology patients (and/or proxy) were offered the HRSN questionnaire in multiple languages on any internet-enabled device via the patient portal or on a tablet in clinic. Responses were immediately available in the EHR for care team review with needs highlighted to support clinical decision making. Aggregate data is available within the DFCI electronic data warehouse and disseminated for internal use via a Tableau dashboard. Results: Between April 23 and May 31, 2023, 1,842 patients completed the HRSN screening questionnaire. Of responders, 246 (13.4%) were non-white, 725 (39.4%) were male, 72 (4.0%) had a non-English preferred language, and the mean age was 57 years at time of response. 12.8% (251) reported at least one HRSN. Reported HRSNs are described in Table 1. Among those reporting at least one need, the most frequently reported HRSNs are food insecurity (38.7%), utility costs (33.5%), and employment (20.7%). Conclusions: Even when considering much of the population seen at our comprehensive cancer center are relatively well-resourced, we find a meaningful proportion (12.8%) of patients reported HRSNs, demonstrating the importance of screening patients to ensure patient-centered care. Future work will determine additional points for rescreening of HRSNs and focus on improving patient’s access and uptake of screening. We will continue socializing and analyzing HRSN data to improve clinical practice and support the development of interventions to connect patients with available resources.[Table: see text]
“I felt super lucky:” Luck and administrative burden in cancer-related financial hardship.
Authors: Henrikson Nora B. , Yi Jean C , Panattoni Laura Elizabeth , Shankaran Veena , Jones Salene M.W.
Published: October 2023

198

Background: Financial hardship after cancer diagnosis is common and leads to earlier mortality and worse quality of life. This qualitative study sought to identify causal and protective factors for financial hardship as part of a larger study to refine a theoretical model and measure of financial hardship. Methods: We recruited female breast cancer survivors at a large comprehensive cancer center. Participants completed a semi-structured interview focused on their reflections of cancer diagnosis and active treatment. Interviews assessed multiple dimensions of financial hardship (coping, impacts, worry/anxiety, depression) and contributing, protective, and contextual factors. We conducted framework qualitative analysis of interview transcripts. Results: We interviewed eighteen women with breast cancer (100% early or regional stage; 77% White; mean age 57; time since diagnosis 3-24 years). Participants reported varying levels of financial hardship during diagnosis and treatment. Financial coping behaviors ranged from minor rebudgeting, to skipping or delaying healthcare, to major decisions about family structure (e.g. having children; marriage or divorce). Even successful financial coping induced stress (“it was just really painful”) because of administrative and time burden: hypervigilance to bills and finances; waiting in phone queues; negotiating with insurance companies and employers; liaising between employer, insurance company, and care team; and learning about, gathering documents, and applying for benefits (e.g. FMLA; disability). Employment and generous health insurance were protective, but out-of-network care and coverage denials tempered this protection and introduced stress. Worry about employment or insurance loss and the administrative burdens required to financially cope also created stress. Other protective factors were largely described as good luck, such as understanding bosses, flexible work arrangements, multiple household incomes, assistance from family and friends, or avoidance of more severe hardship (“we were fortunate we didn't lose our home"). Easily accessible health insurance was also described as good luck. Conclusions: Administrative and time burden required for financial coping behaviors can induce distress for women with breast cancer, even if successful in mitigating financial hardship. Luck emerged as a prominent protective factor. Luck and its relationship to structural factors that generate inequity may have ethical and policy implications for addressing cancer-related financial hardship and is worthy of further study.
ALCANCE Food for Health Equity: Community-driven development of a food insecurity intervention for patients with cancer.
Authors: Hanna Maria T. , Wood Emily Hayes , Medrano Hector S. , Perez Cynthia , Noyola Andrés , Villicana Gerardo , Lopez Guzman Lesly , Reynaga Jajaira , Trotter Chardria , Koontz Zachary M. , Patel Manali I.
Published: October 2023

208

Background: Food insecurity is prevalent among patients undergoing cancer treatment and has been associated with decreased adherence to cancer therapies, malnutrition risk, and poor quality of life. While food insecurity disproportionately impacts low-income, immigrant and non-English speaking populations, few studies have assessed the needs and preferences for these populations as it relates to interventions that can address this growing problem. In previous work, we identified that 50% of populations in our partner clinic screened positive for food insecurity. This study aimed to assess the needs and preferences of low-income, culturally diverse patients with cancer who screened positive for food insecurity and to co-develop an intervention to address these needs. Methods: Participants were recruited among low-income and immigrant adults ≥18 years of age who screened positive for food insecurity using the 2-item Hunger Vital Sign as part of an ongoing parent randomized controlled trial evaluating a precision medicine intervention. 1:1 semi-structured interviews were conducted in English or Spanish to assess dietary habits, barriers to obtaining healthy food, and preferences regarding intervention assistance options, including on-site food pantry, home delivery of food boxes, food vouchers, and cash transfers. Interviews responses were transcribed and thematically analyzed. Results: Of the 110 patients screened for food insecurity as part of the parent trial, 40 (36.4%) screened positive for food insecurity. Among these patients, 31 identified as Hispanic or Latinx (77.5%), and 26 (65%) indicated Spanish as their primary language. Nineteen (47.5%) reported a household income of <$34,000, 24 (60%) were on Medicaid, and 14 (35%) identified as disabled. A total of 10 participants were randomly selected and consented to participate in interviews. Three main themes emerged from interviews: 1) cancer diagnoses necessitated changes to food behaviors including emphasis on nutrient dense and symptomatically tolerated foods; 2) contributors to food insecurity included higher costs of healthy food options, lack of employment during treatment, limited support, and coexisting expenses including financial toxicity from cancer treatment; 3) priorities for assistance included limiting sense of reliance on charity, autonomy in choosing desired food items that are culturally preferent, and timing assistance with other expenses to maximally relieve financial strain. Conclusions: Food insecurity is a critical issue among patients with cancer with disproportionate impact on low-income and immigrant populations. Various opportunities for intervention are well-received by patients and have the potential to reduce the burden of food insecurity among these populations.