bluuebunny/crossref_metadata_2025_split huggingface dataset:
Use of inflammatory markers to triage cancer patients requiring nutritional assessment and interventions.
Authors: Clarke Stephen John , Tan Cindy 
Published: March 2020

e17541 Background: Nutritional status impacts on the outcomes of cancer treatment ( http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/ HealthProfessional ). Nutrition is a concern of cancer patients. Many centres lack the resources to undertake formal nutritional assessments on cancer patients. Inflammatory markers have been shown to correlate with nutritional status and cancer treatment outcomes. The NLR is the ratio of the neutrophil and lymphocyte counts in a full blood count (FBC). Our aim was to determine if the NLR can be used to identify cancer patients needing nutritional assessment and intervention. Methods: A prospective observational study evaluated sequential new patients attending a cancer centre. All were assessed for nutritional status using the patient generated scored global assessment (PGSGA) tool and categorized as A (well nourished), or B/C (malnourished). A FBC was done in the week prior to treatment. Receiver operation characteristic (ROC) curves were used to determine optimal cut-points for NLR to predict malnutrition. Results: 234 patients were enrolled - 112 had advanced cancer. The median age was 60 years (range 25-83), 108 (46%) were male and 101 (43%) were malnourished at baseline. The mean NLR was higher in malnourished patients (4.1 vs 2.5 – p<0.001), however this was due to differences in advanced cancer patients. The optimal cut point for NLR in all patients to predict malnutrition was 5.0 (4.3 in advanced patients). In advanced patients, an NLR ≥4.3 had a sensitivity and specificity for malnutrition of 42.2% (95% CI 30.1-54.3) and 97.9% (95% CI 88.9-99.9), respectively, producing a positive predictive value of 0.96 (95% CI-0.82-1.00). Thus, NLR while strongly correlated with malnutrition is not sensitive enough alone to be used to identify malnourished cancer patients. However, as >98% of patients with a raised NLR had malnutrition, the NLR could be used to triage patients for nutritional assessment and thereby reduce the workload for clinical dieticians. Conclusions: The NLR is a useful indicator of nutritional status, which when elevated is specific for malnutrition. A low NLR should be reassuring in regard to nutritional status in advanced cancer patients.
Impact of zoledronic acid (ZA) versus pamidronate (P) on overall survival (OS) in multiple myeloma (MM).
Authors: Sanfilippo Kristen Marie , Luo Suhong , Gage Brian , Vij Ravi , Carson Kenneth Robert 
Published: March 2020

e17546 Background: Nitrogen-containing bisphosphonates (BPs) have been shown to improve OS compared to non-nitrogen containing BPs in MM (Morgan et al. Lancet 2010). Treatment guidelines recommend use of ZA or P (both nitrogen-containing) in MM patients with bone disease. No study has compared the effect of these two drugs on OS. We compared the impact of ZA versus P on OS in United States Veterans with MM. Methods: We retrospectively identified patients diagnosed with MM from 10/2002-2/2009 within the Veterans Heath Administration Central Cancer Registry who received ZA (n=482) or P (n=757) by linking registry data to pharmacy records. Cox multivariable analysis was used to estimate the association between choice of BP and OS while controlling for potential confounders: body mass index (BMI), age, race, Charlson comorbidity index, year, treatment, hemoglobin (Hgb), creatinine (Cr), and albumin. Results: The median OS in patients receiving ZA was 34.5 months, compared to 26.4 months in the P group. After adjusting for confounders, ZA reduced the risk of death by 24% compared to P (hazard ratio [HR] 0.76; 95% confidence interval [CI]: 0.66-0.88) at 5 years (Table). A sensitivity analysis that compared ZA only (n=482) versus all patients who received P, regardless if they later received ZA (n=1117) continued to show decreased mortality (HR 0.82; 95% CI: 0.71-0.94) after controlling for the same potential confounders. Conclusions: In this, the largest study to evaluate the association between ZA versus P on OS in MM, we found decreased mortality associated with ZA. Given the similar toxicity profiles, this study supports preferential use of ZA over P and may serve as evidence for re-evaluation of current guidelines for BP use in MM. [Table: see text]
Prospective observational study on fertility preservation in young early breast cancer patients: The PREFER (Pregnancy and Fertility) trial.
Authors: Lambertini Matteo , Anserini Paola , Fontana Valeria , Abate Annalisa , Sozzi Fausta , Merlo Franco , Pronzato Paolo , Bighin Claudia , Levaggi Alessia , D'Alonzo Alessia , Giraudi Sara , Iacono Giuseppina , Miglietta Loredana , Poggio Francesca , Del Mastro Lucia 
Published: March 2020

e17548 Background: Approximately 4.5% of breast cancers are diagnosed in women younger than 40 years. Chemotherapy (CT)-induced loss of fertility is a major concern for young patients. Different strategies are available to attempt to preserve ovarian function. We evaluated feasibility and patient preferences of 3 different strategies: oocyte cryopreservation (OC), ovarian tissue cryopreservation (OTC) and temporary ovarian suppression with the administration of LHRH analogue (LHRHa) during CT. Methods: From March 2010 to January 2013 49 breast cancer patients younger than 45 years (median age: 38 [range 25-45]), referred to our institution. They were offered the possibility to reduce the gonadotoxic effects of anticancer treatments: the oncologist proposed both the administration of LHRHa during CT, and a reproductive counselling performed by the gynecologist, where OC and OTC were discussed. The first analysis was planned after 2 years; preliminary data are presented. Results: The majority of patients (42 [85.7%]) accepted the treatment with LHRHa, started at least 1 week before CT. Thirty-eight patients (77.6%) refused the reproductive counselling; the main reason for refusal was previous pregnancies (19 patients [38.8%]). Out of 11 patients (22.4%) who accepted the reproductive counselling, only 3 (6.1%) accepted to undergo OC and 1 (2.0%) OTC. The reasons for refusal were: not eligible for comorbidities 3 patients [6.1%]), fear of delaying cancer treatment (2 patients [4.1%]), fear of the ovarian stimulation required (1 patients [2.0%]) and low successful rate of the technique (1 patients [2.0%]). The 3 patients undergoing OC received a controlled ovarian stimulation with the use of daily injections of recombinant FSH: median length of stimulation was 9 days (range, 8 to 9 days); peak estradiol levels ranged from 280 to 521 pg/ml. An average of 13.3 ± 5.7 oocytes was retrieved, and 8.3 ± 3.1 oocytes cryopreserved per patient. Conclusions: This preliminary analysis suggests that the majority of patients (85.7%) accept the administration of LHRHa during CT and approximately 8.2% of patients undergoes surgical fertility preservation techniques.
Cost-effectiveness analysis of proton versus photon therapy with respect to risk of growth hormone deficiency.
Authors: Mailhot Raymond , Kim Jane , Hollander Abby , Michalski Jeff M. , Tarbell Nancy , Yock Torunn I. , MacDonald Shannon M. 
Published: March 2020

e17553 Background: Proton therapy has been endorsed as a radiotherapy (RT) modality with the potential to avert many RT associated comorbidities. Currently, few proton centers exist, and no evidence-based data as yet adequately informs allotment of care. Childhood cancer survivors of central nervous system (CNS) malignancies have high prevalences of growth hormone deficiency (GHD) after hypothalamic exposure, notable for its cost of treatment greater than $10,000/year. We propose methodology to help guide proton referral of pediatric patients with CNS tumors through cost-effective analysis comparisons for proton and photon hypothalamic received dose. Methods: A Markov cohort model was designed to assess the expected costs and effectiveness for specific RT doses to the hypothalamus. Patients entered the model receiving proton or photon RT for CNS tumors at four and twelve years of age and were followed for 60 more years of life. Patients could experience two health states: GHD or healthy. Risk of GHD was based on data by Merchant et al. Costs were measured in USD and captured cost of GHD and cost of RT. Cost of proton course relative to photon was estimated at $160K. Effectiveness was measured in quality-adjusted life years (QALYs). The main outcome measure used for comparison was the incremental cost-effectiveness ratio (ICER). We assumed a societal willingness to pay threshold of $50,000/QALY. Results: Data were used to generate tables incorporating the differential cost of proton RT to project ICERs for different combinations of hypothalamic RT dose as displayed in the Table below. Conclusions: Despite the high cost of proton therapy, the cost of GHD alone can yield proton RT a cost-effective (even cost-minimizing) strategy when compared to photon RT. This work provides a guide for identifying a set of patients for which proton therapy is particularly cost-effective. [Table: see text]
The City of Hope (COH) performance excellence program (PEP): A physician incentive program to improve health care performance (HCP) in an academic medical center.
Authors: Alvarnas Joseph C. , Kassab Tricia , Avanessian Priscilla , Pierce Michael , Levine Alexandra M. 
Published: March 2020

e17556 Background: The Affordable Care Act (ACA) introduced a pay for performance model focused on: safety, timeliness, effectiveness, efficiency, patient-centered, equitable care. COH is an NCI sponsored Comprehensive Cancer Center, focused on cancer care. Methods: In 2011, a physician led team with representation from finance, QRRM, nursing and legal identified 13 quality measures (QM) where opportunities for improvement (OFI) existed. Selection criteria included measurability, importance, applicability to ACA, physician impact, return on investment and national importance. The QM include HCAHPS score, Healthcare Associated Infection rate (HAI), quantity of blood products internally produced (BP), coder response rate (RR), use of sepsis bundle orders, time to new patient appointments (NPA), OR 1st case on-time starts, timeliness of adjuvant therapy for breast/colon cancer patients, SCIP composite score and use of VTE prophylaxis orders. HCP for the first 4 QM was assessed based upon institutional performance; 6 QM were assessed upon departmental performance. There were 3 build measures (BM): creating a system to obtain advanced directives (AD) on all new patients, creating a system for effective communication with referring physicians and 4 departmental BM based on best practices. Results: PEP performance was assessed between 5/1/12-12/31/12. 174 physicians in 11 departments were eligible for a $2.05 million incentive pool. QM were evaluated using a tiered bonus structure. Significant improvements were seen in HAI, BP production, SCIP, OR starts and timely adjuvant therapy. There were improvements in the use of VTE orders, but aggregate performance fell below payment threshold. The build measure for AD was completed. Conclusions: (1) PEP is an effective tool for physician engagement in an academic medical center. (2) PEP enhanced alignment between the medical group, hospital, nursing and administration. (3) PEP was effective in improving HCP in less than one year from its inception. [Table: see text]
Time from surgery to first adjuvant chemotherapy: Experiences at two Toronto hospitals.
Authors: Polenz Chanele K. , Manoharan Amanda S. , Sevick Laura , Marchand Christina , Hassan Maha , Burkes Ronald L. , Brezden Christine B. 
Published: March 2020

e17557 Background: Optimal treatment of patients with colorectal cancer (CRC) includes the timely administration of adjuvant chemotherapy (AC). While Cancer Care Ontario (CCO) guidelines advise that CRC patients receive their first AC no later than 8 weeks after surgical resection, new data suggests treatment should begin between 4 and 6 weeks. This retrospective study was performed to determine the treatment times and identify barriers at two Toronto hospitals: St. Michael’s Hospital (SMH) and Mount Sinai Hospital (MSH). Methods: Of all 797 patients diagnosed with CRC between January 1, 2005 and April 30, 2012 at SMH and MSH, 483 patients did not meet eligibility criteria. Thus, our sample population of 314 patients had stage II or III CRC, and received both surgical resection and AC at each respective hospital. Data collected included: time from surgery to first AC, patient demographics, and systemic/clinical barriers. Data was analyzed using statistical methods in Excel, assuming p-values <0.05 as significant. Results: The mean ageof the patients was 60.5 years (range 23 – 91); 55% were male and 72% had stage III disease; 75% (237/314) had colon cancer and 75% of AC was the FOLFOX regimen. The mean time from surgery to first AC was 57.4 days (sd = 16.8) or 8.2 weeks (range 4.1-18.7). Referral from surgeon averaged 20 days (sd=29.3). Time from medical oncology consult to first AC averaged 26.5 days (sd=30.8) including 23 days awaiting port-a-cath insertion. Post-operative medical complications affected 23.6% of patients. The presence of a complication was associated with delay in AC (10.6 days, p<0.001). An association between tumour site (eg. colon vs. locally advanced rectal cancer) and delay (p=0.0002) was also observed. Conclusions: Adherence to CCO guidelines can be optimized in CRC patients at SMH and MSH. The presence of a medical complication and tumour site are both factors associated with delays in AC treatment post-surgery. To improve the timeliness of care and achieve greater consistency between hospitals, rapid-cycle improvement of confounding barriers will be adopted.
Oncologists’ perceptions of cost and cancer care in India: A comparison of private practice (PPOs) and non-private practice oncologists (NPPOs).
Authors: Bhattacharya Manisha , Hamilton Erika Paige , Zafar Yousuf 
Published: March 2020

e17562 Background: Cancer incidence is increasing in India, where most patients lack health insurance. Little is known about how out-of-pocket costs affect cancer treatment decision-making by Indian physicians and patients. Methods: We conducted a cross-sectional survey of PPOs and NPPOs in 6 Indian metropolitan areas. Oncologists were surveyed about cost of care and cost discussions with patients. Descriptive statistics and Fisher’s exact tests were used to describe differences in cost perceptions and discussions. Results: 59 oncologists were surveyed (61% response). 78% (n=46) were men. 59% (n=34) were PPOs, and 41% (n=25) were NPPOs. Oncologists routinely discussed cost with their patients (96%, n=57); PPOs and NPPOs were equally likely to do so (p=1.00). According to oncologists, patients seeing NPPOs or PPOs were equally likely to discuss costs before deciding on treatment (p=0.14). 55% (n=32/58) of oncologists discussed cost with patients before prescribing diagnostic tests, and 79% (n=46/58) discussed cost before making treatment decisions. PPOs were more likely than NPPOs to believe that costs may discourage patients from presenting for an initial cancer evaluation (88% vs. 44%; p=0.0009). However, 71% of NPPOs (vs 44% of PPOs; p=0.06) believed that, once diagnosed, more than half of their patients found costs to be a barrier to receiving standard care. Oncologists reported the most costly components of care for their patients to be: 1) chemotherapy; 2) radiotherapy and diagnostic imaging (tied); 4) surgery; 5) indirect costs from lost wages and inpatient admission (tied). When asked about how to reduce costs, oncologists identified: lowering chemotherapy prices (88%, n=52); judicious use/ lowering cost of diagnostics (36%, n=21); optimizing the referral process (22%, n=13). Insurance/subsidies were identified by 15% (n=8). Conclusions: Cost is routinely discussed by Indian patients and oncologists across care settings. Cost can be a deterrent to initial evaluation and a barrier to receiving standard care. Oncologists more commonly suggested reducing costs of diagnostics and therapeutics, rather than expanding insurance or changing referral practices.
Impact of leucovorin shortage on patient treatment.
Authors: Hanna Mina Samir Erian , Kozuch Peter , Thorn Molly , Roitman Janna , Grossbard Michael L. , Becker Daniel Jacob 
Published: March 2020

e17566 Background: Shortages of intravenous leucovorin were initially reported in late 2008, and availability plummeted nationally and at Continuum Cancer Centers of New York (CCCNY) in late 2011. NCCN guidelines recommend either the use of levoleucovorin or low dose leucovorin during the shortage. The impact of the leucovorin shortage on patient therapy remains unknown. Methods: We reviewed patient charts for all outpatients treated with leucovorin at CCCNY between April and September of 2010, 2011, and 2012. We recorded patient characteristics, and leucovorin use (dose, number of treatments); and calculated descriptive statistics. We classified each dose as either low (20-40 mg/m2) or high (200-500mg/m2) and compared leucovorin use between years with Chi Square and ANOVA tests. We also reviewed pharmacy purchasing data to evaluate the economic effect of the leucovorin shortage. Results: We identified 55 patients treated with 313 doses of leucovorin in 2010, 99 patients treated with 582 doses in 2011 and 118 patients treated with 742 doses in 2012. No patients received levoleucovorin. Patient characteristics, disease and stage were similar between years with colorectal cancer accounting for 78%, 69%, and 70% of patients in 2010, 2011, and 2012 (p=0.87). Low dose leucovorin was used in 30.0% of doses in 2010, 30.4% in 2011, and 99.1% in 2012 (p<0.0001). The mean dose/treatment (SD) was 459 mg (296), 499 mg (328), and 47 mg (89), in 2010, 2011, 2012, respectively (p<0.0001). Among patients treated for colon cancer we found no association between stage (III vs. IV) and use of low dose leucovorin in 2010 or 2011. Quantity of leucovorin purchased at one hospital decreased by 63% from 171.75 g in 2010 and 157.50g in 2011 to 63.00 g in 2012. The price of leucovorin was similar at 0.017 $/mg in 2011 and 0.013 $/mg in 2012. Conclusions: Worsening leucovorin drug shortage was associated with a profound change in leucovorin use at CCCNY between 2011 and 2012. In accordance with NCCN guidelines, physicians used more low dose leucovorin. The price of leucovorin remained constant despite limited supply. Additional patient follow up is warranted to evaluate the outcomes of patients treated during the shortage.
Content validity of signs and symptoms measures with the EORTC core module in women with locally advanced or metastatic breast cancer (MBC): A phase II trial with eribulin mesylate.
Authors: Simons W. Robert 
Published: March 2020

e17576 Background: The EORTC-QLQ30 is the core quality of life (QOL) instrument developed by the European Organization for Research and Treatment in Cancer. We assessed content validity for the signs and symptoms component in an investigational trial. Methods: We use a Phase II clinical trial where 291 women with locally advanced or MBC were required to have received prior treatment with an anthracycline, a taxane, and capecitabine. EORTC-QLQ30 was collected every second cycle, before drug administration and before patients were informed of their tumor assessment. We use the reported adverse events (AE) for those signs and symptoms to test the correlation between reported AEs and responses to the QoL questionnaire. The sum of the incidence by patient is generated as well as average scores for each sign and symptom. An endpoint for respondents positively reporting signs and symptoms without any AE is also evaluated (False-Positive). Statistically significant positive correlations between AEs and signs and symptoms as well as negative correlations for False-Positive establish content validity. Results: 283 women provided 1068 QOL assessments. Their general health status was 68.88 (P<0.0001) on a 100 point scale, improving by 7.90 (P=0.0153) when responding to eribulin. Nausea and vomiting were positively correlated with the reported incidence of nausea as AEs, 0.126 (P=0.03) and vomiting (P<0.01); false positives were negatively correlated, (-0.329; P<0.01 and -0.352; P<0.01, respectively). Constipation also satisfied the criteria for content validity, 0.189 (P<0.01) for correspondence and (-0.394; P<0.01) for lack of False-Positives. Diarrhea had a correspondence of 0.292 (P<0.01) and specificity of (-0.260; P<0.01). Dyspnea had a 0.226 (P<0.01) correspondence and (-0.349; P<0.01) specificity. Insomnia failed the criteria. Upset by hair loss was weakly correlated with alopecia but very specific (-0.479; P<0.01). Conclusions: Signs and symptoms as measured by the EORTC-QLQ-BR32 questionnaire have content validity in an investigational setting and they contribute clinically meaningful information to reported AE incidence data. Clinical trial information: NCT00246090.
Is comparative effectiveness research emphasized in oncologic residency training programs? Results of a national survey.
Authors: Zaorsky Nicholas George , Hess Jordan , Den Robert Benjamin , Bar-Ad Voichita , Filicko Joanne , Dicker Adam , Showalter Timothy Norman 
Published: March 2020

e17577 Background: Comparative effectiveness research (CER) is informally defined as an assessment of all available efficacious options for a specific medical condition, with intent to estimate effectiveness and efficiency in specific subpopulations. The American Recovery and Reinvestment Act of 2009 allocated $1.8 B to increase CER and train physicians in its practice. Although program directors (PDs) of medical oncology (MO) and radiation oncology (RO) training programs know that CER is emphasized nationally, it is unknown if CER is emphasized in oncological training programs themselves. We examine the emphasis of CER in MO and RO training programs. Methods: A web-based, anonymous survey was sent to RO PDs (n = 85) and chief residents (CRs; 98); and MO PDs (99), asking them to forward a link to fellows (Fs; 160). Mean weighted Likerts (MWLs ± standard deviations [SDs]) were calculated from scales (1, strongly disagree; 3, neutral; 5, strongly agree). Results: The response rates for RO PDs, RO CRs, MO PDs, and MO Fs were 20%, 21%, 11%, and 10% (combined, 15%, 68/442). Respondents had mixed beliefs in having a clear definition of CER (MWL, 3.1 ± 1.2); their programs encouraging CER (3.2 ± 1.2); including a course on CER (2.3 ± 0.9); or discussing the differences among efficacy, effectiveness, and efficiency (2.9 ± 0.9). Retrospective cohort studies were easy to perform at institutions (4.3 ± 0.8), but less so CER (3.1 ± 1.3). Respondents believed their programs’ research integrated some core values of CER, including comparing treatments to influence clinical decision making (4.6 ± 0.7). Respondents believed CER was important (4.3 ± 0.7); 47% would divert funding from other types of research toward CER; 35% would, only if funding for other research was unaffected. Conclusions: CER is not emphasized in oncologic training programs, and most PDs and trainees cannot clearly define CER. In the era of health care reform and potential future payment reforms, it is anticipated that CER will become an increasingly important component of evidence-based medicine and continuous quality improvement. This study identifies a need for oncology training programs to incorporate education about CER into their curricula.