bluuebunny/crossref_metadata_2025_split huggingface dataset:
Is care coordination associated with improved care quality for comorbid conditions in cancer survivors?
Authors: Snyder Claire Frances , Frick Kevin D. , Herbert Robert J. , Blackford Amanda L. , Neville Bridget A. , Lemke Klaus , Wolff Antonio C. , Carducci Michael Anthony , Earle Craig 
Published: March 2020

6026 Background: Many cancer survivors have comorbid conditions, adding complexity to their already complicated care and requiring greater care coordination. We assessed the role of care coordination in comorbid condition care for cancer survivors. Methods: Using SEER-Medicare, we examined 7 published indicators of quality comorbid condition care in survivors of loco-regional breast, prostate, or colorectal cancer who were diagnosed in 2004, in fee-for-service Medicare, and survived ≥3 years. Comorbid condition care was evaluated during the transition from initial cancer treatment to survivorship (i.e. days 366-1095 post-diagnosis). Coordination risk was categorized as Likely, Possible, or Unlikely using an index developed and tested as part of the ACG case-mix adjustment and predictive modeling tool. The index factors in the number of unique providers, number of specialties, the percentage majority source of care, and generalist visits. We tested the hypothesis that lower coordination risk would be associated with better comorbid condition care using logistic regression, adjusting for socio-demographics, cancer type, and comorbidity. Results: The sample included 8661 survivors (53% prostate, 22% breast, 26% colorectal; mean age 75; 65% male, 85% white). Our hypothesis was not supported. Compared to patients with Unlikely coordination issues, patients with Likely coordination issues were more likely to receive appropriate care on 4 indicators and less likely on 1. Possible coordination issues were associated with better care on 1 indicator and worse care on 1 indicator. To explore this finding further, we conducted post-hoc analyses examining the role of each component of the coordination risk index. Having more unique providers was generally associated with better comorbid condition care, in contrast to the calculation of the index which considers more unique providers a greater risk for coordination issues. Conclusions: These findings suggest that traditional metrics of care coordination may not be valid for survivors of cancer. Understanding the role of care coordination in cancer survivorship care requires development and application of alternative coordination measures.
Quantitative HER2 levels and steroid receptor expression in primary breast cancers and in matched brain metastases.
Authors: Biernat Wojciech , Duchnowska Renata , Trojanowski Tomasz , Mandat Tomasz , Kowalczyk Anna , Czartoryska-Arlukowicz Bogumila , Radecka Barbara , Jarosz Bozena , Staszkiewicz Rafal , Kalinka-Warzocha Ewa , Chudzik Malgorzata , Sperinde Jeff , Haddad Mojgan , Paquet Agnes , Lie Yolanda , Winslow John William , Weidler Jodi Marie , Huang Weidong , Petropoulos Christos J. , Jassem Jacek ,   Polish Brain Metastasis Consortium
Published: March 2020

603 Background: Breast cancer patients with HER2-positive tumors are at high risk for brain metastases. In the current study we examined expression of ER, PR and HER2 in primary breast tumors and in matched brain metastases, as changes of their levels might reflect modes of escape from therapy. Methods: Fifty-three pairs of matched formalin-fixed paraffin-embedded samples from primary breast cancers and brain metastases were assayed for ER and PR status by immuno-histochemistry, whereas HER2 expression was quantified using the novel HERmark assay. Nuclear staining of ER and PR >10%, and relative fluorescence of HER2 >17.8/mm2 were considered as positive results. Results: HER2 levels in brain metastases were generally higher than in the primary tumors (p = 3e-6), with a median increase of 1.9-fold (range 0.08 to 199-fold). There were also substantial differences in ER and PR status between primary tumors and brain metastases. Loss of steroid receptor positivity in brain metastases was more frequent than its gain (ER: 46% vs. 26%; p = 0.16; PR: 57% vs. 23%; p = 0.044). These changes resulted in a net increase in the number of HER2-positive/ER-negative brain metastases, which more than doubled the proportion of primary breast tumors with this phenotype (26% vs. 11%, respectively; p = 0.08). Additionally, HER2 levels in the primary tumors significantly correlated with overall survival when stratified by ER status (p = 0.011). Conclusions: Brain metastases of breast cancer show significant changes in steroid receptor status and in quantitative HER2 levels compared to matched primary tumors. These data provide a rationale for future studies and may help in designing treatment strategies that target the most likely escape pathways of breast cancer.
Timeliness of care and stage at diagnosis of non-small cell lung cancer (NSCLC) with the implementation of a cancer care coordination program (CCCP) at a VA medical center.
Authors: Alsamarai Susan , Chao Herta H. , Yao Xiaopan , Deng Yanhong , Rose Michal G. 
Published: March 2020

6033 Background: Timeliness of care improves patient satisfaction and may improve outcomes. A CCCP was established in Nov 2007 to improve timeliness of care of NSCLC patients at the Veterans Affairs Connecticut (VACT) Healthcare System. Methods: We performed a retrospective cohort analysis of patients diagnosed with NSCLC at VACT between 2005-2010. We compared timeliness of care and stage at diagnosis before and after the implementation of the CCCP. Results: Data from 352 patients was analyzed: 163 with initial abnormal imaging between 1/1/2005 and 10/31/2007, and 189 with imaging between 11/1/2007 and 12/31/2010. Variables associated with a longer interval between the initial abnormal image and the initiation of therapy were: (1) earlier stage (mean of 130 days for stages I/II vs. 87 days for stages III/IV, p<0.001),(2) lack of cancer-related symptoms (145 vs 60 days, p<0.001), (3) presence of medical co-morbidities (111 vs 76 days, p=0.01), and (4) depression (127 vs 98 days, p=0.029). Substance abuse increased the interval from initial abnormal image to tissue diagnosis by 29 days (p=0.032) but did not affect the interval from image to treatment. The mean interval between diagnosis and initiation of treatment was 19 days longer in blacks vs. non-blacks (55 vs 36 days, p=0.0118) although the overall time from abnormal image to diagnosis and to treatment was not statistically different. In a multivariate model adjusting for stage, histology, reason for initial imaging, and presence of a primary care provider, implementation of a CCCP resulted in a mean reduction of 25 days in the time between the first abnormal image and initiation of cancer treatment (126 to 101 days, p=0.0154). The percent of patients diagnosed at stages I and II increased from 32% to 48% (p=0.0065) after the implementation of a CCCP. Conclusions: A centralized, multidisciplinary, hospital-based CCCP can improve timeliness of NSCLC care, and may also help ensure that incidental, early stage lung cancers are treated.
Do patient-reported symptoms predict for emergency department visits? A population-based analysis.
Authors: Barbera Lisa Catherine , Atzema Clare , Sutradhar Rinku , Seow Hsien , Howell Doris , Husain Amna , Sussman Jonathan , Earle Craig , Liu Ying , Dudgeon Deborah Jane 
Published: March 2020

6039 Background: Since 2007 in Ontario, Canada, the Edmonton Symptom Assessment System (ESAS) has been routinely used to assess symptoms in cancer patients in both ambulatory and home-care settings. The purpose of this study was to determine the relationship between individual patient symptoms, and their severity, with the likelihood of an emergency department (ED) visit. Methods: The cohort includes all cancer patients in Ontario who completed an ESAS assessment between January 2007 and March 2009. We linked multiple provincial health databases to describe the cohort and determine if an ED visit occurred within 7 days of the patient’s first ESAS. Multivariate logistic regression was used to determine the association between symptom scores (absent: score 0; mild: 1-3; moderate: 4-7; severe: 8-10) and the likelihood of an ED visit. Results: The cohort included 45,118 unique patients whose first assessment contributes to the study. 3.8% (n=1732) had an ED visit. The patients with ED visits were more likely to be men, to have lung or gastro-intestinal cancer, to have had recent radio or chemotherapy, and to have a shorter survival. The proportion of patients with ED visits increased from 2% to 10-12% as individual symptom scores increased from 0 to 10. Anxiety and depression were not associated with ED visits in the model, regardless of severity. Pain, nausea, drowsiness, appetite and shortness of breath with moderate or severe scores were associated with ED visits. Tiredness and wellbeing were the only symptoms to show a significant association for mild, moderate and severe scores. A well being score of 7-10 (reference score=0) had the highest odds ratio of 1.8 (95% CI 1.4-2.3). Conclusions: Worsening symptoms clearly contribute to ED visits. While specific symptoms like pain are obvious targets for management in the outpatient setting, constitutional symptoms like wellbeing or fatigue are associated with even higher odds. Though difficult to manage, such symptoms also warrant detailed assessment in order to optimize patient outcomes.
Electronic prompt to improve outpatient code status documentation for advanced lung cancer.
Authors: Temel Jennifer S. , Greer Joseph A. , Gallagher Emily R. , Jackson Vicki A. , Lennes Inga Tolin , Park Elyse R. , Pirl William F. 
Published: March 2020

6048 Background: Rates of documentation of end-of-life care preferences in the medical record remain low, even among patients with incurable malignancies. The goal of this study was to assess the impact of electronic prompts to encourage oncology clinicians to document code status in the outpatient electronic health record (EHR) of patients with advanced lung cancers. Methods: We conducted two clinician focus groups (n=15) at an affiliated academic medical center to determine the appropriate content and timing of the electronic reminders. Based on the focus groups, we developed email reminders that were timed to the start of each new chemotherapy regimen. Between 6/09 and 1/11, 102 eligible patients with advanced lung cancer were approached, and 100 (98%) agreed to participate in the prospective study. Email reminders were sent to oncology clinicians at the patient's next outpatient visit and with each new chemotherapy regimen. Using a pre-post design, we compared study participants to a retrospective cohort of 100 consecutive historical controls who began chemotherapy for advanced lung cancer at least one year prior to the start of this study. The primary outcome measure was the documentation of code status in the EHR. Results: Study participants were similar to historical controls, with no significant differences in age, gender, performance status, histology or initial cancer therapy received. At one year follow-up, 33/98 (34%) of participants had a code status documented in the outpatient EHR compared with 12/83 (15%) of historical controls, p=0.003. Mean time to code status documentation was significantly shorter in study participants (8.6 months [95% CI 7.6-9.5]) compared with controls (10.5 months [95% CI 9.8-11.3]), p=0.004. Conclusions: Email prompts triggered by changes in chemotherapy improved the rate and timing of code status documentation in the EHR.
Influence of comorbidity on guideline concordant care for breast cancer: Findings from the Center for Disease Control and Prevention National Program of Cancer Registry (NPCR) patterns of care study.
Authors: Kimmick Gretchen Genevieve , Fleming Steven , Sabatino Susan A , Wu Xiao-cheng , Hwang Wenke , Wilson J. Frank , Lund Mary Jo B. , Cress Rosemary , Anderson Roger T. 
Published: March 2020

6052 Background: Comorbidity burden predicts cancer treatment and may influence outcome. We explore the relationship of specific comorbid illnesses with receipt of guideline concordant care for early stage breast cancer. Methods: The NPCR’s Patterns of Care study reabstracted the medical records of breast cancer cases diagnosed in 2004 from 7 cancer registries. We included women with nonmetastatic in situ and invasive breast cancer, known hormone receptor status, node status, and tumor size. Guideline-concordant management, including surgery, radiation, chemotherapy and endocrine components, was based on NCCN guidelines using tumor size, nodal and hormone receptor status. Comorbidity was measured according to the Adult Comorbidity Evaluation Index (ACE). Multivariate logistic regression models were used to determine factors associated with guideline-concordant care, and included overall ACE scores and 26 separate ACE comorbidity categories, as well as age, race, hormone receptor status, and HER2 status. Results: The study sample included 6904 women (mean age 58.7 and range 20-99 years, 76% white, 45% with ACE comorbidity score of 0, 70% ER and/or PR+, 13% HER2+). Overall, 64% received guideline-concordant care. Receipt of guideline-concordant care varied by overall comorbidity burden (71% for none; 65% for minor; 63% for moderate; 50% for severe; p<0.05). The presence of hypertension (OR 1.26, 95% CI 1.08-1.48) predicted receipt of guideline concordant care, whereas, peripheral artery disease (OR 0.44, 95% CI 0.21-0.93), diabetes (OR 0.78, 95% CI 0.63-0.97) and dementia (OR 0.31, 95% CI 0.13-0.74) predicted lack of guideline concordant care. Older age, black race, and hormone receptor positivity were associated with less, and HER2 positivity with receipt of more guideline-concordant care. Conclusions: Overall those with more comorbidity burden received less guideline-concordant care. However, the effects vary by specific conditions. The odds of receiving guideline-concordant care was greater in those with hypertension and less in those with peripheral arterial disease, diabetes, and dementia.
A neoadjuvant, randomized, open-label phase II trial of afatinib (A) versus trastuzumab (T) versus lapatinib (L) in patients (pts) with locally advanced HER2-positive breast cancer (BC).
Authors: Rimawi Mothaffar F. , Aleixo Sabina B. , Alarcon Rozas Ashley , Matos Neto Joao Nunes , Caleffi Maira , Vinholes Jeferson J.F. , Figueira Alicardo Cesar , Souza Sulene Cunha , Reiriz Andre B. , Arantes Heloisa , Uttenreuther-Fischer Martina Maria , Osborne C. Kent 
Published: March 2020

606 Background: A is an oral, irreversible, ErbB Family Blocker. This Phase II study investigated A, L and T monotherapy in pts with locally advanced HER2 (ErbB2)-positive BC in a 6-wk preoperative treatment window. Methods: This international, multi-institutional, open-label, randomized, Phase II study included pts with HER2-positive locally advanced disease Stage IIIa–c and inflammatory BC with no evidence of distant metastatic disease, at least one tumor lesion ≥5 cm in diameter, and an ECOG score 0–1. Pts agreed to fresh tumor biopsies for biomarker analyses at trial entry, and at 3 and 6 wks of treatment. Pts received 50 mg A once daily, 1500 mg L once daily, or T 2 mg/kg weekly after a loading dose of 4 mg/kg for 6 wks. Results: 73 pts were screened and 29 pts randomized and treated* (10 pts A, 8 pts L, 11 pts T). All pts were female, median age 49 (range 25–88) yrs, 28/29 pts had Stage III disease, 3/29 pts had inflammatory BC, median tumour size was 6.4 cm, and median time to treatment was 1.4 months (range 0–3.4). After 6 wks of treatment, OR was assessed using RECIST 1.0 (Table). Best objective response during treatment was 80%, 75%, and 36.4% in the pts treated with A, L, and T, respectively. Drug-related AEs assessed by CTCAE v.3.0 occurred in all pts treated with A, 75% of pts treated with L, and 45.5% of patients treated with T (largely GI and skin-related AEs for A and L, and GI and musculoskeletal AEs for T). Three pts treated with A and one pt with L had drug-related AEs of CTCAE Grade 3. Conclusions: Afatinib showed a high OR rate in this Phase II trial of a 6-wk preoperative treatment window and compared favorably to two approved agents in HER2-positive BC, albeit at a slightly higher rate of AEs. Further trials will be needed to identify the potential role of A as a single agent or in combination with other agents in HER2-positive BC. [Table: see text]
Clinical and cost impact of diagnostic slide review.
Authors: Cuff Justin , Yarlett Daniel , Arber Daniel 
Published: March 2020

6072 Background: Diagnostic error is postulated to represent a significant source of preventable mortality, morbidity, and cost. A primary pathologic diagnosis of cancer has a relatively high error rate necessitating cost effective solutions to mitigate diagnostic related harm. Methods: A review of 773 consecutive inbound transfers to Stanford, with review of prior pathology material, was performed to measure diagnostic discrepancy. Information was collected about the originating practice size and type, subspecialty area, additional testing, and a description of the disagreement. For a subset of cases, itemized payment data was collected to explore the financial impact of slide review. Results: We found that 9% of cases have diagnostic discrepancies when comparing the incoming working diagnosis with the result of the pathology slide review. Major diagnostic discrepancies, likely to alter treatment, were identified in 3% of cases. Discrepancy rates differed significantly between subspecialty areas (p<0.01) although few areas were spared major error. Disagreements about classification were common as were over/under calling malignancy, grading errors, and incorrect ordering or interpretation of ancillary testing. The subset of cases (n=107) with billing information demonstrated ~42,800 unique charge events associated with these episodes of care. The mean charge for patients was $292,813 (median $130,467). Typical of charge data the dollar amounts exhibited strong right-skew. Average reimbursement was $76,017 (median $23,999) and the median charge:reimbursement ratio was 3.3. When analyzing cases by service line, only 1.4% of charges related to the diagnostic review of the prior pathology material, demonstrating a remarkably small impact on the overall cost. While additional testing was performed on 10% of cases, there was no evidence that cases with a discrepancy were associated with increased overall costs. Conclusions: Diagnostic slide review on prior material is relatively inexpensive in terms of the cost of overall care and permits the detection of significant errors that may affect treatment planning. Pathology slide review represents a clinically impactful and low cost way to prevent errors in diagnosis from becoming errors in management.
Speed of accrual into published phase III oncology trials: A comparison across geographic locations.
Authors: Ruther Nancy R. , Jumonville Alcee , Mathiason Michelle A. , Emmel Ann E. , Wee Sandra K , Go Ronald S. 
Published: March 2020

6074 Background: There is a perception that patient accrual may be slower in the US than it is in Europe (Wang-Gillam A et al, J Clin Oncol 2010;28:3803-3807). However, a systematic study has not been performed. We seek to determine the speed at which patients are accrued into published phase III oncology trials across geographic locations and to identify factors that may influence this process. Methods: We searched MEDLINE and identified all original phase III oncology therapeutic trials published in 2006-2010 (N = 567). Trials with no reported activation and completion dates were excluded (n = 20). Accrual speed per trial was expressed as patients per month and was calculated by dividing the number of patients enrolled by number of months a trial was open. Results: The 547 trials included in our study enrolled 281,340 patients. Most trials were for adults only (95.6%), late stage cancers (77.5%), and involved multinational participation (44.1%). Funding sources were cooperative groups (45.5%), industry (33.8%) and academic centers (20.5%). The top 5 cancers studied were hematologic (19.2%), gastrointestinal (16.5%), lung (16.3%), breast (15.4%), and gynecologic (8.4%). Trial results were negative (57.4%), positive (38.2%), or equivalent (4.4%). The mean (+SD) accrual speeds varied according to trial location (multinational [25.0+25.4], US [13.3+16.5], other countries [11.4+15.7], Europe [8.7+11.8]; [P= .001]), funding source (industry [28.3+24.7], cooperative groups [13.3+19.0], academic [6.8+6.5]; [P= .001]), and cancer type (breast [24.0+29.4], gastrointestinal [20.2+24.2], lung [19.3+22.7], gynecologic [15.3+19.2], hematologic [11.2+10.7]; [P= .001]). After adjusting for funding source, accrual speeds were significantly different across trial locations only in 2 cancers: gastrointestinal (multinational [25.2+3.7], US [24.1+8.2], Europe [11.5+3.7], other [7.5+8.5]; P= .046) and gynecologic (multinational [28.9+5.4], other [10.5+7.8], US [6.6+5.3], Europe [4.2+5.9]; P= .004) studies. Conclusions: Among published phase III oncology trials, multinational studies accrued patients faster in gastrointestinal and gynecologic cancers and at a similar speed in other cancers.
Racial disparities in depressive symptom prevalence and selective serotonin reuptake inhibitor (SSRI) utilization in cancer patients: An analysis from ECOG E2Z02: Symptom Outcomes and Practice Patterns (SOAPP).
Authors: Zhao Fengmin , Wagner Lynne I. , Pirl William F. , Miller Andrew H. , Fisch Michael 
Published: March 2020

6076 Background: Rates of diagnosis and treatment of depression in primary care vary widely by race. It is unclear whether such disparity exists in oncology. Methods: 3106 patients with cancer of the breast, prostate, colon/rectum, or lung were enrolled from multiple sites in a longitudinal study of symptoms. Patient-reported depressed mood (PRD) on a 0-10 numerical rating scale and clinician-reported psychological distress (CRD) were used to identify depressive patients at baseline. Patients also rated depressed mood 4-5 weeks after baseline. A 2-point change was considered clinically significant for change in PRD. Logistic regression models were used to examine the effect of race on prevalence of depression and antidepressant use. Ordinal logistic regression models examined the effect of race on changes in depression. Results: Of the 3106 patients, 2648 were white, 364 were black, and 94 were other race. At baseline, 20% had moderate/severe PRD; CRD was 28%. Black patients had higher rates of depression than whites, but the difference was not significant after adjusting for other covariates (PRD: 24% vs. 20%, adjusted OR=1.1, P=0.6; CRD: 30% vs. 27%, adjusted OR=1.06, P=0.8). Improvement in depressed mood varied by baseline PRD score (57% with severe depression, 51% with moderate, and 14% with mild). In patients with moderate/severe depression at baseline, blacks were less likely to have depression improvement than whites (adjusted OR=0.41, P=0.008 for moderate depression, adjusted OR=0.35, P=0.01 for severe depression). Among patients with depression defined by CRD, 29% were taking an SSRI (blacks: 14%, whites: 31%), Blacks were less likely to take an SSRI than whites (adjusted OR=0.38, P=0.01). Conclusions: Less than one third of patients with depressive symptoms are taking SSRI antidepressants. Black race is not only associated with less improvement in depressive symptoms over time but also lower probability of SSRI utilization.