bluuebunny/crossref_metadata_2025_split huggingface dataset:
A population-based study of medical cannabis utilization in patients with cancer.
Authors: Karim Safiya , Bu Jingyu , Jess Ed , Cheung Winson Y. , Kerba Marc 
Published: October 2019

124 Background: Between 2014 and 2018, access to cannabis for medical purposes was regulated by Health Canada. Surveys have demonstrated that cancer patients use cannabis to manage symptoms and side effects. Medical cannabis utilization patterns in cancer patients under Canada’s regulatory framework have not been well-described. We aimed to determine the proportion of cancer patients who used medical cannabis, timing of use in relation to cancer treatment and sociodemographic factors predicting use. Methods: The Alberta Cancer Registry was used to identify all patients age ≥ 18 diagnosed with invasive cancer in the province from April 01, 2014 to December 31, 2016. These cases were linked to records from the College of Physicians and Surgeons of Alberta database which collects data on patients who received an authorization for medical cannabis. Authorization was used as a surrogate for medical cannabis utilization. Univariate and multivariate logistic regression models were constructed to determine factors associated with medical cannabis utilization. Results: We identified 41,889 patients between April 1, 2014 and December 31, 2016. Median age at cancer diagnosis was 65 and 50% were female. Among these patients, 1,070 (2.5%) used medical cannabis. Of these patients, 541 (51%) used medical cannabis within 1 year of diagnosis, 248 (52%) within one year of the start of systemic therapy and 128 (41%) within one year of the start of radiation therapy. On multivariate analysis, patients aged 18-29 (OR 12.4, 95% CI 7.8-19.7) and those receiving systemic therapy (OR 2.0, 95% CI 1.7-2.4) were more likely to use medical cannabis (p < 0.001). There were 171 unique physicians who authorized medical cannabis of which only 3.5% (6/171) were oncologists. Conclusions: A small proportion of cancer patients used medical cannabis under Health Canada’s regulatory framework. Utilization was associated with a cancer diagnosis and receiving treatment. Younger patients and those undergoing systemic treatment were predictors of medical cannabis use. Further study is required to understand utilization patterns after cannabis legalization and how to incorporate these findings into patient-centered cancer care.
Exploratory analysis of barriers and facilitators to cervical cancer care in rural Tamil Nadu, India.
Authors: Rajashekara Shruthi , Subramanian Malliga J , Rajaraman Swaminathan , Davila Jessica , Anandasabapathy Sharmila 
Published: October 2019

125 Background: Approximately 20% of cervical cancer deaths worldwide occur in India, most notably in rural areas. The key to addressing the cervical cancer epidemic is early detection and treatment of precancerous cervical lesions. Many studies that assess barriers to cervical cancer care in India focus on individual level factors, such as awareness and education. Given the disparities in cervical cancer in India, particularly between rural and urban settings, a comprehensive, multi-level approach to evaluating barriers and facilitators to care is needed. Methods: In December 2018, we used semi-structured interviews and direct observation of 15 community health workers, medical officers and gynecologic oncologists to explore the multi-level barriers and facilitators to cervical cancer care in rural Tamil Nadu. Data collection occurred within an existing organized cervical cancer screening program and was guided by the social-ecological model. Results: Barriers and facilitators to cervical cancer screening and treatment of precancerous lesions were identified at all levels of the social-ecological model. Barriers included fear of and travel distance to urban centers for treatment (individual), limited social support (interpersonal), lack of rural clinical facilities that provide treatment (organizational), competing community health initiatives (community), and lack of cohesive national screening and treatment guidelines (policy). Facilitators included travel distance to local screening services (individual), access to community health workers (interpersonal), institutional initiatives to increase screening access (organizational), mass awareness campaigns (community), and Tamil Nadu State priorities to improve cervical cancer care (policy). Conclusions: This assessment underscores the gap between cervical cancer screening and treatment in rural Tamil Nadu. This data will inform the development of a multi-faceted intervention, targeting all levels of the social-ecological model, to improve the linkage between cervical cancer screening and treatment for precancerous cervical lesions to decrease the burden of disease and mortality in India.
Oncologic services through Project Access and other safety net care coordination programs.
Authors: Hammock James Blake , Williams Courtney , Rocque Gabrielle Betty 
Published: October 2019

126 Background: Since the 1996 formation of Project Access, a nationwide program linking uninsured, low-income, or underserved patients to specialty care, the US has experienced a growth of third-party, safety net care coordination programs that provide sub-specialty care at no or reduced cost. These programs pre-negotiate with local physicians and hospitals to offer pro bono services to patients. Little is known about the provision of oncologic services within these programs. This study evaluated the current landscape of oncologic services within US safety net care coordination programs. Methods: This study reviewed websites via an online search from 04/22/19 - 04/28/19 using keywords “Project Access”, “healthcare”, and individual state names. The websites were reviewed for information on location, services offered, and patient eligibility criteria. Where online data on oncologic services was unavailable, individual programs were called on 05/08/19 for additional information. Five programs were unreachable by phone or e-mail. Results: Websites of 29 safety net care coordination programs in 22 states were identified, serving only approximately 40 counties. Online, one program highlighted "limited" access to oncologic care, while another offered chemotherapy at a reduced cost ($5000/round). When contacted by phone, 55% offered access to oncologic services and 48% assisted with chemotherapy costs. One program provided chemotherapy only if the cancer diagnosis was made after the patient was enrolled in their system. Virtually all programs who offered chemotherapy did so through affiliated large hospital systems. A commonly reported reason for lack of oncology care was a reluctance of oncologists to commit to potential long-term agreements of free care. Online, one program offered PET scans. By phone, 89% offered some imaging. Two programs (7%) explicitly required US citizenship for care. Conclusions: Third-party care coordination centers are increasing in number and provide a novel, and potentially unrecognized, approach to increasing oncology service access. Further research should identify barriers contributing to the relative lack of oncologic services in these programs compared to other specialties.
Characteristics, treatment patterns, and survival from three cohorts of advanced or metastatic cancer patients using health care claims data in the United States.
Authors: Beachler Daniel C , Lamy Francois-Xavier , Russo Leo J , Lanes Stephan , Dinh Jade , Taylor Devon H , Yin Ruihua , Jamal-Allial Aziza , Verpillat Patrice 
Published: October 2019

129 Background: Our main objective was to identify, in healthcare claims data, patients with advanced or metastatic: urothelial carcinoma (amUC), gastric cancer (amGC) and non-small cell lung cancer (amNSCLC) and to report on their characteristics, treatments, and survival rates using contemporaneous real-world data. Methods: This cohort study was conducted in the HealthCore Integrated Research Database (HIRD), from January 2010 to January 2018, which contains healthcare claims data from commercial health plans across the US (60 million lives). We applied algorithms, previously validated on registry data, to the HIRD to define 3 cohorts of advanced stage cancer. Cohort characteristics and treatment patterns were described. Patient vital status was captured through probabilistic linkage with the National Death Index (NDI) and survival was assessed using the Kaplan-Meier method. Results: Algorithms to predict advanced stage cancer resulted in the following cohorts: 1,501 amUC, 6,253 amGC and 38,451 amNSCLC cases. Most patients in each cohort were de novo advanced or metastatic, but subsets were diagnosed at early stage and progressed to advanced stage (ranging from 15.1% for amNSCLC to 23.1% for amUC). Patient characteristics, treatments and survival outcomes are described in Table 1. Not all received systemic treatment; Immune Checkpoint inhibitors (ICI) were used in 5.3%, 2.2% and 10.8% of treated amUC, amGC and amNSCLC patients, respectively. Conclusions: In these cohorts of advanced or metastatic cancer patients, median survival time was limited despite most receiving treatment: radiation, systemic therapy or surgery. Treatment with ICI was low despite recent data in amUC and amNSCLC.[Table: see text]
Impact of in-house specialty pharmacy on access to novel androgen axis inhibitors in men with advanced prostate cancer.
Authors: Handley Nathan , Kirk Siobhan , Driscoll Anna , Binder Adam , Kelly William Kevin 
Published: October 2019

132 Background: Novel androgen axis inhibitors are standard of care treatments in advanced prostate cancer. The billed amounts for these medications are often very high, which may create significant financial toxicity for patients and lead to delays in treatment. Our institution implemented an in-house specialty pharmacy in 2014, that provides these medications and evaluates copay assistance options for all patients. We evaluated the program’s impact on out of pocket cost (OOP) and turnaround time (TAT). Methods: We reviewed available internal specialty pharmacy records to identify prescriptions for abiraterone or enzalutamide filled between 1/1/17 and 12/31/18. Payments were stratified by primary payment (amount reimbursed by the patient’s prescription plan based on the benefit’s design) and copayment assistance. Turnaround times (TAT) in business days were stratified by prescriptions requiring intervention (prior authorization, copayment assistance, or insufficient inventory) and clean prescriptions (those requiring no intervention). Results: One thousand for hundred seventeen prescriptions for 175 unique patients requiring abiraterone (n = 869, 61.3%) or enzalutamide (n = 548, 38.7%) were filled through the institution’s specialty pharmacy. The average amount paid by primary payer was $9,492.96 for a 30 day supply (range: $3,382.48-$12,939.84). Average quoted copay was $577.53 (range $3.08-$10,560.39). 64% of patients received copayment assistance. Average OOP cost per prescription after co-pay assistance was $100.83 (range $0-$8556.64). Three patients declined treatment due to cost (1.7% of overall). Average TAT was 2.98 days for clean prescriptions and 3.36 days for prescriptions needing intervention (p = 0.055). Conclusions: OOP cost varied significantly based on plan design and copayment assistance eligibility. The majority of patients received copayment assistance, which markedly reduced OOP cost. Cost rarely precluded access to treatment. TAT was not significantly prolonged for prescriptions requiring intervention. Further studies to determine impact of pharmacy type on access to specialty medications are indicated.
Call center performance to drive patient access.
Authors: Cummings Chad W. , Comer George , Bealer Nicole , Costantino Patricia , Davis Jonathan , Heard Laphia , Johnson Markita , Kantzes Deborah , Snyder Josette M. , Oh Kimberly 
Published: October 2019

135 Background: Access to oncology care through a specialty call center within a large academic institution was analyzed to determine service levels necessary to schedule patient consults within 7 days of contact. The specialty call center is the primary resource for ambulatory appointment scheduling, and staffed by 1 licensed provider and 6 agents who administratively coordinate patient care. Hours of operation are 8AM-5PM. Methods: Data was analyzed between a period of 1/1/2018 and 9/30/2018 (P1), providing call statistics (S1): inbound & outbound calls, calls not answered, average speed of answer, agent availability. Observations of agents identified key processes, staffing analysis, and productivity levels. A dependency map was developed to identify key inputs and outputs for all call center activities. The number of dependencies were identified for each activity. Results: A dependency map identified 22 unique agent activities, categorized by administrative tasks (n = 9), multi-disciplinary team coordination (n = 7), direct patient interaction (n = 5), and patient benefit processing (n = 3). Average number of inputs per activity yielded 2.4 (Range = 0 to 8), while outputs were 2.0 (Range = 0 to 6). Inbound and outbound calls spanned multiple categories, with 28,730 calls received or placed during P1. 77% of inbound calls were answered, and remaining calls were directed to voicemail. 89% of all calls occurred between 9AM and 4PM, with slight variation each hour. Staffing Analysis revealed 91.3% availability rate equivalent to 5.48 agents available per day. Average call hours (inbound and outbound) per agent ranged from 2.45hrs/day to 5.18 hours/day, with variation attributed to the unique activities. An algorithm was created to determine appropriate staffing levels to ensure S1 requirements and timely coordination of care. Conclusions: A specialty call center requires a detailed understanding of dependencies that contribute to timely scheduling, while maximizing customer service. Dependency mapping provides visibility to clinical and non-clinical teams of necessary activities to coordinate appointments. Staffing models can assist in understanding the variables that influence S1, and provide support for staffing decisions in periods of high/low demand.
Barriers to fertility preservation (FP) in a prospective pan-Canadian study of young women with breast cancer (YWBC).
Authors: Warner Ellen , Yee Samantha , Seminsky Maureen , Lipson David , Glass Karen , Foong Shu , Kennedy Erin Diane , Narod Steven , Quan May Lynn 
Published: October 2019

136 Background: Despite ASCO recommendations that oncologists routinely offer FP to young cancer patients prior to treatment, studies show that only a minority of YWBC are given this option. We sought to determine whether an intervention, including educational materials and regular reminders to breast surgeons, would improve FP referral. The current report examines the rates of FP discussion, referral, uptake and reasons for declining, according to participants’ self-reported pre-diagnosis fertility plans. Methods: Consecutive women ≤ age 40 newly diagnosed with breast cancer at 30 Canadian sites were offered enrolment in a national study of YWBC. At 3 months each participant was surveyed regarding her pre-diagnosis (dx) fertility plans and post-dx oncofertility management. Results: Of the 712 recruits (09/15 to 08/18) with invasive disease (mean age 36), 46%, 15% and 29% had 0, 1 or 2 children respectively and 77% were in a stable relationship. Among the 480 women who completed the fertility survey, 392 (82%) indicated they had a pre-treatment fertility discussion initiated by a health care provider (HCP) - in 232 cases (48%) the surgeon/nurse and in 130 cases (27%) the medical oncologist/ nurse. Only 14 (16%) of the 88 women not approached by a HCP initiated such a discussion. Rates of FP discussion, referral and uptake are shown below. Among the 38 women who definitely wanted (more) children prior to dx and were offered FP but declined the consult or procedure, the commonest reasons were cost (n = 9) and fear that treatment delay (n = 8) or FP (n = 4) could cause recurrence. Conclusions: Post-intervention FP discussion rates were higher than previously reported. Yet 26% of patients who had definitely/probably not completed their family were not referred for a FP consult. Cost remains a significant FP barrier. Studies are needed to confirm the long-term safety of FP for ER+ patients. [Table: see text]
Partnership with an independent genetic counselor and standardized screening: Effect on the identification, referral, and genetic testing of eligible patients in a community oncology clinic.
Authors: Bilbrey Larry Edward , Dickson Natalie R. , Rao Smita K , Shepard Gregg Christian , McGee Kathy , Frailley Susan A , Poole Stacey L , Patton Jeffrey 
Published: October 2019

138 Background: A nine provider, community oncology clinic had limited local access to genetic counseling. Additionally, the practice had no process for identifying appropriate patients for genetic counseling or testing and no method to track referrals and test results. The practice partnered with a contracted genetic counselor and a study was completed to standardize screening and follow-up and to increase referrals and testing. Methods: Baseline data on genetic testing performed in 2018 was obtained from three major genetic testing labs. Based on the NCCN guidelines for genetic assessment, the practice created automated screening reports from the EMR, supplemented by manual chart review, to identify appropriate patients for genetic counseling. Front office, clinical and billing workflows were created. Patients were scheduled to see the counselor via in-person appointments or remotely via a HIPAA compliant telemedicine platform. The genetic counseling sessions included education and consent for testing followed by review and discussion of results. Consultations and genetic testing results were documented in the practice’s EMR. Results: Baseline data showed that the clinic tested 7 patients in 2018; 2 patients in the first quarter. During the pilot from Jan-Mar 2019, 34 patients were referred for genetic counseling; 30 consented to testing. This is a 329% increase over 2018; 1400% for the first quarter. Of the 30 patients tested during the pilot, 6 were positive for a pathogenic mutation. Conclusions: By contracting with a genetic counselor, and establishing procedures for screening, counseling, consenting, testing and follow-up, the practice was able to increase the number of appropriate genetic testing considerably. This process will be scaled to multiple sites of a community practice.
Emergency department-mediated cancer diagnosis among older adults in the United States.
Authors: Sheridan Paige , Lyratzopoulos Georgios , Murphy James Don , Thompson Caroline A. 
Published: October 2019

139 Background: It is estimated that 20-50% of breast, colon and lung cancers are diagnosed in an emergency department (ED) globally. Cancer diagnosis via the ED worsens short-term survival and reduces quality of care. Studies in Europe have shown that older and socioeconomically deprived patients are at a higher risk of ED diagnosis. However, no studies in the U.S. have reported patterns of cancer patients initially presenting to the ED. We identified and characterized older patients who are diagnosed with a malignant tumor following presentation to an ED using data from the Surveillance, Epidemiology and End Results Medicare linked database. Methods: We studied 415,395 Medicare beneficiaries with histologically confirmed first malignant invasive tumors of the breast, colon and rectum, lung and prostate between 2004 and 2013. Patients were excluded if they did not have continuous coverage in the year prior to diagnosis, had more than one primary tumor, or were diagnosed after death. ED-mediated diagnosis was defined as having at least one ED claim in the month before the date of cancer diagnosis. Covariate adjusted generalized linear models were used to estimate prevalence odds ratios for marital status, race, comorbidity, and income levels. Results: Overall, 42,186 (11%) of cancer diagnoses were ED-mediated (by site: breast: 5%, colorectal: 13%, lung: 15%, prostate: 6%). Patients presenting to the ED were more likely to be: unmarried (OR:1.32; 95% CI: 1.29-1.34), Hispanic (OR:1.47; 95% CI: 1.37-1.57) or Black (OR:1.41; 95% CI:1.37-1.45), have 3+ comorbidities (OR:3.08; 95% CI: 3.00-3.16), and in the lowest income quartile (OR:1.26; 95% CI:1.21-1.30). Conclusions: While some cancers diagnosed in the ED may indicate incidental findings, later stage symptomatic cancers not identified until they become an emergency may reflect the failure of public health campaigns and primary care services. Reducing emergency presentation of cancer patients may improve patient outcomes and healthcare system efficiency.
Racial disparities in utilization of gene expression testing in breast cancer patients at an academic medical center.
Authors: Alder Laura , Bear Harry Douglas , Hackney Mary Helen 
Published: October 2019

142 Background: Gene expression profiling of breast cancers, such as the OncotypeDx (ODX) test, PAM 50 and Mammaprint, can define the risk of distant recurrence and assist with decisions about adjuvant chemotherapy. A recent study of all breast cancer patients in Virginia found that only 11.7 % of Caucasian Americans (CA) and 5.1% of African Americans (AA) received genomic testing. Methods: We utilized the Virginia Commonwealth University Health System (VCUHS) Tumor Registry and billing data from 2010-2017 to identify all patients that met the following criteria per NCCN guidelines for genomic testing: early stage (stage I or II) breast cancer, estrogen and/or progesterone receptor positive and lymph node-negative breast cancer. We also obtained records from Genomic Health on ODX testing ordered through VCU Health. Additionally, ODX utilization was stratified by race. We then performed Chi Square analysis. Results: 1080 patients were eligible per NCCN Guidelines. Of these, 248 were eliminated due to having only radiation performed at VCU. 39 were eliminated because initial treatments were at outside hospitals. Of the remaining 793, 536 were CA, 232 AA, 9 Asian and 16 other. Among the patients for whom a genomic test was appropriate, the proportion who actually had such a test performed were: 83.4% for CA, 71.98% for AA, 55.56% for Asians, 81.25 % for Others and 79.7% overall. There was a significant difference between utilization in CAs and AAs (p < 0.001). Conclusions: Breast cancer patients at VCU Health are far more likely to receive gene expression profiling overall compared to the Commonwealth of VA as a whole. This may reflect more equitable and guideline-compliant care in an academic/safety net health system.