bluuebunny/crossref_metadata_2025_split huggingface dataset:
Answering real-world questions using real-world data: Understanding dynamic treatment decisions and outcomes in metastatic colorectal cancer (mCRC).
Authors: Wong Hui-Li , Degeling Koen , Jalali Azim , Shapiro Jeremy David , Kosmider Suzanne , Wong Rachel , Lee Belinda , Burge Matthew E. , Tie Jeanne , Yip Desmond , Nott Louise M. , Khattak Muhammad Adnan , Lim Stephanie Hui-Su , Caird Susan , Ijzerman Maarten J , Gibbs Peter 
Published: May 2019

e18061 Background: The wide range of possible combinations and sequences available for mCRC treatment presents a major challenge to clinicians, who need to determine the optimal approach for an individual patient or patient subset. In the absence of clinical trial evidence, real world data are an increasingly valuable resource that can be utilized not only to understand treatment patterns and outcomes in routine practice, but also to define an optimal treatment strategy for individual patients across multiple lines of therapy. Methods: Real world data from an Australian mCRC registry were used to develop an interactive data visualization tool that displays treatment variation, customizable to different levels of detail and specific patient subsets, based on patient and disease characteristics. Next, a discrete event simulation model was developed to predict progression-free (PFS) and overall survival (OS) for first line palliative treatment with doublet chemotherapy alone or with bevacizumab, based on data of 867 patients that were treated accordingly. Results: Of 2694 Australian patients enrolled, 2057 (76%) started 1st line treatment with chemotherapy and/or a biologic agent, 1087 (40%) and 428 (16%) received 2nd and 3rd line therapy, respectively. Combined, these 3 lines of treatment accounted for 733 unique sequences. After recoding treatment to the most intensive chemotherapy and the first exposed biologic, 472 unique sequences remained. In exploratory analyses, the simulation model estimated that median 1st line PFS (95% CI) of 219 (25%) patients could be improved from 175 (156, 199) to 269 days (247, 293) by targeting a different treatment. Conclusions: This was an initial exploration of the potential for data visualization and simulation modeling to inform understanding of practice in mCRC and to guide clinical decision making. Such tools allow clinicians and health system providers to define variation in practice patterns and to identify opportunities to improve care and outcomes. Ultimately, the aim is to improve the delivery of personalized cancer care, where other applications such as conditional survival and cost-effectiveness analyses may be useful.
Adoption and utilization of NGS-based molecular profiling in community-based oncology practices: Insights from Sarah Cannon.
Authors: McKenzie Andrew , Schlauch Daniel , Sharma Yasha , Spigel David R. , Burris Howard A. , Jones Suzanne Fields , Dilks Holli Hutcheson 
Published: May 2019

e18064 Background: As the price of NGS-based sequencing technologies falls, adoption of those technologies is predicted to increase. To date, a survey of the adoption and utilization of NGS-based technologies as a part routine oncology clinical care has not been performed. Thus, a comprehensive analysis of physician adoption and utilization of commercial NGS testing in the community-setting between 2012 and 2018 was performed. Methods: Medical Oncologists in the Sarah Cannon Research Institute network ordered commercially-available NGS-based molecular profiling for their patients as standard of care. Data use agreements were initiated between SCRI, affiliated medical oncology practices, and commercial NGS testing providers, and patient NGS data were subsequently analyzed starting in 2012. Results: Community-based NGS testing rates within the Sarah Cannon network were 5.75/month in 2012 and 440/month in 2018. Plasma-based NGS testing began in 2014 and comprised 4.9% of total testing compared to 40.1% in 2018. The number of oncologists ordering molecular profiles increased from 11 in 2012 to 269 in 2018. Physician test utilization grew from an average of 6 tests/physician to 22 tests/physician in 2012 and 2018, respectively. NGS tests were performed on 34 different tumor types and biopsies were taken from both primary (~40%) and metastatic (~60%) sites . Tissue-based tests averaged 14 mutations/sample while plasma-based tests averaged 4 mutations/sample. There was a 74% decrease in median time between biopsy collection and NGS test results between 2012 and 2018 (131 and 34 days, respectively), indicating a shift toward the use of fresh – non-archival – tissue in recent years. Conclusions: These data establish NGS-based testing trends in community oncology practices and show that NGS-based tumor testing utilization has increased in the community-setting between 2012 and 2018. NGS testing is performed on a wide array of tumor types and oncologists utilize fresher biopsies.
Automating incidental findings in radiology reports using natural language processing and machine learning to identify and classify pulmonary nodules.
Authors: French Christi , Makowski Maciek , Terker Samantha , Clark Paul Alexander 
Published: May 2019

e18093 Background: Pulmonary nodule incidental findings challenge providers to balance resource efficiency and high clinical quality. Incidental findings tend to be undertreated with studies reporting appropriate follow-up rates as low as 29%. Ensuring appropriate follow-up on all incidental findings is labor-intensive; requires the clinical reading and classification of radiology reports to identify high-risk lung nodules. We tested the feasibility of automating this process with natural language processing (NLP) and machine learning (ML). Methods: In cooperation with Sarah Cannon Research Institute (SCRI), we conducted a series of data science experiments utilizing NLP and ML computing techniques on 8,879 free-text, narrative CT (computerized tomography) radiology reports. Reports used were dated from Dec 8, 2015 - April 23, 2017, came from SCRI-affiliated Emergency Department, Inpatient, and Outpatient facilities and were a representative, random sample of the patient populations. Reports were divided into a development set for model training and validation, and a test set to evaluate model performance. Two models were developed - a “Nodule Model” was trained to detect the reported presence of a pulmonary nodule and a rules-based “Sizing Model” was developed to extract the size of the nodule in millimeters. Reports were bucketed into three prediction groups: > = 6 mm, < 6 mm, and no size indicated. Nodules were considered positives and placed in a queue for follow-up if the nodule was predicted > = 6 mm, or if the nodule had no size indicated and the radiology report contained the word “mass.” The Fleischner Society Guidelines and clinical review informed these definitions. Results: Precision and recall metrics were calculated for multiple model thresholds. A threshold was selected based on the validation set calculations and a success criterion of 90% queue precision was selected to minimize false positives. On the test dataset, the F1 measure of the entire pipeline (lung nodule classification model and size extraction model) was 72.9%, recall was 60.3%, and queue precision was 90.2%, exceeding success criteria. Conclusions: The experiments demonstrate the feasibility of NLP and ML technology to automate the detection and classification of pulmonary nodule incidental findings in radiology reports. This approach promises to improve healthcare quality by increasing the rate of appropriate lung nodule incidental finding follow-up and treatment without excessive labor or risking overutilization.
The impact of race and socioeconomic status on outcomes for HPV-associated squamous cell carcinoma of the head and neck.
Authors: Pike Luke Roy George , Royce Trevor Joseph , Mahal Amandeep R , Kim Daniel W. , Hwang William L. , Mahal Brandon Arvin Virgil , Sanford Nina Niu 
Published: May 2019

e18103 Background: The socioeconomic factors affecting outcomes of human papillomavirus (HPV)-associated squamous cell carcinoma of the head and neck (SCCHN) are poorly characterized. Methods: A custom Surveillance, Epidemiology, and End Results (SEER) database identified adult patients with primary non-metastatic SCCHN and known HPV status diagnosed between 2013-14. Multivariable logistic regression defined associations between patient characteristics and HPV status, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) reported. Fine-Gray competing risks regression estimated adjusted hazard ratios (AHRs) and 95% CIs for cancer-specific mortality (CSM), including a disease subsite*HPV status*race interaction term. Results: 4735 patients with non-metastatic SCCHN and known HPV status were identified. HPV-associated SCCHN was positively associated with oropharyngeal primary, male sex and higher education and negatively associated with uninsured status, single marital status, and non-white race (p≤0.001 for all). For HPV-positive oropharyngeal SCCHN, white race was associated with lower CSM (AHR 0.55, 95%CI 0.34-0.88, p = 0.01) and uninsured status was associated with higher CSM (AHR 3.12, 95%CI 1.19-8.13, p = 0.02). These associations were not observed in HPV-negative or non-oropharynx SCCHN. Accordingly, there was a statistically significant disease subsite*HPV status*race interaction (pint< 0.001). Conclusions: Non-white race and uninsured status were associated with worse CSM in HPV-positive oropharyngeal SCCHN, while no such associations were observed in HPV-negative or non-oropharyngeal SCCHN. These results suggest that, despite having clinically favorable disease, non-white patients with HPV-positive oropharyngeal SCCHN have worse outcomes than their white peers. Further work is needed to understand and reduce socioeconomic disparities in SCCHN.
Examining predictors of female cancer treatment delay in Appalachian women.
Authors: Balkrishnan Rajesh , Batten George P , Desai Raj Piyush , Daniels Zachary H , Novruzov Lydia , Mole Susan J , Stepanov Nonna J , Roger Anderson 
Published: May 2019

e18107 Background: Appalachian women have a higher burden of both morbidity and mortality from female cancers of the breast, ovary and cervix, and have documented treatment delay and poor adherence. The environmental and sociobehavioral risk factors that could contribute towards these issues such as patient non adherence and treatment delay have not been studied. Methods: We conducted a detailed survey of women seeking cancer related preventative care in a tertiary care cancer center in the Appalachian region of Virginia. Survey questions included health behaviors, financial issues, and past health history. The survey was administered to 200 women and a total of 158 complete responses (42 in women with cancer in the recent past) were obtained. Results: There were significant differences between women with and without female cancers with the cancer group being older, less likely to be married, be unemployed and more likely to have received mammograms (All p < 0.05). In multivariate analyses , the major risk factor associated with delaying treatment was the lack of health insurance in the previous year (RR: 0.25, 95% CI: 0.082-0.73). Conclusions: Women in Appalachia face significant barriers in receiving diagnoses and treatment for female cancer including lack of employment, health care insurance and social support. These factors need to be considered while designing interventions to improve access and adherence to cancer treatments in this population.
Disparities in the receipt of palliative care (PC) in metastatic renal cell carcinoma (mRCC).
Authors: Tella Sri Harsha , Kommalapati Anuhya , Tandra Pavan Kumar 
Published: May 2019

e18108 Background: Early integration of PC has shown to improve quality of life and survival in some solid malignancies. In this study we sought to analyze the PC utilization in mRCC patients. Methods: Patients with mRCC reported to NCDB between 2004 & 2015 were extracted and we included the patients who died of mRCC. We classified the patients into three cohorts based on their length of survival ( < 6, 6-24, and > 24 months) to account for disease severity. Using SPSS, we performed multivariable logistic regression to determine the patient and institutional factors determining the PC use. Results: A total of 29,296 patients were analyzed. Overall, 20% (n = 5737) of the patients received PC. Among these, 7%,17%,7%, 53%, and 12% received pain management PC; palliative chemotherapy, surgery, radiation and combination therapies, respectively. On cox multivariate analysis, among patients that survived < 6 months, receipt of PC was associated with better overall survival (OS) [HR: 0.91 (CI:0.87-0.95), p < 0.01]. Patients who received PC were more likely to be of White race, non-Hispanic origin, treated at non-academic facilities, and had higher educational background (p < 0.01) (Table). Patients living in East, Central, and Mountain regions had higher odds of receiving PC than those in the Pacific coast. The odds of receiving PC were significantly higher in patients who survived for < 6 months as compared to that of > 24 months (23 vs 13%, p < 0.01). Conclusions: We noticed a significantly better OS in mRCC patients who received PC. Despite the benefits in OS and guidelines advocating the PC use, the overall PC utilization in mRCC is markedly low and plagued by race, facility type and geographic region. [Table: see text]
Insurance status and racial disparities in detection of early-stage breast cancer.
Authors: Ko Naomi , Hong Susan , Winn Robert , Calip Gregory Sampang 
Published: May 2019

e18121 Background: Racial/ethnic minority women are diagnosed with later stage breast cancer. This study identifies the extent insurance can affect stage differences among a large, diverse population of breast cancer patients in the U.S. Methods: Retrospective, population-based study of women aged 40-64 years diagnosed with stages I-III breast cancer in the Surveillance, Epidemiology and End Results Program between 2010 and 2014. The primary outcome was risk of diagnosis with locally-advanced (stage III) versus early stage breast cancer (stages I-II). Causal mediation analyses were conducted to determine effects of race/ethnicity and proportion of observed differences mediated by health insurance status on earlier stage. Results: A total of 124,415 women (104,468 insured and 19,947 uninsured /Medicaid) were included. Among women with health insurance, a lower proportion was diagnosed with locally-advanced breast cancer compared to uninsured/Medicaid-covered women (11% versus 21%). In multivariable models, non-Hispanic Black (OR = 1.50, 95% CI 1.43-1.58), American Indian/Alaskan Native (OR = 1.38, 95% CI 1.11-1.72) and Hispanic (OR = 1.35, 95% CI 1.28-1.42) women had higher odds of being diagnosed with locally-advanced disease compared to non-Hispanic White women. When adjusting for health insurance and other socioeconomic factors, associations between race/ethnicity and risk of locally-advanced breast cancer were attenuated (non-Hispanic Black: OR = 1.30, 95% CI 1.23-1.37; American Indian/Alaskan Native: OR = 1.15, 95% CI 0.91-1.45; Hispanic: OR = 1.16, 95% CI 1.09-1.22). Approximately half (48% to 50%) of racial differences in risk of locally advanced disease were mediated by health insurance. Conclusions: We find that half of the observed racial/ethnic disparities in upstaging at diagnosis are mediated by health insurance coverage.
Improved hepatocellular carcinoma (HCC) outcomes in a public hospital setting with increased access to procedural-based therapy.
Authors: Ellent Elizabeth S. , Joshi Tejas V , McDaniel Lee S , Boulmay Brian C. 
Published: May 2019

e18137 Background: HCC is the 2nd most common cause of cancer death in the world. We investigate if increased access to various treatment modalities improved outcomes in a public hospital setting. Access to procedural-based treatments improved with development of an in hospital interventional radiology program that resulted from increased public hospital funding starting in 2013 at University Medical Center in New Orleans (UMC). Methods: A retrospective chart review was conducted to analyze 124 patients (pts) diagnosed with HCC from 2013 to 2018 at UMC to determine effect of treatment modality on outcome. Comparative analysis and Fisher’s exact test was performed using a previous study analyzing a similar population (n = 107) from 2007-2013. Results: Pts with HCC treated with transarterial chemoembolization (TACE) had an overall survival (OS) of 82.55% and 54.84% at 1 and 3 years (yr). Pts not treated with TACE had OS of 60.69% and 38.49% at 1 and 3 yr. OS in the 2007-2013 cohort at 1 year was 29%. Progression free survival (PFS) in pts treated with TACE was 52.99% and 22.66% at 1 and 3 yr. PFS in patients not treated with TACE was 58.36% and 50.28% at 1 and 3 yr. Treatment with Sorafenib (S) with or without TACE had OS of 75.84% and 48.43% at 1 and 3 yr. Pts not receiving S had an OS of 69.17% and 48.47% at 1 and 3 yr. PFS was 37.27% and 10.57% in pts treated with S at 1 and 3 yr. PFS for pts not treated with S was 67.00% and 47.02% over 1 and 3 yr. There were 140 total IR procedures which averages to 1.13 IR procedures per pt. Compared to 2007-2013 cohort, more HCC pts had TACE (10% to 56%, p < 0.001) and received S (18% to 39%,p < 0.001). Conclusions: Although PFS was not better for those pts treated with TACE (p value = 0.218), OS was statistically better with TACE (p value = 0.003). Radiologic response rates do not appear to correlate with OS benefit, perhaps due to TACE effect on image interpretation. PFS was decreased in pts treated with S (p value = < 0.0001), possibly due to its use in pts who have progressed despite TACE. The 2013-2018 cohort has superior OS compared to the 2007-2013 cohort at 1 yr. Increased access to procedural- based, locoregional therapy and S positively impacts patient outcomes.
Investigating racial differences in treatment responses through analysis of real-world data (RWD).
Authors: Liu Zongzhi , Ma Meng , Grover Kartikey , Li Li , Goldsweig Howard , Yadav Kamlesh , Zhou Xiang , Mullaney Tommy , Redfern Arielle , Jappe Whitney , Zimmerman Michelle , Prentice Tony , Pan Qi , Oh William K. , Schadt Eric E. , Li Dan , Chen Rong 
Published: May 2019

e18141 Background: Clinical trials remain the most reliable means to evaluate drug efficacy and safety for evidence-based cancer care. However, there is a significant racial disparity among participants in clinical trials. For example, only 1-3% of the participants in registration trials of immune checkpoint inhibitors (CPIs) in advanced non-small cell lung cancers (aNSCLCs) were Black. RWD data enable assessment of whether clinical trial results can be generalized to broader populations. Methods: We analyzed clinical records of > 145,000 cancer patients treated at Mount Sinai hospitals. Therapeutic agents approved by FDA in recent years were assessed for responses across various race groups. Time to treatment discontinuation (TTD) was used as a surrogate clinical endpoint for outcomes. Results: Overall we did not observe significant differences in TTD among different race groups for the following drugs and indications we examined: palbociclib in metastatic breast cancer (mBC), EGFR tyrosine kinase inhibitors in aNSCLC, EGFR antibody cetuximab and panitumumab in metastatic colorectal cancer with wild type KRAS, abiraterone in metastatic castration-resistant prostate cancer (mCRPC), enzalutamide in mCRPC, sorafenib in unresectable hepatocellular carcinoma (HCC), CPIs in metastatic melanoma. For example, the median TTD of palbociclib in combination with fulvestrant or letrozole in post-menopausal women with HR+HER2- mBC was 181, 261, and 160 days in White (n = 114), Black (n = 55), other (n = 48) race groups, respectively (P = 0.61, log-rank test). Among patients with unresectable HCC treated with sorafenib, the median TTD was 64, 49, and 67 days in the White (n = 201), Black (n = 127) and other (n = 243) race groups, respectively (P = 0.70). However, when CPIs in aNSCLC were examined, we observed a significantly longer TTD in the Black group (median TTD not reached; n = 77) compare to the non-Black group (169 days, 95% CI 133-331; n = 211), P = 0.0049, median follow up 194 days. Conclusions: RWD showed there are no apparent differences of treatment response in various race groups for most new therapeutic agents. Preliminary results of CPIs in aNSCLC suggested a favorable response in the Black than the non-Black population.
Impact of a pilot patient navigator program on pediatric cancer outcomes in a low resource setting.
Authors: Schroeder Kristin , Alvi Fatima , Johnston Hartlee , Masalu Nestory Andrew , Chao Nelson Jen An 
Published: May 2019

e18152 Background: Oncology patient navigation programs have been successfully implemented at hospitals throughout the U.S., enhancing the quality of canceer care. In low resource settings, the barriers to receiving cancer care are increased and a patient navigator in this setting has the potential to significantly impact outcomes. However, research on efficacy is limited. Methods: At Bugando Medical Centre (BMC) in Mwanza, Tanzania, semi-structured qualitative interviews of 15 key stakeholders in the oncology department and 15 families of patient with pediatric cancer diagnoses were completed to identify health system delivery and patient related barriers to timeliness of diagnosis, treatment initiation, and treatment completion. Based on identified barriers, a pilot patient navigation program was established to assist patients and their families with care coordination throughout the diagnosis and treatment process. A retrospective analysis of hospital records was conducted of all pediatric oncology patients seen at BMC from 2010-2016, separated by presentation date before or after establishment of navigation program. Collected data includes demographics, diagnosis, time from presentation to oncology evaluation and diagnosis, and treatment completion. Results: Identified patient related barriers included patient diagnosis and treatment knowledge, and complexity of care. Health system delivery barriers included limited provider capacity, and poor care coordination between the oncology providers, other health care services and patient families. A total of 238 patient files were reviewed, with 169 pre- and 69 post- program initiation. Patient groups did not differ by age or gender (p = 0.329 and 0.744), or diagnosis distribution. The average time to oncology evaluation decreased from 49.7 to 16.6 days (p = 0.015), and time to diagnosis decreased from 49.1 to 23.6 days (p = 0.07). Treatment abandonment decreased from 50% to 38% (p < 0.001). Conclusions: In pediatric oncology, early diagnosis is critical to the initiation of chemotherapy and improving outcomes. These data suggest that a patient navigation program is feasible in a LMIC and can impact both health system inefficiency and treatment abandonment, with the potential to improve pediatric cancer outcomes.