bluuebunny/crossref_metadata_2025_split huggingface dataset:
Significance of examined lymph node number in accurate staging and long-term survival in resected stage I-II pancreatic cancer: More is better? A large international population-based cohort study.
Authors: Huang Lei , Jansen Lina , Balavarca Yesilda , van der Geest Lydia , Lemmens Valery , Groot Koerkamp Bas , van Santvoort Hjalmar , Grützmann Robert , Besselink Marc G. , Schrotz-King Petra , Brenner Hermann 
Published: May 2019

6503 Background: Examined lymph node (ELN) number is an important quality metric in cancer care. This large international cohort study aimed to investigate the associations of ELN number with accurate staging and long-term survival in pancreatic cancer (PaC) and to robustly determine the minimal and optimal ELN thresholds. Methods: Population-based data on patients with stage I-II PaC resected in 2003-2015 from the US Surveillance, Epidemiology, and End Results (SEER)-18 Program and Netherlands National Cancer Registry (NCR) were analyzed. Associations of ELN number with stage migration and survival were evaluated using multivariable-adjusted logistic and Cox regression models, respectively. The series of odds ratios (ORs) for stage migration and hazard ratios (HRs) for survival with more ELNs were fitted using a LOWESS smoother, and structural breakpoints were determined by Chow test. Results: Overall 18,303 patients were analyzed. With increasing ELN number, both cohorts exhibited significant proportional increases from node-negative to node-positive disease (ORSEER-18= 1.05, 95% CI = 1.04-1.05; ORNCR= 1.10, 95% CI = 1.08-1.12) and serial improvements in survival (HRSEER-18= 0.98, 95% CI = 0.98-0.99; HRNCR= 0.98, 95% CI = 0.97-0.99) per additional ELN after controlling for confounders. Associations for stage migration and survival remained significant in most stratifications by patient, tumor, and treatment factors. Cut-point analyses suggested a minimal threshold ELN number of 12 and an optimal number of 19, which were validated both internally in the derivative US cohort and externally in the Dutch cohort with the ability to well discriminate different probabilities of both survival and stage migration. Conclusions: In stage I-II PaC, more ELNs are associated with more precise nodal staging, which might largely explain the survival association. Our results robustly conclude 12 ELNs as the minimal and suggest 19 ELNs as the optimal cut-points, for evaluating quality of lymph node examination and possibly for stratifying postoperative prognosis. Our findings provide important references for defining population-based quality metrics in PaC care.
A process to reduce hospital admissions in the OCM population through focused intervention of super-utilizers.
Authors: Perry Manuel , Rudy-Tomczak Katie , Lalanne Joanne , Whalen Allison , Shah Shannon , Hines Scott 
Published: May 2019

6505 Background: A small number of patients (super-utilizers) are responsible for much of the cost in healthcare. In several studies, 5% of patients are responsible for 50% of the cost. Healthcare hot-spotting is the strategic use of data to deliver enhanced resources to selected super-utilizers in an effort to improve the quality of care and to reduce costs. Methods: Patients enrolled in the Oncology Care Model (OCM) who were scheduled to receive cytotoxic, targeted therapy or immunotherapy beginning in the fall of 2017 were screened by nurse practitioners prior to initiating treatment in an effort to identify super-utilizers. Risk factors included high risk disease (stem cell transplant, myelodysplastic syndrome, acute leukemia, stage IV disease), significant co-morbidities (CHF, COPD, renal failure, Insulin Dependent Diabetes , presence of a gastrostomy tube), or an admission to the hospital in the past 6 months. Such patients were provided with enhanced services which included twice weekly outreach by a nurse practitioner between 8am and 10am for a telephonic evaluation of their health status. If the patient was found to have either a new problem that required intervention or a worsening chronic problem, then a same-day appointment was made with the nurse practitioner, oncologist, primary care provider or appropriate specialist. Results: Inpatient admissions decreased from 21.3 per 100 OCM beneficiaries to 18.7 per 100 OCM beneficiaries representing a 12.2% decrease. Inpatient costs were reduced from $979 per beneficiary per month (PBPM) to $885 PBPM representing a decrease of $94 PBPM (9.6% decrease). Conclusions: Targeting oncology super-utilizers based on the nature of their diagnosis, co-morbidities, or history of a recent hospital admission and offering telephonic evaluation reduced hospitalizations and decreased cost resulting in a savings of nearly $600,000 per year for our OCM cohort of 600 beneficiaries. [Table: see text]
The financial impact of physician practice patterns: An analysis of as-needed filgrastim versus prophylactic pegfilgrastim in patients with prostate cancer receiving docetaxel.
Authors: Barrett Christine , Park Seon Jo , Gaertner Kelly , Mao Shifeng 
Published: May 2019

6506 Background: Docetaxel improves survival in metastatic prostate cancer. Patients receiving docetaxel are at an intermediate risk of febrile neutropenia (FN). Granulocyte-colony stimulating factor (G-CSF) reduces the incidence of neutropenia and infection. There is no consensus among physicians on G-CSF use with docetaxel in prostate cancer, and physician preference may significantly impact healthcare costs. The purpose of this study is to assess physician practice patterns by comparing efficacy and cost of as-needed filgrastim (ANF) to prophylactic pegfilgrastim (PPF) for neutropenia in patients with prostate cancer receiving docetaxel. Methods: This retrospective cohort study included patients with prostate cancer that received standard docetaxel and G-CSF, either ANF or PPF, from February 2016 to October 2018 at our institution. In the ANF arm, patients with an ANC less than 1000 cells/µL on day 8 of the cycle received filgrastim. In the PPF arm, patients received pegfilgrastim on day 2 for primary prophylaxis. Patient characteristics, chemotherapy dose intensity, delays, and reductions, and incidence of FN were collected. Results: Of the 65 patients included in this study, 32 received ANF and 33 received PPF. Patients in the ANF arm received an average of 6.0 cycles versus 4.8 cycles in the PPF arm (p = 0.013). The completion rate of planned cycles differed, with 93.8% completion in the ANF arm versus 66.7% in the PPF arm (p = 0.001). Average total drug exposure per patient was greater in the ANF arm than the PPF arm (437.5 mg/m2 versus 343.4 mg/m2; p = 0.007). In both groups, there was no significant difference in dose delays or reductions, or incidence of FN. However, there was a significant difference in cost, with an average of $740.26 per cycle per patient for filgrastim, versus $7327.72 per cycle per patient for pegfilgrastim, based on current average wholesale price. Conclusions: In our study, use of ANF was safe, and did not impact planned dose, intensity, or duration when compared to PPF. In addition, the administration of ANF was associated with significant cost savings. Analysis of G-CSF use in patients with prostate cancer receiving docetaxel at our institution has identified an opportunity for substantial healthcare cost savings.
Impact of a same-day breast biopsy program on disparities in time to biopsy.
Authors: Seidler Matthew , Dontchos Brian Nicholas , Mercaldo Sarah , Miles Randy C. , Narayan Anand , Lehman Constance Dobbins 
Published: May 2019

6508 Background: While screening rates have improved among minorities, racial/ethnic disparities in diagnosis and treatment persist. Many steps in the diagnostic pathway can delay tissue diagnosis, and in usual practice breast biopsies are performed days to weeks after biopsy recommendation. The purpose of this study was to identify if racial/ethnic disparities exist in time from biopsy recommendation to biopsy, and if a same-day biopsy program (biopsy on the same day as the recommendation) eliminates these disparities. Methods: After IRB approval, we identified all diagnostic mammogram and ultrasound exams leading to biopsy pre- (September 2016-March 2017) and post- (September 2017-March 2018) implementation of our same-day biopsy program. We compared the distribution of age, race, language, insurance type, days to biopsy and proportion of same-day biopsies in pre- vs. post-implementation groups using the Wilcoxon test (for continuous variables) and the Pearson’s chi-squared test (for categorical variables). Multivariable linear and logistic models were estimated in pre and post periods to assess if days from biopsy recommendation to biopsy (linear) and having a same-day biopsy (logistic) were associated with age, race, language, and insurance type. Results: 663 and 482 patients underwent biopsy during pre- and post-implementation, respectively. Age, race, language, and insurance type were similar between time periods. For all patients, the same-day biopsy program decreased mean time from diagnostic examination to biopsy from 8 (IQR: 4-13) to 0 (IQR: 0-4) days (p < 0.001). During the pre time period, non-white patients and having government insurance were significantly associated with longer days to biopsy (non-white aCoef: 2.30 (95% CI: 0.58-4.03); insurance aCoef: 1.67 (95% CI: 0.02-3.32); p < 0.05), and increasing age and having government insurance were significantly associated with decreased odds of having a same-day biopsy (age aOR: 0.97 (95% CI 0.95-0.99); insurance aOR: 0.35 (95% CI 0.14-0.88); p < 0.05), after adjustment. During the post time period there was no evidence of these disparities. Conclusions: A same-day biopsy program eliminated racial/ethnic disparities in time from breast biopsy recommendation to biopsy.
The use of optimal evidence-based chemotherapy (chemo) regimens in physician offices versus hospital outpatient facilities.
Authors: Fisch Michael Jordan , Liu Ying , NGUYEN ANN , Barron John , Fishman Ezra , Sylwestrzak Gosia 
Published: May 2019

6514 Background: The proportion of infused chemo administered in hospital outpatient facilities (HOF) increased from 6% in 2004 to 43% in 2014. The average annual cost for patients receiving chemo was significantly higher in HOFs than in physician offices (POs). One option to explore differences in the quality of care between these two settings is to examine the use of chemo regimens, which, based on their efficacy, toxicity, and costs, have been designated as “on-pathway.” This study compared on-pathway rates among patients receiving infused chemo administered in POs vs. those in HOFs. Methods: Using administrative claims data, we identified 61,496 breast, lung, or colorectal cancer patients receiving chemo from 2013 to 2018. Chemo regimens were considered “on-pathway” when they were on payer's program list of optimal regimens when administered. Generalized linear models examined the association between site of service and on-pathway prescribing rates, and costs of care. Models adjusted for age, sex, year, rural status, cancer type and setting, and comorbidities, with fixed effects for providers. Results: Percentage of infused chemo administered in HOFs increased from 44.2% in 2013 to 54.7% in 2018. After adjustment, on-pathway prescribing rate did not differ significantly between HOFs and POs (50.1%, 95% CI: 48.6%-51.5% vs. 49.8%, 95%CI: 48.3%-51.3%, p = 0.65). 6-month chemo cost ($56,885, 95% CI: $54,364-$59,524 vs $32,240, 95% CI: $30,929-$33,605, p < 0.001) and 6-month medical cost ($114,280, 95% CI: $110,716-$117,960 vs $79,455, 95% CI: $77,089-$81,893, p < 0.001) were significantly higher in HOFs vs. POs. Conclusions: Quality of care as measured by use of optimal chemo regimens was similar in hospital and office setting. Cost continues to be significantly higher in hospital setting. These findings provide a strong basis for site-neutral reimbursement policies.
Randomized trial of text messaging (TM) to reduce early discontinuation of aromatase inhibitor (AI) therapy in women with breast cancer: SWOG S1105.
Authors: Hershman Dawn L. , Unger Joseph M. , Grace Hillyer , Moseley Anna , Arnold Kathryn B , Dakhil Shaker R. , Esparaz Benjamin , Kuan Ming C. , Graham Mark , Lackowski Douglas M , Edenfield William Jeffery , Dayao Zoneddy Ruiz , Gralow Julie , Ramsey Scott , Neugut Alfred I. 
Published: May 2019

6516 Background: Non-adherence to AI’s for breast cancer is common and increases risk of recurrence. Text messaging (TM) has been shown to increase adherence to medications for chronic conditions. We conducted a multicenter randomized trial to evaluate if TM reminders improve AI adherence. Methods: Patients taking an AI for ≥30 days and having ≥36 mos of planned therapy were eligible. Patients were randomly assigned 1:1 to receive either TM or NO-TM twice a week for 36 mos. Randomization was stratified by length of time on prior AI therapy ( < 12 (64%) vs. 12-24 mos (36%)) and AI class (anastrozole, letrozole, exemestane). Content themes of the 36 TMs focused on overcoming barriers to adherence. Patients were assessed for discontinuation of AIs every 3 mos for 36 mos. The primary outcome was time to non-adherence, where non-adherence was defined as urine AI metabolite assay results satisfying the following: < 10 [units], undetectable, or no submitted specimen. A stratified Log-rank test was conducted. Multiple sensitivity analyses were performed using Cox regression. Results: In total, 724 patients were registered between May, 2012 and September, 2013, among whom 696 (338/360 (93.9%) on TM and 338/364 (92.9%) on NO-TM) were eligible and adherent at baseline. Observed (time-independent) adherence at 36 mos was 55.4% for TM and 55.4% for NO-TM. The primary analysis showed no difference in time-to-adherence failure between patients on the TM and NO-TM arms (HR = 0.89, 95% CI:0.76,1.05 p = .18). An analysis of negative urine tests alone resulted in similar non-significant results. With missed appointments not counted as failures, time to self-reported discontinuation (89.6% vs. 89.7%; HR = 1.17, 95% CI:0.69-1.98, p = .57) and site reported discontinuation (78.1% vs. 81.1%; HR = 1.31, 95% CI:0.86-2.01, p = .21) were also similar between the 2 groups. Conclusions: As the first large long-term randomized trial of an intervention directed at improving AI adherence, we found high rates of AI discontinuation. Bi-weekly text reminders did not improve adherence to AIs compared to usual care. Improving long—term adherence will likely require sustained behavioral interventions and support. Clinical trial information: NCT01515800.
Impact of Electronically Accessible Pathways (EAPathways) on clinical trial enrollment at a large multisite cancer center.
Authors: Villadolid Jeryl Jean , Jandrisevits Elizabeth , Moore Donald , Patel Jai Narendra , Mileham Kathryn Finch , Kim Edward S. 
Published: May 2019

6517 Background: Clinical pathways streamline evidence-based treatment decisions and provide consistent, high-quality, value-based care. A high-quality clinical pathway should enhance screening and access to clinical trials. Our healthcare system utilizes EAPathways to allow providers to select treatment regimens vetted by section experts, inquire about clinical trials, and refer to relevant programs (e.g. palliative medicine) or testing (e.g. genomics) at a main cancer center and 22 regional sites. With over 400 clinical trials, our goal is to provide access regardless of where a patient lives or receives treatment. We aim to explore the impact of EAPathways on clinical trial enrollment at our healthcare system. Methods: This study is a retrospective review to compare clinical trial inquiries through EAPathways and clinical trial enrollment using Oncore between 1/1/2017 and 7/31/2018. The primary outcome is the success rate reported as the total number of inquiries that resulted in clinical trial enrollment. Other outcomes include a comparison of inquiries and enrollments for hematology and solid tumor oncology, cancer treatment and non-treatment (e.g. specimen collection), and our main cancer center and regional sites. The number of and reason for opting out of treatments or trials was also analyzed. Results: A total of 29.1% (740/2539) of clinical trial inquiries through EAPathways resulted in clinical trial enrollment. Success rates for the following settings were reported: 39.5% (223/564) in hematology, 26.2% (517/1975) in solid tumor oncology, 27.0% (594/2203) in treatment trials, and 43.5% (146/336) in non-treatment clinical trials. Sixty-three percent of enrollments were at our main cancer center compared to regional sites. A total of 39.7% (3356/8453) of patients were enrolled into an opt-out pathway due to reasons such as performance status, organ dysfunction, or hospice. Conclusions: Clinical pathways can provide access to clinical trial enrollment in multiple settings. These baseline metrics will help assess process improvement needs to increase clinical trial enrollment success rates and address reasons for opt-out.
The financial impact of fractionation scheme and treatment planning method for rectal cancer in the United States.
Authors: Moore Assaf , Den Robert Benjamin , Gordon Noa , Sarfaty Michal , Kundel Yulia , Brenner Baruch , Goldstein Daniel A. 
Published: May 2019

6518 Background: Preoperative long-course chemoradiotherapy (CRT) and short-course radiotherapy (SCR) for locally advanced rectal cancer (LARC) were found to have equivalent outcomes in three randomized trials. SCR may have lower acute toxicity and the down-staging following CRT is more well-established. At present, SCR is frequently used in Europe but has not been widely adopted in the United States (US). It is standard to deliver radiotherapy by 3D planning, while the use of Intensity-modulated radiotherapy (IMRT) is controversial. In recent years there has been an increasing focus on understanding the cost and value of cancer care. In this study we aimed to assess the economic impact of fractionation scheme and treatment planning method for payers in the US. Methods: We performed a population-based analysis of the total cost of radiotherapy for LARC in the US annually. The national annual target population of patients was calculated using the Surveillance, Epidemiology, and End Results (SEER) database. Treatment costs for various fractionation schemes were based on billing codes and 2018 pricing by Medicare's Hospital Outpatient Prospective Payment System (OPPS). The cost of chemotherapy was based on the Payment Allowance Limits for Medicare Part B Drugs by Centers for Medicare and Medicaid Services (CMS). Results: We estimate that 12,945 patients with LARC are treated with radiotherapy annually in the US. The cost of CRT with 3-D or IMRT is US$ 15,881.76 and US$ 23,744.82 per patient, respectively. With 3-D SCR the cost is US$ 5,457 per patient. The use of SCR would lead to 64-77% annual savings of US$ 125,701,387 - US$ 236,727,934 in the US compared with 3-D and IMRT based CRT, respectively. IMRT based planning increases the total cost of CRT by 49% and if adopted widely would lead to an excess cost of US$ 101,787,312 annually. Conclusions: SCR may have the potential to save in the region of US$ 0.12-0.23 billion annually in the US, likely without impacting outcomes. Lack of evidence showing benefit with costly IMRT should limit its use to clinical trials. SCR may also lead to lower personal financial toxicity. It would be reasonable for public and private payers to consider which type of radiation is most suited to reimbursement.
Comparative effectiveness of proton therapy versus photon therapy as part of concurrent chemoradiotherapy for locally advanced cancer.
Authors: Baumann Brian Christopher , Mitra Nandita , Harton Joanna , Xiao Ying , Wojcieszynski Andrzej , Gabriel Peter Edward , Zhong Haoyu , Geng Huaizhi , Doucette Abigail , Wei Jenny J. , O'Dwyer Peter J. , Bekelman Justin E. , Metz James M. 
Published: May 2019

6521 Background: Concurrent chemo-radiotherapy is standard-of-care curative treatment for many cancers, but is associated with substantial morbidity. Proton therapy may increase the tolerability or effectiveness of concurrent chemo-radiotherapy by reducing radiation to normal tissues. Methods: We conducted a comparative effectiveness study of adult non-metastatic cancer patients treated with curative intent with proton chemo-radiotherapy vs. photon chemo-radiotherapy from 2011-2016 at the University of Pennsylvania. Re-irradiation and disease sites treated with photon-only therapy were excluded. Data on adverse events and survival was gathered prospectively. Primary endpoint was 90-day adverse events associated with unplanned hospitalizations (CTCAEv4 grade ≥3 adverse events). Secondary endpoints included decline in ECOG performance status during treatment, 90-day grade ≥2 adverse events, disease-free survival (DFS) and overall survival (OS). Modified Poisson regression models with inverse propensity score weighting were fit for both outcomes. Propensity scores were estimated using an ensemble machine-learning approach. Results: 1,483 patients were included (391 proton/1,092 photon). Proton patients were significantly older (median 66 vs. 61), had less favorable Charlson-Deyo comorbidity scores (median 3.0 vs. 2.0), and had lower integral radiation dose to tissues outside the target (p < 0.05 for all). Baseline toxicity and performance status were similar (p > 0.05). In propensity score weighted-analyses, proton chemo-radiotherapy was associated with significantly lower relative risk (RR) of 90-day grade ≥3 adverse events [11.5%(95%CI 8.3-14.7%) for protons; 27.6%(95%CI 24.9-30.2%) for photons; RR 0.31, 95%CI 0.15-0.66, p < 0.01]; 90-day grade ≥2 adverse events (RR 0.78, 95%CI 0.65-0.93, p < 0.01); and decline in performance status during treatment (RR 0.51, 95%CI 0.37-0.71, p < 0.01). There was no difference in DFS or OS. Conclusions: In adults with locally advanced cancer, proton chemo-radiotherapy was associated with significantly reduced acute adverse events causing unplanned hospitalizations with similar disease-free and overall survival.