bluuebunny/crossref_metadata_2025_split huggingface dataset:
Real-world concordance of clinical practice with ASCO and NCCN guidelines for EGFR/ALK testing in aNSCLC.
Authors: Ruggiero John E. , Rughani Jay , Neiman Josh , Swanson Steven , Revol Cindy , Green Robert J. 
Published: April 2017

212 Background: Timely and appropriate biomarker testing guides evidence-based treatment decision-making in advanced non-small cell lung cancer (aNSCLC). American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommend that all treatment-eligible patients with non-squamous, or squamous histology in non-smokers undergo EGFR and ALK biomarker testing prior to initiating first line therapy. Genentech’s Learning and Clinical Integration team and Flatiron Health explored the frequency of EGFR/ALK testing and overall time between advanced disease diagnosis, results receipt and treatment initiation in clinical oncology practices. Methods: Structured and unstructured data were obtained from Flatiron’s electronic health record database. 6,991 patients from 166 clinics diagnosed after 1/1/14 with at least 2 visits before 8/31/15 were randomly selected from the Flatiron aNSCLC national cohort of > 25,000 patients. Dates of specimen collection, results receipt and treatment start were collected. Results: EGFR/ALK testing was conducted in 75% of non-squamous patients with wide variation across practices (< 20% to 100%). For squamous patients, 15% were tested overall, but with dramatic variation across practices (0% to 100%). For patients with a positive test result available prior to initiation of first line treatment, 79% of EGFR+ and 94% of ALK+ patients received the appropriate targeted therapy. However, for those patients tested after initiation of first line therapy, only 41% of EGFR+ and 65% of ALK+ patients received appropriate targeted first line therapy. EGFR/ALK tests results were received > 4 weeks from aNSCLC diagnosis in 32% and 34% of patients, respectively. Validation testing indicated that delays were attributed to non-lab factors, as test results were returned in < 2 weeks in 95% of cases. Conclusions: Wide variation in real-world practice illustrates the need to improve adherence to ASCO and NCCN biomarker testing guidelines. Educational intervention to improve quality of care in aNSCLC should focus on ensuring testing of almost all non-squamous patients, limiting testing to the non-smoking squamous cell population, and ensuring timely ordering of testing by clinicians.
Delays in access to palliative care services among cancer patients in South Texas.
Authors: Rauenzahn Sherri L. , Schmidt Susanne , Aduba Ifeoma , Ali Nazneen , Tenner Laura LaNiel 
Published: April 2017

215 Background: The growing support for integrated palliative and cancer care resulted in the American Society of Clinical Oncology’s new recommendation which states patients “with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment.” Unfortunately, timely access to palliative services remains an issue for cancer patients and centers. The aim of this project is to evaluate how socioeconomic factors impact palliative access for patients in South Texas. Methods: During a 6-month period, patients in oncology clinics completed the Edmonton Symptom Assessment System questionnaire. Scores reaching a predetermined threshold resulted in a provider alert to consider referral to palliative services. We examine time to initial palliative appointment after referral and compare time to visit based on location of palliative services determined by insurance coverage. Results: During our study period, providers referred 47 unique patients with 27 patients eligible to receive care at the University of Texas Medicine System (Group A) and 20 patients qualified for care at the University Hospital System providing services to under-insured and safety net patients (Group B). Of the 47 referred patients, 27 (57%) patients were offered an appointment and only 17 patients (36%) actually had a palliative care visit (13/27 (48%) Group A patients and 4/20 (20%) Group B patients). On average, Group B patients had 25.2 days longer wait times to palliative visits compared to Group A patients. Conclusions: This investigation revealed a discrepancy between referral and actual receipt of care. While this study is limited by a small sample, data suggests that under-insured oncology patients may have significantly different access to palliative services which may impact the quality of cancer care. [Table: see text]
Resource utilization and provider variation in the care of patients with stage IV non-small cell lung cancer six months before death.
Authors: Aakhus Erin , Berman Abigail T. , Crimins Neil , Gabriel Peter Edward , Braun Jennifer , Shulman Lawrence N. , Evans Tracey L. 
Published: April 2017

216 Background: Cost of care of cancer patients near the end of life is a focus for payers and others. The breakdown of costs during this period for patients with Stage IV non-small cell lung cancer (NSCLC) are shifting as therapeutic choices change. We measured and reported variation in utilization, by oncologist, aiming to improve standardization and reduce utilization while maintaining or increasing the quality of care. Methods: Within the University of Pennsylvania Health System (UPHS), we identified all deceased patients with Stage IV NSCLC with first contact of 1/3/2011 to date of death of 4/10/2016, at least 1 chemotherapy visit, and 6 months between first contact and death (N=175). We captured all inpatient and outpatient charges within 6 months of patient death. Results: The median gross total charge per patient was $209,637 (interquartile range, $121,517-$371,196), which consisted of 39% outpatient infusions, 23% radiation therapy, 18% inpatient medical admissions, 11% outpatient radiology, 4.5% professional charges, and <1% ED visits. Infusions of pemetrexed and bevacizumab accounted for 7.3% and 6.1% of the gross total charges, respectively. Only 13/175 (7.4%) of patients received infusions within 14 days of death. Primary oncologist was not found to be a significant driver of variation in total, outpatient, or inpatient gross charges per patient (p=0.097, 0.208, 0.297). However, we showed that professional charges and use of outpatient radiology differed by oncologist (p=0.039, 0.003). We also identified oncologist-driven differences in use of supportive care drugs pegfilgrastim, darbepoietin, and denosumab (p=0.002, <0.001, <0.001). We detected no differences in use of pemetrexed or bevacizumab (p=0.835, 0.521). The differences in number of infusion visits approached significance (p=0.058). Conclusions: Outpatient infusions and radiation therapy were the largest contributors to healthcare resource utilization in the care of Stage IV NSCLC patients in the last 6 months of life. Variation in utilization by primary oncologist was detected in professional charges, outpatient radiology, and the use of supportive care (but not chemotherapeutic) agents.
Quality indicators for cervical cancer care in Japan.
Authors: Watanabe Tomone , Kamitani Satoru , Iwamoto Momoko , Higashi Takahiro 
Published: April 2017

219 Background: Although ensuring high-quality care has a central role in Japanese cancer policy, introduction of a system to evaluate quality is still underway. With the goal of establishing a sustainable measurement system, this study assesses adherence to quality indicators (QIs) as an index for evaluating the quality of care for cervical cancer patients in Japan. Methods: Ten measurable QIs were devised by an expert committee using the modified Delphi method. Adherence to each QI was calculated by using hospital cancer registry data of patients diagnosed during 2013 and claims data between October 1, 2012, and December 31, 2014. Using registry-linked claims data across 281 hospitals, we measured 3 QIs on treatment for CIN3, 3 QIs on stage III or IVA, and 1 QI on stage IVB, respectively. We also measured 1 QI on examination of cancer spread and 1 QI on brachytherapy. Results: Data for 11,925 cervical cancer patients were analyzed. Patients’ mean age was 45.4 years (SD: 15.1). Among the QIs, use of platinum-based chemotherapy among stage IVB patients (99.1%), total hysterectomy as the last treatment among intraepithelial adenocarcinoma patients over age 44 years (87.7%), and selection of cisplatin-based regimen for concurrent chemo-radiation therapy (CCRT) (81.2%) to stage III/IVA diseases marked high adherence. In contrast, evaluation with cystoscope or proctoscope among stage IVA patients (32.4%) and use of CCRT as the initial treatment for stage III or IVA patients (49.5%) had relatively low adherence. Conclusions: The observed variation in adherence to QIs could demonstrate the provision of unstandardized care across Japan. Feedback on the results and continued monitoring are necessary to improve the quality of cervical cancer care.
Referral to infertility counseling in cancer patients undergoing chemotherapy.
Authors: Hathaway Amanda Redden , Rocque Gabrielle Betty 
Published: April 2017

220 Background: Reproductive concerns in survivorship are associated with distress, depression and anxiety. Patients who receive pretreatment fertility counseling report a better quality of life after treatment. Despite this, only about 50% of patients in studies recall discussion of fertility issues prior to chemotherapy. Methods: A retrospective review was conducted to evaluate discussion of fertility in patients ages 19-35 seen at the University of Alabama at Birmingham Hematology/Oncology clinic from 1/1/15-12/31/15. Patients who never received therapy that could alter their childbearing potential were excluded. Patients’ sex, age at diagnosis, type of cancer, documented discussion of fertility implications prior to therapy, and referral to Reproductive Endocrinology (REI) were documented. Rates of discussion of fertility risks and rate of referral were determined. Results: Fifty-four patients met inclusion criteria for the study. 46.3% were female. 30 patients (55.6%) had a hematologic malignancy and 24 patients (44.4%) had a solid tumor malignancy. Documentation of fertility risk was seen in 33.3% of patients with 29.2% referred to REI. Seven (24.1%) patients had hematologic malignancies and eight (33.3%) had solid tumors were referred to REI. Of the 25 female patients, only five (16.7%) were referred to REI, whereas another five patients could have been deemed not suitable for referral due to previous surgery or metastatic disease making the appropriate referral rate of 25%. Of the 29 male patients, nine were referred to REI, one had semen analysis without REI referral, and one refused REI evaluation making overall referral rate 34.5%. 35 of the 54 patients received their initial chemotherapy at our facility, and of those 34.3% were referred to REI. Conclusions: Despite guidelines recommending discussion of fertility risks with all patients of child-bearing age prior to chemotherapy, less than half of patients at our institution are referred to REI. [Table: see text]
Inpatient care use among Californian patients with cancer in the year after diagnosis.
Authors: Whitney Robin L. , Bell Janice , Tancredi Daniel J , Romano Patrick S. , Bold Richard J. , Joseph Jill 
Published: April 2017

235 Background: Inpatient care use is the chief driver of regional spending variation among some cancer patients and contributes more to cancer-related healthcare spending than does any other service category– including costly chemotherapy drugs. However, few studies are available to describe population rates of and reasons for hospitalization. Methods: California Cancer Registry (CCR) data linked with administrative claims data were used to quantify and describe inpatient care use among individuals diagnosed with cancer in California between 2009-2012 (n = 412, 850). Multistate models were used to estimate age-adjusted hospitalization rates, accounting for survival. Characteristics of hospitalizations were described and tabulated, including reasons for admission, procedures, and emergency department (ED) origin. Results: Among individuals with cancer, 62% had at least one hospitalization in the year after diagnosis, nearly half of which originated in the ED (45%). Among individuals with late stage cancers, 73-77% had an admission, 42-66% of which originated in the ED. Many hospitalizations included at least one surgical procedure (54%), diagnostic procedure (24%), or chemotherapy (11%). The most frequent principal diagnoses (other than malignancy) were infection-related (11%), cardiovascular (4%) and complications of a medical device or care (4%). Estimated hospitalization rates were highest for individuals with hepatobiliary/pancreatic cancers (2.5 hospitalizations), bone/soft tissue cancers (2.1 hospitalizations), and digestive system cancers (2.0 hospitalizations), and lowest for individuals with melanoma (0.3 hospitalizations), and breast or prostate cancer (0.6 hospitalizations). Conclusions: The population burden of inpatient care use among individuals with newly diagnosed cancer is substantial. Many hospitalizations originate in the emergency room, suggesting that they are unplanned. Oncology care providers’ efforts to reduce acute care use might target subgroups with higher rates, including hepatobiliary/pancreatic, bone/soft tissue, digestive, and late-stage cancers. Further research is warranted that examines the extent to which such visits are avoidable.
Experience and impact of alopecia in patients (pts) with HER2+ metastatic breast cancer (MBC) in the SystHERs registry.
Authors: Mason Ginny , Mayer Musa , Swain Sandra M. , Kaufman Peter , Tripathy Debu , Hurvitz Sara A. , O'Shaughnessy Joyce , Yardley Denise A. , Brufsky Adam , Rugo Hope S. , Cobleigh Melody A. , Chu Laura Kay , Antao Vincent P. , Morris Anne , Yoo Bongin , Jahanzeb Mohammad 
Published: April 2017

239 Background: Although alopecia is common with systemic chemotherapy, its psychological impact is often overlooked in treatment (tx) decisions. We sought to better understand the impact of alopecia using data from SystHERs, an observational registry of pts with HER2+ MBC. Methods: SystHERs enrolled pts ≥ 18 years within 6 mos of an MBC diagnosis. Pt-reported outcomes are assessed quarterly. The Alopecia Patient Assessment (APA, Genentech) is a validated instrument measuring the incidence of hair loss in the prior 3 mos and the impact of hair loss in the prior 7 days. The APA includes 5 items scored on a 5-point scale (total range: 1–25). Higher scores indicate greater impact. Pts completed the APA within 30–90 days of initial MBC tx. Subgroups with no hair loss, hair loss without impact, or impactful hair loss were compared descriptively. Results: As of June 3, 2016, 591 of 976 pts were eligible for this analysis. Of these, 175 (30%) reported no hair loss, 123 (21%) reported hair loss without impact, and 293 (50%) reported impactful hair loss within 30–90 days of initial MBC tx. Respectively, 23% (41/175), 82% (101/123), and 79% (231/293) were on active chemotherapy, most commonly docetaxel (39% [16/41], 66% [67/101], and 62% [144/231]) and paclitaxel (5% [2/41], 27% [27/101], and 23% [54/231]). Median time from initial chemotherapy tx to APA was 55, 70, and 64 days. Of all pts with no hair loss, 39% had de novo MBC vs 56% of pts with hair loss but no impact and 55% with impactful hair loss. Relative to the no-hair-loss and hair-loss-but-no-impact subgroups, the subgroup with impactful hair loss was younger (median 57 and 59 vs 54 years, respectively) and had more pts with ≥ 2 metastatic sites (51% and 54% vs 63%) and visceral metastases (59% and 63% vs 69%). The median total APA score for pts with impactful hair loss was 8.8 (IQR 7.0–12.5). Conclusions: Of pts reporting hair loss, 79–82% were receiving systemic chemotherapy. Pts with impactful hair loss may have had greater disease burden. Alopecia impacted self-image and embarrassment more than work or social functioning. Clinical trial information: NCT01615068. [Table: see text]
Outpatient management of pediatric oncology patients with low-risk fever and neutropenia: Implementation of new clinical practice guideline at Texas Children's Hospital.
Authors: Bavle Abhishek Amar , Grimes Amanda Bell , Zhao Sibo , Zinn Daniel Joseph , Jackson Andrea , Porea Timothy , Dutta Ankhi , Heczey Andras 
Published: April 2017

26 Background: Traditionally, pediatric oncology patients with fever and severe neutropenia (absolute neutrophil count [ANC] <500) are admitted on empiric intravenous (IV) antibiotics pending blood cultures, fever resolution, and a rising ANC. Based on significant evidence that risk-stratification of these patients with fever and neutropenia (FN) and outpatient management of “low-risk” FN (LRFN) patients with oral antibiotics can be safe and effective, we implemented an institutional clinical practice guideline (CPG) to provide outpatient care for children with LRFN. Methods: A validated “Alexander” clinical decision rule was adopted to risk stratify pediatric oncology patients with FN. A new CPG was formulated for the outpatient management of LRFN patients, with either discharge on presentation or at 24-48 hours after admission, with levofloxacin and close follow-up. All stakeholders were educated regarding the new guidelines and process prior to implementation, and the guidelines were approved by the institutional Evidence Based Outcomes Center. Results: In 9 months since guideline implementation, 10/11 (91%) of the eligible patients have been managed outpatient for LRFN (mean ANC 160, range 0 - 480). Seven patients were discharged home from the ER or oncology clinic. Three patients were discharged early at 24 – 48 hours after admission. Outpatient management was safe, and all but one patient had resolution of fever within 48 hours and negative blood cultures. One patient had a positive blood culture with Staphylococcus epidermidis and was admitted for IV antibiotics with no complications. Parents of 9/10 patients responded to surveys. All 9 families found outpatient management to be a good experience, follow-up easy, and reported no adverse effects with levofloxacin. One family preferred inpatient care due to anxiety, while importantly 8/9 (89%) parents said they preferred outpatient care compared to inpatient observation. Conclusions: Pediatric oncology patients with low-risk fever and neutropenia were successfully idenitified and managed in the outpatient setting without adverse events with a high level of parent satisfaction.
Utilizing patient navigators to enhance oral chemotherapy education and safety for at-risk patients.
Authors: Lin Mingqian , Hackenyos Douglas W , Mao Daqin , Wang Feng Qing , Erban John Kalil , Parsons Susan K. 
Published: April 2017

43 Background: Oral anticancer drugs are increasingly being used as standard therapy. At Tufts Medical Center Cancer Center, 10% of patients on active cancer treatment are receiving oral chemotherapy. To address barriers to medication education and timely management of treatment effects, we began an initiative involving our pharmacy specialist who reviews newly-started oral chemotherapy treatments for safety concerns, dose appropriateness, and drug interactions. In response to the cultural-linguistic needs of our Chinese patients (20% of our patients, largest minority group) and unique challenges of our patients of lower SES (40% of our patients), we are also leveraging patient navigators (PN) to improve timely care and understanding of and adherence to oral cancer medications for our most vulnerable patients. Methods: PN regularly interact with patients and work closely with the care team to address patients’ concerns. Formal PN visits with patients in clinic are documented in the EMR. To assess the scope of issues related to oral chemotherapy and/or supportive care drugs (e.g. anti-nausea, anti-constipation) and the potential impact in using PN, we reviewed PN encounter notes from the first 6 months of 2016 to identify patient-reported issues. Results: In reviewing 492 PN encounter notes from the first 6 months of 2016 (111 patients were navigated), 138 (28%) of all patient encounters involved assistance related to oral chemotherapy, supportive care drugs, and/or comorbidities medications. Examples of patient-reported issues include confusion about purpose and/or type of drug, dosing scheduling, side effects management, and logistical challenges (e.g. refills, copays, specialty pharmacy orders). Conclusions: From the PN encounter notes, we identified a need for more formalized patient-centered interventions to enhance education, monitoring, and patient-provider communication about oral chemotherapy to proactively resolve medication-related issues. We are piloting an evidence-based approach involving pharmacist-PN-patient teaching sessions, tailored patient education tools, and scheduled check-ins between PN and patients adapted from the MASCC Oral Agent Teaching Tool model.
Written care plan and patient enablement: Pre-implementation data from the 4R in Oncology Project.
Authors: Trosman Julia Rachel , Weldon Christine B. , Perez Claudia B. , Kulkarni Swati , Khan Seema Ahsan , Hansen Nora , Nelson Valerie , Stein Jennifer , Simon Melissa A. , Strauss Jonathan Blake , Espino Sasa M. , Bunce Mikele , Pan Wayne , Friedewald Sarah M. , Gradishar William John 
Published: April 2017

55 Background: The IOM ’11 and ’13 reports recommend a written care plan (WCP) at cancer diagnosisto enable teamwork and patient (pt) engagement. Standardized multimodality WCP is a key part of the 4R model of care planning and pt engagement proposed under “NCI ASCO Teams” Project (Trosman JOP 2016). 4R (Right Information / Care / Patient / Time) is under implementation at three centers: academic, community and safety net. As current state assessment prior to implementing 4R and standard multimodality WCP, we surveyed pts not impacted by 4R on care planning, enablement and whether they received any WCP. Methods: Survey of breast cancer stage I-III pts who received care at the three sites Jan ’15 - Mar ’16, prior to 4R. We used simple frequencies and Fisher’s exact test in analysis. Results: Survey response rate: 48%, 197/410. Gaps of > 30% were reported in 6 of 8 aspects of care planning and pt enablement - Table. A non standard WCP was received by 45% of pts. Receiving a WCP impacted whether pts were clear about care (90% with WCP vs 50% without, p < .0001), able to manage own care (81% with WCP vs 59% without, p = .001) and overwhelmed (49% with WCP vs 68% without, p = .006). Care complexity was a significant factor for feeling overwhelmed by pts without WCP (60% of pts receiving > 6 care services felt overwhelmed vs. 39% of pts receiving < = 6 services, p = .04), but not a significant factor in pts with WCP (38% vs 44%, p = .7). More pts with WCP reported well managed care by providers than pts without WCP (78%, 64%, P = .04). Conclusions: Serious gaps found in care planning and pt enablement at our sites support the need for 4R implementation. Even pre-4R, non standard WCPs improve pt understanding of care and ability to manage it, and reduce the impact of care complexity on pts. Providers using WCP appear to also coordinate care, but WCP itself may be an important factor of patient enablement. [Table: see text]