Abstract 2619: Defining real-world recurrence in the AACR Project GENIE Biopharma Collaborative Data

Obtaining information regarding cancer recurrence from a retrospective, EHR-based dataset poses several challenges primarily due to the lack of structured data. Patients are at risk for cancer recurrence beginning at a time point at which they are characterized as having no evidence of disease. The absence of cancer may be indicated on a radiology report or a medical oncologist assessment, requiring manual review and interpretation of potentially ambiguous free text. Further, the recurrence event itself can be defined based on several distinct data sources including pathology, imaging, clinician assessments, or tumor markers. The likelihood of ascertaining recurrence is dependent on the frequency and type of surveillance performed and varies based on tumor type and based on clinicians' thresholds for pursuing workup of borderline or suspicious findings; if follow up assessments are infrequent, there are fewer opportunities to detect recurrence. Given these challenges, there is currently no standardized approach to evaluating cancer recurrence in EHR data, impeding analyses of rare molecular tumor subtypes in multi-institutional linked clinico-genomic databases.

For this analysis, we leveraged the AACR Project GENIE Biopharma Collaborative data based on the PRISSMM curation model to develop an algorithm for identifying recurrence among patients diagnosed with stage I-III non-small cell lung cancer or with stage I-III colorectal cancer. This algorithm involves using curated pathology report data to identify a definitive surgery as the time at which patients have completed curative intent treatment. Subsequent imaging reports, pathology reports, medical oncologist assessments and tumor marker data are then evaluated in order to characterize the timing of specific recurrence events.

We will present the real-world recurrence algorithm, its underlying rationale and discuss applications of recurrence endpoints. Beyond enabling estimates of recurrence-free survival, identifying cancer recurrence will allow for estimation of progression-free survival among stage I-III patients in addition to estimation of PFS among de novo stage IV patients. Estimating PFS in a large cohort of patients with linked phenomic and genomic data has historically been a limitation of these types of datasets. Overcoming this limitation will allow for precision medicine advances in oncology by facilitating data pooling across institutions and enabling examination of rare molecular subtypes in relation to clinically meaningful endpoints.

Citation Format: Jessica A. Lavery, Samantha Brown, Eva Lepisto, Michele L. Lenoue-Newton, Caroline McCarthy, Hira Rizvi, Celeste Yu, Kenneth L. Kehl, Shawn M. Sweeney, Julia E. Rudolph, Nikolaus Schultz, Brooke Mastrogiacomo, Ritika Kundra, Jeremy Warner, Philippe Bedard, Gregory J. Riely, Katherine S. Panageas, Deborah Schrag, AACR Project GENIE Consortium. Defining real-world recurrence in the AACR Project GENIE Biopharma Collaborative Data [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2619.

Quality of life in long-term survivors of advanced melanoma treated with checkpoint inhibitors

Background

Immune checkpoint inhibitors (CIs) have revolutionized treatment of advanced melanoma, leading to an emerging population of long-term survivors. Survivors’ quality of life (QOL) and symptom burden are poorly understood. We set out to evaluate symptom burden and QOL in patients with advanced melanoma alive more than 1 year after initiating CI therapy.

Methods

Cross-sectional surveys, accompanied by chart review of patients with advanced melanoma treated with CIs at Memorial Sloan Kettering Cancer Center, completed therapy, and were alive >1 year after treatment initiation. Surveys were administered between February and August 2018. Surveys included: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, EuroQOL, items from Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events and Fatigue Severity Scale.

Results

We included 90 patients. The most common CI regimens were ipilimumab plus nivolumab (53%) and pembrolizumab (41%); most patients (71%) were not treated in clinical trials. Median time from CI therapy initiation was 40 months and from last dose was 28 months. Fatigue was reported by 28%, with higher fatigue scores in women than men; 12% reported difficulty sleeping. Aching joints (17%) and muscles (12%) were fairly common. Level of functioning was generally high. Overall QOL was excellent though 40% reported ‘some or moderate’ problems with anxiety/depression and 31% with pain/discomfort.

Conclusions

After CI therapy, long-surviving advanced melanoma patients commonly report fatigue but otherwise have moderate symptom burden and good QOL. Ensuring appropriate symptom management will optimize clinical outcomes for these patients.

Real-Time Fluoroscopic Navigation Improves Acetabular Component Positioning During Direct Anterior Approach Total Hip Arthroplasty

We investigated whether a novel, real-time fluoroscopybased navigation system optimized component positioning and leg length in fluoroscopically aided direct anterior approach total hip arthroplasty (DAA-THA). We retrospectively reviewed 75 fluoroscopically assisted DAA-THA performed by a single surgeon: 37 procedures used the software intraoperatively to overlay anteversion, inclination, and leg length information over the existing fluoroscopic radiograph with the aim of enhancing component positioning. The control group consisted of 38 procedures from the single surgeon's patient pool who had undergone non-navigated fluoroscopic assisted DAA-THA 1 month prior to the system's trial. Our results demonstrate that the navigation group measurements were significantly closer to the target numbers with less variation. The mean difference from target value were as follows: for anteversion (control: -4.68°, navigated: -01.0°), inclination (control: -1.87°, navigated: 0.8°), and leg length discrepancy (control: -2.59°, navigated: -0.98°). In addition, surgical time was shorter in the navigation group (75.7 vs. 74 minutes; p = 0.001). The real-time feedback and calculations provided by the navigation software provided a reproducible precision for component positioning and leg length measurement during DAA-THA.

Real-time data quality assurance analysis for real-world, pan-cancer data

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Background: The production of high-quality real-world data requires comprehensive and meticulous data quality assurance (QA) methods to guarantee that adequate standards of accuracy, completeness, and consistency are met. Memorial Sloan Kettering Cancer Center (MSKCC) synthesizes manually curated Electronic Health Record (EHR) data to collect and harmonize the fundamental data elements across all cancer types. Centralized real-time analysis of curated data quality can allow for rigorous review to identify areas of strength and opportunities for improvement in the curation process. Methods: MSKCC built the Core Clinical Data Element (CCDE) data model, which encompasses aspects of PRISSMM, ASCO’s mCODE, and NAACCR tumor registry frameworks, to capture standardized real-world, pan-cancer, pan-specialty data across 11 modules, including cancer genomics, imaging, pathology, surgery, and radiation. A key component within the QA process is source data verification (SDV), the comparison of curated data against source documents to identify inconsistencies. Any discrepancies detected are classified into major and minor violations. Major violations are errors or omissions on core data elements that would impact time interval calculations, such as an incorrect procedure date. Minor violations are errors or omissions on less critical data elements, such as a missing radiation therapy dose. Identifying these inconsistences allows the QA team to recognize patterns in curation errors and distinguish areas for curator retraining. Results: With limited functionality in basic standard data quality checks that exist across various data storage platforms, an interactive application was developed using the R Shiny package to access data as cases are recorded and summarize findings from SDV in real time. The app has two panels, each stratified by CCDE module. The first panel details the total number of forms curated and percentage of forms that underwent SDV, with each form representing one of the 11 modules. The other panel consists of a set of tables that summarize specific major and minor violations based on user selection of a denominator of either patients (e.g. how many patients had a violation on at least one imaging report) or forms (e.g. how many imaging reports had a violation). We will demonstrate the utility of the app and discuss benefits of real time evaluation in large-scale, real-world EHR curation efforts. Conclusions: We recommend automated, user-friendly tools to assess data quality of such efforts. With real-time analysis, the tool allows for ongoing and regular data checks, enabling clarification of directives and retraining of curators as necessary early in the curation process. As the data curation efforts expand to more cancer cohorts, the app examines data quality of each cohort to ensure consistent evaluation. This offers transparency of data quality to ensure usability in real-world data for rigorous research.

Pan-cancer evaluation of homologous repair deficiency somatic mutations and response to first-line anti-neoplastic therapy

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Background: Homologous recombination is a major mechanism of defective DNA repair, but it remains uncertain whether homologous repair deficient (HRD) tumors have favorable prognosis or are more/less likely to respond to treatment than tumors lacking such mutations. Objective: To determine whether lung (NSCLC) and colorectal (CRC) HRD+ tumors have better survival or response to chemotherapy than HRD- tumors. Methods: Patients with de novo stage IV NSCLC or CRC who had next generation sequencing (NGS) between 2015-2018 from one of four cancer centers were identified. Records were curated using the PRISSMM framework to ascertain treatment, overall survival (OS) and progression free survival based on imaging (PFS-I) and oncologists’ notes (PFS-M). Each NSCLC or CRC tumor was categorized as HRD+ if NGS revealed an oncogenic/likely oncogenic mutation in: ATM, BAP1, BARD1, BLM, BRCA1, BRCA2, BRIP1, CHEK2, FAM175A, FANCA, FANCC, NBN, PALB2, RAD50, RAD51, RAD51C, RTEL1, or MRE11A based on the OncoKB database. The tumor was categorized as HRD- if no oncogenic mutation in any of these genes was evident and HRD indeterminate (HRD?) if no mutation was identified but the panel did not include all genes. OS, PFS-I and PFS-M from start of first line therapy were reported by HRD status. The percentage with a good response to first line therapy (≥2x the median) and exceptional response (≥3x the median) was estimated for each endpoint. Results: For NSCLC 4% were HRD+, 59% HRD- and 37% HRD?. For CRC there were 5% HRD+, 60% HRD- and 35% HRD?. There were no significant differences for any survival endpoint between patients who were HRD+ vs HRD- in univariable analyses. The proportion of good and exceptional responders to first line systemic chemotherapy also did not vary by HRD status, though patients with HRD+ CRC were potentially more likely to be exceptional responders. Similarly, no differences between HRD+ and HRD- tumors were apparent for the subgroup receiving platinum containing therapy. Conclusions: NSCLC and CRC patients with somatic mutations in HRD oncogenic genes did not differ from patients lacking such a mutation with respect to OS or PFS. CRC patients with HRD+ tumors may be more likely to be exceptional responders, but sample sizes are limited. By May, the analysis will include breast and pancreatic cancer cases.[Table: see text]

TOXICITY AND EFFICACY OF INTRAVITREAL MELPHALAN FOR RETINOBLASTOMA: 25 µg Versus 30 µg

PURPOSE

To compare retinal toxicity as measured by electroretinogram, ocular, and patient survival in retinoblastoma treated with intravitreal melphalan at two concentrations (25 vs. 30 µg).

METHODS

Single-center, retrospective analysis of retinoblastoma eyes receiving 25-µg or 30-µg intravitreal melphalan from September 2012 to January 2019. Ocular toxicity was measured by electroretinogram of evaluable injections in 449 injections in 136 eyes. A repeated-measures linear mixed model with a random intercept and slope was applied to account for repeated measures for each eye.

RESULTS

Average decline in electroretinogram after each additional injection was -4.9 µV (95% confidence interval -6.3 to -3.4); electroretinogram declined by -4.6 µV (95% confidence interval -7.0 to -2.2) after 25-µg injections and -5.2 µV (95% confidence interval -6.6 to -3.8) after 30-µg injections (P = 0.66). Injection at a new clock site hour was associated with a -3.91-µV lower average (95% confidence interval -7.8 to -0.04).

CONCLUSION

Electroretinogram-measured toxicity in retinoblastoma eyes treated with intravitreal injections was not found to be different across 25-µg and 30-µg injections. There were no cases of extraocular extension or metastatic deaths in our patient population.

Favorable outcomes of COVID-19 in recipients of hematopoietic cell transplantation

BACKGROUNDUnderstanding outcomes and immunologic characteristics of cellular therapy recipients with SARS-CoV-2 is critical to performing these potentially life-saving therapies in the COVID-19 era. In this study of recipients of allogeneic (Allo) and autologous (Auto) hematopoietic cell transplant and CD19-directed chimeric antigen receptor T cell (CAR T) therapy at Memorial Sloan Kettering Cancer Center, we aimed to identify clinical variables associated with COVID-19 severity and assess lymphocyte populations.METHODSWe retrospectively investigated patients diagnosed between March 15, 2020, and May 7, 2020. In a subset of patients, lymphocyte immunophenotyping, quantitative real-time PCR from nasopharyngeal swabs, and SARS-CoV-2 antibody status were available.RESULTSWe identified 77 patients with SARS-CoV-2 who were recipients of cellular therapy (Allo, 35; Auto, 37; CAR T, 5; median time from cellular therapy, 782 days; IQR, 354-1611 days). Overall survival at 30 days was 78%. Clinical variables significantly associated with the composite endpoint of nonrebreather or higher oxygen requirement and death (n events = 25 of 77) included number of comorbidities (HR 5.41, P = 0.004), infiltrates (HR 3.08, P = 0.032), and neutropenia (HR 1.15, P = 0.04). Worsening graft-versus-host disease was not identified among Allo recipients. Immune profiling revealed reductions and rapid recovery in lymphocyte populations across lymphocyte subsets. Antibody responses were seen in a subset of patients.CONCLUSIONIn this series of Allo, Auto, and CAR T recipients, we report overall favorable clinical outcomes for patients with COVID-19 without active malignancy and provide preliminary insights into the lymphocyte populations that are key for the antiviral response and immune reconstitution.FUNDINGNIH grant P01 CA23766 and NIH/National Cancer Institute grant P30 CA008748.

Impact of provider volume on front-line chemotherapy guideline compliance and overall survival in elderly patients with advanced ovarian cancer

PURPOSE

We sought to evaluate whether provider volume or other factors are associated with chemotherapy guideline compliance in elderly patients with epithelial ovarian cancer (EOC).

METHODS

We queried the SEER-Medicare database for patients ≥66 years, diagnosed with FIGO stage II-IV EOC from 2004 to 2013 who underwent surgery and received chemotherapy within 7 months of diagnosis. We compared NCCN guideline compliance (6 cycles of platinum-based doublet) and chemotherapy-related toxicities across provider volume tertiles. Factors associated with guideline compliance and chemotherapy-related toxicities were assessed using logistic regression. Overall survival (OS) was compared across volume tertiles and Cox proportional-hazards model was created to adjust for case-mix.

RESULTS

1924 patients met inclusion criteria. The overall rate of guideline compliance was 70.3% with a significant association between provider volume and compliance (64.5% for low-volume, 72.2% for medium-volume, 71.7% for high-volume, p = .02). In the multivariate model, treatment by low-volume providers and patient age ≥ 80 years were independently associated with worse chemotherapy-guideline compliance. In the survival analysis, there was a significant difference in median OS across provider volume tertiles with median survival of 32.8 months (95%CI 29.6, 36.4) low-volume, 41.9 months (95%CI 37.5, 46.7) medium-volume, 42.1 months (95%CI 38.8, 44.2) high-volume providers, respectively (p < .01). After adjusting for case-mix, low-volume providers were independently associated with higher rates of mortality (aHR 1.25, 95%CI: 1.08, 1.43).

CONCLUSIONS

In a modern cohort of elderly Medicare patients with advanced EOC, we found higher rates of non-compliant care and worse survival associated with treatment by low-volume Medicare providers. Urgent efforts are needed to address this volume-outcomes disparity.

The Genomic Landscape of SMARCA4 Alterations and Associations with Outcomes in Patients with Lung Cancer

PURPOSE

SMARCA4 mutations are among the most common recurrent alterations in non-small cell lung cancer (NSCLC), but the relationship to other genomic abnormalities and clinical impact has not been established.

EXPERIMENTAL DESIGN

To characterize SMARCA4 alterations in NSCLC, we analyzed the genomic, protein expression, and clinical outcome data of patients with SMARCA4 alterations treated at Memorial Sloan Kettering.

RESULTS

In 4,813 tumors from patients with NSCLC, we identified 8% (n = 407) of patients with SMARCA4-mutant lung cancer. We describe two categories of SMARCA4 mutations: class 1 mutations (truncating mutations, fusions, and homozygous deletion) and class 2 mutations (missense mutations). Protein expression loss was associated with class 1 mutation (81% vs. 0%, P < 0.001). Both classes of mutation co-occurred more frequently with KRAS, STK11, and KEAP1 mutations compared with SMARCA4 wild-type tumors (P < 0.001). In patients with metastatic NSCLC, SMARCA4 alterations were associated with shorter overall survival, with class 1 alterations associated with shortest survival times (P < 0.001). Conversely, we found that treatment with immune checkpoint inhibitors (ICI) was associated with improved outcomes in patients with SMARCA4-mutant tumors (P = 0.01), with class 1 mutations having the best response to ICIs (P = 0.027).

CONCLUSIONS

SMARCA4 alterations can be divided into two clinically relevant genomic classes associated with differential protein expression as well as distinct prognostic and treatment implications. Both classes co-occur with KEAP1, STK11, and KRAS mutations, but individually represent independent predictors of poor prognosis. Despite association with poor outcomes, SMARCA4-mutant lung cancers may be more sensitive to immunotherapy.

The experience of financial toxicity among advanced melanoma patients treated with immunotherapy

Purpose To measure financial toxicity and explore its association with quality of life (QOL) in an emerging population of survivors: advanced melanoma patients treated with immunotherapy. Design Cross-sectional survey and medical record review. Sample 106 survivors (39% response). Median time since start of immunotherapy was 36.4 months (range: 14.2-133.9). Methods The Comprehensive Score for Financial Toxicity measured financial toxicity, and the EORTC-QLQ30 assessed QOL and functioning across five domains. Data were collected online, by phone, or in clinic. Findings: Younger patients (<65 years) reported higher financial toxicity (p < .001) than older patients. Controlling for age, financial toxicity was correlated with QOL (p < .001), financial difficulties (p < .001), and EORTC-QLQ30 functioning subscales. Conclusions Given the demonstrated association between financial toxicity and QOL, our study highlights the importance of addressing financial toxicity, particularly among patients receiving high-cost treatments. Implications for Psychosocial Providers: Providers should educate patients and their caregivers about cost-management techniques, link them with available resources, and provide psychosocial counseling to alleviate related distress.

Trends in chronic opioid therapy among survivors of head and neck cancer

BACKGROUND

Survivors of head and neck cancer (HNC) have increased risk of opioid misuse.

METHODS

Using Surveillance, Epidemiology and End-Results-Medicare data, we matched adults ≥66 years diagnosed with HNC 2008-2015 with cancer-free controls. We computed odds ratios (OR) for receipt of chronic opioid therapy (COT, claims for ≥90 consecutive days) for HNC survivors compared to controls each year after matching through 2016.

RESULTS

The cohort of HNC survivors declined from 5107 in the first year after diagnosis to 604 in the sixth year after diagnosis. For 5 years, rates of COT among HNC survivors exceeded that of controls. Differences between survivors and controls declined each year (ORs: year 1, 4.36; year 2, 2.60; year 3, 2.18; year 4, 1.85; and year 5, 1.35; all P-values <.05).

CONCLUSIONS

Among older HNC survivors, cancer-associated opioid use in the first years after diagnosis suggests that the benefit of opioids must balance the risk of opioid misuse.

Comparison of efficacy and toxicity of intravitreal melphalan formulations for retinoblastoma

Objective

Intravitreal melphalan injections are commonly used in the treatment for intraocular retinoblastoma. This study compares retinal toxicity and ocular survival between two formulations, with and without propylene glycol (Alkeran vs. Evomela, respectively).

Methods

A retrospective cohort study of retinoblastoma patients who received intravitreal injections of Alkeran and Evomela at 30 μg from September 2012 to January 2019 at a single tertiary care center were enrolled. Retinal toxicity was measured using electroretinogram (ERG) and compared using a multivariate analysis of 338 injections in 101 eyes of 96 patients. Ocular survival of 163 eyes in 150 patients was compared across formulations using Cox proportional hazards model. Eyes were censored at the time a patient received a dose other than 30 μg.

Results

Overall, ERG decline (mean, 95% CI) for each injection was -5.58 μV (-7.17, -3.99). No significant differences in ERG decrement were found between Alkeran (with alcohol) -5.52uV (-6.99, -4.05). and Evomela (without alcohol) -5.65uV (-8.31 to -2.98) formulations (p = 0.93). Ocular survival at 24 months was 93.6% (95% CI 86.2, 97.1) with alcohol and 91.7% (95% CI 53.9, 98.8) without alcohol. The hazard ratio (HR) for without vs with alcohol was 0.50 (95% CI 0.06 to 4.07); no significant difference in ocular survival was found between formulations (p = 0.52)

Conclusions and relevance

No differences were found in retinal toxicity and ocular survival between 30 μg intravitreal injections of Alkeran or Evomela for intraocular retinoblastoma. Given the increased stability of Evomela, intravitreal treatment could be expanded to centers without the ability to supply Alkeran due to its shorter safety window; however, Alkeran is less expensive. For those with existing infrastructure, Alkeran is a comparable, cost-effective alternative.

Progression-free survival estimates in non-small cell lung cancer when RECIST is unavailable: Project GENIE’s integration of genomic, therapeutic and phenomic data

9622

Background: Molecular tumor profiling has become an integral component of oncology practice but linked genomic-phenomic data remain scarce. Recurrence, treatment response and progression are not structured consistently in medical records and this deficit has been a roadblock to discovery of biomarkers that are associated with favorable outcomes. Methods: The Genomics Evidence Neoplasia Information Exchange (GENIE) consortium is an AACR sponsored project to link and share genomic and phenomic data to promote discovery in precision medicine. 3 cancer centers that routinely perform somatic tumor profiling for advanced cancers agreed to curate anti-neoplastic treatment exposures and outcomes including recurrence, progression, response and survival using a standard method. 6 cancer types (lung, colorectal, breast, prostate, pancreas and bladder) were selected and a REDCAP database captures anti-neoplastic treatments, and specific elements from pathology, radiology and oncology reports. Curators abstract data using data fields that rely on the PRISSMM standard. “Real world” progression free survival (PFS) was identified based on curation of: 1) the text of radiologists’ reports for CT, PET/CT, PET and MRI scans (PFSI) and 2) medical oncologists’ notes (PFSM). PFSI and PFSM were estimated from the start of 1st line anti-neoplastic systemic therapy until progression or death for all patients with molecularly characterized non-small cell lung cancer (NSCLC). Results: Genomic sequencing was performed between 2015 and 2017 for 748 patients with NSCLC treated at three major cancer centers. Median age at diagnosis was 66 years (interquartile range 58, 73) and 43% were male. As shown in the table, when RECIST assessments are unavailable, estimates of PFS vary based on whether they are derived from radiologists’ or oncologists’ interpretations. Conclusions: Radiologists’ reports and oncologists’ reports provide different PFS estimates. Cohort studies should specify the method used to define “real world” endpoints. Project GENIE will have 1800 NSCLC patients with curated endpoints by the ASCO meeting. [Table: see text]

Chronic opioid therapy among a high-risk cancer survivor population

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Background: Head and neck cancer (HNC) survivors are at increased risk of opioid dependence, due to exposure to opioids during treatment, history of tobacco and alcohol use, and substantial pain after treatment. Chronic opioid therapy (COT) is a risk factor for dependence, and rates of COT vary widely between populations of cancer survivors. We hypothesized that COT use is greater among HNC survivors than among those who never had cancer. Methods: We used SEER-Medicare to identify adults ≥66 years diagnosed with HNC between 2008 and 2015. HNC survivors were matched 1:3 at date of diagnosis on age, sex, comorbidity, and region with cancer-free controls. Survivors and controls had complete coverage with fee-for-service Medicare Parts A, B, and D for each year after matching. Survivors and controls with no COT in the year prior to matching date and were followed for COT use through 2016. The presence of claims for opioid dispensings over ≥90 consecutive days (COT) was calculated for each year after cancer diagnosis among survivors alive at the start of each year and for controls. We computed odds ratios (OR) for COT use for HNC survivors compared to matched controls in each year after matching date, using a hierarchical logistic regression model accounting for matching and repeated measurements across years. Results: The population of HNC survivors declined from 5,107 in the year after diagnosis to 604 in Year 6. Among HNC survivors, COT use remained relatively steady each year after diagnosis. (Table). For the first 5 years after matching date, rates of COT among HNC survivors exceeded that of controls, with the difference between survivors and controls declining each year (OR 4.36 for Year 1, OR 2.60 for Year 2, OR 2.18 for Year 3, OR 1.85 for Year 4, and OR 1.35 for Year 5, all p-values < 0.05). By Year 6, rates of COT use did not differ between HNC cases and controls. Conclusions: In the first year after diagnosis, HNC survivors have more than 4 times the odds of COT use compared to cancer-free controls. Cancer-associated COT use declines over time. Strategies for appropriate pain management for HNC survivors should balance the risk of opioid dependence, particularly in the early years after diagnosis, with the benefit of improved comfort and function. [Table: see text]

Predictors of electronic patient-reported outcomes use in the survivorship setting

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Background: Patient-reported outcomes (PRO) offer insight into patient perception of health and symptom burden. Despite a shift toward electronic PRO (ePRO), optimal administration methods are unclear. Our institution recently began ePRO collection in survivorship clinics: patients are invited via email to complete a health survey on our online patient portal prior to annual visits, enabling clinician review of symptoms in advance of the visit. Patients who do not complete an ePRO survey at home are offered an iPad or paper survey at visit check-in. In the first year of ePRO, 87 patients inadvertently submitted multiple responses to the questionnaire, across two modalities. This study aimed to 1) assess determinants of ePRO completion across modalities (portal, iPad, paper); and, 2) among patients who submitted multiple surveys, compare consistency of responses in surveys completed within 30 days of each other. Methods: We reviewed records for 10194 patients seen in breast, thoracic, colorectal, and gynecologic survivorship clinics over one year. Demographics, disease/treatment details, and PRO responses (symptoms, health behaviors, etc.) were extracted. For aim 1, we used multivariate regression to determine predictors of completion method. For aim 2, we calculated Cohen’s kappa coefficients to compare responses based on completion modality. Results: Most patients (65.6%) completed the survey on an iPad in clinic; 16.7% on the portal, 17.7% on paper in clinic. Younger age (p < .001), white race (p < .001), less fatigue (p = .01), and English as primary language (p < .001) were associated with portal use in multivariate analyses. In general, Cohen’s Kappa analyses revealed high agreement between surveys. Conclusions: Our findings highlight demographic gaps in ePRO acceptance. Although most patients completed an ePRO (portal or iPad), few completed it at home in advance of their visit, which has implications for clinic flow and clinician preparation for visits. However, our finding of consistent symptom reporting across mode and location of completion is reassuring. Future work should seek to improve comfort with ePRO completion at home among groups less likely to accept it and explore the implications of symptom burden on ePRO acceptance.

Assessing whether cancer stage is needed to evaluate measures of hospital surgical performance

RATIONAL, AIMS, AND OBJECTIVES

While public reports of hospital-level surgical quality measures are becoming increasingly common in health care, a comprehensive national assessment of surgical quality across multiple cancer sites has yet to be developed. Fee-for-service (FFS) Medicare claims present a potential resource from which to measure outcomes following cancer surgery given the national scope of patients and providers. However, due to the administrative nature of the data, clinical cancer information such as stage is not recorded. Leveraging the Surveillance, Epidemiology, and End Results (SEER) registry linked to FFS Medicare claims to analyse outcomes for patients whom we ultimately know stage information, we determined whether Medicare claims are suitable for measuring provider quality following cancer surgery by assessing the extent to which the lack of stage information modifies assessments of provider performance.

METHODS

We identified patients aged 66 and older undergoing cancer surgery between 2011 and 2013 from SEER-Medicare. We compared the changes in the risk-standardized rates (RSRs), decile rankings, and c-statistics with and without risk adjustment for cancer stage for three measures of hospital performance: 30-day mortality, surgical complications, and unplanned readmissions.

RESULTS

The RSR changed by at most 11.4% for mortality and by less than 4% for complications and readmissions, indicating that measures of hospital performance were stable with and without adjustment for stage. The relative performance of hospitals was also stable, as demonstrated by fewer than 20% of hospitals changing decile rank. The c-statistic declined by less than 2% across all measures, indicating that model fit was not substantially worsened without this information.

CONCLUSION

These findings support the use of FFS Medicare claims for hospital-level analyses of short-term outcomes following cancer surgery. Quality reporting based on these analyses can be used to help patients choose among hospitals and for evaluating policies to improve surgical cancer care.

Assessment of variation in 30-day mortality following cancer surgeries among older adults across US hospitals

Background

While public reporting of surgical outcomes for noncancer conditions is common, cancer surgeries have generally been excluded. This is true despite numerous studies showing outcomes to differ between hospitals based on their characteristics. Our objective was to assess whether three prerequisites for quality assessment and reporting are present for 30‐day mortality after cancer surgery: low burden for timely reporting, hospital variation, and potential for public health gains.

Study Design

We used Fee‐for‐Service (FFS) Medicare claims to examine the extent of variation in 30‐day cancer surgical mortality between 3860 US hospitals. We included 340 489 surgeries for 12 cancer types for FFS Medicare beneficiaries aged ≥66 years, 2011‐2013. Hierarchical mixed‐effects logistic regression models adjusted for patient and hospital characteristics and with a random hospital effect were fit to obtain hospital‐specific risk‐standardized mortality rates (RSMRs) and 99% confidence intervals (CI). We calculated a hospital odds ratio to describe the difference in mortality risk for a hospital above vs below average quality and estimated the potential mortality reduction.

Results

The median number of cancer surgeries per hospital was 34. The median RSMR overall was 2.41% (99% CI 2.28%, 2.66%). In aggregate and for most cancers, variation between hospitals exceeded that due to differences in patient and hospital characteristics. For individual cancers, relative differences exceeded 20% in mortality risk between patients undergoing surgery at a hospital below vs above average quality, with the potential for an estimated 500 deaths prevented annually given hypothetical improvements.

Conclusion

Quality measurement and reporting of 30‐day mortality for cancer surgery is worthy of consideration.

Pediatric Fingertip Injuries: Association With Child Abuse

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

The New York State Safe Motherhood Initiative: Early Impact of Obstetric Hemorrhage Bundle Implementation

OBJECTIVE

To determine the effects of the Safe Motherhood Initiative's (SMI) obstetric hemorrhage bundle in New York State (NYS).

STUDY DESIGN

In 2013, the SMI convened interprofessional workgroups on hemorrhage, venous thromboembolism, and hypertension tasked with developing evidence-based care bundles. Participating hospitals submitted data measured before, during, and after implementation of the hemorrhage bundle: maternal mortality, intensive care unit (ICU) admission, cardiovascular collapse, hysterectomy, and transfusion of ≥4 units of red blood cells (RBCs). Data were analyzed for trends stratified by implementation status.

RESULTS

Of the 123 maternity hospitals in NYS, 117 participated, of which 113 submitted data. Of 250,719 births, transfusion of ≥4 units RBCs (1.8 per 1,000) and ICU admissions (1.1 per 1,000) were the most common morbidities. Four hemorrhage-related maternal deaths (1.6 per 100,000) and 10 cases of cardiovascular collapse requiring cardiopulmonary resuscitation (4.0 per 100,000) occurred. Hemorrhage morbidity did not change over the five quarters studied. Risks were similar across hospital level of care and implementation status.

CONCLUSION

Statewide implementation of bundles is feasible with resources critical to success. The low hemorrhage-related maternal death rate makes changes in mortality risk difficult to detect over short time intervals. Long-term and timely data collection with individual expert case review will be required.

A rectal cancer organoid platform to study individual responses to chemoradiation

Rectal cancer (RC) is a challenging disease to treat that requires chemotherapy, radiation and surgery to optimize outcomes for individual patients. No accurate model of RC exists to answer fundamental research questions relevant to patients. We established a biorepository of 65 patient-derived RC organoid cultures (tumoroids) from patients with primary, metastatic or recurrent disease. RC tumoroids retained molecular features of the tumors from which they were derived, and their ex vivo responses to clinically relevant chemotherapy and radiation treatment correlated with the clinical responses noted in individual patients' tumors. Upon engraftment into murine rectal mucosa, human RC tumoroids gave rise to invasive RC followed by metastasis to lung and liver. Importantly, engrafted tumors displayed the heterogenous sensitivity to chemotherapy observed clinically. Thus, the biology and drug sensitivity of RC clinical isolates can be efficiently interrogated using an organoid-based, ex vivo platform coupled with in vivo endoluminal propagation in animals.

Factors Associated with Utilizing the Same Hospital for Subsequent Total Hip or Knee Arthroplasty in Osteoarthritis Patients

BACKGROUND

Little is known about the factors that drive hospital-switching behavior of patients when they seek a second total joint arthroplasty (TJA) surgery.

METHODS

We analyzed the population-based, all-payer California Healthcare Cost and Utilization Project (HCUP) data for a cohort undergoing sequential TJAs for osteoarthritis (N = 48,800) from 2006 to 2011, excluding TJA for fracture. We used multivariable logistic regression analysis to identify factors associated with returning to the same hospital for each surgery, including rural or urban, surgery sequence and timing, Deyo-Charlson comorbidity index, age, sex, race and ethnicity, and insurance.

RESULTS

Overall, 15.1% of subjects (7,364/48,000) utilized a different hospital for their second surgery. Increasing years between TJAs was associated with decreasing odds of going to the same hospital for the second TJA (p < 0.05). Subjects switching from private insurance to Medicare between surgeries were much less likely to return to same hospital (OR: 0.53; 95% CI: 0.47-0.59), as were those with alternate-joint sequencing (e.g., hip-knee). Those with Medicaid were somewhat less likely to return for the second surgery (OR: 0.87; 95% CI: 0.75-1.01). Urban and rural residents were equally likely to return to the same hospital (p > 0.05). Increasing age was associated with increasing likelihood of returning to the same hospital [e.g., ages 75- 79, OR: 1.36 (95% CI: 1.19-1.56) and ages 80+, OR: 1.41 (95% CI: 1.22-1.63)].

CONCLUSION

Fifteen percent of patients switched hospitals for their second TJA within the 6-year study period. Those with Medicare or who had surgery on the alternate joint for second surgery were more likely to switch hospitals as were those who waited longer between surgeries and those living in a rural environment.

Opportunity for performance measurement: 30-day mortality following cancer surgeries across U.S. hospitals

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Background: While public reporting of surgical outcomes for non-cancer conditions is common, measures of outcomes following surgery for cancer have generally been excluded. This is true even though numerous studies show large variations between hospitals. We assessed whether prerequisites for quality reporting are present for the measure of 30-day cancer surgical mortality: low burden for timely reporting, hospital variation, and potential for public health gains. Methods: We used Fee-for-Service (FFS) Medicare claims to examine the extent of variation in 30-day mortality between 3,860 U.S. hospitals performing cancer surgery for patients ≥66 years, 2011-2013. Hierarchical mixed-effects logistic regression models adjusted for patient and hospital characteristics and with a random hospital effect were fit to obtain hospital-specific risk-standardized mortality rates (RSMRs) and 99% confidence intervals (CI). From these models we calculated a hospital odds ratio to describe the difference in the mortality risk for a hospital above versus below average quality and estimated the potential reduction in mortality under a scenario of improved quality for the lowest performers. Outcomes included extent of hospital variability in 30-day mortality after cancer surgery; and impact on lives saved from improving performance at outlier hospitals. Results: Over the three-year observation period, the median number of cancer surgeries performed per hospital was 34. For individual cancer sites, it was < 10, except for breast (median 17) and colorectal (median 14). The median RSMR overall was 2.41% (99% CI 2.28%, 2.66%). Breast had the lowest RSMR (median 0.24%) and gastroesophageal the highest (median 5.72%). In aggregate and for most individual cancers, variation between hospitals exceeded that due to differences in patient and hospital characteristics, and was robust to excluding emergent cases. For individual cancer sites, relative differences exceeded 20% in the risk of 30-day mortality between patients undergoing surgery at a hospital below average quality versus above average quality, with the potential for an estimated 500 deaths prevented annually given hypothetical improvements. Conclusions: Quality measurement and reporting of 30-day mortality for cancer surgery is worthy of consideration.