Abstract P5-13-10: Recommendations to improve the lived experience of early stage and metastatic breast cancer patients in Canada

Introduction: In 2017, the Canadian Breast Cancer Network (CBCN) undertook two surveys of Canadians who have experienced a breast cancer diagnosis to better understand the lived experience of patients and what opportunities exist to improve support for patients, survivors and their families and minimize the impact of this disease. There were 278 people diagnosed with early stage breast cancer, defined as stage I, II or III for the purpose of this report, and 180 people living with metastatic breast cancer, or stage IV breast cancer, who responded to these surveys.

Results: The survey data shows that while patients feel supported and well cared for in certain aspects there are still significant opportunities for improvement. CBCN has identified five overarching factors that could greatly improve health outcomes and the quality of life of Canadians who experience a breast cancer diagnosis.

1. Improved Educational Resources: The quality and availability of patient education has increased over the past couple of decades; however, there are still some patient friendly educational resources including, specific resources for newly diagnosed metastatic breast cancer patients; decision aids that support breast cancer surgery and post-surgery decisions; navigation of financial resources; treatment timelines and recovery expectations; private insurance navigation and information on dying-well.

2. Increased Access to Treatments: This challenge was specifically identified and vocalized by people living with metastatic breast cancer. Efforts need to continue to shorten the drug approval process time, increase equitable access to new medications for all Canadians, and ensure equitable access for take home oral cancer medications.

3. Increased Access to Information: Information available to patients about their health and treatment has increased; however, there is still information that isn't always communicated to patients that would help them make informed decisions about their health. This includes information about breast density, palliative care options and information around clinical trials.

4. Integrated Systemic Supports: The health care system as a whole is responsible for many of the services and supports that patients need to achieve optimal health and manage their breast cancer; however, these supports can be challenging to navigate and are sometimes lacking. Supports that need to be addressed at a systemic level include developing survivorship care plans for early stage patients, patient navigation, communication tools to support general practitioners during the diagnosis process, access to psychosocial professionals and increased Employment Insurance Sickness Benefits.

5. Increased Awareness and Understanding of Metastatic Breast Cancer: A lack of accurate statistics and overall awareness of metastatic breast cancer makes it challenging to truly understand the impact of this disease and also leaves people living with an incurable form of breast cancer feeling isolated and disconnected. Accurate statistics and increased awareness would help further the understanding of the impact of this stage of breast cancer and better support those with it.

Citation Format: Gordon J, Ammendolea C, Chari N, Armstrong R, Hall W. Recommendations to improve the lived experience of early stage and metastatic breast cancer patients in Canada [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-10.

Implementing a Fee-for-Service Cervical Cancer Screening and Treatment Program in Cameroon: Challenges and Opportunities

Background: Cervical cancer screening is one of the most effective cancer prevention strategies, but most women in Africa have never been screened. In 2007, the Cameroon Baptist Convention Health Services, a large faith-based health care system in Cameroon, initiated the Women's Health Program (WHP) to address this disparity. Trained nurses provide fee-for-service cervical cancer screening using visual inspection with acetic acid enhanced by digital cervicography (VIA-DC), prioritizing care for women living with HIV/AIDS. They also provide clinical breast examination, family planning (FP) services, and treatment of reproductive tract infections (RTI) and refer for further tests and treatment indicated. Methods: We retrospectively reviewed and analyzed WHP medical records from women who presented for cervical cancer screening from 2007-2014. Results: In 8 years, WHP nurses screened 44,979 women for cervical cancer. The number of women screened increased nearly every year. The WHP is sustained primarily on fees-for-service, with external funding totaling about $20,000 annually. In 2014, of 12,191 women screened for cervical cancer, 99% received clinical breast exams, 19% received FP services, and 4.7% received treatment of RTIs. We document successes, challenges, solutions implemented, and recommendations for optimizing this screening model. Conclusion: The WHP's experience using a cost-recovery model and offering multiple services in a single clinic rather than stand-alone cervical cancer screening may be a practical model to make cervical cancer screening services accessible, comprehensive and sustainable. Integrating other women's health services enabled women to address additional health care needs.

Financial Resources Digital Navigation Tool for Metastatic Breast Cancer Patients

Background and context: Although Canadians enjoy a universal health care system, there continues to be costs to patients that are not covered by the system. The economic impact of breast cancer is huge and, in many cases, devastating for patients and their families. As a result there is a need for educational and navigational resources that assist patients with the financial burden of facing a metastatic breast cancer diagnosis. Aim: The aim of this project is to develop an online navigation tool that will assist Canadians living with metastatic breast cancer source financial supports and resources to help lessen the financial impact of their diagnosis. Strategy/Tactics: An advisory board of people living with metastatic breast cancer was convened to help guide this project and provide input on the lived experience and financially challenges of Canadians living with this stage of the disease. The input from the advisory board along with the responses from a survey of over 150 Canadian metastatic breast cancer patients informed the type of information that should be included in the resource. Through an environmental scan and research of various financial supports, a comprehensive list of financial resources available locally, regionally and nationally was compiled. This data were integrated into a database that will be accessed through an intuitive online interface that will be integrated with CBCN´s Web site. The advisory board reviewed the draft content and framework to ensure that identified needs and priorities have been addressed. All content was translated into French as this tool will be offered in both French and English. The anticipated launch of this resource is November 2018. Outcomes: CBCN anticipates that over 1200 people living with metastatic breast cancer will access this resource in the first year and that over 50 institutions will be informed that this tool is available for their patients. Given that this will be a unique resource, CBCN expects that patients, health care professionals and support workers will access this resource to better support people living with metastatic breast cancer. What was learned: This resource has not launched, but based on CBCN´s research and the feedback of the patient advisory board, it is understood that there is a great need for this financial resources navigation tool.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

An environmental scan of emergency response systems and services in remote First Nations communities in Northern Ontario

Background: Approximately 24,000 Ontarians live in remote Indigenous communities with no road access. These communities are a subset of Nishnawbe Aski Nation (NAN), a political grouping of 49 First Nations communities in Northern Ontario, Canada. Limited information is available regarding the status of emergency care in these communities.

Objective: We aimed to understand emergency response systems, services, and training in remote NAN communities.

Design: We used an environmental scan approach to compile information from multiple sources including community-based participatory research. This included the analysis of data collected from key informant interviews (n=10) with First Nations community health leaders and a multi-stakeholder roundtable meeting (n=33) in October 2013.

Results: Qualitative analysis of the interview data revealed four issues related to emergency response systems and training: (1) inequity in response capacity and services, (2) lack of formalised dispatch systems, (3) turnover and burnout in volunteer emergency services, and (4) challenges related to first aid training. Roundtable stakeholders supported the development of a community-based emergency care system to address gaps.

Conclusions: Existing first response, paramedical, and ambulance service models do not meet the unique geographical, epidemiological and cultural needs in most NAN communities. Sustainable, context-appropriate, and culturally relevant emergency care systems are needed.

Premixed vs basal-bolus insulin regimen in Type 2 diabetes: comparison of clinical outcomes from randomized controlled trials and real-world data

AIM

To evaluate the concordance between data derived from randomized controlled trial (RCT) and real-world estimates of HbA_1c and weight change after 24 weeks of initiation of a basal-bolus compared with a premixed insulin regimen in people with Type 2 diabetes.

METHODS

Data eight RCTs were pooled after a systematic review of studies examining basal-bolus (n = 1893) or premixed (n = 1517) regimens. Real-world data were extracted from the UK primary care dataset for people on basal-bolus (n = 7483) or premixed insulin regimens (n=10 744). The mean differences between HbA_1c and weight from baseline were calculated using t-tests, while analysis of variance was used to compare the two treatment regimens. Linear regression analyses were used to determine the predictors of this change.

RESULTS

Both insulin regimens were associated with HbA_1c reductions (real-world data -0.28%; RCT data, -1.4%) and weight gain (real-world data, +0.27 kg; RCT data, +2.96 kg) but there were no significant differences between basal-bolus and premixed insulin. Discordances in the pattern of treatment response were observed, however, between real-world and RCT data for both insulin regimens. For any given baseline HbA_1c concentration, the change in HbA_1c in the RCTs was greater than in real-world conditions and for those with baseline weight above ~60 kg, RCT data showed overall weight gain in contrast to slight weight loss in the real-world population. Lastly, for both randomized controlled trial and real-world populations, while greater baseline weight was associated with reduced response to treatment, the association was much steeper in the RCT than in the real-world population. In addition, greater baseline weight was associated with greater weight reductions in both premixed insulin and basal-bolus insulin regimens, although to a lesser extent with the latter.

CONCLUSION

These results highlight specific discrepancies in the HbA_1c reduction and weight change in insulin regimen between real world versus RCT populations; with greater reduction in HbA_1c and greater increase in weight observed in the RCT population than in the real-world population. Also, the basal-bolus regimens in both real-world and RCT populations showed greater reduction in HbA_1c compared to the premix regimen (though more marked in RCTs), while the premix regimen showed greater increase in weight in real-world, as against basal-bolus in the RCT population.

Dicarboxylic acids as pH sensors for hyperpolarized 13C magnetic resonance spectroscopic imaging

Imaging tumoral pH may help to characterize aggressiveness, metastasis, and therapeutic response. We report the development of hyperpolarized [2-13C,D10]diethylmalonic acid, which exhibits a large pH-dependent 13C chemical shift over the physiological range. We demonstrate that co-polarization with [1-13C,D9]tert-butanol accurately measures pH via13C NMR and magnetic resonance spectroscopic imaging in phantoms.

The cost-effectiveness of exenatide twice daily (BID) vs insulin lispro three times daily (TID) as add-on therapy to titrated insulin glargine in patients with type 2 diabetes

OBJECTIVE

To evaluate the cost-effectiveness of exenatide twice daily (BID) vs bolus insulin lispro three times daily (TID) as add-on therapy when glycemic control is sub-optimal with titrated basal insulin glargine and metformin.

METHODS

The analysis was based on the recent 4B Study, which compared exenatide BID and lispro TID as add-on therapies in subjects with type 2 diabetes insufficiently controlled, despite titrated insulin glargine. The Cardiff Diabetes Model was used to simulate patient costs and health benefits beyond the 4B Study. The Swedish healthcare perspective was adopted for this analysis; costs are reported in €EUR to aid interpretation. The main outcome measure was the cost per quality-adjusted life-year (QALY) gained with exenatide BID compared to lispro TID.

RESULTS

Exenatide BID was associated with an incremental cost of €1,270 and a QALY increase of +0.64 compared with lispro TID over 40 years. The cost per QALY gained with exenatide BID compared with lispro TID was €1,971, which is within conventional limits of cost-effectiveness. Cost-effectiveness results were generally robust to alternative assumptions and values for key model parameters.

LIMITATIONS

Extrapolation of trial data over the longer term can be influenced by modeling and parameter uncertainty. Cost-effectiveness results were generally insensitive to alternative values of key model input parameters and across scenarios.

CONCLUSIONS

The addition of exenatide BID rather than insulin lispro to basal insulin is associated with similar or better clinical outcomes. Illustrated from the Swedish healthcare perspective, analysis with the Cardiff Diabetes Model demonstrated that exenatide BID represents a cost-effective treatment alternative to lispro TID as add-on therapy in type 2 diabetes patients insufficiently controlled on basal insulin.