Resource needs screening and matching at an academic oncology center: RESOURCE preliminary results

178

Background: The social determinants of health contribute to patient (pt) health status throughout the cancer care continuum. Here we describe preliminary results of RESOURCE, a pragmatic intervention to ID and intervene on pt resource needs at an academic oncology center. RESOURCE is an EHR-integrated questionnaire (qst), given when establishing oncology care, that IDs the following needs: transportation; financial, food, & housing security; cost of care; education & employment; and caregiving burden. Pts from an HUP population or reporting resource needs on the cancer center’s intake qst are screened with RESOURCE. Those randomized to the intervention reporting a resource need receive an EHR-mediated referral to internal resource specialist and financial assistance teams. Methods: All adult cancer pts may complete the EHR-integrated intake qst. We compared historic rates of reported vulnerability from the intake qst with resource needs reported in RESOURCE. Intake qst data from 6/2015 – 4/2022 included 21,343 respondents with data on financial security, social isolation, health literacy, and health numeracy. RESOURCE data from 6/2021 – 6/2022 on the domains above included 75 respondents (125 will be accrued in total; no conditions will end accrual early). The intake qst is available for all adult cancer pts (response rate 24%; RESOURCE response rate of 87%). and The following were compared with χ2 tests: the demographic profile of each pt population; and the proportion of respondents with any one need ID'd by RESOURCE vs the intake qst. These preliminary results allow us to determine if we may prepare to scale RESOURCE upon the study’s completion. Results: The enriched pt population of RESOURCE means that there is a statistically significant difference in demographics between the general pt population responding to the intake qst and the RESOURCE pts responding to the RESOURCE by each category (p-values < 0.01). A higher proportion of pts identified a need on the intake qst (61%) than on RESOURCE (41%). RESOURCE pts most commonly reported the following needs: paying utility bills (24%), food security (20%), and cost of care (19%). Conclusions: While a larger proportion of pts reported a resource need on the intake qst, the RESOURCE qst had a far superior response rate; this discrepancy makes it difficult to determine which qst is better at determining resource needs. The RESOURCE qst allows us to see the type of need in greater detail. Collecting this data systematically allows us to quantify the resource needs of our pts so we can provide adequate support staff and resources.[Table: see text]

Predictors of electronic health record (EHR) portal registration and frequency of portal use among patients with cancer prior to engagement in the IMPACT Consortium symptom management trials

419

Background: The patient portal is part of an electronic health record (EHR) that allows patients to communicate with their healthcare team. The portal also provides a platform for patients to receive and complete symptom surveys that can be directly integrated into the EHR, allowing clinical care teams to monitor symptoms and provide cancer symptom management. The Improving Management of symPtoms during And following Cancer Treatment (IMPACT) consortium, supported by the National Cancer Institute’s Cancer MoonshotSM, aims to improve symptom control for cancer patients through assessment and symptom management interventions deployed via the EHR. This initiative presents an opportunity to examine portal enrollment and variation in use, factors critical to successful implementation, especially among groups that have high cancer symptom burden. To this end, we examine: 1) relationships between portal enrollment prior to the launch of IMPACT interventions and neighborhood broadband access, demographic, and social characteristics; and 2) frequency of pre-intervention portal use for any purpose among enrollees. Methods: Data are derived from two of three IMPACT research centers. Enrollment in and frequency of portal use, mode of accessing the portal (web vs. phone), social, demographic, and cultural factors were extracted from the EHR. Rural Urban Commuting Area (RUCA) codes were used to classify population density and degree of rurality. Broadband access was estimated using 2015-2019 American Community Survey estimates matched to zip codes from enrolled IMPACT patients and classified as a patient’s residence being in a community with high (≥85% of households) or low (< 85% of households) access. Bivariate comparisons and adjusted odds ratios were used to describe all associations. Results: Forty-seven percent of patients (22,596/48,034) were enrolled in the portal prior to the intervention. Patients in zip codes with low broadband access and those who were men, > 65 years old, not White, of Hispanic ethnicity, or disabled or not employed had significantly lower odds of being enrolled in the portal. If enrolled, 21% (n = 4825) used the portal at least once a week. Less variation was found in the average frequency of portal use, but patients younger than 40, and those who were Black, disabled, unemployed, or those who used a mobile device to access the portal had the lowest odds of accessing it at least once a week. Conclusions: Significant disparities in portal enrollment exist across demographic groups and among those with limited broadband access. Among those enrolled, most used the portal less than once a week. Fewer differences in frequency of use were observed by sociodemographic factors. Improving portal enrollment and frequency of use may be critical for symptom management interventions deployed via patient portals.

Severe symptom reporting in surgical patients assessed through an EHR-integrated ePRO questionnaire at 6 cancer centers

243

Background: Patients (pts) undergoing surgery for suspected malignancy may experience burdensome post-operative symptoms which can compromise outcomes and necessitate acute care. In prior randomized controlled trials at academic medical centers, patient-reported outcome (PRO)-based symptom management solutions improved clinical outcomes. Attempts to generalize this approach to real-world surgical pts have been challenged by perceptions that severe symptoms rarely occur, responding to severe symptoms can be burdensome, and uncertainty about which symptoms are likely to be severe and need interventions. Methods: Six US-based healthcare systems deployed eSyM, an EHR-integrated symptom management program. Pts undergoing surgery for suspected or confirmed thoracic (THOR), gastrointestinal (GI), and gynecologic (GYN) malignancies received automated questionnaires via MyChart portal 1-3 times weekly for up to 3 months after discharge. Questionnaires based on the PRO-CTCAE included 10 required and 20 optional symptoms, all scored as 0 (no symptoms), 1 (mild), 2 (moderate), or 3 (severe). Additional questions assessed functional status, overall wellbeing, wound discharge, and wound redness. Frequency and predictors of severe reporting were assessed using descriptive statistics and logistic regression modeling. Results: 21,012 surgical eSyM questionnaires were submitted between October 2019 - March 2022 by 3,781 unique pts (median age 63 years, 66.9% female, 92.1% white, 57.9% married, and 37.5% retired). 17% of questionnaires (16% of GI, 14% of GYN, and 21% of THOR) included at least 1 severe symptom. Frequencies of severe symptom reporting appear in Table with physical function impairment, general pain, and fatigue as the top three. Severe symptoms were more likely to be reported by younger, female, or unemployed pts(p < 0.01). In comparison to GI pts, GYN pts reported fewer and THOR pts reported more severe symptoms (p < 0.03). Conclusions: A meaningful minority of pts reported severe symptoms, suggesting that symptom monitoring could benefit pts without over-taxing clinicians. There were few strong patient-level predictors of severe symptoms, arguing that population surveillance may be preferable to targeted surveillance. Interventions are needed to address common severe symptoms and future studies should define most effective mitigation strategies for these symptoms. Clinical trial information: NCT03850912. [Table: see text]

Estimating long-term mortality in women with hormone receptor-positive breast cancer: The 'ESTIMATE' tool

PURPOSE

The risk of breast cancer-specific mortality (BCSM) persists for at least 20 years from diagnosis. Estimating the risk of BCSM over this extended period along with competing risks of death would aid clinical decision-making. We aimed to develop an interactive tool called 'ESTIMATE', to explore the Surveillance, Epidemiology, and End Results (SEER) registry to quantify residual risks of BCSM, non-BCSM and all-cause mortality in non-metastatic, hormone receptor (HR)-positive breast cancer patient subgroups at any given time after diagnosis, up to 20 years.

METHODS

Using SEER data, we included 264,237 women with invasive, non-metastatic, HR-positive breast cancer diagnosed from 1990 to 2006. We developed a tool that provides a nonparametric estimate of the residual cumulative risk of BCSM and non-BCSM by year 20 after any specified time from initial diagnosis, among patients defined by baseline clinical and pathologic variables, using Gray's subdistribution method.

RESULTS

ESTIMATE allows the user to input patient and tumour characteristics and the preferred timeframe. For example, patients in the age group of 40-49 diagnosed with T1cN1, grade II breast cancer who survived 7 years, have a 14% (95% confidence interval [CI]: 11.9%-16.1%) residual cumulative risk of BCSM in the next 13 years, and a 6.4% (95% CI: 4.7%-8.1%) residual cumulative risk of non-BCSM over the same period.

CONCLUSIONS

ESTIMATE provides population-based risks of BCSM, non-BCSM and all-cause mortality through 20 years after diagnosis of HR-positive breast cancer, based on patient and tumour characteristics. ESTIMATE can inform discussions about prognosis, a balance between competing risks and aid clinical decision-making.

Framework for integrating electronic patient-reported data in routine cancer care: an Oncology Intake Questionnaire

Objective

As part of ongoing implementation of electronic patient-reported outcome tools at the Dana-Farber Cancer Institute, here we describe the development of the electronic New Patient Intake Questionnaire.

Materials and Methods

The original New Patient Intake Questionnaire includes a review of symptoms, oncology history, family history, health behaviors, health and social status, health literacy and numeracy, which was modified for integration into the EHR using content determination, build and configuration, implementation, analytics, and interventions. The engagement of key stakeholders, including patients, clinical staff, and providers, throughout the development and deployment of the electronic Questionnaire was crucial to producing a successful tool. Continual modifications based on input of stakeholders (such as mode of tool deployment) were made to ensure the utility and usability of the tool for both patients and providers.

Results

Implementation of the EHR-integrated electronic New Patient Intake Questionnaire improved collection of the PRD by increasing questionnaire accessibility for patients, while also providing all available data to clinicians and researchers. Careful consideration of the content and configuration of the questionnaire allowed for a successful, institute-wide implementation of the tool.

Discussion

This effort demonstrates the feasibility of implementation of a system-wide electronic questionnaire, emphasizing the importance of iterative refinement to create a tool that is both patient-centric and usable for clinicians.

Conclusions

The electronic New Patient Intake Questionnaire allows for systematic collection of the PRD, which should benefit cancer care outcomes through innovative care delivery and healthcare interventions.

Implementation of patient-reported outcomes for symptom management in oncology practice through the SIMPRO research consortium: a protocol for a pragmatic type II hybrid effectiveness-implementation multi-center cluster-randomized stepped wedge trial

Background

Many cancer patients experience high symptom burden. Healthcare in the USA is reactive, not proactive, and doctor-patient communication is often suboptimal. As a result, symptomatic patients may suffer between clinic visits. In research settings, systematic assessment of electronic patient-reported outcomes (ePROs), coupled with clinical responses to severe symptoms, has eased this symptom burden, improved health-related quality of life, reduced acute care needs, and extended survival. Implementing ePRO-based symptom management programs in routine care is challenging. To study methods to overcome the implementation gap and improve symptom control for cancer patients, the National Cancer Institute created the Cancer-Moonshot funded Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium.

Methods

Symptom Management IMplementation of Patient Reported Outcomes in Oncology (SIMPRO) is one of three research centers that make up the IMPACT Consortium. SIMPRO, a multi-disciplinary team of investigators from six US health systems, seeks to develop, test, and integrate an electronic symptom management program (eSyM) for medical oncology and surgery patients into the Epic electronic health record (EHR) system and associated patient portal. eSyM supports real-time symptom tracking for patients, automated clinician alerts for severe symptoms, and specialized reports to facilitate population management. To rigorously evaluate its impact, eSyM is deployed through a pragmatic stepped wedge cluster-randomized trial. The primary study outcome is the occurrence of an emergency department treat-and-release event within 30 days of starting chemotherapy or being discharged following surgery. Secondary outcomes include hospitalization rates, chemotherapy use (time to initiation and duration of therapy), and patient quality of life and satisfaction. As a type II hybrid effectiveness-implementation study, facilitators and barriers to implementation are assessed throughout the project.

Discussion

Creating and deploying eSyM requires collaboration between dozens of staff across diverse health systems, dedicated engagement of patient advocates, and robust support from Epic. This trial will evaluate eSyM in routine care settings across academic and community-based healthcare systems serving patients in rural and metropolitan locations. This trial’s pragmatic design will promote generalizable results about the uptake, acceptability, and impact of an EHR-integrated, ePRO-based symptom management program.

Trial registration

ClinicalTrials.gov NCT03850912. Registered on February 22, 2019. Last updated on November 9, 2021.

Strategies for implementing an ePRO-based symptom management program (eSyM) across six cancer centers

12017

Background: Electronic patient-reported outcome (ePRO)-based symptom management can improve cancer care outcomes. However, implementation is challenging as it requires 1) tremendous technical resources to integrate ePROs into the electronic health record (EHR), 2) substantial buy-in from clinicians and patients, 3) between visit symptom management, and 4) institutional investment to support engagement. Methods: The SIMPRO Consortium developed and deployed eSyM, an EHR-integrated ePRO-based symptom management program for medical oncology and surgery patients, at 6 cancer centers between September 2019-March 2022. Site teams document new and changes to implementation strategies monthly using REDCap (data collection is ongoing). Strategies are itemized using the Expert Recommendations for Implementation Change (ERIC) list and mapped to the Consolidated Framework for Implementation Research (CFIR) list of barriers. The SIMPRO Coordinating Center (Dana-Farber) reviews all ERIC-CFIR classifications for consistency. Results: To date, 162 distinct strategies have been documented. On average, sites have implemented 23 strategies, 5 preparing for go-live and 18 remaining active beyond go-live. Preparation of clinical staff, training, and routine program evaluation are consistent high impact strategies. Other adaptive strategies have varied across sites, including various approaches to patient and provider engagement. Foundational strategies have been deployed by the coordinating center to support the multi-center initiative. Conclusions: Methodical deployment using theory-based implementation strategies may foster adoption of novel health care delivery systems by patients, clinicians, and institutions. Attention to the specific high-value strategies identified by the SIMPRO Consortium could support similar ePRO deployment at other institutions. [Table: see text]

Implementing systematized patient-facing Lynch syndrome (LS) risk assessment in oncology using the electronic health record (EHR) system

10503

Background: Lynch syndrome (LS) is the most common inherited cause of colorectal (CRC) and endometrial cancers. Significant provider and institutional level barriers limit LS detection, even in oncology patients with LS-associated cancers. PREMM5 is a validated tool based on personal and family cancer history that is recommended by national professional societies for LS risk assessment. This project’s goal was to study the feasibility of patient-facing LS risk assessment using a PREMM5 screener embedded in an electronic health record (EHR) system, as a means of improving LS identification. Methods: The PREMM5 LS screener intake questions were adapted to be completed by patients rather than healthcare providers. Screener adaptation and implementation involved iterative review by multidisciplinary experts and multilevel stakeholder engagement. The patient-facing PREMM5 LS screener was embedded in the EHR (Epic) at the Dana-Farber Cancer Institute (DFCI) to enable remote (via the EHR patient portal) and on-site completion (in clinic waiting rooms). All new gastrointestinal (GI) cancer patients seen at DFCI for initial oncology consultation from 6/2020-12/2021 were invited through the portal to complete the screener. PREMM5 scores ≥2.5% were considered “positive”, with genetics referral recommended. Beginning 2/2021, the EHR generated an automated provider-facing alert for positive screens. Results: 35% (1504/4262) of new GI cancer patients completed the screener. 367/1504 (24%) had a positive PREMM5 screen (mean age 53 years), of whom 66% were male, and 62%, 12% and 10% had CRC, neuroendocrine and pancreas cancer respectively. 97% (357/367) of screen positives completed the PREMM5 screener remotely through the portal. 102/367 (28%) received a genetics referral as a result of their positive PREMM5 screen (not including 75 genetics referrals outside this workflow), 13 of whom had a pathogenic variant (PV) on germline testing, including 4 with LS ( MSH2, MSH6, PMS2), and others with PVs in ATM, BRCA2, CHEK2, NTHL1, RAD50 and RECQL4. Conclusions: A practice-wide patient-facing EHR-integrated PREMM5 risk assessment workflow is feasible and identified nearly 1 in 4 general GI oncology patients as warranting genetic evaluation, resulting in the identification of numerous actionable germline PVs. This method of deployment could make genetic risk assessment more accessible to non-genetics providers. The suboptimal screener completion rate and 28% genetics referral rate among positive screens suggest the need for additional refinements, including patient and provider engagement and outreach to positive screens who do not follow up with appointments for genetic evaluation.

Impact of high-deductible health plans on delays in metastatic cancer diagnosis

6503

Background: High-deductible health plans (HDHPs) have grown rapidly in recent years, and now cover over one-half of U.S. workers. Patients in HDHPs are liable for the costs of all cancer-related care until their annual deductible is met, with the exception of screening tests such as colonoscopy and mammography. Due to increased out-of-pocket obligations, patients may postpone presenting for concerning symptoms or diagnostic testing, leading to delayed diagnosis. We therefore assessed the impacts of HDHPs on the timing of metastatic cancer detection. Methods: Using a nationally representative cohort of privately insured members in a national commercial and Medicare Advantage database (2003-2017), we studied 345,401 individuals age 18-64 years whose employers mandated a switch from a low-deductible (≤$500) plan to a high-deductible (≥$1,000) plan. Our control group consisted of 1,654,775 contemporaneous individuals whose employers offered only low-deductible plans. Both groups had a 1-year baseline period when all members were enrolled in low-deductible plans, and we followed members for a maximum of 13.5 years. Participants were matched with respect to age, gender, race/ethnicity, morbidity (ACG) score, poverty level, geographic region, employer size, baseline primary cancer, baseline medical and pharmacy costs, and follow-up duration. We used a validated claims-based algorithm to detect incident metastatic cancer diagnoses. We assessed time to metastatic cancer diagnosis in the baseline period (pre-HDHP switch) and follow-up period (post-HDHP switch) using a weighted Cox proportional hazards model. Results: After matching, there were no systematic differences between the HDHP and control groups with regard to observable baseline characteristics (standardized differences < 0.1). The mean age of participants was 42 years and the mean ACG score was 0.75. 49% were female, 48% lived in low-income neighborhoods, and 62% were White. We detected 1,668 metastatic events over a mean follow-up period of 38 months. There were no differences in time to metastatic diagnosis in the baseline year, prior to the HDHP switch (HR 0.96, p = 0.67). After employer-mandated HDHP switch, HDHP participants had lower odds of metastatic cancer diagnosis (HR 0.88, p = 0.01), indicative of delayed detection relative to the control group. Conclusions: Compared with conventional health plans, HDHPs are associated with delayed detection of metastatic cancer. These findings imply that patients postpone seeking care for concerning symptoms or defer diagnostic testing when exposed to high cost-sharing. Given recent advances that have improved survival of patients with advanced-stage cancers, future research efforts should investigate the impacts of HDHPs on quality of life, engagement in palliative care, and use of treatments in this patient population.

Factors associated with short- and long-term survival in metastatic HER2+ breast cancer

1047

Background: There have been significant therapeutic advances for HER2+ metastatic breast cancer (MBC) over the past decade. The aim of this study was to evaluate prognostic factors in metastatic HER2+ disease and their relationship with short- and long-term overall survival (OS) in the modern era. Methods: We evaluated patients (pts) with de novo metastatic HER2+ breast cancer diagnosed between years (y) 2010 and 2018, reported in SEER. Univariate analyses were performed to determine the effect of each variable on OS. Significant variables were included in a multivariate Cox model for OS that evaluated all pts diagnosed 2010 – 2018. Univariate and multivariate logistic regression was used to evaluate the association of each variable with short (< 2 y) and long (≥ 5 y) term OS. To allow sufficient follow up, only pts diagnosed 2010 – 2016 were included in the logistic regression for OS < 2 y, and only those diagnosed 2010 – 2014 were included for OS ≥ 5 y. Results: We included 5,576 pts with a median follow up of 48 months (IQR 25 – 73 months). Median OS was 41 months. The proportion alive at 2 y, 5 y, and 8 y, was 63.3% (95% CI 62.0% - 64.7%), 37.8% (95% CI 36.2% - 39.4%) and 26.8% (95% CI 24.8% - 28.9%), respectively. In multivariate analysis for OS, older vs younger age (HR 2.5), black vs white pts (HR 1.4), non-ductal non-lobular vs ductal (HR 2.7), bone metastases vs not (HR 1.2), brain metastases vs not (HR 1.8), liver metastases vs not (HR 1.6), lung metastases vs not (HR 1.3), 6 metastatic organ sites vs 1 (HR 3.6), ER/PR- vs + (HR 1.3), < $35k income vs ≥ $75k (HR 1.8), and being diagnosed in earlier years (HR 1.06 per each prior year) had significantly worse OS (all p≤0.044). Similar results were seen for breast cancer-specific survival. Factors associated with < 2 y OS in adjusted models were older age (OR 3.8), black race (OR 1.5), non-ductal non-lobular (OR 4.6), brain metastases (OR 3.0), liver metastases (OR 2.0), lung metastases (OR 1.6), ER/PR- (OR 1.7) and lower income (OR 1.6), all p < 0.04. Number of metastatic organ sites was not significant in this model. Factors associated with ≥ 5 y OS in adjusted models were younger age (OR 2.9), white vs black race (OR 1.7), fewer metastatic organ sites (OR 2.6), ER/PR+ (OR 1.3), and higher income (OR 3.3), all p < 0.02. Specific organ sites (bone, brain, liver and lung) were not significant in this model. Conclusions: In this cohort of pts with de novo HER2+ MBC, OS improved significantly over the study period, and a considerable proportion of pts were still alive at 8 y. Factors associated with shorter survival included older age, black race, lower income, and the presence of visceral or brain metastases. Long-term (≥ 5 y) survival was associated with both demographic (younger age, white race, higher income) and tumor-related (fewer metastatic sites, ER/PR positivity) factors.

A phase II feasibility study of electronic patient reported outcomes (ePROs) for oral cancer directed therapies (OCDT)

e13509

Background: Patients receiving oral cancer directed therapy (OCDT) may be at greater risk of toxicity and non-adherence than those on intravenous treatments. Electronic patient reported outcomes (ePROs) have the potential to mitigate those risks by alerting clinicians to patient status between visits, prompting earlier intervention. Best practices for ePROs implementation are not yet defined. We sought to demonstrate the feasibility of ePROs between visits for patients receiving OCDT both without and with asynchronous nursing triage calls for severe symptoms. Methods: In this Phase II feasibility study, patients were prospectively enrolled into two arms. In the first arm, “passive management” (Arm 1) patients were sent weekly ePROs with 15 symptoms, graded 0 (none) to 3 (severe), through the electronic patient portal (ePP). Responses were available for review by clinicians via the electronic medical record (EMR). In the second arm, “active management” (Arm 2) patients received the same weekly ePROs. If a patient responded with a severe symptom, a nurse would call within one business day to triage the concern. The primary outcome was 30-day feasibility, defined as a patient responding to 50% or more of ePROs sent during this period. Secondary outcomes included feasibility at 60- and 90-days, unplanned healthcare utilization (urgent care, ED visit or hospitalization), and nursing calls. At the time the Arm 2 was enrolling, a language-concordant interface for the EMR and ePP became available. The study was amended to include primarily Spanish speaking patients with a language concordant ePROs survey. Results: 100 patients were enrolled, 50 per arm. 10 patients who primarily spoke Spanish were included in Arm 2; the remaining 90 patients were fluent in English. 96 patients were eligible for evaluation of 30-day feasibility, 92 for 60-day, and 86 for 90-day. The 30-day feasibility by arm was 57% in Arm 1 and 45% in Arm 2 (p = 0.26). The 30-day feasibility in the Spanish language subgroup of the Arm 2 was 56%. Nursing calls in the first 30-days were 101 in Arm 1 and 109 in Arm 2. Multivariable regression for predictors of responding to 50% or more of ePROs in days 0-30 did not identify statistically significant correlates of feasibility. Conclusions: ePROs administered via an ePP were feasible the first 30 days on oral cancer directed treatment. Adding nurse triage calls between visits and a language concordant process for primarily Spanish speaking patients were feasible. Larger studies are needed to determine which factors truly impact use of the program and, most importantly, adherence and quality of life.[Table: see text]

Implementation of electronic patient-reported outcomes in head and neck oncology at a comprehensive cancer center

12115

Background: Monitoring electronic patient reported outcomes (ePROs) has demonstrated impact on quality of life and survival in oncology. Maintaining high response rates to ePRO measures is critical in routine care. We evaluate the routine care implementation of head and neck oncology (HNO)-focused ePROs and the impact of patient demographics and assignment method on response rate. Methods: Since October 2021, patients diagnosed with head and neck cancer (PHN) at Dana-Farber Cancer Institute (DFCI) have had the opportunity to respond to the EHR-integrated European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ- H&N43) at clinic visits, not to exceed every 30 days. PHN are also prompted at 7 and 14 days postoperative, regardless of clinic visit. HNO clinicians selected EORTC QLQ- H&N43 because of its actionable scores and limited overlap with cross-cutting ePRO tools at DFCI. Reviewed by Patient and Family Advisory Council members, PHN can respond to the questionnaire in English or Spanish via any internet-enabled device or tablet provided in clinic. Tablet assignment rates are sent via automated report to the HNO clinic manager. Results: Between October 2021 and January 2022, PHN responded to 64% of questionnaires for eligible clinic visits (1618/2535). Post-operatively, 65% of PHN responded to EORTC QLQ- H&N43 at least once within 28 days of surgery. Prompted at 7 and 14 days, PHN responded to 44% (133/300) of all post-operative questionnaires. Overall, PHN responded on their own device 50% of the time and on tablets in clinic 50% of the time. Response rates significantly associated with race, primary language, and age at clinic, but not post-operatively due to low sample size. PHN with a primary language other than English, older PHN, and PHN with races other than white responded less frequently, with the exception of Asian PHN in clinic who had the highest response rates. Clinician champions, EHR-integration, and a timely feedback loop to clinic managers facilitated response rates. Conclusions: Successful implementation of HNO ePROs is aided by clinical engagement and availability of real-time response rate data. ePRO response rate in HNO was found to be associated with race, primary language, age, and assignment method. Further work to focus on improving disparities within response rates and linking automatic interventions to scores is needed. [Table: see text]

Geospatial Disparities in the Treatment of Curable Breast Cancer Across the US

IMPORTANCE

Patient factors help explain disparities in breast cancer treatments and outcomes.

OBJECTIVE

To determine the extent to which geospatial variation in initial breast cancer care can be attributed to region vs patient factors with the aim of guiding quality improvement efforts.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective population-based cohort study from January 1, 2007, through December 31, 2016, using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database that included 31 571 patients diagnosed with stage I to III breast cancer from 2007 through 2013. Five metrics of care delivery were defined: stage I at diagnosis, chemotherapy receipt, radiation therapy receipt, endocrine therapy (ET) initiation (year 1), and ET continuation (years 3-5). Data analysis was performed from January to June 2021.

EXPOSURES

Stage I diagnosis and treatment with chemotherapy, radiation therapy, or ET.

MAIN OUTCOMES AND MEASURES

For each metric, total variance was attributed proportionally to 4 domains-random, patient factors (eg, age, race and ethnicity, socioeconomic status), region (health service area [HSA]), and unexplained-using hierarchical multivariable modeling.

RESULTS

Of 31 571 total patients (median [IQR] age, 71 [68-75] years), 19 391 (61.4%) had stage I disease at diagnosis. Among eligible patients, 17 297 of 21 190 (81.6%) received radiation therapy, 7204 of 9903 (72.8%) received chemotherapy, 13 115 of 26 855 (48.8%) initiated ET, and 13 944 of 26 855 (52.1%) continued ET. Geospatial density (ie, heat) maps highlight regional performance patterns. For all 5 metrics, region/HSA explained more observed variation (24%-48%) than patient factors (1%-4%); the largest share of variation was unexplained (35%-54%). The metrics with the largest proportion of total variance attributed to region/HSA were ET initiation and continuation (28% and 39%, respectively).

CONCLUSIONS AND RELEVANCE

In this cohort study, there was substantial unexplained geospatial variation in initial breast cancer care. The variance attributed to region/HSA was multifold larger than that explained by patient factors. The importance of patient factors such as race and ethnicity notwithstanding, future quality improvement efforts should focus on reducing unwarranted geospatial variation, especially including optimizing the delivery of ET in low-performing regions.

Abstract P2-10-01: Estimating risk of breast cancer-specific mortality (BCSM) and non-BCSM in patients with triple-negative breast cancer

Background: Triple-negative breast cancer (TNBC) is associated with high risk of distant recurrence and death. At present, our ability to estimate risk of death from causes other than breast cancer is limited. Particularly among elderly patients (pts), who have been historically underrepresented in clinical trials. In pts with TNBC, assessing both risks is important for our treatment recommendations. The aim of this study was to evaluate risk of BCSM and non-BCSM in TNBC by patient (pt) and tumor characteristics. Methods: Using data from the Surveillance, Epidemiology, and End Results (SEER) program, we identified women diagnosed with non-metastatic invasive TNBC between 2010-2016. Fine and Gray regression was used to evaluate the association of BCSM with pre-specified variables including pt age, tumor size (T), nodal status (N), and tumor grade, while considering deaths from other causes as competing events. We then estimated cumulative risk of BCSM, non-BCSM and all-cause mortality within subgroups defined by baseline clinical and pathologic variables. We conducted a subset analysis of N0 pts older than 50 years, given that we anticipated this subgroup would have the most clinically useful balance between BCSM and non-BCSM. Results: We included 37,293 pts. Age distribution was: 27.1% &lt;50 years, 51.3% 50-69 years, 15.0% 70-79 years, and 6.6% ≥80 years. Among all pts, 42.4% presented with T2 tumors and 69.5% had N0 disease. In adjusted Fine and Gray regression, risks of BCSM were higher for pts aged &gt;80 years vs 50-69 years (Hazard ratio [HR] 1.62; 95% CI, [1.45 - 1.80]), T4 vs T1a (HR 8.51; 95% CI, [6.20 - 11.68]), N3 vs N0 (HR 6.31; 95% CI, [5.70 - 7.00]) and grade III/IV vs grade I (HR 2.10; 95% CI, [1.44 - 3.07]). The cumulative risk of BCSM in year 0-7 was 10.7% for N0, 27.9% for N1, 46.4% for N2 and 64.0% for N3. In contrast, the cumulative risk of non-BCSM over the same period ranged from 7.5% in N1 to 8.7% in N2. The table shows risks of BCSM, non-BCSM and all-cause mortality among pts with N0 disease by age at diagnosis and tumor size. Pts 50-69 years had an increasing cumulative risk of BCSM by tumor size up to 13.0% in those with T2 tumors, while the risk of non-BCSM ranged from 4.8% to 5.9%. Pts aged 70-79 years with T1a/b, N0 tumors had risks of BCSM that were approximately 60% lower than the risks of non-BCSM. In pts aged ≥80 years, the risk of non-BCSM increased and is significantly higher than BCSM in patients with T1b-T2 disease. Conclusions: The risk of BCSM in TNBC depends on traditional clinicopathologic factors and is in general, much higher than the risk of non-BCSM. However, the high risk of non-BCSM among older pts is substantial which needs to be taken into consideration when making treatment recommendations. An interactive tool to estimate risks of BCSM, non-BCSM and all-cause mortality for TNBC will be presented at the meeting.

BCSMnon-BCSMAll-cause mortalityCumulative risk (%) and 95% CICumulative risk (%) and 95% CICumulative risk (%) and 95% CIyears 0-7years 0-7years 0-7Tumor size among age 50-69, N0 onlyT1a2.6 (1.0 - 4.3)5.9 (3.2 - 8.6)8.5 (5.3 - 11.6)T1b3.9 (2.8 - 5.0)4.8 (3.3 - 6.3)8.7 (6.9 - 10.5)T1c8.1 (6.9 - 9.4)4.8 (3.9 - 5.8)13.0 (11.4 - 14.5)T213.0 (11.6 - 14.4)5.5 (4.4 - 6.5)18.5 (16.8 - 20.2)Tumor size among age 70-79, N0 onlyT1a6.1 (0 - 12.7)13.9 (7.0 - 20.9)20.0 (10.2 - 28.7)T1b5.3 (3.0 - 7.7)13.3 (9.0 - 17.7)18.6 (13.7 - 23.3)T1c11.0 (8.7 - 13.4)14.3 (11.4 - 17.2)25.3 (21.7 - 28.8)T221.0 (17.4 - 24.6)17.4 (13.4 - 21.5)38.5 (33.3 - 43.2)Tumor size among age ≥80, N0 onlyT1a6.6 (0 - 19.7)27.0 (11.0 - 43.1)33.7 (11.8 - 50.1)T1b7.1 (2.1 - 12.2)33.2 (23.2 - 43.2)40.3 (28.9 - 49.9)T1c8.4 (5.2 - 11.6)32.7 (26.4 - 39.0)41.1 (34.1 - 47.3)T222.7 (18.1 - 27.3)41.6 (34.2 - 49.1)64.3 (56.0 - 71.1)

Citation Format: Jose P Leone, Noah Graham, Julieta Leone, Sara M Tolaney, Bernardo A Leone, Rachel A Freedman, Michael J Hassett, Carlos T Vallejo, Eric P Winer, Nancy U Lin, Nabihah Tayob. Estimating risk of breast cancer-specific mortality (BCSM) and non-BCSM in patients with triple-negative breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-10-01.

Real-World Analysis of Off-Label Use of Molecularly Targeted Therapy in a Large Academic Medical Center Cohort

PURPOSE

The primary objective of this study is to quantify the use of off-label molecularly targeted therapy and describe the clinical situations in which off-label targeted therapy are used. A key secondary objective is to report the outcomes of patients treated with off-label use of targeted therapy.

PATIENTS AND METHODS

We searched the electronic health record between 2000 and 2020 at our center to characterize the volume, clinical settings, and outcomes associated with off-label use of targeted therapies in different types of solid tumors.

RESULTS

Among 46,712 patients who received targeted therapies, we identified 119 instances of off-label use of targeted therapy. Colon cancer was the most common cancer type to receive off-label targeted therapy in 18 patients (15.1%), followed by 13 with non-small-cell lung cancer (10.9%), eight with cholangiocarcinoma (6.7%), and seven with glioblastoma (5.9%). The most frequent molecular rationale for off-label therapy came from a comprehensive next-generation sequencing test (53.7%). The most frequently mutated gene that provided the rationale for targeted therapy was BRAF (20.1%), with BRAFV600E being the most common molecular alteration overall (15.1%). The median duration of off-label targeted therapy was 3.58 months, and the overall survival of treated patients was 7.59 months. There were 37 patients (31.1%) treated for longer than 6 months, 23 patients (19.3%) who survived ≥ 2 years, and 13 patients who were still on therapy as of June 2020.

CONCLUSION

In this large cohort study of patients with solid tumors, off-label use of targeted therapy was uncommon. With that said, a notable proportion of patients had treatment durations ≥ 6 months and survivals of ≥ 2 years.

eSyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems

PURPOSE

Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available.

METHODS

As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes.

RESULTS

eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts.

CONCLUSION

eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

Patterns of Medical Care Cost by Service Type for Patients With Recurrent and De Novo Advanced Cancer

OBJECTIVES

There is limited knowledge about the cost patterns of patients who receive a diagnosis of de novo and recurrent advanced cancers in the United States.

METHODS

Data on patients who received a diagnosis of de novo stage IV or recurrent breast, colorectal, or lung cancer between 2000 and 2012 from 3 integrated health systems were used to estimate average annual costs for total, ambulatory, inpatient, medication, and other services during (1) 12 months preceding de novo or recurrent diagnosis (preindex) and (2) diagnosis month through 11 months after (postindex), from the payer perspective. Generalized linear regression models estimated costs adjusting for patient and clinical factors.

RESULTS

Patients who developed a recurrence <1 year after their initial cancer diagnosis had significantly higher total costs in the preindex period than those with recurrence ≥1 year after initial diagnosis and those with de novo stage IV disease across all cancers (all P < .05). Patients with de novo stage IV breast and colorectal cancer had significantly higher total costs in the postindex period than patients with cancer recurrent in <1 year and ≥1 year (all P < .05), respectively. Patients in de novo stage IV and those with recurrence in ≥1 year experienced significantly higher postindex costs than the preindex period (all P < .001).

CONCLUSIONS

Our findings reveal distinct cost patterns between patients with de novo stage IV, recurrent <1-year, and recurrent ≥1-year cancer, suggesting unique care trajectories that may influence resource use and planning. Future cost studies among patients with advanced cancer should account for de novo versus recurrent diagnoses and timing of recurrence to obtain estimates that accurately reflect these care pattern complexities.

Outcomes in breast cancer from the patient perspective: Development of an innovative, user-centered platform for collection and reporting of patient-reported data

188

Background: Transition towards a patient-centered healthcare model has been recognized as an important step towards improving the quality and coordination of breast cancer care. Although evidence suggests that patient self-reporting of quality of life improves clinical care, there are significant barriers to successful collection and use of patient-reported data (PRD) including a lack of a technology designed to fully engage patients and providers, limited electronic health record (EHR) integration, and suboptimal clinical implementation strategies. To address this, our team developed imPROVE, an innovative and customizable patient-reported data (PRD) collection platform consisting of a patient web-application and a clinician portal. Methods: This study was performed as a quality improvement initiative at Dana-Farber Cancer Institute (DFCI) and Brigham and Women’s Hospital (BWH). Multiple perspectives were sought from key stakeholders to ensure that the content and design of the platform target the needs of the end-users and garners the latest in technological advances. Development and testing were performed using best practices in user-centered design and agile development, and iterative programming sprints followed by stakeholder feedback and testing. Content was evaluated using probing questions about relevance, comprehensiveness, and clarity. Design was assessed through feedback about the look and feel of the platform and its usability. Results: A multidisciplinary team of 28 stakeholders in the field of breast cancer care, patient-reported outcomes research and value-based healthcare was assembled. Recurring group meetings (n = 8), individual patient interviews (n = 23), and two focus groups with the DF/HCC Breast Cancer Advocacy Group, were conducted. The resultant application is a hybrid mHealth application that is supported by iOS and Android and is comprised of five screens (myCare, myStory, myResources, myCommunity, myNotes). Patients are provided written and graphical displays of their PRD as well as tailored resources that are customized depending on their type and stage of treatment. The clinician portal is comprised of an overview table listing all patients enrolled for each individual clinician, as well as individual patient profiles demonstrating demographic, clinical, and outcomes data. Conclusions: imPROVE has the potential to create a paradigm shift in the delivery of care for breast cancer patients. Next steps will include implementation of imPROVE within the breast oncology and plastic surgery services at DFCI and BWH.

Leveraging mobile health technology and research methodology to optimize patient education and self-management support for advanced cancer pain

PURPOSE

Patient education is critical for management of advanced cancer pain, yet the benefits of psychoeducational interventions have been modest. We used mobile health (mHealth) technology to better meet patients' needs.

METHODS

Using the Agile and mHealth Development and Evaluation Frameworks, a multidisciplinary team of clinicians, researchers, patients, and design specialists followed a four-phase iterative process to develop comprehensive, tailored, multimedia cancer pain education for a patient-facing smartphone application. The target population reviewed the content and provided feedback.

RESULTS

The resulting application provides comprehensive cancer pain education spanning pharmacologic and behavioral aspects of self-management. Custom graphics, animated videos, quizzes, and audio-recorded relaxations complemented written content. Computable algorithms based upon daily symptom surveys were used to deliver brief, tailored motivational messages that linked to more comprehensive teaching. Patients found the combination of pharmacologic and behavioral support to be engaging and helpful.

CONCLUSION

Digital technology can be used to provide cancer pain education that is engaging and tailored to individual needs. A replicable interdisciplinary and patient-centered approach to intervention development was advantageous. mHealth interventions may be a scalable approach to improve cancer pain. Frameworks that merge software and research methodology can be useful in developing interventions.

Prospective Study Testing a Simplified Paclitaxel Premedication Regimen in Patients with Early Breast Cancer

Background

In early trials, hypersensitivity reactions (HSRs) to paclitaxel were common, thus prompting the administration of antihistamines and corticosteroids before every paclitaxel dose. We tested the safety of omitting corticosteroids after cycle 2 during the paclitaxel portion of the dose‐dense (DD) doxorubicin‐cyclophosphamide (AC)–paclitaxel regimen.

Patients, Materials, and Methods

In this prospective, single‐arm study, patients who completed four cycles of DD‐AC for stage I–III breast cancer received paclitaxel 175 mg/m² every 2 weeks for four cycles. Patients received a standard premedication protocol containing dexamethasone, diphenhydramine, and a histamine H2 blocker prior to the first two paclitaxel cycles. Dexamethasone was omitted in cycles three and four if there were no HSRs in previous cycles. We estimated the rate of grade 3–4 HSRs.

Results

Among 127 patients enrolled, 125 received more than one dose of protocol therapy and are included in the analysis. Fourteen (11.2%; 90% confidence interval, 6.9%–20.0%) patients had any‐grade HSRs, for a total of 22 (4.5%; 3.1%–6.4%) HSRs over 486 paclitaxel cycles. Any‐grade HSRs occurred in 1.6% (0.3%–5.0%), 6.5% (3.3%–11.3%), 7.4% (3.9%–12.5%), and 2.6% (0.7%–6.6%) of patients after paclitaxel cycles 1, 2, 3, and 4, respectively. Dexamethasone use was decreased by 92.8% in cycles 3 and 4. Only one patient experienced grade 3 HSR in cycles 3 or 4, for a rate of grade 3/4 HSR 0.4% (0.02%–2.0%) (1/237 paclitaxel infusions). That patient had grade 2 HSR during cycle 2, and the subsequent grade 3 event occurred despite usual dexamethasone premedication. A sensitivity analysis restricted to patients not known to have received dexamethasone in cycles 3 and 4 found that any‐grade HSRs occurred in 2.7% (3/111; 0.7%–6.8%) and 0.9% (1/109; 0.05%–4.3%) of patients in cycle 3 and 4, respectively.

Conclusion

Corticosteroid premedication can be safely omitted in cycles 3 and 4 of dose‐dense paclitaxel if HSRs are not observed during cycles 1 and 2.

Implications for Practice

Because of the potential for hypersensitivity reactions (HSRs) to paclitaxel, corticosteroids are routinely prescribed prior to each dose, on an indefinite basis. This prospective study, including 125 patients treated with 486 paclitaxel cycles, demonstrates that corticosteroids can be safely omitted in future cycles if HSRs did not occur during cycles 1 and 2 of paclitaxel and that this strategy reduces the use of corticosteroids in cycles 3 and 4 by 92.8% relative to current standard of care.

To avoid hypersensitivity reactions, corticosteroids are routinely prescribed before each dose of paclitaxel. This article reports the results of a study that focused on whether corticosteroids could be safely omitted in later cycles of treatment if reactions did not occur during earlier cycles.