Design, data linkage, and implementation considerations in the first cooperative group led study assessing financial outcomes in cancer patients and their informal caregivers

BACKGROUND

Few studies have assessed the financial impact of cancer diagnosis on patients and caregivers in diverse clinical settings. S1417CD, led by the SWOG Cancer Research Network, is the first prospective longitudinal cohort study assessing financial outcomes conducted in the NCI Community Oncology Research Program (NCORP). We report our experience navigating design and implementation barriers.

METHODS

Patients age ≥ 18 within 120 days of metastatic colorectal cancer diagnosis were considered eligible and invited to identify a caregiver to participate in an optional substudy. Measures include 1) patient and caregiver surveys assessing financial status, caregiver burden, and quality of life and 2) patient credit reports obtained from the credit agency TransUnion through a linkage requiring social security numbers and secure data transfer processes. The primary endpoint is incidence of treatment-related financial hardship, defined as one or more of the following: debt accrual, selling or refinancing home, ≥20% income decline, or borrowing money. Accrual goal was n = 374 patients in 3 years.

RESULTS

S1417CD activated on Apr 1, 2016 and closed on Feb 1, 2019 after reaching its accrual goal sooner than anticipated. A total of 380 patients (median age 59.7 years) and 155 caregivers enrolled across 548 clinical sites. Credit data were not obtainable for 76 (20%) patients due to early death, lack of credit, or inability to match records.

CONCLUSIONS

Robust accrual to S1417CD demonstrates patients' and caregivers' willingness to improve understanding of financial toxicity despite perceived barriers such as embarrassment and fears that disclosing financial status could influence treatment recommendations.

Abstract C006: Sociodemographic predictors of adherence to postoperative surveillance colonoscopy among patients diagnosed with nonmetastatic colorectal cancer

Background: Despite progress in colorectal cancer (CRC) screening and treatment over the past two decades, striking disparities in CRC survival persist among racial/ethnic minorities, with Blacks experiencing a 10% lower 5-year overall survival compared to Whites (American Cancer Society, 2017). One potential reason for the disparity in survival may be due to lower rates of appropriate surveillance care among racial/ethnic minorities. Among CRC patients, postoperative surveillance (PS) received at recommended intervals within 5-years following surgery improves overall survival up to 33% (Rodríguez-Moranta, 2006). Unfortunately, minority CRC survivors are approximately 30% less likely to receive PS compared to non-Hispanic Whites (NHW) (Carpentier, 2013). There are likely multiple underlying factors contributing to disparities in the timely receipt of recommended PS procedures such as colonoscopy, a PS procedure with adherence proportions as low as 18% among CRC patients. The differences in CRC patients who adhere or do not adhere to PS procedures are understudied.

Purpose: Based on Andersen's (1978, 1995, 2007) Behavioral Model of Health Services Use, this study will assess the association between individual- and contextual-level factors and adherence to PS colonoscopy among Medicare beneficiaries from different racial/ethnic groups.

Methods: This is a retrospective population-based cohort study using the SEER-Medicare linked database (2009-2014). Medicare beneficiaries diagnosed with CRC as their first cancer and who received surgical resection for CRC stage II and III, and who are between the ages of 66 and 85, are included in this sample. Chi-squared test will be used to assess significant differences in the distribution of patient characteristics across race/ethnicity, and analysis of variance (ANOVA) is used to assess differences for age as a continuous variable. Descriptive statistics will be presented for all demographic and socioeconomic variables to describe the characteristics of the sample population, stratified by racial/ethnic group. A hierarchical generalized linear model will be used to assess adherence to PS colonoscopy as a nonlinear function of explanatory variables defined at the individual- and contextual-levels. The adjusted odds with 95% confidence intervals of adherence to PS colonoscopy also will be presented by racial/ethnic group.

Conclusions: Appropriate surveillance following a CRC diagnosis is critical for improving CRC outcomes. Characteristics that are unique to racial/ethnic minorities may contribute to lower rates of adherence to PS colonoscopy, leading to poor survival outcomes. Findings from the proposed research may help guide future public health and clinical interventions focused on improving the timely receipt of PS procedures among older adults.

Citation Format: Janeth Sanchez, Veena Shankaran, Joseph Unger, Margaret Madeleine, Beti Thompson. Sociodemographic predictors of adherence to postoperative surveillance colonoscopy among patients diagnosed with nonmetastatic colorectal cancer [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr C006.

Abstract A058: Patient and neighborhood factors associated with receipt of surveillance colonoscopy among Medicare beneficiaries with surgically resected colorectal cancer

Background: After colorectal cancer (CRC) surgery, surveillance with colonoscopy is an important step for the early detection of local recurrence. Unfortunately, surveillance colonoscopy is underutilized and only about 55% of CRC patients receive a colonoscopy as recommended. Lower rates are observed among racial/ethnic minorities. Identifying the factors that contribute to disparities in receipt of surveillance colonoscopy can assist researchers in developing targeted interventions to promote surveillance colonoscopy for the early detection of recurrence. Purpose: This study assesses the association between patient- and neighborhood-level factors and receipt of surveillance colonoscopy. Methods: This retrospective population-based cohort study uses the National Cancer Institutes’ Surveillance, Epidemiology and End Results (SEER) – Medicare linked data collected from 2009 to 2014. We identified beneficiaries with surgically resected CRC stages II and III between the ages of 66 and 85. We used multivariate logistic regression to assess the effect of factors on receipt of colonoscopy. Results: A total of 6,602 patients were identified. Overall, 57.5% of patients received a colonoscopy within 18-months after surgery. After adjusting for patient- and neighborhood-level factors, Blacks had 29.6% lower odds of receiving a colonoscopy compared to non-Hispanic Whites (NHWs) (p=.002). Hispanics had 12.9% lower odds of receiving a colonoscopy compared to NHWs, however, this association was not significant (p>.05). Among NHWs, older age, male gender, and single status were significantly associated with lower odds of receipt of colonoscopy. Clinical factors, such as higher stage, no comorbidities and receipt of chemotherapy, were significantly associated with higher odds of receipt of colonoscopy, but only among NHWs. The odds of receipt of surveillance colonoscopy was 35% lower among NHWs patients with Medicaid coverage compared to NHWs without coverage. Although not significant, Black and Hispanic patients with Medicaid coverage were more likely to receive a colonoscopy compared to their racial/ethnic counterparts without coverage. Hispanics residing in neighborhoods with median household incomes of $90K+ had significantly lower odds of receipt of colonoscopy compared to Hispanics residing in neighborhoods with incomes of $0-$30K. Conclusion: Receipt of initial surveillance colonoscopy remains low and disparities exist between Blacks and NHW patients. The association between factors that assess a patient’s ability to access colonoscopy and actual receipt of colonoscopy suggest inequitable access to surveillance colonoscopy within and across racial/ethnic groups.

Citation Format: Janeth I Sanchez, Veena Shankaran, Joseph Unger, Beti Thompson. Patient and neighborhood factors associated with receipt of surveillance colonoscopy among Medicare beneficiaries with surgically resected colorectal cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A058.

Cumulative incidence of financial hardship in metastatic colorectal cancer patients: Primary endpoint results for SWOG S1417CD

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Background: Despite evidence that rising cancer care costs are contributing to “financial toxicity” in cancer pts, no studies, to our knowledge, have prospectively assessed the financial impact of cancer diagnosis (dx) using both self-reported and objective financial measures. S1417CD, led by the SWOG Cancer Research Network and conducted in the NCI Community Oncology Research Program (NCORP), was the first national prospective cohort study to evaluate time-to-first evidence of major financial hardship (MFH) in pts with newly diagnosed mCRC. We present results of the primary endpoint analysis. Methods: Pts age ≥ 18 within 120 days of mCRC dx receiving systemic treatment completed surveys every 3 months (mo) for 12 mo. MFH was defined as ≥ 1 occurrence of self-reported increase in debt, new loans, selling home, refinancing home, or ≥ 20% income decline during the 12 mo study period. Cumulative incidence (CI) of MFH was estimated to account for competing risk of death. Additional endpoints, not reported here, included quality of life, caregiver strain, and changes in credit status over 12 mo. Results: In total, 380 pts (median age 59.9) across 126 clinic sites were enrolled, with 377 eligible and evaluable for the primary endpoint (reached 12 mo assessment, death, or MFH endpoint); complete data were available for 92% of pts as of Jan 23, 2020. Most pts were white (78%), male (61%), and insured (98%), with annual income ≤ $50,000 (56%). Cumulative incidence of MFH at 12 mo was 71.5% (95% CI: 65.9%-76.3%), with 24.6%, 52.4%, and 61.8% at 3, 6, and 9 mo. The dominant components of MFH were new debt (12-mo CI, 56.7%) and >20% decline in income (26.7%); 104 (41%) pts reported ≥ 2 elements of MFH. In a secondary analysis excluding new debt, 12 mo cumulative incidence of MFH was 42.9% (95% CI: 37.2%-48.5%), with 10.3%, 24.4%, and 31.9% at 3, 6, and 9 mo. Conclusions: In a national sample of mCRC pts on systemic tx, financial hardship, most commonly in the form of increased debt, accumulates progressively over time. Nearly 3 out of 4 pts experiencing MFH at 12 mo despite access to health insurance coverage. These findings underscore the need for clinic and policy solutions such as early financial navigation and elimination of cost sharing to protect pts from financial devastation as they continue with tx. Clinical trial information: NCI-2015-01885 . [Table: see text]

Comparison of Treatment, Cost, and Survival in Patients With Metastatic Colorectal Cancer in Western Washington, United States, and British Columbia, Canada

PURPOSE

Few studies have directly compared health care utilization, costs, and outcomes between patients treated in the US multipayer health system and Canada's single-payer system. Using cancer registry and claims data, we assessed treatment types, costs, and survival for patients with metastatic colorectal cancer (mCRC) in Western Washington State (WW) and British Columbia (BC).

MATERIALS AND METHODS

Patients age ≥ 18 years diagnosed with mCRC in 2010 and later were identified from the BC Cancer database and a regional database linking WW SEER to claims from Medicare and two large commercial insurers. Demographics, treatment characteristics, costs of systemic therapy, and survival data were obtained from these databases and compared between the two regions.

RESULTS

A total of 1,592 patients from BC and 901 from WW were included in the study. Median age was similar (BC, 66 years; WW, 63 years), but patients in BC were more likely to be male (57.1% v 51.2%; P ≤ .01) and to have de novo metastatic disease (61.0% v 38.3%; P ≤ .01). The use of radiation therapy was similar between regions (BC, 31.2%; WW, 33.9%; P = .18), but primary tumor resection was more common in BC (74.1% v 66.3%; P ≤ .01) as was hepatic metastasectomy (12.4% v 2.3%; P ≤ .01). Similar percentages of patients received systemic therapy (BC, 68.8%; WW, 67.1%; P = .40), but costs were significantly higher for first-line systemic therapy in WW ($6,226 v $15,792 per patient per month; P ≤ .01). Median overall survival was similar (BC, 16.9 months; WW, 18 months).

CONCLUSION

Cost of systemic therapy for mCRC was significantly higher for patients in WW than in BC, but this did not translate to a difference in overall survival.

Impact of performance status on treatment outcomes: A real-world study of advanced urothelial cancer treated with immune checkpoint inhibitors

BACKGROUND

Immune checkpoint inhibitors (ICIs) represent an appealing treatment for patients with advanced urothelial cancer (aUC) and a poor performance status (PS). However, the benefit of ICIs for patients with a poor PS remains unknown. It was hypothesized that a poor Eastern Cooperative Oncology Group (ECOG) PS (≥2 vs 0-1) would correlate with shorter overall survival (OS) in patients receiving ICIs.

METHODS

In this retrospective cohort study, clinicopathologic, treatment, and outcome data were collected for patients with aUC who were treated with ICIs at 18 institutions (2013-2019). The overall response rate (ORR) and OS were compared for patients with an ECOG PS of 0 to 1 and patients with an ECOG PS ≥ 2 at ICI initiation. The association between a new ICI in the last 30 and 90 days of life (DOL) and death location was also tested.

RESULTS

Of the 519 patients treated with ICIs, 395 and 384 were included in OS and ORR analyses, respectively, with 26% and 24% having a PS ≥ 2. OS was higher in those with a PS of 0 to 1 than those with a PS ≥ 2 who were treated in the first line (median, 15.2 vs 7.2 months; hazard ratio [HR], 0.62; P = .01) but not in subsequent lines (median, 9.8 vs 8.2 months; HR, 0.78; P = .27). ORRs were similar for patients with a PS of 0 to 1 and patients with a PS ≥ 2 in both lines. Of the 288 patients who died, 10% and 32% started ICIs in the last 30 and 90 DOL, respectively. ICI initiation in the last 30 DOL was associated with increased odds of death in a hospital (odds ratio, 2.89; P = .04).

CONCLUSIONS

Despite comparable ORRs, ICIs may not overcome the negative prognostic role of a poor PS, particularly in the first-line setting, and the initiation of ICIs in the last 30 DOL was associated with hospital death location.

Real-world outcomes of first-line U.S. patients with unresectable advanced or metastatic gastroesophageal adenocarcinoma by primary tumor location

304

Background: Gastric cancer clinical trials are inconsistent in their inclusion of esophageal adenocarcinoma (EAC). Thus it is uncertain if outcomes are similar among subgroups of gastroesophageal adenocarcinoma. The aim of this study was to compare baseline characteristics and clinical outcomes of US patients with EAC versus Gastroesophageal Junction Cancer (GEJC) and Gastric Cancer (GC) treated in real world clinical settings. Methods: Adult patients with unresectable, advanced or metastatic GC, GEJC, or EAC diagnosed between January 2011 and November 2018 were identified from the Flatiron Health database. Patients with a positive HER2 test, or who received trastuzumab, were excluded. Overall survival (OS) was defined as time from first-line (1L) treatment initiation to death or loss of follow-up. Survival analyses were conducted using Kaplan-Meier methods with log-rank test and Cox models. Results: A total of 3052 patients (969 EAC and 2083 GEJC/GC) met eligibility criteria. Out of all EAC patients, 90% were males and 76% were white. Within the GEJC/GC patients, 67% were males and 57% were white. Median age was 66 years for both cohorts while proportion with ECOG PS of 0 or 1 was 78% for EAC and 84% for GEJC/GC among patients with ECOG scores. The proportion of patients receiving 1L treatment was comparable (78% for EAC, 76% for GEJC/GC) across groups with FOLFOX being the most frequent treatment (25% for EAC and 29% for GEJC/GC). There was no significant difference in OS between the two groups, with median OS of 9.1 and 9.6 months for EAC and GEJC/GC, respectively (HR 0.957, 95% CI: 0.863 - 1.062, p = 0.41). Conclusions: In this US real-world analysis, OS did not differ significantly between patients with EAC and patients with GEJC/GC who received 1L treatment, suggesting that these two populations may have comparable survival benefit from systemic therapy.

Intensity of end-of-life (EOL) cancer care in Western Washington (WA) versus Alberta (AB), Canada (CA)

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Background: Aggressive care at the EOL may lead to unnecessary suffering and healthcare costs for patients (pts) with cancer. Despite similar populations and state-of-the-art cancer delivery systems, we hypothesize that EOL care may be more intense in the United States (US) multi-payer system vs the CA single-payer system. Using cancer registry and claims data, we compared EOL cancer care between WA and AB. Methods: Adult pts with AJCC stage II-IV solid tumors who died between 2014 and 2016 were identified from regional population-based cancer registries in WA and AB. Data sources were 1) WA State Cancer Registry (WSCR) and Western WA Cancer Surveillance System (CSS) linked to enrollment files and claims from four regional insurers and 2) CA National Ambulatory Care Reporting System (NACRS), Discharge Abstracts Database (DAD), and CT records from AB Health Services. Proportions of pts receiving chemotherapy (CT), ICU admission, or > 1 ED visit in the last 30 days of life (DOL) in WA and AB were determined and compared using two sample z-test with two-tailed hypothesis (α = 0.05). Results: 11,177 AB and 7,906 WA pts met study inclusion criteria. Median age was 71 (IQR 61-79) and 75 (IQR 68-82) for AB and WA, respectively. The most common cancer types represented include lung (31% AB; 35% WA), colorectal (17% AB; 9% WA), breast (10% AB; 6% WA) and prostate (11% AB; 4% WA). A similar proportion of pts in WA and AB experienced multiple ED visits in the last 30 DOL (12.4% WA vs 12.1% AB). CT use in the last 14 and 30 DOL was greater in WA vs AB (6.3% and 13.4% vs 2.7% and 6.6%, respectively) and ICU admissions in the last 30 DOL were substantially greater in WA vs AB (19.9% vs 3.9%). Conclusions: CT use and ICU admissions in the last 30 DOL were more common in WA than AB. The lower rate of ICU admissions in AB may be due to a provincial effort to prioritize goals of care discussions . Future studies to characterize and compare drivers of inappropriately aggressive EOL care may help improve cancer care for patients (pts) in the US and AB.

[Table: see text]

A pilot study of a comprehensive financial navigation program in cancer patients and caregivers

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Background: Few studies have reported on interventions to alleviate financial toxicity (FT) in cancer patients (pts) and informal caregivers (cgs). We developed a financial navigation program in collaboration with Consumer Education and Training Services (CENTS), Patient Advocate Foundation (PAF), and Family Reach Foundation (FRF), to offer financial coaching, insurance navigation, and assistance with unpaid non-medical bills. We conducted a pilot study to assess feasibility of enrolling cgs with pts and to describe the assistance provided. Methods: Pts with any stage solid tumor actively receiving treatment (tx) at the Seattle Cancer Care Alliance were asked to identify a cg who could participate. Pts or pt/cg dyads received an online financial education course and monthly contact for 6 months (mo) with CENTS and PAF. Subjects were referred to FRF for assistance in paying non-medical bills. We describe pt and cg characteristics, and assistance provided by the program. Results: Of 54 pts approached, 30 (median age 59.5, 61% white, 97% stage III/IV disease) were consented. Most pts (53%) had income ≤ $25,000, and all were insured (48% commercial, 28% Medicare, 21% Medicaid). 18 cgs (67% spouse/partner) were consented. At consent, 55% of pts reported debt in the prior 3 mo. Mean score using the COST PRO FT measure (range 0-44, lower score = higher FT) was 17.4 at baseline. After pts’ physical health, out-of-pocket costs were the most stressful aspects of tx for cgs. Cgs with high financial burden from caregiving more often reported taking on new debt, dipping into retirement accounts, or changing their jobs or hours. CENTS coaches assisted with budgeting, updating wills, and employment rights counsel. PAF case managers assisted with financial assistance for drugs, cost of living (e.g. transportation), disability applications, and secured $6,950 in debt relief. FRF dispersed $4,133, primarily for housing expenses. Conclusions: Implementing a financial navigation program that engages both pts and cgs is feasible. This lower income, financially stressed population received $11,000 in financial assistance. Future work will focus on evaluating the impact of this program on financial and psychosocial outcomes in pts and cgs.

Docetaxel, Oxaliplatin, and 5-Fluorouracil (DOF) in Metastatic and Unresectable Gastric/Gastroesophageal Junction Adenocarcinoma: A Phase II Study with Long-Term Follow-Up

Lessons Learned.

Adding docetaxel to the modified FOLFOX7 backbone (DOF) is a feasible three‐drug combination therapy for advanced gastric cancer with high activity, providing evidence that leucovorin is not necessary in this setting.

The DOF regimen represents an alternative to the FLOT (5‐FU 2,600 mg/m² as 24‐hour infusion with leucovorin 200 mg/m², oxaliplatin 85 mg/m², and docetaxel 50 mg/m²) regimen that can be considered in select patients with advanced gastric cancer and is a potential choice in the curative setting.

Background.

The combination of docetaxel, cisplatin, and 5‐fluorouracil (5‐FU) demonstrates high response rates in advanced gastric cancer, albeit with increased toxicity. Given the efficacy of platinum‐taxane‐fluoropyrimidine regimens, this phase II study evaluated the efficacy and toxicity of docetaxel, oxaliplatin, and 5‐FU (DOF) for the treatment of metastatic or unresectable gastric or gastroesophageal junction (GEJ) adenocarcinoma.

Methods.

Patients with metastatic or unresectable gastric or GEJ adenocarcinoma with no prior therapy for metastatic disease received docetaxel 50 mg/m² on day 1, oxaliplatin 85 mg/m² on day 1, and 5‐FU 2,400 mg/m² continuous intravenous infusion over 46 hours; cycles were repeated every 2 weeks. The primary endpoint was overall response rate (ORR).

Results.

Forty‐four patients were enrolled. Assessment of treatment response and toxicity was feasible in 41 and 43 patients, respectively. ORR was 73.2% (68.3% partial response; 4.9% complete response). Therapy was discontinued for progressive disease in 53%, toxicity in 26%, and death on treatment in 16%. Two patients underwent surgical resection. Thirty‐three patients (76.7%) received at least seven cycles (7–34). Grade 3–4 toxicities occurred in 31 patients (72.1%), including neutropenia (23.3%), neurologic (20.9%), and diarrhea (14.0%). Median overall survival was 10.3 months.

Conclusion.

DOF demonstrates a high response rate, expected safety profile, and prolonged survival and remains an option for select patients with unresectable or metastatic gastric or GEJ adenocarcinoma.

Design and accrual of S1417CD: Development of a prospective financial impact assessment tool in patients with metastatic colorectal cancer (mCRC)

TPS6652

Background: Few studies have assessed the financial impact of cancer diagnosis (dx) in diverse patients (pts) and caregivers (cgs) using objective and standard financial measures. S1417CD, led by the SWOG Cancer Research Network, is the first prospective cohort study assessing financial outcomes to be conducted in the NCI Community Oncology Research Program (NCORP). We present our experience with design and accrual. Methods: Pts age ≥ 18 within 120 days of mCRC dx were considered eligible and asked to identify a caregiver (cg) who could participate concurrently. The primary endpoint is incidence of treatment-related financial hardship, defined as ≥ 1 of the following: debt accrual, selling/refinancing home, ≥ 20% income decline, or borrowing money. Measures include 1) pt and cg surveys (baseline (BL), 3, 6, 9 and 12 months (mo)) assessing out-of-pocket spending, financial impacts, cg burden, and quality of life and 2) pt credit reports (BL, 6, and 12 mo). Linkage to records from TransUnion, a national credit agency, required pt social security number (SSN) and processes for batched credit report transfer via secure web portal. The accrual goal was n = 374 pts in 3 years. The study activated on Apr 1, 2016 and closed on Feb 1, 2019 after reaching its accrual goal. A total of 380 pts (median age 59.7 years) and 155 cgs enrolled (41% cg participation). Enrollment steadily increased during the study period; 56% enrolled in the last 12 mo. Credit data were not obtainable for 76 (20%) pts due to early death, lack of credit, or inability to match records. S1417CD, the first cooperative group led study assessing financial outcomes in the community setting, completed enrollment faster than anticipated. Required SSN collection was not a barrier to enrollment, which improved as sites became familiar with data security measures. Robust accrual to S1417CD demonstrates pts’ and cgs’ desire to improve understanding of financial toxicity and its solutions. Follow-up will conclude in 12 mo with results to follow. SWOG plans to launch a randomized study (S1912) assessing the impact of financial navigation on household finances, using credit data for primary endpoint assessment. Clinical Trials Registry Identifier NCI-2015-01885. Clinical trial information: NCT02728804.

Outcomes of patients (pts) with metastatic urothelial cancer (mUC) and poor performance status (PS) receiving anti-PD(L)1 agents

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Background: Anti-PD(L)1 immune checkpoint inhibitors (ICI) prolong overall survival (OS) after platinum chemotherapy in mUC. However, clinical outcomes in pts with poor PS at time of ICI initiation are unknown. We hypothesized that ICI initiation in pts with ECOG PS 2-3 would be associated with worse outcomes vs. pts with ECOG PS < 2, and impact death location. Methods: A retrospective cohort study in 8 institutions identified pts with mUC who received ICI. Demographic, clinicopathologic, treatment (tx) patterns, tx response, and outcomes were collected. Primary endpoint: overall response rate (ORR). Secondary endpoints: median (m) OS in pts receiving ICI as 1st and 2nd line (1L, 2L); odds of dying in hospital (vs elsewhere) for pts receiving ICI (vs no tx) within 30 days of death; and estimated drug cost for pts with ICI within 30 days of death based on average wholesale price. Unadjusted logistic regression was used to assess association between ORR and ECOG PS (2-3 vs < 2) and wald test was used to compare mOS between ECOG PS (2-3 vs < 2). Results: 194 consecutive pts (30% women, 41% never smokers, median age at diagnosis 69) treated with ICI for mUC were identified. Median number of total tx lines was 2; all pts received ≥1 ICI line (6 pts received 2 ICI lines); 97, 79, 17 and 7 pts received ICI in 1L, 2L, 3L and 4L, respectively; 26% pts with ICI in 1L and 2L had ECOG PS 2-3. ORR and mOS are shown in table. Among 106 pts who died, 96 had available death location; of those, 8% received ICI within 30 days of death. Starting ICI within 30 days of death (vs no tx) was associated with higher odds of hospital death (OR 6.05, 95%CI 1.3-27.6). Estimated average ICI cost/pt within 30 days of death was $1400.58. Conclusions: Pts with ECOG PS 2-3 at time of ICI initiation had similar ORR vs ECOG PS < 2 but worse mOS. ICI initiation within 30 days from death was associated with higher likelihood of hospital death. ICI may not circumvent the negative prognostic role of poor PS, so biomarker-based pt selection is critical. Limitations include lack of adjustment for selection bias and other confounders at time of ICI initiation; data validation is ongoing. [Table: see text]

A retrospective analysis of clinical outcomes among patients with infiltrative hepatocellular carcinoma (iHCC): A single institution study

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Background: iHCC is an aggressive disease with poorly characterized treatment outcomes. We sought to describe clinical and radiographic features of iHCC, describe overall survival (OS), and compare outcomes of sorafenib (SOR) use with a cohort of non-infiltrative hepatocellular carcinoma (niHCC) patients. Methods: Radiology reports from the University of Washington with an Li-RADS (LR) assignment, 2013-2017, were reviewed (5037 reports, 1954 patients (pts)) for terms indicative of iHCC. Results: : 102 cases were identified, with 43% arising from known niHCC. iHCC size is difficult to measure but when reported, median was 8cm (interquartile range 5-10cm). Other radiographic features: vascular invasion 72%, R lobe only 62%. Clinical data were obtained via medical record review. The cohort was primarily male (83%), White (65%), age > 55 (88%), HCV (74.5%), heavy alcohol use (67%). At diagnosis: BCLC stage C (76%), ALBI grade 2 (62%) and 3 (21%). Median OS after diagnosis was 5.7 months (m). 38 (37%) pts were too ill to receive therapy. OS for de novo iHCC and for iHCC arising from niHCC did not differ (7.5m vs 5.1m, p = NS). All niHCC pts who received SOR in any line of therapy were identified among pts with a LR 5 lesion in at least one of the aforementioned radiology reports, 2013-2017. Pts who received SOR on trial and/or combined with another agent were excluded. Clinical data for the 83 niHCC pts were abstracted and compared to the 25 iHCC pts who received SOR, any line of therapy. Based on χ2 analyses, the 2 groups did not differ by age, sex, race, BCLC stage at SOR initiation, ECOG status at SOR initiation, HCC etiology, ALBI grade at SOR initiation, or previous locoregional therapy. OS after initiation of SOR was 14.1m for niHCC, 10.5m for iHCC, p = NS. PFS after SOR was 3.7m for niHCC, 7m for iHCC, p = NS. AFP at the time of SOR initiation was higher in iHCC than niHCC (median 1331 vs 48, respectively, p = 0.004), with median %AFP change after 30 days -13% in iHCC and +6% in niHCC, p = NS. Decrease in AFP after 30 days of therapy was associated with improved OS among niHCC (21m versus 7m, p = 0.001) but not among iHCC pts (p = NS). Conclusions: iHCC is a poorly understood subset of HCC with underlying biology not well defined. Compared to niHCC, clinical outcomes with sorafenib do not appear to differ in this cohort. Future characterization of outcomes with Y-90 and immune checkpoint inhibitors is warranted.

Small bowel adenocarcinoma: A single center experience

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Background: Small bowel adenocarcinoma (SBA) represents only 2% of GI malignancies. There is limited data to guide clinical decisions, largely extrapolated from colorectal cancers (CRC). We evaluated treatment strategies and outcomes in patients (pts) with early and advanced SBA. Methods: We identified 56 pts with SBA diagnosed between 1/2005 - 1/2018 and treated at our institution. Demographics, pathological features, treatments, and molecular data were abstracted via medical record review. Data was analyzed with SAS statistical software. Results: Median age was 61, 54% male, site: duodenum (D 37.5%), duodenal ampula (A 17.9%), jejunum (J 19.6%), ileum (I 12.5 %), unknown (12.5%). Predisposing conditions were: IBD (6), Lynch (2), and Peutz-Jeghers syndromes (1). Stage (stg) at diagnosis was I (5%), II (20%), III (34%) and IV (41%). Primary tumor resection occurred in 33 pts: 21 received adjuvant chemotherapy, mostly FOLFOX; 17 developed metastatic disease. Treatment for metastatic SBA (n = 40) included 5FU-based chemotherapy without or with anti-VEGF (n = 18), or anti-EGFR therapies (n = 9). Median lines of therapy was 2 (range 1-7). For pts with stg I-III SBA, median DFS/OS was 21/38 mos. For stg IV pts, OS was 19.8 mos; 18/35/8/14 mos for D, A, J and I, respectively. Molecular biomarkers with targeted (28) or next generation sequencing (10) were available for 28 metastatic SBA pts: KRAS MUT (8), TP53 MUT (5), ERBB2 MUT (2), MSI-H (2), ERBB2, CCNE1 amplification (1 each), and NRAS, BRAF, CDKN2A, ERBB3, ATM, PIK3CA MUT (1 each). OS was 20 vs 19 mos for pts with KRAS WT vs MUT stg IV SBA, respectively. Among 16 pts with KRAS WT SBA, OS for those treated (9) or not (7) with anti-EGFR antibodies was 25 mos vs 21 mos. One pt with KRAS WT, ERBB2 amplification/ERBB2 V777L activating mutation is alive 5yrs+ from stg IV diagnosis on anti-EGFR plus chemotherapy (best response was 4 mos SD with trastuzumab/pertuzumab). Conclusions: This retrospective study demonstrates heterogeneity among SBA, overall inferior outcomes compared to CRC pts, and emphasizes genomic alterations which could be exploited therapeutically. Randomized studies for KRAS WT SBA pts should test the benefit from anti-EGFR targeted therapies in this rare tumor type.

A Multicenter Phase II Study of AMG 337 in Patients with MET-Amplified Gastric/Gastroesophageal Junction/Esophageal Adenocarcinoma and Other MET-Amplified Solid Tumors

PURPOSE

MET gene amplification is associated with poor prognosis in gastric/gastroesophageal junction/esophageal (G/GEJ/E) cancers. We determined antitumor activity, safety, and pharmacokinetics of the small-molecule MET inhibitor AMG 337 in MET-amplified G/GEJ/E adenocarcinoma or other solid tumors.Patients and Methods: In this phase II, single-arm study, adults with MET-amplified G/GEJ/E adenocarcinoma (cohort 1) or other MET-amplified solid tumors (cohort 2) received AMG 337 300 mg/day orally in 28-day cycles. The primary endpoint was objective response rate (ORR; cohort 1). Secondary endpoints included ORR (cohort 2), progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

Of 2101 patients screened for MET amplification, 132 were MET-amplified and 60 were enrolled: 45 in cohort 1, and 15 in cohort 2. Fifty-six patients (97%) had metastatic disease; 57 had prior lines of therapy (1 prior line, 29%; ≥2 prior lines, 69%). A protocol-permitted review showed efficacy that was lower-than-expected based on preliminary data from a first-in-human study, and enrollment was stopped. Fifty-eight patients received ≥1 AMG 337 dose. ORR in cohort 1 was 18% (8 partial responses). No responses were observed in cohort 2. Of 54 evaluable patients, median (95% CI) PFS and OS were 3.4 (2.2-5.0) and 7.9 (4.8-10.9) months, respectively. The most frequent adverse events (AEs) were headache (60%), nausea (38%), vomiting (38%), and abdominal pain, decreased appetite, and peripheral edema (33% each); 71% had grade ≥3 AEs and 59% had serious AEs.

CONCLUSIONS

AMG 337 showed antitumor activity in MET-amplified G/GEJ/E adenocarcinoma but not in MET-amplified non-small-cell lung cancer.See related commentary by Ma, p. 2375.

Links Between Communication and Relationship Satisfaction Among Patients With Cancer and Their Spouses: Results of a Fourteen-Day Smartphone-Based Ecological Momentary Assessment Study

Cancer treatment poses significant challenges not just for those diagnosed with the disease but also for their intimate partners. Evidence suggests that couples' communication plays a major role in the adjustment of both individuals and in the quality of their relationship. Most descriptive studies linking communication to adjustment have relied on traditional questionnaire methodologies and cross-sectional designs, limiting external validity and discernment of temporal patterns. Using the systemic-transactional model of dyadic coping as a framework, we examined intra- and inter-personal associations between communication (both enacted and perceived) and relationship satisfaction (RS) among patients with stage II-IV breast or colorectal cancer and their spouses (N = 107 couples). Participants (mean age = 51, 64.5% female patients, and 37.4% female spouses) independently completed twice-daily ecological momentary assessments (EMA) via smartphone for 14 consecutive days. Items assessed RS and communication (expression of feelings, holding back from expression, support and criticism of partner, and parallel ratings of partner behavior). Linear mixed models employing an Actor Partner Interdependence Model were used to examine concurrent, time-lagged, and cross-lagged associations between communication and RS. Expressing one's feelings was unassociated with RS. Holding back from doing so, in contrast, was associated with lower RS for both patients and spouses in concurrent models. These effects were both intrapersonal and interpersonal, meaning that when individuals held back from expressing their feelings, they reported lower RS and so too did their partner. Giving and receiving support were associated with one's own higher RS for both patients and spouses in concurrent models, and for patients in lagged models. Conversely, criticizing one's partner and feeling criticized were maladaptive, associated with lower RS (own and in some cases, partner's). Cross-lagged analyses (evening RS to next-day afternoon communication) yielded virtually no effects, suggesting that communication may have a stronger influence on short-term RS than the reverse. Findings underscore the importance of responsive communication, more so than expression per se, in explaining both concurrent and later relationship adjustment. In addition, a focus on holding back from expressing feelings may enhance the understanding of RS for couples coping with cancer.

Comparison of chemotherapy use, cost, and survival in patients with metastatic colorectal cancer in Western Washington and British Columbia

LBA3579

Background: Few studies have directly compared health care utilization, costs, and outcomes between geographically similar patients (pts) treated in the U.S.’ multi-payer health system versus Canada’s single-payer system. Using cancer registry and claims data, we assessed systemic therapy (ST) use, cost, and survival for metastatic colorectal cancer (mCRC) pts in Western Washington (WW) and British Columbia (BC). Methods: Pts age ≥ 18 diagnosed with mCRC in 2010 and later were identified from 1) the BC Cancer Agency database and 2) a regional database linking WW SEER to claims from two large commercial insurers. Demographic and treatment characteristics for the two populations were compared using two-sample T tests. ST costs (first-line and lifetime) were expressed as mean per patient per month costs; Canadian costs were expressed in US dollars using the Purchasing Power Parity for Health in 2009. Median survival was reported for both populations. Results: 1622 BC pts and 575 WW pts were included in the analysis. BC pts were more likely to be older (median age 60 vs 66) and male (57% vs 48%, p = < 0.01). A greater proportion of WW versus BC pts received ST (79% vs. 68%, p < 0.01). FOLFIRI plus bevacizumab was the most common first-line regimen in BC (32%) while FOLFOX was the most common first-line regimen in WW (39%). The mean monthly cost of first-line therapy per patient was significantly higher in WW than BC ($12,345 vs $6,195, p = < 0.01), and this was true for all regimens assessed. Mean lifetime monthly ST costs were significantly higher in WW ($7,883 vs $4,830, p = < 0.01). There was no difference in median overall survival between populations among those receiving ST (21.4 months (95% CI 18.0-26.2) in WW and 22.1 months (20.5-23.7) in BC) or among those not receiving ST (5.4 months (2.4-7.7) WW versus 6.3 months (5.2-7.3) BC). Conclusions: Utilization and cost of ST for mCRC was significantly higher for patients in WW compared to BC without differences in overall survival in treated and untreated patients.

Impact of trained oncology financial navigators on patient out-of-pocket spending

OBJECTIVES

Patients with cancer often face financial hardships, including loss of productivity, high out-of-pocket (OOP) costs, depletion of savings, and bankruptcy. By providing financial guidance and assistance through specially trained navigators, hospitals and cancer care clinics may be able mitigate the financial burdens to patients and also minimize financial losses for the treating institutions.

STUDY DESIGN

Financial navigators at 4 hospitals were trained through The NaVectis Group, an organization that provides training to healthcare staff to increase patient access to care and assist with OOP expenses. Data regarding financial assistance and hospital revenue were collected after instituting these programs.

METHODS

Amount and type of assistance (free medication, new insurance enrollment, premium/co-pay assistance) were determined annually for all qualifying patients at the participating hospitals.

RESULTS

Of 11,186 new patients with cancer seen across the 4 participating hospitals between 2012 and 2016, 3572 (32%) qualified for financial assistance. They obtained $39 million in total financial assistance, averaging $3.5 million per year in the 11 years under observation. Patients saved an average of $33,265 annually on medication, $12,256 through enrollment in insurance plans, $35,294 with premium assistance, and $3076 with co-pay assistance. The 4 hospitals were able to avoid write-offs and save on charity care by an average of $2.1 million per year.

CONCLUSIONS

Providing financial navigation training to staff at hospitals and cancer centers can significantly benefit patients through decreased OOP expenditures and also mitigate financial losses for healthcare institutions.

Metastatic colorectal cancer (mCRC) treatment patterns in the Medicare population

823

Background: Few studies have examined how patterns of care relate to clinical consensus guidelines for metastatic colorectal cancer (mCRC) in real-world settings. This study investigated treatment patterns around systemic therapies for older mCRC patients using SEER-Medicare data. Methods: We utilized data from a linkage of national Medicare claims data with records from the 12 Surveillance, Epidemiology, and End Results (SEER) regions for patients diagnosed with stage IV CRC between 2011 and 2014. Other inclusion criteria included adenocarcinoma histology, being > 65 years of age, and continuous Part A/B enrollment 12 months prior to diagnosis. We conducted bivariate analysis and multivariate modeling to evaluate the association between age, race, gender, SEER region, and comorbidity score with receipt of systemic therapy. We examined first and subsequent lines of therapy, and classified them as adherent or non-adherent to NCCN guidelines. Results: Of 102,461 CRC patients, 6,360 (6.2%) patients had evidence of metastatic disease and met all inclusion criteria. 3,155 (49.6%) received no systemic therapy. Of the 2,976 (46.8%) who received systemic therapy with identifiable regimens, FOLFOX/CAPOX was the most common 1L regimen (32.9%), followed by 5-FU or capecitabine alone (26.4%) – both identified as guideline-adherent therapies. Non-guideline adherent regimens (such as use of single-agent oxaliplatin or bevacizumab) were uncommon as 1L therapies (1.4%). 1,553 patients (52.2%) progressed to a 2L therapy, 715 (24.0%) progressed to a 3L therapy, and 320 (10.8%) to a 4L therapy. A large proportion of 2L (26.9%) and 3L (24.2%) treatments contained bevacizumab. 96 patients (3.2%) received regorafenib, representing 6.7% of 3L and 10.6% of 4L therapies. Patients who did not receive systemic therapy were older (mean age of 80.8 vs 74.9) and had multiple comorbidities (63.1% vs 48.4% with Klabunde score > 1). Conclusions: In a Medicare-insured mCRC cohort, patients generally received systemic therapy adhering to consensus guidelines. However, many patients did not receive systemic therapy – suggesting there may be delays in diagnosis and barriers to treatment which lower systemic therapy utilization.