American Society of Clinical Oncology's Global Oncology Leadership Task Force: Findings and Actions

In response to rising cancer incidence and mortality rates in low- and middle-income countries and the increasingly global profile of ASCO’s membership, the ASCO Board of Directors appointed the Global Oncology Leadership Task Force (Task Force) to provide recommendations on ASCO’s engagement in global oncology. To accomplish its work, the Task Force convened meetings of global oncology experts, conducted focus group discussions with member groups, did site visits to South America and India, and met regularly to analyze the findings and develop recommendations. Task Force findings included global concerns, such as access to care, and specific concerns of middle- and low-resource settings. The need to strengthen health systems and the importance of alliances with a range of international cancer stakeholders were emphasized. Task Force recommendations to the ASCO Board of Directors were based on a three-part global oncology strategy of professional development, improvement of access to quality care, and acceleration of global oncology research. Specific areas of focus within each of these strategic pillars are provided along with an update on areas of ASCO activity as these recommendations are implemented.

A stakeholder-informed randomized, controlled comparative effectiveness study of an order prescribing intervention to improve colony stimulating factor use for cancer patients receiving myelosuppressive chemotherapy: the TrACER study

Colony stimulating factors (CSF) are widely prescribed to avoid febrile neutropenia (FN) among cancer patients receiving chemotherapy, but studies show their use is often not consistent with practice guidelines. In addition, there is limited high quality evidence assessing benefits and harms of primary prophylactic-CSF (PP-CSF) in the setting of chemotherapy that poses an intermediate risk of FN. To address these issues, with funding from the Patient Centered Outcomes Research Institute (PCORI) and the National Cancer Institute's Community Oncology Research Program, SWOG is sponsoring a prospective, cluster randomized controlled pragmatic trial of an automated order entry protocol for PP-CSF among patients with breast, lung and colorectal cancer receiving myelosuppressive chemotherapy, with a nested randomized controlled trial of PP-CSF for patients receiving intermediate risk chemotherapy. Primary outcomes include adherence to practice guidelines, overall rates of FN and rates of FN among persons receiving intermediate risk chemotherapy. The study, the first pragmatic trial in the National Cancer Institute's cancer cooperative clinical trials network, will provide critical evidence to inform physician and patient decision-making around PP-CSF use and practice policies regarding automated orders in cancer components.

Untapped Potential of Observational Research to Inform Clinical Decision Making: American Society of Clinical Oncology Research Statement

ASCO believes that high-quality observational studies can advance evidence-based practice for cancer care and are complementary to randomized controlled trials (RCTs). Observational studies can generate hypotheses by evaluating novel exposures or biomarkers and by revealing patterns of care and relationships that might not otherwise be discovered. Researchers can then test these hypotheses in RCTs. Observational studies can also answer or inform questions that either have not been or cannot be answered by RCTs. In addition, observational studies can be used for postmarketing surveillance of new cancer treatments, particularly in vulnerable populations. The incorporation of observational research as part of clinical decision making is consistent with the position of many leading institutions. ASCO identified five overarching recommendations to enhance the role of observational research in clinical decision making: (1) improve the quality of electronic health data available for research, (2) improve interoperability and the exchange of electronic health information, (3) ensure the use of rigorous observational research methodologies, (4) promote transparent reporting of observational research studies, and (5) protect patient privacy.

Patterns in provider types and cost of surveillance testing in early-stage breast cancer patients: A regional study

6582

Background: Although ASCO Choosing Wisely guidelines recommend against routine surveillance testing or imaging for asymptomatic individuals with early-stage breast cancer (ESBC) treated with curative intent, they are frequently performed. Physician specialty and costs associated with surveillance testing and imaging were examined in ESBC patients. Methods: Cancer registry patient records in Western Washington from 2007 to 2015 were linked with claims from two regional commercial insurers. Selected patients had been diagnosed with stage I/II breast cancer and treated with mastectomy or lumpectomy + radiation. Surveillance was considered from the first 4 month gap in treatment (surgery, chemo, radiation) through 13 months or restart of treatment. Evaluation and Management (E&M) and procedure codes for tumor marker (CEA, CA 15-3, CA 27.29) and advanced imaging (PET, CT, bone scan) were identified. Specialty codes were used to determine provider type. Physician visits were matched to tests using E&M codes in the +/- 7 days around each test. Cost included total reimbursed amount from insurers during the surveillance period. Results: During surveillance, 2,193 patients averaged 13.3 physician visits [median: 11, IQR: 8-17]. Oncologists (91%) and PCPs (83%) were the most common specialties with an average of 3.7 visits each. Overall, 37% of patients received tumor marker tests (avg = 2.8 tests/patient) and 17% received advanced imaging (avg = 1.5 images/patient). The mean total cost during the surveillance period was $18,403 (SD $26,640). Costs were higher for those patients who received tumor marker testing or advanced imaging. Conclusions: Patients frequently see oncologists and PCPs during early surveillance. Targeting oncologists to improve appropriate tumor marker testing could have the largest impact on aligning practice with Choosing Wisely recommendations and potentially reducing the financial burden on patients. [Table: see text]

Predictors of advanced imaging use during breast cancer surveillance

e18337

Background: Our objectives were to determine advanced imaging use (whole body imaging with bone scan, CT, or PET-CT and breast MRI) during breast cancer surveillance, and to identify drivers of potential imaging overuse as outlined by ASCO’s Choosing Wisely initiative. Methods: Cancer registry records for 2923 women diagnosed with primary breast cancer in Washington State from January 1, 2007 to December 31, 2014 were linked with claims data from two regional commercial insurance plans. Inclusion criteria included women with AJCC stage 0-3 disease treated with curative intent. Women without continuous insurance enrollment from 3 months prior to diagnosis until 14 months after diagnosis were excluded. Surveillance began 4 months after the end of primary therapy and lasted for 15 months or until restart of treatment. Women’s (age, race, family history) and tumor (grade, receptor status, stage) characteristics were collected. Evaluation and management codes from claims data were used to determine mammography, advanced imaging, and tumor biomarker use during the peri-diagnostic and surveillance periods. Multivariate logistic regression models were used to identify factors associated with advanced imaging use during surveillance. Results: Of eligible women, 80.0% (2332/2923) received mammography, 16.5% (483/2932) received whole body imaging, and 21.5% (670/2932) received breast MRI during the surveillance period. Whole body imaging was significantly associated with increasing stage of disease (stage 3: OR = 3.39, 95% CI: 2.30-5.02), peri-diagnostic whole body imaging (OR = 1.80, 95% CI: 1.36-2.38), and surveillance tumor biomarker use (OR = 1.83, 95% CI: 1.46-2.31). Significant predictors of surveillance breast MRI included young age ( < 45 years: OR = 2.40, 95% CI:1.78- 3.25), family history (OR = 1.58, 95% CI:1.26-1.98), peri-diagnostic breast MRI (OR = 2.01, 95% CI: 1.56-2.59), and surveillance tumor biomarker use (OR = 1.74, 95% CI:1.41-2.17). Conclusions: Peri-diagnostic use of advanced imaging and surveillance use of tumor biomarkers are associated with advanced imaging use during surveillance, and may represent targets for interventions to increase adherence to Choosing Wisely clinical guidelines.

The role of chronic disease in the costs of potentially preventable emergency department use during treatment: A regional study

6505

Background: The Centers for Medicare and Medicaid Services (CMS) released a quality metric for potentially preventable chemotherapy-associated emergency department (ED) use, effective in 2020. This metric excludes diagnoses with emerging evidence for outpatient management, such as proactive symptom management (PSM) and those for ambulatory care sensitive chronic conditions. Little is known about the intersection between potentially preventable ED visits due to cancer vs. other chronic disease. This study characterized the number and costs of ED visits during treatment. Methods: Western Washington cancer registry records from 2011- 2015 were linked with claims from two commercial insurers. Patients with newly diagnosed solid tumors undergoing initial treatment with chemotherapy or radiation were eligible. ED use was tracked one year post treatment initiation. ED diagnosis codes for fields 1-10 from the CMS metric and the PSM literature were labeled “Potentially Preventable” (Pp). Codes from the Agency for Healthcare Research and Quality’s Prevention Quality Indicators (PQI) for Chronic Conditions were labeled “Potentially Preventable-Chronic Disease” (PpChronic). Costs were adjusted to $2016. Results: Of the 7,053 eligible patients, 2,543 (36.1%) visited the ED (median # visits [IQR]: 1 [1-2]). The most commonly listed codes included Pain (1,054 visits) and Dyspnea (279 visits) for Pp, Hypertension-PQI (652 visits) and COPD-PQI (206 visits) for PpChronic, and Diabetes (247 visits) and Hyperlipidemia (181 visits) for the other codes. Spending on ED visits including both potentially preventable cancer and chronic disease diagnoses totalled $706,552 (20% of ED costs). Conclusions: One fifth of ED costs potentially resulted from simultaneous poor cancer symptom and chronic disease management. Future research should explore the role of chronic illness in categorizing which ED visits are potentially preventable during cancer treatment. [Table: see text]

Neutropenia related hospitalization risk in lung cancer patients with chemotherapy

e18290

Background: We sought to describe outcomes following granulocyte-colony stimulating factor (G-CSF) prophylaxis in patients with lung cancer receiving chemotherapy regimens with low to intermediate risk for inducing neutropenia related hospitalization. Methods: We identified 11,233 lung cancer (all histologies) patients ≥ 18 years from 14 commercial US health plans. All patients received first cycle chemotherapy during 2008–2013. 5,423 patients received one of the 3 regimens: carboplatin and paclitaxel, cisplatin and etoposide, carboplatin and etoposide. Primary prophylaxis (PP) was defined as G-CSF administration within 5 days of chemotherapy. Outcome was neutropenia, fever, or infection-related hospitalization within 21 days. Regression and number-needed-to-treat (NNT) analyses were used. Results: A total of 11,233 patients received any chemotherapy (21.2% PP), were older (median years 64 PP; 64 no PP) and had at least 1 non-cancer comorbidity (79.8% PP; 77.9% no PP). About 2,776 patients received Carbo/Paclitaxel (13.9% PP), 1,356 patients received Cisp/Etop (23% PP) and 1,291 patients received Carbo/Etop (45.8% PP) regimens. PP was associated with lower risk of neutropenia related hospitalization for any chemotherapy (4.7% PP; 7.5% no PP; odds ratio [OR] 0.61; 95% CI 0.49 – 0.74), for Cisp/Etop (5.1% PP; 8.8% no PP; OR 0.56; 95% CI 0.32 – 0.97) and Carbo/Etop (5.6% PP; 11% no PP; OR 0.48; 95% CI 0.31 – 0.73), but not Carbo/Paclitaxel (5.7% PP; 6.7% no PP; OR 0.84; 95% CI 0.53 – 1.32) regimens. Based on NNT, the total cost of PP for 36 patients with any chemotherapy regimen to avoid one hospitalization would be $128,952 (mean hospitalization cost = $11,900, Standard Deviation [SD] = $9,541). For 28 patients with Cisp/Etop, it would be $101,920 (mean hospitalization cost = $16,957, SD = $16,135). For 19 patients with Carbo/Etop, it would be $63,270 (mean hospitalization cost = $11,356, SD = $6,949). Conclusions: Primary G-CSF prophylaxis was associated with some benefit in lowering neutropenia-related hospitalization in patients with lung cancer receiving Cisp/Etop and Carbo/Etop regimens, although the cost to treat patients remains high. Future studies need to examine the value of continued G-CSF use in subsequent cycles.

Systematic reviews and meta-analyses in geriatric oncology

e21517

Background: Cancer incidence for most malignancies increases with age with the majority diagnosed after age 65. Aging is also associated with an increasing number of major comorbidities and greater risk and consequences of treatment-related complications. Geriatric Oncology has emerged as a subdiscipline within oncology focused on clinical management and research related to the elderly. Methods: A comprehensive search of the English language literature between 1990-2016 was undertaken for systematic reviews or meta-analyses (SRMAs) related to geriatric oncology. Titles, abstracts and full text manuscripts when needed were reviewed. 1,088 potentially eligible records were identified including 703 not limited to elderly patients, 89 not cancer studies and 236 not SRMAs. Results:More than half of 61 eligible studies were published in the last five years including systematic reviews in 42 (69%), meta-analyses in 42 (69%) and both in 23 (40%). Studies came from Europe (30), US (14), Canada (9), Asia (7) and South America (1) with elderly age cutoffs ranging from > 60 to > 80. While 17 reviews included multiple cancer types, 44 were limited to lung cancer (9), colorectal cancer (8), breast cancer (7), multiple myeloma (5) and lymphoma (4). Research focus was survivorship or end-of-life (41), treatment (24), geriatric assessment (11) and supportive care (8). Studies were limited to randomized controlled trials (37), non-RCTs (9) and both (16). The primary outcome was overall survival (39), progression free or relapse-free survival (15), response or recurrence (11), treatment-related toxicity (21) and geriatric assessment or frailty (9). More than half of SRMAs included < 10 studies while 20% included > 30 with the number of subjects in included trials ranging from 153 to > 15,000. Conclusions: The development of Geriatric Oncology has spanned nearly three decades. While a strong evidence base of published research including rigorous SRMAs in Geriatric Oncology has only emerged over the past decade, steady growth across a range of topics and outcomes relevant to cancer in the elderly is apparent.

Costs, Trends, and Related Factors in Treating Lung Cancer Patients in 67 Hospitals in Guangxi, China

Lung cancer is a common disease with high mortality in China. Recent economic advances have led to improved medical capabilities, while costs associated with treating this disease have increased. Such change contributes to a commonly held belief that healthcare costs are out of control. However, few studies have examined this issue. Here, we use 34,678 hospitalization summary reports from 67 Guangxi hospitals (period 2013-2016) to document costs, temporal trends, and associated factors. Findings from this study are surprising in that they debunk the myth of uncontrolled healthcare costs. In addition, results and experiences from Guangxi are informative for other comparable regions.

Cost-Effectiveness Analysis of Prophylaxis Treatment Strategies to Reduce the Incidence of Febrile Neutropenia in Patients with Early-Stage Breast Cancer or Non-Hodgkin Lymphoma

OBJECTIVE

The objective of this study was to evaluate the cost effectiveness of no prophylaxis, primary prophylaxis (PP), or secondary prophylaxis (SP) with granulocyte colony-stimulating factors (G-CSFs), i.e., pegfilgrastim, lipegfilgrastim, filgrastim (6- and 11-day), or lenograstim (6- and 11-day), to reduce the incidence of febrile neutropenia (FN) in patients with stage II breast cancer receiving TC (docetaxel, cyclophosphamide) and in patients with non-Hodgkin lymphoma (NHL) receiving R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) over a lifetime horizon from a Belgian payer perspective.

METHODS

A Markov cycle tree tracked FN events during chemotherapy (3-week cycles) and long-term survival (1-year cycles). Model inputs, including the efficacy of each strategy, risk of reduced relative dose intensity (RDI), and the impact of RDI on mortality, utilities, and costs (in €; 2014 values) were estimated from public sources and the published literature. Incremental cost-effectiveness ratios (ICERs) were assessed for each strategy for costs per FN event avoided, life-year (LY) saved, and quality-adjusted LY (QALY) saved. LYs and QALYs saved were discounted at 1.5% annually. Deterministic and probabilistic sensitivity analyses (DSAs and PSAs) were conducted.

RESULTS

Base-case ICERs for PP with pegfilgrastim relative to SP with pegfilgrastim were €15,500 per QALY and €14,800 per LY saved for stage II breast cancer and €7800 per QALY and €6900 per LY saved for NHL; other comparators were either more expensive and less effective than PP or SP with pegfilgrastim or had lower costs but higher ICERs (relative to SP with pegfilgrastim) than PP with pegfilgrastim. Results of the DSA for breast cancer and NHL comparing PP and SP with pegfilgrastim indicate that the model results were most sensitive to the cycle 1 risk of FN, the proportion of FN events requiring hospitalization, the relative risk of FN in cycles ≥2 versus cycle 1, no history of FN, and the mortality hazard ratio for RDI (<90% vs ≥90% [for NHL]). In the PSAs for stage II breast cancer and NHL, the probabilities that PP with pegfilgrastim was cost effective or dominant versus all other prophylaxis strategies at a €30,000/QALY willingness-to-pay threshold were 52% (other strategies ≤24%) and 58% (other strategies ≤24%), respectively.

CONCLUSION

From a Belgian payer perspective, PP with pegfilgrastim appears cost effective compared to other prophylaxis strategies in patients with stage II breast cancer or NHL at a €30,000/QALY threshold.

Association of Risk Factors, Mortality, and Care Costs of Adults With Acute Myeloid Leukemia With Admission to the Intensive Care Unit

Importance

Adults with acute myeloid leukemia (AML) commonly require support in the intensive care unit (ICU), but risk factors for admission to the ICU and adverse outcomes remain poorly defined.

Objective

To examine risk factors, mortality, length of stay, and cost associated with admission to the ICU for patients with AML.

Design, Setting, and Participants

This study extracted information from the University HealthSystem Consortium database on patients 18 years or older with AML who were hospitalized for any cause between January 1, 2004, and December 31, 2012. The University HealthSystem Consortium database contains demographic, clinical, and cost variables prospectively abstracted by certified coders from discharge summaries. Outcomes were analyzed using univariate and multivariable statistical techniques. Data analysis was performed from November 15, 2013, to August 15, 2016.

Main Outcomes and Measures

Primary outcomes were admission to the ICU and inpatient mortality among patients requiring ICU care. Secondary outcomes included length of stay in the ICU, total hospitalization length of stay, and cost.

Results

Of the 43 249 patients with AML (mean [SD] age, 59.5 [16.6] years; 23 939 men and 19 310 women), 11 277 (26.1%) were admitted to the ICU. On multivariable analysis (with results reported as odds ratios [95% CIs]), independent risk factors for admission to the ICU included age younger than 80 years (1.56 [1.42-1.70]), hospitalization in the South (1.81 [1.71-1.92]), hospitalization at a low- or medium-volume hospital (1.25 [1.19-1.31]), number of comorbidities (10.64 [8.89-12.62] for 5 vs none), sepsis (4.61 [4.34-4.89]), invasive fungal infection (1.24 [1.11-1.39]), and pneumonia (1.73 [1.63-1.82]). In-hospital mortality was higher for patients requiring ICU care (4857 of 11 277 [43.1%] vs 2959 of 31 972 [9.3%]). On multivariable analysis, independent risk factors for death in patients requiring ICU care included age 60 years or older (1.16 [1.06-1.26]), nonwhite race/ethnicity (1.18 [1.07-1.30]), hospitalization on the West coast (1.19 [1.06-1.34]), number of comorbidities (18.76 [13.7-25.67] for 5 vs none), sepsis (2.94 [2.70-3.21]), invasive fungal infection (1.20 [1.02-1.42]), and pneumonia (1.13 [1.04-1.24]). Mean costs of hospitalization were higher for patients requiring ICU care ($83 354 vs $41 973) and increased with each comorbidity, from $50 543 for patients with no comorbidities to $124 820 for those with 5 or more comorbidities.

Conclusions and Relevance

Admission to the ICU is associated with high mortality and cost that increase proportionally with the comorbidity burden in adults with AML. Several demographic factors and medical characteristics identify patients at risk for admission to the ICU and mortality and provide an opportunity for testing primary prevention strategies.

Clinic level variation in emergency department and inpatient utilization in a community setting

226

Background: Early studies of the oncology medical home suggest that intensive outpatient care (e.g. 24-hour phone triage, same-day infusion) reduces emergency department (ED) and inpatient (IP) use during cancer treatment. Little is known about which services are most cost-effective. One strategy is to measure observed variation in ED and IP rates to pinpoint care features associated with low-use clinics. This study examined clinic-level variation in ED and IP use in a community setting. Methods: Cancer registry records for Western Washington from 2011 to 2015 were linked with claims from two regional commercial insurers. Included patients were diagnosed with breast, lung, colorectal, or prostate cancer and treated with chemotherapy or radiation. All ED and IP use was tracked 1 year after treatment start using claims data. Observed clinic rates were measured as the percentage of patients with 1 or more visits. Expected clinic rates were determined from regional average rates weighted by clinic’s cancer-specific stage mix. Observed-to-expected clinic ratios were calculated and the Wilson Score test (95% CI) was used to determine statistically different rates. Results: The 18 clinics included 4,558 eligible patients (median 196 pts/clinic; range: 35-859). Unstaged lung patients had the highest ED rates (38.5%); unstaged breast had the lowest (13.3%). The highest IP rate was among unstaged colorectal (66.7%); the lowest in local breast (11.1%). One clinic had an observed rate that was significantly above its expected rate in both ED only and ED to IP. One clinic was significantly below its expected rate in both ED to IP and IP only. Conclusions: Even after adjusting for cancer-specific stage, there was sizable clinic-level variation in the percentage of patients visiting the ED or IP. Investigation into care delivery features and practice characteristics, along with further risk adjustment, may yield insights into best practices and identify clinics for intervention. [Table: see text]

Development of cancer care episodes to measure costs for breast, colorectal, and non-small cell lung cancer

29

Background: Cancer care costs are rising, creating concerns about affordability. As a result, delivery systems are creating alternative payment structures to lower costs while maintaining or improving quality. As cancer care delivery often involves multiple provider systems, measuring cost may be difficult. In response, using commercial insurance claims linked to cancer registry records, we constructed broadly applicable, reproducible, clinically relevant episodes to measure costs. Methods: Cancer registry records for patients diagnosed in Western Washington from January 2007-June 2016 were linked with claims from two regional commercial insurers. Patients are age 18+, diagnosed with breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) and enrolled with a single insurance plan. With oncologist input, we constructed three care phases: diagnosis (30 days before diagnosis to first treatment), initial treatment (first treatment through first 4 month treatment gap), and end of life (last 30 days). Costs include all claims paid within the phase (2016 inflation adjusted). Supportive care includes colony-stimulating factors, blood transfusions, antibiotics, antivirals, antifungals, and antiemetics. Results: This study included 8,727 patients at diagnosis, 7,686 during treatment, and 1,736 at end of life. Diagnosis phase averaged 54 days and cost $6,936 (SD $11,761, median $4,021). Treatment averaged 126 days, with costs of $61,148 (SD $75,432, median $35,750). Average end-of-life costs were $15,829 (SD $30,222, median $2,347). The table below provides an example of the variation in costs during the treatment phase using local-stage tumors. Conclusions: Clinically relevant episodes of care and cost measures can be constructed using claims-registry data. This allows for identification of high-cost care categories and areas with large-cost variability, which may be helpful when designing value-based reimbursement programs or identifying areas for potential cost-reduction.[Table: see text]

Patient engagement on claims-registry reports of cost and quality

159

Background: Moving cancer care towards a value framework requires patients, providers, and payers to weigh cost, quality, and outcomes in decision-making. Many efforts are underway to help providers and payers make value decisions, but little has been developed for patients. Our regional value in cancer care effort used a claims-registry database to develop quality and cost reports aiming to provide actionable data to all stakeholders. Methods: Reports were generated using cancer registry records for Western WA from 2007-2015 linked with claims from two regional commercial insurers. Patients were presented quality reports on regionally prioritized metrics and the 2012 ASCO Choosing Wisely guidelines on breast cancer surveillance and EOL care. Patients also reviewed cost reports for episodes of care (diagnosis, treatment, end-of-life (EOL)) and out-of-pocket (OOP) cost estimates. Feedback stemmed from 1) stakeholder meetings over a 2-year period, 2) working groups of patients, payers and providers, and 3) an annual regional meeting on value in cancer care. Results: In total, 13 patients provided feedback at one or more outreach event. See table. Conclusions: Reports from a claims-registry database may not support the information needs of patients for care decision-making or representing “value”. Patients desired understanding more about patients “like them” for decision-making. [Table: see text]

Costs of potentially preventable emergency department use during cancer treatment: A regional study

2

Background: There is growing recognition that many emergency department (ED) visits during cancer treatment may be related to poorly controlled disease or treatment-related symptoms and could be prevented. An RCT using the Symptom Tracking and Reporting (STAR) tool for proactive symptom management decreased the percentage of patients admitted to the ED (34% vs. 41%; p=0.02). Little is known about the costs of potentially preventable ED visits in a community setting. This study examined the number and costs of ED visits and their associated diagnoses. Methods: Cancer registry records for patients in Western Washington from 2011 to 2015 were linked with claims from two regional commercial insurers. Patients diagnosed with a solid tumor and treated with chemotherapy or radiation were selected. All ED utilization was tracked for 1 year after the start of treatment. ED-related diagnoses codes were labeled “Potentially Preventable” (PP) if they mapped to the 13 symptom categories targeted by STAR (e.g. pain, nausea) and non-PP otherwise. Costs of ED visits were inflation-adjusted and include claims with ED-related procedure, revenue, and place of service codes. All subsequent inpatient costs were excluded, likely under-estimating total costs. Results: Of the 7,075 eligible patients, 2,543 (35.9%) visited the ED an average of 1.79 times. Pain (720 visits), Dyspnea (279 visits), and Nausea (232 visits) were the most common potentially preventable diagnoses; Hypertension (506 visits), Fever (230 visits), and Diabetes (215 visits) were the most common non-PP diagnoses. $1,134,254 (25.2% of the total ED costs) was spent on PP ED visits. Of PP ED visits 20.3% (178/875) resulted in an inpatient stay. Conclusions: In our community setting, at least one quarter of ED costs were potentially the result of poor symptom management. An investment in better symptom management has a significant opportunity to both improve cancer care and lower total costs.[Table: see text]

Out of system (OOS) costs for oncology clinics treating patients with breast, colorectal, and non-small cell lung cancer in Washington state

5

Background: As payers move from fee-for-service to episode-based reimbursement, there is a need for oncology providers to accurately measure in- and out-of-system resource use and cost for patients under their care. Medicare assigns management of a patient to only one provider, yet delivery systems may assume contractual responsibility for a patient with cancer’s entire episode costs, including care received outside of their system. Accordingly, the goal of this study was to estimate OOS care for patients with breast, colorectal (CRC), and non-small cell lung cancer (NSCLC). Methods: Cancer registry records for patients with breast, CRC, or NSCLC diagnosed in Western Washington State from January 2007 to June 2016 were linked with claims from two regional commercial insurers. The analysis focused on initial treatment phase: first day of treatment (surgery, radiation, chemotherapy) through the first 4-month gap in treatment. Patients were assigned an oncology provider group by identifying the clinic Tax ID Number (TIN) with the most Evaluation & Management (E&M) claims with a cancer diagnosis. Claims were considered in system if the TIN matched the assigned clinic. Costs included claims paid to all providers (adjusted to 2016 dollars). Results: The study included 7,686 newly diagnosed patients with breast, CRC, or NSCLC. The average cost for the initial treatment phase was $61,147/patient (SD $75,432, median $35,750). Nearly 31% of claims paid (mean $18,684, SD $32,649) were out of system. Among OOS costs, 24% were for inpatient care, 68% were for outpatient care, and 8% were for outpatient pharmacy. Conclusions: Among newly diagnosed patients with breast, CRC, or NSCLC, approximately 1/3 of costs for the initial treatment period stemmed from OOS care. Developing best practices for the reporting and management of OOS will be critical for organizations to succeed under episode-based reimbursement plans.[Table: see text]

Abstract P2-16-01: Relationship between overall survival and surrogate measures in patients with metastatic breast cancer treated with chemotherapy

Background: While metastatic breast cancer (MBC) is considered an incurable disease, nearly one-fifth of patients live longer than five years following diagnosis. In an effort to identify novel agents earlier, surrogate end points of overall survival (OS) such as response or progression are often employed in randomized controlled trials (RCTs). The goal of this analysis is to evaluate patterns of outcome reporting and the relationship of OS with surrogate measures in RCTs of patients with MBC.

Methods: The analysis was based on data from a systematic review of patients with MBC evaluating the clinical impact of chemotherapy intensity on survival. Reports of phase 2-3 RCTs published between 1990-2013 comparing more intense chemotherapy regimens (higher dose intensity or use of additional agents) with less intense were identified. For each RCT, clinical, treatment, demographic and outcome data were extracted. Outcomes evaluated included OS, progression free survival (PFS), and time to progression (TTP) with a focus on median survival and hazard ratios (HRs) as measures of treatment effect. Survival post progression (SPP) was calculated as the difference between median survival and median progression free time. The relations between various outcome measures were estimated utilizing weighted Pearson correlation coefficient (CORR) adjusted by Fisher's transformation. Weights were assigned proportionally to the sample size of individual RCTs.

Results: The review identified 70 eligible RCTs including 15,043 patients with MBC. Average median OS, PFS, and TTP were 19.2, 6.9, and 8.1 months reported in 96%, 60%, and 43% of studies, respectively. Progression could be determined in 66 studies, while 6 RCTs provided both outcomes. TTP was more often utilized in earlier studies (65% in 1990-2000, 35% in 2001-2008, and 33% in 2009-2013) and it was superseded by PFS in later years (20%, 70% and 81%, respectively). Only 37%, 33%, and 11% of RCTs reported HRs for OS, PFS, and TTP, respectively. HRs were more often available in recent publications (20% in 1990-2000, 22% in 2001-2008, 63% in 2009-2013 provided HR for OS). The correlation between reported HR and HR estimated by the ratio of arm-specific median survival times was high for OS (CORR=0.87, 95%CI: 0.73-0.94) and TTP (CORR=0.92, 95%CI: 0.61-0.99) and slightly lower for PFS (CORR=0.72, 95%CI: 0.44-0.87). The relationship between OS and surrogate measures (PFS, TTP) was weaker. The correlation between HR for OS and PFS was 0.49 (95%CI: 0.21-0.69) and for OS and TTP it was 0.26 (95%CI: -0.13-0.58). Survival time following progression was dependent on treatment type and was longer in less intense arms than more intense (mean SPP: 12.4 months vs. 11.4 months, P=0.0155).

Conclusions: In RCTs of patients with MBC treated with chemotherapy, when HR is not reported and if necessary statistical conditions are met, the HR approximated by ratio of median survival times may be a suitable proxy estimate. In agreement with other reports, neither PFS nor TTP are acceptable surrogate outcomes for OS in MBC, as survival following progression may be substantial. In these patients, crossover and post-trial treatments may influence the relationship between OS and surrogate measures.

Citation Format: Culakova E, Poniewierski MS, Crawford J, Dale DC, Lyman GH. Relationship between overall survival and surrogate measures in patients with metastatic breast cancer treated with chemotherapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-16-01.

Impact of the elimination of cost sharing for mammographic breast cancer screening among rural US women: A natural experiment

BACKGROUND

Rural US women experience disparities in breast cancer screening and outcomes. In 2006, a national rural health insurance provider, the National Rural Electric Cooperative Association (NRECA), eliminated out-of-pocket costs for screening mammography.

METHODS

This study evaluated the elimination of cost sharing as a natural experiment: it compared trends in screening before and after the policy change. NRECA insurance claims data were used to identify all women aged 40 to 64 years who were eligible for breast cancer screening, and mammography utilization from 1998 through 2011 was evaluated. Repeated measures regression models were used to evaluate changes in utilization over time and the association between screening and sociodemographic factors.

RESULTS

The analysis was based on 45,738 women enrolled in the NRECA membership database for an average of 6.1 years and included 279,940 person-years of enrollment. Between 1998 and 2011, the annual screening rate increased from 35% to a peak of 50% among women aged 40 to 49 years and from 49% to 58% among women aged 50 to 64 years. The biennial screening rate increased from 56% to 66% for women aged 40 to 49 years and from 68% to 73% for women aged 50 to 64 years. Screening rates increased significantly (P < .0001) after the elimination of cost sharing and then declined slightly after changes to government screening guidelines in 2009. Younger women experienced greater increases in both annual screening (6.2%) and biennial screening (5.6%) after the elimination of cost sharing in comparison with older women (3.0% and 2.6%, respectively). In a multivariate analysis, rural residence, lower population income, and lower population education were associated with modestly lower screening.

CONCLUSIONS

In a national sample of predominantly rural working-age women, the elimination of cost sharing correlated with increased breast cancer screening. Cancer 2017;123:2506-15. © 2017 American Cancer Society.

Patterns of surveillance testing in commercially insured patients with breast cancer across provider types: A regional study

4

Background: Oncologists, primary care physicians (PCPs), and other clinicians provide care for breast cancer patients following active treatment. Clinical practice guidelines are largely consistent in recommended number of clinic visits and annual mammograms. However, surveys of oncologists and PCPs have found variation in attitudes toward surveillance intensity, perceptions of care responsibility, and adherence to Choosing Wisely guidelines. This study examined if surveillance of patients with early stage breast cancer varied by whether they obtained follow up care with oncologists, PCPs or both. Methods: Cancer registry records for patients in Western Washington from 2007 to 2015 were linked with claims from two regional commercial insurers. Patients were selected if they had been diagnosed with stage I/II breast cancer and treated with mastectomy or lumpectomy + radiation. The surveillance period starts at the first 4 month gap in treatment (surgery, chemo, radiation) through 13 months from gap start or restart of treatment. Evaluation and Management (E&M) codes for visits and procedure codes for biomarker and advanced imaging (PET, CT, bone scan) were identified in claims. Specialty codes were used to determine type of provider seen. Physician visits were matched to tests using E&M codes in the ± 7 days around each test. Results: During surveillance, 2046 patients averaged 12.2 physician visits per patient [median: 10, IQR: 7-15]. Oncologists (92%) and PCPs (82%) were the most common specialties with an average of 4.0 and 4.2 visits respectively. 73% of patients received mammography (avg # exams = 1.6) , 37% biomarkers (avg = 2.7) and 16% advanced imaging (avg = 1.5). The majority of biomarkers and the largest proportion of advanced imaging occurred near an oncology visit. Conclusions: Patients frequently see oncologists and PCPs during early surveillance. Targeting oncologists for intervention on potentially inappropriate biomarker testing could have the largest impact on aligning practice with Choosing Wisely recommendations. [Table: see text]

Thromboembolic events (TE) among patients with metastatic pancreatic ductal adenocarcinoma (mPDA) after chemotherapy (Chemo)

280

Background: Clinical trials suggest that patients with mPDA are at high risk of TE from both disease and treatment. TE rates and anticoagulant use among mPDA patients after first line chemo were investigated. Methods: Medicare beneficiaries enrolled in parts A, B, and D; diagnosed with mPDA; aged ≥ 65 years; and starting chemo between 1/1/2007 and 12/31/2012 were obtained from Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Eligible patients were enrolled from 12 months before chemo and followed until death, post-chemo disenrollment, or 12/31/2012. Arterial (ICD-9 410-411, 433-434), venous (ICD-9 415.1x, 453.4x, 453.8x, 453.9), and total TE were defined as ≥ 2 outpatient diagnoses ≥ 30 days apart, one inpatient diagnosis, or one outpatient diagnosis followed by outpatient anticoagulants within 90 days. Post-chemo TE incidence was calculated as the number of first events per 100 person-years (PY) for patients with and without TE 12 months before chemo. Time from chemo to first TE was estimated using the Kaplan-Meier (KM) method. Results: Among 1,308 eligible patients, mean age was 74 years [range 65-93]; 56% were female; 85% had no prior TE. Overall, 419 (32%) had a TE after chemo including 121 (9%) arterial and 363 (28%) venous TE. The table shows incidence, and time to TE for those with and without prior TE. Outpatient anticoagulants were prescribed for 276 (25%) patients with no prior TE and 110 (57%) patients with prior TE. Table. TE incidence and time to TE among mPDA patients after chemo Conclusions: mPDA patients face a substantial risk of TE after chemo, with nearly one-third of patients without prior TE and one-half of patients with prior TE experiencing events during treatment. These high rates of TE indicate the importance of conducting risk assessments for preventive measures early during a patients’ care.[Table: see text]

Chemotherapy Use at the End of Life in Uganda

Purpose Avoiding chemotherapy during the last 30 days of life has become a goal of cancer care in the United States and Europe, yet end-of-life chemotherapy administration remains a common practice worldwide. The purpose of this study was to determine the frequency of and factors predicting end-of-life chemotherapy administration in Uganda. Methods Retrospective chart review and surveys and interviews of providers were performed at the Uganda Cancer Institute (UCI), the only comprehensive cancer center in the area, which serves a catchment area of greater than 100 million people. All adult patients at the UCI with reported cancer deaths between January 1, 2014, and August 31, 2015 were included. All UCI physicians were offered a survey, and a subset of physicians were also individually interviewed. Results Three hundred ninety-two patients (65.9%) received chemotherapy. Age less than 55 years (odds ratio [OR], 2.30; P = .004), a cancer diagnosis greater than 60 days before death (OR, 9.13; P < .001), and a presenting Eastern Cooperative Oncology Group performance status of 0 to 2 (OR, 2.47; P = .001) were associated with the administration of chemotherapy. More than 45% of patients received chemotherapy in the last 30 days of life. No clinical factors were predictive of chemotherapy use in the last 30 days of life, although doctors reported using performance status, cancer stage, and tumor chemotherapy sensitivity to determine when to administer chemotherapy. Patient expectations and a lack of outcomes data were important nonclinical factors influencing chemotherapy administration. Conclusion Chemotherapy is administered to a high proportion of patients with terminal cancer in Uganda, raising concern about efficacy. Late presentation of cancer in Uganda complicates end-of-life chemotherapy recommendations, necessitating guidelines specific to sub-Saharan Africa.

Issues on the Use of White Blood Cell Growth Factors in Oncology Practice

Appropriate use of myeloid growth factors may reduce the risk of neutropenic complications including febrile neutropenia (FN) in patients receiving cancer chemotherapy. The recently updated American Society of Clinical Oncology (ASCO) Guidelines on the Use of the White Blood Cell Growth Factors recommends routine prophylaxis with these agents starting in the first cycle when the risk of FN is 20% or greater. However, the risks for neutropenic complications and the risk of serious adverse consequences from FN vary considerably with different chemotherapy regimens as well as other disease-, treatment-, and patient-specific risk factors. Considerably more information is now available on the major risk factors for FN. Multivariable risk models combining factors look promising but require further validation. Most clinical studies of myeloid growth factor prophylaxis assessed relative risk (RR) of FN but were not powered to evaluate the effect of prophylaxis on disease-free or overall survival. Accumulating evidence suggests, however, that the appropriate use of these agents in selected patients may improve both short-term and long-term survival by reducing the immediate risk of mortality accompanying patients with high-risk disease developing FN as well as improving disease-free and overall survival by enabling the delivery of full dose intensity chemotherapy and reducing the risk of disease recurrence in patients treated with curative intent. Further studies to evaluate risk factors and models for FN are needed to guide clinical and shared decision making for the optimal personalized use of these agents and offer patients at increased risk the best chance of long-term disease control.

Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose To provide current recommendations on the use of sentinel node biopsy (SNB) for patients with early-stage breast cancer. Methods PubMed and the Cochrane Library were searched for randomized controlled trials, systematic reviews, meta-analyses, and clinical practice guidelines from 2012 through July 2016. An Update Panel reviewed the identified abstracts. Results Of the eight publications identified and reviewed, none prompted a change in the 2014 recommendations, which are reaffirmed by the updated literature review. Conclusion Women without sentinel lymph node (SLN) metastases should not receive axillary lymph node dissection (ALND). Women with one to two metastatic SLNs who are planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND (in most cases). Women with SLN metastases who will undergo mastectomy should be offered ALND. These three recommendations are based on randomized controlled trials. Women with operable breast cancer and multicentric tumors, with ductal carcinoma in situ, who will undergo mastectomy, who previously underwent breast and/or axillary surgery, or who received preoperative/neoadjuvant systemic therapy may be offered SNB. Women who have large or locally advanced invasive breast cancer (tumor size T3/T4), inflammatory breast cancer, or ductal carcinoma in situ (when breast-conserving surgery is planned) or are pregnant should not undergo SNB.

Risk of Neutropenia-Related Hospitalization in Patients Who Received Colony-Stimulating Factors With Chemotherapy for Breast Cancer

Purpose

To describe outcomes after granulocyte colony-stimulating factor (G-CSF) prophylaxis in patients with breast cancer who received chemotherapy regimens with low-to-intermediate risk of induction of neutropenia-related hospitalization.

Patients and Methods

We identified 8,745 patients age ≥ 18 years from a medical and pharmacy claims database for 14 commercial US health plans. This retrospective analysis included patients with breast cancer who began first-cycle chemotherapy from 2008 to 2013 using docetaxel and cyclophosphamide (TC); docetaxel, carboplatin, and trastuzumab (TCH); or doxorubicin and cyclophosphamide (conventional-dose AC) regimens. Primary prophylaxis (PP) was defined as G-CSF administration within 5 days of beginning chemotherapy. Outcome was neutropenia, fever, or infection-related hospitalization within 21 days of initiating chemotherapy. Multivariable regressions and number-needed-to-treat analyses were used.

Results

A total of 4,815 patients received TC (2,849 PP; 1,966 no PP); 2,292 patients received TCH (1,444 PP; 848 no PP); and 1,638 patients received AC (857 PP; 781 no PP) regimen. PP was associated with reduced risk of neutropenia-related hospitalization for TC (2.0% PP; 7.1% no PP; adjusted odds ratio [AOR], 0.29; 95% CI, 0.22 to 0.39) and TCH (1.3% PP; 7.1% no PP; AOR, 0.19; 95% CI, 0.12 to 0.30), but not AC (4.7% PP; 3.8% no PP; AOR, 1.21; 95% CI, 0.75 to 1.93) regimens. For the TC regimen, 20 patients (95% CI, 16 to 26) would have to be treated for 21 days to avoid one neutropenia-related hospitalization; with the TCH regimen, 18 patients (95% CI, 13 to 25) would have to be treated.

Conclusion

Primary G-CSF prophylaxis was associated with low-to-modest benefit in lowering neutropenia-related hospitalization in patients with breast cancer who received TC and TCH regimens. Further evaluation is needed to better understand which patients benefit most from G-CSF prophylaxis in this setting.

Using cancer registry records linked with health insurance records to measure costs and services at end-of-life

186

Background: Studies suggest that end-of-life (EOL) care for persons with cancer in the United States is variable and often misaligned with patient and family preferences. To better understand these issues, we developed reports on high-priority quality indicators and costs at EOL. Methods: Surveillance, Epidemiology, and End Results (SEER) records for solid tumor patients diagnosed with cancer in Western Washington state between 1/1/2007 and 12/31/2015 were linked with enrollment and claims from two regional commercial insurers. Using claims, we then developed algorithms to characterize EOL care for breast, colorectal, and non-small cell lung cancer (NSCLC), including costs of care at 90- and 30-days prior to death. Costs include all claims paid for ED, hospital, outpatient, and pharmacy care. We estimated patient out-of-pocket costs as the difference between allowed and paid claim amounts. Results: See Table. Across the largest 10 clinics in the region there was considerable variability in the average costs of cancer care in the last 90 days of life. The clinic-specific average ranged from $24,532 to $72,931 for breast cancer, $30,495 to $65,975 for colorectal cancer and $23,320 to $59,641 for NSCLC. Conclusions: At the end of life, care for patients with advanced breast, lung, and colorectal cancer is highly variable, costly to patients, and may be misaligned with the goals and preferences for patients and their family members. While the results may reflect both appropriate and unnecessary care, the large variation across clinics suggests opportunities for improvement. Further research is needed to identify factors associated with use of low-value, high-cost services at the end of life. [Table: see text]

Health care utilization and costs at end of life among patients with leukemia or lymphoma in a regional cancer registry-insurance claims linked database

184

Background: End-of-life (EOL) care for persons with hematologic malignancies is variable and often involves high-intensity services at death approaches, which may not reflect patient or family preferences. We characterized healthcare utilization and associated costs in the last 30 days of life among subjects with leukemia or lymphoma to better understand patterns of care in this population. Methods: We linked enrollment and claims records from two regional commercial insurers to Surveillance, Epidemiology, and End Results (SEER) records for patients diagnosed with leukemia or lymphoma in Western Washington state between January 1, 2007 and December 31, 2015. We developed algorithms to characterize EOL care and calculate costs from both the payer and patient perspective for the last 30 days of life. Costs are derived from paid claims for inpatient, outpatient, and pharmacy utilization. Patient out-of-pocket costs are calculated as the difference between allowed and paid claim amounts. Results: See Table. Conclusions: In this analysis, a majority of subjects usedat least one form of high intensity care in the last 30 days of life, and average out-of-pocket costs were considerable. Future research will focus on developing interventions to assess patient and family preferences for intensity of care to better inform the provision of high-value care in this population. [Table: see text]

Innovations in American Society of Clinical Oncology Practice Guideline Development

Since the beginning of its guidelines program in 1993, ASCO has continually sought ways to produce a greater number of guidelines while maintaining its commitment to using the rigorous development methods that minimize the biases that threaten the validity of practice recommendations. ASCO is implementing a range of guideline development and implementation innovations. In this article, we describe innovations that are designed to (1) integrate consideration of multiple chronic conditions into practice guidelines; (2) keep more of its guidelines current by applying evolving signals or (more) rapid, for-cause updating approaches; (3) increase the number of high-quality guidelines available to its membership through endorsement and adaptation of other groups’ products; (4) improve coverage of its members’ guideline needs through a new topic nomination process; and (5) enhance dissemination and promote implementation of ASCO guidelines in the oncology practice community through a network of volunteer ambassadors. We close with a summary of ASCO’s plans to facilitate the integration of data from its rapid learning system, CancerLinQ, into ASCO guidelines and to develop tactics through which guideline recommendations can be embedded in clinicians’ workflow in digital form. We highlight the challenges inherent in reconciling the need to provide clinicians with more interactive, point-of-care guidance with ASCO’s abiding commitment to methodologic rigor in guideline development.

Risk of infection among patients with non-metastatic solid tumors or non-Hodgkin's lymphoma receiving myelosuppressive chemotherapy and antimicrobial prophylaxis in US clinical practice

Purpose Guidelines generally do not recommend oral antimicrobials for prophylaxis against chemotherapy-related infections in patients with solid tumors. Evidence on antimicrobial prophylaxis use, and associated chemotherapy-related infection risk, in US clinical practice is limited. Methods A retrospective cohort design and data from two US private healthcare claims repositories (2008-2011) were employed. Study population included adults who received myelosuppressive chemotherapy for non-metastatic cancer of the breast, colon/rectum, or lung, or for non-Hodgkin's lymphoma. For each subject, the first chemotherapy course was characterized, and within the first course, each chemotherapy cycle and chemotherapy-related infection episode was identified. Use of prophylaxis with oral antimicrobials and colony-stimulating factors in each cycle also was identified. Results A total of 7116 (22% of all) non-metastatic breast cancer, 1833 (15%) non-metastatic colorectal cancer, 1999 (15%) non-metastatic lung cancer, and 1949 (21%) non-Hodgkin's lymphoma patients received antimicrobial prophylaxis in ≥1 cycle. Mean number of antimicrobial prophylaxis cycles during the course among these patients was typically <2, with little difference across cancers and chemotherapy regimens. Fluoroquinolones were the most commonly received class of antimicrobials, accounting for 20%-50% all antimicrobials administered. Among subjects who received first-cycle antimicrobial prophylaxis, chemotherapy-related infection risk in that cycle ranged from 3% to 6% across cancer types. Among patients who received first-cycle antimicrobial prophylaxis and developed chemotherapy-related infections, 38%-67% required inpatient care. Chemotherapy-related infection risk in subsequent cycles with antimicrobial prophylaxis was comparable. Conclusion The results of this study suggest that use of antimicrobial prophylaxis during myelosuppressive chemotherapy is far from uncommon in clinical practice. The results also suggest that an important minority of cancer chemotherapy patients receiving antimicrobial prophylaxis still develop serious infection requiring hospitalization.

Importance of Risk Factors for Febrile Neutropenia Among Patients Receiving Chemotherapy Regimens Not Classified as High-Risk in Guidelines for Myeloid Growth Factor Use

BACKGROUND

Clinical practice guidelines recommend prophylaxis in patients with cancer receiving a colony-stimulating factor (CSF) when the risk of febrile neutropenia (FN) is high (>20%). For patients receiving chemotherapy regimens not documented as high-risk, the decision regarding CSF prophylaxis use can be challenging, because some patients may be at high risk based on a combination of the regimen and individual risk factors.

METHODS

A retrospective cohort design and US private health care claims data were used. Study subjects received chemotherapy regimens classified as "low" or "intermediate," or unclassified, in terms of FN risk, and were stratified by cancer and regimen. For each subject, the first chemotherapy course, and each cycle and FN episode within the course, were identified. FN incidence proportions were estimated by the presence and number of risk factors and chronic comorbidities.

RESULTS

Across the 17 tumor/regimen combinations considered (n=160,304 in total), 74% to 98% of patients had 1 or more risk factor for FN and 41% to 89% had 2 or more. Among patients with 1 or more risk factor, FN incidence ranged from 7.2% to 29.0% across regimens, and the relative risk of FN (vs those without risk factors) ranged from 1.1 (95% CI, 0.8-1.3) to 2.2 (95% CI, 1.5-3.0). FN incidence increased in a graded and monotonic fashion with the number of risk factors and comorbidities.

CONCLUSIONS

In this retrospective evaluation of patients with cancer receiving chemotherapy regimens not classified as high-risk for FN in US clinical practice, most patients had 1 or more FN risk factor and many had 2 or more. FN incidence was found to be elevated in these patients, especially those with multiple risk factors.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

A Validated Risk Score for Venous Thromboembolism Is Predictive of Cancer Progression and Mortality

BACKGROUND

Retrospective studies have suggested an association between cancer-associated venous thromboembolism (VTE) and patient survival. We evaluated a previously validated VTE Clinical Risk Score in also predicting early mortality and cancer progression.

METHODS

A large, nationwide, prospective cohort study of adults with solid tumors or lymphoma initiating chemotherapy was conducted from 2002 to 2006 at 115 U.S. practice sites. Survival and cancer progression were estimated by the method of Kaplan and Meier. Multivariate analysis was based on Cox regression analysis adjusted for major prognostic factors including VTE itself.

RESULTS

Of 4,405 patients, 134 (3.0%) died and 330 (7.5%) experienced disease progression during the first 4 months of therapy (median follow-up 75 days). Patients deemed high risk (n = 540, 12.3%) by the Clinical Risk Score had a 120-day mortality rate of 12.7% (adjusted hazard ratio [aHR] 3.00, 95% confidence interval [CI] 1.4-6.3), and intermediate-risk patients (n = 2,665, 60.5%) had a mortality rate of 5.9% (aHR 2.3, 95% CI 1.2-4.4) compared with only 1.4% for low-risk patients (n = 1,200, 27.2%). At 120 days of follow-up, cancer progression occurred in 27.2% of high-risk patients (aHR 2.2, 95% CI 1.4-3.5) and 16.4% of intermediate-risk patients (aHR 1.9, 95% CI 1.3-2.7) compared with only 8.5% of low-risk patients (p < .0001).

CONCLUSION

The Clinical Risk Score, originally developed to predict the occurrence of VTE, is also predictive of early mortality and cancer progression during the first four cycles of outpatient chemotherapy, independent from other major prognostic factors including VTE itself. Ongoing and future studies will help determine the impact of VTE prophylaxis on survival.

IMPLICATIONS FOR PRACTICE

The risk of venous thromboembolism (VTE) is increased in patients receiving cancer chemotherapy. In this article, the authors demonstrate that a popular risk score for VTE in patients with cancer is also associated with the risk of early mortality in this setting. It is important that clinicians evaluate the risk of VTE in patients receiving cancer treatment and discuss the risk and associated symptoms of VTE with patients. Individuals at increased risk should be advised that VTE is a medical emergency and should be urgently diagnosed and appropriately treated to reduce the risk of serious and life-threatening complications.

Selection of Optimal Adjuvant Chemotherapy Regimens for Human Epidermal Growth Factor Receptor 2 (HER2) -Negative and Adjuvant Targeted Therapy for HER2-Positive Breast Cancers: An American Society of Clinical Oncology Guideline Adaptation of the Cancer Care Ontario Clinical Practice Guideline

PURPOSE

A Cancer Care Ontario (CCO) guideline on the selection of optimal adjuvant chemotherapy regimens for early breast cancer including adjuvant targeted therapy for human epidermal growth factor receptor 2 (HER2)-positive breast cancers was identified for adaptation.

METHODS

The American Society of Clinical Oncology (ASCO) has a policy and set of procedures for adapting clinical practice guidelines developed by other organizations. The CCO guideline was reviewed for developmental rigor and content applicability.

RESULTS

On the basis of the content review of the CCO guideline, the ASCO Panel agreed that, in general, the recommendations were clear and thorough and were based on the most relevant scientific evidence, and they presented options that will be acceptable to patients. However, for some topics addressed in the CCO guideline, the ASCO Panel formulated a set of adapted recommendations on the basis of local context and practice beliefs of the Panel members.

RECOMMENDATIONS

Decisions regarding adjuvant chemotherapy regimens should take into account baseline recurrence risk, toxicities, likelihood of benefit, and host factors such as comorbidities. In high-risk HER2-negative populations with excellent performance status, anthracycline- and taxane-containing regimens are the standard of care. Docetaxel and cyclophosphamide for four cycles is an acceptable non-anthracycline regimen. In high-risk HER2-positive disease, sequential anthracycline and taxanes administered concurrently with trastuzumab or docetaxel, carboplatin, and trastuzumab for six cycles are recommended. An alternative regimen in a lower-risk, node-negative, HER2-positive population is paclitaxel and trastuzumab once per week for 12 cycles. Trastuzumab should be given for 1 year. Platinum salts should not be routinely administered in the adjuvant triple-negative population until survival efficacy data become available.

Biomarker Tests for Molecularly Targeted Therapies: Laying the Foundation and Fulfilling the Dream

Precision medicine focuses on the management of individual patients on the basis of biomarkers and other distinguishing characteristics, with the overarching objective of improving clinical outcomes. The rapid proliferation of biomarker tests and targeted therapies has revolutionized patient care in a variety of serious disorders. Targeted cancer therapies interrupt oncogenic molecular pathways driven by mutations, overexpression, or translocation of specific genes. However, there is concern that the emergence of large-scale genomic data is exceeding our capacity to appropriately analyze and interpret the results.In 2014, the Institute of Medicine convened the Committee on Policy Issues in the Clinical Development and Use of Biomarkers for Molecularly Targeted Therapies. This committee conducted a study to develop recommendations to address diverse and interconnected development, regulatory, clinical practice, and reimbursement issues. The committee conducted an extensive search of the relevant literature and invited testimony from a wide range of experts in the field. The final report of the committee's study and deliberations was released on March 4, 2016, focusing on ways to achieve 10 goals to further advance the development and appropriate clinical use of biomarker tests for molecularly targeted therapies.This article presents an overview of the committee's study and resulting recommendations, which cover establishment of clinical utility, regulatory oversight, coverage and reimbursement, health system data integration, as well as education and access. The committee's recommendations presented and discussed here are fundamentally grounded in the understanding that, when properly validated and appropriately implemented, these assays and corresponding therapies hold considerable promise to enhance the quality of patient care and improve meaningful clinical outcomes.

Association Between Use of the 21-Gene Recurrence Score Assay and Receipt of Chemotherapy Among Medicare Beneficiaries With Early-Stage Breast Cancer, 2005-2009

IMPORTANCE

Guidelines recommend consideration of chemotherapy for most patients with early-stage, estrogen receptor-positive, invasive breast cancer in the absence of additional prognostic information. The 21-gene recurrence score (RS) assay has been shown in limited academic settings to reduce physician recommendations for adjuvant chemotherapy. Associations between the adoption of the assay and receipt of chemotherapy in the general population have not been examined.

OBJECTIVE

To examine whether adoption of the RS assay in a nationally representative sample of patients with early-stage breast cancer was associated with use of chemotherapy.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of Medicare beneficiaries who received a diagnosis of incident breast cancer between 2005 and 2009 using Surveillance, Epidemiology, and End Results data set with linked Medicare claims.

MAIN OUTCOMES AND MEASURES

Receipt of chemotherapy within 12 months after diagnosis.

RESULTS

A total of 44,044 patients had low-risk (24.0%), intermediate-risk (51.3%), or high-risk disease (24.6%, lymph node positive) as defined by National Comprehensive Cancer Network (NCCN) guidelines and met the study criteria. We observed no overall association between receipt of the RS assay and chemotherapy (odds ratio [OR], 1.03 [99% CI, 0.88-1.19]). In multivariable analysis, there was a significant interaction between NCCN risk and use of the RS assay, with assay use associated with lower chemotherapy use in high-risk patients (OR, 0.36 [99% CI, 0.26-0.50]) and greater chemotherapy use in low-risk patients (OR, 3.71 [99% CI, 2.30-5.98]), compared with no receipt of the assay (P=.006 for the overall interaction). Results were similar in prespecified subgroup analyses of patients 70 years and younger, with the exception of a shift toward lower chemotherapy use during 2008 (OR, 0.90 [99% CI, 0.77-.1.05]; P=.09) and 2009 (OR, 0.81 [99% CI, 0.66-0.99]; P=.007). In unadjusted analyses, overall chemotherapy use decreased over time in patients 70 years or younger with high-risk disease and those receiving the assay.

CONCLUSIONS AND RELEVANCE

The impact of the adoption of the RS assay on receipt of chemotherapy was strongly population dependent and was associated with relatively lower chemotherapy use in groups with high-risk disease and relatively higher chemotherapy use in patients with low-risk disease. Overall use of chemotherapy decreased during the study period in patients who were most likely to receive chemotherapy.

Regional initiative to use data transparency to improve cancer care

39

Background: In the context of many initiatives aimed at measuring quality and value in cancer care, the Hutchinson Institute for Cancer Outcomes Research (HICOR) has adopted a multi-stakeholder approach to characterize oncology care, prioritize areas for improvement, design programs, and evaluate outcomes. Beginning in 2014, HICOR initiated a process to move towards data transparency in the reporting of regional quality and value metrics. Methods: The HICOR team constructed clinic-level adherence reports for community-prioritized metrics and the 2012 ASCO Choosing Wisely recommendations using a registry-claims linked database. In the fall of 2014, a national external advisory board reviewed methodology for measuring adherence. De-identified regional results were presented at a provider meeting in late 2014 to elicit provider feedback on methodology and on strategies for reporting clinic-identified adherence. Clinics were privately given their own adherence data. In 2015, revised de-identified regional reports were presented at a Value in Cancer Care Summit poster session and made available through HICOR IQ, a regional oncology informatics platform, for further discussion. Results: Results show that no clinic was also the best or worst performing clinic. The table shows the performance by clinic for the 5 Choosing Wisely recommendations. There is now increased demand by clinics to view their own adherence benchmarked with the region as a next step in moving towards full data transparency. Additionally, there is support from provider members in the community to re-identify clinics in order to compare results against their peers. Conclusions: Using an iterative, transparent, multi-stakeholder process, it is feasible build regional consensus towards releasing clinic-level adherence to quality and value metrics. By consulting trusted experts in the field and allowing multiple opportunities to provide feedback, providers are requesting even more transparency in order use the oncology measures to improve care in their practice and the region. [Table: see text]