Real-World Effectiveness of Dasatinib Versus Imatinib in Newly Diagnosed Patients With Chronic Myeloid Leukemia

INTRODUCTION

Limited data exist comparing dasatinib with imatinib in clinical practice. This study assessed real-world outcomes associated with first-line (1L) dasatinib or imatinib treatment of chronic myeloid leukemia (CML).

PATIENTS AND METHODS

This retrospective, observational, United States multisite cohort study analyzed electronic medical record data from adults with Philadelphia chromosome-positive (Ph+) CML in the chronic phase (CML-CP) after 1L dasatinib or imatinib between January 2014 and September 2018. Rates of and times to major molecular response (MMR) and deep molecular response (DMR) were assessed overall and in subgroups (low vs. intermediate/high risk, aged <65 vs. ≥65 years, low/normal vs. high body mass index [BMI]).

RESULTS

The dasatinib cohort (n = 309) experienced higher rates of MMR (n = 304, 79% vs. 65%, P < .001) and DMR (44% vs. 25%, P < .001) vs. the imatinib cohort with shorter median times to MMR (11.9 vs. 14.7 months, P < .001) and DMR (30.3 vs. 66.1 months, P < .001). Patients with intermediate-/high-risk disease and those aged <65 years had higher MMR and DMR rates and achieved response earlier with dasatinib (P < .01). Patients with low-risk disease treated with dasatinib had higher rates of DMR (60% vs. 32%, P = .01). Across BMI strata, rates of MMR and DMR were higher with dasatinib (P < .05).

CONCLUSIONS

Patients with CML-CP treated with 1L dasatinib achieved higher rates of, with shorter times to, MMR and DMR versus 1L imatinib. These clinically meaningful improvements were observed across subgroups.

Better together? costs of first-line chemoimmunotherapy for advanced non-small cell lung cancer

OBJECTIVES

Recent advances have created options for first-line (1L) treatment of advanced/metastatic non-small cell lung cancer (aNSCLC). The study objectives were to describe the utilization of 3 classes of 1L treatment-chemotherapy (CT), immunotherapy (IO), and chemoimmunotherapy (IO+CT)-and the total, third-party payer, direct health care costs.

STUDY DESIGN

Retrospective, administrative claims database analysis of patients with aNSCLC who initiated 1L treatment between January 1, 2017, and May 31, 2019, with IO, CT, or IO+CT.

METHODS

Microcosting enumerated health care resource utilization, including antineoplastic drug costs, using standardized costs. Generalized linear models estimated per-patient per-month (PPPM) costs during 1L treatment, and adjusted cost differences in 1L among treatment cohorts were calculated using recycled predictions.

RESULTS

A total of 1317 IO-, 5315 CT-, and 1522 IO+CT-treated patients were identified. Utilization of CT declined from 72.3% to 47.6% between 2017 and 2019, replaced by use of IO+CT, which increased from 1.8% to 29.8%. Total PPPM costs in 1L were highest with IO+CT at $32,436, compared with $19,000 and $17,763 in the CT and IO cohorts, respectively. Adjusted analyses showed that PPPM costs were $13,933 (95% CI, $11,760-$16,105) higher in the IO+CT vs IO cohort (P < .001) and IO costs were $1024 (95% CI, $67-$1980) lower than CT (P = .04).

CONCLUSIONS

IO+CT accounts for almost one-third of 1L aNSCLC treatment modalities, coinciding with a reduction in treatment with CT. Costs for patients treated with IO were lower than those for patients treated with both IO+CT and CT alone, driven primarily by antineoplastic drug and associated medical costs.

Abstract P1-11-05: Provider perceptions of DESTINY-Breast04, HER2-low directed treatment, and interstitial lung disease

Background: Human epidermal growth factor receptor 2 (HER2)-targeted therapies are an established treatment for patients with HER2-positive breast cancer, however, these therapies have not proven effective in the HER2-negative setting. Until recently, HER2 status was used to guide treatment decisions based on a binary classification of positive or negative. A new pathological category, HER2-low, has emerged as a subtype of interest within the breast cancer treatment landscape. HER2-low status is defined as a HER2 immunohistochemistry score of 1+ or 2+ and a negative in-situ hybridization result. DESTINY-Breast04 (DB04) was the first trial to evaluate a HER2-targeted agent within the metastatic HER2-low breast cancer setting. The anti-HER2 agent trastuzumab deruxtecan (T-DXd) demonstrated promising clinical activity in HER2-low expressing tumors. However, development of T-DXd-related interstitial lung disease (ILD) remains a concern when using this therapy. This survey-based study aimed to evaluate community oncologists’ perceptions of the DB04 data, HER2-low directed treatment, and management of ILD. Methods: U.S.-based oncologists (n=83) convened at two live meetings in June 2022 to review clinical updates presented at ASCO 2022. Participant characteristics and demographic data were collected via an online survey prior to the respective meetings. Perceptions/reactions to clinical updates were captured in real-time via electronic keypad. Data were summarized using descriptive statistics. Results: Among respondents, 83.1% identified as community providers, with an average experience of 20.7 years in practice. On average, participants reported that 88.2% of their time is allocated towards direct patient care, with roughly 18 patients seen per clinic day. Nearly half of respondents (49.4%) reported awareness of HER2-low as a distinct pathological category prior to the presentation of DB04 at ASCO 2022, however, less than 10% of respondents had previously used this sub-category to determine therapy. Increased T-DXd-related ILD, which occurred in 12% of trial participants, was cited as the greatest limitation of the DB04 trial by over one-third (37.3%) of respondents. After reviewing real-world evidence data of ILD incidence in metastatic breast cancer, nearly one-third (31%) of respondents reported that their observed ILD rates are less than DB04, but more (36%) said that ILD can be hard to quantify because patients are not always symptomatic. When asked if the ILD rate associated with T-DXd would limit their selection of this agent for their patients with breast cancer, approximately one-quarter (24.1%) of respondents indicated that they would reserve T-DXd use for patients without symptomatic pulmonary disease. However, the majority of respondents (60.2%) indicated that they would not limit their use of T-DXd based on ILD rates, with most (55.4%) opting for a risk-management approach involving increased monitoring for the development of ILD-related adverse events. Conclusions: Advancements in assay interpretation have made it possible to differentiate gradients of HER2 expression, creating a space for pathological sub-categories within a formerly binary paradigm. Among providers who reported awareness of HER2-low as a distinct pathological sub-category, few had used this as a benchmark to guide their treatment decisions prior to the presentation of DB04 at ASCO 2022. Newer anti-HER2 agents, such as T-DXd, provide a potential new standard of care for patients with HER2-low expressing tumors. Despite the concern of ILD rates associated with T-DXd use, the majority of providers do not view this as a limiting factor due to the ability to closely monitor patients for the development of adverse events coupled with appropriate provider/patient education.

Citation Format: Brooke Leon, Robert Bone, Yolaine Jeune-Smith, Bruce Feinberg. Provider perceptions of DESTINY-Breast04, HER2-low directed treatment, and interstitial lung disease [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-11-05.

Real-world observational study of current treatment patterns and outcomes in recurrent or locally advanced/metastatic non-small cell lung cancer

BACKGROUND

Treatment for recurrent or advanced/metastatic non-small cell lung cancer (aNSCLC) has advanced in the past 5 years with immunotherapy (IO). This study sought to describe first-line (1L) aNSCLC treatment patterns and clinical outcomes.

METHODS

In this retrospective, multisite cohort study, community oncologists reported data for randomly selected stage IIIB/IV, EGFR-/ALK wild-type aNSCLC patients who initiated 1L systemic therapy from 01/01/2016 to 12/31/2019. Follow-up was through November 2020. Demographics, clinical characteristics, treatment patterns, disease response, progression, and death/last follow-up date were described. Overall response rate (ORR) was calculated using tumor measurements applying RECIST v1.1 guidelines. Progression-free survival (PFS) and overall survival (OS) were calculated from 1L initiation by Kaplan-Meier method.

RESULTS

497 patients from 46 sites were included. The most common 1L regimens (%) were platinum-doublet chemotherapy plus IO (PDC+IO) (40.6%), PDC (29.4%), IO monotherapy (20.7%), and PDC+bevacizumab (6.2%). From 2016 to 2019, 1L PDC declined from 63% to 10%, whereas 1L PDC+IO increased from 14% to 58%. The ORRs were 64.9%, 32.9%, 60.2%, and 61.3% for 1L PDC+IO, PDC, IO monotherapy, and PDC+bevacizumab, respectively. Median 1L PFS/OS (months) was 15.6/26.5, 5.3/13.7, 17.8/not reached, 10.8/18.6, respectively, for PDC+IO, PDC, IO monotherapy, and PDC+bevacizumab. Among patients who received only 1L treatment (n = 299), 41.5% had no further therapy and were deceased.

CONCLUSIONS

Although the 1L treatment paradigm has recently shifted to IO-based regimens, 41.5% did not survive past 1L. Median 1L PFS did not exceed 1.5 years and median OS remained limited across all 1L treatment groups, illustrating continued unmet aNSCLC therapeutic needs.

The Use and Knowledge of Validated Geriatric Assessment Instruments Among US Community Oncologists

PURPOSE

The use of a standardized geriatric assessment (GA) to inform treatment decisions in older adults with cancer improves quality of life, reduces treatment-related toxicity, and is guideline-recommended. This study aimed to assess community oncologists' knowledge and utilization of GAs.

METHODS

Between September 2019 and February 2020, practicing US-based oncologists were invited to attend live meetings and complete web-based surveys designed to collect information on treatment decision making and various practice-based challenges in oncology care.

RESULTS

Among the 349 oncologists surveyed, 74% practiced in a community setting. Sixty percent did not use a formal GA to inform treatment decisions for any of their older patients; the most common reasons for not using a GA were "Too cumbersome to incorporate into routine practice" (44%) and "Adds no value beyond the comprehensive history and physical exam" (36%). Validated GA instruments used in routine clinical practice included: Mini-Mental State Exam (54%), Comprehensive Geriatric Assessment (23%), Cancer and Aging Research Group toxicity tool (12%), and Chemotherapy Risk Assessment Scale for High-Age Patients tool (9%). Nineteen percent of oncologists were not aware of any validated GA instruments. Eastern Cooperative Oncology Group performance status and comorbidities were the most frequently used assessment factors to inform treatment decisions (88% and 73%, respectively).

CONCLUSION

Many oncologists have not incorporated GA tools because of perceptions that GAs are difficult to implement or do not add any value. Increasing education of the benefits of GA-directed therapy could help to increase GA utilization among community oncologists.

OUP accepted manuscript

Background

Patients and Methods

Results

Conclusion

RE-MIND: Comparing Tafasitamab + Lenalidomide (L-MIND) with a Real-world Lenalidomide Monotherapy Cohort in Relapsed or Refractory Diffuse Large B-cell Lymphoma

PURPOSE

Tafasitamab, an Fc-modified, humanized, anti-CD19 monoclonal antibody, in combination with lenalidomide, demonstrated efficacy in transplant-ineligible patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL), in the single-arm, phase II L-MIND study (NCT02399085). RE-MIND, a retrospective observational study, generated a historic control for L-MIND to delineate the contribution of tafasitamab to the efficacy of the combination.

PATIENTS AND METHODS

Data were retrospectively collected from patients with R/R DLBCL treated with lenalidomide monotherapy for comparison with tafasitamab + lenalidomide-treated patients (L-MIND). Key eligibility criteria were aligned with L-MIND. Estimated propensity score-based Nearest Neighbor 1:1 Matching methodology balanced the cohorts for nine prespecified prognostic baseline covariates. The primary endpoint was investigator-assessed best overall response rate (ORR). Secondary endpoints included complete response (CR) rate, progression-free survival (PFS), and overall survival (OS).

RESULTS

Data from 490 patients going through lenalidomide monotherapy were collected; 140 qualified for matching with the L-MIND cohort. The primary analysis included 76 patients from each cohort who received a lenalidomide starting dose of 25 mg/day. Cohort baseline covariates were comparable. A significantly better ORR of 67.1% (95% confidence interval, 55.4-77.5) was observed for the combination therapy versus 34.2% (23.7-46.0) for lenalidomide monotherapy [odds ratio, 3.89 (1.90-8.14); P < 0.0001]. Higher CR rates were achieved with combination therapy compared with lenalidomide monotherapy [39.5% (28.4-51.4) vs. 13.2% (6.5-22.9)]. Survival endpoints favored combination therapy. Lenalidomide monotherapy outcomes were similar to previously published data.

CONCLUSIONS

RE-MIND enabled the estimation of the additional treatment effect achieved by combining tafasitamab with lenalidomide in patients with R/R DLBCL.

562 Real-world assessment of current treatment patterns and clinical outcomes among patients with EGFR and ALK wild type non-small cell lung cancer (NSCLC) in the US

Background

Treatment for advanced non-small cell lung cancer (NSCLC) has dramatically advanced in the past 5 years with the advent of immunotherapy (IO). This study sought to describe treatment patterns and clinical outcomes in a representative sample of NSCLC patients.

Methods

Patients were identified by physicians from a voluntary sample of community practices across the US. Stage IIIB/IV NSCLC patients with EGFR/ALK wild-type initiating any first-line (1L) systemic therapy between 01/01/2016 and 12/31/2019 with at least 2 months of follow-up (unless deceased) were included, and were followed until November 2020. Sampling quotas included 250 patients who initiated 1L in 2016/2017 and 250 patients who did so in 2018/2019. Best tumor response was collected from patient charts during each line of therapy (LOT). Progression-free survival (PFS) and overall survival (OS) were calculated from initiation of 1L by Kaplan-Meier method. Baseline characteristics and clinical outcomes are described and presented by treatment regimen received.

Results

Of 500 submitted patients, 497 were included post QA/QC. Across all patients, mean age at 1L initiation was 65 years, 57.3% were male, 92.9% had stage IV disease, and 68.6% were ECOG-OS 0/1 (Table 1). Overall, 60.2% (n=299), 33.2% (n=165), and 6.6% (n=33) received 1, 2, or =3 LOTs during the study period. Most common 1L regimens (%) were platinum-doublet chemotherapy plus IO (PDC+IO) (40.6%), PDC (29.4%), IO monotherapy (20.7%), PDC+bevacizumab (6.2%); while most common 2L regimens were IO monotherapy (42.4%), single-agent chemotherapy (SAC) (18.2%), SAC+VEGF inhibitor (15.7%), PDC (8.1%), and PDC+bevacizumab (5.6%). Over 90% of pts who received IO monotherapy had PD-L1 >50%. Moving from 2016/2017 to 2018/2019, utilization of 1L PDC declined from 45.0% to 13.7% while utilization of 1L PDC+IO increased from 27.3% to 54.0%. Among those who received only one LOT (n=299), 44.5% were still on 1L, 14.0% stopped receiving 1L, and 41.5% were deceased. Overall response rates were 67.3%, 35.6%, 60.2%, and 61.3% for 1L PDC+IO, PDC, IO monotherapy, and PDC+bevacizumab, respectively (Table 1). First-line median PFS/OS (months) was 15.6/26.5, 5.3/13.7, 17.8/NR, and 10.8/18.6, respectively for PDC+IO, PDC, IO monotherapy, and PDC+bevacizumab (table 1).

Abstract 562 Table 1

Conclusions

Data from 2016 to 2020 was used provide a contemporary assessment of treatment patterns among EGFR/ALK wild-type NSCLC patients. Although 1L treatment utilization shifted to IO-based regimens in recent years, 41.5% of patients did not survive to receive second-line therapy, 1L PFS did not exceed 1.5 years, and median OS remained limited across all 1L treatment groups.

Ethics Approval

On August 20, 2020, Western Institutional Review Board (WIRB) approved a request for a waiver of authorization for use and disclosure of protected health information (PHI) for this research. The study is exempt under 45 CFR § 46.104(d)(4).

Abstract PS7-55: Evolution of prescribing trends for HR+/HER2- metastatic breast cancer (mBC) in a post-CDK4/6i world

Background:There is limited real-world (RW) evidence describing treatment patterns among oncologists since clinical guidelines have established a preference for CDK4/6 inhibitors (CDK4/6i) plus an aromatase inhibitor (AI) or fulvestrant for first-line (1L) HR+/HER2- mBC. The objective of this RW study was to assess the influence of common clinical attributes on prescriber trends in 1L HR+/HER2- mBC by conducting a Discrete Choice Experiment (DCE) and evaluating the clinical decision-making via retrospective medical chart review.

Methods:Via a web-based instrument, medical oncologists were presented four hypothetical clinical scenarios (CS) to assess the influence of three clinical attributes on CDK4/6i prescribing preference via DCE: pre-menopausal (pre-M) vs post-M, prior adjuvant (PA) vs no PA, and bulky liver metastases (BuLM) vs no or unknown BuLM. Respondents selected their preferred 1L treatment for each CS: single-agent chemotherapy, combination chemotherapy, hormonal therapy, or CDK4/6i. Proportion of providers selecting CDK4/6i were reported in each scenario (e.g., pre-M vs post-M). Next, a planned subset of providers completed a physician chart abstraction (PCA) summarizing demographics, clinical characteristics, 1L and subsequent regimens for HR+/HER2- mBC patients 18 years or older at diagnosis, and who initiated ≥1 line of mBC therapy. Descriptive statistics were used to examine differences between preferred (via DCE) 1L regimens (hormonal therapy, CDK4/6i, chemotherapy) and PCA 1L regimens (chart review).

Results:47 medical oncologists from all U.S. census regions participated in the DCE, of which 17 completed 52 unique PCAs. Provider characteristics: mean 22.7 (5, 50) years in practice; mean 23.3 (3, 80) unique HR+/HER2- mBC patients treated monthly. PCA patient characteristics: median age 61 (38, 87) years; post-M = 88.5% and PA = 40.4% (Table 1). Across DCE and PCA patients, overall 1L CDK4/6i preference was 67.6% (DCE) and 84.6% (PCA) (Table 1). By patient attribute, CDK4/6i DCE preference and PCA use were, respectively: pre-M= 55% vs 67%; post-M = 80% vs 87%; PA= 66% vs 87%, no PA = 70% vs 83%. CDK4/6i preference for patients with BuLM was 55% but could only be assessed in DCE (Table 2). Chemotherapy as an alternative to, or prior to, CDK4/6i was 23.3% in DCE (19.1% vs 4.2%) and 5.8% in PCA (5.8% vs 0%).

Conclusion:Our research demonstrates that RW use of a CDK4/6i regimen in 1L HR+/HER2- mBC is higher than reported preference for CDK4/6i as assessed through DCE overall and in all CS. CDK4/6i preference in DCE was lowest for pre-M (55%) and PA (66%), while RW use was above 80% in all cases except for pre-M (67%). The use of chemotherapy prior to, or as an alternative to, CDK4/6i was both a preference in DCE and an observation in RW patients, which may relate to continued guideline inclusion of 1L chemotherapy which may warrant additional research to address continued relevance in the CDK4/6i era.

Table 1: Patient characteristics, HR+/HER2-DCE(N=188)PCA(N=52)Age, mean (median, range)54 (54; 38-71)61 (63; 38-87)Menopausal status, n (%)Pre-menopause94 (50)6 (11.6)Post-menopause94 (50)46 (88.5)Prior adjuvant therapy, n (%)94 (50)21 (40.4)CDK4/6i0 (0)3 (5.8)Site of Metastases, n (%)Liver94 (50)0 (0)Other/Unknown94 (50)52 (100)1L Therapy, n (%)Hormone-based therapy14 (7.4)5 (9.6)Chemotherapy27 (19.1)3 (5.8)CDK4/6i-based therapy127 (67.6)44 (84.6)Immediately following chemotherapy8 (4.2)

Table 2: CDK4/6i use as a function of clinical characteristicsCDK4/6i Usen (%)Pre-M(N=94)Post-M(N=94)PA(N=94)No PA(N=94)BuLM(N=94)No/Unk BuLM(N=94)DCE52 (55)75 (80)62 (66)65 (70)52 (55)75 (80)CDK4/6i Usen (%)Pre-M(N=6)Post-M(N=46)PA(N=23)No PA(N=29)BuLM(N=0)No/Unk BuLM (N=52)PCA4 (67)40 (87)20 (87)24 (83)0 (0)44 (85)p-value.59.30.05.15NA.47

Citation Format: Bruce Feinberg, Igoni Dokubo, Jeff Wojtynek, Jonathan Kish. Evolution of prescribing trends for HR+/HER2- metastatic breast cancer (mBC) in a post-CDK4/6i world [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-55.

Physician treatment of metastatic triple-negative breast cancer in the immuno-oncology era: a discrete choice experiment

Aim: Guidelines list atezolizumab with nab-paclitaxel (ANP) as the preferred first-line (1L) therapy for metastatic triple-negative breast cancer (mTNBC) with PD-L1 expression ≥1%, but which clinical attributes impact ANP prescribing? Materials & methods: Medical oncologists participated in a discrete choice experiment (DCE) with four hypothetical mTNBC clinical scenarios to assess influences of: PD-L1 expression, menopausal status, prior adjuvant therapy and bulky liver metastases. Results: A total of 47% chose ANP in 1L irrespective of menopausal status, prior adjuvant therapy or tumor bulk. PD-L1 expression was the only attribute with a significant impact on ANP preference, with 69% choosing ANP for those with ≥1% expression versus only 26% for those with <1% (p < 0.00001). Conclusion: ANP choice for 1L mTNBC deviated from guidelines.

Making the case for EGFR TKI sequencing in EGFR mutation-positive NSCLC: a GioTag study US patient analysis

Aim: To assess time-to-treatment failure (TTF) in US patients with EGFR mutation-positive non-small-cell lung cancer (NSCLC) who received sequential afatinib-osimertinib treatment in the global, observational GioTag study. Patients & methods: Patients had EGFR T790M mutation-positive disease after first-line afatinib and subsequently received osimertinib. The primary outcome was TTF. Results: In 129 patients at US centers, median TTF was 28.4 months (90% CI: 27.0-34.1). Median overall survival was 47.6 months (90% CI: 35.5-51.5). Conclusion: Sequential afatinib-osimertinib in this US-treated population was associated with long median TTF and represents an effective, evidence-based treatment option for US patients with EGFR mutation-positive NSCLC not presenting with active brain metastases or de novo T790M. Clinical Trial Registration: NCT03370770 (ClinicalTrials.gov).

Perceptions of community hematologists/oncologists on barriers to chimeric antigen receptor T-cell therapy for the treatment of diffuse large B-cell lymphoma

Objective: To determine the perceptions of US community-based hematologists/oncologists regarding approved CAR-T therapies in relapsed/refractory large B-cell lymphoma and barriers to their adoption in practice. Materials & methods: In February and November 2019, US physicians with diverse geographic representation submitted responses via a web-based survey prior to or via an audience response system at the live meetings. Results: In February and November, 46 and 29% of physicians indicated that they had not referred any patients for CAR-T therapy, respectively. Cumbersome logistics, high cost and toxicity were defined as major barriers to prescribing CAR-T therapy. Conclusions: These findings highlight a need to improve processes, and address costs, to ensure timely access to this potentially curative therapy for relapsed/refractory large B-cell lymphoma patients.

FRI0096 CLINICAL BENEFITS REPORTED IN AMPLE TRIAL OBSERVED IN A REAL-WORLD (RW) COHORT OF US RHEUMATOID ARTHRITIS (RA) PATIENTS

Background:

Efficacy observed in controlled trials may not reflect RW effectiveness, given documented differences in patient populations and management.1

Objectives:

This study aimed to assess disease measures over time as measured in a trial setting (AMPLE) and in a separate RW observational setting, both among patients with RA treated with abatacept.

Methods:

The RW cohort comprised retrospective patient-level data abstracted by 31 community rheumatologists for adult RA patients treated with abatacept who had an anti-cyclic citrullinated peptide-2 titer ≥250 AU/mL. AMPLE was a phase III, randomized controlled trial of RA patients treated with abatacept that assessed disease measures over a 2-year follow-up. Data included demographics, treatments, labs, and disease measures (tender and swollen joint counts (TJC, SJC), C-reactive protein (CRP), American College of Rheumatology-20 (ACR20) and ACR50 at baseline and 3 and 6 months) and were summarized descriptively. Disease measures were evaluated across AMPLE and RW cohorts.

Results:

Of the 291 RW patients and 318 AMPLE patients, the majority were female (70%, 81%), white (72%, 81%), and RF-positive (91%, 76%), respectively (Table 1). The mean ages at abatacept initiation were 54.7 and 51.4 years old in RW and AMPLE, respectively. Concomitant corticosteroids (45%, 65%) and methotrexate (62%, 100%) were common in RW and AMPLE, respectively. All patients in AMPLE were biologic naïve, whereas 83% of RW patients had prior biologic use. AMPLE administered abatacept subcutaneously (SC), while 37% of RW patients received abatacept SC. Patients had median SJC and TJC of 6 and 8 in RW and 13 and 22 in AMPLE at abatacept initiation, respectively (Table 2). SJC (TJC) improved a median of 65% (60%) and 68% (66%) at 3 months and 75% (67%) and 76% (75%) at 6 months in RW and AMPLE, respectively (Fig 1). The majority of patients achieved ACR20 at 3 months (79% and 60%) and 6 months (88% and 66%) in RW and AMPLE, respectively, while 58% and 32% achieved ACR50 at 3 months and 67% and 45% at 6 months, respectively (Fig 2).

Table 1:

Patient Characteristics.

RW cohort(n=291)AMPLE cohort(n=318)Female (n, %)205 (70%)259 (81%)White (n, %)209 (72%)257 (81%Age at abatacept initiation, years (mean, SD)54.7 (14.8)51.4 (12.6)RF-positive* (n, %)249 (91%)240 (76%)Concomitant medications (n, %) Corticosteroids†132 (45%)207 (65%) Methotrexate179 (62%)318 (100%)Prior biologic use (n, %)241 (83%)0 (0%)Route of administration (n, %) Intravenous183 (63%)0 (0%) Subcutaneous108 (37%)318 (100%)

LEGEND: *among 274 with known RF status;†corticosteroids in AMPLE cohort at any time in the 2-year study period

Table 2.

Changes in Disease Activity.

RW cohort(n=291)AMPLE cohort(n=318)SJC (median) Baseline value613 3-month value24 6-month value13TJC (median) Baseline value822 3-month value37 6-month value25CRP, mg/dL (mean) Baseline value1.081.6 3-month value0.470.8 6-month value0.300.8ACR20 achieved (n, %) 3-month value194 (79%)191 (60%) 6-month value78 (88%)209 (66%)ACR50 achieved (n, %) 3-month value144 (58%)103 (32%) 6-month value60 (67%)144 (45%)

LEGEND: values soonest after 3 months and value between 6-9 months used for RW cohort; values at days 85 and 197 used for AMPLE cohort.

Conclusion:

Despite differences in patient characteristics, improvements in SJC and TJC, as well as high rates of ACR20 and ACR50, were observed in both trial setting and RW settings. These improvements in disease activity were observed at similar magnitudes in both settings, demonstrating that trial efficacy is achievable in RW clinical practice with abatacept treatment.

References:

[1]Kilcher G, Hummel N, Didden EM, et al. Rheumatoid arthritis patients treated in trial and real-world settings: comparison of randomized trials with registries.Rheumatology. 2018;57(2):354-369.

Disclosure of Interests:

Andrew Klink Employee of: I am employed by Cardinal Health., Xue Han Employee of: BMS, Francis Lobo Shareholder of: Bristol-Myers Squibb (US), Employee of: Bristol-Myers Squibb (US), Rick Szymialis Shareholder of: BMS, Employee of: BMS, Jenny Lam Shareholder of: A few shares in Gilead in IRA account, Grant/research support from: Currently, a BMS fellowship (not a full-time employee), Bruce Feinberg Employee of: I am employed by Cardinal Health.

Frequency and Causes of Burnout in US Community Oncologists in the Era of Electronic Health Records

BACKGROUND:

Physician burnout, characterized by exhaustion of physical or emotional strength, cynicism, and lack of achievement, has become a worsening phenomenon in medicine, contributing to higher health care costs and patient/physician dissatisfaction. How burnout has affected hematologists and oncologists is not well studied.

METHODS:

US community oncologists/hematologists were queried via a Web-based survey from September-November 2018. Physicians were asked about frequency of burnout symptoms, drivers of work-related stress, and their perceptions on management of workload.

RESULTS:

Among the 163 physicians surveyed, 46% felt a substantial amount of stress at work. Most physicians felt emotionally (85%) and physically (87%) exhausted. A majority of physicians felt lethargic (67%), ineffective (64%), and/or detached (63%). In a typical workweek, 93% needed time beyond time allocated to clinical care to complete work responsibilities. Electronic health record (EHR) responsibilities caused moderate to excessive stress at work for 67% of physicians; 79% of physicians worked on EHRs outside of clinic hours. Other sources of excessive stress were changing reimbursement models (33%), interactions with payers (31%), and increasing patient and caregiver demands (31%). A third of physicians have considered retiring early or changing their career path to cope. To combat burnout, physicians’ practices have used advanced practice providers, invested in information technology, and/or hired additional administrative staff. However, the majority of physicians stated they had optimal or good control over their workload.

CONCLUSION:

Most oncologists experience burnout symptoms and require additional time beyond that allocated to clinical care to complete their workload. The discordance between oncologists’ admission of stress and exhaustion while claiming good control over those same burdens warrants exploration in future research.

Abstract P5-14-13: Real-world dosing and CBC monitoring in patients with metastatic breast cancer during palbociclib plus letrozole therapy

Background: Palbociclib in combination with letrozole (P+L) was the first cyclin-dependent-kinase 4/6 inhibitor approved in the U.S for treatment of metastatic breast cancer (mBC). Per the U.S. label, the recommended starting dose for Palbociclib (P) is 125 mg and patients should have complete blood count (CBC) monitoring prior to the start of treatment, at the beginning of each cycle, on day 15 of the first 2 cycles, and as clinically indicated. We sought to evaluate adherence to these FDA label in patients receiving P+L as initial endocrine-based therapy. Methods: Adult post-menopausal women with metastatic HR+/HER2- breast cancer who initiated P+L on or after 02/03/2015 were randomly identified by providers in the Cardinal Health Oncology Provider Extended Network (OPEN), which includes over 7,000 US oncologists/hematologists. Providers who were part of OPEN who responded to an initial feasibility request (survey) indicating an interest to participate in the study and treating the patients of interest were invited to participate. Providers were asked to randomly select eligible patients treated with P+L who were initiated on first-line P+L at least 3 months following their first treatment of any patient with P+L. Providers were asked to indicate that the patient had been randomly selected from among all eligible patients and were able to enter up to 10 total patients. All data were abstracted by the patient's treating provider in an electronic case report form (eCRF). Providers abstracted data related to patient characteristics, dosing, and frequency of CBC monitoring in the 30 days prior to and during the first 2 cycles of therapy of randomly selected patients from the time of initiation of P+L through Feb 2019 (or end of follow up/death). Providers completed data validation by re-entering select data from randomly selected patients (10% of the total sample) and for patients which were flagged for quality control review by Cardinal Health clinical research staff and data analytics team members when the results were inconsistent or deviated from the population averages. Results: Thirty-one providers submitted 202 eCRFs, of which 193 were eligible (9 patients removed with non-verifiable data). Demographics: mean age was 65.0 y/o (SD = 10.5), 74.6% white, 38.6% commercially insured. Clinical characteristics: 65.8% de novo metastatic, 51.3% visceral disease at initiation of P+L, 25.4% bone only disease, 10.4% ECOG-PS ≥2. Median follow-up from P+L initiation was 15.4 months, 45.6% of patients had discontinued P+L at data cut-off. Overall, 86.0%, 13.5%, and 0.5% of patients initiated treatment of P at the 125 mg, 100 mg, and 75mg dose, respectively. Dose reductions were reported in 17.1% of patients. CBC testing was conducted prior to P+L initiation in 99.0% of patients; median number of CBC tests during cycle 1 was 2.0; 37% of patients had only one CBC test. In cycle 2, median number of CBC tests was 1.5 and 46.5% of patients had only one CBC test. Conclusions: Physicians were generally compliant with the Palbociclib package insert recommendations for dosing and monitoring during the first cycle, less so for monitoring during the second cycle in women with HR+/HER2- mBC. Funding: Pfizer Inc.

Citation Format: Jonathan Kish, Talia Miller, Damion Nero, Djibril Liassou, Xianchen Liu, Lynn McRoy, Bruce Feinberg, Lin Zhan, Jeffrey Trocio. Real-world dosing and CBC monitoring in patients with metastatic breast cancer during palbociclib plus letrozole therapy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-14-13.

Real-world treatment patterns, cost of care and effectiveness of therapies for patients with squamous cell carcinoma of head and neck pre and post approval of immuno-oncology agents

Aims: In 2016, nivolumab and pembrolizumab were approved for the treatment of squamous cell carcinoma of the head and neck (SCCHN) following progression after initial platinum-based therapy. We sought to explore the uptake, effectiveness, and impact on healthcare resource utilization (HRU) and total costs of care pre and post introduction of immuno-oncology (IO) agents.Materials and Methods: Recurrent/metastatic SCCHN patients were identified from a healthcare claims clearinghouse by selecting patients with a claim for distant metastases or who initiated systemic therapy at least 120 days following discontinuation of platinum-based therapy. Two cohorts were created according to the date of post-platinum therapy (PPT) initiation: pre-IO = 08/01/2014-07/31/2015; post-IO = 08/01/2016-07/31/2017. Treatment patterns and effectiveness (duration of treatment, time to next treatment) during first-line (1 L) PPT, HRU, and costs were compared between propensity-score matched patients from each cohort.Results: Of 716 patients identified (pre-IO = 265, post-IO = 451) 46.3% of post-IO patients received IO post-platinum. In 229 matched patients 20.0% of the post-IO compared to 10.7% of the pre-IO (p=.02) had at least a 6 month duration of 1 L PPT. Inpatient admissions during 1 L PPT: 34.1% post-IO versus 48.0% pre-IO (p= <.01). PPPM total costs of care in 1 L PPT were significantly greater post-IO ($11,535) compared to pre-IO ($9,054, p=.002). Time to next treatment (from 1 L PPT start) was 6.1 months pre-IO versus 7.4 months post-IO (p=.046).Limitations: Recurrent SCCHN patients were identified using a validated claims-based algorithm but misclassification may occur. Requiring patients to have received 1 L PPT the pre-IO cohort may be systematically different that the post-IO cohort as pre-IO patients were more likely to have not received further treatment beyond 1 L PPT.Conclusions: The significant uptake of IO therapy resulted in longer durations of therapy, lower rates of hospitalizations although higher treatment costs. The results suggest IO treatment provides additional clinical benefits to recurrent/metastatic SCCHN patients.

Comparative Effectiveness of Palliative Chemotherapy in Metastatic Breast Cancer: A Real-World Evidence Analysis

BACKGROUND

In the absence of randomized controlled trials, real-world evidence may aid practitioners in optimizing the selection of therapy for patients with cancer. The study's aim was to determine real-word use, as well as compare effectiveness, of single-agent and combination chemotherapy as palliative treatment for female patients with metastatic breast cancer (mBC).

MATERIALS AND METHODS

Using administrative claims data from the Symphony Health's Integrated Oncology Dataverse, female patients with mBC treated with at least one chemotherapy-only treatment (COT) between January 1, 2013, and December 31, 2017 were selected. The frequency of use of single-agent versus combination chemotherapy overall and by line of therapy (LOT) was calculated whereas effectiveness was measured using time to next treatment (TNT).

RESULTS

A total of 12,381 patients with mBC were identified, and 3,777 (31%) received at least one line of COT. Of the 5,586 observed LOTs among the 3,777 patients, 66.5% were single-agent and 33.5% combination chemotherapy. Combination chemotherapy was most frequently used in first-line (45%) and least frequently in fifth-line (16%). Across all LOTs, median TNT was significantly longer for single-agent versus combination chemotherapy (5.3 months vs. 4.1 months, p < .0001). Comparison of median TNT by LOT showed significance in third-line and greater but not in first-line or second-line. Among single agents, the median TNT for patients receiving capecitabine was longest in comparison to all other single agents.

CONCLUSIONS

The frequency of combination COT use, particularly in first-line, warrants further research given published guideline recommendations. The observed TNT difference favoring single-agent treatment in later lines supports guideline recommendations. Variance between single-agent preference and observed TNT was noteworthy.

IMPLICATIONS FOR PRACTICE

Although published data from evidence- and consensus-based guidelines recommend single-agent over combination chemotherapy, the extensive list of agents available for use and a gap in the comparative effectiveness research of these agents have resulted in significant variances in patterns of care. The aim of this study was to assess real-world treatment patterns and their effectiveness during palliative therapy of metastatic breast cancer. The objective was to understand when and how chemotherapy-only treatment is used in metastatic breast cancer and whether comparative effectiveness analysis supports the observed patterns of care.

Patterns of Care Among Real-World Patients with Metastatic Neuroendocrine Tumors

BACKGROUND

Although recent pivotal trials (PROMID, CLARINET) have established somatostatin analogs (SSAs) as first-line agents for neuroendocrine tumors (NETs), their use in clinical practice is largely unknown. We aimed to understand real-world management and treatment of gastroenteropancreatic (GEP) NETs.

MATERIALS AND METHODS

Patients with metastatic GEP-NETs treated with SSAs, lanreotide depot or octreotide long-acting release (LAR), between January 1, 2015, and December 31, 2015, were identified from a U.S. claims database supplemented with chart review for a subset of patients. Descriptive statistics summarized patients' demographics, clinical characteristics, treatment patterns, and healthcare resource use. Univariate and multivariate comparisons were made across SSA groups.

RESULTS

Among 548 patients treated with an SSA for metastatic GEP-NET (lanreotide = 108; octreotide = 440), demographic and clinical characteristics were similar across groups, except more patients with pancreatic NETs were treated with lanreotide (38.7% vs. 6.3%, p < .01). More octreotide patients had a diagnosis of carcinoid syndrome compared with lanreotide patients (19.8% vs. 11.1%, p = .02). Approximately 1.1% of patients received lanreotide (>120 mg every 4 weeks [Q4W]) at a dose above label compared with 12.7% of octreotide patients (>30 mg Q4W; p < .01). At 1.5 years after SSA initiation, 85.7% (95% confidence interval, 74.3%-92.3%) were still on index SSA as reported by the physician. Variances between chart review and claims data were significant.

CONCLUSION

SSAs were common in first-line systemic intervention, but dose escalations and dosing deviations outside of label were noted. Variances between claims and chart review warrant additional research to compare methodologies. With an increasing focus on value-based care in oncology, it is critical to understand the use of, and outcomes with, these agents in community practices.

IMPLICATIONS FOR PRACTICE

The aim of this study was to enhance understanding of real-world management and treatment of metastatic neuroendocrine tumors (NETs), with particular focus on systemic therapy with a somatostatin analog (SSA). As per published guidelines, SSAs are common in first-line systemic intervention, but dose escalations and dosing deviations outside of the label are noted for symptom control. Nevertheless, oncologists must weigh the implications of the use of above-label dosing of SSAs to manage and treat patients with metastatic NET within a value-based care framework.

Health Care Resource Utilization and Costs in First-Line Treatments for Patients with Metastatic Melanoma in the United States

BACKGROUND

The treatment landscape for patients with metastatic melanoma has changed dramatically with the introduction of novel therapies, such as targeted therapies and immunotherapies, in recent years. Health care resource utilization (HCRU) and cost data are needed to further evaluate these treatments in a value-based health care system.

OBJECTIVE

To examine HCRU and total cost of care among U.S. metastatic melanoma patients treated with first-line systemic therapies, including immunotherapies, targeted therapies, and chemotherapy.

METHODS

A retrospective observational study was conducted using a U.S. claims database. Adults with ≥ 2 claims for melanoma and ≥ 1 claim for metastasis between January 1, 2012, and June 30, 2017, were identified. Patients had pharmacy and medical enrollment ≥ 6 months before and ≥ 3 months following first-line treatment start. Per patient per month (PPPM) HCRU and costs were calculated by first-line treatment drug class: PD-1 inhibitors, CTLA-4 inhibitors, CTLA-4 + PD-1 combination, BRAF monotherapy, BRAF + MEK combination, and chemotherapy. Adjusted odds ratios (ORs) for HCRU were estimated by logistic regressions and adjusted costs were estimated by generalized linear models using log-link with gamma distribution to control for differences in patient characteristics across groups.

RESULTS

Among 1,599 metastatic melanoma patients (PD-1, n = 255; CTLA-4, n = 555; CTLA-4 + PD-1, n = 88; BRAF, n = 210; BRAF + MEK, n=102; chemotherapy=389), mean age ranged from 59-68 years, and the majority were male (62%). Any hospitalization during first-line treatment was less frequent among PD-1-treated patients (25.9%) compared with 34.7%-45.5% of all other groups (all P < 0.05). PPPM hospitalizations were lowest in PD-1 (0.06) compared with 0.09-0.16 across all other groups (all P < 0.05), and PPPM emergency department (ED) visits were lowest in PD-1 (0.09) compared with 0.13-0.18 across all other groups (all P < 0.05), except for BRAF + MEK (0.14, P = 0.08). CTLA-4, CTLA-4 + PD-1, and BRAF + MEK had increased odds of hospitalization compared to PD-1 (adjusted ORs = 2.10, 2.35, 2.15, respectively; all P < 0.05). Total adjusted PPPM costs were significantly lower for PD-1 ($13,059) compared with CTLA-4 ($25,583), CTLA-4 + PD-1 ($31,310), and BRAF + MEK ($21,517) and higher compared to BRAF ($8,158) and chemotherapy ($6,361).

CONCLUSIONS

Hospitalizations and ED visits represent important HCRU for metastatic melanoma patients and were lowest among PD-1-treated patients compared with any other systemic therapies (except for ED visits when compared with BRAF + MEK). Total monthly costs varied substantially across first-line regimens and were significantly lower in PD-1-treated patients compared with patients treated with CTLA-4, CTLA-4 + PD-1, and BRAF + MEK.

DISCLOSURES

This study was funded by Merck Sharp & Dohme, a subsidiary of Merck & Co. Klink, Feinberg, and Nero are employees of Cardinal Health Specialty Solutions, which received funding from Merck to conduct this study. Chmielsowki is a consultant to Merck but received no funding for the development of this manuscript. Ahsan and Liu are employees of Merck. Chmielowski reports advisory board/speaker fees from Bristol-Myers Squibb, Merck, Genentech/Roche, Iovance Biotherapeutics, HUYA Bioscience International, Compugen, Array BioPharma, Regeneron, Biothera, Janssen, and Novartis. Ahsan has a patent (US20160008380A1) pending.

Reports of the demise of chemotherapy have been greatly exaggerated

Does the rapid integration of both targeted and immuno-oncology drugs into treatment guidelines across solid tumors and hematologic malignancies herald the beginning of the end of chemotherapy as a foundational element in systemic cancer treatment? We respond to similar assertions posited after the 2018 American Society of Clinical Oncology Annual Meeting with an analysis of past, current, and future treatment of breast cancer-a tumor central to the evolution of modern cancer treatment principles. Our conclusions assert that reports of the demise of chemotherapy are greatly exaggerated and, as chemotherapy is likely to remain foundational for years to come, research is warranted to improve its patient-centricity.

HSR19-095: Healthcare Resource Utilization and Costs in Patients Treated with Systemic Therapies in Metastatic Melanoma

Background: The treatment (tx) landscape for patients (pts) with metastatic melanoma (MM) has changed dramatically from systemic chemotherapy (chemo) to novel therapies, including targeted therapies (TT) and immunotherapies (IO mono- and combination therapy) in recent years. Healthcare resource utilization (HCRU) and cost data are needed to further evaluate tx in a value-based healthcare system. The study aimed to describe HCRU and total cost of care among first line (1L) US MM pts treated with IO, TT, or chemo. Methods: A retrospective observational study was conducted using a U.S. claims database. Adults with ≥2 claims for melanoma and ≥1 claim for metastasis between January 1, 2012 and June 30, 2017 were identified. Pts had pharmacy and medical enrollment ≥6 months pre and ≥3 months post 1L tx start. Per pt per month (PPPM) HCRU and costs were calculated by 1L tx drug class: PD-1, CTLA-4, CTLA-4+PD-1, mono-TT, combo-TT, and chemo. Adjusted odds ratios (OR) for HCRU were estimated by logistic regressions, and adjusted costs were estimated by generalized linear models to control for differences in pt characteristics across groups. Results: Among 1,599 MM pts (255 PD-1, 555 CTLA-4, 88 CTLA-4+PD-1, 210 mono-TT, 102 combo-TT, 389 chemo), mean age ranged from 59–68 years across tx groups, and the majority was male (62%). Any hospitalization during 1L was less frequent among PD-1 (26%) compared to 35%–46% of all other groups (all P<.05). CTLA-4, CTLA-4+PD-1, and combo-TT had increased odds of hospitalization compared to PD-1 (adjusted ORs: 2.10, 2.35, 2.15, respectively; all P<.05). Total adjusted PPPM costs were significantly lower for PD-1 compared to CTLA-4, CTLA-4+PD-1 and combo-TT and higher compared to mono-TT and chemo (Table 1). Conclusions: Hospitalizations represent an important healthcare resource for MM pts and were lowest among PD-1. Total monthly costs varied substantially across 1L regimens and were significantly lower in PD-1 compared to CTLA-4, CTLA-4+PD-1, and combo-TT. HCRU and costs differentiate 1L MM regimens.

Treatment sequence of lenalidomide and hypomethylating agents and the impact on clinical outcomes for patients with myelodysplastic syndromes

Lenalidomide and hypomethylating agents (HMAs) azacitidine and decitabine are approved for treating myelodysplastic syndromes (MDS), but optimal sequencing is unclear. Adults with MDS were identified from a US payer claims database (Inovalon MORE² Registry) to compare outcomes with lenalidomide followed by HMA (LEN-HMA) or HMA followed by lenalidomide (HMA-LEN). There were 96 patients who received LEN-HMA and 89 who received HMA-LEN. LEN-HMA-treated patients had a longer time to second treatment discontinuation (29.0 vs. 19.0 months, p=.009; adjusted hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.29-0.91, p=.023). LEN-HMA-treated patients had a longer median time to insurance disenrollment (22.4 vs. 16.1 months, p<.001; adjusted HR 0.64, 95% CI: 0.44-0.92, p=.017), used as a proxy for survival. Longer treatment duration and survival with LEN-HMA support first-line use of lenalidomide in MDS in sequence with HMAs.

Real-world evidence and the behavioral economics of physician prescribing

The projections for the rising cost of healthcare have spurred robust dialogue, and among the many targets for cost control are specialty drugs. An important question thus becomes: Are behavioral economic factors driving physician prescribing? This article presents a review of leading behavioral economic theories and their application to the results of an Oncology Medical Home pilot that reversed incentives from drug administration to patient care. A host of these theories may explain the irrational economic actors in regard to physician prescribing, including heuristics, framing, and defaults. Ultimately, the complex interplay of behavioral economics may result in reimbursement methodology alternatives to the prevailing fee-for-service payment system having less impact on prescribing behavior than has been conjectured.

Symposium: Animal welfare challenges for today and tomorrow

The increasing separation of the public from production agriculture means there is often a lack of knowledge among consumers about current production practices and a perception that increased productivity and economic efficiency are necessarily associated with a decline in animal welfare. A symposium was organized to present information about animal welfare issues and the challenges they pose for both scientists and the poultry and allied industries. Companion papers provide information about understanding public attitudes and physiological/immunological approaches to welfare assessment, while this paper outlines current and future challenges to egg and meat production and industry responses to those challenges. For broiler chickens, increases in growth rate result in corollary increases in metabolic heat generation and water consumption, leading to the need for continuing improvements in housing, ventilation, and litter management. Stocking densities, lighting programs, muscle myopathies, and use of antibiotics are also areas that require research attention. In the layer industry, the key challenge is housing, with the industry undergoing a shift from conventional cage housing to alternatives like enriched colonies or cage-free. While these alternative systems have hen welfare advantages, there are also welfare disadvantages that require the development of mitigation strategies, and it is also essential to address associated issues including economic, environmental, egg safety, and worker health impacts. Concerns on the horizon include euthanasia of surplus male chicks and spent hens as well as beak-trimming. The humaneness of slaughter methods is an important welfare and consumer confidence issue, and the current regulations for poultry slaughter in the USA are discussed and compared to those for livestock. The poultry and allied industries, including retailers, are responding to these concerns by consulting with experts, developing science-based animal care standards and auditing programs, strengthening training and oversight programs, promoting research, and improving communication channels. In future, intensifying multi-disciplinary research efforts and developing mechanisms to improve communication between scientists and stakeholders, including the public, will be critical to addressing these issues.

Physician behavior impact when revenue shifted from drugs to services

OBJECTIVES

In partnership with a large nonprofit healthcare insurer for the Mid-Atlantic region of the United States, we launched the first cancer clinical pathway in the United States in August 2008. Due to its early success with regard to savings and physician participation and compliance, a second-generation pathways program-the Oncology Medical Home-was piloted in 2011. This program offered a physician reimbursement model that shifted the source of revenue from drug reimbursement margin to professional charges for cognitive services (evaluation and management codes). We report our observations of the impact of that reimbursement model on physician prescribing behavior.

STUDY DESIGN

This was a retrospective analysis.

METHODS

A select group of practices that participated in the first-generation pathways program were invited to voluntarily participate in the Oncology Medical Home and its cognitive weighted reimbursement design. A matched control group was chosen from the first-generation pathways participants. Comparisons of physician behavior parameters were made pre- and postimplementation and between the Oncology Medical Home practices and the first-generation pathways control group.

RESULTS

Physician behavior was not significantly modified by cognitive weighted reimbursement. No significant change in frequency of office visits for established patients was observed. No change in chemotherapy prescribing was observed. Observed increases in generic regimen use were no different than matched control.

CONCLUSIONS

Observations from this oncology medical home pilot program suggest that reimbursement methodology alternatives to the prevailing fee-for-service may have less impact on prescribing behavior than has been conjectured. Future research is ongoing to validate these observations and assess additional influences on prescribing behavior.

Measurement of vacuum-assisted photoionization at 1 GeV for Au and Ag targets

We report a measurement of photon impact ionization of K and L shell of Au and K shell of Ag targets in the 1-GeV energy range. We show that the cross section is dominated by a contribution from a new channel called vacuum-assisted photoionization. In this process the energy-momentum balance associated with the removal of the innershell electron is obtained by conversion of a high-energy photon into an electron-positron pair. This measurement is consistent with the theoretical prediction that vacuum-assisted photoionization is the most probable ionization mechanism at very high energies.

Central neuraxial blockade promotes external cephalic version success after a failed attempt

External cephalic version (ECV) has been successfully used to decrease the fetal and maternal morbidity and costs of cesarean delivery. As there are limited data regarding the use of central neuraxial blockade in the setting of previously failed ECV attempts, we sought to evaluate the efficacy and safety of spinal and epidural anesthesia in this setting. A retrospective review of all ECV attempts performed by a single experienced obstetrician between 1995 and 1999 was conducted. Standardized tocolytic and anesthetic regimens were used. A total of 77 patients underwent ECV attempts; of these, 37 (48%) were unsuccessful, 15 of which consented to further attempts with anesthesia. Neuraxial anesthesia was associated with frequent ECV success in both multiparous 4/4 (100%) and nulliparous 9/11 (82%) parturients. Overall 5/6 (83%) and 8/9 (89%) (P = NS) ECV attempts were successful with spinal and epidural anesthesia, respectively, with 2/5 (40%) and 6/8 (75%) (P = NS) resulting in vaginal deliveries. One successful ECV in the epidural group had an urgent cesarean delivery for persistent fetal bradycardia with good neonatal and maternal outcomes. We conclude central neuraxial anesthesia promotes successful ECV after previously failed ECV attempts.

IMPLICATIONS

Our retrospective analysis of central neuraxial techniques, both epidural and spinal anesthesia, noted a significant success rate in the setting of previously failed external cephalic version attempts.