Time toxicity in early phase clinical trials (EP-CTs)

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Background: EP-CTs are an increasingly important treatment option for patients with cancer, yet often require intensive monitoring. Little is known about the time that EP-CT participants spend in-hospital, and how that time compares to study requirements. Methods: We retrospectively reviewed the electronic health record (EHR) of consecutive patients enrolled in EP-CTs at Massachusetts General Hospital from 2017-2019 to obtain patient characteristics (demographics and clinical factors) and EP-CT investigational agent (immunomodulatory therapy [IM], targeted inhibitor [TI], antibody drug conjugate [ADC]/chemotherapy prodrug). We identified protocol requirements by reviewing the study calendar for in-hospital days for any reason, including clinician visits and diagnostic tests. We identified the real-world number of days spent at the hospital by reviewing the EHR for in-hospital days. We used descriptive statistics to compare patient characteristics and outcomes for those with higher time toxicity, defined as 5+ real-world visits during the first 28 days on trial, versus lower time toxicity. Results: Among 421 patients (median age = 63.0 years, 56.9% female, 97.6% metastatic disease), 43.2% participated in IM trials, 43.0% TI, and 13.8% ADC. Most common tumor types were gastrointestinal (GI) (22.3%) and lung (20.0%). Over the first 28 days on trial, protocol requirements listed an average of 5.2 in-hospital days, yet real-world data demonstrated that patients had an average of 6.6 in-hospital days (p < 0.001). TI trial participants had the highest average number of anticipated protocol visits compared with those on other trials (5.5 [TI] vs 5.3 [ADC] vs 5.0 [IM], p = 0.027). In real-world data, those on ADC trials had the highest average number of visits (7.5 [ADC] vs 7.1 [TI] vs 5.7 [IM], p < 0.001). Those with 5+ real-world visits during the first 28 days were more likely to have GI cancer (25.8% vs 13.9%, p = 0.011) and less likely to have lung cancer (16.7% vs 27.9%, p = 0.011). Patients with more visits were also less likely to have traveled 50+ miles to the hospital (48.8% vs 59.8%, p = 0.04). Notably, 19.5% of patients (N = 82) were hospitalized during the first 28 days on trial, with an average length of stay of 4.9 days. Those with 5+ visits had fewer days, on average, from trial start to admission (371.9 vs 650.8, p < 0.001) and fewer days on trial (mean 156.0 vs 235.0, p = 0.001). There was no significant difference in days from trial start to death for those with higher versus lower time toxicity (mean 464.6 vs 526.4, p = 0.177). Conclusions: EP-CTs represent a potentially time-intensive treatment option, as we found that patients spend over one-fifth of their first 28 days on trial at the hospital for various visits. Our findings indicate that patients may often experience more in-hospital days than what the protocol states. These data could help inform patient-clinician discussions regarding EP-CT participation and the potential time toxicity involved.

Patient-reported hope, quality of life, symptom burden, coping, and financial toxicity in early-phase clinical trial participants

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Background: Early phase clinical trials (EP-CTs) investigate novel treatment options in oncology, with recent advances in personalized therapy leading to improved outcomes and offering hope to patients with cancer. However, little research has sought to understand associations of patient-reported hope with quality of life (QOL), symptom burden, coping, and financial toxicity in EP-CT participants. Methods: We prospectively enrolled consecutive adults with cancer participating in EP-CTs at Massachusetts General Hospital from 04/2021-05/2022. Participants completed baseline surveys prior to treatment initiation that assessed hope (Herth Hope Index [HHI], higher scores indicate greater hope), QOL (Functional Assessment of Cancer Therapy-General), symptom burden (physical: Edmonton Symptom Assessment System [ESAS]; psychological: Patient Health Questionaire-4 [PHQ4]), coping (Brief COPE: self-blame, acceptance, denial, emotional support, active, behavioral disengagement), and financial toxicity (COST tool, higher scores indicate greater financial wellbeing). We used regression models to determine associations of hope scores with patient-reported QOL, symptom burden, coping, and financial toxicity. Results: Of 157 eligible patients, we enrolled 129 (enrollment rate 82.2%, median age = 62.5 years [range 33.0-83.0], 53.9% female, and 96.0% metastatic cancer). Most common cancer types were gastrointestinal (37.5%), breast (20.3%), lung (8.6%), and head and neck (7.8%). Patients had an average HHI score of 27.5 (range 15.3 – 36.0), with 30.5% reporting high levels of hope. We found associations of higher hope scores with better QOL (B = 0.24, p < 0.001) and lower symptom burden (ESAS-physical: B = -0.14, p < 0.001; PHQ4-depression: B = -2.07, p < 0.001; PHQ4-anxiety: B = -0.93, p = 0.001). We also found that hope scores were associated with patients’ coping (self-blame [B = -1.44, p < 0.001]; acceptance [B = 1.40, p < 0.001], denial [B = -1.12, p = 0.004], emotional support [B = 0.99, p < 0.001], active [B = 1.02. p = 0.001], behavioral disengagement [B = -2.52, p < 0.001]). Lastly, we found that higher hope scores were associated with greater financial wellbeing (B = 0.11, p = 0.026). Conclusions: In this prospective cohort study, we demonstrated a substantial proportion of EP-CT participants had high baseline hope and identified associations of hope scores with other important patient-reported outcomes. Specifically, we found novel associations of higher hope scores with better QOL, lower symptom burden, more adaptive coping mechanisms, and greater financial wellbeing, underscoring the importance of targeting these patient-reported outcomes when seeking to enhance the care experience of EP-CT participants.

Relationship of travel distance with patient demographics, advance care planning, and survival in early-phase clinical trials (EP-CTs)

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Background: EP-CTs are often conducted at large academic centers, which may require some patients to travel further for their care. Little is known about either the distance EP-CT participants travel for their care or the association of distance traveled with patient characteristics and outcomes. Methods: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs at Massachusetts General Hospital from 2017-2019 to obtain patient characteristics (demographics and clinical factors) and outcomes (including time spent on trial, survival, and presence or absence of an advance care planning [ACP] discussion, defined as documentation of a code status or goals of care conversation in the medical record). We also used patients’ home zip codes to derive the social deprivation index (SDI; a composite demographic measurement from 0-100 quantifying social determinants of health, with higher numbers indicating more disadvantage). To estimate distance traveled, we calculated the miles traveled in one direction driving from home zip code to trial site. We used descriptive statistics to compare patient characteristics and outcomes for those traveling < 50 miles (short distance) versus those traveling 50+ miles (long distance). Results: Among 421 patients (median age = 63.0 years, 56.9% female, 97.6% metastatic disease), median distance traveled was 36.4 miles. Half of patients (n = 217; 51.5%) traveled 50+ miles to receive care on trial. There were no significant differences between those traveling short and long distances in most patient characteristics evaluated, including age (60.9 vs 60.6 years; p = 0.635), sex (53.9% female vs 57.6%; p = 0.447), race (85.3% white vs 84.8%; p = 0.346), marital status (71.8% married vs 69.3%; p = 0.586), insurance (51% private vs 54.4%; p = 0.266), cancer type (22.5% GI vs 21.2%; p = 0.666), prior lines of therapy (52.5% one-two lines vs 51.2%; p = 0.981), and performance status (62.3% ECOG 1 vs 66.8%; p = 0.270. However, those with a higher SDI score were less likely to travel a long distance for trial participation (mean SDI 36.7 for short distance vs 30.5 for long distance; p = 0.026). Patients traveling a long distance were less likely to have a documented ACP discussion (48.8% vs 66.7%; p < 0.001). We found no significant difference in time spent on trial between those traveling short and long distances (mean days: 98 vs 93.5; p = 0.175) or in time from coming off trial to death (mean days: 147.7 vs 153.7; p = 0.099). Conclusions: We found that half of EP-CT participants travel 50+ miles in one direction to their trial site, with disparities in travel distance based on the social deprivation index. Notably, those traveling long distances were less likely to have a documented ACP discussion. Our findings suggest several unmet needs in the EP-CT population and highlight opportunities for future intervention development.

Protocol requirements and logistical intensity of early-phase clinical trials (EP-CTs)

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Background: EP-CTs are increasingly important options for patients with cancer and often involve intensive monitoring. Characterizing the time burden and logistical intensity of EP-CT protocols could help patients and clinicians make informed decisions about trial participation. Methods: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs at Massachusetts General Hospital from 2017-2019 to obtain baseline characteristics (demographics and clinical factors), EP-CT investigational agent (immunomodulatory [IM], targeted inhibitor [TI], antibody drug conjugate [ADC]/chemotherapy prodrug), and logistical intensity (visit frequency required per protocol and presence of extended visits). We defined visit frequency as the number of visits required per protocol within the first 28 days on trial. We defined an extended visit as six or more hours required in clinic on at least one day during the first 28 days on study. We evaluated associations among patient characteristics, investigational agents, logistical intensity, and time spent on trial. Results: Among 421 patients (median age = 63.0 years, 56.9% female, 97.6% metastatic disease), 43.2% were enrolled in IM EP-CTs, 43.0% TI, and 13.8% ADC/chemotherapy prodrug investigational agents. Patients enrolled on ADC/prodrug trials had the highest burden of metastatic disease (mean sites: 2.8 [ADC] vs 2.4 [TI] vs 2.3 [IM], p = 0.007) and oldest age (mean years: 64.0 [ADC] vs 61.7 [IM] vs 58.5 [TI], p = 0.003). However, those on ADC trials had the most days spent on trial (mean days: 78.3 [TI] vs 102.2 [IM] vs 131.8 [ADC], p = 0.003). Patients enrolled on TI trials had the highest required visit frequency compared with those enrolled on other trials (mean visits: 5.5 [TI] vs 5.3 [ADC] vs 5.0 [IM], p = 0.027). Additionally, those on TI trials were most likely to have an extended visit (82.3% [TI] vs 58.2% [IM] vs 29.3% [ADC], p < 0.001) and least likely to receive first in human therapy (38.1% [TI] vs 74.1% [ADC] vs 74.2% [IM], p < 0.001). Conclusions: In this cohort of patients participating in EP-CTs, we found that those enrolled on TI trials had the highest per protocol visit frequency and greatest likelihood of required extended visits. Those on ADC trials spent the most days on trial despite having the highest average age and burden of metastatic disease. These data highlight the time burden and logistical intensity of EP-CTs, underscoring certain trials as especially time intensive, which may help inform trial selection and participation.

Patient-reported hope, quality of life (QOL), symptom burden, and coping mechanisms in early phase clinical trial participants

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Background: Early phase clinical trials (EP-CTs) investigate novel treatment options in oncology, with recent advances in personalized therapy leading to improved outcomes and offering hope to patients with cancer. However, little research has sought to understand associations of patient-reported hope with QOL, symptom burden, and coping mechanisms in EP-CT participants. Methods: We prospectively enrolled consecutive adults with cancer participating in EP-CTs at Massachusetts General Hospital from 04/2021-01/2022. Participants completed baseline surveys prior to treatment initiation that assessed hope (Herth Hope Index [HHI], higher scores indicate greater hope), QOL (Functional Assessment of Cancer Therapy-General), symptom burden (physical: Edmonton Symptom Assessment System [ESAS]; psychological: Patient Health Questionaire-4 [PHQ4]), and coping mechanisms (Brief COPE). We used independent samples t-test to test for mean differences between groups and regression models to explore associations of hope with patient characteristics as well as patient-reported QOL, symptom burden, and coping mechanisms. Results: Of 92 eligible patients, we enrolled 85 (enrollment rate 92.4%, median age = 61.4 years [range 54.7-68.9]; 56.5% female, and 95.3% metastatic cancer). Most common cancer types were gastrointestinal (41.2%), breast (21.2%), lung (7.1%), and gynecologic (7.1%). Patients had an average HHI score of 28.2 (range 12.0-36.0), with 32.9% reporting high levels of hope. We found that married patients had higher mean hope score compared with non-married patients (28.9 versus 26.1, p = 0.024), those with children had higher mean hope scores than those without (28.9 versus 25.9, p = 0.013), and those who had received 3 or more lines of prior therapy compared with 1-2 (29.3 versus 27.2, p = 0.045) had higher hope scores. We also found associations of hope with patients’ QOL (B = 0.24, p < 0.001), symptom burden (ESAS-physical: B = -0.13, p = 0.001; PHQ4-depression: B = -2.26 p = < 0.001; PHQ4-anxiety: B = -0.94, p = 0.008), and coping (self-blame [B = -1.39, p = 0.003]; acceptance [B = 1.23, p = 0.002], denial [B = -1.09, p = 0.009], support [B = 1.06, p = 0.002], active [B = 0.73. p = 0.034], disengage [B = -3.24, p < 0.001]). Conclusions: In this prospective cohort study, we demonstrated that a substantial proportion of EP-CT participants had high baseline hope, and we identified several patient factors associated with their hope scores. We also found novel associations of higher hope scores with better QOL, lower symptom burden, and more adaptive coping mechanisms. Collectively, our findings highlight the potential for patient-reported hope to represent a key factor to consider when seeking to improve outcomes in EP-CT participants.

Time burden and logistical intensity of early-phase clinical trials (EP-CTs)

84

Background: EP-CTs are increasingly important options for patients with cancer and often involve intensive monitoring. Thus, characterizing the time burden and logistical intensity of EP-CTs could help patients and clinicians make informed decisions regarding trial participation. Methods: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs at Massachusetts General Hospital from 2017-2019 to obtain baseline characteristics (demographics and clinical factors), EP-CT investigational agent (immunomodulatory therapy [IM], targeted inhibitor(s) [TI], antibody drug conjugate [ADC]/chemotherapy prodrug), and logistical intensity (trial visit frequency, presence of extended visits, distance traveled in one direction from home zip code to trial site). We defined visit frequency as the number of visits per protocol within the first 28 days on trial. We defined an extended visit as six or more hours in clinic on at least one day during the first 28 days on study. We investigated associations among patient characteristics, investigational agent, and logistical intensity. Results: Among 421 patients (median age=60.6 years, 55.8% female, 97.4% metastatic disease), most (73.6%) had two or more sites of metastatic disease. EP-CTs included 43.2% IM, 43.0% TI, and 13.8% ADC/chemotherapy prodrug. Patients enrolled in ADC/prodrug trials had the highest burden of metastatic disease (mean sites: 2.8 [ADC] vs 2.4 [TI] vs 2.3 [IM], p = 0.007) and oldest age (mean years: 64.0 [ADC] vs 61.7 [IM] vs 58.5 [TI], p = 0.003). Patients enrolled on TI trials had the highest visit frequency compared with those enrolled on other trials (mean visits: 5.5 [TI] vs 5.3 [ADC] vs 5.0 [IM], p = 0.027) and the fewest days spent on trial (mean days: 78.3 [TI] vs 102.2 [IM] vs 131.8 [ADC], p = 0.003). Patients enrolled on TI trials were also most likely to have an extended visit (82.3% [TI] vs 58.2% [IM] vs 29.3% [ADC], p < 0.001) and least likely to receive first in human therapy (38.1% [TI] vs 74.1% [ADC] vs 74.2% [IM], p < 0.001). Distance traveled from home to clinic did not significantly differ across trial type (median miles traveled: 35.1 [TI] vs 34.1 [IM] vs 33.2 [ADC], p = 0.884). Conclusions: In this cohort of patients participating in EP-CTs, we found that a plurality enrolled in IM studies. Those receiving ADC/prodrug regimens were older and had a higher burden of disease. On average, patients participating in EP-CTs had over five visits in the first month, with those enrolled on TI trials having the highest visit frequency and greatest likelihood of extended visits. Patients on TI trials also spent the fewest total days on trial. Despite the lack of significant differences in distance traveled, most patients were still traveling over 30 miles to get to the trial site. These data highlight the time burden and logistical intensity of various EP-CTs, which may help inform patient-clinician discussions about trial participation.

Identifying early-phase clinical trial (EP-CT) participants at risk for poor outcomes

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Background: EP-CTs investigate novel treatment options, with recent advances in personalized therapy leading to increased response rates, decreased toxicity, and improved survival. Identifying EP-CT participants at risk for poor outcomes could help identify those who may benefit most from targeted supportive care efforts. Methods: We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs from 2017-2019 to obtain baseline characteristics (demographics and clinical factors), clinical outcomes (survival, time on trial, completion of dose-limiting toxicity [DLT] period, emergency room [ER] visits, hospitalizations, and hospice use), and receipt of supportive care services before/during trial (palliative care, social work, physical therapy [PT], and nutrition). We calculated the validated Royal Marsden Hospital (RMH) prognosis score using data at the time of EP-CT enrollment based on patients’ lactate dehydrogenase, serum albumin, and number of sites of metastasis. RMH scores range from 0-3, with scores of 2+ indicating a poor prognosis. We examined differences in patient characteristics, clinical outcomes, and receipt of supportive care services based on the RMH prognosis score. Results: Among 350 patients (median age = 63.2 years [range 23.0-84.3]; 57.1% female, 98.0% metastatic cancer), the most common cancer types were lung (23.4%), gastrointestinal (20.3%), and breast (12.0%). Nearly one-third (31.7%) had an RMH score indicating a poor prognosis. Patients with a poor prognosis RMH score had a worse performance status (ECOG ≥1: 80.2% vs 58.1%, p <.001) and more prior treatment (3+ prior lines: 48.6% vs 34.7%, p =.001) than those with a better prognosis score. Those with a poor prognosis RMH score had worse survival (median: 147 vs 402 days, p <.001) and shorter time on trial (median: 49 vs 84 days, HR = 1.53, p <.001), as well as a lower likelihood of completing the DLT period (72.1% vs 80.8%, p =.015). Patients with a poor prognosis score had a higher risk for ER visits (HR 1.66; p =.037) and hospitalizations (HR 1.69; p =.016) while on trial, with earlier hospice enrollment (HR 2.22; p =.006) following the trial. Patients with a poor prognosis score were significantly more likely to receive palliative care before/during trial (46.8% vs 27.6% p =.001), but not social work (41.4% vs 41.4% p = 1.00), PT (44.1% vs 34.7%; p =.098), or nutrition (40.5% vs 37.2%; p =.557). Conclusions: EP-CT participants represent a unique population of patients with advanced cancer, and we identified a group at risk for particularly poor outcomes, including worse survival, shorter time on trial, and greater use of healthcare services. Although patients with a poor prognosis score had higher rates of palliative care use, under half received supportive care services, underscoring the need for efforts to prospectively target these patients with interventions that address their supportive care needs.

Supportive care services and goals of care in early phase clinical trials (EP-CTs)

26

Background: EP-CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the use of supportive care services and timing of goals of care (GOC) discussions in EP-CTs. Methods: We conducted a retrospective review of consecutive patients with cancer enrolled on EP-CTs at Massachusetts General Hospital from 2017-2019. We collected information about patients’ demographic/clinical characteristics, use of supportive care services (palliative care [PC], social work [SW], physical therapy [PT], and nutrition), as well as documentation of GOC discussions and code status (before/during EP-CT vs after/never) via chart review. We examined patient characteristics associated with earlier receipt of supportive care services (before/during EP-CT vs after/never) and compared differences in the timing of GOC discussions and code status documented based on the receipt of supportive care services. Results: Among 425 patients enrolled on EP-CTs (median age 63.0; 56.0% female; 97.4% metastatic cancer; 22.1% gastrointestinal cancer), under half received supportive care services before/during trial (PC: 33.2% before/during, 66.8% post/never; SW: 41.9% before/during, 58.1% post/never; PT: 38.4% before/during, 61.6% post/never; and Nutrition: 33.2% before/during, 62.1% post/never). We identified the most common reasons for consulting each of the supportive care services (PC: 82.4% symptom management and 12.4% GOC; SW: 65.3% adjustment to illness and 23.8% referral for resources; PT: 44.8% safety/discharge planning and 24.6% mobility concerns; Nutrition: 73.2% for symptoms of anorexia/poor appetite and 21.5% nutrition assessment). Patients with GI cancer were more likely than those with other cancers to receive PC and SW before/during EP-CT (PC: 29.8% v 18.3%, p =.009; SW: 27.5% v 18.2%, p =.025). Earlier PC was associated with earlier hospice referral (HR = 1.95, p =.014) and shorter survival (HR = 1.54, p <.001). Patients receiving earlier supportive care services were more likely to have GOC discussions documented earlier (PC: 65.2% v 13.0%, p <.001; SW: 41.0% v 22.7%, p <.001; PT: 38.7% v 25.2%, p =.005; Nutrition: 39.1% v 25.0%, p =.002). Patients with earlier PC were more likely to have earlier documented code status (46.8% v 24.3%, p <.001), but not for any other service. Conclusions: In this cohort of patients with advanced cancer, under half received supportive care services before/during their participation in EP-CTs. We found that symptom management represented a common reason for referral to supportive care, highlighting the needs of this population. Patients who received earlier supportive care services were more likely to have earlier documentation of GOC discussions, with those receiving earlier PC having code status documented earlier and also experiencing earlier hospice use and shorter survival. These findings underscore the utility of supportive care services in EP-CTs.

Palliative care referrals in patients with advanced cancer on early-phase cancer clinical trials (EP-CTs)

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Background: EP-CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the utilization of supportive care services, specifically palliative care (PC), in this population. Methods: We conducted a retrospective review of consecutive patients enrolled on EP-CTs at the MGH Cancer Center from 2017-2019. Sociodemographic and clinical variables, including utilization of PC services, were obtained via chart review. Details of the PC evaluation were compared between patients who received first referral to PC while enrolled on an EP-CT versus those who received a PC referral at any point after diagnosis. Results: Among 426 patients enrolled on EP-CTs (median age 63 years; 44% male), 249 (59%) received a PC referral at any time following a diagnosis of cancer (median age 57 years, 58% male). Eighty-six (35%) were referred prior to enrollment on EP-CT, 44 (18%) were referred while on EP-CT, and 119 (48%) were referred post-EP-CT. Patients referred on EP-CT were younger (median 56 vs 63 years, p < 0.0001) than those enrolled on EP-CTs. For patients referred while on EP-CT, 48% had a PC consult within 30 days of enrollment (range: 0-530 days); median number of PC visits was 3 (range: 0-37); median time from first PC consult to death or termination of EP-CT was 32 days (range: 1-213). Of 44 patients referred on EP-CT, 2 (5%) died while on EP-CT. Of the remaining patients, median time from first PC consult to date of death was 79 days (IQR: 45-178 days). Most common reasons for referral included pain (22, 50%), non-pain symptoms (21, 48%), and goals of care/advanced care planning (20, 45%). Of these referrals, 13 (30%) were initiated as inpatients versus 31 (70%) as outpatients. Pain was most commonly cited for outpatient referral (35%), followed by non-pain symptoms (25%) and goals of care (23%). Non-pain symptoms (40%) and goals of care (36%) were most commonly cited reasons for inpatient referral, followed by pain (24%). Of referrals while on EP-CT, 23 (52%) were made by EP-CT staff, including MD and APP, 7 (16%) from the primary oncologist, and 1 (2%) was self-referral. 26 (57%) of patients referred to PC during trial were also referred to hospice, with a median time from last PC consult to hospice referral of 24 days (range: -2-322). Conclusions: A majority of patients with advanced cancer enrolled on EP-CTs received a PC referral. The timeline and method of referral varied, but most patients did not receive a referral until or following enrollment on an EP-CT. Future work will focus on developing a standard referral protocol for patients enrolled on EP-CTs.

Involvement of social work services in patients with advanced cancer in early-phase clinical trials (EP-CTs)

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Background: Early integration of supportive care in patients with advanced cancer has improved quality of life, symptom burden, and survival. Participants in EP-CTs often are highly pre-treated and the demands of participation can exacerbate financial and psychosocial concerns. Integration of social work services can address a broad scope of concerns including behavioral health, psychosocial needs, physical health, and financial concerns. Little data exists regarding the use of social work services in this patient population. Methods: We conducted a retrospective chart review of consecutive patients enrolled in EP-CTs at the MGH Cancer Center during 2017-2019. Information including sociodemographic data, clinical variables, and the use of social work services were captured from the electronic health record. We reviewed documentation in social work notes to determine reason for referral while participating on trial. Results: Of 426 EP-CT participants, 64% ( n = 272) received social work consultations at any time during their cancer course (consultations occurred a median of 23 months [range 0 – 444] following diagnosis). Compared to those who did not receive consultation, patients receiving consultation were younger (median age 60.5 years vs 65 years, p < .001) and more likely to have children (63% vs 46%, p < .001). More than half (59%, n = 159) of consultations occurred prior to EP-CT enrollment, while 14% (n = 39) were during patients’ time on EP-CT. The most common reasons for referral on trial included adjustment to illness (41%), limited patient resources (23%), and home/family support (15%). A quarter of referrals (27%, n = 74) were initiated after patients left the trial (27%, n = 74). There were no significant differences in demographic or clinical variables between those referred on EP-CT versus before or after EP-CT. For those who received social work consultation while on EP-CT, median time from date on treatment to consultation was 18 days (0 – 182 days) while median time on EP-CT was 55 days (2 – 576 days). Patients received a median of 2 visits (1 – 20) while on EP-CT. Physicians and research nurses were most likely to refer patients (31% vs 26%, respectively) while 10% of patients self-referred to social work. Conclusions: Over half of EP-CT participants received social work consultations during their cancer course. Most patients who received consultation on an EP-CT did so for psychosocial support. Future research should focus on determining how best to integrate social work into the care of EP-CT participants.

Understanding the supportive care needs of early-phase cancer clinical trial (CT) participants

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Background: Early phase CTs investigate novel therapeutic approaches for patients with cancer, but little is known about the use of supportive care services among participants in early phase CTs. Methods: We conducted a retrospective chart review of consecutive patients enrolled in Phase 1 CTs from 2017-2019, capturing sociodemographics, clinical data, and use of supportive care services from the electronic health record. We calculated the Royal Marsden Hospital (RMH) prognostic score using data at the time of CT trial enrollment based on patients’ lactate dehydrogenase, albumin, and number of sites of metastasis. The RMH score ranges from 0-3, with scores of 2+ indicating a poor prognosis. We explored differences in patient characteristics, supportive care use, and clinical outcomes based on the RMH prognosis score. Results: Among 426 patients treated on Phase 1 CTs during the study period, the median age was 63.0 years (range 20.5-85.2 years), and most were female (56.1%), white race (85.1%), and had metastatic cancer (97.7%). The most common cancer types were gastrointestinal (22.1%), lung (20.0%), and breast (10.6%) cancer. Under half (31.6%) had an RMH score indicating a poor prognosis. Patients with a poor prognosis score had a worse performance status (ECOG ≥1: 80.2% v 58.3%, p < .001) and more prior treatment (3+ prior lines: 49.5% v 35.0%, p = .001) compared to those without a poor prognosis score. Those with a poor prognosis score were more likely to receive palliative care before or during CT participation (40.5% v 27.1%, p = .011). We observed no significant differences in the rates of nutrition (69.1% v 64.0%), social work (62.2% v 63.8%), or physical therapy (64.5% v 61.7%) consults between those with and without a poor prognosis score. We found that those with an RMH score indicating a poor prognosis had a shorter time on trial (median: 49 vs 87 days, p < .001) and worse survival (median: 139 v 379 days, p < .001). Conclusions: Early phase CT participants represent an advanced cancer population with unique supportive care needs, and we identified a group with a particularly poor prognosis for whom earlier intervention with supportive care services may be needed. Our findings highlight the need to prospectively examine these characteristics along with patient-reported outcomes to better understand the distinct supportive care needs of this population and guide the development of targeted interventions.

The lived experience of AYA mothers with advanced breast cancer

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Background: Little is known about daily life experiences of young mothers with advanced breast cancer. Limited research suggests they face unique challenges differing from those of women at other life stages and with earlier stages of breast cancer. The larger study aimed to describe and interpret the lived experiences of young women with advanced breast cancer to contribute to our understanding of the needs of this population. Their role as mothers emerged as a significant theme. The goal of the overall study was to inform the development of person-centered interventions. Methods: Van Manen’s hermeneutic phenomenological method was employed in this longitudinal qualitative study. AYA women (25-39 years) with advanced breast cancer were purposively recruited via private Facebook groups specifically for women with breast cancer. Enrollment continued until thematic saturation was achieved. Data were collected through one or more semi-structured interviews over 6 months depending upon participant willingness, desire, or ability. Journals were provided to write additional thoughts. Data were drawn from interviews about daily life experiences. A major theme related to their identities as mothers emerged. Results: Twelve AYA women (mean age: 35.9) were included. All were married, had at least one child (10 months -14 years, median: 6.0 years), and most (n=7, 72.7%) worked full-time. Twelve participated in the first interview, 9 in a second interview, and 6 in a third interview. Three returned journals. The meaning of their experiences as mothers is captured by the theme: “ I’m Still Mom” and 7 subthemes: “ it’s so hard”, ” being a mom still”, “ what I can still do”, “there’s not enough time”, “being remembered”, “searching for resources”, and “ it’s not easy for my kids”. Conclusions: Being a mother is the first priority for these AYA women with advanced breast cancer, but they are hindered in their parenting activities by physical effects of their cancer and its treatment, uncertainty about their future, and worry for their children’s future. This study provides a base for further research on daily priorities for this population to inform future interventions to optimize quality of life consistent with their parenting priorities.

A state-wide initiative to promote genetic testing in an underserved population

Genetic testing for cancer susceptibility has been widely studied and utilized clinically. Access to genetic services in research and practice is largely limited to well-insured, Caucasian individuals. In 2009, the Cancer Resource Foundation (CRF) implemented the Genetic Information for Treatment Surveillance and Support (GIFTSS) program to cover the out-of-pocket expenses associated with cancer genetic testing, targeting high-risk individuals with limited financial means and limited health insurance coverage. Here, we (i) describe the characteristics of participants in the Massachusetts (MA) GIFTSS program and (ii) evaluate mutations found in this diverse sample. A secondary retrospective data analysis was performed using de-identified demographic data obtained from laboratory requisition forms and cancer genetic testing result information from the laboratory source. Eligible participants were those who utilized the MA GIFFTS program from 2009 through December of 2014. Data were summarized using descriptive measures of central tendency. Participants were residents of Massachusetts who had health insurance and had a reported income within 250-400% of the federal poverty level. Genetic testing results were categorized following clinical guidelines. Overall, 123 (13%) of participants tested positive for a mutation in a cancer susceptibility gene. For those with a cancer diagnosis, 65 (12%) were found to have a positive result and 20 (7%) had a variant of uncertain significance (VUS). For those unaffected patients, 58 (15%) had a positive result and 10 (3%) were found to have a VUS. The results from this study are useful in describing genetic testing outcomes in this high-risk underserved community. Repeatedly, the literature reports that individuals from diverse or limited resource settings are less likely to access genetic testing. Continued research efforts should be devoted to promoting the access of genetic testing in the high-risk, underserved community.

The Feasibility, Safety, and Efficacy of Using a Wireless Pedometer to Improve the Activity Level in a Cohort of Nurses

PURPOSE

This study had two aims: (1) to test the feasibility, safety, and efficacy of using a wireless pedometer in a cohort of nurses; and (2) to understand if wireless pedometer use increased number of steps walked, number of flights of stairs climbed, daily activity level, and improved personal perception of health.

DESIGN

This study used a nonexperimental exploratory design to test the feasibility and efficacy of using a wireless pedometer in a cohort of nurses. Pre- and posttest measures captured the number of steps walked, flights of stairs climbed, activity level, and perception of health.

RESULTS

Sample characteristics: 27 females, 3 males; 90% non-Hispanic Caucasian, 3% Hispanic; 47% between the ages of 55 and 65 years. Eighty percent of the participants reported that they were caregivers of other people. There was a significant increase from baseline to the end of the study in the following measures: self-perception of steps walked ( p < .001), flights of stairs climbed ( p < .005), self-perception of daily activity ( p < .001), and although there was an improvement in self-perception of health, the change was not significant.

CONCLUSIONS

The wireless pedometer was a feasible, safe, and efficacious device to use. This study may have implications for interventions aimed at improving caregiver health.

Quality of life during rehabilitation: Rectal cancer patient and partner experiences with altered bowel function

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Background: In 2010, the American Cancer Society has estimated rectal cancer affects over 39,670 adult patients in the United States. Five-year disease-free survival for rectal cancer patients with stage II/III disease ranges from 60-70%. Current gaps exist regarding long-term effects after treatment including altered bowel function and health-related quality of life (HR-QOL) concerns from rectal cancer patient and partners' perspectives both individually and together during rehabilitation and as cancer survivors. The purpose of this study was to: (1) describe the experiences of adult rectal cancer patients and their partners during rehabilitation from cancer treatment, including long- term effects; (2) examine health-related quality of life (HR-QOL) issues for rectal cancer patients and their partners including well-being and coping during their rehabilitation and as survivors.

Methods: A qualitative descriptive study for a planned sample of 20 adult rectal cancer patients, stage II/III, and their partners from an academic health science hospital and cancer center has been conducted. Twelve patients and their partners have currently completed face to face semi-structured interviews. Patient participants were at least 6 months to 5 years post treatment. Qualitative descriptive design used purposive sampling to obtain broad information on rectal cancer patients' and partners' perspectives for content analysis.

Results: Preliminary findings have revealed unexpected difficulties; chronic bowel function alterations; symptom unpredictability; nutrition intolerances; patient/partner adjustments; social concerns in going places, reactions by friends, work and financial strains; and, acceptance in living with it or chronic life changes as survivors. Partners acknowledged their own needs for information and support to assist their spouse or significant other. Further rich, thick descriptions will be presented in presentation of findings for 20 patient and partner responses.

Conclusions: Survivorship follow-up regarding these concerns should be emphasized for rectal cancer patients and their partners to formalize interventions for study to enhance HR-QOL well-being.

No significant financial relationships to disclose.

Abstract P1-10-01: Genetic Information for Treatment, Surveillance and Support [GIFTSS]: Initial Evaluation of a Program for the Underserved

Background: Predictive genetic mutation testing in known cancer susceptibility genes can provide individuals and families with valuable information about their risk(s) of developing specific cancers. However, individuals from underserved groups often identified by race, ethnicity, or socioeconomic status are at a disadvantage in accessing this service compared with mainstream populations, which leads to a growing healthcare disparity in clinical genetics and care. In 2006 Massachusetts enacted one of the boldest Healthcare Reform Acts (HCRA) in the nation. The MA HCRA provides complete subsidized, comprehensive health insurance to adults earning up to 150% of the Federal Poverty Level (FPL). Unfortunately, this health insurance did not include genetic testing as a covered service. In addition, these patients were often found ineligible for local and national financial relief programs because they were considered ‘insured'. A recent survey of Certified Genetic Counselors (CGCs) in Massachusetts suggested underutilization of genetic testing because of lack of insurance coverage, co-pay and deductible costs.

In 2009 the Cancer Resource Foundation, Inc. (CRF), a non-profit 501 (c) (3) Foundation in Massachusetts, with generous support from Myriad Genetics Laboratories, Inc., established Genetic Information for Treatment, Surveillance and Support (GIFTSS), a voucher program for molecular genetic diagnostic testing for those who met medical (high risk) and financial (low income) criteria. Through Webinars and publications, CRF informed CGCs and other healthcare providers of this unique program. The GIFTSS application was available in English, Spanish, and Portuguese and eligibility was determined within 24 hours. The purpose of this evaluation is to describe the feasibility of the GIFTSS program in reaching the underserved and to identify BRCA1/BRCA2 and other mutations among these populations.

Methods: From November 2009 through June 2010, 85 patients were enrolled in the voucher program. Race, ethnicity, age, and cancer genetic mutations were examined. Myriad Genetics provided de-identified genetic test results for the cohort. IRB approval was obtained. Feedback about the GIFTSS program was also solicited from CGCs and clinical providers. Results: Of the first 44 participants, 42% were racial/ethnic minorities comprising African, Native American, Asian, Ethiopian, Latin American/Caribbean and South American ancestry. 15.9% (n=7) had a deleterious mutation of BRCA1/BRCA2 and 4.5% (n=2) had a genetic variant of unknown significance in one of the genes. Median age of enrollees was 39. Feedback from the CGCs and healthcare providers indicates the need for: plain language and multi-lingual/cultural genetic risk information; extended financial and emotional support of mutation carriers to consider risk reduction services; additional counseling options for rural patients; and multi-lingual counseling services.

Conclusion: The GIFTSS program succeeded in reaching an underserved and racially and ethnically diverse population. Surprisingly, a high percentage of mutations was identified among a group that generally lacks access to testing. Further research, education and support services among this population are warranted.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-10-01.

Effect of calcaneal osteotomy and plantar fasciotomy on arch configuration in a flatfoot model

Seven fresh-frozen cadaver specimens had a calcaneal osteotomy performed obliquely through the posterior portion of the calcaneus. Angular relationships between the first metatarsal and talus were recorded with the use of a motion-analysis system in the transverse, sagittal, and coronal planes. The specimen was mounted in a testing machine and loaded via an intramedullary rod to 150, 350, and 550 N. A flatfoot model was created, and repeat measurements were obtained. The calcaneal osteotomy was then displaced 1 cm medially, and repeat measurements were made at each of the three load levels. The calcaneal osteotomy was then returned to its original position, the plantar fascia was divided, and the new angular measurements were obtained. The calcaneal osteotomy was again displaced 1 cm, and repeat angular measurements were obtained. A mild consistent flatfoot deformity was created in all three axes before the plantar fascia was cut. A statistically significant increase in deformity was noted after cutting the plantar fascia. A correction of the flatfoot deformity in all three planes occurred with the medial displacement of the calcaneal osteotomy, which was greater at the lower load levels. We noted that a medial displacement calcaneal osteotomy partially corrected a flatfoot deformity in all three planes. The correction occurred with or without an intact plantar fascia and, therefore, is independent of the structure. We also noted an increased deformity after dividing the plantar fascia. This study provides some biomechanical insight as to the corrective effect of a medial displacement calcaneal osteotomy in correcting a flatfoot deformity.