Health System Practices and Perspectives of Social Risk Screening in Oncology

PURPOSE/OBJECTIVE(S)

Social risks (e.g., food insecurity) are adverse social/economic conditions associated with poor health outcomes. Among patients with cancer, presence of social risks is associated with increased late-stage diagnoses, care delays, and mortality. The purpose of this project was to assess the perspectives and practices regarding social risk screening within a large NCI-designated cancer center.

MATERIALS/METHODS

Email invitations to complete a secure, online survey were distributed to oncology healthcare staff (e.g., oncologists, nurses, pharmacists, medical assistants, social workers, and patient navigators) at Moores Cancer Center between June 1, 2022 and July 31, 2022. The 6-item survey collected information on clinical role, current practices and perceived barriers to screening for social risks as part of routine care. Respondents were categorized as MD-trained providers versus non-MD clinical staff. Descriptive statistics were used, including Fisher's exact test to compare responses by respondent type (MD vs non-MD). All analyses were conducted using data management and decision management software. This project was approved by the UCSD Institutional Review Board.

RESULTS

A total of 59 respondents completed the survey, including 20 MDs (34%) and 39 non-MD staff (66%). Overall, most respondents reported asking patients about their social risks (75%) and communicating information about patients' social risks with other healthcare staff when clinically relevant (84%). MDs were significantly more likely to agree that they ask patients about social risks when clinically relevant than non-MDs (95% vs 64%, p = 0.024). MDs were also more likely to communicate, review and use social risk information than their non-MD colleagues. The most reported barriers to integrating social risk information into clinical care, overall, included insufficient time (73%), uncertainty about who is responsible (70%), and lack of knowledge about existing tools (75%) for asking patients about social risks, as well as lack of resources to address social risks (76%). Non-MDs were more likely to cite concern that patients and families will feel uncomfortable answering questions about social risks (67% vs 20% of MDs, p = 0.003) as a barrier. Only 30% of MDs and 46% of non-MDs agreed that "asking about social risks is outside of the scope of my role" was a barrier.

CONCLUSION

Most oncology providers and staff agree that obtaining social risk information is important for patient care. Developing clinic-based solutions that integrate social risk screening and referral workflows within the oncology setting is imperative to reduce cancer health disparities. Future efforts that leverage the use of electronic health records to conduct social risk screening and streamline referrals to community-based resources in oncology may improve cancer health equity.

Association of Transgender or Gender Non-Binary Identity on Disease Characteristics and Survival Outcomes in Prostate Cancer

PURPOSE/OBJECTIVE(S)

While it is becoming increasingly common for people to identify as transgender or gender-non-binary, our understanding of the influence of gender identity on disease severity of hormone-sensitive malignancies, including prostate cancer (PC) is limited. The goal of this study is to compare the aggressiveness of disease and survival outcomes between transgender or gender non-binary (TG) and cis-gender (CG) patients with PC.

MATERIALS/METHODS

The cohort included patients diagnosed with PC between 1999 and 2022 within the Veterans Health Administration (VHA) Database. TG patients were identified with an ICD 9 or 10 diagnosis code that occurred prior to PC diagnosis. Treatment information and baseline disease characteristics were ascertained through the VHA electronic health records. Multivariable logistic regressions were performed to estimate the association between TG status and presenting with Gleason > = 8, PSA > 20 ng/mL, and metastatic disease at diagnosis. Covariates in these models included age at diagnosis, race, ethnicity, marital status, and smoking status. Metastases were identified through natural language processing from cancer or radiology documents. Time to metastases was defined as the time from PC diagnosis to metastases, with other causes of death considered as competing risks. The association between TG identity status and metastatic disease was calculated with a Cox regression model. The difference in overall survival was assessed with the Kaplan-Meier method and log-rank test.

RESULTS

The final cohort was composed of 282,264 individuals, 219 (0.08%) of which were identified as TG. TG patients have similar odds of presenting with presenting with Gleason Score ≥8 (Odds Ratio (OR) 1.18, p = 0.31), PSA >20 ng/mL (OR 0.78, p = 0.59), and metastasis at diagnosis (OR 0.47, p = 0.29). There were 34,918 patients who develop metastatic disease at any time, 24 of which were TG. The 10-year cumulative incidence of metastases for TG and CG individuals was 11.5% (95% Confidence Interval (CI): 6.6-16.1%) and 13.9% (CI: 13.7-14.0%), respectively. There was no significant difference between TG status and risk of developing metastases (Hazard Ratio (HR) 0.93, p = 0.71). The 10-year overall survival for TG and CG was 73.4% (CI: 66.5-80.9%) and 65.0% (CI: 64.8-65.2%), respectively. There was no significant difference between TG status and overall survival (Hazard Ratio (HR) 0.83, p = 0.13).

CONCLUSION

TG individuals do not appear to have a difference in disease characteristics at diagnosis or survival compared to CG individuals. Future research should be done to determine the effect of gender affirming treatment on these outcomes. Furthermore, it is unclear if diagnosis codes are accurately identifying TG individuals.

Association between National Area Deprivation Index Rank on Disease Characteristics in Prostate Cancer

PURPOSE/OBJECTIVE(S)

Social determinants of health (SDH) play a large role in an individual's health; in recent years, there has been a push to examine the impact of one's neighborhood or "place." Previous studies have showed that living in a disadvantage neighborhood is associated with worth health outcomes. We hypothesize that equal access care will diminish the effects of living in a disadvantaged neighborhood.

MATERIALS/METHODS

We identified non-Hispanic African American (AA) and White (NHW) men diagnosed with PC between 2012 and 2015 in the Veterans Health Administration (VHA). Patient SDH was measured using census tract level 2015 Area Deprivation Index (ADI) information. The ADI is a composite measure that includes factor such as housing quality, income, health care access etc. We measured both National and State ADI rank as a continuous variable from 1 to 10 with 10 being highest deprivation. Patient information was gathered at the census tract level while ADI is assigned at the census block group. In order to get all information on the same geographic level, we averaged the ADI to its corresponding census tract. Associations between ADI and disease characteristics at diagnosis were measured using multivariable logistic regression models including age, race, and marital status as covariates.

RESULTS

The final cohort was composed of 25,222 men (8,384 AA and 16,838 NHW.) At the national level, there was no significant association between ADI and Gleason Score ≥8 (Odds Rations (OR) 0.99 [95% Confidence Interval (CI):0.98 - 1.00]), PSA >20 ng/mL (OR 0.99 [95% CI: 0.98 - 1.01]), and metastasis at diagnosis (OR 1.01 [CI: 0.98-1.04]).

CONCLUSION

Our results are consistent with our hypothesis that equal access care diminishes the impacts of living within a disadvantaged neighborhood. Future research should investigate the interaction between health care access and social and demographic factors.

Results From a Multi-Institutional Pilot Study of iContour, an Interactive Online Platform with Real-Time Feedback to Improve Contouring Education for Radiation Oncology Residents

PURPOSE/OBJECTIVE(S)

Numerous studies have shown that variability in contouring by radiation oncologists is common and associated with poor clinical outcomes. Contouring is taught via an apprenticeship model during residency with inconsistent results. Currently, there is no standardized contouring curriculum. We hypothesized that an interactive online educational platform for learners to practice contouring and receive real-time visual feedback would be a useful curricular tool.

MATERIALS/METHODS

The iContour platform displays anonymized DICOM data and allows for input and analysis of user contours in a web-based interface. Nine cases are available from the Head/Neck (H+N), Gynecologic (Gyn), and Gastrointestinal (GI) disease sites. The system presents users with a case and asks them to contour representative slices from 2-3 target volumes or OARs. Upon submission, users are shown several forms of feedback. These include immediate visual comparison with expert contours on the same dataset (all cases), customized feedback based on overlap with prespecified "avoidance" and "inclusion" structures that highlight common mistakes (Gyn cases), and tumor control probability models to estimate the clinical impact of a user's contour variations on patient outcomes (H+N cases). Some cases include short videos outlining anatomy and contouring principles which are shown before the user contours. A pilot study was performed to evaluate technical performance and educational utility. Pre- and post-surveys with Likert-type questions (1-5 scale from strongly disagree to strongly agree) were used to assess user satisfaction and preferences regarding feedback.

RESULTS

A total of 9 residents participated (median PGY3, range PGY2-5) from 5 institutions in 2 countries. Each participant completed 2 cases from a single disease site (n = 3 each for H+N, Gyn and GI), one with educational videos and one without. 67% of users had completed a prior clinical rotation in their disease site. Overall, residents felt the system was a useful educational tool (mean Likert score 4.67 +/- 0.47) and were interested in using it during clinical rotations (4.89 +/- 0.31). Most participants (7/9) felt iContour was more useful than existing resources for contouring education. Residents unanimously (9/9) found direct visual comparison with expert contours the most useful type of feedback, and that cases with videos before contouring were more educational.

CONCLUSION

The iContour platform is a useful educational tool for radiation oncology residents. Participants felt receiving immediate visual feedback on contours was a valuable learning experience. Short instructional videos before contouring can be utilized to provide "just in time" teaching. A randomized study to formally assess the platform's impact on contouring skills is planned.