Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study

PURPOSE

Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients.

METHODS

We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care.

RESULTS

Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death.

CONCLUSION

Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.

Low physical function Post-Cancer diagnosis is associated with higher mortality risk in postmenopausal women

BACKGROUND

Postmenopausal women with cancer experience an accelerated physical dysfunction beyond that expected through aging alone due to cancer and its treatments. The aim of this study is to determine whether declines in physical function after cancer diagnosis are associated with all-cause mortality and cancer-specific mortality.

METHODS

This prospective cohort study included 8,068 postmenopausal women enrolled in the Women's Health Initiative (WHI) who were diagnosed with cancer and had physical function assessed within 1-year of cancer diagnosis. Self-reported physical function was measured using the 10-item physical function subscale of the RAND 36-Item Health Survey. Cause of death was determined by medical record review with central adjudication and linkage to the National Death Index. Death was adjudicated through February 2022.

RESULTS

Over a median follow-up of 7.7 years from cancer diagnosis 3,316 (41.1%) women died. Our results showed that for every 10% decline in the physical function score after cancer diagnosis, all-cause mortality and cancer-specific mortality were significantly reduced by 12% (HR, 0.88; 95% CI, 0.87 to 0.89) and (HR, 0.88; 95%CI, 0.86 to 0.91), respectively. Further categorical analyses showed a significant dose-response relationship between post-diagnosis physical function categories and mortality outcomes (trend test P < .001), where the median survival time for women in the lowest physical function quartile was 9.1 (8.6, 10.6) years compared to 18.4 (15.8, 22.0) years for women in the highest physical function quartile.

CONCLUSION

Postmenopausal women with low physical function after cancer diagnosis may be at higher risk of mortality from all causes and cancer-related mortality.

Randomized Trial of a Volunteer-Led Symptom Assessment Intervention on Documentation, Patient-Reported Outcomes, and Health Care Use Among Veterans With Lung Cancer

PURPOSE

Identification and documentation of Veterans' symptoms are crucial for optimal lung cancer care delivery. The objective of this study was to determine whether a volunteer-led proactive telephone symptom assessment intervention could improve comprehensive symptom documentation.

METHODS

Veterans with lung cancer were randomly assigned to usual care (control group) or usual care with proactive symptom assessment in which a peer volunteer made weekly phone calls to assess patient symptoms under nurse practitioner supervision. The primary outcome was oncologist documentation of symptoms in the electronic health record at all clinical visits within 6 months after enrollment. Secondary outcomes included patient satisfaction with decision, patient activation, health-related quality of life (HRQOL), and symptom burden, measured at baseline, and 3, 6, and 9 months after enrollment, and acute care use within 9 months after enrollment.

RESULTS

Among 60 Veterans randomly assigned, median (range) age was 70.2 (50-86) years; 57 (95.0%) were male. More intervention participants had oncologist documentation of symptoms than control group participants (24 [77.4%] v seven [24.1%], respectively; odds ratio, 16.46 [95% CI, 4.58 to 59.16]). Intervention group participants had greater improvements over time in HRQOL (expected mean difference, 25.3 [95% CI, 15.00 to 35.70]) and patient activation (expected mean difference, 13.6 [95% CI, 3.79 to 23.39]), lower symptom burden (expected mean difference, -6.39 [95% CI, -15.21 to -2.46]), lower rates of emergency room visits (incidence rate ratio, 0.48 [95% CI, 0.30 to 0.75]), and hospitalizations (incidence rate ratio, 0.47 [95% CI, 0.28 to 0.77]) than control group participants.

CONCLUSION

This symptom assessment intervention is an effective strategy for Veterans with lung cancer.

Lay healthcare worker financial toxicity intervention: a pilot financial toxicity screening and referral program

PURPOSE

Financial toxicity is a source of significant distress for patients with urologic cancers, yet few studies have addressed financial burden in this patient population.

METHODS

We developed a financial toxicity screening program using a lay health worker (LHW) and social worker (SW) to assess and mitigate financial toxicity in a single academic medical clinic. As part of a quality improvement project, the LHW screened all newly diagnosed patients with advanced stages of prostate, kidney, or urothelial cancer for financial burden using three COST tool questions and referred patients who had significant financial burden to an SW who provided personalized recommendations. The primary outcome was feasibility defined as 80% of patients with financial burden completing the SW consult. Secondary outcomes were patient satisfaction, change in COST Tool responses, and qualitative assessment of financial resources utilized.

RESULTS

The LHW screened a total of 185 patients for financial toxicity; 82% (n = 152) were male, 65% (n = 120) White, and 75% (n = 139) reported annual household income >$100,000 US Dollars; 60% (n = 114) had prostate cancer. A total of 18 (9.7%) participants screened positive for significant financial burden and were referred to the SW for consultation. All participants (100%) completed and reported satisfaction with the SW consultation and had 0.83 mean lower scores on the COST Tool post-intervention assessment compared to pre-intervention (95% confidence interval [0.26, 1.41]).

CONCLUSION

This multidisciplinary financial toxicity intervention using an LHW and SW was feasible, acceptable, and associated with reduced financial burden among patients with advanced stages of urologic cancers. Future work should evaluate the effect of this intervention among cancer patients in diverse settings.

Challenges and Solutions to Support Oncology Professionals Serving Underserved Populations With Cancer in the United States: Results From the ASCO Serving the Underserved Task Force

PURPOSE

Little data exist regarding approaches to support oncology professionals who deliver cancer care for underserved populations. In response, ASCO developed the Serving the Underserved Task Force to learn from and support oncology professionals serving underserved populations.

METHODS

The Task Force developed a 28-question survey to assess oncology professionals' experiences and strategies to support their work caring for underserved populations. The survey was deployed via an online link to 600 oncology professionals and assessed respondent and patient demographic characteristics, clinic-based processes to coordinate health-related social services, and strategies for professional society support and engagement. We used chi-square tests to evaluate whether there were associations between percent full-time equivalent (FTE) effort serving underserved populations (<50% FTE v ≥50% FTE) with responses.

RESULTS

Of 462 respondents who completed the survey (77% response rate), 79 (17.1%) were Asian; 30 (6.5%) Black; 43 (9.3%) Hispanic or Latino/Latina; and 277 (60%) White. The majority (n = 366, 79.2%) had a medical doctor degree (MD). A total of 174 (37.7%) had <25% FTE, 151 (32.7%) had 25%-50% FTE, and 121 (26.2%) had ≥50% FTE effort serving underserved populations. Most best guessed patients' sociodemographic characteristics (n = 388; 84%), while 42 (9.2%) used data collected by the clinic. Social workers coordinated most health-related social services. However, in clinical settings with high proportions of underserved patients, there was greater reliance on nonclinical personnel, such as navigators (odds ratio [OR], 2.15 [95% CI, 1.07 to 4.33]) or no individual (OR, 2.55 [95% CI, 1.14 to 5.72]) for addressing mental health needs and greater reliance on physicians or advance practice practitioners (OR, 2.54 [95% CI, 1.11 to 5.81]) or no individual (OR, 1.91 [95% CI, 1.09 to 3.35]) for addressing childcare or eldercare needs compared with social workers. Prioritization of solutions, which did not differ by FTE effort serving underserved populations, included a return-on-investment model to support personnel, integrated health-related social needs screening, and collaboration with the professional society on advocacy and policy.

CONCLUSION

The findings highlight crucial strategies that professional societies can implement to support oncology clinicians serving underserved populations with cancer.

Effect of a Community Health Worker-Led Intervention Among Low-Income and Minoritized Patients With Cancer: A Randomized Clinical Trial

PURPOSE

To determine whether a community health worker (CHW)-led intervention could improve health-related quality of life (HRQoL; primary outcome) more than usual care among low-income and racial and ethnic minoritized populations newly diagnosed with cancer.

METHODS

This randomized clinical trial was conducted from November 1, 2018, until August 31, 2021, in outpatient cancer clinics in Atlantic City, NJ, and Chicago, IL. Hourly low-wage worker members of an employer union health fund age 18 years or older with newly diagnosed solid tumor and hematologic malignancies were randomly assigned 1:1 to usual care (control group) or usual care augmented with a trained CHW for 12 months (intervention group). The CHW assisted participants with advance care planning (ACP), proactively screened symptoms, and referred participants to community-based resources for identified health-related social needs. Usual care comprised nurse case management and benefits redesign (waived copayments and free transportation for any cancer care received at preferred oncology clinics in each city). The primary outcome was HRQoL. Secondary outcomes included patient activation, satisfaction with decision, ACP documentation, health care use, total health care costs, and overall survival.

RESULTS

A total of 160 participants were enrolled. Intervention group participants had a greater increase in mean HRQoL scores at 4-month and 12-month follow-up as compared with baseline than control group participants (expected mean difference, 11.25 [95% CI, 7.28 to 15.22]; 11.29 [95% CI, 6.96 to 15.62], respectively).

CONCLUSION

In this randomized trial, a CHW-led intervention significantly improved HRQoL for low-income and racial and ethnic minoritized patients with cancer more than usual care alone.

Understanding Barriers and Facilitators to High-Quality Cancer Care Among Veterans With Lung Cancer: A Qualitative Study

PURPOSE

Veteran populations have higher lung cancer incidence and worse overall survival compared with non-Veteran populations. Although recent clinical advancements have reduced lung cancer death rates, these advances are not routinely received among Veteran populations because of multilevel factors, including Veterans' complex comorbidities, limited health literacy, and other economic and social disadvantages. This study aimed to assess Veterans' perspectives regarding their lung cancer care with a specific focus on identifying modifiable barriers to evidence-based care delivery.

METHODS

We conducted 1:1 semistructured interviews with 24 Veterans diagnosed with lung cancer at the Veterans Affairs Palo Alto Health Care System. All interviews were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis.

RESULTS

Four themes emerged. These included (1) social and economic disadvantages can prevent routine delivery of evidence-based cancer care; (2) fragmented care contributes to worsening patient mental and emotional well-being; (3) lack of health system interventions to address limited health literacy inhibits patient engagement in shared decision making regarding diagnosis, genomic and molecular testing, targeted and other treatments, and end-of-life care; and (4) deep appreciation for care and VA trustworthiness facilitates adherence to cancer care recommendations.

CONCLUSION

This study revealed critical gaps in lung cancer care delivery and the role of institution-engendered trust in overcoming barriers in the VA system. Targeted solutions should address the identified barriers to routine, evidence-based lung cancer care delivery among Veterans.

Diversity in Cancer Care: Current Challenges and Potential Solutions to Achieving Equity in Clinical Trial Participation

ABSTRACT

Access to and participation in cancer clinical trials determine whether such data are applicable, feasible, and generalizable among populations. The lack of inclusion of low-income and marginalized populations limits generalizability of the critical data guiding novel therapeutics and interventions used globally. Such lack of cancer clinical trial equity is troubling, considering that the populations frequently excluded from these trials are those with disproportionately higher cancer morbidity and mortality rates. There is an urgency to increase representation of marginalized populations to ensure that effective treatments are developed and equitably applied. Efforts to ameliorate these clinical trial inclusion disparities are met with a slew of multifactorial and multilevel challenges. We aim to review these challenges at the patient, clinician, system, and policy levels. We also highlight and propose solutions to inform future efforts to achieve cancer health equity.

Clinic-based Assessment and Support for Family Caregivers of Patients With Cancer: Results of a Feasibility Study

Background

Cancer caregiving is burdensome with unique needs, highlighting the importance of assessing caregivers' distress. Caregivers often accompany patients to healthcare visits, presenting an opportunity to complete distress screening at patients' point-of-care.

Objective

To evaluate the feasibility of caregiver distress screening at patients' point-of-care and implementing a caregiver psychoeducational session.

Methods

We approached caregivers in outpatient cancer clinic waiting rooms. Participants completed depression, burden, anxiety, quality of life, and stress measures. A psychoeducational session with a psychologist was offered to those meeting clinical cutoffs for depression and/or burden. Fifty caregivers completed 1+ measure; however, due to incomplete consent documentation, findings from 23 caregivers are reported.

Results

22% of caregivers screened positive for depression, 30% burden, and 70% anxiety. More than half rated stress as moderate or higher. Mental wellbeing was slightly below that of the general population. More than 75% screened positive on 1+ distress measure. Of the 9 caregivers who met cutoffs for depression and/or burden, two (22%) accepted the psychoeducational session.

Conclusion

Caregivers were moderately receptive to distress screening during patients' visits, but were less receptive to engaging in the psychoeducational session due to time constraints and privacy concerns.

Implications for Practice

Assessing caregivers' distress can facilitate referrals for supportive services. Offering caregivers psychoeducational intervention outside of patient care may not be acceptable. Future research may evaluate the integration of routine caregiver screening within patient care to promote engagement with mental health services.

Foundational

This research offers a unique method of assessing cancer caregivers' distress.

Leveraging Goals of Care Interventions to Deliver Personalized Care Near the End of Life

This Viewpoint discusses barriers to and opportunities for incorporating goal of care communications into end-of-life care.

Assessing the Needs of Those Who Serve the Underserved: A Qualitative Study among US Oncology Clinicians

BACKGROUND

The American Society of Clinical Oncology established the 'Supporting Providers Serving the Underserved' (SUS) Task Force with a goal to develop recommendations to support cancer clinicians who deliver care for populations at risk for cancer disparities. As a first step, the Task Force explored barriers and facilitators to equitable cancer care delivery.

METHODS

Clinicians across the United States who deliver care predominantly for low-income and racially and ethnically minoritized populations were identified based on lists generated by the Task Force and the Health Equity Committee. Through purposive sampling based on geographical location, clinicians were invited to participate in 30-60 min semi-structured interviews to explore experiences, barriers, and facilitators in their delivery of cancer care. Interviews were recorded, transcribed, imported into qualitative data management software, and analyzed using thematic analysis.

RESULTS

Thematic analysis revealed three major themes regarding barriers (lack of executive leadership recognition of resources; patient-related socio-economic needs; clinician burnout) and two major themes regarding facilitators (provider commitment, experiential training).

CONCLUSIONS

Findings reveal modifiable barriers and potential solutions to facilitate equitable cancer care delivery for populations at risk for cancer disparities.

"I Have Constant Fear": A National Qualitative Study on the Impact of COVID-19 on Cancer Care and Potential Solutions to Improve the Cancer Care Experience During the COVID-19 Pandemic

PURPOSE

The COVID-19 pandemic has greatly affected cancer care delivery for patients, including cancellation or delays in surveillance imaging, clinic visits, and treatments. Yet, gaps remain in understanding the extent of the impact of the COVID-19 pandemic on patients with cancer and potential ways to overcome these impacts.

METHODS

We conducted semistructured, in-depth, one-on-one qualitative interviews among adults with a past or current history of cancer in the United States. Participants from a parent quantitative survey were purposively sampled to participate in a qualitative interview. Interview questions addressed (1) experiences with cancer care delivery during the COVID-19 pandemic; (2) unmet concerns regarding care and other impacts; and (3) approaches to improve patient experiences. We conducted inductive thematic analysis.

RESULTS

Fifty-seven interviews were conducted. Four themes emerged: (1) concern regarding the risk of COVID-19 infection among patients with cancer and their families; (2) disruptions in care increased patients' anxiety about poor cancer outcomes and death from cancer; (3) significant social and economic impacts; and (4) increased social isolation and anxiety about the future. Suggestions for current clinical practice include (1) clear communication on patients' health risks; (2) increased attention to mental health needs and access to mental health services; and (3) routine use of telemedicine as frequently as possible when clinically appropriate.

CONCLUSION

These rich findings reveal the significant impact of the COVID-19 pandemic on patients with cancer and potential approaches to mitigate the impact from the patient perspective. The findings not only inform current cancer care delivery but also health system responses to future public health or environmental crises that may pose a unique health risk for patients with cancer or disrupt their care.

Increasing Racial and Ethnic Equity, Diversity, and Inclusion in Cancer Treatment Trials: Evaluation of an ASCO-Association of Community Cancer Centers Site Self-Assessment

Clinical trial participants do not reflect the racial and ethnic diversity of people with cancer. ASCO and the Association of Community Cancer Centers collaborated on a quality improvement study to enhance racial and ethnic equity, diversity, and inclusion (EDI) in cancer clinical trials. The groups conducted a pilot study to examine the feasibility, utility, and face validity of a two-part clinical trial site self-assessment to enable diverse types of research sites in the United States to (1) review internal data to assess racial and ethnic disparities in screening and enrollment and (2) review their policies, programs, procedures to identify opportunities and strategies to improve EDI. Overall, 81% of 62 participating sites were satisfied with the assessment; 82% identified opportunities for improvement; and 63% identified specific strategies and 74% thought the assessment had potential to help their site increase EDI. The assessment increased awareness about performance (82%) and helped identify specific strategies (63%) to increase EDI in trials. Although most sites (65%) were able to provide some data on the number of patients that consented, only two sites were able to provide all requested trial screening, offering, and enrollment data by race and ethnicity. Documenting and evaluating such data are critical steps toward improving EDI and are key to identifying and addressing disparities more broadly. ASCO and Association of Community Cancer Centers will partner with sites to better understand their processes and the feasibility of collecting screening, offering, and enrollment data in systematic and automated ways.

Use of Machine Learning and Lay Care Coaches to Increase Advance Care Planning Conversations for Patients With Metastatic Cancer

PURPOSE

Patients with metastatic cancer benefit from advance care planning (ACP) conversations. We aimed to improve ACP using a computer model to select high-risk patients, with shorter predicted survival, for conversations with providers and lay care coaches. Outcomes included ACP documentation frequency and end-of-life quality measures.

METHODS

In this study of a quality improvement initiative, providers in four medical oncology clinics received Serious Illness Care Program training. Two clinics (thoracic/genitourinary) participated in an intervention, and two (cutaneous/sarcoma) served as controls. ACP conversations were documented in a centralized form in the electronic medical record. In the intervention, providers and care coaches received weekly e-mails highlighting upcoming clinic patients with < 2 year computer-predicted survival and no prior prognosis documentation. Care coaches contacted these patients for an ACP conversation (excluding prognosis). Providers were asked to discuss and document prognosis.

RESULTS

In the four clinics, 4,968 clinic visits by 1,251 patients met inclusion criteria (metastatic cancer with no prognosis previously documented). In their first visit, 28% of patients were high-risk (< 2 year predicted survival). Preintervention, 3% of both intervention and control clinic patients had ACP documentation during a visit. By intervention end (February 2021), 35% of intervention clinic patients had ACP documentation compared with 3% of control clinic patients. Providers' prognosis documentation rate also increased in intervention clinics after the intervention (2%-27% in intervention clinics, P < .0001; 0%-1% in control clinics). End-of-life care intensity was similar in intervention versus control clinics, but patients with ≥ 1 provider ACP edit met fewer high-intensity care measures (P = .04).

CONCLUSION

Combining a computer prognosis model with care coaches increased ACP documentation.

Health Care Professionals' Perspectives on Implementation, Adoption, and Maintenance of a Community Health Worker-Led Advance Care Planning and Cancer Symptom Screening Intervention: A Qualitative Study

PURPOSE

Advance care planning (ACP) and symptom screening are nationally recommended for all patients with advanced stages of cancer. Yet, routine delivery of such care remains challenging because of multilevel barriers. We hired and trained community health workers (CHWs) to assist with delivery of these services across the United States. The aim of this study was to explore health care professionals' perspectives on barriers and facilitators to these team-based approaches.

METHODS

We conducted semistructured interviews with 44 health care professionals in 21 cancer clinics in seven US cities using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We recorded, transcribed, and analyzed interviews using the framework analysis approach.

RESULTS

Participants noted barriers and facilitators to implementation, adoption, and maintenance of CHW-led ACP and symptom management approaches. Participants were initially skeptical; however, they noted a positive shift in their views over time because of personal experiences and effectiveness in their clinics. There was significant variation in adoption with some using a prescriptive top-down approach and others a bottom-up approach. Most agreed that the combination of top-down and bottom-up approaches would be most efficient and effective for promoting team-based care. All participants discussed implementation and provided suggestions for maintenance including organizational support, leadership, and CHW retention.

CONCLUSION

CHW-led ACP and proactive symptom management interventions are effective and accepted by cancer care professionals at scale. Tailoring on the basis of organization and local contexts is required to ensure successful adoption, implementation, and maintenance of these effective team-based care delivery approaches.

Exploring cancer care needs for Latinx adults: a qualitative evaluation

PURPOSE

Latinx adults with cancer, as compared with non-Latinx White adults, are diagnosed with more advanced stages and experience worse quality of life. Identifying barriers in cancer care among low-income Latinx adults is crucial to designing and implementing culturally appropriate interventions. The objective of this study was to explore the specific barriers encountered by Latinx adults after a cancer diagnosis and perspectives on the use of community health workers (CHWs) to address these barriers.

METHODS

We conducted semi-structured qualitative interviews with low-income Latinx adults with a past or current history of cancer and/or their caregivers in a community oncology clinic located in an agricultural community in California. Analysis was based in grounded theory and performed using the constant comparative method.

RESULTS

Sixteen interviews were conducted with patients alone (n = 11), a caregiver alone (n = 1), and patient-caregiver pairs (n = 4 patients; n = 4 caregivers). Four major themes emerged: (1) low cancer health literacy including cancer diagnosis and treatment, cancer fatalism, navigating next steps after diagnosis, advance directives, and precision medicine; (2) challenges in communicating and receiving supportive services due to language barriers; (3) stress and anxiety regarding financial hardships related to job loss, insurance barriers, and the COVID-19 pandemic; (4) the need for supportive, bilingual, and bicultural personnel to assist in overcoming these challenges.

CONCLUSIONS

Low-income Latinx adults with cancer and their caregivers experience health literacy, communication, and financial barriers that impede quality cancer care delivery. Embedding CHWs in the care team could be one way to address these barriers to culturally concordant, accessible care.

Understanding the barriers and experiences of veterans with lung cancer

160

Background: Veteran populations have higher lung cancer incidence and lower overall survival rates than non-veterans. Despite clinical advancements in lung cancer which reduce lung cancer death rates and access to care, many Veterans face barriers in receipt of such guideline-based care due to many factors including complex comorbidities, low health literacy, and significant economic and social disadvantages. In fact, the underrepresentation of Veterans in clinical trials confer even more difficulty to ensure cancer treatment and prognosis thoughtfully considers their unique challenges and needs. Few studies have evaluated Veterans’ perspectives regarding unmet needs and potential solutions to address equitable care delivery among these populations. The objective of this study was to evaluate Veterans’ perspectives regarding their lung cancer care to identify modifiable barriers that could be addressed to improve care. Methods: We conducted semi-structured interviews with fourteen Veterans diagnosed with lung cancer at the VA Palo Alto Health Care System. All interviews were recorded, transcribed and analyzed interviews using the constant comparative method of qualitative analysis. Results: All participants noted the main barrier to lung cancer care was transportation with inadequate financial coverage for gas and extensive commutes that contributed to significant anxiety and stress regarding their cancer care. Participants noted challenges in navigating the health system and suggested better understanding of the structure and function of cancer care team members to overcome these barriers. Participants noted difficulty comprehending and interpreting their cancer prognosis and were unaware of advance directives. All participants were unaware of precision medicine, namely molecular tumor testing or genomic cancer sequencing and its implications on their treatments. Conclusions: This study revealed critical gaps in lung cancer among Veterans in one VA facility. Targeted solutions should be considered to address barriers identified which include transportation access, proactive distress management, and knowledge regarding lung cancer care delivery.

Assessing the needs of those who serve the underserved: A national survey among cancer care clinicians

175

Background: In 2009, ASCO confirmed that addressing cancer care disparities is critical for the Society and committed to approaches to eliminate such disparities. Yet, gaps remain in identifying the best approaches to do so. It remains unknown which cancer care providers serve patients from “underserved populations'' (defined as individuals who have historically received inadequate health care and health care services), what unmet needs they experience in their cancer care delivery, and how best to engage and support these providers. The objectives of this study were to explore challenges faced by providers serving underserved patients to inform development of a broader online survey and identify solutions that ASCO can implement to better support these providers. Methods: A multi-phase mixed-methods approach was utilized. Phase 1 involved key informant semi-structured interviews with 12 oncology providers caring for adult patients in the US from April to May 2021. Phase 2 involved survey development based on themes identified in Phase 1. The survey assessed: provider needs; processes for eliciting, documenting, and addressing social and economic needs of patients; and how ASCO could best support these providers. Phase 3 involved email distribution of the online survey in May 2022 to 5800 individuals identified through ASCO’s customer database. Eligibility criteria included providing care for adults with cancer in the US and prior consent to receive ASCO survey communications. Results: Of 477 respondents, the majority were ASCO members (88%), in an academic practice (57%), medical oncologists (77%), non-Hispanic (89%) and/or Caucasian/White (67%) and had > 15 years’ clinical experience (57%). A majority (60%) provided ≥25% of their clinical time providing cancer care to underserved populations and routinely engaged with administration to secure resources (61%) and local community organizations to obtain services (42%) for patients. Most (43-77%) indicated that a social worker/case manager was primarily responsible for addressing patient social needs. The majority reported that identification and dissemination of best practices (55%) and development of a return-on-investment business model (60%) would best help address patient needs. Some respondents expressed a desire to collaborate with ASCO on policy reform (32%) and for ASCO to help build or strengthen partnerships with local initiatives (29%). Conclusions: This is the first US-based survey assessing barriers and solutions to delivering cancer care among underserved populations. The findings from this work provide insights about how ASCO can help equip practices to address the social needs of their patients. Further work will be conducted to develop and implement suggested solutions.

Acute care utilization at the end of life: Does race/ethnicity matter?

189

Background: Lung cancer is the leading cause of US cancer deaths. Providing high quality care near end-of-life (EOL) is critical. Hispanic and Black patients with cancer receive less palliative and hospice care referrals and have less knowledge of advance directives compared to non-Hispanic Whites. While it is posited that such inequities can result in disparities in acute care use and goal-discordant care at the EOL among racial/ethnic minority populations, few studies have evaluated whether acute care utilization at the EOL for patients with lung cancer differs by race/ethnicity. Methods: Adult patients with a lung cancer diagnosis who died between 2005-2019 were identified in the California Cancer Registry database linked to a hospital discharge abstracts from the Office of Statewide Health Planning and Development. ICD9/10 codes were used to identify aggressive EOL care defined as: hospital/ED visit, death, intubation, CPR, and dialysis within 14-days of death. Logistic regression models estimated the odds of such care by race and ethnicity. Models were adjusted in apriori considerations of age, income, socioeconomic status, insurance, geography, histology, stage, comorbidities, and care receipt at NCI-designated hospitals. Results: Among 207,429 patients included, mean age was 74 years, 51% were male, 83.6% lived in urban areas, 28% had income 200% below Federal Poverty Level, 48.8% had Medicare, 91.8% received care in a non-NCI designated cancer center and 48.3% had stage IV disease. Black, Hispanic and Asian/Pacific Islander patients compared to Non-Hispanic Whites had increased odds of aggressive EOL care (See Table). Conclusions: This study demonstrates disparities in acute care use and aggressive care delivery among racial and ethnic minorities with lung cancer at the EOL. Solutions are urgently needed to reduce such disparities in care.[Table: see text]

Community health workers and precision medicine: A randomized controlled trial

BACKGROUND

Precision cancer care has reduced cancer-related mortality. However, minorities remain less likely to receive precision medicine than White populations with cancer due to language and system-level barriers. Precision medicine knowledge increases involvement in treatment decisions and receipt of such treatment. Few interventions exist that seek to improve precision medicine knowledge among low-income and racial and ethnic minorities with cancer.

METHODS

We designed a randomized controlled trial to evaluate the effectiveness of a community health worker (CHW)-delivered intervention on patients' knowledge of precision medicine in partnership with a community oncology clinic in Monterey County, California. Eligibility includes adults with newly diagnosed, progression or recurrence of cancer, low-income, or racial and ethnic minorities, or uninsured, insured by Medicaid or by a local agricultural employer. We will randomize 110 patients with cancer to the intervention or usual cancer care. The intervention group will be assigned to a CHW who will deliver culturally tailored and personalized education on precision medicine and advance care planning, screen for social determinants of health barriers and connect patients to community resources. The primary outcome is precision medicine knowledge measured by a 6-item survey adapted from Davies at baseline, 3-, 6- and 12-months post-enrollment. Exploratory outcomes include patient satisfaction with decision, activation, health care utilization, and receipt of evidence-based precision medicine care.

CONCLUSION

This trial will assess whether the CHW-led intervention can increase knowledge of precision medicine as well as several exploratory outcomes including receipt of evidence-based cancer care among low-income and racial and ethnic minority adults with cancer.

CLINICALTRIALS

gov Registration # NCT04843332.

Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer: A Randomized Clinical Trial

Importance

Deficiencies in advance care planning and symptom management are associated with avoidable acute care use among patients with cancer. Community health worker (CHW)-led approaches may be an approach to reduce acute care use but remain untested in community settings.

Objective

To determine whether a CHW-led advance care planning and symptom screening intervention can reduce acute care use more than usual care in a community setting.

Design, Setting, and Participants

This randomized clinical trial was conducted among patients with newly diagnosed advanced-stage or recurrent solid and hematologic cancers from August 8, 2017, through November 30, 2021. Data analysis was performed November 30, 2021, through January 1, 2022, by intention to treat.

Interventions

Participants were randomized 1:1 to usual care (control group) or usual care with the 6-month CHW-led intervention (intervention group).

Main Outcomes and Measures

The primary outcome was acute care use. Secondary outcomes included advance care planning documentation, supportive care use, patient-reported outcomes, survival, and end-of-life care use.

Results

Among 128 participants, median (range) age was 67 (19-89) years; 61 (47.7%) were female; and 2 (1.6%) were American Indian or Alaska Native, 11 (8.6%) were Asian, 5 (3.9%) were Black, 23 (18.0%) were Hispanic or Latino, 2 (1.6%) were of mixed race, 2 (1.6%) were Native Hawaiian or other Pacific Islander, 86 (67.2%) were White, and 20 (15.6%) did not report race. Intervention participants had 62% lower risk of acute care use than the control (hazard ratio, 0.38; 95% CI, 0.19-0.76) within 6 months. At 12 months, intervention participants had 17% lower odds of acute care use (odds ratio [OR], 0.83; 95% CI, 0.69-0.98), 8 times the odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times the odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), nearly double the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and nearly double the odds of improved mental and emotional health from enrollment to 6 and 12 months postenrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4.65, respectively) than the control. There were no differences in the death (control, 26 [40.6%] vs intervention, 32 [50.0%]). Fewer intervention participants had acute care use (0 vs 6 [23.1%]) in the month before death than the control.

Conclusions and Relevance

In this randomized clinical trial, integration of a CHW-led intervention into cancer care reduced acute care use and is one approach to improve cancer care delivery for patients with advanced stages of disease in community settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT03154190.

Perspectives of Low-Income and Minority Populations With Lung Cancer: A Qualitative Evaluation of Unmet Needs

PURPOSE:

Lung cancer is the second most common cancer and the leading cause of cancer death in the United States. Persistent disparities remain in the incidence, mortality, and quality of lung cancer care received among minorities and populations with low income. This study aims to evaluate perspectives of low-income and minority patients with lung cancer on health system–level barriers and facilitators to high-quality lung cancer care delivery.

METHODS:

Informed by community-based participatory research, we conducted semistructured interviews with 48 patients with lung cancer in the San Francisco Peninsula and Central Coast regions of California. We recorded, transcribed, and analyzed interviews using thematic analysis.

RESULTS:

Participants described four major structural and process barriers in current lung cancer care: unmet psychosocial support needs, lack of understanding of precision medicine, undertreated symptoms, and financial concerns about cancer, which exacerbate concerns regarding families' well-being. Participants described that trusting relationship with their cancer care team members was a facilitator for high-quality care and suggested that proactive integration of proactive psychosocial and community-based peer support could overcome some of the identified barriers.

CONCLUSION:

This study identified modifiable health system lung cancer care delivery barriers that contribute to persistent disparities. Opportunities to improve care include integration of community-based peer support.

Do no harm: A call to action on COVID-19 and mask requirements

The COVID‐19 pandemic has challenged physicians in all specialties over the past 2 years. Continued harms caused by policies, or lack thereof, should promote those of us in the cancer field to lead by example.

Patient perspectives on window of opportunity clinical trials in early-stage breast cancer

PURPOSE

Window of opportunity trials (WOT) are increasingly common in oncology research. In WOT participants receive a drug between diagnosis and anti-cancer treatment, usually for the purpose of investigating that drugs effect on cancer biology. This qualitative study aimed to understand patient perspectives on WOT.

METHODS

We recruited adults diagnosed with early-stage breast cancer awaiting definitive therapy at a single-academic medical center to participate in semi-structured interviews. Thematic and content analyses were performed to identify attitudes and factors that would influence decisions about WOT participation.

RESULTS

We interviewed 25 women diagnosed with early-stage breast cancer. The most common positive attitudes toward trial participation were a desire to contribute to research and a hope for personal benefit, while the most common concerns were the potential for side effects and how they might impact fitness for planned treatment. Participants indicated family would be an important normative factor in decision-making and, during the COVID-19 pandemic, deemed the absence of family members during clinic visits a barrier to enrollment. Factors that could hinder participation included delay in standard treatment and the requirement for additional visits or procedures. Ultimately, most interviewees stated they would participate in a WOT if offered (N = 17/25).

CONCLUSION

In this qualitative study, interviewees weighed altruism and hypothetical personal benefit against the possibility of side effect from a WOT. In-person family presence during trial discussion, challenging during COVID-19, was important for many. Our results may inform trial design and communication approaches in future window of opportunity efforts.

Racial and Ethnic Disparities in Cancer Care During the COVID-19 Pandemic

IMPORTANCE

The full effect of the COVID-19 pandemic on cancer care disparities, particularly by race and ethnicity, remains unknown.

OBJECTIVES

To assess whether the race and ethnicity of patients with cancer was associated with disparities in cancer treatment delays, adverse social and economic effects, and concerns during the COVID-19 pandemic and to evaluate trusted sources of COVID-19 information by race and ethnicity.

DESIGN, SETTING, AND PARTICIPANTS

This national survey study of US adults with cancer compared treatment delays, adverse social and economic effects, concerns, and trusted sources of COVID-19 information by race and ethnicity from September 1, 2020, to January 12, 2021.

EXPOSURES

The COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES

The primary outcome was delay in cancer treatment by race and ethnicity. Secondary outcomes were duration of delay, adverse social and economic effects, concerns, and trusted sources of COVID-19 information.

RESULTS

Of 1639 invited respondents, 1240 participated (75.7% response rate) from 50 US states, the District of Columbia, and 5 US territories (744 female respondents [60.0%]; median age, 60 years [range, 24-92 years]; 266 African American or Black [hereafter referred to as Black] respondents [21.5%]; 186 Asian respondents [15.0%]; 232 Hispanic or Latinx [hereafter referred to as Latinx] respondents [18.7%]; 29 American Indian or Alaska Native, Native Hawaiian, or multiple races [hereafter referred to as other] respondents [2.3%]; and 527 White respondents [42.5%]). Compared with White respondents, Black respondents (odds ratio [OR], 6.13 [95% CI, 3.50-10.74]) and Latinx respondents (OR, 2.77 [95% CI, 1.49-5.14]) had greater odds of involuntary treatment delays, and Black respondents had greater odds of treatment delays greater than 4 weeks (OR, 3.13 [95% CI, 1.11-8.81]). Compared with White respondents, Black respondents (OR, 4.32 [95% CI, 2.65-7.04]) and Latinx respondents (OR, 6.13 [95% CI, 3.57-10.53]) had greater odds of food insecurity and concerns regarding food security (Black respondents: OR, 2.02 [95% CI, 1.34-3.04]; Latinx respondents: OR, 2.94 [95% CI, [1.86-4.66]), financial stability (Black respondents: OR, 3.56 [95% CI, 1.79-7.08]; Latinx respondents: OR, 4.29 [95% CI, 1.98-9.29]), and affordability of cancer treatment (Black respondents: OR, 4.27 [95% CI, 2.20-8.28]; Latinx respondents: OR, 2.81 [95% CI, 1.48-5.36]). Trusted sources of COVID-19 information varied significantly by race and ethnicity.

CONCLUSIONS AND RELEVANCE

In this survey of US adults with cancer, the COVID-19 pandemic was associated with treatment delay disparities and adverse social and economic effects among Black and Latinx adults. Partnering with trusted sources may be an opportunity to overcome such disparities.

A Community-Engaged Process for Adapting a Proven Community Health Worker Model to Integrate Precision Cancer Care Delivery for Low-income Latinx Adults With Cancer

INTRODUCTION

Disparities in precision cancer care delivery among low-income Latinx adults are well described. In prior work, we developed a community health worker-led goals of care and cancer symptom assessment intervention. The objective of this study was to adapt this intervention for a community setting, incorporating precision cancer care delivery.

METHODS

We used a two-phased systematic approach to adapt an evidence-based intervention for our community. Specifically, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify barriers and facilitators to precision cancer care delivery via 1-hr interviews with Latinx adults with cancer, Latinx caregivers, community leaders, primary care and oncology clinicians, and community health workers. Interviews were recorded, transcribed, and analyzed using the constant comparative method and grounded theory analysis. Phase 2 involved interviews with key community advisors using the Expert Panels Method to decide on final adaptations.

RESULTS

Using this community-engaged approach, we identified specific intervention adaptations to ensure precision cancer care delivery in a community setting, which included: (a) expansion of the intervention inclusion criteria and mode of delivery; (b) integration of low-literacy precision cancer care intervention activities in Spanish in collaboration with community-based organizations; (c) ensuring goals reflective of patient and community priorities.

CONCLUSIONS

This systematic and community-engaged approach to adapt an intervention for use in delivering precision cancer care strengthened an evidence-based approach to promote the needs and preferences of patients and key community stakeholders.

Addressing Latinx CANcer Care Equity (ALCANCE) randomized controlled trial: Precision medicine and community health workers

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Background: Cancer mortality has declined over the past decade due to clinical advances including precision medicine. Despite these clinical advancements, low-income and racial/ethnic minorities experience worse cancer morbidity and mortality. Specifically, these populations have lower rates of genomic testing and are significantly underrepresented in precision medicine research. Community-based, culturally tailored approaches are needed to address these ongoing disparities. The objective of this randomized controlled trial is to test whether a community health worker (CHW)-led intervention can improve patient understanding of precision medicine topics and delivery of evidence-based cancer care more than usual cancer care alone. Methods: We developed a county-wide cancer care initiative and a community advisory board (CAB) comprised of patient, caregiver, payer, clinician, and governmental stakeholders in Monterey County—comprised of 60% Latinx, non-English speaking, immigrant populations. As guided by the CAB, we developed a CHW-model to provide education on precision medicine and screen for complications of social determinants of health in 1:1 discussions with patients. In collaboration with a local community oncology clinic, we plan to randomize 110 patients with cancer who are receiving active treatment into usual care or usual care plus the CHW-led intervention. Inclusion criteria includes patients who are: 1) 18 years of age or older; 2) racial/ethnic minorities; 3) low-income; 4) uninsured or insured by Medicaid and/or local agricultural employers; and 5) speak English or Spanish. Exclusion criteria includes: 1) lack capacity to consent to study procedures; 2) plan to move from the area within a year. We will measure the effect of the intervention on patient knowledge of precision medicine using a survey adapted from Davies et al. Secondary outcomes include effect on health-related quality of life using the Functional Assessment of Cancer Therapy – General, patient activation using the Patient Activation Measure, satisfaction using the Satisfaction with Decision Scale, prognosis and treatment preferences using an adapted survey by Weeks et al., healthcare utilization, and receipt of evidence-based cancer care. We will administer surveys at baseline, 3-, 6- and 12-months post-enrollment. To date, 67 participants have been enrolled. This study will show if CHW-models increase knowledge of precision medicine in this population. Clinical trial information: NCT04843332.

Improving supportive care for patients with thoracic cancer

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Background: Improving lung cancer care among Veterans is a priority within the Veterans Affairs due to higher rates of lung cancer incidence, morbidity, and mortality among Veterans compared to non-veterans. Unaddressed symptom burden is common due to many factors including complex comorbidities, psychosocial challenges, smoking history and limited social support networks. Additionally, complications from social determinants of health can obstruct successful discussions of symptom-burden between Veterans and their clinical care teams which can limit compliance with recommended symptom management strategies. To overcome these barriers, we conducted a randomized controlled trial to test the effectiveness of a lay volunteer-led proactive symptom assessment and symptom intervention. The objective was to determine if the intervention improved clinician documentation from baseline to 6-months post-enrollment compared to usual care. Secondary outcomes included change in patient activation, health-related quality of life (HrQOL), and symptom-burden. Methods: Patients were randomized into the lay volunteer proactive symptom assessment intervention plus usual cancer care (intervention group) or usual cancer care alone (control group). We conducted electronic health record review to assess primary cancer-clinician symptom documentation of Veterans’ symptoms identified as moderate-to-severe at baseline and 6-months using the Edmonton Symptom Assessment Scale. Patient surveys with validated assessments were used to assess patient activation, HrQOL and symptom burden at baseline (time of enrollment) and 6-months post-enrollment. We used regression models to evaluate differences in our primary and secondary outcomes. Results: 60 Veterans were consented and randomized into the study (29 control; 31 intervention). There were no differences in demographic or clinical factors across groups. The median age was 70 years (range 56-85), 95% were male, 70% identified their race as White, 53% were married and 48% had a 2-year or 4-year college degree. The majority had at least 3 comorbidities (54%), diagnosed with stage 3 or 4 (62%) and received systemic treatment with chemotherapy and/or radiation (77%). At 6-months post-enrollment as compared to baseline, the intervention group had greater improvements in symptom documentation (56% from 12.5% vs. 29% from 43%, p = 0.01), greater improvements in patient activation (p<0.001), HrQOL (<0.001), and lower symptom burden (p<0.001) than the control group. Conclusions: Integration of proactive symptom assessment by lay volunteers has a significant and meaningful effect on symptom documentation, patient activation, quality of life, and reducing symptom burden among Veterans with lung cancer. Clinical trial information: NCT03216109.

Availability of data for screening, offering, and consenting patients to cancer clinical trials: Report from an ASCO-ACCC collaboration

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Background: Only a small fraction of patients with cancer participate in treatment trials. Patients identifying as members of racial and ethnic minority groups are consistently underrepresented in these trials. A recent systematic review reported that patients, regardless of race and ethnicity, are willing to enroll in trials if asked to participate by their treating clinician. Prospective and longitudinal data and metrics at the site- and clinician-level are necessary to understand whether patients are equitably considered for clinical trials. Methods: ASCO and Association of Community Cancer Centers (ACCC) developed a self-assessment for trial sites to record and gauge the number of patients across races and ethnicities screened, offered, and enrolled into clinical trials. Research sites, from across the US, were recruited through an open call to apply to participate in the ASCO-ACCC Pilot Project. There were 65 sites assigned to this pilot study, which tested the feasibility and utility of the site assessment. Sites were asked to enter 2019 and 2020 aggregate data for each step along the clinical trial enrollment continuum by select races and ethnicities (Black, Hispanic/Latinx, White) and overall. Results: 62 of 65 sites completed the study and represented a range of settings and practice types (61% academic, 26% hospital/health system, 13% independent). Only 2 sites (3%) were able to provide the data requested at each enrollment step in the assessment (table). Sites that collected the data did not do so routinely (table) and most had to compile data through multiple sources and/or manual extraction (40-100% across enrollment steps). Sites with missing data reported they did not collect data at all (36-64% across enrollment steps), did not collect data in a systematic way (0-29% across enrollment steps), or stated it would be too burdensome to manually review charts to extract data (12-29% across enrollment steps). Conclusions: Data collection and routine evaluation of participation metrics, by race and ethnicity, are necessary to assess and monitor equity and diversity in clinical trials. Most sites in this study did not collect, or routinely collect, data for screening, offering, and consenting patients to clinical trials. Without these data, sites are unable to evaluate and monitor whether their patients have equitable access to clinical trials or establish strategies to address any inequities. ASCO and ACCC will continue to partner with sites to better understand their processes and the feasibility of collecting such data in a systematic and automated way, such as through electronic health record systems. [Table: see text]

The effect of a multilevel community health worker-led intervention on health-related quality of life, patient activation, acute care use, and total costs of care: A randomized controlled trial

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Background: Low-income and minority populations have less activation in their cancer care, lower health-related quality of life, greater acute care use and total costs of care than affluent and white populations. Community-based interventions are needed to improve patient experiences and quality of cancer care equitably among these populations. We used community-based participatory methods to refine a previously tested intervention for use in urban communities. The intervention, LEAPS, uses community health workers trained to activate patients in discussions with their cancer clinicians regarding advance care planning and symptom-burden and to connect patients with community-based resources to overcome social determinants of health. We conducted a randomized controlled trial of LEAPS in collaboration with an employer-union health plan in Atlantic City, NJ and Chicago, IL. Members of the employer-union health plan with newly diagnosed with hematologic and solid tumor cancers were randomized to the 6-month LEAPS intervention. The objective of the study was to determine whether LEAPS improved quality of life (primary). Secondarily, we evaluated the effect of LEAPS on patient activation, acute care use, and total costs of care. Methods: We used generalized linear regression models to evaluate differences in quality of life and patient activation scores between groups from baseline to 4- and 12-months post-enrollment and regression models offset for length of follow-up to compare emergency department use, hospitalizations, and total costs of care. Results: A total of 160 patients were consented and randomized into the study (80 intervention; 80 control). There were no differences in demographic or clinical factors across groups. The majority were non-White (74%), female (53%), mean age 57 years with breast (31%) or lung cancer (21%) and Stage 3 or 4 (63%) disease. At 4- and 12-months follow-up, the intervention group had greater improvements in quality of life overtime as compared to the control group (difference in difference: 11.5 p < 0.001) and greater change in patient activation overtime (difference in difference: 11.9 (p < 0.001)). At 12-months follow-up there were no differences in emergency department use (0.44 (0.71) versus 0.73 (0.22) p = 0.22) however intervention group participants had fewer hospitalizations (1.55 (0.86) vs. 2.29 (1.31), p = 0.002) and lower median total costs of care ($72,585 vs. $153,980, p = 0.04). Conclusions: Integrating community-based interventions into clinical cancer care delivery for low-income and minority populations can significantly improve patient activation, reduce hospitalizations and total costs of care. These interventions may represent a sustainable resource to facilitate equitable, value-based cancer care. Clinical trial information: NCT03699748.

Increasing Racial and Ethnic Diversity in Cancer Clinical Trials: An American Society of Clinical Oncology and Association of Community Cancer Centers Joint Research Statement

A concerted commitment across research stakeholders is necessary to increase equity, diversity, and inclusion (EDI) and address barriers to cancer clinical trial recruitment and participation. Racial and ethnic diversity among trial participants is key to understanding intrinsic and extrinsic factors that may affect patient response to cancer treatments. This ASCO and Association of Community Cancer Centers (ACCC) Research Statement presents specific recommendations and strategies for the research community to improve EDI in cancer clinical trials. There are six overarching recommendations: (1) clinical trials are an integral component of high-quality cancer care, and every person with cancer should have the opportunity to participate; (2) trial sponsors and investigators should design and implement trials with a focus on reducing barriers and enhancing EDI, and work with sites to conduct trials in ways that increase participation of under-represented populations; (3) trial sponsors, researchers, and sites should form long-standing partnerships with patients, patient advocacy groups, and community leaders and groups; (4) anyone designing or conducting trials should complete recurring education, training, and evaluation to demonstrate and maintain cross-cultural competencies, mitigation of bias, effective communication, and a commitment to achieving EDI; (5) research stakeholders should invest in programs and policies that increase EDI in trials and in the research workforce; and (6) research stakeholders should collect and publish aggregate data on racial and ethnic diversity of trial participants when reporting results of trials, programs, and interventions to increase EDI. The recommendations are intended to serve as a guide for the research community to improve participation rates among people from racial and ethnic minority populations historically under-represented in cancer clinical trials. ASCO and ACCC will work at all levels to advance the recommendations in this publication.

Improving supportive care for patients with Thoracic Malignancies – A randomized controlled trial

Veterans have higher lung cancer incidence and mortality rates than civilians. Frequently, Veterans with lung cancer suffer from undertreated symptoms due to complex comorbidities, limited social support, and reluctance in discussing symptoms with their oncologists. Evidence supports proactive symptom screening among civilians with cancer; however, no studies to date have evaluated whether Veteran volunteer-led proactive symptom screening is feasible and effective among Veterans with lung cancer.

The “Improving Supportive Care for Patients with Thoracic Malignancies” study was co-developed by a pre-established Veteran and Family Advisory Board. Veterans with lung cancer are randomized in a 1:1 allocation to either a 9-month intervention combined with usual oncology care (intervention group) or usual oncology care alone (control group). A Veteran volunteer is assigned to all Veterans in the intervention group and conducts weekly symptom assessments using validated symptom surveys and reviews all symptom scores with an oncology nurse practitioner. The primary outcome is to evaluate whether the intervention improves documentation of symptoms at 6 months post-enrollment among Veterans in the intervention group as compared with the control group. Secondary outcomes include changes in patient-reported outcomes (i.e., symptom burden, patient activation, patient satisfaction with decision, health-related quality of life) and differences in acute care use (i.e., emergency department visits, hospitalizations) from baseline (time of enrollment in the study) to 3-, 6-, and 9-months post enrollment.

This study addresses a significant concern expressed by Veterans and their caregivers. Findings can advance our understanding of how to improve symptom-burden among Veterans with lung cancer.

ClinicalTrials.gov Registration #NCT03216109.

The evolving landscape of sex-based differences in lung cancer: a distinct disease in women

In stark contrast to a few decades ago when lung cancer was predominantly a disease of men who smoke, incidence rates of lung cancer in women are now comparable to or higher than those in men and are rising alarmingly in many parts of the world. Women face a unique set of risk factors for lung cancer compared to men. These include exogenous exposures including radon, prior radiation, and fumes from indoor cooking materials such as coal, in addition to endogenous exposures such as oestrogen and distinct genetic polymorphisms. Current screening guidelines only address tobacco use and likely underrepresent lung cancer risk in women. Women were also not well represented in some of the landmark prospective studies that led to the development of current screening guidelines. Women diagnosed with lung cancer have a clear mortality benefit compared to men even when other clinical and demographic characteristics are accounted for. However, there may be sex-based differences in outcomes and side effects of systemic therapy, particularly with chemotherapy and immunotherapy. Ongoing research is needed to better investigate these differences to address the rapidly changing demographics of lung cancer worldwide.

Sex-based differences in lung cancer span the care continuum. This suggests lung cancer may increasingly be viewed as a distinct disease in women, with implications for screening and treatment. Lung cancer research should capture these sex-based differences.https://bit.ly/2WfhaB4

Incidence of Lung Cancer Among Never-Smoking Asian American, Native Hawaiian, and Pacific Islander Females

BACKGROUND

Although lung cancer incidence rates according to smoking status, sex, and detailed race/ethnicity have not been available, it is estimated that more than half of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females with lung cancer have never smoked.

METHODS

We calculated age-adjusted incidence rates for lung cancer according to smoking status and detailed race/ethnicity among females, focusing on AANHPI ethnic groups, and assessed relative incidence across racial/ethnic groups. We used a large-scale dataset that integrates data from electronic health records from 2 large health-care systems-Sutter Health in Northern California and Kaiser Permanente Hawai'i-linked to state cancer registries for incident lung cancer diagnoses between 2000 and 2013. The study population included 1 222 694 females (n = 244 147 AANHPI), 3297 of which were diagnosed with lung cancer (n = 535 AANHPI).

RESULTS

Incidence of lung cancer among never-smoking AANHPI as an aggregate group was 17.1 per 100 000 (95% confidence interval [CI] = 14.9 to 19.4) but varied widely across ethnic groups. Never-smoking Chinese American females had the highest rate (22.8 per 100 000, 95% CI = 17.3 to 29.1). Except for Japanese American females, incidence among every never-smoking AANHPI female ethnic group was higher than that of never-smoking non-Hispanic White females, from 66% greater among Native Hawaiian females (incidence rate ratio = 1.66, 95% CI = 1.03 to 2.56) to more than 100% greater among Chinese American females (incidence rate ratio = 2.26, 95% CI = 1.67 to 3.02).

CONCLUSIONS

Our study revealed high rates of lung cancer among most never-smoking AANHPI female ethnic groups. Our approach illustrates the use of innovative data integration to dispel the myth that AANHPI females are at overall reduced risk of lung cancer and demonstrates the need to disaggregate this highly diverse population.

Abstract IA-21: Applying a data integrative and convergence epidemiology approach to study multilevel risk factors for cancer in distinct AANHPI populations

Background: For Asian American, Native Hawaiian and Pacific Islander (AANHPI) females, lung cancer is one of the most common cancers and the leading cause of cancer death. More than half of lung cancers among AANHPI females occur among never-smokers, but incidence rates of lung cancer according to smoking status have not been available. Purpose: With a large, integrated dataset of electronic health record data from two healthcare systems—Sutter Health in Northern California and Kaiser Permanente Hawai'i—linked to state cancer registry data on incident lung cancer diagnoses 2000-2013, we describe incidence of lung cancer according to smoking status among females across detailed race and ethnicity. Methods: We calculated age-adjusted incidence rates for lung cancer according to smoking status and detailed race and ethnicity among females, focusing on AANHPI ethnic groups, and assessed relative incidence across racial and ethnic groups. The study population included N=1,222,694 females (n=244,147 AANHPI), n=3,297 (n=535) of whom were diagnosed with lung cancer. We examined relative incidence across group defined by detailed race and ethnicity. We also provided incidence of lung cancer among AANHPI males who never smoked in a supplement. Results: Among AANHPI female groups, proportions of lung cancers among never-smokers ranged from 25% among Native Hawaiian to 80% among Chinese females. Incidence of lung cancer among never-smoking AANHPI females as an aggregate was 17.1 per 100,000 (95% CI: 14.9, 19.4), but rates varied widely across ethnic groups. Never-smoking Chinese females had the highest rate (22.8; 95% CI: 17.3, 29.1). Except for Japanese females, incidence among every never-smoking AANHPI female ethnic group was higher than that of all never-smoking females combined. Never-smoking AANHPI males also have higher incidence of lung cancer compared to other groups defined by race and ethnicity. Conclusions: The integrative data analysis approach offers great advantages over traditional cancer cohorts, but it does require substantial time and effort to assure data confidentiality, integrity, and transparency to provide robust results. However, with convergence epidemiology—in this case leveraging needed expertise in data science and analysis to answer an epidemiology question—it is also a valuable approach to study disparate cancer outcomes among small populations. Illustrating this, our study is the first to document high rates of lung cancer among never-smoking AANHPI ethnic groups, dispels the myth that AANHPI females are at overall reduced risk of lung cancer, and demonstrates the need to disaggregate this highly diverse population. Results should inform lung cancer prevention strategies among AANHPI populations.

Citation Format: MIndy C. DeRouen, Alison J. Canchola, Caroline A. Thompson, Anqi Jin, Sixiang Nie, Carmen Wong, Daphne Lichtensztajn, Laura Allen, Manali I. Patel, Yihe G. Daida, Harold S. Luft, Salma Shariff-Marco, Peggy Reynolds, Heather A. Wakelee, Su-Ying Liang, Beth E. Waitzfelder, Iona Cheng, Scarlett L. Gomez. Applying a data integrative and convergence epidemiology approach to study multilevel risk factors for cancer in distinct AANHPI populations [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA-21.

The Impact of COVID-19 on Patients With Cancer: A National Study of Patient Experiences

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic abruptly disrupted cancer care. The impact of these disruptions on patient experiences remain relatively understudied. The objective of this study was to assess patients' perspectives regarding the impact of COVID-19 on their experiences, including their cancer care, emotional and mental health, and social determinants of health, and to evaluate whether these outcomes differed by cancer stage.

MATERIALS AND METHODS

We conducted a survey among adults with cancer across the United States from April 1, 2020 to August 26, 2020 using virtual snowball sampling strategy in collaboration with professional organizations, cancer care providers, and patient advocacy groups. We analyzed data using descriptive statistics, χ2 and t tests.

RESULTS

Three hundred twelve people with cancer participated and represented 38 states. The majority were non-Hispanic White (n=183; 58.7%) and female (n=177; 56.7%) with median age of 57 years. Ninety-one percent spoke English at home, 70.1% had health insurance, and 67% had access to home internet. Breast cancer was the most common diagnosis (n=67; 21.5%). Most had Stage 4 disease (n=80; 25.6%). Forty-six percent (n=145) experienced a change in their care due to COVID-19. Sixty percent (n=187) reported feeling very or extremely concerned that the pandemic would affect their cancer and disproportionately experienced among those with advanced cancer stages compared with earlier stages (P<0.001). Fifty-two percent (n=162) reported impact of COVID-19 on 1 or more aspects of social determinants of health with disproportionate impact among those with advanced cancer stages compared with earlier stages.

CONCLUSIONS

COVID-19 impacted the care and well-being of patients with cancer and this impact was more pronounced among people with advanced cancer stages. Future work should consider tailored interventions to mitigate the impact of COVID-19 on patients with cancer.

Association of a Lay Health Worker-Led Intervention on Goals of Care, Quality of Life, and Clinical Trial Participation Among Low-Income and Minority Adults With Cancer

PURPOSE

New approaches are needed to overcome low supportive care and clinical trial participation among low-income and minority adults with cancer. The objective of this project was to determine whether a lay health worker intervention was associated with improvements in supportive care and trial participation.

METHODS

We conducted a quality improvement initiative in collaboration with a union organization. We enrolled union members newly diagnosed with cancer into a 6-month lay health worker-led intervention from October 15, 2016, to February 28, 2017. The primary outcome was goals of care. Secondary outcomes were health-related quality of life (HRQOL), health care use, and trial participation. All outcomes except HRQOL were compared with a cohort of union members diagnosed within the 6-month preintervention period.

RESULTS

Sixty-six adults participated in the intervention group, and we identified 72 adults in the control group. Demographic characteristics were similar between groups. The mean age was 56.0 years; 47 (34%) were male, and 22 were White (16%). Within 6 months enrollment, more intervention group participants, as compared with the control, had clinician-documented goals of care (94% v 26%; P < .001) and participated in cancer clinical trials (72% v 22%; P < .001). At 4 months postenrollment, as compared with baseline, intervention participants experienced HRQOL improvements (mean difference, 3.98 points; standard deviation, 2.83; P < .001). Before death, more intervention group participants used palliative care and hospice than the control group.

CONCLUSION

Lay health worker-led interventions may improve supportive care and clinical trial participation among low-income and minority populations with cancer.

A randomized controlled trial of the effect of a community-based intervention on patient activation, health-related quality of life, and acute care use

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Background: Low-income and minority populations have disproportionately less activation in their cancer care, worse health-related quality of life (HrQOL), and greater acute care use than affluent and white populations. Community-based interventions are needed to improve patient experiences and quality of cancer care among these populations. We used community-based participatory methods to refine a previously tested intervention for use in Atlantic City NJ. The intervention, LEAPS, uses community health workers trained to activate patients to discuss advance care planning and their symptom burden with cancer clinicians and to connect patients with culturally-relevant community resources to overcome complications from social determinants of health. We conducted a randomized controlled trial of LEAPS in collaboration with a employer-union health fund. Members of the employer-union health fund with newly diagnosed with hematologic and solid tumor cancers were randomized to the 6-month intervention or to usual care. The objective was to determine if the intervention improved HrQOL at 4 months post-enrollment as compared to baseline more than usual care and secondarily the effect on change in patient activation at 4 months post-enrollment as compared to baseline and acute care use within 12 months post-enrollment. Methods: We conducted patient interviews to assess HrQOL and patient activation and obtained claims data for health care use. We used regression models to evaluate differences in health-related quality of life (validated Functional Assessment of Cancer Therapy-General) scores and patient activation (validated Patient Activation Measure) scores between groups over time and exact poisson regression adjusted for length of follow-up to compare emergency department and hospitalization utilization. Results: A total of 160 patients were consented and randomized into the study (80 intervention; 80 control). There were no differences in demographic or clinical factors across groups. The majority were non-white (74%), female (53%), mean age 57 years. The most common diagnoses were breast (31%) and lung (21%) cancer and the majority were diagnosed with stage 3 or 4 (63%). At 4 months, the intervention group had greater improvements in quality of life as compared to the control group (difference in difference: 9.56 p < 0.001), greater change in patient activation (difference in difference: 12.43 (p < 0.001)), and lower acute care use (hospital visits (1.10 (1.53) +/- 1.83 (1.31), p = 0.02) and emergency department use (1.2 (2.82) versus 3.47 (3.62) p = 0.03). Conclusions: Integration of community-based interventions into cancer care for low-income and minority populations may be a more effective and sustainable way to ensure equitable cancer care. Clinical trial information: NCT03699748.

Coaches Activating Reaching and Engaging Patients (CAREPlan): A randomized controlled trial combining two evidence-based interventions to improve goals of care documentation

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Background: In our prior work, community or lay health worker-led goals of care interventions improved goals of care documentation by clinicians and decreased health care use at the end of life. Other studies have demonstrated improvements in provider-patient communication and goals of care documentation using the Serious Illness Care Program. The objective of this study was to determine whether the combination of these two interventions could improve goals of care documentation among patients with advanced stages of genitourinary cancers at an academic center. Methods: A randomized controlled trial was conducted from April 3, 2019, through October 30, 2019, among patients with metastatic or recurrent cancer on at least second line therapy in the urologic oncology clinics at Stanford Cancer Center. Patients were randomized to usual care or the intervention with a lay navigator trained to assist patients with establishing end-of-life care preferences using the Serious Illness Conversation Guide. The primary outcome was goals of care documentation by the primary oncologist. We used intent to treat analyses, descriptive statistics to compare demographic and clinical factors, and a logistic regression adjusting for imbalance to determine the effect on the primary outcome. Results: Two-hundred participants were randomized and included in the intent to treat analysis. Median age was 72 years, majority were male (n=175, 87.5%) and self-identified as non-Hispanic white (n=123, 61.5%). The majority had prostate cancer (n=110, 53.5%), followed by kidney cancer (n=51, 25.5%), and urothelial cancer (n=29, 14.5%) and most had stage IV disease at diagnosis (n=186, 93%). There were no significant differences in demographic or clinical factors except for gender; there were more females on the control arm (n=8 vs n=17, p=0.01) thus analysis of the primary outcome was adjusted for gender. The adjusted analysis showed that at 12 months post-enrollment, the intervention significantly increased goals of care documentation by the primary oncologist as compared to the control group (53.7% vs 32.6%, p=0.002). Conclusions: The CAREPlan program increased goals of care documentation by the primary oncologist at this single academic medical center. Clinical trial information: NCT03856463.

Financial Toxicity of Cancer Care: An Analysis of Financial Burden in Three Distinct Health Care Systems

PURPOSE

The financial toxicity of cancer care is a source of significant distress for patients with cancer. The purpose of this study is to understand factors associated with financial toxicity in three distinct care systems.

METHODS

We conducted a cross-sectional survey of patients in three care systems, Stanford Cancer Institute (SCI), VA Palo Alto Health Care System (VAPAHCS), and Santa Clara Valley Medical Center (SCVMC), from October 2017 to May 2019. We assessed demographic factors, employment status, and out-of-pocket costs (OOPCs) and administered the validated COmprehensive Score for financial Toxicity tool. We calculated descriptive statistics and conducted linear regression models to analyze factors associated with financial toxicity.

RESULTS

Four hundred forty-four of 578 patients (77%) completed the entire COmprehensive Score for financial Toxicity tool and were included in the analysis. Most respondents at SCI were White, with annual household income (AHI) > $50,000 USD and Medicare insurance. At the VAPAHCS, most were White, with AHI ≤ $50,000 USD and insured by the Veterans Administration. At SCVMC, most were Asian and/or Pacific Islander, with AHI ≤ $25,000 USD and Medicaid insurance. Low AHI (P < .0001), high OOPCs (P = .003), and employment changes as a result of cancer diagnosis (P < .0001) were associated with financial toxicity in the pooled analysis. There was variation in factors associated with financial toxicity by site, with employment changes significant at SCI, OOPCs at SCVMC, and no significant factors at the VAPAHCS.

CONCLUSION

Low AHI, high OOPCs, and employment changes contribute to financial toxicity; however, there are variations based on site of care. Future studies should tailor financial toxicity interventions within care delivery systems.

Use of a computer model and care coaches to increase advance care planning conversations for patients with metastatic cancer

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Background: Patients with metastatic cancer benefit from advance care planning (ACP) conversations. Despite initiatives which train providers to have ACP conversations using the serious illness care program (SICP) conversation guide, few patients have a documented prognosis discussion due to busy clinic schedules and difficulty in deciding the right times to have such conversations. We designed an intervention to improve ACP by incorporating a validated computer model to identify patients at high risk for mortality in combination with lay care coaches. We investigated whether this would improve end of life quality measures. Methods: Four Stanford clinics were included in this pilot; all received SICP training. Two clinics (thoracic and genitourinary) underwent the intervention (computer model + care coach), and two clinics (sarcoma and cutaneous) served as the control. For providers in the intervention, an email was sent every Sunday listing the metastatic cancer patients who would be seen in clinic the following week and a predicted prognosis generated by the model. A lay care coach contacted patients with a predicted survival ≤2 years to have an ACP conversation with them. After, the care coach notified the provider to suggest discussion regarding prognosis with the patient. Criteria for a patient visit to be included in the analysis were: age ≥18, established patient, has sufficient EMR data for computer model, and no prior prognosis documentation. The primary outcome was documentation of prognosis in the ACP form by the end of the week following the clinic visit. Results: 5330 visits in 1298 unique patients met the inclusion criteria. Median age was 67 (range 19-97); 790 male, 508 female. 1970 visits were with patients with ≤2 year predicted survival. Prognosis discussion was documented by providers in the ACP form for 8.1% of intervention visits compared to 0.07% of control visits (p=0.001 in mixed effects model). Of the 1298 unique patients, 84 were deceased by December 2020. 41.7% died in the hospital. 59.5% were enrolled in hospice prior to death, and 19.0% were hospitalized in the ICU ≤14 days prior to death. Of deceased patients with ACP form prognosis documentation, 5.0% had ≥2 hospitalizations in the 30 days before death compared to 23.4% of deceased patients with no prognosis documented (p=0.10). For ≥ 2 ER visits in the 30 days before death, the proportions were 5.0% and 20.3% (p=0.17). Conclusions: This pilot study supports that our intervention is associated with higher rates of prognosis discussions and documentation. There was a trend towards better quality of end of life care as noted by higher rates of hospice enrollment and less intensive care at end of life. These results merit further investigation as a means to improve goal-concordant care and ensure appropriate care for cancer patients at the end of life.

Addressing cancer care needs for Latino adults: A formative qualitative evaluation

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Background: Cancer remains the number one cause of death among the Latino population despite the decrease in cancer incidence and mortality in the United States. Latino patients experience worse quality of life, more advanced stages of disease, and longer times to definitive diagnosis and treatment initiation. Yet there are few interventions that leverage clinical and community-based approaches to address these disparities. The aim of this formative qualitative study was to explore the specific care needs and barriers encountered by Latino patients to refine a community-based intervention delivered by community health workers (CHWs). Methods: We conducted semi-structured, in-depth, one-on-one qualitative interviews with low-income, Latino adults with a past or current history of cancer and/or their caregivers in a county comprised of 80% Latino populations in California. Interviews were conducted in Spanish, audio-recorded, transcribed and translated. Analysis was based in grounded theory and performed using the constant comparative method. Results: Fourteen interviews were conducted with a total of 18 participants; 9 involved the patient, 4 involved the patient and a designated caregiver, and 1 involved a caregiver only. Four major themes emerged that included: 1) lack of overall understanding of all aspects of cancer including their cancer diagnosis, significance of advance directives, precision medicine, and cancer care plans; 2) severe challenges in communicating cancer care needs and receiving support services due to language barriers; 3) stress and anxiety regarding financial hardships related to job loss and insurance barriers; 4) the need for supportive, bilingual and bicultural personnel to assist in overcoming these challenges. Conclusions: Latino patients with cancer and caregivers described major barriers they encounter after a cancer diagnosis. Participants described important approaches to address these cancer specific needs and reduce cancer disparities among these populations.

Integrating Electronic Health Record, Cancer Registry, and Geospatial Data to Study Lung Cancer in Asian American, Native Hawaiian, and Pacific Islander Ethnic Groups

BACKGROUND

A relatively high proportion of Asian American, Native Hawaiian, and Pacific Islander (AANHPI) females with lung cancer have never smoked. We used an integrative data approach to assemble a large-scale cohort to study lung cancer risk among AANHPIs by smoking status with attention to representation of specific AANHPI ethnic groups.

METHODS

We leveraged electronic health records (EHRs) from two healthcare systems-Sutter Health in northern California and Kaiser Permanente Hawai'i-that have high representation of AANHPI populations. We linked EHR data on lung cancer risk factors (i.e., smoking, lung diseases, infections, reproductive factors, and body size) to data on incident lung cancer diagnoses from statewide population-based cancer registries of California and Hawai'i for the period between 2000 and 2013. Geocoded address data were linked to data on neighborhood contextual factors and regional air pollutants.

RESULTS

The dataset comprises over 2.2 million adult females and males of any race/ethnicity. Over 250,000 are AANHPI females (19.6% of the female study population). Smoking status is available for over 95% of individuals. The dataset includes 7,274 lung cancer cases, including 613 cases among AANHPI females. Prevalence of never-smoking status varied greatly among AANHPI females with incident lung cancer, from 85.7% among Asian Indian to 14.4% among Native Hawaiian females.

CONCLUSION

We have developed a large, multilevel dataset particularly well-suited to conduct prospective studies of lung cancer risk among AANHPI females who never smoked.

IMPACT

The integrative data approach is an effective way to conduct cancer research assessing multilevel factors on cancer outcomes among small populations.

The effect of a lay health worker intervention on acute care use, patient experiences and end-of-life care: Results from a randomized clinical trial

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Background: Previously, among Veterans with cancer, lay health workers (LHWs) trained to discuss patients’ goals of care reduced acute care use, improved patient experiences and reduced total costs of care at the end-of-life. Among Medicare-Advantage beneficiaries with cancer, LHWs trained to proactively assess patient symptoms reduced symptom burden, acute care use and total costs of care. It is unknown whether LHWs can assist with both goals of care and symptom assessments in community settings. The objective of this randomized clinical trial was to determine the effect of a LHW-led goals of care and symptom assessment intervention on acute care use and secondarily goals of care documentation, satisfaction and end-of-life healthcare use among patients with advanced cancer in a community practice. Methods: Newly diagnosed patients with advanced stages of solid and hematologic malignancies who planned to receive care at the oncology practice were randomized from 8/11/2016 through 2/5/2020 into intervention and control groups. Patients completed validated satisfaction surveys at randomization and 9 months follow-up and were followed for 12 months. We compared risk of death using Cox Models, healthcare use and satisfaction using generalized regression models adjusted for length of follow-up. Results: 128 patients were randomized; 64 in the intervention and 64 in the control. The mean age was 67 years; 22% identified as Hispanic/Latino; 57% White, 30% Asian Pacific Islander, 8% Black or African American, 1% Native Hawaiian, 1% American Indian/Alaskan Native, 3% multiple races/ethnicities. There were no survival differences. Intervention patients were less likely to utilize the emergency department (OR: 0.35; 95% CI 0.17-0.72) and hospital (OR: 0.48; 95% CI 0.23-0.98) and had lower mean emergency department visits (1.05 +/- 1.74 versus 1.84 +/- 2.55, p = 0.04) and hospitalizations per year (0.63 +/- 1.28 versus 1.26 +/- 2.23, p = 0.04) as compared to control patients. More intervention patients had their goals of care documented (94% versus 52% p < 0.001) and used hospice (35% versus 14% p = 0.004) as compared to control patients. There were no differences in palliative care use (89% versus 77% p = 0.09). At 9 months follow-up as compared to baseline, intervention patients experienced greater improvements in satisfaction with care (difference-in-difference: 0.41, 95% CI 0.22-0.60, p < 0.001). Among 30 patients who died (n = 16 intervention; n = 16 control), more patients in the intervention used hospice (81% versus 43%) and fewer used acute care in the last month (37% versus 81%, p = 0.012) than in the control. Conclusions: An LHW intervention reduced acute care use among patients with cancer, improved patient experiences and end-of-life care. This intervention may be a scalable approach to improve care delivery and experiences for patients after a diagnosis of cancer. Clinical trial information: NCT03154190.

Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic

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Background: The COVID-19 pandemic prompted rapid changes in cancer care delivery. We sought to examine oncology provider perspectives on clinical decisions and care delivery during the pandemic and to compare provider views early versus late in the pandemic. Methods: We invited oncology providers, including attendings, trainees and advanced practice providers, to complete a cross-sectional online survey using a variety of outreach methods including social media (Twitter), email contacts, word of mouth and provider list-serves. We surveyed providers at two time points during the pandemic when the number of COVID-19 cases was rising in the United States, early (March 2020) and late (January 2021). The survey responses were analyzed using descriptive statistics and Chi-squared tests to evaluate differences in early versus late provider responses. Results: A total of 132 providers completed the survey and most were white (n = 73/132, 55%) and younger than 49 years (n = 88/132, 67%). Respondents were attendings in medical, surgical or radiation oncology (n = 61/132, 46%), advanced practice providers (n = 48/132, 36%) and oncology fellows (n = 16/132, 12%) who predominantly practiced in an academic medical center (n = 120/132, 91%). The majority of providers agreed patients with cancer are at higher risk than other patients to be affected by COVID-19 (n = 121/132, 92%). However, there was a significant difference in the proportion of early versus late providers who thought delays in cancer care were needed. Early in the pandemic, providers were more likely to recommend delays in curative surgery or radiation for early-stage cancer (p < 0.001), delays in adjuvant chemotherapy after curative surgery (p = 0.002), or delays in surveillance imaging for metastatic cancer (p < 0.001). The majority of providers early in the pandemic responded that “reducing risk of a complication from a COVID-19 infection to patients with cancer” was the primary reason for recommending delays in care (n = 52/76, 68%). Late in the pandemic, however, providers were more likely to agree that “any practice change would have a negative impact on patient outcomes” (p = 0.003). At both time points, the majority of providers agreed with the need for other care delivery changes, including screening patients for infectious symptoms (n = 128/132, 98%) and the use of telemedicine (n = 114/132, 86%) during the pandemic. Conclusions: We found significant differences in provider perspectives of delays in cancer care early versus late in the pandemic which reflects the swiftly evolving oncology practice during the COVID-19 pandemic. Future studies are needed to determine the impact of changes in treatment and care delivery on outcomes for patients with cancer.

The impact of COVID-19 on patients with cancer: A qualitative study

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Background: The SARS‐CoV‐2/COVID‐19 pandemic greatly impacted the health of many patients with cancer. We conducted in-depth interviews with patients across the United States to better understand the effect of the COVID-19 pandemic on their cancer care, emotional and mental health, and to solicit suggestions for how health care providers could mitigate these concerns. Methods: We contacted respondents from the Impact of COVID-19 on Cancer parent study. The parent study used a snowball sampling approach to survey patients nationally regarding cancer delays between April 2020 and October 2020. We invited all respondents who volunteered for future studies to participate in a 40-minute interview regarding their experiences and suggestions for how health care providers could mitigate COVID19-related concerns. Interviews were conducted between August 2020 and October 2020, recorded, transcribed and analyzed using qualitative thematic content analysis. Results: A total of 34 participants were contacted and consented to participate in this study. Four overarching themes were identified: (1) significant concern regarding infection risk; (2) concerns regarding care changes, such as delays, worsening cancer outcomes; (3) concern regarding loss of employment, health insurance, and transportation on cancer treatment, affordability, and prognosis; and (4) worsening emotional and mental health due to social isolation. Suggestions for the clinical team included: 1) specific and direct guidance from health care providers on how to mitigate infection risk; 2) screening for and access to mental health services; 3) continuation of cancer treatment, surveillance, and clinical trials without delays and 4) allowing caregivers to attend appointments. Conclusions: In this national qualitative study of patients with cancer, participants identified that COVID-19 and modifications to their cancer care worsened their emotional and mental health with growing concerns about the impact of the virus and socioeconomic status on their cancer outcomes. Specific suggestions for health care providers, such as anticipatory guidance, access to mental health services, and expanded visitation should be considered to improve patient experiences with care during the pandemic.

Addressing financial toxicity in urologic oncology patients

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Background: Financial toxicity, or the financial burden related to cancer care, is a source of distress for urologic oncology patients. This study aimed to address financial toxicity among prostate, kidney and bladder cancer patients and test the feasibility of a lay-health worker (LHW) and social work (SW) driven intervention. Methods: LHW assessed financial burden in urologic oncology patients with advanced cancer who presented for return visits at a single academic center. The LHW collected responses to three statements on a Likert scale – “I worry about the financial problems I will have in the future because of my illness or treatment”, “My cancer or treatment has reduced satisfaction with my present financial situation”, and “I feel financially stressed”. Patients who responded, “Very much” (4) or “Quite a bit” (3) to all statements were offered a one-on-one consultation with a trained SW. The SW provided personalized recommendations after review of patients' financial information, insurance status, and out of pocket costs. SW referred patients to appropriate support services including those offered by the hospital, government, nonprofits and private corporations. Pre-specified outcomes included pre/post-intervention financial toxicity and patient satisfaction with the intervention. Results: 145 patients (67%) agreed to be screened for financial toxicity by the LHW. Most participants were White (n = 100, 69%), male (n = 130, 90%), married (n = 104, 72%) and with incomes > $100,000 (n = 111, 77%). The majority had prostate cancer (n = 87, 60%), followed by kidney cancer (n = 36, 25%) and bladder cancer (n = 22, 15%). 12% (n = 26) responded “I worry about the financial problems I will have in the future because of my illness or treatment”, “Very much” or “Quite a bit”. 14% (n = 20) responded “My cancer or treatment has reduced satisfaction with my present financial situation”, “Very much” or “Quite a bit”. 12% (n = 17) reported “I feel financially stressed”, “Very much” or “Quite a bit”. A total of 14 patients were eligible for the intervention and were referred for a one-on-one SW consultation. Post-intervention results indicated excellent patient satisfaction with the intervention and a significant improvement in financial toxicity. 100% of patients reported the SW “provided financial resources that were beneficial to me”, and 78% (n = 11) had a decrease in financial toxicity score post-intervention (average decrease = -1, p = 0.05038). Conclusions: In this single institution study of prostate, kidney and bladder cancer patients with overall low baseline financial burden a LHW and SW driven intervention was feasible and effective in reducing financial toxicity.