1
|
Salz T, Meza AM, Bradshaw PT, Jinna S, Moryl N, Kriplani A, Tringale K, Flory J, Korenstein D, Lipitz-Snyderman A. Role of primary care in opioid prescribing for older head and neck cancer survivors. Cancer 2024; 130:3913-3925. [PMID: 39072710 PMCID: PMC11511644 DOI: 10.1002/cncr.35478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Older head and neck cancer (HNC) survivors have concerning rates of potentially unsafe opioid prescribing. Identifying the specialties of opioid prescribers for HNC survivors is critical for targeting the settings for opioid safety interventions. This study hypothesized that oncology and surgery providers are primarily responsible for opioid prescriptions in the year after treatment but that primary care providers (PCPs) are increasingly involved in prescribing over time. METHODS Using linked Surveillance, Epidemiology, and End Results-Medicare data, a retrospective analysis was conducted of adults aged >65 years diagnosed between 2014 and 2017 with stage I-III HNC and who had ≥6 months of treatment-free follow-up through 2019. Starting at treatment completion, opioid fills were assigned to a prescriber specialty: oncology, surgery, primary care, pain management, or other. Prescriber patterns were summarized for each year of follow-up. Multinomial logistic regression models captured the likelihood of opioids being prescribed by each specialty. RESULTS Among 5135 HNC survivors, 2547 (50%) had ≥1 opioid fill (median, 2.1-year follow-up). PCPs prescribed 47% of all fills (42%-55% each year). PCPs prescribed opioids to 45% of survivors with ≥1 opioid fill, which was a greater share than other specialties. PCPs prescribed longer supplies of opioids (median, 20 days/fill; median, 30 days/year) than oncologists or surgeons. The likelihood of an opioid being prescribed by an oncology provider was four times lower than that of it being prescribed by a PCP. CONCLUSIONS PCP involvement in opioid prescribing remains high throughout HNC survivorship. Interventions to improve the safety of opioid prescribing should target primary care, as is typical for opioid reduction efforts in the noncancer population.
Collapse
|
2
|
Doshi SD, Charvadeh YK, Seier K, Bange EM, Daly B, Lipitz-Snyderman A, Polubriaginof FCG, Buckley M, Kuperman G, Stetson PD, Schrag D, Morris MJ, Panageas KS. Perspectives on Telemedicine Visits Reported by Patients With Cancer. JAMA Netw Open 2024; 7:e2445363. [PMID: 39546309 PMCID: PMC11568458 DOI: 10.1001/jamanetworkopen.2024.45363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 09/22/2024] [Indexed: 11/17/2024] Open
Abstract
Importance The COVID-19 pandemic catalyzed rapid adoption of telemedicine visits for cancer care delivery. However, patients' experiences with telemedicine remain poorly understood. Objective To understand patients' satisfaction with telemedicine visits at a comprehensive cancer center. Design, Setting, and Participants This survey study included patients with cancer at a US cancer center between 2020 and 2023. Eligible patients completed surveys in English conducted after their first telemedicine appointment via an online patient portal. Data were analyzed between January and June 2024. Exposures Patient surveys about telemedicine experiences, with a specific comparison with an in-person visit. Structured items elicited satisfaction with the specific visit, preferences for future use of telemedicine, and technical ease of use; unstructured free-text responses were also elicited. Main Outcomes and Measures Proportion of patients who indicated that telemedicine visits were superior or preferred to in-person visits. Secondary outcomes included multivariable analysis of barriers to telemedicine use and variations in patient experiences by demographic characteristics over the observation period, and free-text analysis of unstructured responses describing the telemedicine experience using the BERTopic algorithm and a language model. Results A total of 27 435 telemedicine users completed surveys from May 2020 to October 2023 (median [IQR] age, 65 [55-72] years; 15 072 female [54.9%]; 1771 Asian [6.7%], 1339 Black [5.1%], 22 742 White [85.9%]). Overall, 18 025 of 24 418 patients (73.8%) rated their first telemedicine visit as good as or better than an in-person visit, and 4606 (18.9%) rated it superior to an in-person visit. The proportion of patients rating a telemedicine visit superior to an in-person visit evolved from 17% in 2020 to 20% in 2023. Structured questions revealed a positive view of telemedicine, while free-text analyses highlighted issues with technology. Conclusions and Relevance In this survey study of perspectives on telemedicine visits, a large majority of patients at a comprehensive cancer center expressed satisfaction with telemedicine visits in proportions that remained consistent beyond the end of the pandemic. These findings challenge health care systems to integrate telemedicine into routine cancer care and to overcome remaining technical challenges and barriers to ease of use.
Collapse
|
3
|
Bange EM, Daly RM, Lipitz-Snyderman A, Kuperman G, Polubriaginof FCG, Liebertz C, Doshi SD, Stevanovic K, Chan K, Bernal C, Charvadeh YK, Chen Y, Chimonas S, Stetson P, Schrag D, Morris MJ, Panageas KS. Transforming patient-centered cancer care using telehealth: the MATCHES Center. J Natl Cancer Inst Monogr 2024; 2024:76-82. [PMID: 38924792 PMCID: PMC11207685 DOI: 10.1093/jncimonographs/lgae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/12/2024] [Accepted: 02/03/2024] [Indexed: 06/28/2024] Open
Abstract
Modern cancer care is costly and logistically burdensome for patients and their families despite an expansion of technology and medical advances that create the opportunity for novel approaches to care. Therefore, there is a growing appreciation for the need to leverage these innovations to make cancer care more patient centered and convenient. The Memorial Sloan Kettering Making Telehealth Delivery of Cancer Care at Home Efficient and Safe Telehealth Research Center is a National Cancer Institute-designated and funded Telehealth Research Center of Excellence poised to generate the evidence necessary to inform the appropriate use of telehealth as a strategy to improve access to cancer services that are convenient for patients. The center will evaluate telehealth as a strategy to personalize cancer care delivery to ensure that it is not only safe and effective but also convenient and efficient. In this article, we outline this new center's research strategy, as well as highlight challenges that exist in further integrating telehealth into standard oncology practice based on early experiences.
Collapse
|
4
|
Rendle KA, Tan ASL, Spring B, Bange EM, Lipitz-Snyderman A, Morris MJ, Makarov DV, Daly R, Garcia SF, Hitsman B, Ogedegbe O, Phillips S, Sherman SE, Stetson PD, Vachani A, Wainwright JV, Zullig LL, Bekelman JE. A Framework for Integrating Telehealth Equitably across the cancer care continuum. J Natl Cancer Inst Monogr 2024; 2024:92-99. [PMID: 38924790 PMCID: PMC11207920 DOI: 10.1093/jncimonographs/lgae021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/23/2024] [Accepted: 04/15/2024] [Indexed: 06/28/2024] Open
Abstract
The COVID-19 pandemic placed a spotlight on the potential to dramatically increase the use of telehealth across the cancer care continuum, but whether and how telehealth can be implemented in practice in ways that reduce, rather than exacerbate, inequities are largely unknown. To help fill this critical gap in research and practice, we developed the Framework for Integrating Telehealth Equitably (FITE), a process and evaluation model designed to help guide equitable integration of telehealth into practice. In this manuscript, we present FITE and showcase how investigators across the National Cancer Institute's Telehealth Research Centers of Excellence are applying the framework in different ways to advance digital and health equity. By highlighting multilevel determinants of digital equity that span further than access alone, FITE highlights the complex and differential ways structural determinants restrict or enable digital equity at the individual and community level. As such, achieving digital equity will require strategies designed to not only support individual behavior but also change the broader context to ensure all patients and communities have the choice, opportunity, and resources to use telehealth across the cancer care continuum.
Collapse
|
5
|
Gillespie EF, Santos PMG, Curry M, Salz T, Chakraborty N, Caron M, Fuchs HE, Ledesma Vicioso N, Mathis N, Kumar R, O’Brien C, Patel S, Guttmann DM, Ostroff JS, Salner AL, Panoff JE, McIntosh AF, Pfister DG, Vaynrub M, Yang JT, Lipitz-Snyderman A. Implementation Strategies to Promote Short-Course Radiation for Bone Metastases. JAMA Netw Open 2024; 7:e2411717. [PMID: 38787561 PMCID: PMC11127116 DOI: 10.1001/jamanetworkopen.2024.11717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/11/2024] [Indexed: 05/25/2024] Open
Abstract
Importance For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings. Objective To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions). Design, Setting, and Participants This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023. Exposures Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians. Main Outcomes and Measures The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy. Results Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly. Conclusions and Relevance In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.
Collapse
|
6
|
Saadat LV, Schofield E, Bai X, Curry M, Saskin R, Lipitz-Snyderman A, Soares KC, Kingham TP, Jarnagin WR, D'Angelica MI, Wright FC, Irish JC, Coburn NG, Wei AC. ASO Visual Abstract: Treatment Patterns and Outcomes in Pancreatic Cancer: A Comparative Analysis of Ontario and the United States. Ann Surg Oncol 2024; 31:1493-1494. [PMID: 37957507 DOI: 10.1245/s10434-023-14516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
|
7
|
Saadat LV, Schofield E, Bai X, Curry M, Saskin R, Lipitz-Snyderman A, Soares KC, Kingham TP, Jarnagin WR, D'Angelica MI, Wright FC, Irish JC, Coburn NG, Wei AC. Treatment Patterns and Outcomes in Pancreatic Cancer: A Comparative Analysis of Ontario and the USA. Ann Surg Oncol 2024; 31:58-65. [PMID: 37833463 PMCID: PMC11614116 DOI: 10.1245/s10434-023-14375-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Comparative studies evaluating quality of care in different healthcare systems can guide reform initiatives. This study seeks to characterize best practices by comparing utilization and outcomes for patients with pancreatic cancer (PC) in the USA and Ontario, Canada. METHODS Patients (age ≥ 66 years) with PC were identified from the Ontario Cancer Registry and SEER-Medicare databases from 2006 to 2015. Demographics and treatment (surgery, radiation, chemotherapy, or multimodality (surgery and chemotherapy)) were described. In resected patients, neoadjuvant therapy, readmission, and 30- and 90-day postoperative mortality rates were calculated. Survival was assessed using Kaplan-Meier curves. RESULTS This study includes 38,858 and 11,512 patients with PC from the USA and Ontario, respectively. More female patients were identified in the USA (54.0%) versus Ontario (46.9%). In the entire cohort, US patients received more radiation in addition to other therapies (18.8% vs. 13.5% Ontario) and chemotherapy alone (34.3% vs. 19.0% Ontario). While rates of resection were similar (13.4% USA vs.12.5% Ontario), multimodality therapy was more common in the UAS (9.0% vs. 6.4%). Among resected patients, neoadjuvant chemotherapy was uncommon in both groups, although more frequent in the USA (12.0% vs. 3.2% Ontario). The 30- and 90-day postoperative mortality rates were lower in Ontario vs. the USA (30-day: 3.26% vs. 4.91%; 90-day: 7.08% vs. 10.96%), however, overall survival was similar between the USA and Ontario. CONCLUSIONS We observed substantive differences in treatment and outcomes between PC patients in the USA and Ontario, which may reflect known differences in healthcare systems. Close evaluation of healthcare policies can inform initiatives to improve care quality.
Collapse
|
8
|
Chimonas S, Lipitz-Snyderman A, Spiegelhoff Z, Chakraborty N, Seier K, White C, Kuperman G. Persistence of Telemedicine Usage for Breast and Prostate Cancer after the Peak of the COVID-19 Pandemic. Cancers (Basel) 2023; 15:4961. [PMID: 37894328 PMCID: PMC10605853 DOI: 10.3390/cancers15204961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
While COVID-19 catalyzed a shift to telemedicine, little is known about the persistence of remote cancer care in non-emergent times. We assessed telemedicine use at a high-volume academic cancer center in New York City and analyzed breast and prostate cancer visits pre-COVID-19, peak COVID-19, and post-peak. Descriptive statistics assessed visit mode (in person, telemedicine) and type (new, follow-up, other) by department/specialty, with Fisher's exact tests comparing peak/post-peak differences. The study included 602,233 visits, with telemedicine comprising 2% of visits pre-COVID-19, 50% peak COVID-19, and 30% post-peak. Notable variations emerged by department/specialty and visit type. Post-peak, most departments/specialties continued using telemedicine near or above peak levels, except medicine, neurology, and survivorship, where remote care fell. In psychiatry, social work, and nutrition, nearly all visits were conducted remotely during and after peak COVID-19, while surgery and nursing maintained low telemedicine usage. Post-peak, anesthesiology and neurology used telemedicine seldom for new visits but often for follow-ups, while nursing showed the opposite pattern. These trends suggest department- and visit-specific contexts where providers and patients choose telemedicine in non-emergent conditions. More research is needed to explore these findings and evaluate telemedicine's appropriateness and impact across the care continuum.
Collapse
|
9
|
Chimonas S, Lipitz-Snyderman A, Matsoukas K, Kuperman G. Electronic consent in clinical care: an international scoping review. BMJ Health Care Inform 2023; 30:e100726. [PMID: 37423643 PMCID: PMC10335420 DOI: 10.1136/bmjhci-2022-100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 05/21/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE Digital technologies create opportunities for improvement of consenting processes in clinical care. Yet little is known about the prevalence, characteristics or outcomes of shifting from paper to electronic consenting, or e-consent, in clinical settings. Thus questions remain around e-consent's impact on efficiency, data integrity, user experience, care access, equity and quality. Our objective was to scope all known findings on this critical topic. MATERIALS AND METHODS Through an international, systematic scoping review, we identified and assessed all published findings on clinical e-consent in the scholarly and grey literatures, including consents for telehealth encounters, procedures and health information exchanges. From each relevant publication, we abstracted data on study design, measures, findings and other study features. MAIN OUTCOME MEASURES Metrics describing or evaluating clinical e-consent, including preferences for paper versus e-consenting; efficiency (eg, time, workload) and effectiveness (eg, data integrity, care quality). User characteristics were captured where available. RESULTS A total of 25 articles published since 2005, most from North America or Europe, report on the deployment of e-consent in surgery, oncology and other clinical settings. Experimental designs and other study characteristics vary, but nearly all focus on procedural e-consents. Synthesis reveals relatively consistent findings around improved efficiency and data integrity with, and user preferences for, e-consent. Care access and quality issues are less frequently explored, with disparate findings. DISCUSSION AND CONCLUSION The literature is nascent and largely focused on issues that are immediate and straightforward to measure. As virtual care pathways expand, more research is urgently needed to ensure that care quality and access are advanced, not compromised, by e-consent.
Collapse
|
10
|
Mitchell AP, Meza AM, Panageas KS, Lipitz-Snyderman A, Farooki A, Morris MJ. Real-world use of bone modifying agents in metastatic, castration-resistant prostate cancer. Prostate Cancer Prostatic Dis 2023; 26:126-132. [PMID: 35798857 PMCID: PMC10251421 DOI: 10.1038/s41391-022-00573-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bone modifying agents (BMAs) prevent skeletal related events among patients with metastatic, castration-resistant prostate cancer (mCRPC) involving bone and prevent osteoporotic fractures among patients at high risk. BMA utilization for patients with mCRPC has not been well quantified. METHODS We used linked SEER registry and Medicare claims data. We included men diagnosed with stage IV prostate adenocarcinoma during 2007-2015, aged > = 66 at diagnosis, with sufficient continuous enrollment in Medicare Parts A, B, and D, who received androgen deprivation therapy. We limited to those who subsequently received a CRPC-defining treatment (CDT). We identified patients with evidence of bone metastasis using claims. Our primary outcome was receipt of a BMA (zoledronic acid or denosumab) within 180 days of initiating CDT. RESULTS Among 1292 included patients, 1034 (80%) had bone metastasis. BMA use within 180 days of initiating CDT was higher among patients with bone metastases than those without (705/1034 [68%] vs 56/258 [22%]). Among patients without bone metastasis, those with high osteoporotic fracture risk were more likely than those without to receive a BMA (OR = 2.48, 95% CI: 1.17, 5.29); however, only 26% of patients with high fracture risk received a BMA. Among patients who received BMAs, most (62%) first initiated them >90 days before initiating CDT. CONCLUSIONS Two-thirds of patients with mCRPC and bone metastases received BMAs within 180 days after initiating CDT. A greater proportion of patients without bone metastasis may warrant BMA therapy for osteoporotic fracture prevention. Some patients with bone metastasis may be able to delay BMA initiation until CRPC.
Collapse
|
11
|
Buckley MT, O'Shea MR, Kundu S, Lipitz-Snyderman A, Kuperman G, Shah S, Iasonos A, Houston C, Terzulli SL, Lengfellner JM, Sabbatini P. Digitalizing the Clinical Research Informed Consent Process: Assessing the Participant Experience in Comparison With Traditional Paper-Based Methods. JCO Oncol Pract 2023; 19:e355-e364. [PMID: 36534933 PMCID: PMC10022878 DOI: 10.1200/op.22.00425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/14/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Consent processes are critical for clinical care and research and may benefit from incorporating digital strategies. We compared an electronic informed consent (eIC) option to paper consent across four outcomes: (1) technology burden, (2) protocol comprehension, (3) participant agency (ability to self-advocate), and (4) completion of required document fields. METHODS We assessed participant experience with eIC processes compared with traditional paper-based consenting using surveys and compared completeness of required fields, over 3 years (2019-2021). Participants who consented to a clinical trial at a large academic cancer center via paper or eIC were invited to either pre-COVID-19 pandemic survey 1 (technology burden) or intrapandemic survey 2 (comprehension and agency). Consent document completeness was assessed via electronic health records. RESULTS On survey 1, 83% of participants (n = 777) indicated eIC was easy or very easy to use; discomfort with technology overall was not correlated with discomfort using eIC. For survey 2, eIC (n = 262) and paper consenters (n = 193) had similar comprehension scores. All participants responded favorably to at least five of six agency statements; however, eIC generated a higher proportion of positive free-text comments (P < .05), with themes such as thoroughness of the discussion and consenter professionalism. eIC use yielded no completeness errors across 235 consents versus 6.4% for paper (P < .001). CONCLUSION Our findings suggest that eIC when compared with paper (1) did not increase technology burden, (2) supported comparable comprehension, (3) upheld key elements of participant agency, and (4) increased completion of mandatory consent fields. The results support a broader call for organizations to offer eIC for clinical research discussions to enhance the overall participant experience and increase the completeness of the consent process.
Collapse
|
12
|
Lipitz-Snyderman A, Chimonas S, Mailankody S, Kim M, Silva N, Kriplani A, Saltz LB, Sihag S, Tan CR, Widmar M, Zauderer M, Weingart S, Perchick W, Roman BR. Clinical value of second opinions in oncology: A retrospective review of changes in diagnosis and treatment recommendations. Cancer Med 2023; 12:8063-8072. [PMID: 36737878 PMCID: PMC10134380 DOI: 10.1002/cam4.5598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 12/08/2022] [Accepted: 12/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Data on the clinical value of second opinions in oncology are limited. We examined diagnostic and treatment changes resulting from second opinions and the expected impact on morbidity and prognosis. METHODS This retrospective cohort study included patients presenting in 2018 to a high-volume cancer center for second opinions about newly diagnosed colorectal, head and neck, lung, and myeloma cancers or abnormal results. Two sub-specialty physicians from each cancer type reviewed 30 medical records (120 total) using a process and detailed data collection guide meant to mitigate institutional bias. The primary outcome measure was the rate of treatment changes that were "clinically meaningful", i.e., expected to impact morbidity and/or prognosis. Among those with treatment changes, another outcome measure was the rate of clinically meaningful diagnostic changes that led to treatment change. RESULTS Of 120 cases, forty-two had clinically meaningful changes in treatment with positive expected outcomes (7 colorectal, 17 head and neck, 11 lung, 7 myeloma; 23-57%). Two patients had negative expected outcomes from having sought a second opinion, with worse short-term morbidity and unchanged long-term morbidity and prognosis. All those with positive expected outcomes had improved expected morbidity (short- and/or long-term); 11 (0-23%) also had improved expected prognosis. Nine involved a shift from treatment to observation; 21 involved eliminating or reducing the extent of surgery, compared to 6 adding surgery or increasing its extent. Of the 42 with treatment changes, 13 were due to clinically meaningful diagnostic changes (1 colorectal, 5 head and neck, 3 lung, 4 myeloma; 3%-17%) . CONCLUSIONS Second-opinion consultations sometimes add clinical value by improving expected prognoses; more often, they offer treatment de-escalations, with corresponding reductions in expected short- and/or long-term morbidity. Future research could identify subgroups of patients most likely to benefit from second opinions.
Collapse
|
13
|
Chimonas S, Lipitz-Snyderman A, Gaffney K, Kuperman GJ. Electronic Consent at US Cancer Centers: A Survey of Practices, Challenges, and Opportunities. JCO Clin Cancer Inform 2023; 7:e2200122. [PMID: 36595735 PMCID: PMC10166541 DOI: 10.1200/cci.22.00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/03/2022] [Accepted: 11/16/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Digital technologies create opportunities for improving consenting processes in cancer care and research. Yet, little is known about the prevalence of electronic consenting, or e-consent, at US cancer care institutions. METHODS We surveyed institutions in the National Comprehensive Cancer Network about their capabilities for clinical, research, and administrative e-consents; technologies used; telemedicine consents; multilingual support; evaluations; and opportunities and challenges in moving from paper-based to electronic processes. Responses were summarized across responding institutions. RESULTS Twenty-five institutions completed the survey (81% response rate). Respondents were from all census regions and included freestanding and matrix cancer centers. Twenty (80%) had e-consent capabilities, with variability in the extent of adoption: One (5%) had implemented e-consent for all clinical, research, and administrative needs while 19 (95%) had a mix of paper and electronic consenting. Among those with e-consent capabilities, the majority (14 of 20, 70%) were using features embedded in their electronic health record. Most had a combination of paper and e-consenting for clinical purposes (18, 72%). About two-thirds relied entirely on paper for research consents (16, 64%) but had at least some electronic processes for administrative consents (15, 60%). Obstacles to e-consenting included challenges with procuring or maintaining hardware, content management, workflow integration, and digital literacy of patients. Successes included positive user experiences, workflow improvements, and better record-keeping. Only two of 20 (10%) respondents with e-consent capabilities had evaluated the impact of automating consent processes. CONCLUSION E-consent was prevalent in our sample, with 80% of institutions reporting at least some capabilities. Further progress is needed for the benefits of e-consenting to be realized broadly.
Collapse
|
14
|
Green AK, Tabatabai SM, Aghajanian C, Landgren O, Riely GJ, Sabbatini P, Bach PB, Begg CB, Lipitz-Snyderman A, Mailankody S. Clinical Trial Participation Among Older Adult Medicare Fee-for-Service Beneficiaries With Cancer. JAMA Oncol 2022; 8:1786-1792. [PMID: 36301585 PMCID: PMC9614676 DOI: 10.1001/jamaoncol.2022.5020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/11/2022] [Indexed: 11/14/2022]
Abstract
Importance Clinical trials play a critical role in the development of novel cancer therapies, and precise estimates of the frequency with which older adult patients with cancer participate in clinical trials are lacking. Objective To estimate the proportion of older adult Medicare Fee-for-Service (FFS) beneficiaries with cancer who participate in interventional cancer clinical trials, using a novel population-based methodology. Design, Setting, and Participants In this retrospective cohort study evaluating clinical trial participation among older adult patients with cancer from January 1, 2014, through June 30, 2020, claims data from Medicare FFS were linked with the ClinicalTrials.gov to determine trial participation through the unique National Clinical Trial (NCT) identifier. The proportion of patients with newly diagnosed or newly recurrent cancer in 2015 participating in an interventional clinical trial and receiving active cancer treatment from January 2014 to June 2020 was estimated. Data analysis was performed from November 18, 2020, to November 1, 2021. Exposures Patients with cancer aged 65 years or older with Medicare FFS insurance, with and without active cancer treatment. Main Outcomes and Measures Enrollment in clinical trials among all patients with cancer 65 years and older and among patients receiving active cancer treatments as defined by the presence of at least 1 NCT identifier corresponding to an interventional cancer clinical trial in Medicare claims. Results Among 1 150 978 patients (mean [SD] age, 75.7 [8.4] years; 49.9% men and 50.1% women) with newly diagnosed or newly recurrent cancer in 2015, 12 028 (1.0%) patients had a billing claim with an NCT identifier indicating enrollment in an interventional cancer clinical trial between January 2014 and June 2020. In a subset of 429 343 patients with active cancer treatment, 8360 (1.9%) were enrolled in 1 or more interventional trials. Patients enrolled in a trial tended to be younger, male, a race other than Black, and residing in zip codes with high median incomes. Conclusions and Relevance Findings of this cohort study show that clinical trial enrollment among older adult patients with cancer remains low, with only 1.0% to 1.9% of patients with newly diagnosed or recurrent cancer in 2015 participating in an interventional cancer clinical trial as measured by the presence of NCT identifiers in Medicare claims. These data provide a contemporary estimate of trial enrollment, persistent disparities in trial participation, and only limited progress in trial access over the past 2 decades.
Collapse
|
15
|
Buckley MT, O'Shea M, Lipitz-Snyderman A, Kuperman G, Shah S, Redelman-Sidi Y, Lengfellner JM, Terzulli SL, Houston C, Sabbatini P. Electronic research consents for complex early-phase I-II clinical trials integrated with telemedicine visits compared with in-person encounters. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1514 Background: Based on our previous research with patient satisfaction for electronic consenting (95% of 940 respondents would recommend it another patient), we hypothesized that telemedicine (telemed) would be received as well as or better than in-person clinical research (CR) consent encounters for complex early-phase clinical trial (Phase I-II) and clinical genetic consent discussions by patients. Oncologist experiences to date have shown that telemed works well for uncomplicated clinical scenarios, but its performance alongside increased care complexity is less clear from the patient perspective. Methods: We conducted a one-time survey of adult patients having a telemed consent visit between 8/31/21 and 2/13/22 and an in-person clinic visit. Nine CR specific questions covered visit preference and empowerment across 6 high value consent agency domains. Results: 513 patients completed the survey and consented across 96 Clinical trials (CT), including genetic, therapeutic, diagnostic, and quality of life. Consent discussions were performed by 75 clinicians and 41 non-clinicians, with the majority (64%) for clinical genetic and Phase I-II CTs. Most patients (52%) preferred telemed over in-person clinic visits (19%) when all visit related factors (time, cost, convenience, quality of care, healthcare team interaction) were considered ( P<.05) (Table). Comparing their last in-person visit with telemed, patients reported feeling either less stressed/overwhelmed (16%) for their consent discussion or about the same (39%) using telemed, and 6% were more stressed ( P<.05). Patients expressed equal comfort taking agency-supported action across 6 domains regardless of consent setting. Conclusions: Electronic consenting via telemed is the preferred method for consent in complex early-phase clinical trials when all visit factors are considered and performs as well across 6 key agency domains when compared with in-person visits. Telemed does not contribute additional stress to consent appointments for most patients and performs well across complex clinical genetic and Phase I-II clinical trial discussions. Our findings suggest telemed and electronic consent should be offered as an option for patients throughout their treatment continuum. Beyond MSK, our data support a broader call for organizations to offer telemed platforms for CT discussions to increase overall patient satisfaction and potentially increase participation. [Table: see text]
Collapse
|
16
|
Green AK, Tabatabai SM, Bai X, Mishra Meza A, Lesny AM, Aghajanian C, Landgren O, Riely GJ, Sabbatini P, Salner A, Lipkin S, Ip A, Bach PB, Begg CB, Mailankody S, Lipitz-Snyderman A. Validation of a Population-Based Data Source to Examine National Cancer Clinical Trial Participation. JAMA Netw Open 2022; 5:e223687. [PMID: 35315914 PMCID: PMC8941352 DOI: 10.1001/jamanetworkopen.2022.3687] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services requires health care organizations to report the National Clinical Trial (NCT) identifier on claims for items and services related to clinical trials that qualify for coverage. This same NCT identifier is used to identify clinical trials in the ClinicalTrials.gov registry. If linked, this information could facilitate population-based analyses of clinical trial participation and outcomes. OBJECTIVE To evaluate the validity of a linkage between fee-for-service (FFS) Medicare claims and ClinicalTrials.gov through the NCT identifier for patients with cancer enrolled in clinical trials. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 2 complementary retrospective analyses for a validation assessment. First, billing data from 3 health care institutions were used to estimate the missingness of the NCT identifier in claims by calculating the proportion of known participants in cancer clinical trials with no NCT identifier on any submitted Medicare claims. Second, the Surveillance Epidemiology and End Results-Medicare data set, which includes a subset of all FFS Medicare beneficiaries for whom health insurance claims are linked with cancer registry data, was used to identify adult patients diagnosed with cancer between 2006 and 2015 with an NCT identifier in claims corresponding to an interventional cancer clinical trial. To estimate the accuracy of the NCT identifier when present, the proportion of NCT identifiers that corresponded to trials that were aligned with the patients' known primary or secondary diagnoses was calculated. Data were analyzed from March 2020 to March 2021. EXPOSURES An NCT identifier present in Medicare claims. MAIN OUTCOMES AND MEASURES The main outcome was participating in a clinical trial relevant to patient's cancer diagnosis. RESULTS A total of 1 171 816 patients were included in analyses. Across the 3 participating institutions, there were 5061 Medicare patients enrolled in a clinical trial, including 3797 patients (75.0%) with an NCT identifier on at least 1 billing claim that matched the clinical trial on which the patient was participating. Among 1 171 816 SEER-Medicare patients, 29 138 patients (2.5%) had at least 1 claim with a value entered in the NCT identifier field corresponding to 32 950 unique patient-NCT identifier pairs. There were 26 694 pairs (81.0%) with an NCT identifier corresponding to a clinical trial registered in ClinicalTrials.gov, of which 10 170 pairs (38.1%) were interventional cancer clinical trials. Among these, 9805 pairs (96.4%) were considered appropriate. CONCLUSIONS AND RELEVANCE In this cohort study, this data linkage provided a novel data source to study clinical trial enrollment patterns among Medicare patients with cancer on a population level. The presence of the NCT identifiers in claims for Medicare patients participating in clinical trials is likely to improve over time with increasing adherence with the Centers for Medicare & Medicaid Services mandate.
Collapse
|
17
|
Mitchell AP, Meza AM, Farooki A, Panageas K, Bach PB, Lipitz-Snyderman A, Morris MJ. Use of bone modifying agents for metastatic castrate-resistant prostate cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
55 Background: Bone modifying agents (BMAs) prevent skeletal related events (SREs) among patients with metastatic, castrate-resistant prostate cancer (mCRPC) involving the bone. The utilization of BMAs among patients with mCRPC and bone metastasis has not been well defined, and the number of patients who may benefit but are undertreated is not known. We conducted this study to measure patterns of BMA among mCRPC patients. Methods: We used linked SEER cancer registry and Medicare claims data. Our cohort included men newly diagnosed with de-novo stage IV prostate adenocarcinoma during 2007-2015, with followup through 2016. We included those age > = 66 at diagnosis, had continuous enrollment in Medicare Parts A and B from 180 days prior to diagnosis through the outcome period and Part D from diagnosis through outcome period, and who received androgen deprivation therapy. We further limited the cohort to those who subsequently received a CRPC-defining therapy (eg., abiraterone, sipuleucel-T, docetaxel if occurring prior to CHAARTED trial results). We grouped the cohort according to those who did vs. did not have evidence of bone metastasis in claims. Our primary outcome was receipt of a BMA (zoledronic acid or denosumab) within 180 days of initiating a CRPC-defining therapy. Among patients who received BMAs after initiating CRPC therapy, we further characterized the time at which they first initiated a BMA. Results: Our sample included 1,303 patients, of which 85% had evidence of bone metastasis. Overall, 58% received a BMA within 180 days of initiating a CRPC-defining therapy. 66% of patients with evidence of bone metastasis received BMAs, compared to 16% of those without evidence. Of patients who received BMAs, 38% first received BMAs between 90 days prior to starting CRPC therapy and 180 days after; the remaining 62% were previously receiving BMAs during the castrate-sensitive phase of disease. Among patients with evidence of bone metastasis who initiated CRPC-defining therapy in 2007-2009, 65% received BMAs; this proportion was 69% and 64% for those began CRPC therapy during 2010-2013 and 2014-2016, respectively. Conclusions: Approximately two-thirds of patients with mCRPC and bone metastases received BMAs within 180 days of initiating a CRPC-defining therapy. In most cases BMA therapy was initiated while patients still had castrate-sensitive disease, for which BMAs are indicated only at lower doses for the prevention of osteoporotic fractures. Further work is needed to understand whether real-world dosing is in line with clinical indications, and whether the one-third of patients who did not receive BMA therapy appropriately reflects the proportion of patients with contraindications. Further work is also needed to characterize patient and provider factors associated with appropriate BMA use.
Collapse
|
18
|
Salz T, Mishra A, Gennarelli RL, Lipitz-Snyderman A, Moryl N, Tringale KR, Boudreau DM, Kriplani A, Jinna S, Korenstein D. Safety of opioid prescribing among older cancer survivors. Cancer 2022; 128:570-578. [PMID: 34633662 PMCID: PMC9377378 DOI: 10.1002/cncr.33963] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cancer survivors receive more long-term opioid therapy (LTOT) than people without cancer, but the safety of LTOT prescribing is unknown. METHODS Opioid-naive adults aged ≥66 years who had been diagnosed in 2008-2015 with breast, lung, head and neck, or colorectal cancer were identified with data from Surveillance, Epidemiology, and End Results cancer registries linked with Medicare claims. Survivors with 1 or more LTOT episodes (≥90 consecutive days) occurring ≥1 year after their cancer diagnosis and before censoring at hospice entry, another cancer diagnosis, 6 months before death, or December 2016 were included. The safety of prescribing during the first 90 days of the first LTOT episode was measured during follow-up. As a positive safety indicator, the proportion of survivors with concurrent nonopioid pain management was measured. Indicators of less safe prescribing were the proportion of survivors with a high average daily opioid dose (≥90 morphine milligram equivalents) and the proportion of survivors with concurrent benzodiazepine dispensing. Multivariable logistic regression analyses were conducted to identify clinical predictors of each safety outcome. RESULTS In all, 3628 cancer survivors received LTOT during follow-up (median duration, 4.9 months; interquartile range, 3.5-8.0 months). Seventy-two percent of the survivors received multimodal pain management concurrently with LTOT. Eight percent of the survivors had high-dose opioid prescriptions; 25% of the survivors received benzodiazepines during LTOT. Multivariable analyses identified variations in safety measures by multiple clinical factors, although none were consistently significant across outcomes. CONCLUSIONS To improve safe LTOT prescribing for survivors, efforts should focus on increasing multimodal pain management and reducing inappropriate benzodiazepine prescribing. Different clinical predictors of each outcome suggest different drivers of safe prescribing.
Collapse
|
19
|
Weingart SN, Atoria CL, Pfister D, Classen D, Killen A, Fortier E, Epstein AS, Anderson C, Lipitz-Snyderman A. Risk Factors for Adverse Events in Patients With Breast, Colorectal, and Lung Cancer. J Patient Saf 2021; 17:e701-e707. [PMID: 29419566 PMCID: PMC6078829 DOI: 10.1097/pts.0000000000000474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to identify risk factors associated with medical errors and iatrogenic injuries during an initial course of cancer-directed treatment. METHODS In this retrospective cohort study of 400 patients 18 years or older undergoing an initial course of treatment for breast, colorectal, or lung cancer at a comprehensive cancer center, we abstracted patient, disease, and treatment-related variables from the electronic medical record. We examined adverse events (AEs) and preventable AEs by risk factor using the χ2 or Fisher exact tests. We estimated the association between risk factors and the relative risk of an additional AE or preventable AE in multivariable negative binomial regression models with backwards selection (P < 0.1). RESULTS There were 304 AEs affecting 136 patients (34%) and 97 preventable AEs affecting 53 patients (13%). In multivariable analyses, AEs were overrepresented in those with lung cancer compared with patients with breast cancer (incident rate ratio = 1.9, 95% confidence interval = 1.1-3.2). Nonwhite race (1.6, 1.0-2.6), Hispanic or Latino ethnicity (2.0, 0.9-4.1), advanced disease (1.7, 1.1-2.6), use of each additional class of high-risk nonchemotherapy medication (1.6, 1.3-1.9), and chemotherapy (2.1, 1.3-3.3) were all associated with risk of an additional AE. Preventable AEs were associated with lung cancer (7.4, 2.4-23.2), Hispanic or Latino ethnicity (5.5, 1.7-17.9), and high-risk nonchemotherapy medications (1.5, 1.2-2.0). CONCLUSIONS Risk factors for AEs among patients with cancer reflected patients' underlying disease, cancer-directed therapy, and high-risk noncancer medications. The association of AEs with ethnicity merits further research. Risk factor models could be used prospectively to identify patients with cancer at increased risk of harm.
Collapse
|
20
|
Saadat LV, Schofield E, Bai X, Curry M, Lipitz-Snyderman A, Jarnagin WR, Wright FC, Irish JC, Coburn NG, Wei AC. Healthcare System Variability in Pancreatic Cancer Treatment and Outcomes: A Comparative Analysis Between the US and Ontario. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
21
|
Mitchell AP, Mishra A, Panageas KS, Lipitz-Snyderman A, Bach PB, Morris MJ. Real-World Use of Bone Modifying Agents in Metastatic Castration-Sensitive Prostate Cancer. J Natl Cancer Inst 2021; 114:419-426. [PMID: 34597380 DOI: 10.1093/jnci/djab196] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/10/2021] [Accepted: 09/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bone modifying agent (BMA) therapy is recommended for metastatic castration-resistant prostate cancer (mCRPC) but not metastatic castration-sensitive prostate cancer (mCSPC). BMA treatment in mCSPC may therefore constitute overuse. METHODS In this retrospective cohort study using linked Surveillance, Epidemiology, and End Results-Medicare data, we included patients diagnosed with stage IV prostate adenocarcinoma from 2007-2015, who were age ≥66 years at diagnosis and received androgen deprivation or antiandrogen therapy. We excluded patients who had previously received BMAs or had existing osteoporosis, osteopenia, hypercalcemia, or prior bone fracture. The primary outcome was receipt of BMA (zoledronic acid or denosumab) within 180 days of diagnosis (emergence of CRPC within this time frame is unlikely). Secondary outcome was BMA within 90 days. Exposures of interest included practice location (physician office vs. hospital outpatient) and specialty (medical oncologist vs. urologist) of treating physician. RESULTS Our sample included 2,627 patients, of which 52.9% were treated by medical oncologists and 47.1% by urologists; 77.7% and 22.3% received care in physician office and hospital outpatient locations, respectively. Overall, 23.6% received a BMA within 180 days; 18.4% did within 90 days. BMA therapy was more common among patients treated by oncologists (odds ratio = 8.23, 95% confidence interval = 6.41 to 10.57) and in physician office locations (odds ratio = 1.33, 95% confidence interval = 1.06 to 1.69). Utilization has increased: 17.3% of patients received BMAs from 2007-2009 (17.3% zoledronic acid, 0% denosumab), and 28.1% from 2012-2015 (8.4% zoledronic acid, 20.3% denosumab). CONCLUSIONS Among mCSPC patients who had no evidence of high osteoporotic fracture risk, over one-quarter received BMAs in recent years. This overuse may lead to excess costs and toxicity.
Collapse
|
22
|
Mathis NJ, Yang JT, Vaynrub M, Santos Martin E, Kotecha R, Panoff J, Salner AL, McIntosh AF, Gupta R, Gulati A, Yerramilli D, Xu A, Bartelstein M, Guttmann D, Yamada Y, Pfister DG, Lin D, Lapen K, Lipitz-Snyderman A, Gillespie EF. Multidisciplinary consensus recommendations for the management of non-spine bone metastases: Results of a modified Delphi process in a community-academic partnership. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e24092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24092 Background: Local therapy for bone metastases is becoming increasingly complex, but national guidelines remain limited. We leveraged a community-academic partnership to develop consensus recommendations for multidisciplinary treatment of non-spine bone metastases which are generalizable to diverse practice settings. Methods: We convened a group of 15 physicians (9 radiation oncologists, 2 orthopaedic surgeons, 2 medical oncologists, 1 interventional radiologist, 1 interventional pain specialist) treating bone metastases across 4 institutions from Apr 2020-Feb 2021. We distributed a survey to identify questions warranting consensus development in the treatment of non-spine bone metastases. A literature review was conducted to inform answer statements, and evidence was rated using the Strength of Recommendation Taxonomy. A modified Delphi process was employed to reach consensus defined (a priori) as ³75% of respondents indicating “agree” or “strongly agree”. Results: A total of 16 questions were identified, including indications for multidisciplinary discussion or referral (n=4), appropriate use and duration of RT (n=4), and handling of systemic therapies during RT (n=5). After 2 rounds of modified Delphi process, consensus has been reached on 9 questions (see Table). Strength of Recommendation was rated A (1/9, 11%), B (5/9, 56%), or C (3/9, 33%). Conclusions: Our consensus process provides guidance for management of non-spine bone metastases that expands upon current guidelines. We also highlight areas where prospective trials are needed, including the role of RT prior to stabilization surgery and the selection of patients for ablative treatment. [Table: see text]
Collapse
|
23
|
Lipitz-Snyderman A, Vater L, Curry M, Li D, Rubin DM, Radzyner M, Duck E, Bach PB, Schenker Y. Cancer hospital advertising and outcomes: trust the messenger? Lancet Oncol 2020; 20:760-762. [PMID: 31162089 DOI: 10.1016/s1470-2045(19)30316-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 12/23/2022]
|
24
|
Salz T, Lavery JA, Lipitz-Snyderman A, Boudreau D, Moryl N, Gillespie EF, Korenstein D. Chronic opioid therapy among a high-risk cancer survivor population. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19107 Background: Head and neck cancer (HNC) survivors are at increased risk of opioid dependence, due to exposure to opioids during treatment, history of tobacco and alcohol use, and substantial pain after treatment. Chronic opioid therapy (COT) is a risk factor for dependence, and rates of COT vary widely between populations of cancer survivors. We hypothesized that COT use is greater among HNC survivors than among those who never had cancer. Methods: We used SEER-Medicare to identify adults ≥66 years diagnosed with HNC between 2008 and 2015. HNC survivors were matched 1:3 at date of diagnosis on age, sex, comorbidity, and region with cancer-free controls. Survivors and controls had complete coverage with fee-for-service Medicare Parts A, B, and D for each year after matching. Survivors and controls with no COT in the year prior to matching date and were followed for COT use through 2016. The presence of claims for opioid dispensings over ≥90 consecutive days (COT) was calculated for each year after cancer diagnosis among survivors alive at the start of each year and for controls. We computed odds ratios (OR) for COT use for HNC survivors compared to matched controls in each year after matching date, using a hierarchical logistic regression model accounting for matching and repeated measurements across years. Results: The population of HNC survivors declined from 5,107 in the year after diagnosis to 604 in Year 6. Among HNC survivors, COT use remained relatively steady each year after diagnosis. (Table). For the first 5 years after matching date, rates of COT among HNC survivors exceeded that of controls, with the difference between survivors and controls declining each year (OR 4.36 for Year 1, OR 2.60 for Year 2, OR 2.18 for Year 3, OR 1.85 for Year 4, and OR 1.35 for Year 5, all p-values < 0.05). By Year 6, rates of COT use did not differ between HNC cases and controls. Conclusions: In the first year after diagnosis, HNC survivors have more than 4 times the odds of COT use compared to cancer-free controls. Cancer-associated COT use declines over time. Strategies for appropriate pain management for HNC survivors should balance the risk of opioid dependence, particularly in the early years after diagnosis, with the benefit of improved comfort and function. [Table: see text]
Collapse
|
25
|
Salz T, Mishra AA, Gennarelli RL, Lipitz-Snyderman A, Boudreau D, Moryl N, Tringale KR, Korenstein D. Opioid safety among high-risk cancer survivors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e19169 Background: To mitigate risks of opioid-related harms, ASCO’s pain management guidelines for cancer survivors recommend that opioids be used in conjunction with other pharmacologic and non-pharmacologic approaches. The guidelines also recommend caution when prescribing opioids and benzodiazepines concurrently. We evaluated these 2 metrics of safe prescribing as applied to chronic opioid therapy (COT) among older survivors of head and neck cancer (HNC) and lung cancer (LC), two growing populations with high pain burden and prevalent risk factors for opioid-related harms (e.g., opioid use during treatment, history of substance use, distress). Methods: Using SEER-Medicare, we identified opioid-naïve adults diagnosed 2008-2015 with HNC or LC. We restricted analyses to survivors with ≥1 COT episode (≥90 days) occurring ≥1 year after cancer diagnosis and ≤120 days prior to hospice entry or cancer-related death (survivorship period). We report 2 opioid safety metrics during the survivorship period: 1) the proportion of survivors with non-opioid pain management (≥1 dispensing for a non-opioid, non-benzodiazepine pain medication or ≥1 claim for pain management procedure) concurrent with the first 90 days of the first COT episode and 2) the proportion of survivors with 0 dispensings for benzodiazepines within the first 90 days of the first COT episode. Results: Among opioid-naïve HNC (N = 5,500) and LC (N = 21,090) patients, 306 HNC (5.6%) and 927 LC survivors (4.4%) received COT during follow-up. Median duration of first survivorship COT episode was 5.2 and 4.9 months for HNC and LC, respectively. 64% of HNC survivors received non-opioid pain management concurrent with their first COT episode; 55% received an analgesic and 24% underwent a procedure. 75% of LC survivors received non-opioid pain management concurrent with their first COT episode; 67% received an analgesic and 35% underwent a procedure. 79% of HNC and 81% of LC survivors did not receive benzodiazepines during the first COT episode. Conclusions: Among older survivors of LC and HNC, less than 6% receive COT. However, of those, one-half of HNC survivors and more than a third of LC survivors receive guideline-discordant care by using COT without other pain management strategies or while using benzodiazepines. To minimize opioid-related harms, efforts should focus on improving safe COT prescribing practices for survivors. [Table: see text]
Collapse
|