Processes for identifying caregivers and screening for caregiver and patient distress in community oncology: results from WF-1803CD

BACKGROUND

Despite their vital roles, informal caregivers of adult cancer patients are commonly overlooked in cancer care. This study describes processes for identifying cancer caregivers and processes for distress screening and management among caregivers and patients in the understudied community oncology setting.

METHODS

Supportive care leaders from the National Cancer Institute Community Oncology Research Program practices completed online survey questions regarding caregiver identification, caregiver and patient distress screening, and distress management strategies. We described practice group characteristics and prevalence of study outcomes. Multivariable logistic regression explored associations between practice group characteristics and caregiver identification in the electronic health record (EHR).

RESULTS

Most (64.9%, 72 of 111) supportive care leaders reported routine identification and documentation of informal caregivers; 63.8% record this information in the EHR. Only 16% routinely screen caregivers for distress, though 92.5% screen patients. Distress management strategies for caregivers and patients are widely available, yet only 12.6% are routinely identified and screened and had at least 1 referral strategy for caregivers with distress; 90.6% are routinely screened and had at least 1 referral strategy for patients. Practices with a free-standing outpatient clinic (odds ratio [OR] = 0.29, P = .0106) and academic affiliation (OR = 0.01, P = .04) were less likely to identify and document caregivers in the EHR. However, higher oncologist volume was associated with an increased likelihood of recording caregiver information in the EHR (OR = 1.04, P = .02).

CONCLUSIONS

Despite high levels of patient distress screening and management, few practices provide comprehensive caregiver engagement practices. Existing patient engagement protocols may provide a promising platform to build capacity to better address caregiver needs.

Modified CARG score using data from the electronic health record to predict chemotherapy toxicity in older adults

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Background: Older adults starting chemotherapy are at greater risk of toxicity compared with younger patients. Additional tools are needed to aid in management decisions for this population. The Cancer and Aging Research Group (CARG) chemotherapy toxicity calculator is one such tool, which stratifies older adults into high, intermediate, or low risk for chemotherapy toxicity (Hurria, A., Mohile, S., Tew, W. P., & et al. (2016). Validation of a prediction tool for chemotherapy toxicity in older adults with cancer. Journal of Clinical Oncology, 34(20), 2366–2371. https://doi.org/10.1200/jco.2015.65.4327). This tool relies on a face-to-face encounter to ask questions, e.g. “How is your hearing?” or “Can you take your own medicines?” in addition to lab values such as hemoglobin and creatinine clearance. We modified the CARG chemo toxicity calculator to include data points which could be pulled from the electronic health record (EHR) without the need for a face-to-face encounter to assess for an association with emergency department (ED) visits and hospital admissions. Methods: Retrospective data analysis was conducted using the EHR of patients over age 65 diagnosed with a solid tumor from 1/1/2019 to 12/31/2020 who started chemotherapy. A modified CARG score was calculated using age, cancer type, number of drugs, hemoglobin, creatinine clearance, and falls within the past 6 months. The remaining items needed to calculate the complete CARG score were excluded since they were not accessible in the EHR. We assessed ED visits leading to admission, ED visits leading to discharge, direct admissions, and the total of all 3 visit types for all patients. Results: A modified CARG score was calculated for 763 patients. Multiple models were evaluated and negative binomial distribution was found to be the best fitted for our data. For every one unit increase in our calculated score the number of ED visits which lead to hospital admission increased by 6% (p-value = 0.0156). Additionally, there was a 5% increase in combined ED visits, ED visits leading to admission, and direct admissions for every one unit increase in risk score (p-value = 0.0063). ED visits that did not lead to admission were found not to have an association with the risk score (p-value= 0.1263). (Table) Conclusions: A modified CARG score using data obtained from patients’ EHR had a statistically significant association with increased ER visits that resulted in hospital admission and with the total of ED visits leading to admission, ED visits leading to discharge, direct admissions. Using these outcomes as a surrogate for toxicity, we deduce that a simple tool could be used to predict chemotherapy toxicity in older adults. [Table: see text]

Caregiver engagement practices in National Cancer Institute Clinical Oncology Research Program settings: Implications for research to advance the field

BACKGROUND

Supportive care interventions have demonstrated benefits for both informal and/or family cancer caregivers and their patients, but uptake generally is poor. To the authors' knowledge, little is known regarding the availability of supportive care services in community oncology practices, as well as engagement practices to connect caregivers with these services.

METHODS

Questions from the National Cancer Institute Community Oncology Research Program (NCORP)'s 2017 Landscape Survey examined caregiver engagement practices (ie, caregiver identification, needs assessment, and supportive care service availability). Logistic regression was used to assess the relationship between the caregiver engagement outcomes and practice group characteristics.

RESULTS

A total of 204 practice groups responded to each of the primary outcome questions. Only 40.2% of practice groups endorsed having a process with which to systematically identify and document caregivers, although approximately 76% were routinely using assessment tools to identify caregiver needs and approximately 63.7% had supportive care services available to caregivers. Caregiver identification was more common in sites affiliated with a critical access hospital (odds ratio [OR], 2.44; P = .013), and assessments were less common in safety-net practices (OR, 0.41; P = .013). Supportive care services were more commonly available in the Western region of the United States, in practices with inpatient services (OR, 2.96; P = .012), and in practices affiliated with a critical access hospital (OR, 3.31; P = .010).

CONCLUSIONS

Although many practice groups provide supportive care services, fewer than one-half systematically identify and document informal cancer caregivers. Expanding fundamental engagement practices such as caregiver identification, assessment, and service provision will be critical to support recent calls to improve caregivers' well-being and skills to perform caregiving tasks.

Feasibility of blood testing combined with PET-CT to screen for cancer and guide intervention

Cancer treatments are often more successful when the disease is detected early. We evaluated the feasibility and safety of multicancer blood testing coupled with positron emission tomography-computed tomography (PET-CT) imaging to detect cancer in a prospective, interventional study of 10,006 women not previously known to have cancer. Positive blood tests were independently confirmed by a diagnostic PET-CT, which also localized the cancer. Twenty-six cancers were detected by blood testing. Of these, 15 underwent PET-CT imaging and nine (60%) were surgically excised. Twenty-four additional cancers were detected by standard-of-care screening and 46 by neither approach. One percent of participants underwent PET-CT imaging based on false-positive blood tests, and 0.22% underwent a futile invasive diagnostic procedure. These data demonstrate that multicancer blood testing combined with PET-CT can be safely incorporated into routine clinical care, in some cases leading to surgery with intent to cure.

Building a real-time clinical dashboard to identify and target supportive care interventions in patients with cancer: The Lung Cancer Report Card (LCRC)

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Background: Many studies aiming to improve supportive care of patients with cancer have been single or bundled large population intervention(s). Potential use of unified clinical data architectures has not been realized in oncology, despite large patient-specific data sources generated during routine clinical care (electronic health records). Such systems can systematically apply clinical algorithms and data analytics to identify care gaps in individual patients with specific needs. Methods: Utilizing a design-think paradigm, we developed the LCRC, a near real-time interactive dashboard identifying actionable care gaps in all patients with lung cancer currently followed at Geisinger. Using an iterative process, data analysts served an expanded role in clinical delivery of targeted supportive oncology care, including recommending measures of risk for admission. Results: The table shows aggregate data as of 6/30/2019. Using the LCRC, we were able to identify 174 open care gaps in a population of 1199 active patients. We were also able to identify ‘high-risk’ clinical features in individual patients and the entire patient population. This was completed with analytics alone, without the need for lengthy chart review. Conclusions: By utilizing a population health view, the health system can more accurately estimate resources needed to better address patient needs. The LCRC can be used to directly determine the choice of supportive care interventions for specific patients with lung cancer. [Table: see text]

QOL assessment integrated into the clinical care of cancer survivors to identify needs and direct care

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Background: Validated survey tools have been used to measure the quality of life (QOL) of patients treated for cancer, however, there are newer studies that have shown both an improvement in QOL, and improvement in overall survival using these tools. We integrated the Functional Assessment of Cancer Therapy – General Population (FACT-GP v.4) to direct the deployment of resources and interventions to improve the care of patients who have completed potentially curative therapy for cancer. Methods: This is an observational study of patients who received cancer therapy with curative intent in the last 18 months. The FACT-GP was administered by an RN via telephone. Patients contacted received and reviewed a Survivorship Care Plan (SCP) as defined by the American College of Surgeons Committee on Cancer. Patients who had a total score less than 60 on FACT-GP and/or had a score less than 12 on the Emotional Well-Being subscale (EWB) were considered high-risk and were referred to the Survivorship MDC for in-person evaluation. Results: From 10/1/2018 to 12/31/2018, 114 patients were referred to the cancer survivorship program. Of these, 64 (56%) patients had FACT-GP administered and were evaluated. 45 of these (70%) only completed the FACT-GP and received an SCP. 21 patients had a total score less than 60 and/or an EWB sub-score less than 12 and were identified as high-risk. 15 (72%) patients were seen in MDC, 4 (19%) patients were seen in conjunction with a scheduled appointment by the MDC team, 2 (9%) patients refused further evaluation. 66.7% of patients in the survivorship program were referred to Oncology Behavioral Health compared to 18.2% of all oncology patients. Survivorship patients in the cohort had a baseline utilization of the emergency department (ED) of 4.1% (10 of 241) from 1/1/2018 to 9/30/2018 and 0 (0 of 64) after the initiation of the intervention from 10/1/2018 to 12/31/2018. Conclusions: Integrating a validated QOL tool (FACT-GP) as a therapeutic intervention is feasible and may both identify needs and direct services for cancer survivors while possibly decreasing ED utilization. Clinical trial information: NCT03835052.

Total Mastectomy or Breast Conservation Therapy? How Radiation Oncologist Accessibility Determines Treatment Choice and Quality: A SEER Data-base Analysis

Mastectomy and breast conservation therapy (BCT) are equivalent in survival for treatment of early stage breast cancer. This study evaluated the impact of radiation oncologist accessibility on choice of breast conserving surgery (BCS) versus mastectomy, and the appropriate receipt of radiotherapy after BCS. In the National Cancer Institute Survival, Epidemiology, and End Results data base, the authors selected breast cancer cases from 2004 to 2008 with the following criteria: T2N1M0 or less, lobular or ductal histology, and treatment with simple or partial mastectomy. We combined the Health Resources and Services Administration Area Resource File to define average radiation oncologist density (ROD) by county over the same time period. We evaluated tumor characteristics, demographic information, and ROD with respect to BCS rates and receipt of radiation therapy after BCS in univariable and multivariable analyses. In 118,773 cases analyzed, mastectomy was performed 33.2% of the time relative to BCS. After adjustment for demographic and tumor variables, the odds of having BCS versus mastectomy were directly associated with ROD (multiplicative change in odds for a single unit increase in ROD [95% CI] = 1.02 [1.01-1.03]; p < 0.001). Adjuvant radiation therapy was not administered in 28.2% of BCS cases. When adjusting for demographic and tumor variables, the odds of having BCS without adjuvant radiation were inversely associated with ROD (0.95 [0.94-0.97]; p < 0.001). We observed a direct relationship between ROD and BCS rates independent of demographic and tumor variables, and an inverse trend for omission of radiotherapy after BCS. Access to radiation oncologists may represent an important factor in surgical choice and receiving appropriate BCT in early stage breast cancer.

Outpatient implementation of a patient self-reported symptom system in an integrated health system

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Background: To date, process-related outcomes dominate the landscape of the measurement of quality of oncologic care. Use of patient-reported outcomes has the potential to enhance value-based performance measurement. We performed a pilot study of integrating patient-reported data (PRD), into the daily work-flow of outpatient oncology clinics in an integrated health system, Geisinger Health System (GHS). Methods: All patients in the pilot were asked their pain scores by nurses according to existing procedures. In addition, the MD Anderson Symptom Inventory (MDASI) questionnaire was given to patients via touch screens in exam rooms. Four oncologists participated in the study at two sites. The study was reviewed by the GHS IRB and was granted exemption status. Results: 63 patients successfully used the touch screen monitors to complete the MDASI with minimal impact to clinic flow. Compared to the existing EHR-prompted nursing-collected pain score method, the PRD/MDASI method identified an additional 31% of patients with severe pain who were previously identified as having “no pain” (Table). 75% of patients identified as having “moderate pain” by the current method report “severe pain” by the PRD method. Conclusions: This pilot study demonstrates that the collection of PRD can be integrated into routine oncological clinic workflows with minimal interference with clinical flow. The study also shows that the collection of PRD may be superior to clinician screening at the time of the encounter alone. GHS will integrate PRD fully into its EHR in August 2014. GHS is developing evidence-based, standardized symptom management protocols and expanding the use of PRD in clinical care. [Table: see text]

Temozolomide in non-small-cell lung cancer: preliminary results of a phase II trial in previously treated patients

Virtually all patients with advanced non-small-cell lung cancer (NSCLC) relapse. Docetaxel has an established, Food and Drug Administration-approved role as salvage therapy in previously treated, platinum-exposed patients. However, the response rate in phase III studies is < 15%, and median survival is only 6-8 months. Temozolomide, a novel triazene derivative with activity in melanoma and anaplastic astrocytoma, has demonstrated activity in C26 adenocarcinoma, Lewis lung cancer, and in phase I studies. A phase II trial was mounted using a unique schedule of oral temozolomide 75 mg/m2 daily for 6 weeks every 8-10 weeks, in patients with previously treated, advanced, incurable NSCLC. Eligibility stipulated an Eastern Cooperative Oncology Group performance status (PS) of 0-2, adequate end organ function, up to 1 prior chemotherapy for advanced (relapsed or metastatic) disease, and up to 1 prior regimen in the context of radiosensitization, adjuvant therapy, or induction. From March 2000 through January 2002, 47 patients (24 male, 23 female) were enrolled. The median age was 67 years. Sixteen patients had a PS of 2, 22 had a PS of 1, and 9 had a PS of 0. It was too early to evaluate 9 patients. Toxicity, with the exception of mild nausea and thrombocytopenia, was negligible. Three patients had a delayed recovery of platelets prompting discontinuation of treatment. Of the 38 evaluable patients, 1 patient had a complete response, 2 patients had a partial response, 12 had stable disease, and 19 had disease progression. Four patients were not evaluable. Six patients died within 30 days of taking temozolomide; 5 of these deaths were not related to treatment upon review by an independent data safety monitoring committee. Temozolomide, using a unique 6-week continuous schedule, has demonstrated activity in the salvage therapy of advanced NSCLC. Toxicity is modest, and accrual to this study continues.