Healthcare providers' experiences of continuing care for older adults with cancer during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic has caused great strain on older adults with cancer and their healthcare providers. This study explored healthcare providers' reported changes in cancer care, clinical barriers to care, patient questions, and the overall experiences of caring for older adults with cancer during the COVID-19 crisis.

METHODS

The Advocacy Committee of the Cancer and Aging Research Group and the Association of Community Cancer Centers developed a survey for healthcare providers of adults with cancer, inquiring about their experiences during the pandemic. Responses from the survey's four open-ended items were analyzed by four independent coders for identification of common themes using deductive and inductive methods.

RESULTS

Participants (n = 137) represented a variety of demographic and clinical experiences. Six overall themes emerged, including (1) telehealth use, (2) concerns for patient mental health, (3) patient physical and social isolation, (4) patient fear of contracting COVID-19, (5) continued disruptions to cancer care, and (6) patients seeking guidance, particularly regarding COVID-19 vaccination. Questions fielded by providers focused on the COVID-19 vaccination's safety and efficacy during older adults' cancer treatment.

CONCLUSIONS

Additional resources (e.g., technology support, established care guidelines, and sufficient staffing) are needed to support older adults with cancer and healthcare providers during the pandemic. Future research should explore universally effective in-person and virtual treatment strategies for older adults with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Persistence of telehealth barriers, particularly a lack of infrastructure to support telehealth visits, social isolation, and restrictive visitor policies as a result of COVID-19, negatively impacted the mental health of older adults with cancer.

Barriers to Clinical Trial Implementation Among Community Care Centers

Importance

While an overwhelming majority of patients diagnosed with cancer express willingness to participate in clinical trials, only a fraction will enroll onto a research protocol.

Objective

To identify critical barriers to trial enrollment to translate findings into actionable practice changes that increase cancer clinical trial enrollment.

Design, Setting, and Participants

This survey study included designated site contacts at oncology practices with teams who were highly involved with the Association of Community Cancer Centers (ACCC) Community Oncology Research Institute (ACORI) clinical trials activities, all American Society of Clinical Oncology (ASCO)-ACCC collaboration pilot sites, and/or sites providing care to at least 25% African American and Hispanic residents. To determine participation trends among health care practices in oncology-focused research, identify barriers to clinical trial implementation and operation, and establish unmet needs for cancer clinics interested in trial participation, a 34-question survey was designed. Survey questions were defined within 3 categories: cancer center demographic characteristics, clinical trial characteristics, and referral practices. The survey was distributed through email and was open from June 20 through October 5, 2022.

Main Outcomes and Measures

Participation in and barriers to conducting oncology trials in different community oncology settings.

Results

The survey was distributed to 100 cancer centers, with completion by 58 centers (58%) across 25 states. Fifty-two centers (88%) reported that they conduct therapeutic clinical trials, of which 33 (63%) were from urban settings, 11 (21%) were from suburban settings, and 8 (15%) were from rural settings. Only 25% of rural practices (2 of 8) offered phase 1 trials, compared with 67% of urban practices (22 of 33) (P = .01). Respondents noted challenges in conducting research, including patient recruitment (27 respondents [52%]), limited staffing (27 [52%]), and nonrelevant trials for their patient population (25 [48%]). Among sites not offering therapeutic trials, barriers to research conduct included limited infrastructure, funding, and staffing. Most centers (46 of 58 [79%]) referred patients to outside centers for clinical trial enrollment, particularly in the context of late-stage disease and/or disease progression. Only 17 of these sites (37%) had established protocols for patient follow-up subsequent to outside referral.

Conclusions and Relevance

In this national survey study of barriers to clinical trial implementation, most sites offered therapeutic trials, but there were significant disparities in trial availability across care settings. Furthermore, fundamental deficiencies in trial support infrastructure limited research activity, including within programs currently conducting research as well as at sites interested in future clinical research opportunities. These results identify crucial unmet needs for oncology clinics to effectively offer clinical trials to patients seeking care.

Identifying Key Barriers for Radiation Oncology Financial Advocacy Programs

PURPOSE/OBJECTIVE(S)

Financial toxicity is a devastating outcome for patients with cancer and can impact their treatment adherence and health outcomes. One survey reveals that most radiation oncologists are "very concerned" with the negative impact treatment-related costs have on patients, and another survey found that more than 20 percent of patients experience financial toxicity related to their radiation therapy treatment. Financial advocates within cancer programs and practices can help mitigate patients' financial toxicity by supporting shared decision-making and helping with treatment cost planning. In 2022, ACCC set out to explore how financial advocates in radiation oncology provide financial navigation to patients with cancer and address the challenges they may face. Identify barriers to financial toxicity mitigation and treatment access challenges for patients with cancer undergoing radiation therapy.

MATERIALS/METHODS

ACCC worked with an expert multidisciplinary Financial Advocacy Network Advisory Committee to conduct two, semi-structured discussion sessions on financial advocacy in radiation oncology. Prepared discussion topics included challenges and opportunities in delivering financial advocacy services, financial barriers to care and strategies to mitigate financial toxicity, and processes for prior authorizations and claim denials in the radiation oncology setting.

RESULTS

Twenty-one participants attended the first session, and 17 participants attended the second session. Participants included financial navigators and counselors, oncology social workers, nurse navigators, and cancer program or practice administrators. Three major challenges emerged from both sessions: (1) Inadequate financial assistance from independent, charitable foundations to help pay for patients' deductibles, additional radiation treatment out-of-pocket costs, and care-related transportation costs. (2) Lack of best practices to handle prior authorization and avoid denials. (3) Lack of preparedness for changes imposed by the Radiation Oncology (RO) Model, which would impact care planning.

CONCLUSION

Many cancer programs and practices have implemented financial advocacy services but remain restricted in the available assistance for radiation therapy patients. Radiation therapy represents a significant component of anti-cancer treatment and addressing the lack of financial support for patients is critical to improving patients' treatment adherence and health outcomes. Payment policies must be reformed to address complex prior authorization requirements and patients would benefit from greater financial support for radiation treatment and costs of wrap-around supportive services.

Healthcare providers' attitudes towards delay in cancer treatment during COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has created unprecedented obstacles leading to delays in treatment for older adults with cancer. Due to limited resources at the height of the pandemic, healthcare providers were constantly faced with ethical dilemmas regarding postponing or rescheduling care for their patients.

MATERIALS AND METHODS

Two survey-based studies were conducted at different time-points during the pandemic looking at factors affecting oncology care providers' attitudes towards delay in treatment for older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. Change in provider attitude over time was analyzed by comparing responses from the 2020 and 2021 surveys. Data analysis included descriptive statistics and chi-squares.

RESULTS

In 2020, 17.5% of respondents were strongly considering/considering postponing cancer treatment for younger patients (age 30 and below), while 46.2% were considering delaying treatment for patients aged >85. These responses were in stark contrast to the results of the 2021 survey, where only 1.4% of respondents strongly considered postponing treatment for younger patients, and 13.5% for patients aged >85.

DISCUSSION

All recommendations to postpone treatment for older adults with cancer must be made after mutual discussion with the patient. Throughout the COVID-19 pandemic, oncology care providers had to consider multiple factors while treating patients, frequently making most decisions without appropriate institutional support.

Differences in urban and suburban/rural settings regarding care provision and barriers of cancer care for older adults during COVID-19

PURPOSE

Care for older adults with cancer became more challenging during the COVID-19 pandemic, particularly in urban hotspots. This study examined the potential differences in healthcare providers' provision of as well as barriers to cancer care for older adults with cancer between urban and suburban/rural settings.

METHODS

Members of the Advocacy Committee of the Cancer and Aging Research Group, with the Association of Community Cancer Centers, surveyed multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Respondents were recruited through organizational listservs, email blasts, and social media messages. Descriptive statistics and chi-square tests were used.

RESULTS

Complete data was available from 271 respondents (urban (n = 144), suburban/rural (n = 127)). Most respondents were social workers (42, 44%) or medical doctors/advanced practice providers (34, 13%) in urban and suburban/rural settings, respectively. Twenty-four percent and 32.4% of urban-based providers reported "strongly considering" treatment delays among adults aged 76-85 and > 85, respectively, compared to 13% and 15.4% of suburban/rural providers (Ps = 0.048, 0.013). More urban-based providers reported they were inclined to prioritize treatment for younger adults over older adults than suburban/rural providers (10.4% vs. 3.1%, p = 0.04) during the pandemic. The top concerns reported were similar between the groups and related to patient safety, treatment delays, personal safety, and healthcare provider mental health.

CONCLUSION

These findings demonstrate location-based differences in providers' attitudes regarding care provision for older adults with cancer during the COVID-19 pandemic.

Enhancing Coordination Around Cancer Biomarker and Hereditary Genetic Testing Among Members of the Multidisciplinary Care Team

Introduction/Objective

Advances in precision medicine necessitate a closer integration across pathologists, genetic counselors, and other members of the multidisciplinary cancer care team (MDT). Recognizing that physical distancing and fragmented communication may hinder care delivery, the Association of Community Cancer Centers (ACCC) ran a multi-year initiative to explore ways to improve MDT care coordination.

Methods/Case Report

ACCC held a multistakeholder leadership summit to identify and discuss critical issues regarding biomarker and hereditary genetic testing and the ways in which pathology and genetic counseling professionals interface with the cancer MDT. Through a consensus-driven process, participants identified key opportunities for achieving optimal integration. ACCC also conducted a national survey to explore barriers around biomarker and hereditary genetic testing. Building off these insights, ACCC conducted virtual workshops at three community cancer programs to improve processes around biomarker testing and targeted treatment planning.

Results (if a Case Study enter NA)

The pathology leadership summit identified the following priorities: 1) streamline and standardize the biomarker test ordering process; 2) improve tissue handling to optimize timely biomarker testing; 3) strengthen communication between pathologists and genetic counselors; 4) empower pathologists with leadership opportunities. In the ACCC survey (n=659), 57% indicated that some or most of their pathologists were generalists. 21% only held one general tumor board. 6% indicated that pathologists often do not attend tumor boards or cancer committee meetings. 64% indicated that pathologists can directly access some or all medical oncology patient records. 67% sent some or most biopsy samples out for biomarker testing. In the ACCC workshops, cancer programs in KS, NC, and NV identified ways to improve the timeliness of genetic counseling referrals and coordinate biomarker testing. Following the workshops, 64% indicated they planned to make moderate or significant changes in their processes.

Conclusion

Improving collaboration across pathologists, genetic counselors, and the rest of the cancer MDT may lead to more timely and comprehensive biomarker and hereditary genetic testing. These findings may help cancer programs refine processes of care.

Reducing preventable ED visits in patients with advanced NSCLC: Collective insights from three cancer centers

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Background: While many patients with advanced NSCLC have complex medical needs, emergency department (ED) visits may be preventable if clinicians predict, identify and treat symptoms early and deliver outpatient interventions. The Association of Community Cancer Centers (ACCC) evaluated how cancer centers participating in a multi-phase initiative found ways to reduce preventable ED visits in patients with advanced NSCLC. Methods: After holding QI workshops, ACCC followed-up with three centers located in AL, OK, and OH. These centers aimed to improve lung cancer symptom management, patient education, and care coordination related to the CMS Measure #OP-35 diagnoses: dehydration, diarrhea, emesis, nausea, pain, or pneumonia. Results: Patient Education and Reminders: Patients who undergo systemic treatment often need to be reminded to call their medical oncology team if they develop symptoms. Examples of effective practices include: a patient education and reminder campaign to “call-first” before visiting the ED; wallet cards with phone numbers; and ongoing reminders whenever patients come for infusion or clinician visits. Intensive Care Coordination: Some patients with advanced NSCLC may be “high risk” for ED utilization (eg, co-morbidities, social determinants, etc.). Intensive care coordination delivered by nurses may be directed specifically at these patients. Interventions may include scheduled phone calls and/or telehealth visits to assess symptoms and coordinate outpatient interventions. Immune-related Adverse Events (irAEs): Patients with advanced NSCLC may receive immune checkpoint inhibitors which may cause irAEs. Colitis may lead to dehydration, diarrhea, emesis, nausea; pneumonitis may be misdiagnosed as pneumonia. One center began using a patient symptom questionnaire delivered by a nurse navigator and managed 94% of irAE symptoms in the outpatient setting. Another center surveyed ED providers to assess gaps in identifying irAE symptoms an formed a multidisciplinary irAE work group to discuss patient management and facilitate increased awareness and early recognition. These efforts led to a series of education programs for ED staff. Early Palliative Care: Since early palliative care is associated with reduced ED utilization, one center streamlined palliative care referrals in the outpatient setting by developing an electronic pathway. 91% of patients with advanced cancer enrolled after initial consult; only 24% made an ED visit. Conclusions: While many ED visits are necessary, some may be preventable, especially if members of the multidisciplinary cancer care team risk-stratify patients, proactively identify and empower patients to “call first,” treat symptoms early, and provide early palliative care. The collective insights from these cancer centers provide guidance around sustainable strategies that can potentially reduce preventable ED visits.

A mixed-methods study to identify key priorities around improving team-based care coordination for patients receiving combination IV and oral systemic anti-cancer therapy

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Background: When combination medical therapy incorporates both IV and oral anti-cancer agents, patients may experience compound side effects and face challenges with treatment adherence. To assess how community cancer programs may improve care coordination for patients receiving combination IV/oral systemic therapy, the Association of Community Cancer Centers (ACCC) conducted a mixed-methods study that involved healthcare professionals (HCPs), patients and caregivers. Methods: The study followed a sequential quantitative-qualitative design to answer questions around the barriers or challenges associated with combination IV/oral systemic therapy. The quantitative phase included an online survey of HCPs (by ACCC) and a survey of patients and caregivers (by Edge Research, in collaboration with several patient advocacy organizations). In the quantitative phase, the survey results were contextualized through two HCP focus groups and individual HCP interviews. Results: Comparing and contrasting the patient survey (n = 113) and HCP survey (n = 157) results revealed insights around the following themes: Top Challenges: Patients felt their top challenges were side effects (57.5%); inconvenience going to medical appointments (37.2%); and financial burden (36.3%). HCPs perceived top challenges as cost of care to the patient (24.0%); coordination and delivery of oral agents (22.1%); and health insurance coverage (21.9%). In focus groups, HCPs explained how they were investing significant staffing resources to prevent and mitigate financial toxicity, especially for patients receiving oral therapies. Methods of Communication: 35.4% of patients “highly preferred” using email to communicate with HCPs about their combination regimens. However, HCPs felt that email was one of the least effective methods of communicating with patients. In focus groups, HCPs agreed that email is convenient when communicating about non-urgent matters. However, they were concerned that some patients may use email to communicate about urgent issues. Treatment-related AEs: When patients experienced treatment-related AEs, 30.1% said their clinicians tried a dose modification or hold. HCPs had mixed perceptions regarding the effectiveness of dose holidays. Those who felt this was highly effective included: advanced practice providers (42.9%), nurses (28.1%); oncologists (16.7%); and pharmacists (16.7%). Conclusions: This study identifies opportunities to improve care coordination for patients receiving combination IV/oral systemic anti-cancer regimens. These findings may inform the creation and dissemination of effective practices and quality improvement projects. These results may also help cancer programs tailor resources and incorporate proactive steps to address some of the key challenges patients may face.

Defining key care events to integrate biomarker testing in the workup for patients with advanced non–small cell lung cancer (aNSCLC)

346

Background: Biomarker testing is critical in management of aNSCLC, but timely testing for newly diagnosed patients is challenging. Clinician and patient perspectives on barriers to timely biomarker testing for patients with health disparities have been reported (Boehmer et al 2021, 2022; Martin et al 2022). To address barriers, we are developing a novel intervention to integrate biomarker testing into aNSCLC workup using the 4R Oncology Model (Trosman et al 2016, 2021). The intervention facilitates timing and sequencing of key care events enabling biomarker testing as well as incorporating clinician and patient perspectives. We report care events which form the foundation of the intervention. Methods: We conducted focus groups with 12 clinicians at 3 Association of Community Cancer Centers (ACCC) member programs. Each clinician treats patients with NSCLC and socioeconomic and/or health disparities. Results: We identified 5 key care events facilitating biomarker testing that should be integrated into workup for patients newly diagnosed with aNSCLC (Table). For each event, we defined dependency to enable timing and sequencing of care and considerations for clinicians and patients. Conclusions: The 5 key care events, dependencies, and clinician and patient considerations represent a basis for incorporating biomarker testing into the aNSCLC workup that is both patient and clinician centric. Implementation and evaluation of the 4R Oncology model incorporating the 5 key care events are underway at 3 cancer centers.[Table: see text]

Use of the Delphi method to develop a guideline-based geriatric oncology gap assessment

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Background: Older adults are more likely to be diagnosed with cancer than their younger counterparts. Because the underlying health status of older adults with cancer is generally heterogeneous, geriatric assessment (GA) is helpful for uncovering age-related vulnerabilities and guiding subsequent care planning. GA provides multidimensional, multidisciplinary evaluations of pertinent health domains. When used to evaluate an older adult with cancer prior to initiating therapy, GA and screening tools can help oncologists differentiate between fit and frail patients and tailor their treatment accordingly. Methods: The Association of Community Cancer Centers (ACCC) conducted a 4-round Delphi method to achieve expert consensus (≥75%) related to 9 domains of geriatric oncology care from a multidisciplinary perspective. A survey was conducted with 70 international clinicians working in geriatric oncology to assess perspectives on guideline-recommended GA tools in clinical practice. Facilitator led focus groups were conducted to review the results in a large group format and come to consensus. Aggregated results were shared back with the group to ensure effective capture of group discussion regarding validated clinical practice tools to include as resources in the gap assessment instrument. Results: A 32 question geriatric oncology gap assessment was developed in an online survey platform. This tool was beta tested by 30 individuals at cancer programs of various types and regions across the US. A final version was published and made accessible for multidisciplinary teams to self-assess care delivery for older adults with cancer in 9 domains: Functional Status; Cognition; Comorbidities; Decision Making: Screening, Life Expectancy, Chemo Toxicity; Pharmacy/Medication Management; Psychological Health; Nutrition; Patient Goals and Needs; and Communication and Workforce Training. Within each domain, respondents select the level (see Table) that most closely represents the practice(s) at their institution. A personalized report is generated. Sample Question. Conclusions: The ACCC geriatric oncology gap assessment offers cancer programs a validated way to evaluate care delivery for older adults with cancer. To optimize workflow, cancer programs should consider utilizing gap assessment results to develop and advance scalable quality improvement programs at their institution, taking into consideration resource level and infrastructure.[Table: see text]

Assessing effectiveness of a self-guided training program for oncology financial advocates

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Background: Financial toxicity can be a devastating side effect for patients with cancer and their families, and may impact access to and delivery of care, treatment compliance, and outcomes. Financial advocates mitigate financial toxicity for patients and their families, liaise between payers/providers/pharmacies/patients, support shared decision-making and care planning processes through provision of cost and coverage information, and mitigate institutional financial toxicity. Training on effective financial navigation interventions, financial health literacy, patient engagement, oncology fundamentals, and measurement of impact is critical for advocates. Methods: The Association of Community Cancer Centers (ACCC) Financial Advocacy Boot Camp is a self-paced eLearning program consisting of 9 modules designed to build knowledge and skills of financial advocates. Users interact with education across two levels within the ACCC Learning Management System. To evaluate effectiveness of this content, pre- and post-assessments and evaluation forms for registered learners from 1/1/2020 to 12/31/20 were exported and exploratory analysis was performed on this data set of 538 participants. Results: 51% of respondents are oncology financial advocates; 7% are industry representatives; and the remaining 42% are a mix of patient navigators, nurse navigators, social workers, pharmacists, APPs, and nurses. 363 participants fully completed at least one of two levels. Most participants agreed or strongly agreed that each of the modules improved their knowledge and skills: 94% increased their ability to incorporate effective screening methods to identify patients at risk of financial toxicity, 95% are better able to review the evolving landscape of health insurance provided by public and private payers, and 97% both increased their ability to find patient assistance programs and resources for patients and can describe how to guide patients through the process of improving insurance coverage. 79% identified specific examples of what they will do differently after the training, including implementing screening and follow-up protocols, adjusting communication approaches with patients, proposing quality improvement projects, and accessing resources. Conclusions: Training, such as the Financial Advocacy Boot Camp, that builds knowledge and skills in financial screening, communication, and navigation can help cancer programs improve staffs’ ability to mitigate patient and institutional financial toxicity. Future research efforts should further define financial advocacy competencies, measure patient and institutional impact of financial navigation interventions, and assess effective practices for implementation of financial advocacy training in cancer programs.

Learnings from a multiphase, mixed-methods lung cancer quality initiative in U.S. community cancer centers

254

Background: Quality improvement (QI) in cancer care delivery requires understanding the setting, clearly defining problem(s), and identifying targeted solutions. The Association of Community Cancer Centers (ACCC) conducted a national project to identify and provide guidance on key issues in care for patients with stage III/IV non-small cell lung cancer (NSCLC). We report the problems and solutions identified after a mixed-methods baseline data evaluation. Methods: The multi-phase ACCC QI initiative was guided by an expert steering committee. A request for applications was advertised to all ACCC programs, with committee members ranking each site in pre-specified categories (ex., replicability, practice champion engagement). After selection of sites, baseline data assessed programs’ patient populations, current care delivery practices, processes of care, and biomarker testing rates. A full-day workshop was conducted with multidisciplinary team members and expert faculty to review baseline data, refine problem statements, and identify site-specific QI solutions. Results: The 6 participating US sites were regionally diverse with a rural/urban mix. In baseline data, median patient ages were 65-72 years and patients treated were 50% stage III/50% stage IV. Biomarker testing practices, use of multidisciplinary tumor board, and clinical care pathways varied across sites. Five key QI areas were identified: 1.Management of immune related adverse events (irAE), 2.Biomarker testing, 3.Emergency visit management (EVM), 4.Access to clinical trials, and 5.Smoking cessation. Two sites identified problems with irAE management during immunotherapy (IT). The first identified needs for proactive symptom identification, assessment, and management. Solutions included: 1. a patient questionnaire to identify early signs of irAEs and 2. pilot testing a nurse-administered questionnaire. A second site identified that front-line clinicians may not be properly identifying possible irAEs. Solutions included: 1. form an IT toxicity working group and 2. educate front-line clinicians about irAEs. Two sites focused on biomarker testing. The first problem identified was inefficient tracking of testing results. Solutions were: 1. assign a nurse navigator to track, enter, and communicate test results and 2. proactively coordinate appointments for patients with positive test results. The second site identified delayed care when inadequate tissue was obtained. Solutions included: 1. pathology-driven reflex testing and 2. liquid biopsy order at diagnosis. Similar problems/solutions were developed for EVM, clinical trial access, and smoking cessation. Conclusions: Challenges in lung cancer care delivery can be identified and addressed using an intentional QI approach. Clearly defining the problem and identifying potential solution(s) are critical steps and should occur before implementation.

Survey of cancer care providers' attitude toward care for older adults with cancer during the COVID-19 pandemic

OBJECTIVES

Care for older adults with cancer became more challenging during the COVID-19 pandemic. We sought to examine cancer care providers' attitudes toward the barriers and facilitators related to the care for these patients during the pandemic.

MATERIALS AND METHODS

Members of the Advocacy Committee of the Cancer and Aging Research Group, along with the Association of Community Cancer Centers, developed the survey distributed to multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Participants were recruited by email sent through four professional organizations' listservs, email blasts, and messages through social media.

RESULTS

Complete data was available from 274 respondents. Only 15.4% had access to written guidelines that specifically address the management of older adults with cancer during the COVID-19 pandemic. Age was ranked fifth as the reason for postponing treatment following comorbid conditions, cancer stage, frailty, and performance status. Barriers to the transition to telehealth were found at the patient-, healthcare worker-, and institutional-levels. Providers reported increased barriers in accessing basic needs among older adults with cancer. Most respondents agreed (86.3%) that decision making about Do Not Resuscitate orders should be the result of discussion with the patient and the healthcare proxy in all situations. The top five concerns reported were related to patient safety, treatment delays, healthcare worker mental health and burnout, and personal safety for family and self.

CONCLUSION

These findings demand resources and support allocation for older adults with cancer and healthcare providers during the COVID-19 pandemic.

Shared decision-making attitudes and practices in multidisciplinary cancer care teams

180

Background: Patients who engage in decision making are more likely to experience confidence in treatment decisions, satisfaction with treatment, and trust in clinicians. The Association of Community Cancer Centers (ACCC) conducted a survey to explore multidisciplinary team attitudes and practices around shared decision-making (SDM) and health literacy. Methods: ACCC convened a steering committee of multidisciplinary specialists and advocacy representatives to guide this research. The survey included 26 mostly closed-ended questions and was open to multidisciplinary cancer programs from 10/29/19 to 2/20/20. Exploratory analysis was performed on this data set of 305 complete responses. Results: While most respondents reported engaging patients in decision-making to some degree, only 50% reported that SDM is a top organizational priority. 33% reported organizational efforts to formally integrate SDM into the clinical workflow, with only 15% indicating staff opportunities for basic SDM training. The three most frequently cited perceived barriers to engaging in SDM were patients feeling overwhelmed (53%), wanting to defer decisions to clinicians (46%), and having limited health literacy (46%). Only 13% indicated that lack of time was a barrier. Less than half (41%) of respondents reported using patient decision aids to support SDM. Respondents represented a wide range of multidisciplinary team members, though surgical oncologists and general surgeons (20% and 16% respectively) are overrepresented in the results. Conclusions: SDM is commonly accepted as essential to patient engagement but clarity in terminology and prioritizing formal integration of SDM into practice is limited. Strategies to improve integration of SDM into oncology practice should include: 1) Educational initiatives and tools to overcome barriers to SDM, including patient decision aids and SDM training, 2) Initiatives to address health literacy as it relates to patient and caregiver engagement in decision making, 3) Psychosocial support for patients whose emotional upset is a barrier to SDM, 4) Healthcare policies that encourage and incentive providers to engage in SDM. Future analyses will require concurrent assessment of patient, caregiver, healthcare professional, and administrator perspectives.

Experiences of healthcare providers of older adults with cancer during the COVID-19 pandemic

Objectives

Care for older adults with cancer became more challenging during the COVID-19 pandemic. We sought to examine healthcare providers' clinical barriers, patient questions, and overall experiences related to care delivery for these patients during the pandemic.

Materials and methods

Members of the Advocacy Committee of the Cancer and Aging Research Group along with the Association of Community Cancer Centers developed a 20-question survey for healthcare providers of older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. This manuscript reports the qualitative data from the survey's three open-ended questions. Free text, open-ended survey items were analyzed by two independent coders for identification of common themes using NVivo software. Theme agreement was reached through consensus and count comparisons of participant responses were made.

Results

Healthcare system organizational challenges and meeting basic needs and support were commonly reported themes among respondents (n = 274). Barriers to care delivery included organizational challenges, patients' access to resources and support, concerns for patients' mental and physical health, and telehealth challenges. Respondents reported older adults were asking about their health and cancer care as well as access to basic needs and supports. Providers described worrying about patients' mental health, fear of personal safety, frustration in multi-level institutions, as well as experiencing positive leadership and communication.

Conclusion

Providers are faced with balancing their concerns for personal and patient safety. These findings demand resources and support allocation for older adults with cancer and healthcare providers during the COVID-19 pandemic.

GERIATRIC ASSESSMENT ADOPTION IN COMMUNITY CANCER CENTERS: TRENDS, BARRIERS, AND RECOMMENDATIONS

Addressing the needs of older adults with cancer is critical for the delivery of high-quality, patient-centered care. The Association of Community Cancer Centers (ACCC) has identified barriers and best practices for serving this growing patient population in order to help support the multidisciplinary team in understanding and proactively preparing for this large subgroup of patients. A survey was administered to 332 cancer professionals. 95% agreed that their older adult patients would benefit from a comprehensive geriatric assessment, yet only 17% of respondents are performing CGAs. 74% of respondents are not using any screening tool to identify high risk patients. The top three barriers to this were time/personnel and limited familiarity with available, validated tools. 61% are not focused on increasing older adult participation in clinical trials which leads to a disparity in care. Techniques for evaluating fitness, cognitive status, psychological status, comorbidities, and toxicity risk were often informal and not recorded in an EMR. Three in-depth focus groups were completed at programs demonstrating effective, yet different models of care for an older population. City of Hope Cancer Center is running a Senior Adult program under a grant where patients receive care in concordance with a score (CARG toxicity calculator) and a team review with a geriatrician. Sidney Kimmel Cancer Center has a consultative clinic where patients attend a 2-hour appointment to complete a comprehensive geriatric assessment with oncology, geriatrics, and specialists including pharmacy and nutrition. ACCC has recommended resources to address deficits in care, particularly in the community setting.

Integration of pathology within the multidisciplinary cancer care team

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Background: In an era of precision medicine the role of pathology in the diagnosis/management of cancer is evolving. Pathologists are positioned at the intersection of multiple points along the cancer care continuum. Starting at diagnosis pathologists provide expert interpretation and may recommend biomarker testing to guide treatment decisions. Methods: ACCC joined with partners AMP, ASCP, and CAP administered a survey in June 2018. 659 responses were received from a multidisciplinary group and a variety of cancer program settings. Results: Respondents reported that breakdowns in communication are most likely to occur when selecting and ordering biomarker tests (78%) and when reporting the results of the tests (34%). The top 5 challenges reported were coverage/reimbursement, insufficient quantity of material, turnaround time, test selection/ordering, and communication across the multidisciplinary team. There were sizable gaps in regular ordering of NGS among those with 1 tumor board (28%), 2-3 tumor boards (42%) and 4+ tumor boards (64%). Current use of liquid biopsy remains low with the majority (52%) reporting that clinicians rarely order ctDNA testing (12% “routinely”). Time to receiving test results varied with 58% reporting 5-10 business days, 19% reporting <5 business days and 24% >10 business days. 43% indicated pathologists are authorized to order all types of cancer biomarker tests. 56% have molecular pathologists on staff, 24% have a cancer genetics team. 62% report pathology has access to all inpatient records (38% outpatient records). Conclusions: Programs viewed as having integrated pathology participation feature pathologists leading institutional biomarker testing protocols, active participation at tumor boards and standardized reflexive testing pathways that reduce waste & turnaround time. Full integration is a critical piece to ensure patients receive appropriate and timely care.

Multidisciplinary cancer teams and utilization of resources for metastatic breast cancer (MBC): A landscape analysis

186

Background: An estimated 250k Americans are currently living with MBC. While breast cancer is a high-profile disease receiving significant public funding, patients with metastatic breast cancer face unique challenges. ACCC seeks to expand the conversation to address gaps between early & metastatic disease and improve the management of MBC in the community setting. Communication challenges that cancer care teams face with MBC patients include: using a tailored and thoughtful approach, balancing hope and realism, patient engagement during conversations, incorporating principles of shared decision making, patient financial concerns, and family/caregiver involvement. Methods: An environmental scan was completed of nationally available resources. A survey on MBC Communication strategies was administered in a variety of oncology provider settings from Dec. 2018-Jan 2019. Results: Patient psychosocial needs were identified as the top challenge for working with MBC patients vs. Stage 1-3. 57% reported difficulty managing patient expectations, 55% reported patient financial concerns. While 66% of cancer programs offer a general breast cancer support group, only 27% offer a Stage 4 group. 59% of respondents rely on casual conversations with patients to assess what they want, only 34% ask patients to define what quality of life would mean for them. 33% document goals in the EMR. Over 150 free resources specific to MBC were categorized from diagnosis through hospice, resulting in a curated online library that clinicians can use with their patients. Conclusions: This patient population should be given specialized care to address their unique diagnosis and improve communications with their care team. The ACCC Resource Library gives both low and highly resourced programs access to more supportive care tailored to metastatic breast cancer.

The in vivo assessment of tibial motion in the transverse plane in anterior cruciate ligament-reconstructed knees

Twenty-one knees with acutely injured anterior cruciate ligaments were reconstructed with patellar tendon autografts. Eight of the knees had concomitant medial ligament injuries that were not addressed surgically. Follow-up evaluation (average, 25 months) included computed tomography measurements to analyze transverse-plane laxity in both translation and rotation. These measurements were performed with the patient's leg in a load cell device that stabilizes the distal femur and applies known anterior translational force to the proximal tibia at approximately 20 degrees of flexion. A torque apparatus was used to apply internal and external rotational torque to the leg. Images of the tibial plateau in neutral, internal, and external rotation were performed, with and without an anterior translational force. Both knees of each patient were tested and categorized as group I (anterior cruciate ligament-reconstructed) or group II (uninjured). Translation as measured by computed tomography averaged 1 mm side-to-side difference. Internal rotation averaged 8.7 degrees in group I knees and 10.8 degrees in group II knees. External rotation averaged 9.1 degrees in group I knees and 7.4 degrees in group II knees. The eight knees with concomitant medial ligament injuries were analyzed separately; external rotation without anterior load in group I was 9.5 degrees, compared with 5 degrees in group II. This difference was significant (P < 0.01).

The measurement of subacromial contact pressure in patients with impingement syndrome

This study presents the subacromial contact pressure findings in 25 patients who underwent an arthroscopic acromioplasty for impingement syndrome. All patients failed a course of conservative management before surgery. Patients were evaluated, both before and after acromioplasty, by examination, UCLA functional score, and radiographic assessment of acromial morphology. At the time of surgery, a 4 x 10 mm air-filled catheter was placed beneath the anterior aspect of the acromion under arthroscopic visualization. Subacromial contact pressures were recorded throughout an arc of shoulder motion. Mean pressure and standard deviation were derived from three trials. This protocol was performed on all patients and the results were statistically evaluated. The mean subacromial pressure before acromioplasty was 11.7, 35.6, 50.1, 51.1, and 57.4 mm Hg at abduction arcs of 0 degrees , 90 degrees , and 180 degrees, hyperabduction (forced passive limit of abduction), and cross-reach (arm adducted across the patient's chest with the shoulder internally rotated), respectively. The pressure after acromioplasty decreased to 1.6, 7.8, 15.9, 22.8, and 16.5 mm Hg, respectively. This decrease was significant in all positions (P = .016 at 0 degrees and <.001 in all other positions). At 90 degrees of abduction, pressure always decreased in internal rotation and increased in external rotation. Maximal contact pressure developed in either hyperabduction or cross-reach in all patients except two. Preoperative testing for the position of maximum impingement pain generally correlated with the position of maximum contact pressure.

Rapidly progressive extensive subcutaneous emphysema associated with an implantable intratracheal oxygen catheter

Localized subcutaneous emphysema is a recognized complication of transtracheal oxygen catheters. It usually occurs in the immediate postoperative period or in association with catheter tip migration. This is a case of rapidly progressive, extensive subcutaneous emphysema apparently resulting from paroxysms of coughing in a patient with a normally functioning implanted intratracheal oxygen catheter several weeks after placement.

Indirect fertility analysis in painters exposed to ethylene glycol ethers: sensitivity and specificity

Semen analysis has proven useful in the clinical diagnosis of infertility and is the most widely used method of monitoring the effects of occupational exposure on male fertility. Collection and analysis of semen samples in a field setting, however, require a highly motivated population and excellent technical resources, limiting the widespread application of the method. Techniques of monitoring male worker fertility using questionnaires to avoid some of the difficulties of semen analysis have been developed. These methods compare the rate of observed births for wives of workers with expected birth rates derived either from U.S. fertility tables or from unexposed workers. The present study compares the sensitivity of this questionnaire method with that of semen analysis in an evaluation of reproductive function in men exposed to ethylene glycol ethers. The reproductive function of 74 married painters exposed to ethylene glycol ethers was compared with that of 51 married controls employed at a shipyard. The groups differed in sperm count, but the questionnaire method showed no effect of exposure on fertility. This analysis suggests that the questionnaire assessment of fertility is less sensitive than semen analysis as a screening tool for male reproductive function.

An amperometric needle-type glucose sensor tested in rats and man

An amperometric glucose-measuring 25 gauge (0.5 mm diameter) needle-type sensor has been developed using a glucose oxidase and dimethyl ferrocene paste behind a semi-permeable membrane situated over a window in the needle. Electron transfer results in direct current generation. Sensors have been tested subcutaneously in the abdomen both in anaesthetized rats (40 sensors, 11 rats) and in normal, conscious man (20 sensors, 10 subjects). In rats the blood glucose was modulated by glucose and by insulin infusion. In man the glucose concentrations were rapidly changed by use of a glucose clamp at 12 mmol/l plasma concentration for 2 h, after which the glucose returned to normal. In rats the median correlation between glucose change was 0.83 with an interquartile range from 0.70 to 0.92, and in man the median correlation was 0.80 with an interquartile range 0.67 to 0.86. Hysteresis, a measure of the accuracy on the upswing and downswing, was not a problem and cross-correlation showed no phase-lag. There were quantitative differences between in vitro calibration and the performance in vivo, reflecting the different conditions of use. The current in response to a glucose concentration was stable over 6.0 h in rats and 4.5 h in man.

Electrochemical, photoelectrochemical, electrocatalytic and catalytic reduction of redox proteins

Redox proteins catalyse the reactions of a wide variety of otherwise intractable substrates, such as dinitrogen, alkanes, arenes, terpenes and steroids. Two major factors impede the utilization of these enzymes--the inefficient electron transfer between the enzyme and electrode, and the properties often, but not inevitably, associated with enzymes, such as instability, complexity, and expense. We have now shown that the former can be overcome and that proteins can be coupled, via electrodes, to a number of energy sources; the latter is the subject of much effort elsewhere. We demonstrated previously that certain redox proteins can be reduced very efficiently electrochemically (Fig. 1a). Light and hydrogen are the two other convenient energy sources that could be used for such reductions, and we now report the reduction of cytochrome c by these means.

Development of an assay for aryl hydrocarbon (benzo(a)pyrene) hydroxylase in human peripheral blood monocytes

An assay has been developed and measurements of aryl hydrocarbon [benzo(a)pyrene] hydroxylase have been made in peripheral blood monocytes from a human population. Treatment with benz(a)anthracene in cell culture increased aryl hydrocarbon hydroxylase activity from 6.5 to 37-fold in monocytes from each of 25 apparently healthy donors. A weak correlation (r = 0.38) was observed between the induction ratios obtained with monocytes and lymphocytes from the same donors. Reproducibilities of the monocyte and lymphocyte assays were comparable. In monocytes, the measurement of basal and induced aryl hydrocarbon hydroxylases activity does not require pretreatment with mitogens as is the case with lymphocytes. Monocytes also exhibit a much wider range of induction ratios than do lymphocytes.