Excess morbidity and mortality associated with underuse of estrogen replacement therapy in premenopausal women who undergo surgical menopause

BACKGROUND

Contrary to clinical guidelines, there has been a decrease over time in estrogen therapy use in premenopausal women undergoing bilateral oophorectomy for benign indications.

OBJECTIVE

This study aimed to estimate the excess morbidity and mortality associated with current patterns of estrogen therapy use in women who undergo bilateral oophorectomy with hysterectomy for benign indications.

STUDY DESIGN

We developed 2 Bayesian sampling Markov state-transition models to estimate the excess disease incidence (incidence model) and mortality (mortality model). The starting cohort for both models were women who had undergone bilateral oophorectomy with hysterectomy for benign indications at the age of 45 to 49 years. The models tracked outcomes in 5-year intervals for 25 years. The incidence model estimated excess incidence of breast cancer, lung cancer, colorectal cancer, coronary heart disease, and stroke, whereas the mortality model estimated excess mortality due to breast cancer, lung cancer, coronary heart disease, and all-other-cause mortality. The models compared current rates of estrogen therapy use with optimal (100%) use and calculated the mean difference in each simulated outcome to determine excess disease incidence and death.

RESULTS

By 25 years after bilateral oophorectomy with hysterectomy, there were an estimated 94 (95% confidence interval, -158 to -23) fewer colorectal cancer cases, 658 (95% confidence interval, 339-1025) more coronary heart disease cases, and 881 (95% confidence interval, 402-1483) more stroke cases. By 25 years after bilateral oophorectomy with hysterectomy, there were an estimated 189 (95% confidence interval, 59-387) more breast cancer deaths, 380 (95% confidence interval, 114-792) more coronary heart disease deaths, and 759 (95% confidence interval, 307-1527) more all-other-cause deaths. In sensitivity analyses where we defined estrogen therapy use as a duration of >2 years of use, these differences increased >2-fold.

CONCLUSION

Underuse of estrogen therapy in premenopausal women who undergo oophorectomy is associated with substantial excess morbidity and mortality.

Cost-Effectiveness of Adjuvant Olaparib for Patients With Breast Cancer and Germline BRCA1/2 Mutations

Importance

The OlympiA trial found that 1 year of adjuvant olaparib therapy can improve distant disease-free survival and overall survival from early-stage breast cancer in patients with a germline BRCA1/2 mutation. However, olaparib, an oral poly-adenosine diphosphate ribose polymerase inhibitor, is estimated to cost approximately $14 000 per month in the US.

Objective

To estimate the incremental cost-effectiveness of adjuvant olaparib compared with no olaparib in eligible patients.

Design, Setting, and Participants

In an economic evaluation from a health care system perspective, the cost-effectiveness of adjuvant olaparib was analyzed using a Markov state-transition model. The model simulated costs and lifetime health outcomes of 42-year-old women with high-risk early-stage breast cancer and a known BRCA1/2 mutation who completed definitive primary therapy and neoadjuvant or adjuvant systemic therapy. The study was conducted from August 2021 to July 2023. The effectiveness of olaparib was based on the findings of the OlympiA randomized clinical trial, and other model parameters were identified from the literature. The model was calibrated to the 1-, 2-, 3-, and 4-year distant disease-free and overall survival observed in the OlympiA trial, and olaparib was assumed to reduce the risk of distant recurrence only in the first 4 years.

Exposure

One year of adjuvant olaparib or no adjuvant olaparib.

Main Outcome and Measure

Incremental cost-effectiveness ratio (ICER) in 2021 US dollars per quality-adjusted life-year (QALY) gained. All outcomes were discounted by 3% annually.

Results

In the base case, adjuvant olaparib was associated with a 1.25-year increase in life expectancy and a 1.20-QALY increase at an incremental cost of $133 133 compared with no olaparib. The resulting ICER was approximately $111 000 per QALY gained. At a willingness-to-pay threshold of $150 000 per QALY, olaparib was cost-effective at its 2021 price and in more than 92% of simulations in probabilistic sensitivity analysis. The results were sensitive to assumptions about the effectiveness of olaparib and quality of life for patients with no disease recurrence.

Conclusions and Relevance

In this study, from a US health care system perspective, adjuvant olaparib was a cost-effective option for patients with high-risk, early-stage breast cancer and a germline BRCA1/2 mutation.

Screening for lung cancer: 2023 guideline update from the American Cancer Society

Lung cancer is the leading cause of mortality and person-years of life lost from cancer among US men and women. Early detection has been shown to be associated with reduced lung cancer mortality. Our objective was to update the American Cancer Society (ACS) 2013 lung cancer screening (LCS) guideline for adults at high risk for lung cancer. The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer due to a history of smoking. The ACS Guideline Development Group (GDG) utilized a systematic review of the LCS literature commissioned for the US Preventive Services Task Force 2021 LCS recommendation update; a second systematic review of lung cancer risk associated with years since quitting smoking (YSQ); literature published since 2021; two Cancer Intervention and Surveillance Modeling Network-validated lung cancer models to assess the benefits and harms of screening; an epidemiologic and modeling analysis examining the effect of YSQ and aging on lung cancer risk; and an updated analysis of benefit-to-radiation-risk ratios from LCS and follow-up examinations. The GDG also examined disease burden data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. The GDG judged that the overall evidence was moderate and sufficient to support a strong recommendation for screening individuals who meet the eligibility criteria. LCS in men and women aged 50-80 years is associated with a reduction in lung cancer deaths across a range of study designs, and inferential evidence supports LCS for men and women older than 80 years who are in good health. The ACS recommends annual LCS with low-dose computed tomography for asymptomatic individuals aged 50-80 years who currently smoke or formerly smoked and have a ≥20 pack-year smoking history (strong recommendation, moderate quality of evidence). Before the decision is made to initiate LCS, individuals should engage in a shared decision-making discussion with a qualified health professional. For individuals who formerly smoked, the number of YSQ is not an eligibility criterion to begin or to stop screening. Individuals who currently smoke should receive counseling to quit and be connected to cessation resources. Individuals with comorbid conditions that substantially limit life expectancy should not be screened. These recommendations should be considered by health care providers and adults at high risk for lung cancer in discussions about LCS. If fully implemented, these recommendations have a high likelihood of significantly reducing death and suffering from lung cancer in the United States.

Association Between Copayment Assistance, Insurance Type, Prior Authorization, and Time to Receipt of Oral Anticancer Drugs

PURPOSE

Oral anticancer drugs (OACDs) have become increasingly prevalent over the past decade. OACD prescriptions require coordination between payers and providers, which can delay drug receipt. We examined the association between insurance type, pursuit of copayment assistance, pursuit of prior authorization (PA), and time to receipt (TTR) for new OACD prescriptions.

METHODS

We prospectively collected data on new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019, including demographic and clinical characteristics, insurance type, and pursuit of PA and copayment assistance. TTR was defined as the number of days from prescription to OACD receipt. We summarized TTR using cumulative incidence and compared TTR by insurance type, pursuit of copayment assistance, and PA activity using the log-rank test.

RESULTS

Our cohort of 1,024 patients was 53% male, and 40% were younger than 65. Twenty-six percent had commercial insurance only, 16% had Medicaid only, and 59% had Medicare with or without additional insurance. Eighty-six percent of prescriptions were successfully received. Across all prescriptions, 69% involved PA activity, and 21% involved the copayment assistance process. In unadjusted analyses, prescriptions involving the copayment assistance process had longer TTR compared with those not involving assistance (log-rank P value = .005) and OACDs covered by Medicare/commercial insurance had a longer TTR compared with Medicaid (log-rank P value = .006). The PA process was not associated with TTR (log-rank P value = .124).

CONCLUSION

The process for obtaining OACDs is complex. The copayment assistance process and Medicare/commercial insurance are associated with delayed TTR. New policies are needed to reduce time to OACD receipt.

Advancing Survivors Knowledge (ASK Study) of Skin Cancer Surveillance After Childhood Cancer: A Randomized Controlled Trial in the Childhood Cancer Survivor Study

PURPOSE

To improve skin cancer screening among survivors of childhood cancer treated with radiotherapy where skin cancers make up 58% of all subsequent neoplasms. Less than 30% of survivors currently complete recommended skin cancer screening.

PATIENTS AND METHODS

This randomized controlled comparative effectiveness trial evaluated patient and provider activation (PAE + MD) and patient and provider activation with teledermoscopy (PAE + MD + TD) compared with patient activation alone (PAE), which included print materials, text messaging, and a website on skin cancer risk factors and screening behaviors. Seven hundred twenty-eight participants from the Childhood Cancer Survivor Study (median age at baseline 44 years), age > 18 years, treated with radiotherapy as children, and without previous history of skin cancer were randomly assigned (1:1:1). Primary outcomes included receiving a physician skin examination at 12 months and conducting a skin self-examination at 18 months after intervention.

RESULTS

Rates of physician skin examinations increased significantly from baseline to 12 months in all three intervention groups: PAE, 24%-39%, relative risk [RR], 1.65, 95% CI, 1.32 to 2.08; PAE + MD, 24% to 39%, RR, 1.56, 95% CI, 1.25 to 1.97; PAE + MD + TD, 24% to 46%, RR, 1.89, 95% CI, 1.51 to 2.37. The increase in rates did not differ between groups (P = .49). Similarly, rates of skin self-examinations increased significantly from baseline to 18 months in all three groups: PAE, 29% to 50%, RR, 1.75, 95% CI, 1.42 to 2.16; PAE + MD, 31% to 58%, RR, 1.85, 95% CI, 1.52 to 2.26; PAE + MD + TD, 29% to 58%, RR, 1.95, 95% CI, 1.59 to 2.40, but the increase in rates did not differ between groups (P = .43).

CONCLUSION

Although skin cancer screening rates increased more than 1.5-fold in each of the intervention groups, there were no differences between groups. Any of these interventions, if implemented, could improve skin cancer prevention behaviors among childhood cancer survivors.

Abstract PD6-06: PD6-06 Racial and ethnic disparities with influenza vaccine use in long-term survivors of metastatic breast cancer

Background: Due to therapeutic advancements, people diagnosed with metastatic breast cancer (MBC) are living longer. This is particularly true for elderly patients who are often diagnosed with more indolent disease. However, elderly patients have higher rates of comorbidity and are vulnerable to other adverse health outcomes, but the primary care management of patients with advanced cancer may be sub-optimal. Every year influenza results in hundreds of thousands of hospitalizations and tens of thousands of deaths. Guidelines recommend the influenza vaccine annually for those over the age of 65 as well as those with cancer based on studies showing a 40-60% reduction in hospitalizations and death. Patterns of use in patients with MBC is unknown. Methods: A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Patients were included if they were diagnosed with stage IV MBC from 1/1/2008 – 12/31/2017, were ≥65 years of age, and had continuous Medicare enrollment for 12 months prior to diagnosis and at least three months after. Our primary outcome of interest was influenza vaccine use identified via CPT codes and defined as any use, use among patients surviving > 3-years, use among patients surviving >5-years, and repeated vaccine use. We then conducted bivariate analyses using demographic variables, including race, ethnicity, SES, age, and marital status, and clinical factors, including chemotherapy use, ER/PR positivity, and HER2 positivity. A multivariable logistic model was used to identify factors associated with influenza vaccine use in each cohort. Results: We identified 5182 patients with stage IV MBC during the study period that met our inclusion criteria. Overall, the median survival was 21 months and only 44% received at least one vaccination at any time after diagnosis. Within the cohort with the > 3-year survival (n=1864), only 1222 (66%) received an influenza vaccination at least one time and only 54% received the vaccine at least two times during 3 years of follow-up. Among patients with at least five-years of survival (n=763), 73% received at least one vaccination and only 65% received the vaccine at least two times during 5 years of follow-up. In a bivariate analysis in the 3-year survival cohort, we found that black race (47% vs 67%, p< 0.001) and Hispanic ethnicity (53% vs 66%, p=0.026), compared to white race and non-Hispanic ethnicity, respectively, were significantly associated with decreased vaccine use. The only factor associated with increased use was chemotherapy exposure. A multivariable model found lower odds of influenza vaccine receipt for black patients (OR=0.44, 95% CI 0.30-0.65, p< 0.001) and Hispanic patients (OR=0.58, 95% CI 0.36-.94, p=0.026). Similar findings were found in the 5-year survival cohort. Ongoing landmark analyses will be presented evaluating the impact of vaccination on survival. Conclusions: Over 50% of survivors with MBC do not receive the influenza vaccine after diagnosis. Importantly black and Hispanic patients with MBC are about half as likely to receive the influenza vaccine as white patients. Given the known impact of influenza vaccination in the elderly, improving access to vaccination could be an important strategy to reduce disparities in health outcomes. Our findings demonstrate primary care access disparities amongst the MBC population and indicate a need for educational and policy-based interventions.

Citation Format: Sahil D. Doshi, David DeStephano, Melissa K. Accordino, Elena B. Elkin, Jason D. Wright, Dawn Hershman. PD6-06 Racial and ethnic disparities with influenza vaccine use in long-term survivors of metastatic breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD6-06.

Impact of a Hospital-Based Specialty Pharmacy in Partnership With a Care Coordination Organization on Time to Delivery and Receipt of Oral Anticancer Drugs

PURPOSE

Oral anticancer drug (OACD) prescriptions require extensive coordination between providers and payers, which can delay drug receipt. Specialty pharmacies facilitate communication between multiple entities. In 2018, our cancer center partnered with a freestanding organization to implement a hospital-based specialty pharmacy (HB-SP). We evaluated the time to drug receipt (TTR) before and after HB-SP implementation.

METHODS

Data were prospectively collected on all new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019. In fall 2018, a HB-SP was initiated. We collected patient sociodemographic, clinical, and prescription data. TTR was the number of days from OACD prescription to drug receipt. We used multivariable logistic regression to examine factors associated with TTR ≤ 7 days before and after HB-SP implementation.

RESULTS

In total, 954 patients were included, representing 1,102 new OACDs. The majority of prescribed drugs were targeted OACDs (56%, n = 617), and 71% (n = 779) required prior authorization. Of all prescriptions, 84% (n = 960) were successfully received with an overall median TTR of 7 days. In unadjusted analysis, HB-SP implementation, drug class, race and ethnicity, and prior authorization requirement were significantly associated with TTR. Adjusted analyses found that patients were more likely to receive their drugs ≤ 7 days after HB-SP implementation (53% v 47%; adjusted odds ratio [aOR], 1.29; 95% CI, 1.00 to 1.68; P = .05).

CONCLUSION

The implementation of a HB-SP in partnership with a collaborative care model contributed to a decrease in TTR for OACDs. This difference is in part attributable to improved care coordination and communication. A centralized approach may improve overall efficiency due to fewer practice disruptions.

Implementation of Systematic Financial Screening in an Outpatient Breast Oncology Setting

PURPOSE

Implementation of routine financial screening is a critical step toward mitigating financial toxicity. We evaluated the feasibility, sustainability, and acceptability of systematic financial screening in the outpatient breast oncology clinic at a large, urban cancer center.

METHODS

We developed and implemented a stakeholder-informed process to systematically screen for financial hardship and worry. A 2-item assessment in English or Spanish was administered to patients through the electronic medical record portal or using paper forms. We evaluated completion rates and mode of completion. Through feedback from patients, clinicians, and staff, we identified strategies to improve completion rates and acceptability.

RESULTS

From March, 2021, to February, 2022, 3,500 patients were seen in the breast oncology clinic. Of them, 39% (n = 1,349) responded to the screening items, either by paper or portal, 12% (n = 437) preferred not to answer, and the remaining 49% (n = 1,714) did not have data in their electronic health record, meaning they were not offered screening or did not complete the paper forms. Young adults (18-39 years) were more likely to respond compared with patients 70 years or older (61% v 30%, P < .01). English-preferring patients were more likely to complete the screening compared with those who preferred Spanish (46% v 28%, P < .01). Non-Hispanic White patients were more likely to respond compared with Non-Hispanic Black patients and with Hispanic patients (46% v 39% v 32%, P < .01). Strategies to improve completion rates included partnering with staff to facilitate paper form administration, optimizing patient engagement with the portal, and clearly communicating the purpose of the screening.

CONCLUSION

Systematic financial screening is feasible, and electronic data capture facilitates successful implementation. However, inclusive procedures that address language and technology preferences are needed to optimize screening.

New and Persistent Sedative-Hypnotic Use After Adjuvant Chemotherapy for Breast Cancer

BACKGROUND

Sedative-hypnotic medications are used to treat chemotherapy-related nausea, anxiety, and insomnia. However, prolonged sedative-hypnotic use can lead to dependence, misuse, and increased health-care use. We aimed to estimate the rates at which patients who receive adjuvant chemotherapy for breast cancer become new persistent users of sedative-hypnotic medications, specifically benzodiazepines and nonbenzodiazepine sedative-hypnotics (Z-drugs).

METHODS

Using the MarketScan health-care claims database, we identified sedative-hypnotic-naïve patients who received adjuvant chemotherapy for breast cancer. Patients who filled 1 and more prescriptions during chemotherapy and 2 and more prescriptions up to 1 year after chemotherapy were classified as new persistent users. Univariate and multivariable logistic regression analyses were used to estimate odds of new persistent use and associated characteristics.

RESULTS

We identified 22 039 benzodiazepine-naïve patients and 23 816 Z-drug-naïve patients who received adjuvant chemotherapy from 2008 to 2017. Among benzodiazepine-naïve patients, 6159 (27.9%) filled 1 and more benzodiazepine prescriptions during chemotherapy, and 963 of those (15.6%) went on to become new persistent users. Among Z-drug-naïve patients, 1769 (7.4%) filled 1 and more prescriptions during chemotherapy, and 483 (27.3%) became new persistent users. In both groups, shorter durations of chemotherapy and receipt of opioid prescriptions were associated with new persistent use. Medicaid insurance was associated with new persistent benzodiazepine use (odds ratio = 1.88, 95% confidence interval = 1.43 to 2.47) compared with commercial or Medicare insurance.

CONCLUSIONS

Patients who receive sedative-hypnotic medications during adjuvant chemotherapy for breast cancer are at risk of becoming new persistent users of these medications after chemotherapy. Providers should ensure appropriate sedative-hypnotic use through tapering dosages and encouraging nonpharmacologic strategies when appropriate.

Factors Associated With Patients Not Receiving Oral Anticancer Drugs

IMPORTANCE

Oral anticancer drugs (OACDs) are increasingly prescribed for cancer treatment and require significant coordination of care. Retrospective studies suggest that 10% to 20% of OACD prescriptions are never received by the patients, but the reasons behind this are poorly understood.

OBJECTIVES

To estimate the rate of failure to receive OACD prescriptions among patients with cancer and to examine the underlying reasons for this failure.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study was conducted among patients with cancer who were prescribed a new OACD from January 1, 2018, to December 31, 2019, at an urban academic medical center. Data analysis was conducted between 2021 and 2022.

MAIN OUTCOMES AND MEASURES

Patient demographic, clinical, and insurance data and OACD delivery dates were collected. The reasons for a failure to receive a prescribed OACD within 3 months were confirmed by manual review of medical records and were classified into 7 categories: clinical deterioration, financial access, clinician-directed change in decision-making, patient-directed change in decision-making, transfer of care, loss to follow-up, and unknown or other. A multivariable random-effects model was developed to identify factors associated with failure to receive a prescribed OACD.

RESULTS

The cohort included 1024 patients (538 men [53%]; mean [SD] age, 66.2 [13.9] years; 463 non-Hispanic White patients [45%], 140 non-Hispanic Black patients [14%], and 300 Hispanic patients [29%]), representing 1197 new OACD prescriptions. Of the 1197 prescriptions, 158 (13%) were categorized as having not been received by the patient. The most common reason for the failure to receive a prescribed OACD was due to patient and clinician decision-making (73 of 158 [46%]), and 20 cases (13%) in which prescriptions were not received were associated with financial access issues. In multivariable analysis, patients with a nonmetastatic solid malignant neoplasm were significantly less likely to not receive their OACDs than those with a hematologic malignant neoplasm (odds ratio, 0.57 [95% CI, 0.33-1.00]; P = .048).

CONCLUSIONS AND RELEVANCE

This cohort study of patients prescribed a new OACD found that 13% of prescriptions were not received. The failure to receive a prescribed OACD was most frequently due to a change in clinical decision-making or patient choice. Ultimately, the reasons for the failure to receive a prescribed OACD were multifactorial and may have been appropriate in some cases.

Study protocol of a multiphase optimization strategy trial (MOST) for delivery of smoking cessation treatment in lung cancer screening settings

BACKGROUND

There is widespread agreement that the integration of cessation services in lung cancer screening (LCS) is essential for achieving the full benefits of LCS with low-dose computed tomography (LDCT). There is a formidable knowledge gap about how to best design feasible, effective, and scalable cessation services in LCS facilities. A collective of NCI-funded clinical trials addressing this gap is the Smoking Cessation at Lung Examination (SCALE) Collaboration.

METHODS

The Cessation and Screening to Save Lives (CASTL) trial seeks to advance knowledge about the reach, effectiveness, and implementation of tobacco treatment in lung cancer screening. We describe the rationale, design, evaluation plan, and interventions tested in this multiphase optimization strategy trial (MOST). A total of 1152 screening-eligible current smokers are being recruited from 18 LCS sites (n = 64/site) in both academic and community settings across the USA. Participants receive enhanced standard care (cessation advice and referral to the national Quitline) and are randomized to receive additional tobacco treatment components (motivational counseling, nicotine replacement patches/lozenges, message framing). The primary outcome is biochemically validated, abstinence at 6 months follow-up. Secondary outcomes are self-reported smoking abstinence, quit attempts, and smoking reduction at 3 and 6 months. Guided by the Implementation Outcomes Framework (IOF), our evaluation includes measurement of implementation processes (reach, fidelity, acceptability, appropriateness, sustainability, and cost).

CONCLUSION

We will identify effective treatment components for delivery by LCS sites. The findings will guide the assembly of an optimized smoking cessation package that achieves superior cessation outcomes. Future trials can examine the strategies for wider implementation of tobacco treatment in LDCT-LCS sites.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03315910.

Efficacy of a password-protected, pill-dispensing device with mail return capacity to enhance disposal of unused opioids after cancer surgery

BACKGROUND

Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery.

METHODS

A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction.

RESULTS

Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved.

CONCLUSIONS

Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.

Cost effectiveness of adjuvant olaparib for BRCA-mutated, early-stage breast cancer

6593

Background: An interim analysis of the OlympiA trial found that olaparib given in the adjuvant setting can improve distant disease-free and overall survival for patients with early-stage, BRCA-mutated breast cancer; however, the cost-effectiveness of adjuvant olaparib is unknown. This study aimed to evaluate the cost-effectiveness of adjuvant olaparib in patients with early-stage, BRCA-mutated breast cancer. Methods: We used a decision-analytic model to compare outcomes of treatment with and without one year of oral olaparib after completion of systemic therapy in 42-year-old women with BRCA-mutated, early-stage breast cancer. Olaparib’s effectiveness was based on the OlympiA trial, and other model parameters were identified from the literature. We calibrated the model to reflect the 1-, 2-, and 3-year distant disease-free survival (DDFS) and overall survival (OS) observed in the OlympiA trial, and we assumed that olaparib reduced the risk of distant recurrence only in the first 3 years. Olaparib was estimated to cost $14,523 per month. Average lifetime costs were estimated from a health care system perspective in 2021 $ US, and incremental cost-effectiveness ratios (ICER) were estimated as $ per quality-adjusted life-year (QALY) gained. Costs, life-years, and QALYs were discounted by 3% annually. Results: Simulating the OlympiA trial, DDFS for the olaparib arm was 94.3% at 12 months, 90.0% at 24 months, and 87.5% at 36 months, compared to placebo with DDFS of 90.2%, 83.9%, and 80.4% respectively. Similarly, OS for the olaparib arm was 98.1%, 94.8%, and 92.0% compared to 96.9%, 92.3%, and 88.3% with placebo at 12, 24, and 36 months respectively. In the base case, adjuvant olaparib was associated with a 1.21-year increase in life expectancy and a 1.15-QALY increase at an incremental cost of $131,167 compared to placebo. The resulting ICER was about $114,500/QALY gained. At a willingness-to-pay threshold of USD$150,000/QALY, olaparib was cost effective at its current price. Results were sensitive to assumptions about the effectiveness of olaparib and its impact on quality of life. Conclusions: Adjuvant olaparib is cost-effective for women with early-stage, BRCA-mutated breast cancer at the current price of olaparib in the U.S. and at a willingness-to-pay threshold of $150,000. As such, clinicians and payers should consider adjuvant olaparib as a cost-effective option for this patient population. [Table: see text]

Evaluation of a pharmacist-led video consultation to identify drug interactions among patients initiating oral anticancer drugs

1592

Background: The past decade has seen a dramatic increase in the number of oral anti-cancer drug (OACD) approvals in the United States. Though polypharmacy and drug-drug interactions (DDIs) likely contribute to OACD toxicity, the prevalence of these features in patients on OACDs remains largely unknown. We aimed to evaluate a one-time 30-minute pharmacist-led video consultation among metastatic cancer patients initiating OACDs to identify medication list inaccuracies as well as the prevalence, characteristics, and severity of OACD-related potential DDIs. Methods: We conducted a single-arm, prospective telehealth intervention study among 29 patients initiating OACDs to evaluate a one-time 30-minute pharmacist-led video consultation. The video visits focused on identifying and discussing polypharmacy and potential DDIs, and pharmacists then communicated recommendations to each patient's oncologist. We estimated the prevalence, characteristics (QTc prolongation, absorption interactions, etc.), and severity of OACD-related potential DDIs. Lexicomp and Micromedex were used to assess potential DDIs and measure severity on a standardized scale (A – D, X). In addition, we assessed the prevalence of medication list inaccuracies, polypharmacy, and patient satisfaction. Results: Twenty-five patients completed the intervention (86% completion rate) of whom 40% were 75 years of age or older and 60% were men. The majority were white (68%) and non-Hispanic (76%). Sixteen patients (68%) had a solid tumor diagnosis. Nearly half (48%) were insured by Medicare. The median number of medications per patient was 9 with a range of 4 – 21, and 96% of patients had at least 5 prescriptions listed. The median number of medication list errors was 2 with a range of 0 – 16, with at least 1 error for 76% and more than 1 error for 52% of patients. Pharmacists identified potential OACD-related interactions in 9 cases (40%). These included change in drug absorption or metabolism (7), QTc prolongation (1), hypotension (1), and bleeding (1). Interactions were classified as either category C (8) or D (2), requiring close monitoring or a change in treatment, respectively. All patients expressed a high level of satisfaction with the video visit. Conclusions: Polypharmacy, medication list errors, and potential DDIs are prevalent among patients initiating OACDs despite use of an electronic medical record requiring medication reconciliation. Our study suggests that a one-time remote 30-minute pharmacist-led video consultation can effectively identify and address OACD-related potential DDIs, which may decrease medication complexity and improve adherence in this population.

Efficacy of a password-protected, pill-dispensing device with mail return capacity to enhance disposal of unused opioids after cancer surgery

12019

Background: Opioid misuse is a public health crisis. Initial opioid exposures often occur post-operatively, and 10% of opioid-naïve patients who undergo cancer surgery subsequently become long-term opioid users. It has been shown that 70% of opioids prescribed post-operatively go unused, but only 9% of unused pills are disposed of appropriately, which increases the risk of unintended use. We evaluated the impact of an inexpensive, password-protected pill-dispensing device with mail return capacity on disposal of unused pills after cancer surgery. Methods: We conducted a prospective, proof-of-concept pilot study among adult patients scheduled for major cancer-related surgery. Enrolled patients received opioid prescriptions in a pill-dispensing device (Addinex) from a specialty pharmacy. The mechanical device linked to a smartphone app, which provided passwords on a prescriber-defined schedule. Patients were able to enter unique passwords into the device to receive their pills if the prescribed time had elapsed. The smartphone app provided clinical guidance based on patient-reported pain levels, and suggested tapering strategies. Patients were instructed to return the device in a DEA-approved mailer when opioid use was no longer required for acute pain control. Unused pills were destroyed upon receipt. The primary objective was to determine the feasibility of device return, defined as > 50% within 6 weeks. We also explored total pill use and return, patterns of device use and patient satisfaction. Results: We enrolled 30 patients between October 2020 and December 2021. The median age was 46 (range 29–72). Surgical procedures included abdominal hysterectomy (13), mastectomy and reconstruction (10), and soft tissue tumor resections (7). Overall, the majority of participants (n = 24, 80%) returned the device, and more than half (n = 17, 57%) returned the device within 6 weeks of surgery. There were 19 patients who obtained opioids from the device. Among these patients, the majority were satisfied with the device (n = 14, 74%); felt the benefits of the device justified the added steps involved (n = 14, 74%); and would sign up to receive opioids in the device again (n = 13, 68%). The other 11 patients used no opioids. None of these non-users reported any opioid requirements for pain control, and all but one (n = 10, 91%) returned the device and unused pills. In total, 567 opioids were prescribed, and 170 (30%) were used. Of the 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were returned by mail. Conclusions: We found that use of an inexpensive pill-dispensing device with mail return capacity was a feasible and effective strategy to enhance disposal of unused post-operative opioids. Interestingly, a substantial number of prescribed pills were unused. This system also improves confidence with indicated opioid use while reducing diversion.

Implementing a mHealth intervention to increase colorectal cancer screening among high-risk cancer survivors treated with radiotherapy in the Childhood Cancer Survivor Study (CCSS)

Background

Cancer survivors treated with any dose of radiation to the abdomen, pelvis, spine, or total body irradiation (TBI) are at increased risk for developing colorectal cancer (CRC) compared to the general population. Since earlier detection of CRC is strongly associated with improved survival, the Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines recommend that these high-risk cancer survivors begin CRC screening via a colonoscopy or a multitarget stool DNA test at the age of 30 years or 5 years following the radiation treatment (whichever occurs last). However, only 37% (95% CI 34.1–39.9%) of high-risk survivors adhere to CRC surveillance. The Activating cancer Survivors and their Primary care providers (PCP) to Increase colorectal cancer Screening (ASPIRES) study is designed to assess the efficacy of an intervention to increase the rate of CRC screening among high-risk cancer survivors through interactive, educational text-messages and resources provided to participants, and CRC screening resources provided to their PCPs.

Methods

ASPIRES is a three-arm, hybrid type II effectiveness and implementation study designed to simultaneously evaluate the efficacy of an intervention and assess the implementation process among participants in the Childhood Cancer Survivor Study (CCSS), a North American longitudinal cohort of childhood cancer survivors. The Control (C) arm participants receive electronic resources, participants in Treatment arm 1 receive electronic resources as well as interactive text messages, and participants in Treatment arm 2 receive electronic educational resources, interactive text messages, and their PCP’s receive faxed materials. We describe our plan to collect quantitative (questionnaires, medical records, study logs, CCSS data) and qualitative (semi-structured interviews) intervention outcome data as well as quantitative (questionnaires) and qualitative (interviews) data on the implementation process.

Discussion

There is a critical need to increase the rate of CRC screening among high-risk cancer survivors. This hybrid effectiveness-implementation study will evaluate the effectiveness and implementation of an mHealth intervention consisting of interactive text-messages, electronic tools, and primary care provider resources. Findings from this research will advance CRC prevention efforts by enhancing understanding of the effectiveness of an mHealth intervention and highlighting factors that determine the successful implementation of this intervention within the high-risk cancer survivor population.

Trial registration

This protocol was registered at clinicaltrials.gov (identifier NCT05084833) on October 20, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08082-3.

Abstract PD5-08: New and persistent sedative hypnotic use after adjuvant chemotherapy for breast cancer

Introduction: Sedative-hypnotic medications, such as benzodiazepines (BZDs) and non-benzodiazepine sedative-hypnotics (Z-drugs), are used to treat chemotherapy-related nausea, anxiety and insomnia. While effective for these indications, prolonged use can lead to dependence, misuse and increased healthcare utilization. We aimed to estimate rates of new and persistent BZD and Z-drug use after adjuvant chemotherapy for breast cancer. Methods: We used the MarketScan health care claims database to identify patients who received adjuvant chemotherapy for breast cancer from 2008 to 2017. We categorized prescriptions for BZDs or Z-drugs into three periods: 365 days prior to chemotherapy to the start of chemotherapy (period 1); start of chemotherapy to 90 days after the end of chemotherapy (period 2); and 90 days to 365 days after chemotherapy (period 3). Patients who filled no BZD prescriptions in period 1 were considered BZD-naïve. Those who then filled at least one BZD prescription in period 2, and at least two BZD prescriptions in period 3, were classified as new persistent BZD users. The same definitions were used for Z-drugs. We used multivariable logistic regression to estimate associations between patient characteristics and new persistent use of BZDs and Z-drugs. Results: We identified 17,532 BZD-naïve patients and 21,863 Z-drug-naïve patients who received adjuvant chemotherapy for breast cancer. The median age was 57 for BZD-naïve patients (IQR = 13) and 56 for Z-drug-naïve patients (IQR = 13). The majority of patients had commercial or Medicare insurance (92.6% BZD-naïve, 92.7% Z-drug-naïve) versus Medicaid. A slight majority received lumpectomy (56.6% BZD-naïve, 55.1% Z-drug-naïve) versus mastectomy. Roughly half of patients received less than 4 months of chemotherapy (48.0% BZD-naïve, 48.6% Z-drug-naïve). Among BZD-naïve patients, 4,447 (25%) filled at least one BZD prescription during chemotherapy, and 1,192 (7% of all BZD-naïve patients, 27% of those filling at least one BZD prescription during chemotherapy) became new persistent BZD users after chemotherapy. Among Z-drug naïve patients, 2,160 (10%) filled at least one Z-drug prescription during chemotherapy, and 730 (3% of all Z-drug-naïve patients, 34% of those filling at least one prescription during chemotherapy) became new persistent Z-drug users afterwards. There were 115 patients who became new persistent users of both types of sedative-hypnotics. Several characteristics were associated with new persistent BZD use: age 50-65 (Table 1; OR = 1.23, p = 0.01) and age &gt; 65 (OR = 1.38, p = 0.005) relative to age ≤ 49; as well as Medicaid insurance, relative to commercial and Medicare insurance (OR = 1.68, p &lt; 0.0001). Chemotherapy duration of less than 4 months was associated with both new persistent BZD and Z-drug use relative to 4 or more months of chemotherapy (OR = 1.17, p = 0.03 for BZDs; OR = 1.58, p &lt; 0.0001 for Z-drugs). Conclusion: Women who receive sedative-hypnotic medications during adjuvant chemotherapy for breast cancer are at risk of becoming persistent users of these medications after chemotherapy. With an awareness of this observation, providers can take steps to ensure appropriate use of these medications, through tapering dosages and encouraging non-pharmacologic strategies when appropriate.

Associations between Patient Characteristics and New Persistent Sedative-Hypnotic UseNew Persistent BZD UseNew Persistent Z-Drug UseVariableOdds Ratio95% CIp valueOdds Ratio95% CIp valueAge (years)≤ 49ReferentReferent50-651.231.05 - 1.430.011.210.99 - 1.480.07&gt; 651.381.10 - 1.720.0050.950.68 - 1.310.7InsuranceMedicaid1.681.31 - 2.16&lt;0.00010.760.50 - 1.150.2OtherReferentReferentSurgeryMastectomy1.090.95 - 1.250.20.890.74 - 1.070.2LumpectomyReferentReferentChemotherapy duration&lt; 4 months1.171.02 - 1.340.031.581.31 - 1.89&lt;0.0001≥ 4 monthsReferentReferent

Citation Format: Jacob C. Cogan, Rohit R. Raghunathan, Melissa P. Beauchemin, Melissa K. Accordino, Elena B. Elkin, Alexander Melamed, Jason D. Wright, Dawn L. Hershman. New and persistent sedative hypnotic use after adjuvant chemotherapy for breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD5-08.

A model for an undergraduate research experience program in quantitative sciences

We developed a summer research experience program within a freestanding comprehensive cancer center to cultivate undergraduate students with an interest in and an aptitude for quantitative sciences focused on oncology. This unconventional location for an undergraduate program is an ideal setting for interdisciplinary training in the intersection of oncology, statistics, and epidemiology. This paper describes the development and implementation of a hands-on research experience program in this unique environment. Core components of the program include faculty-mentored projects, instructional programs to improve research skills and domain knowledge, and professional development activities. We discuss key considerations such as effective partnership between research and administrative units, recruiting students, and identifying faculty mentors with quantitative projects. We describe evaluation approaches and discuss post-program outcomes and lessons learned. In its initial two years, the program successfully improved students' perception of competence gained in research skills and statistical knowledge across several knowledge domains. The majority of students also went on to pursue graduate degrees in a quantitative field or work in oncology-centric academic research roles. Our research-based training model can be adapted by a variety of organizations motivated to develop a summer research experience program in quantitative sciences for undergraduate students.

Association between insurance plan, prior authorization, and time to receipt of oral anticancer drugs

6

Background: The past decade has seen a dramatic increase in the number of Food and Drug Administration approvals of oral anti-cancer drugs (OACDs). Most OACD prescriptions require coordination between payers and providers, which can delay drug receipt. In May 2021, two bills were introduced in the US House of Representatives (HR 3173 and HR 3258) to streamline the prior authorization (PA) process. In this study, we examined clinical and process-related factors associated with PA and time to drug receipt (TTR) for patients who received a new OACD prescription. Methods: We prospectively collected data on all new OACD prescriptions for adult oncology patients from 1/1/2018 to 12/31/2019. We collected patient demographic, medical, and insurance data, drug type (hormonal, chemotherapy, targeted), and specialty pharmacy interactions with payers and financial assistance groups, including PA information. TTR was defined as the number of days from OACD prescription to patient receipt of the drug. We used multivariable logistic regression to separately assess factors associated with TTR and factors associated with PA for patients who received a new OACD prescription. Results: The cohort for both models included 883 patients who were prescribed 1014 new OACDs. Of these prescriptions, 72.3% (N=733) required PA. The median age was 66 and 44% identified as White. The median TTR was 7 days (IQR 0 – 142; 25% ≥ 14 days; and 5% ≥ 30 days). In unadjusted analyses, PA was associated with insurance and drug type and delayed TTR was associated with PA and insurance type. In a multivariable analysis, patients with Medicaid insurance were more likely to require PA compared to patients with Medicare (OR 1.93 (1.14 – 3.32), p=0.03). In addition, patients prescribed targeted and hormone therapies were more likely to require PA than those prescribed oral chemotherapy (targeted: OR 3.33 [2.38 – 4.68], p<0.001; hormone: OR 4.26 [2.45 – 7.65], p<0.001). A separate multivariable analysis showed that PA is associated with delayed TTR (OR 1.62 [1.18 – 2.24], p=0.003) and that Medicaid is associated with a shorter TTR (OR 0.59 [0.37 – 0.94], p=0.03). Conclusions: The current process for obtaining OACDs is complex and multifaceted. Seventy two percent of delivered OACDs require PA, which is associated with delayed TTR. Earlier intervention and new health policies are needed to reduce time to OACD receipt. [Table: see text]

Factors associated with failure to receive oral anticancer drugs

41

Background: Oral anti-cancer drugs (OACDs) have become increasingly prescribed over the last 10 years and require a significant amount of care coordination. Preliminary administrative database studies have shown that 10-15% of prescriptions are never received by the patient, but the reasons behind this are poorly understood. In this study, we prospectively identified failure to receive (FR) cases in which OACD prescriptions were never received by patients, examined underlying reasons for FR, and assessed clinical and process-related factors associated with FR. Methods: We prospectively collected data on new OACD prescriptions for adult oncology patients at a large, urban academic cancer center from 1/1/2018 to 12/31/2019. We collected patient demographic, clinical, and insurance data, OACD delivery date, and interactions with payers and financial assistance groups. FR was defined as failure to receive a prescribed OACD. Reasons for FR were confirmed by manual chart review and classified into seven categories: clinical deterioration, financial access, provider-driven clinical decision making, patient-directed change, transfer of care, lost to follow up, and other. We calculated the relative proportion of each FR category and used multivariable logistic regression to identify factors associated with FR, including initiation of a prior authorization and drug class. Results: The cohort included 1,080 patients who were prescribed 1,269 new OACDs. Of these prescriptions, 13% (N=163) were categorized as FR. Among the 158 patients with FR, average patient age was 66 years, 55% identified as non-Hispanic white, 61% had any Medicare plan, 11% had Medicaid only, and 25% had commercial insurance. Overall, 18% of FR cases were attributed to clinical deterioration, 13% to financial access, 29% to provider-driven clinical decision making, 17% to patient-directed change, 13% to transfer of care, and 5% were lost to follow up. Univariate analysis showed that FR was less likely in cases where prior authorization was initiated (p < 0.001) and multivariate analysis confirmed this result (OR 0.47 [CI 0.33-0.66], p < 0.001). Conclusions: Though the majority of oncology patients prescribed OACDs received the drug, 13% of patients in our study experienced FR. FR is associated with a lack of prior authorization initiation, which may reflect barriers to access, a change in clinical decision-making, or patient choice. Ultimately, FR is multifactorial and may be appropriate in some cases. More work is needed to determine whether improved access would increase uptake in some patients. [Table: see text]

Incorporating systematic financial screening into the electronic health record

184

Background: Routine screening for financial hardship may identify patients at risk of financial crisis (bankruptcy or inability to afford food or medication). Identifying financial hardship risk is a critical step toward mitigating financial toxicity, associated with earlier mortality and poorer quality of life. We are studying the implementation of systematic financial hardship screening using the electronic health record (EHR) in a large, urban, outpatient cancer center. Methods: Guided by the Consolidated Framework for Implementation Research, we met with key stakeholders, including providers, medical assistants (MA’s), administrative staff, and patient advocates to develop a process to systematically screen all cancer patients for financial hardship risk using 2 items (Q1 and Q3) from the Comprehensive Score for Financial Toxicity (COST). We initiated the process in the breast oncology clinic and partnered with EPIC to integrate the items in the EHR and patient portal. In March 2021, we implemented systematic screening, with automatic prompts to reassess monthly. Results: The workflow includes two mechanisms for patients to complete the 2 items: through the online patient portal during appointment check-in; or through a paper form in English or Spanish, distributed to patients during check-in. An EHR flag was created to notify staff if the patient is due to complete the questions during check-in. During vital signs assessment, the MA collects the form and enters the responses into the EHR. Two important factors were identified to improve the implementation: 1) Patient support to facilitate EHR portal use to reduce clinic workflow congestion; and 2) printed resources for patients who express financial concern. Ongoing discussions reveal that certain clinic days are busier, during which staff find it difficult to review EHR flag, provide and collect paper forms. To date, of 1,358 patients seen in the breast oncology clinic, 526 (39%) have responded to the question, “I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment,” and of those, 278 (53%) responded “not at all” or “a little bit.” Of the 532 patients (39%) who responded to the question, “I worry about the financial problems I will have in the future as a result of my illness or treatment,” 215 (40%) responded “quite a bit” or “very much.” Conclusions: Preliminary analysis highlights the complexities of initiating systematic financial screening in oncology clinics. However, interim results suggest financial hardship is prevalent. Next steps include: expanding to pediatric and gynecologic oncology; building a dashboard to inform financial referrals; comparison of the 2-item screener to the COST survey in a subset of patients; qualitative interviews and focus groups with patients and staff to improve current procedures and optimize the use of dashboards and alerts to focus interventions and referrals on patients most in need.

Efficacy of a password-protected pill-dispensing device to enhance disposal of unused opioids after cancer surgery

264

Background: Opioid misuse is a public health crisis. Initial opioid exposures often occur post-operatively, and 10% of opioid-naïve patients who undergo cancer surgery subsequently become long-term opioid users. It has been shown that 70% of opioids prescribed post-operatively go unused, but only 9% of unused pills are disposed appropriately, which increases the risk of unintended use. We evaluated the impact of an inexpensive, password-protected dispensing device with mail return capacity on retrieval of unused pills after cancer surgery. Methods: Adult patients scheduled for major cancer-related surgery were eligible. Enrolled patients received opioid prescriptions in a password-protected, pill-dispensing device (Addinex) from a specialty pharmacy. The mechanical device links to a smartphone app, which provides passwords on a prescriber-defined schedule. Patients request a password when they are in pain, enter the password into the device and receive a pill if the prescribed time has elapsed. The smartphone app provides clinical guidance based on patient-reported pain levels, and suggests tapering strategies. Patients are instructed to return the device in a DEA-approved mailer when opioid use is no longer required for pain control. Unused pills are destroyed upon receipt. The primary objective was to determine the feasibility of device return, defined as > 50% of patients with device return. We also explored patterns of device use, patient reported outcomes, and device satisfaction via surveys and semi-structured interviews. Results: Between October, 2020 and April, 2021, 13 patients completed the study; 4 patients are currently enrolled. Among the initial 13 patients, 7 underwent abdominal hysterectomy, 4 underwent mastectomy and 2 underwent cutaneous tumor resections. The majority of these patients (n = 10, 77%) returned the device, and more than half (n = 7, 54%) returned the device within 6 weeks of surgery. Only a minority of patients (n = 5, 38%) used the device to obtain opioids; most (n = 8, 62%) used no opioids at home, and all of these patients returned the device and the unused pills. Of 11 patients who participated in semi-structured interviews, most (n = 7, 64%) said they felt safer having opioids in the device instead of a regular pill bottle. Among device users, the majority (n = 4, 80%) reported an overall positive experience. All non-users reported having no opioid requirement for pain control. Conclusions: Our early findings suggest that use of an inexpensive, password-protected, pill-dispensing device to assist with opioid dispensing and return is feasible, with a high rate of device and unused opioid return to the pharmacy. This strategy may be effective for reducing opioid diversion. Analyses and recruitment are ongoing to evaluate the benefits of reducing post-operative opioid consumption.

Impact of a hospital specialty pharmacy in partnership with a free-standing care coordination organization on time to delivery and receipt of oral anticancer drugs

43

Background: Most oral anti-cancer drugs (OACD) prescriptions require extensive coordination between providers and payers, which can delay drug receipt. Specialty pharmacies are intended to facilitate communication between multiple entities to deliver OACDs with increased efficiency. In 2018, our cancer center partnered with Shields Health Solutions (SHS), a freestanding organization providing care coordination to implement a hospital-based specialty pharmacy. We evaluated the rate of failed drug receipt (FR) and time to drug receipt (TTR) before and after specialty pharmacy implementation. Methods: We prospectively collected data on all new OACD prescriptions for adult oncology patients at a large, urban cancer center from 1/1/2018 to 12/31/2019. In fall 2018, a specialty pharmacy was opened to facilitate drug procurement for patients. We collected patient demographic, clinical, and insurance data, OACD name, date prescribed, delivery date, and interactions with payers and financial assistance groups. For prescriptions received, TTR was the number of days from OACD prescription to patient receipt of the drug. FR was defined as failure to receive a prescribed OACD. We excluded OACD prescriptions for a washout period of two months during pharmacy initiation. We used multivariable logistic regression to examine factors associated with TTR > 7 days and FR before and after specialty pharmacy implementation. Results: In total, 883 patients were prescribed 1145 new OACDs. The majority of prescribed drugs were targeted treatment (56%, N = 646) and 72% (N = 819) required prior authorization (PA). Of all prescriptions, 86% (N = 999) were successfully received with an overall median TTR of 7 days. Adjusted analyses showed that patients were more likely to receive their drugs in less than 7 days after specialty pharmacy implementation (OR: 1.4 95% CI 1.04 – 1.81), p = 0.03). In an unadjusted analysis, patients were more likely to receive their initial medications after specialty pharmacy implementation, compared to before specialty pharmacy implementation (89% vs. 84%, p = 0.04). Multivariable analysis showed a trend toward more patients receiving drugs after specialty pharmacy implementation (OR: 1.42, 95% CI 0.98 – 2.03, p = 0.06). Conclusions: The implementation of a hospital-based specialty pharmacy in partnership with SHS decreased TTR. This difference is in part attributable to improved care coordination and communication. A centralized approach may improve overall efficiency due to fewer clinical practice disruptions.

New and persistent controlled substance use among patients undergoing mastectomy and reconstructive surgery

PURPOSE

Prolonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M + R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications.

METHODS

Using the MarketScan health-care claims database, we identified opioid- and sedative-hypnotic-naïve women who had M + R from 2008 to 2017. Women who filled ≥ 1 peri-operative prescription and ≥ 2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors.

RESULTS

We evaluated 23,025 opioid-naïve women and 25,046 sedative-hypnotic-naïve women. We found that 17,174 opioid-naïve women filled a peri-operative opioid prescription, and of those, 2962 (17.2%) became opioid NPUs post-operatively. Additionally, 9426 sedative-hypnotic-naïve women filled a peri-operative sedative-hypnotic prescription, and of those, 1612 (17.1%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤ 49 [OR 1.77 (95% CI 1.40-2.24)] and age 50-64 [1.60 (1.27-2.03)] compared to age ≥ 65; Medicaid insurance [2.34 (1.40-3.90)]; southern residence [1.42 (1.22-1.64)]; breast cancer diagnosis [2.24 (1.28-3.91)]; and chemotherapy [2.17 (1.94-2.42)]. Risk of NPU increased with higher risk score. Women with ≥ 3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors [2.94 (2.51-3.43)]. Comparable findings were seen regarding new persistent opioid use.

CONCLUSION

Women who have M + R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient's risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.

Patient factors associated with time to medication receipt of oral anti-cancer drugs

1519

Background: The past decade has seen a dramatic increase in the number of Food and Drug Administration approvals of oral anti-cancer drugs (OACDs). Most OACD prescriptions require coordination between providers, payers, specialty pharmacists, and financial assistance organizations, which can delay drug receipt. We evaluated median time to OACD receipt (TTR) from initial OACD prescription submission and assessed clinical and process-related factors associated with TTR. Methods: We prospectively collected data on all new OACD prescriptions for adult oncology patients at a large, urban outpatient cancer center from 1/1/2018 to 12/31/2019. We collected patient demographic, medical, and insurance data; prescription submission and delivery dates; and interactions with payers and financial assistance groups. TTR was defined as the number of days from OACD initial prescription to patient receipt of the drug. We estimated the median TTR across all patients and used multivariable logistic regression to identify factors associated with TTR above the median. Results: The cohort included 1080 patients who were prescribed 1269 new OACDs. Of these prescriptions, 84% (N=1069) were received, and 71% (N=896) required prior authorization. The median patient age was 66, 44% identified as Non-Hispanic White (White), 25% of patients had commercial insurance, 16% had Medicaid alone, and 58% had Medicare alone or in combination with another plan. The median TTR per patient was 7 days (IQR 0 – 142; 25% ≥ 14 days and 5% ≥ 30 days). In unadjusted analyses, insurance and race/ethnicity were associated with TTR. Compared with patients covered by Medicaid, those with Medicare and supplemental insurance (a partial, not free-standing plan) had nearly 2.5 times the odds of TTR >7 days controlling for other factors. Race/ethnicity showed a trend toward longer TTR with Non-Hispanic Black (Black) patients having a longer TTR compared to White patients, controlling for other factors. We did not observe statistically significant effects of either comorbidity or prior authorization requirement on TTR. Conclusions: Though the majority of oncology patients prescribed OACDs receive the drug, 71% of prescriptions required prior authorization and a quarter of patients waited at least two weeks. Disparities in TTR are primarily driven by financial factors, specifically insurance type.[Table: see text]

Comparison of Cochlear Implant Device Fixation-Well Drilling Versus Subperiosteal Pocket. A Cost Effectiveness, Case-Control Study

OBJECTIVE

To compare surgical characteristics and complications between well drilling (WD) and subperiosteal pocket techniques (SPT) for receiver/stimulator (R/S) fixation of cochlear implant (CI), and conduct cost-effectiveness analysis.

STUDY DESIGN

Retrospective clinical study, decision-analysis model.

SETTING

Tertiary referral center.

PATIENTS

Three-hundred and eighty-eight CI recipients with a minimum of 6-months follow-up.

INTERVENTIONS

CI surgery using either WD or SPT for R/S fixation. A decision-analysis model was designed using data from a systematic literature review.

MAIN OUTCOME MEASURES

Surgical operation time, rates of major and minor long-term complications were compared. Incremental cost-effectiveness was also estimated, comparing the two methods of fixation.

RESULTS

We compared 179 WD with 209 SPT. Surgery time was significantly shorter in SPT (148 versus 169 min, p = 0.001) and remained significant after adjustment for possible confounders. Higher rates of major complications requiring surgical intervention were found with SPT (10.5% versus 4.5%, p = 0.042), however, the difference was not significant after adjusting for follow-up time (47.8 versus 32.5 months for SPT, WD respectively; p < 0.001). The incremental cost-effectiveness ratio for WD (compared with SPT) was $48,795 per major complication avoided, which was higher than the willingness-to-pay threshold of $47,700 (average cost of 2 h revision surgery).

CONCLUSIONS

SPT was found to be faster but potentially risks more complications, particularly relating to device failure. Further long-term studies are required to validate these differences. Based on data from the current literature, neither of the methods is compellingly cost-effective over the other, and surgeons can base their choice on personal preference, comfort, and previous training.

Cost-Effectiveness of Smoking Cessation Interventions in the Lung Cancer Screening Setting: A Simulation Study

BACKGROUND

Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches.

METHODS

We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios.

RESULTS

Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence.

CONCLUSION

All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

Promoting Breast Cancer Surveillance: The EMPOWER Study, a Randomized Clinical Trial in the Childhood Cancer Survivor Study

PURPOSE

The aim of the current study was to increase the uptake of screening mammography among high-risk women who were treated for a childhood cancer with chest radiotherapy.

PATIENTS AND METHODS

Two hundred four female survivors in the Childhood Cancer Survivor Study who were treated with chest radiotherapy with 20 Gy or greater, age 25 to 50 years, and without breast imaging in the past 24 months were randomly assigned 2:1 to receive a mailed informational packet followed by a tailored telephone-delivered brief motivational interview (intervention) versus an attention control. Primary outcome was the difference in the proportion of participants who completed a screening mammogram by 12 months as evaluated in an intent-to-treat analysis. Stratum-adjusted relative risk (RR) and 95% CI were estimated using the Cochran-Mantel-Haenszel method. Secondary outcomes included the completion of screening breast magnetic resonance imaging (MRI) and barriers to screening and moderating factors.

RESULTS

Women in the intervention group were significantly more likely than those in the control group to report a mammogram (45 [33.1%] of 136 v 12 [17.6%] of 68; RR, 1.9; 95% CI, 1.1 to 3.3). The intervention was more successful among women age 25 to 39 years (RR, 2.2; 95% CI, 1.1 to 4.7) than among those age 40 to 50 years (RR, 1.4; 95% CI, 0.6 to 3.2). The proportion of women who reported a breast MRI at 12 months was similar between the two groups: 16.2% (intervention) compared with 13.2% (control; RR, 1.2; 95% CI, 0.6 to 2.5). Primary barriers to completing a screening mammogram and/or breast MRI included lack of physician recommendation, deferred action by survivor, cost, and absence of symptoms.

CONCLUSION

Use of mailed materials followed by telephone-delivered counseling increased mammography screening rates in survivors at high risk for breast cancer; however, this approach did not increase the rate of breast MRI. Cost of imaging and physician recommendation were important barriers that should be addressed in future studies.

Personalized Treatment for Small Renal Tumors: Decision Analysis of Competing Causes of Mortality

Purpose To compare the effectiveness of personalized treatment for small (≤4 cm) renal tumors versus routine partial nephrectomy (PN), accounting for various competing causes of mortality. Materials and Methods A state-transition microsimulation model was constructed to compare life expectancy of management strategies for small renal tumors by using 1 000 000 simulations in the following ways: routine PN or personalized treatment involving percutaneous ablation for risk factors for worsening chronic kidney disease (CKD), and otherwise PN; biopsy, with triage of renal cell carcinoma (RCC) to PN or ablation depending on risk factors for worsening CKD; active surveillance for growth; and active surveillance when MRI findings are indicative of papillary RCC. Transition probabilities were incorporated from the literature. Effects of parameter variability were assessed in sensitivity analysis. Results In patients of all ages with normal renal function, routine PN yielded the longest life expectancy (eg, 0.67 years in 65-year-old men with nephrometry score [NS] of 4). Otherwise, personalized strategies extended life expectancy versus routine PN: in CKD stages 2 or 3a, moderate or high NS, and no comorbidities, MRI guidance for active surveillance extended life expectancy (eg, 2.60 years for MRI vs PN in CKD 3a, NS 10); and with Charlson comorbidity index of 1 or more, biopsy or active surveillance for growth extended life expectancy (eg, 2.70 years for surveillance for growth in CKD 3a, NS 10). CKD 3b was most effectively managed by using MRI to help predict papillary RCC for surveillance. Conclusion For patients with chronic kidney disease and small renal tumors, personalized treatment selection likely extends life expectancy. © RSNA, 2019 Online supplemental material is available for this article.

Long-term quality of life in older patients with HPV-related oropharyngeal cancer

BACKGROUND

We explored if age affects quality of life (QOL) in survivors of locally advanced human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (SCC).

METHODS

In a cross-sectional survey of 185 patients, at least 12 months from radiation, we evaluated generic (EuroQOL-5D questionnaire [EQ-5D]) and head and neck specific (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35-questions [EORTC-QLQ-H&N35]) QOL questionnaires and compared differences between younger (<65) and older (≥65) patients.

RESULTS

The median age was 57.0 years (range 25-77 years), and 31 patients (16.8%) were ≥65 years old. There was no significant difference in EQ-5D global QOL scores by age (P = .53). Patients ≥65 years reported more immobility (P < .01), problems with social eating (P < .0001), and coughing (P < .01). Patients ≥65 years were not more likely to ever require a gastrostomy (P = .24) but were more likely to remain gastrostomy-dependent at the time of the survey (P = .02).

CONCLUSION

Despite similar generic QOL, older survivors may have more mobility problems and issues with social eating compared with younger survivors deserving of further evaluation.

Quantifying performance thresholds for recommending screening mammography: a revealed preference analysis of USPSTF guidelines

PURPOSE

During ongoing controversies about mammography screening, many investigators have stated that performance improvements in screening mammography may mitigate concerns about harms. However, there have been few attempts to quantify performance improvements required to recommend mammography screening. Based on USPSTF benchmarks, we utilized revealed preference methods to ascertain quantitative thresholds at which screening mammography would be recommended beyond biennial screening in women 50 and older.

METHODS

Benefits of routine screening mammography (breast cancer deaths averted) were from published USPSTF meta-analyses. Potential harms (10-year cumulative probability of at least one false-positive) were from published Breast Cancer Surveillance Consortium estimates. We identified the implicit threshold (benefit/harm ratio) to recommend biennial screening starting at age 50. Using this threshold, we ascertained reductions of false-positives required to recommend more frequent screening and screening initiation under age 50 using revealed preference analyses.

RESULTS

Using USPSTF implied benefit/harm ratio, routine biennial screening would be recommended starting at 40 if false-positives declined by at least 62%. Reductions of false-positive proportions of 74% would be required to recommend annual screening starting at 40 and reductions of false-positive proportions of 31% would be required to support annual screening starting at 50.

CONCLUSIONS

Using USPSTF revealed preferences, 31-74% reductions in false-positives would be required to recommend mammography screening beyond biennial screening starting at age 50. Widespread implementation of tomosynthesis and reducing recall rates to the lower end of recommended recall rates (5-12%) would provide support for expanding screening beyond biennial screening in women age 50.

Percutaneous Ablation Versus Partial and Radical Nephrectomy for T1a Renal Cancer: A Population-Based Analysis

Background

Stage T1a renal cell carcinoma (RCC) (tumors <4 cm) is usually curable. Nephron-sparing partial nephrectomy (PN) has replaced radical nephrectomy (RN) as the standard of care for these tumors. Radical nephrectomy remains the first alternative treatment option, whereas percutaneous ablation (PA), a newer, nonsurgical treatment, is recommended less strongly because of the relative paucity of comparative PA data.

Objective

To compare PA, PN, and RN outcomes.

Design

Observational cohort analysis using inverse probability of treatment-weighted propensity scores.

Setting

Population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry data linked to Medicare claims.

Patients

Persons aged 66 years or older who received treatment for T1a RCC between 2006 and 2011.

Interventions

PA versus PN and RN.

Measurements

RCC-specific and overall survival, 30- and 365-day postintervention complications.

Results

4310 patients were followed for a median of 52 months for overall survival and 42 months for RCC-specific survival. After PA versus PN, the 5-year RCC-specific survival rate was 95% (95% CI, 93% to 98%) versus 98% (CI, 96% to 99%); after PA versus RN, 96% (CI, 94% to 98%) versus 95% (CI, 93% to 96%). After PA versus PN, the 5-year overall survival rate was 77% (CI, 74% to 81%) versus 86% (CI, 84% to 88%); after PA versus RN, 74% (CI, 71% to 78%) versus 75% (CI, 73% to 77%). Cumulative rates of renal insufficiency 31 to 365 days after PA, PN, and RN were 11% (CI, 8% to 14%), 9% (CI, 8% to 10%), and 18% (CI, 17% to 20%), respectively. Rates of nonurologic complications within 30 days after PA, PN, and RN were 6% (CI, 4% to 9%), 29% (CI, 27% to 30%), and 30% (CI, 28% to 32%), respectively. Ten percent of patients in the PN group had intraoperative conversion to RN. Seven percent of patients in the PA group received additional PA within 1 year of treatment.

Limitations

Analysis of observational data may have been affected by residual confounding by provider or from selection bias toward younger, healthier patients in the PN group. Findings from this older study population are probably less applicable to younger patients. Use of SEER-Medicare linked files prevented analysis of patients who received treatment after 2011, possibly reducing generalizability to the newest PA, PN, and RN techniques.

Conclusion

For well-selected older adults with T1a RCC, PA may result in oncologic outcomes similar to those of RN, but with less long-term renal insufficiency and markedly fewer periprocedural complications. Compared with PN, PA may be associated with slightly shorter RCC-specific survival but fewer periprocedural complications.

Primary Funding Source

Association of University Radiologists GE Radiology Research Academic Fellowship and Society of Interventional Radiology Foundation.

Association of Hospital Costs With Complications Following Total Gastrectomy for Gastric Adenocarcinoma

Importance

Postoperative complications are associated with increased hospital costs following major surgery, but the mechanism by which they increase cost and the categories of care that drive this increase are poorly described.

Objective

To describe the association of postoperative complications with hospital costs following total gastrectomy for gastric adenocarcinoma.

Design, Setting, and Participants

This retrospective analysis of a prospectively collected gastric cancer surgery database at a single National Cancer Institute-designated comprehensive cancer center included all patients undergoing curative-intent total gastrectomy for gastric adenocarcinoma between January 2009 and December 2012 and was conducted in 2015 and 2016.

Main Outcomes and Measures

Ninety-day normalized postoperative costs. Hospital accounting system costs were normalized to reflect Medicare reimbursement levels using the ratio of hospital costs to Medicare reimbursement and categorized into major cost categories. Differences between costs in Medicare proportional dollars (MP $) can be interpreted as the amount that would be reimbursed to an average hospital by Medicare if it paid differentially based on types and extent of postoperative complications.

Results

In total, 120 patients underwent curative-intent total gastrectomy for stage I through III gastric adenocarcinoma between 2009 and 2012. Of these, 79 patients (65.8%) were men, and the median (interquartile range) age was 64 (52-70) years. The 51 patients (42.5%) who underwent an uncomplicated total gastrectomy had a mean (SD) normalized cost of MP $12 330 (MP $2500), predominantly owing to the cost of surgical care (mean [SD] cost, MP $6830 [MP $1600]). The 34 patients (28.3%) who had a major complication had a mean (SD) normalized cost of MP $37 700 (MP $28 090). Surgical care was more expensive in these patients (mean [SD] cost, MP $8970 [MP $2750]) but was a smaller contributor to total cost (24%) owing to increased costs from room and board (mean [SD] cost, MP $11 940 [MP $8820]), consultations (mean [SD] cost, MP $3530 [MP $2410]), and intensive care unit care (mean [SD] cost, MP $7770 [MP $14 310]).

Conclusions and Relevance

Major complications were associated with tripled normalized costs following curative-intent total gastrectomy. Most of the excess costs were related to the treatment of complications. Interventions that decrease the number or severity of postoperative complications could result in substantial cost savings.

Measuring the Value of New Drugs: Validity and Reliability of 4 Value Assessment Frameworks in the Oncology Setting

BACKGROUND

Several organizations have developed frameworks to systematically assess the value of new drugs.

OBJECTIVE

To evaluate the convergent validity and interrater reliability of 4 value frameworks to understand the extent to which these tools can facilitate value-based treatment decisions in oncology.

METHODS

Eight panelists used the American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), Institute for Clinical and Economic Review (ICER), and National Comprehensive Cancer Network (NCCN) frameworks to conduct value assessments of 15 drugs for advanced lung and breast cancers and castration-refractory prostate cancer. Panelists received instructions and published clinical data required to complete the assessments, assigning each drug a numeric or letter score. Kendall's Coefficient of Concordance for Ranks (Kendall's W) was used to measure convergent validity by cancer type among the 4 frameworks. Intraclass correlation coefficients (ICCs) were used to measure interrater reliability for each framework across cancers. Panelists were surveyed on their experiences.

RESULTS

Kendall's W across all 4 frameworks for breast, lung, and prostate cancer drugs was 0.560 (P= 0.010), 0.562 (P = 0.010), and 0.920 (P < 0.001), respectively. Pairwise, Kendall's W for breast cancer drugs was highest for ESMO-ICER and ICER-NCCN (W = 0.950, P = 0.019 for both pairs) and lowest for ASCO-NCCN (W = 0.300, P = 0.748). For lung cancer drugs, W was highest pairwise for ESMO-ICER (W = 0.974, P = 0.007) and lowest for ASCO-NCCN (W = 0.218, P = 0.839); for prostate cancer drugs, pairwise W was highest for ICER-NCCN (W = 1.000, P < 0.001) and lowest for ESMO-ICER and ESMO-NCCN (W = 0.900, P = 0.052 for both pairs). When ranking drugs on distinct framework subdomains, Kendall's W among breast cancer drugs was highest for certainty (ICER, NCCN: W = 0.908, P = 0.046) and lowest for clinical benefit (ASCO, ESMO, NCCN: W = 0.345, P = 0.436). Among lung cancer drugs, W was highest for toxicity (ASCO, ESMO, NCCN: W = 0. 944, P < 0.001) and lowest for certainty (ICER, NCCN: W = 0.230, P = 0.827); and among prostate cancer drugs, it was highest for quality of life (ASCO, ESMO: W = 0.986, P = 0.003) and lowest for toxicity (ASCO, ESMO, NCCN: W = 0.200, P = 0.711). ICC (95% CI) for ASCO, ESMO, ICER, and NCCN were 0.800 (0.660-0.913), 0.818 (0.686-0.921), 0.652 (0.466-0.834), and 0.153 (0.045-0.371), respectively. When scores were rescaled to 0-100, NCCN provided the narrowest band of scores. When asked about their experiences using the ASCO, ESMO, ICER, and NCCN frameworks, panelists generally agreed that the frameworks were logically organized and reasonably easy to use, with NCCN rated somewhat easier.

CONCLUSIONS

Convergent validity among the ASCO, ESMO, ICER, and NCCN frameworks was fair to excellent, increasing with clinical benefit subdomain concordance and simplicity of drug trial data. Interrater reliability, highest for ASCO and ESMO, improved with clarity of instructions and specificity of score definitions. Continued use, analyses, and refinements of these frameworks will bring us closer to the ultimate goal of using value-based treatment decisions to improve patient care and outcomes.

DISCLOSURES

This work was funded by Eisai Inc. Copher and Knoth are employees of Eisai Inc. Bentley, Lee, Zambrano, and Broder are employees of Partnership for Health Analytic Research, a health services research company paid by Eisai Inc. to conduct this research. For this study, Cohen, Huynh, and Neville report fees from Partnership for Health Analytic Research. Outside of this study, Cohen receives grants and direct consulting fees from various companies that manufacture and market pharmaceuticals. Mei reports a grant from Eisai Inc. during this study. The other authors have no disclosures to report. Study concept and design were contributed by Bentley and Broder, with assistance from Elkin and Cohen. Bentley took the lead in data collection, along with Elkin, Huynh, Mukherjea, Neville, Mei, Popescu, Lee, and Zambrano. Data interpretation was performed by Bentley and Broder, along with Elkin, Cohen, Copher, and Knoth. The manuscript was written primarily by Bentley, along with Elkin and Broder, and revised by Bentley, Broder, Elkin, Cohen, Copher, and Knoth. Select components of this work's methods were presented at ISPOR 19th Annual European Congress held in Vienna, Austria, October 29-November 2, 2016, and Society for Medical Decision Making 38th Annual North American Meeting held in Vancouver, Canada, October 23-26, 2016.

Validity and reliability of four value frameworks for cancer drugs

6603

Background: Little is known about the validity and reliability of value assessment frameworks. Methods: Eight panelists used the ASCO, ESMO, ICER, and NCCN frameworks to conduct value assessments of 15 drugs for advanced lung and breast cancers and castration refractory prostate cancer. Panelists received instructions and published clinical data to complete the assessments, assigning each drug a numeric or letter score. We used Kendall’s W coefficient to measure convergent validity by cancer type among frameworks and intraclass correlation coefficients (ICC) to measure framework inter-rater reliability across cancers. Panelists were surveyed on their experiences. Results: Kendall’s W for breast, lung, and prostate cancer drugs were 0.560 ( p= 0.010), 0.562 ( p= 0.010), and 0.920 ( p< 0.001), respectively. Pairwise and subdomain W are shown in the table. ICC (95% CI) for ASCO, ESMO, ICER, and NCCN were 0.800 (0.660-0.913), 0.818 (0.686-0.921), 0.652 (0.466-0.834), and 0.153 (0.045-0.371), respectively. Panelists generally agreed the frameworks were logically organized and easy to use. Conclusions: Convergent validity among the frameworks was fair to excellent, increasing with clinical benefit subdomain concordance and simplicity of drug trial data. Inter-rater reliability, highest for ASCO and ESMO, improved with clarity of instructions and specificity of score definitions. Continued use, analyses, and refinements of the frameworks will bring us closer to using value-based treatment decisions to improve patient care and outcomes. [Table: see text]

Cost-effectiveness analysis of first-line treatments for early-stage, low-grade follicular lymphoma

6619

Background: Low-grade follicular lymphoma (FL) can present as localized stage I to II disease in up to one-third of patients. Upfront involved-site radiation therapy (RT) to 24-30Gy is the preferred first-line management strategy for these patients. However, the National LymphoCare Study found that less than one quarter of patients with early-stage, low-grade FL received upfront RT, while more than half received either chemoimmunotherapy or observation. Methods: We performed a cost-effectiveness analysis using a Markov state-transition model to simulate the progression of early-stage, low-grade FL in a cohort of 60-year-old men. The following first-line treatments were compared: RT, observation, rituximab induction (RI), rituximab and bendamustine (BR), and rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP). Patients who relapsed received second-line therapies that were dependent on their first-line treatment: RT for RI and observation, RCHOP for RT and BR, and BR for RCHOP. Disease-progression probabilities and other model inputs were from published trials. Results: First-line RT followed by RCHOP for relapses had a quality-adjusted life expectancy (QALE) of 11.4 years, superior to first-line observation, RI, BR, and RCHOP strategies. First-line RT strongly dominated observation, BR, and RCHOP. Compared with RI, first-line RT resulted in an incremental cost-effectiveness ratio of $2,740 per quality-adjusted life year. The probability of dying from other causes, the probability of a complete response to RT, and the probability of relapse had the greatest impact on both cost and effectiveness expected values. Conclusions: In contrast to current practice patterns, first-line RT is the most effective upfront treatment for patients with early-stage, low-grade FL. Further, first-line RT paired with RCHOP for relapses is a cost-effective treatment paradigm, relative to other strategies. [Table: see text]

Facilitating informed decisions about breast cancer screening: development and evaluation of a web-based decision aid for women in their 40s

Background

Expert groups and national guidelines recommend individualized decision making about screening mammography for women in their 40s at low-to-average risk of breast cancer. We created Breast Screening Decisions (BSD), a personalized, web-based decision aid, to help women decide when to start and how often to have routine screening mammograms. We evaluated BSD in a large, prospective pilot trial of women and their clinicians.

Methods

Women ages 40–49 were invited to use BSD before a scheduled preventive care visit. One month post-visit, users were asked about decisional conflict, knowledge, perceptions and worry about breast cancer and screening. They were also asked whether they had a screening mammogram since their visit, scheduled an appointment for a screening mammogram, or if they were planning to schedule an appointment within the next six months. Women who responded “no” to each of these successive questions were considered to have no plan for a screening mammogram within the next 6 months, unless they explicitly stated that they were unsure about screening mammography. Clinicians were surveyed regarding mammography discussions and perceived patient knowledge and anxiety.

Results

Of 1,100 women invited to use BSD, 253 accessed the website, and 168 were eligible to participate in the pilot study. One-fifth had a family history of breast cancer, and at least 76% had any prior mammogram. At follow-up, 88% of BSD users reported discussing mammography at their visit, and 77% said they had a screening mammogram since the visit or that they made or were planning to make a screening mammogram appointment. The average decisional conflict score was 22.5, within the threshold for implementing decisions. Decisional conflict scores were lowest in women who said that they had or planned to have a mammogram (mean 21.4, 95% CI 18.3-24.6), higher in those who did not (mean 24.8, 95% CI 19.2-30.5), and highest in those who were unsure (mean 31.5, 95% CI 13.9-49.1). Most BSD users expressed accurate perceptions of their breast cancer risk and the benefits and limitations of screening.

Conclusions

A web-based decision aid may support informed, individualized decisions about screening mammography and facilitate discussions about screening between women in their 40s and their clinicians.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0423-7) contains supplementary material, which is available to authorized users.

Validity and Reliability of Value Assessment Frameworks for New Cancer Drugs

BACKGROUND

Several organizations have developed frameworks to systematically assess the value of new drugs. These organizations include the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO), the Institute for Clinical and Economic Review (ICER), and the National Comprehensive Cancer Network (NCCN).

OBJECTIVES

To understand the extent to which these four tools can facilitate value-based treatment decisions in oncology.

METHODS

In this pilot study, eight panelists conducted value assessments of five advanced lung cancer drugs using the ASCO, ESMO, and ICER frameworks. The panelists received instructions and published clinical data required to complete the assessments. Published NCCN framework scores were abstracted. The Kendall's W coefficient was used to measure convergent validity among the four frameworks. Intraclass correlation coefficients were used to measure inter-rater reliability among the ASCO, ESMO, and ICER frameworks. Sensitivity analyses were conducted.

RESULTS

Drugs were ranked similarly by the four frameworks, with Kendall's W of 0.703 (P = 0.006) across all the four frameworks. Pairwise, Kendall's W was the highest for ESMO-ICER (W = 0.974; P = 0.007) and ASCO-NCCN (W = 0.944; P = 0.022) and the lowest for ICER-NCCN (W = 0.647; P = 0.315) and ESMO-NCCN (W = 0.611; P = 0.360). Intraclass correlation coefficients (confidence interval [CI]) for the ASCO, ESMO, and ICER frameworks were 0.786 (95% CI 0.517-0.970), 0.804 (95% CI 0.545-0.973), and 0.281 (95% CI 0.055-0.799), respectively. When scores were rescaled to 0 to 100, the ICER framework provided the narrowest band of scores.

CONCLUSIONS

The ASCO, ESMO, ICER, and NCCN frameworks demonstrated convergent validity, despite differences in conceptual approaches used. The ASCO inter-rater reliability was high, although potentially at the cost of user burden. The ICER inter-rater reliability was poor, possibly because of its failure to distinguish differential value among the sample of drugs tested. Refinements of all frameworks should continue on the basis of further testing and stakeholder feedback.

ReCAP: Hospitalizations in Older Adults With Advanced Cancer: The Role of Chemotherapy

PURPOSE

Hospital readmissions are often cited as a marker of poor quality of care. Limited data suggest some readmissions may be preventable depending upon definitions and available outpatient support.

METHODS

General criteria to define preventable and not preventable admissions were developed before data collection began. The records of sequential nonsurgical oncology readmissions were reviewed independently by two reviewers. When the reviewers disagreed about assigning admissions as preventable or not preventable, a third reviewer was the tie breaker. The reasons for assigning admissions as preventable or not preventable were analyzed.

RESULTS

Seventy-two readmissions occurring among 69 patients were analyzed. The first two reviewers agreed that 18 (25%) of 72 were preventable and that 29 (40%) of 72 were not. A third reviewer found four of the split 25 cases to be preventable; therefore, the consensus preventability rate was 22 (31%) of 72. The most common causes of preventability were overwhelming symptoms in patients who qualified for hospice but were not participating in hospice and insufficient communication between patients and the care team about symptom burden. The most common reason for assignment of a not preventable admission was a high symptom burden among patients without strong indications for hospice or for whom aggressive outpatient management was inadequate. The median survival after readmission was 72 days.

CONCLUSION

A substantial proportion of oncology readmissions could be prevented with better anticipation of symptoms in high-risk ambulatory patients and enhanced communication about symptom burden between patients and physicians before an escalation that leads to an emergency department visit. Managing symptoms in patients who are appropriate for hospice is challenging. Readmission is a marker of poor prognosis.

Surgeon Adoption of Minimally Invasive Radical Prostatectomy

INTRODUCTION

Minimally invasive radical prostatectomy has become the most common surgical treatment for prostate cancer. In this study we describe patterns of minimally invasive radical prostatectomy adoption among surgeons who performed open radical prostatectomy before their first minimally invasive radical prostatectomy and those who did not.

METHODS

We performed a retrospective cohort study using the population based SEER (Surveillance, Epidemiology, and End Results)-Medicare data set. We identified all surgeons who performed minimally invasive radical prostatectomy in 2003 to 2010 in men with prostate cancer 66 years old or older. Surgeons were classified as "converters" if they performed open radical prostatectomy before their first minimally invasive radical prostatectomy or "de novos" if they had not. We estimated annual minimally invasive radical prostatectomy volume and the proportion of prostatectomies performed minimally invasively. We used logistic regression to identify predictors of minimally invasive radical prostatectomy discontinuation.

RESULTS

A total of 11,511 minimally invasive radical prostatectomies were performed by 738 minimally invasive radical prostatectomy surgeons (converters 337 and de novos 401). Converters performed 55% of all minimally invasive radical prostatectomies and had higher median annual minimally invasive radical prostatectomy volume than de novos (4 vs 2). About 34% of converters and 54% of de novos discontinued minimally invasive radical prostatectomy after their first year. Second year discontinuation of minimally invasive radical prostatectomy was more likely among de novo surgeons (OR 1.9, 95% CI 1.3-2.7) and less likely among surgeons with higher minimally invasive radical prostatectomy volume in their first year (OR 0.5, 95% CI 0.5-0.6).

CONCLUSIONS

During the years of the greatest growth in minimally invasive radical prostatectomy, surgeon adoption of this technique varied by surgeon type and volume. Many surgeons discontinued, and possibly abandoned, minimally invasive radical prostatectomy. Based on these observations, experienced and higher volume surgeons will be most successful adopting new surgical technology.

Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer

IMPORTANCE

Interventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions.

OBJECTIVE

To assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases.

MAIN OUTCOME AND MEASURES

To assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use.

RESULTS

Cohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively).

CONCLUSIONS AND RELEVANCE

Physicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.

Preference Assessment Method Affects Decision-Analytic Recommendations: A Prostate Cancer Treatment Example

Purpose. To evaluate the effect of preference assessment method on treatment recommended by an individualized decision-analytic model for early prostate cancer. Methods. Health state preferences were elicited by time tradeoff, rating scale, and a power transformation of the rating scale from 63 men ages 55 to 75. The authors used these values in a Markov model to determine whether radical prostatectomy or watchful waiting yielded the greater quality-adjusted life expectancy. Results. Time tradeoff and transformed rating scale recommendations differed widely. Time tradeoff and transformed rating scale utilities differed in their treatment recommendation for 21% to 52% of men, and the mean difference in quality-adjusted life years varied from less than 0.5 to greater than 1.0. Conclusions. Treatment recommendations from the prostate cancer decision model were sensitive to the method of preference assessment. If decision analysis is used to counsel individual patients, careful considerationmust be given to the method of preference elicitation.

Employment and return to work following chemoradiation in patient with HPV-related oropharyngeal cancer

Background

Human papillomavirus (HPV)-positive oropharyngeal cancer primarily affects working-age adults. Chemotherapy and radiation (CTRT) used to treat this disease may adversely impact a survivors' ability to work after treatment.

Methods

We surveyed participants with HPV-positive oropharyngeal cancer who completed CTRT regarding employment. We examined the associations between 1) sociodemographic and clinical factors and employment outcomes, and 2) health-related quality of life and satisfaction with ability to work.

Results

102 participants were employed full-time at diagnosis for pay and surveyed at a median of 23 months post-CTRT (range 12-57 months). The median age at diagnosis was 57 years (range 25-76 years). During CTRT, 8 % stopped working permanently, 89 % took time off or reduced responsibility but later returned, and 3 % reported no change. For those who took time off but returned, median time to return to work was 14.5 weeks. In multivariable analysis, younger age predicted for needing more than the median time off. At time of survey, 85 % participants were working, 7 % had retired, and 8 % were not working for other reasons. Seventeen percent of participants were not satisfied with their current ability to work, which was associated with poorer health-related quality of life and persistent treatment toxicities (p < 0.001).

Conclusions

CTRT interrupts employment in the majority of working patients with HPV-positive oropharyngeal cancer but most return. However, treatment-related toxicities might lead to dissatisfaction with ability to work.

Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage

IMPORTANCE

Instituting widespread measurement of outcomes for cancer hospitals using administrative data is difficult owing to lack of cancer-specific information such as disease stage.

OBJECTIVE

To evaluate the performance of hospitals that treat patients with cancer using Medicare data for outcome ascertainment and risk adjustment and to assess whether hospital rankings based on these measures are altered by the addition of cancer-specific information.

DESIGN, SETTING, AND PARTICIPANTS

Risk-adjusted cumulative mortality rates of patients with cancer were captured in Medicare claims data from 2005 through 2009 nationally and assessed at the hospital level. Similar analyses were conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the subset of the United States covered by the SEER program to determine whether the inclusion of cancer-specific information (only available in cancer registries) in risk adjustment altered measured hospital performance. Data were from 729 279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10 or more patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon, and other. An additional sample of 18 677 similar patients were included from the SEER-Medicare administrative data.

MAIN OUTCOMES AND MEASURES

Risk-adjusted mortality overall and by cancer category, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data.

RESULTS

There were large survival differences between different types of hospitals that treat Medicare patients with cancer. At 1 year, mortality for patients treated by hospitals exempt from the Medicare prospective payment system was 10% lower than at community hospitals (18% vs 28%) across all cancers, and the pattern persisted through 5 years of follow-up and within specific cancer categories. Performance ranking of hospitals was consistent with or without SEER-Medicare disease stage information (weighted κ ≥ 0.81).

CONCLUSIONS AND RELEVANCE

Potentially important outcome differences exist between different types of hospitals that treat patients with cancer after risk adjustment using information in Medicare administrative data. This type of risk adjustment may be adequate for evaluating hospital performance, since the additional adjustment for data available only in cancer registries does not seem to appreciably alter measures of performance.

Patterns of surveillance imaging after nephrectomy in the Medicare population

OBJECTIVES

To characterize patterns of imaging surveillance after nephrectomy in a population-based cohort of older patients with kidney cancer.

PATIENTS AND METHODS

Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified patients aged ≥ 66 years who underwent partial or radical nephrectomy for localized kidney cancer diagnosed between 2000 and 2009. Primary outcomes were chest imaging (X-ray or computed tomography [CT]) and abdominal imaging (CT, MRI or ultrasonography) in Medicare claims from 4 to 36 months after surgery. We estimated the frequency of imaging in three time periods (postoperative months 4-12, 13-24, 25-36), stratified by tumour stage. Repeated-measures logistic regression was used to identify the patient and disease characteristics associated with imaging.

RESULTS

Rates of chest imaging were 65-80%, with chest X-ray surpassing CT in each time period. Rates of abdominal imaging were 58-76%, and cross-sectional imaging was more common than ultrasonography in each time period. Use of cross-sectional chest and abdominal imaging increased over time, while the use of chest X-ray decreased (P < 0.01). Ultrasonography use remained stable for patients with T1 and T2 disease, but the rate of use decreased in patients with T3 disease (P < 0.05). Rates of chest and abdominal imaging increased with tumour stage (P < 0.001).

CONCLUSIONS

Patterns of imaging suggest possible overuse in patients at low risk of recurrence and underuse in those at greater risk. New surveillance imaging guidelines may reduce unwarranted variability and promote risk-based, cost-effective management after nephrectomy.

Traditional versus streamlined management of basal cell carcinoma (BCC): A cost analysis

BACKGROUND

Facing rising incidence of basal cell carcinoma (BCC) and increasing pressure to contain health care spending, physicians need to contemplate cost-effective paradigms for managing BCC.

OBJECTIVE

We sought to perform a cost analysis comparing the traditional BCC management scheme with a simplified detect-and-treat scheme that eliminates the biopsy before initiating definitive treatment.

METHODS

A decision analytic model was developed to compare the costs of traditional BCC management with the detect-and-treat scheme, under which qualifying lesions diagnosed clinically were either treated with shave removal or referred to Mohs micrographic surgery for on-site histologic check. Values for model parameters were based on literature and our institutional data analysis. Costs were based on 2014 Medicare fee schedule.

RESULTS

The average cost per lesion with detect-and-treat scheme was $449 for non-Mohs micrographic surgery-indicated lesions (vs $566 with traditional management, $117 in savings) and $819 for Mohs micrographic surgery-indicated lesions (vs $864 with traditional management, $45 in savings). The combined weighted average savings per case was $95 (15% of total average cost). Conclusions were similar under various plausible scenarios.

LIMITATIONS

Model parameter values may vary based on individual practices.

CONCLUSIONS

A simplified management strategy eliminating routine pretreatment biopsy can reduce BCC treatment cost without compromising quality of care.