Retrospective analysis of characteristics associated with higher-value radiotherapy episodes of care for bone metastases in Medicare fee-for-service beneficiaries

OBJECTIVES

The Centers for Medicare & Medicaid Services' newly enacted Radiation Oncology Model ('RO Model') was designed to test the cost-saving potential of prospective episode-based payments for radiation treatment for 17 cancer diagnoses by encouraging high-value care and more efficient care delivery. For bone metastases, evidence supports the use of higher-value, shorter courses of radiation (≤10 fractions). Our goal was to determine the prevalence of short radiation courses (≤10 fractions) for bone metastases and the setting, treatment and patient characteristics associated with such courses and their expenditures.

DESIGN

Using the RO Model episode file, we evaluated receipt of ≤10 fractions of radiotherapy for bone metastases and expenditures by treatment setting for Medicare fee-for-service beneficiaries during calendar years 2015-2017.Using unadjusted and adjusted regression models, we determined predictors of receipt of ≤10 fractions and expenditures. Multivariable models adjusted for treatment and patient characteristics.

RESULTS

There were 48 810 episodes for bone metastases during the period. A majority of episodes for ≤10 fractions occurred in hospital-outpatient settings (62.8% (N=22 715)). After adjusting for treatment and patient factors, hospital-outpatient treatment setting remained a significant predictor of receiving ≤10 fractions (adjusted OR 2.03 (95% CI 1.95, 2.12; p<0.001) vs free-standing). The greatest adjusted contributors to total expenditures were number of fractions (US$-3424 (95% CI US$-3412 to US$-3435) for ≤10 fractions vs >10; p<0.001) and treatment type (including US$7716 (95% CI US$7424 to US$8018) for intensity modulated radiation therapy vs conventional external beam; p<0.001).

CONCLUSIONS

A measurable performance gap exists for delivery of higher-value bone metastases radiotherapy under an episode-based model, associated with increased expenditures. The RO Model may succeed in improving the value of bone metastases radiation. Increasing the capacity of free-standing centres to implement palliative-focused services may improve the ability of these practices to succeed under the RO Model.

The Safety and Efficacy of Radiation Therapy with Concurrent Dexamethasone, Cyclophosphamide, Etoposide, and Cisplatin-Based Systemic Therapy for Multiple Myeloma

INTRODUCTION

The concurrent delivery of radiation therapy (RT) with salvage chemotherapies in the management of relapsed and refractory multiple myeloma (MM) is an area of ongoing investigation. This study examined the safety and efficacy of palliative RT given in the setting of concurrent dexamethasone, cyclophosphamide, etoposide, and cisplatin (DCEP).

PATIENTS AND METHODS

Fifty-five patients with MM received RT to 64 different sites within three weeks of receiving DCEP from 2010 to 2020. A median dose of 20 Gray (range 8-32.5 Gy) was delivered in a median of 5 fractions (range 1-15). Patients received a median of 1 cycle (range 1-5) of DCEP. Rates of hematologic and RT toxicity were recorded along with pain, radiographic, and laboratory responses to treatment.

RESULTS

RT was completed in 98% of patients. 21% of patients experienced RTOG grade 3+ hematologic toxicity before RT, which increased to 35% one-month post-RT (P = .13) before decreasing to 12% at 3 to 6 months (P = .02). The most common toxicity experienced was thrombocytopenia. Grade 1 to 2 non-hematologic RT-related toxicity was reported in 15% of patients while on treatment and fell to 6% one-month after completing RT. Pain resolved in 94% of patients with symptomatic lesions at baseline. Stable disease or better was observed in 34/39 (87%) of the targeted lesions on surveillance imaging.

CONCLUSION

RT administered concurrently with DCEP was well-tolerated by most of the patients in this series, with low rates of hematologic and RT-related toxicity. RT was also very effective, with the vast majority of patients demonstrating resolution of their pain and a significant response on follow-up imaging.

The Impact of Dementia on Cancer Treatment Decision-Making, Cancer Treatment, and Mortality: A Mixed Studies Review

Dementia and cancer occur commonly in older adults. Yet, little is known about the effect of dementia on cancer treatment and outcomes in patients diagnosed with cancer, and no guidelines exist. We performed a mixed studies review to assess the current knowledge and gaps on the impact of dementia on cancer treatment decision-making, cancer treatment, and mortality. A search in PubMed, Medline, and PsycINFO identified 55 studies on older adults with a dementia diagnosis before a cancer diagnosis and/or comorbid cancer and dementia published in English from January 2004 to February 2020. We described variability using range in quantitative estimates, ie, odds ratios (ORs), hazard ratios (HRs), and risk ratios (RR) when appropriate and performed narrative review of qualitative data. Patients with dementia were more likely to receive no curative treatment (including hospice or palliative care) (OR, HR, and RR range = 0.40-4.4, n = 8), while less likely to receive chemotherapy (OR and HR range = 0.11-0.68, n = 8), radiation (OR range = 0.24-0.56, n = 2), and surgery (OR range = 0.30-1.3, n = 4). Older adults with cancer and dementia had higher mortality than those with cancer alone (HR and OR range = 0.92-5.8, n = 33). Summarized findings from qualitative studies consistently revealed that clinicians, caregivers, and patients tended to prefer less aggressive care and gave higher priority to quality of life over life expectancy for those with dementia. Current practices in treatment-decision making for patients with both cancer and dementia are inconsistent. There is an urgent need for treatment guidelines for this growing patient population that considers patient and caregiver perspectives.

Impact of Radiotherapy on Daily Function Among Older Adults Living with Advanced Cancer

Radiation therapy (RT) improves quality of life and symptomatic burden for patients with advanced malignancies. However, RT can also confer toxicity and little is known about the contribution of geriatric conditions to RT-related outcomes in older adults. This study aims to examine changes in daily function among RT patients at 1 and 6 months following RT. We reviewed charts of 137 patients who underwent RT with intent to improve daily functioning. ADL and IADL scores ranging from 0-6 and 0-8, respectively were collected at baseline, 1-, and 6-months post-RT. Latent class analysis of baseline ADL and IADL was conducted to categorize patients into two classes (high and low deficit). Latent transition analysis was used to examine transitions at each time point. One-hundred seventy courses of RT were identified; 99 were fully evaluable. Median age was 66 years. For ADL and IADL, at baseline 28.9% and 28.3% were classified as high deficit and 71.1%, 71.3% as low deficit respectively; 2% and 7% of low deficit patients had the potential to move to high deficit group at 1 month; and 20% and 13% had the potential to have the same movement from 1 to 6 months. All patients classified as high deficit for both measures at 1 month remained so at 6 months. ADL and IADL functioning may be useful in describing changes in daily function after and identifying groups of patients who may benefit from additional supportive geriatric and/or palliative care interventions.

Development and validation of a machine learning-based prediction model for near-term in-hospital mortality among patients with COVID-19

OBJECTIVES

To develop and validate a model for prediction of near-term in-hospital mortality among patients with COVID-19 by application of a machine learning (ML) algorithm on time-series inpatient data from electronic health records.

METHODS

A cohort comprised of 567 patients with COVID-19 at a large acute care healthcare system between 10 February 2020 and 7 April 2020 observed until either death or discharge. Random forest (RF) model was developed on randomly drawn 70% of the cohort (training set) and its performance was evaluated on the rest of 30% (the test set). The outcome variable was in-hospital mortality within 20-84 hours from the time of prediction. Input features included patients' vital signs, laboratory data and ECG results.

RESULTS

Patients had a median age of 60.2 years (IQR 26.2 years); 54.1% were men. In-hospital mortality rate was 17.0% and overall median time to death was 6.5 days (range 1.3-23.0 days). In the test set, the RF classifier yielded a sensitivity of 87.8% (95% CI: 78.2% to 94.3%), specificity of 60.6% (95% CI: 55.2% to 65.8%), accuracy of 65.5% (95% CI: 60.7% to 70.0%), area under the receiver operating characteristic curve of 85.5% (95% CI: 80.8% to 90.2%) and area under the precision recall curve of 64.4% (95% CI: 53.5% to 75.3%).

CONCLUSIONS

Our ML-based approach can be used to analyse electronic health record data and reliably predict near-term mortality prediction. Using such a model in hospitals could help improve care, thereby better aligning clinical decisions with prognosis in critically ill patients with COVID-19.

Abstract A101: The impact of dementia on cancer treatment decision-making, cancer treatment, and survival

Introduction: Dementia and cancer are common conditions affecting older adults. Yet, little is known about the effect of dementia on cancer treatment decision-making and the subsequent health outcomes in people diagnosed with cancer. We performed a mini review of the recent literature to assess the current knowledge and gaps on the impact of dementia on cancer treatment decision-making, treatment received, and survival. Methods: A systematic search of the PubMed database with keywords “dementia,” “cancer,” “treatment decision-making,” and “management” was performed to identify studies on older adults with a diagnosis of dementia before a diagnosis of cancer and/or comorbid cancer and dementia published in the English language from January 2004 to December 2018. We used the Mixed Methods Appraisal Tool to critically appraise the methodological quality of studies. We conducted meta-analyses wherever quantitative elements could be extracted to derive the summary odds ratios (ORs) and hazard ratios (HRs). Results: There were 55 studies (out of 829 from the initial search) included in the final full text-review. Health professionals, care givers, and patients with dual cancer and dementia tended to prefer less aggressive care and gave higher priority to quality of life over life expectancy. However, they also faced unique challenges. The decision-making processes varied widely among health professionals because of differences in personal opinion, lack of specific guidelines, difficulty in obtaining informed consent, and expectations of patient discomfort. Consistent with previously published findings on decision-making preferences, the meta-analysis showed that people with dementia were less likely to receive chemotherapy (OR=0.32 (95% CI: 0.31 to 0.35), nstudies=12), radiation therapy (OR=0.56 (95% CI: 0.18 to 1.78), nstudies=6), and surgery (OR=0.61 (95% CI: 0.34 to 1.08), nstudies=5) than other treatment. In addition, people with cancer and dementia had greater odds of receiving no treatment versus any treatment (OR=4.25 (95% CI: 1.65 to 10.90), nstudies=5). Older adults with both cancer and dementia had worse survival than those with cancer alone (HR =1.97 (95% CI: 1.67 to 2.31), nstudies=19). Conclusions: Our review showed that an underlying dementia diagnosis was associated with greater odds of receiving less and no cancer treatment, and with worse survival. Current practices in treatment-decision making and overall cancer management for patients with the dual diagnosis are inconsistent. There is an urgent need for guidelines in this growing population of cancer and dementia patients.

Citation Format: Yaelin Caba Silverio, Bian Liu, Emanuela Taioli, Kavita Dharmarajan. The impact of dementia on cancer treatment decision-making, cancer treatment, and survival [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A101.

Comparison of statistical and machine learning models for healthcare cost data: a simulation study motivated by Oncology Care Model (OCM) data

Background

The Oncology Care Model (OCM) was developed as a payment model to encourage participating practices to provide better-quality care for cancer patients at a lower cost. The risk-adjustment model used in OCM is a Gamma generalized linear model (Gamma GLM) with log-link. The predicted value of expense for the episodes identified for our academic medical center (AMC), based on the model fitted to the national data, did not correlate well with our observed expense. This motivated us to fit the Gamma GLM to our AMC data and compare it with two other flexible modeling methods: Random Forest (RF) and Partially Linear Additive Quantile Regression (PLAQR). We also performed a simulation study to assess comparative performance of these methods and examined the impact of non-linearity and interaction effects, two understudied aspects in the field of cost prediction.

Methods

The simulation was designed with an outcome of cost generated from four distributions: Gamma, Weibull, Log-normal with a heteroscedastic error term, and heavy-tailed. Simulation parameters both similar to and different from OCM data were considered. The performance metrics considered were the root mean square error (RMSE), mean absolute prediction error (MAPE), and cost accuracy (CA). Bootstrap resampling was utilized to estimate the operating characteristics of the performance metrics, which were described by boxplots.

Results

RF attained the best performance with lowest RMSE, MAPE, and highest CA for most of the scenarios. When the models were misspecified, their performance was further differentiated. Model performance differed more for non-exponential than exponential outcome distributions.

Conclusions

RF outperformed Gamma GLM and PLAQR in predicting overall and top decile costs. RF demonstrated improved prediction under various scenarios common in healthcare cost modeling. Additionally, RF did not require prespecification of outcome distribution, nonlinearity effect, or interaction terms. Therefore, RF appears to be the best tool to predict average cost. However, when the goal is to estimate extreme expenses, e.g., high cost episodes, the accuracy gained by RF versus its computational costs may need to be considered.

State-Level Variations in the Utilization of Lung Cancer Screening Among Medicare Fee-for-Service Beneficiaries: An Analysis of the 2015 to 2017 Physician and Other Supplier Data

BACKGROUND

Lung cancer screening (LCS) is an important secondary prevention measure to reduce lung cancer mortality. The goal of this study was to assess state-level variations in LCS among the US elderly during the first 3 years since Medicare began its LCS reimbursement policy in 2015.

METHODS

This ecological study examined the relations between LCS utilization density, defined as the number of low-dose CT (LDCT) or shared decision-making and counseling (SDMC) services per 1,000 Medicare fee-for-service (FFS) beneficiaries derived from the Medicare Provider Utilization and Payment Data: Physician and Other Supplier public use file, and state-level factors from several publicly available data sources. The study included Kruskal-Wallis tests and a cluster analysis.

RESULTS

In 2017, the median utilization density per 1,000 Medicare FFS beneficiaries was 3.32 for LDCT and 0.46 for SDMC, which was 24 and 13 times the 2015 level, respectively. From 2015 to 2017, the total number of unique providers billed for LCS increased from 222 to 3,444 for LDCT imaging and from 20 to 523 for SDMC. Higher utilizations for both LDCT and SDMC services tended to concentrate in the northeastern and upper Midwest states than in the southwest states. The cluster of states with high utilization density did not include those states with the most lung cancer mortality and/or smoking prevalence.

CONCLUSIONS

A steady increase was noted in LCS utilization since Medicare began its reimbursement policy. The utilization and its growth varied across the United States and differed between LDCT imaging and SDMC, indicating large growth potentials for LCS and for states with high lung cancer mortality and smoking prevalence.

Dose Selection for Multiple Myeloma in Modern Era

PURPOSE

The management of multiple myeloma (MM) has evolved over the past 20 years, secondary to novel biologic therapeutics. Radiation therapy remains an important intervention in the management of painful lytic bone lesions. However, the currently used radiation therapy regimens were developed in the pre-biologic therapy era. The goal of this study is to assess the effects of dose and fractionation in pain control for patients with MM in the modern era.

METHODS AND MATERIALS

We conducted a retrospective study based on data collected from patients who received radiation therapy at our institute between 2007 and 2017. A total of 130 patients (266 treatment sites) were included in this study. Univariate Cox proportional hazards models were used to analyze the association of risk of pain recurrence with treatment characteristics and compute the hazard ratios (HRs).

RESULTS

The median follow-up time was 14 months. Patients who received a total dose of 20 to <30 Gy (including 20 Gy) had a significantly lower probability of pain recurrence when compared with those who received <20 Gy (HR, 0.36; 95% confidence interval, 0.14-0.94; P = .0365). There was no statistically significant difference in treatment response or pain recurrence between the different fraction numbers and sizes. However, we noted a trend indicating lower pain recurrence in the group that received 6 to 10 fractions of radiation therapy (P = .06). Among the most commonly used regimens, 8 Gy in a single fraction resulted in a statistically significant increased chance of pain recurrence compared with 20 Gy in 10 fractions and a borderline statistically significant increased chance of pain recurrence when compared with 30 Gy in 10 fractions.

CONCLUSIONS

Radiation therapy remains highly effective at managing lytic bone lesions in patients with MM, and 6- to 10-fraction treatment courses are equally as effective as longer courses at treating these lesions. Treatment with 20 Gy in 10 fractions resulted in a significantly lower probability of pain recurrence when compared with 8 Gy in 1 fraction.

Identifying Potentially Avoidable Hospitalizations in Medicare Patients With Prostate Cancer: A Retrospective Analysis

PURPOSE:

If identifiable, potentially avoidable hospitalizations (PAHs) can serve as an important target for cost containment efforts in oncology.

METHODS:

PAHs among a cohort of Medicare patients with prostate cancer were identified using a two-stage consensus-driven review process. In stage 1, two clinicians independently evaluated admissions records using a case review form, which we modified from a previous study to assess for PAHs. In stage 2, any admissions that the reviewers disagreed on or were unsure of were re-examined in a larger group of clinicians to yield a consensus determination regarding avoidability. Univariable and multivariable regression analyses were performed to identify factors predictive of PAH.

RESULTS:

There were 160 admissions among this cohort of 210 patients from January 2012 to June 2015, of which 99 were evaluable. Consensus-driven clinical review yielded an overall PAH rate of 28.3%. Factors associated with increased PAH risk were admission for symptoms related to cancer (odds ratio [OR], 7.33; P < .001), presence of a social contributor to admission (OR, 4.40; P = .014), and history of alcohol or drug abuse (OR, 4.93; P = .025). Admission for a noncancer condition was associated with decreased PAH risk (OR, 0.32; P = .011). On multivariable analysis, presence of a social contributor to admission (OR, 9.35; P = .002) and admission as a result of a noncancer condition (OR, 0.16; P = .038) remained predictive of PAH risk.

CONCLUSION:

A significant proportion of hospitalizations among patients with prostate cancer are potentially avoidable. Understanding factors predictive of risk for PAH can help inform programs aimed at avoiding such admissions to improve overall care quality and value.

Overall Survival Trends and Clinical Characteristics of Plasmacytoma in the United States: A National Cancer Database Analysis

BACKGROUND

Given the rarity of plasmacytoma, large-scale database analysis can provide useful information regarding the clinical presentation and patient-related factors impacting overall survival (OS).

MATERIALS AND METHODS

The National Cancer Data Base was queried for patients with plasmacytoma between 2004 and 2013, excluding patients with systemic disease. Plasmacytomas were classified as originating in bone (P-bone), in extramedullary tissue (P-EM), or unspecified. Survival was estimated using the Kaplan-Meier and log-rank test method. We used Cox regression to determine specific outcomes adjusting for demographic, socioeconomic, geographic, facility type, year of diagnosis, and comorbid factors.

RESULTS

In total, 6225 patients were identified, of which 61.5% were men. The median age at diagnosis was 64 years (range, 18-90 years), and the median follow-up was 58 months. The primary site of disease was P-bone in 4056 (65.1%) patients and P-EM in 1468 (23.6%), and the remaining 701 patients were P-unspecified. The unadjusted median survival for solitary P-bone was 89 months (95% confidence interval, 82.9-95.0 months), and for solitary P-EM was 117.3 months (95% confidence interval, 108.8 months to not reached). Factors associated with improved OS include younger age, private insurance, higher income, solitary lesion, and lower comorbidity score. Patients with P-bone disease treated at academic facilities had improved OS. Only 65% of patients with solitary plasmacytoma lesions received radiation treatment. Age greater than 75 years and increased distance to treatment facility was associated with a decreased likelihood of receiving radiation.

CONCLUSIONS

This is the largest study examining outcomes of patients with plasmacytoma using a large database analysis, revealing unique aspects of P-EM versus P-bone and underutilization of radiation treatment.

The Safety Profile of Concurrent Therapy for Multiple Myeloma in the Modern Era

Purpose

The management of multiple myeloma has evolved in the modern era, partially owing to the increasing number of biologic therapeutics. Nonetheless, radiation remains an important treatment in the management of painful lytic lesions from multiple myeloma. The goal of this study is to evaluate the side effect profile of radiation therapy (RT) while patients are concurrently treated with biologic agents.

Methods and Materials

We conducted a retrospective study based on data collected from patients receiving RT at our institute from 2007 to 2017. A total of 130 patients (279 treatment sites) were included in this study with a median follow-up time of 14 months. Patients were required to be receiving a biological agent at least within 1 month before starting and up to 1 month after RT. Generalized estimating equations with a log link function and binomial distribution were used to estimate the prevalence ratio (PR) and corresponding 95% confidence interval (CI) and compare the side effects between patients with RT alone and RT + biologic agent.

Results

The median age of all patients in our cohort was 64 years, with 53 men (58.9%) and 37 women (41.1%). The mean Karnofsky performance status score of all cohorts was 80. No significant difference in incidence of acute (PR: 1.33; 95% CI, 0.80-2.22; P = .2660) or subacute (PR: 0.90; 95% CI, 0.49-1.67; P = .7464) toxicities was found between patients with or without biologic agents who were treated concurrently with RT. No significant difference was found in reduction in laboratory values between patients with or without biologic agents treated concurrently with RT for white blood cells (P = .6916), platelets (P = .7779), or hematocrit (P = .0858).

Conclusions

Our study did not detect any significant toxicity rates from palliative radiation while patients were concurrently treated with biologic agents.

Palliation of Ulcerative Breast Lesions with Radiation

BACKGROUND/AIM

Patients with advanced breast cancer may experience ulcerative breast lesions. Breast cancer with ulcerative lesions has been shown to severely affect a patient's quality of life (QoL). The role of palliative radiation therapy (RT) in the management of ulcerative breast lesions needs to be further explored.

PATIENTS AND METHODS

We retrospectively reviewed the RT records for all patients who underwent palliative RT for breast cancer at our urban academic medical center. A total of 13 patients were identified, and we herein report their demographics, treatment characteristics, and clinical outcomes.

RESULTS

The mean age of the patients receiving palliative RT for ulcerative breast cancer was 64 years. All patients had stage IV disease when they were evaluated for RT. The mean radiation dose received for palliative RT was 27.54 Gy in 11 fractions, with a median dose of 30 Gy in 15 fractions. Six (46%) patients had received prior RT to the same breast, with a median dose of 59.5 Gy in 31 fractions. Among these six patients, the average interval between initial RT and ulceration was 69.5 months. The median overall survival for the whole patient cohort since ulceration was 5 months and the mean survival did not differ between patients with previous history of RT and RT-naïve patients (4.50 vs. 4.57; p=0.95). Six out of the nine (69%) patients who received 30 Gy or more reported clinical improvement, whereas none of the four patients who received less than 30 Gy reported any benefit. There were no radiation-associated toxicities reported by patients.

CONCLUSION

These data suggest that palliative RT (≥30 Gy) is an efficacious treatment for ulcerative breast cancer with minimal toxicity. Prior RT should not be a contraindication, as patients with previous history of RT have similar low toxicity rates compared to RT-naïve patients.

A unique presentation of occult primary breast cancer with a review of the literature

We are reporting a case of a 34-year-old woman with occult primary breast cancer discovered after initially presenting with neurological symptoms. She was successfully treated with neoadjuvant chemotherapy followed by definitive axillary lymph node dissection and ipsilateral whole breast radiotherapy. The case presented is unique due to the rarity of occult primary breast cancer, especially in light of her initial confounding neurological signs and symptoms, which highlights the importance of careful staging.

Identification of ubiquitin ligases required for skeletal muscle atrophy

Skeletal muscle adapts to decreases in activity and load by undergoing atrophy. To identify candidate molecular mediators of muscle atrophy, we performed transcript profiling. Although many genes were up-regulated in a single rat model of atrophy, only a small subset was universal in all atrophy models. Two of these genes encode ubiquitin ligases: Muscle RING Finger 1 (MuRF1), and a gene we designate Muscle Atrophy F-box (MAFbx), the latter being a member of the SCF family of E3 ubiquitin ligases. Overexpression of MAFbx in myotubes produced atrophy, whereas mice deficient in either MAFbx or MuRF1 were found to be resistant to atrophy. These proteins are potential drug targets for the treatment of muscle atrophy.