Learning to Overcome Barriers to Electronic Patient-Reported Outcome Implementation: Lessons From the Field

#Implementation of #ePROs in real world settings, lessons learned.

Physicians' Hierarchy of Tumor Biomarkers for Optimizing Chemotherapy in Breast Cancer Care

BACKGROUND

Tumor biomarkers are regularly used to guide breast cancer treatment and clinical trial enrollment. However, there remains a lack of knowledge regarding physicians' perspectives towards biomarkers and their role in treatment optimization, where treatment intensity is reduced to minimize toxicity.

METHODS

Thirty-nine academic and community oncologists participated in semi-structured qualitative interviews, providing perspectives on optimization approaches to chemotherapy treatment. Interviews were audio-recorded, transcribed, and analyzed by 2 independent coders utilizing a constant comparative method in NVivo. Major themes and exemplary quotes were extracted. A framework outlining physicians' conception of biomarkers, and their comfortability with their use in treatment optimization, was developed.

RESULTS

In the hierarchal model of biomarkers, level 1 is comprised of standard-of-care (SoC) biomarkers, defined by a strong level of evidence, alignment with national guidelines, and widespread utilization. Level 2 includes SoC biomarkers used in alternative contexts, in which physicians expressed confidence, yet less certainty, due to a lack of data in certain subgroups. Level 3, or experimental, biomarkers created the most diverse concerns related to quality and quantity of evidence, with several additional modulators.

CONCLUSION

This study demonstrates that physicians conceptualize the use of biomarkers for treatment optimization in successive levels. This hierarchy can be used to guide trialists in the development of novel biomarkers and design of future trials.

Distance from a cultural model of substance use risk, internalization, and self-stigma in urban Brazil

Introduction

A cognitive theory of culture as socially distributed cultural models has proven useful in research. Cultural models exist in two forms: the model shared by individuals in a social group, and individual versions of that model modified by personal experience. In previous research we documented a shared cultural model of substance use risk among a general population sample in urban Brazil. Here we examine how this model is distributed among persons under treatment for substance use/misuse and the implications for perceived and self-stigma.

Methods

A convenience sample of 133 persons under treatment rated the influence of risk factors for substance use/misuse. The configuration of those ratings and the cultural distance of persons under treatment from the general population model were calculated. Degree of stigma perceived in the wider society and degree of self-stigma were also assessed.

Results

Persons under treatment aggregate risk factors to a greater extent than the general population. Using a cultural distance metric, the more distant persons under treatment are from the general population model, the lower their self-stigma regarding substance use.

Discussion

Some individuals under treatment separate their understanding of substance use/misuse from shared perspectives in the wider society, which in turn reduces self-stigma. These findings add an additional perspective on the relationship of culture and the individual.

Assessing the Impact of Family Caregivers in Clinical Encounter Participation on Patient Activation in the Metastatic Breast Cancer Setting

Objective

Caregivers support individuals undergoing cancer treatment by assisting with activities, managing care, navigating healthcare systems, and communicating with care teams. We explored the quantity and quality of caregiver participation during recorded clinical appointments in women with metastatic breast cancer.

Methods

This was a convergent parallel mixed methods study. Caregiver participation quality was operationalized using a summative thematic content analysis to identify and sum caregiver roles performed during appointments. Caregiver participation quantity was measured by calculating the proportion of speaking time. Participation quality and quantity were compared to patient activation, assessed using the Patient Activation Measure.

Results

Fifty-three clinical encounters were recorded. Identified caregiver roles included: General Support; Management of Treatment or Medication; Treatment History; Decision-Making; Insurance or Money; Pharmacy; Scheduling; Travel Concerns; General Cancer Understanding; Patient Specific Cancer Understanding; Caregiver-Initiated or Emphasis on Symptom Severity; and Caregiver Back-Up of Patient Symptom Description. Caregivers averaged 5 roles (SD 3): 48% of patients had low quality (< 5 roles) and 52% had high quality (> 6 roles). Regarding quantity, caregivers spoke on average for 4% of the encounter, with 60% of patients having low quantity (< 4%) and 40% of patients having high quantity (> 4%). Greater quality and quantity of caregiver participation was associated with greater patient activation.

Conclusions

Caregivers perform a variety of roles during oncological decision-making visits aiding both patient and provider. Greater participation in terms of quantity and quality by the caregiver was associated with greater patient activism, indicating a need for better integration of the caregiver in clinical decision-making environments.

Factors associated with completeness in documentation of diagnostic work-up and treatment in patients with breast cancer in Sudan

Purpose

This study evaluates the relationship between geography and ethnicity on the completeness of documentation of diagnostic work-up and treatment modalities in Sudan for patients with breast cancer.

Methods

This retrospective study used data abstracted from patients with breast cancer receiving cancer care at Sudan's largest cancer centre (Radiation and Isotopes Center Khartoum) in 2017. Patient demographic and clinical characteristics were abstracted from paper medical records. Odds ratios and 95% confidence intervals were estimated to evaluate complete diagnostic work-up on ethnic group, origin and residence using binomial logistic regression models.

Results

Of 237 patients, the median age was 52 (interquartile range 43-61). Most often patients identified as Arab (68%), originated from Central, Northeastern and Khartoum regions (all 28%) and lived in the Khartoum region (52%). Overall, 49% had incomplete diagnostic work-up, with modest differences by ethnicity and geography. In adjusted analyses, non-statistical differences were found between the ethnic group, geographic origin and residence and having complete diagnostic work-up. For treatment modality, significant differences were observed between receptor status and receiving hormone therapy (p = 0.004). Only 28% of patients with HR+ breast cancer received hormonal therapy. For those with HR- or undocumented breast cancer subtype, 36% and 17% received hormone therapy, respectively.

Conclusion

Approximately half of Sudanese patients with breast cancer had incomplete diagnostic work-up, irrespective of ethnicity and geography. Moreover, a high proportion of patients received inappropriate treatment. This underlines a considerable systems-based quality gap in care delivery, demanding efforts to improve diagnostic work-up for all patients with breast cancer in Sudan.

Abstract P6-05-54: "Clinical Trials are Space Travel": Moderators of Recurrence Stress among Breast Cancer Oncologists

Background: Being an oncologist means accepting that some patients will have disease recurrence despite the most expert treatments. The universality of that experience, however, does not negate the potential for decisional regret and emotional distress on the part of the physician. The broad scale movement towards treatment optimization in medicine likely complicates this experience, as enrollment in de-escalation clinical trials inevitably means that the patient will receive less than the current standard of care. The objective of this study was to assess physician perceptions of potential emotional distress and decisional regret following patient recurrence through exploring the broad range of factors that either moderate or exacerbate those experiences. Methods: Physicians who treat breast cancer in academic and community settings across the United States participated in a qualitative interview designed to assess physician perspectives regarding patient enrollment in de-escalation clinical trials. Purposive sampling techniques were utilized to construct a balanced sample (sex, time in practice) of 39 participants. A subsection of the interview schedule centered on the experiences of decisional regret and distress surrounding patient recurrence. Interviews were recorded, transcribed, and analyzed in order to identify shared themes. Two independent coders performed a content analysis, identifying and recording factors that impact the level of distress that the physician may feel. Results: Thirty-six physicians provided in depth responses regarding their experience when a patient recurs. A total of 21 factors that affected recurrence stress were identified and spanned broad categories including patient features, disease biology, the design of the clinical trial, and characteristics of the physician. All participants expressed willingness to enroll patients in de-escalation-focused clinical trials. However, approximately half of the sample indicated that the experience would be worse after enrollment in a de-escalation trial than after a traditional intensification trial, and a quarter admitted that patient recurrence after a de-escalation trial would impact their decision making regarding future patient enrollment. Individuals not likely to experience distress emphasized having a strong trial rationale, informed patient consent, and engaging in shared decision-making, while greater distress centered on the fear of “not doing enough” and the patient missing out on necessary treatment. Conclusions: Many factors contribute to the experience of physician decisional regret and emotional distress after patient recurrence. Although most physicians recognize the importance of de-escalation focused clinical trials, a significant proportion indicated a greater potential for distress following patient recurrence in such trials and offered insight into how trial design and the process of patient enrollment can be improved to minimize potential distress.

Citation Format: Nicole L. Henderson, Andrews Courtney, Lawhon Valerie, Stacey A. Ingram, Lisa Zubkoff, Nadine Tung, Lynne Wagner, Lauren P. Wallner, Antonio C. Wolff, Gabrielle B. Rocque. "Clinical Trials are Space Travel": Moderators of Recurrence Stress among Breast Cancer Oncologists [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 P6-05-54.

Abstract P6-01-04: The Hierarchy of Biomarkers

Background: Biomarkers with robust analytical and clinical validity can help optimize therapy decisions within clinical trials for patients with breast cancer, particularly if some data on clinical utility also exist. However, little is known about how physicians enrolling in clinical trials view them. Physician comfort with the integral use of conventional and investigational biomarkers for reducing chemotherapy intensity within clinical trials is explored in this study. Method: A convenience sample of academic and community oncologists from across the United States were invited to participate in qualitative interviews that explored their perspectives on the use of biomarkers for the de-escalation of chemotherapy in patients with breast cancer. Purposive sampling techniques were used to identify participants, ensuring even distribution of gender, work setting, and time practicing medical oncology. Interviews were audio-recorded and transcribed. Transcripts were analyzed by two independent coders to identify major themes and exemplary quotes in NVivo. A framework for understanding how providers conceptualize biomarkers was created. Results: There was a total of 39 physicians with a median age of 50; 51% of physicians were academic and 49% were community-based. 44% of oncologists have been in practice for less than 15 years, and 36% and 20% of oncologists were in practice for 15-30 years and over 30 years, respectively. The model on physician level of comfort for biomarker use consisted of 1) standard of care biomarkers, 2) standard biomarkers in newer contexts, and 3) experimental biomarkers with inclusion of additional related subthemes. There was a shared theme among physicians that historical experience with a biomarker made them more comfortable in de-escalation of chemotherapy. The greatest level of physician comfort with biomarker for de-escalation of chemotherapy came with biomarkers used in standard of care (e.g., MammaPrint, Oncotype DX). Themes related to these biomarkers included: strong level of evidence, agreement with NCCN guidelines, and widespread use in the community. For example, one physician stated, “for me to use a prognostic biomarker … typically it’s going to have to at least be within the NCCN guidelines or out there”. Secondly, physicians expressed reasonable confidence with some reluctance in the use of standard of care biomarkers in contexts that differ from where they were initially tested (i.e., use of biomarker in patients with different features or disease biology). These themes included the use of biomarkers in specific subtypes of cancer and when there is less supportive evidence. One physician commented, “It’s just hard to analyze and really know whether [pathCR in ER+ setting] actually holds like it does for other tumor biologies”. There was more hesitation and least comfort with experimental biomarkers (e.g., tumor-infiltrating lymphocytes, circulating tumor DNA). For experimental biomarkers, physicians were primarily concerned with the quality and quantity of evidence supporting their use. Prospective trials were favored over retrospective; however, physicians were accepting if the retrospective study included a large sample, other biomarkers were used in conjunction, or multiple studies confirmed the results. Other themes that emerged regarding experimental biomarkers were their testing in diverse populations and reproducibility. Physicians expressed contentment with experimental biomarkers that were proven in “multiple big enough studies”, were “reproducible and not subjective”, and “demonstrate utility in the patient population that’s relevant”. Conclusion: Biomarkers can be divided into 3 successive levels: 1) standard of care biomarkers, 2) standard biomarkers in newer contexts, and 3) experimental biomarkers. Level of comfort concerning the use of biomarkers for de-escalation of chemotherapy is related to level of evidence for experimental biomarkers.

Citation Format: Noon Eltoum, Halle thannickal, Nicole L. Henderson, Lynne I. Wagner, Lauren P. Wallner, Antonio C. Wolff, Gabrielle B. Rocque. The Hierarchy of Biomarkers [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 P6-01-04.

Discovery of the Griffiths phase in the itinerant magnetic semiconductor Fe1-xCoxS2

Critical points that can be suppressed to zero temperature are interesting because quantum fluctuations have been shown to dramatically alter electron gas properties. Here, the metal formed by Co doping the paramagnetic insulator FeS2, Fe1-xCoxS2 is demonstrated to order ferromagnetically at x > xc = 0.01+/-0.005, where we observe unusual transport, magnetic, and thermodynamic properties. We show that this magnetic semiconductor undergoes a percolative magnetic transition with distinct similarities to the Griffiths phase, including singular behavior at xc and zero temperature.

Juxtaglomerular cell tumor in pregnancy

BACKGROUND

Although rare, two thirds of juxtaglomerular cell tumors of the kidney occur in young women in their reproductive years.

CASE

A primigravid woman with a 6-year history of chronic hypertension was evaluated for the sudden onset of uncontrolled hypertension, proteinuria, and hypokalemia at 16 weeks' gestation. An abdominal sonogram revealed a left flank mass, and magnetic resonance imaging confirmed that the mass was of renal origin. The worsening hypertension was not controlled with labetolol, methyldopa, nifedipine, or hydralazine, and required a nitroglycerine drip. The patient had left nephrectomy and subsequently miscarried at 19 weeks' gestation. Her blood pressure gradually decreased and normalized within 6 months. A pathologic examination of the renal mass confirmed that it was a juxtaglomerular cell tumor.

CONCLUSION

This tumor should be considered in the differential diagnosis as a cause of severe hypertension in pregnancy.

Aspartyl beta -hydroxylase (Asph) and an evolutionarily conserved isoform of Asph missing the catalytic domain share exons with junctin

The mouse aspartyl beta-hydroxylase gene (Asph, BAH) has been cloned and characterized. The mouse BAH gene spans 200 kilobase pairs of genomic DNA and contains 24 exons. Of three major BAH-related transcripts, the two largest (6,629 and 4,419 base pairs) encode full-length protein and differ only in the use of alternative polyadenylation signals. The smallest BAH-related transcript (2,789 base pairs) uses an alternative 3' terminal exon, resulting in a protein lacking a catalytic domain. Evolutionary conservation of this noncatalytic isoform of BAH (humbug) is demonstrated in mouse, man, and Drosophila. Monoclonal antibody reagents were generated, epitope-mapped, and used to definitively correlate RNA bands on Northern blots with protein species on Western blots. The gene for mouse junctin, a calsequestrin-binding protein, was cloned and characterized and shown to be encoded from the same locus. When expressed in heart tissue, BAH/humbug preferably use the first exon and often the fourth exon of junctin while preserving the reading frame. Thus, three individual genes share common exons and open reading frames and use separate promoters to achieve differential expression, splicing, and function in a variety of tissues. This unusual form of exon sharing suggests that the functions of junctin, BAH, and humbug may be linked.

Application of differential scanning calorimetry to the study of solid drug dispersions

The present study describes the application of differential scanning calorimetry (DSC) to ascertain the crystalline state of a drug with a melting point of approximately 53 degrees C after dispersion on hydrophilic carriers by either simple mixing or by fusion. The carriers examined include polyethylene glycol 6000 and colloidal silicon dioxides. The most interesting of the systems investigated, in which the drug is gradually transformed from the crystalline to the amorphous state at room temperature, are physical mixtures of the drug and colloidal silicon dioxides. The crystalline transformation is manifested by the gradual decrease in the endothermic transition energy of the physical mixture with time. The crystalline transformation is characteristically biphasic with initially fast first-order kinetics, followed by a slow conversion process. The rate of transformation is dependent on the drug-silicon dioxide ratio, temperature, and certain physical properties of the silicon dioxides. An inverse relationship exists between transition energy and the in vitro dissolution rate of the drug in the physical mixtures with silicon dioxide. This suggests that DSC may provide a useful method for evaluating the effects of formulation variables upon dissolution rate.

Kinetics and mechanism of degradation of cefotaxime sodium in aqueous solution

The degradation kinetics and mechanism of a potent new cephalosporin, cefotaxime sodium, in aqueous solution were investigated at pH 0-10 at 25 degrees and an ionic strength of 0.5. The degradation rates were determined by high-pressure liquid chromatography and were observed to follow pseudo first-order kinetics with respect to cefotaxime sodium concentration. The data suggested that the rate of degradation was influenced significantly by solvolytic, hydrogen ion, and hydroxide ion catalysis. No primary salt effects were observed in the acid or neutral regions; however, a positive salt effect was observed at pH 8.94. Buffer catalysis due to the buffer species employed was not seen during the kinetic studies. The pH-rate profile at 25 degrees indicated that the maximum stability of cefotaxime sodium occurred in the pH 4.5-6.5 region. In aqueous solution, cefotaxime was shown to degrade by two parallel reactions: de-esterification at the C-3 position and beta-lactam cleavage. Good agreement between the theoretical pH-rate profile and the experimental data support the proposed degradation process.