Pre- and Post-Treatment Patient-Reported Financial Toxicity in Head and Neck Cancer: Identifying Influential Factors and Clinical Significance

PURPOSE/OBJECTIVE(S)

Head and neck cancer patients are at high-risk for financial stress due to the often complex, time-consuming, and expensive treatments that can impact physical function and quality of life. It is important to identify factors that affect financial toxicity early on in treatment and to help mitigate their effects. The goals of this study are to assess patient-reported financial toxicity prior to and after completion of radiation therapy (RT) and to uncover any interactions with socioeconomic factors, quality of life, treatment satisfaction, and treatment adherence.

MATERIALS/METHODS

A total of 80 patients who were evaluated for RT to the head and neck region between July 2021 and December 2022 and had completed surveys prior to the initiation of RT were included. Surveys included the FACIT-COST and FACIT-TS-G. Patient clinical information and demographics were collected. Linear regression was used to evaluate categorical variables and Pearson correlation was used to evaluate continuous variables and their associations with COST.

RESULTS

The median pre-RT COST was 29.5 (range 4-44) with lower scores indicating worse financial toxicity. The majority of patients were white (69%), non-Hispanic (75%), and English-speaking (75%). 65% had Medicare, 14% had Medicaid, and 21% had other insurance. 60 of 80 (75%) patients ultimately underwent RT at our institution. 34 (57%) missed at least one day of scheduled RT fractions and 11 (14%) patients had G-tubes placed. Lower COST was associated with decreased age, thyroid primary disease, advanced stage, metastatic disease, Medicaid insurance, Hispanic ethnicity, unemployment, and G-tube placement. Higher COST was associated with cutaneous primary disease and ability to speak English, while Medicare insurance trended toward significance. 18 of 80 patients (23%) completed follow-up surveys post-RT and 9 reported a decrease in COST. At baseline, the standard deviation of the COST was 10.6. Effect size was defined as the number of standard deviation change. Mean decrease in COST was 9.4 (effect size of 89%). Mean FACT-TS-G was lower, indicating decreased treatment satisfaction, for these patients as compared to those that had the same or increased COST compared to baseline, (17.4 vs. 22.7, p < 0.01). There were more missed RT days, 4 vs. 1, and G-tube placements, 2 vs. 0, in those with decreased COST as well.

CONCLUSION

Worse baseline financial toxicity was associated with younger age, advanced stage, metastatic disease, Medicaid insurance, unemployment, and G-tube placement. Those that reported worsened financial toxicity after RT reported worse treatment satisfaction and had more missed RT days and G-tube placements. These findings support work to better understand financial toxicity as it may predict those at higher risk of missing treatments, particularly crucial considering prolonged RT duration is linked to poorer outcomes. Future efforts will focus on automating early referrals to case managers and social work services for these patients.

Severity of Financial Toxicity for Patients Receiving Palliative Radiation Therapy

PURPOSE/OBJECTIVE(S)

Patients receiving palliative radiotherapy (RT) are often at their most vulnerable state, but the impact of financial toxicity on their health and quality of life (QOL) is not well-described. We set out to determine the degree of financial toxicity in a population undergoing palliative RT.

MATERIALS/METHODS

A review of patients referred for palliative RT at our site was conducted. Financial toxicity was determined with COST-FACIT, and previously suggested grading cutoffs were used. Additional patient-reported outcome (PRO) instruments included the EORTC overall health and quality of life questions and the FACIT-TS-G (treatment satisfaction). Multiple imputations by chained equations using predictive mean matching were used for incomplete responses. Spearman's rank correlation coefficient, Kruskal-Wallis testing, and linear regressions were used to measure associations.

RESULTS

A total of 53 patients were identified who had completed PRO surveys between May 2021 and December 2022. Median COST was 25 (range 0-44), with lower scores indicating greater financial toxicity. 49% reported grade 0 financial toxicity (COST ≥26), 32% had grade 1 financial toxicity (COST 14-25), 19% had grade 2 financial toxicity (COST 1-13), and 6% had grade 3 financial toxicity (COST = 0). Overall, cancer caused financial hardship among 45%. Higher COST was moderately associated with higher overall health (rho = 0.36, p = 0.02) and weakly associated with higher QOL (rho = 0.28, p = 0.07). From a demographic standpoint, median area family income from census tract data was $98,598 (range $32,303-$190,833), and higher income was associated with higher COST (rho = 0.47, p<0.001). Having Medicare (beta = 13.8, p = 0.003) or private (beta = 13.5, p = 0.001) coverage (rather than Medicaid) were associated with less financial toxicity, whereas having an underrepresented minority background (beta = -13.2, p<0.001), or having a non-English language preference (rho = 0.40, p = 0.003) were associated with greater financial toxicity. Median time from diagnosis was 12.9 mo, and 40% of patients had ≥2 prior systemic therapies. The median RT dose was 25 Gy (range 4-45 Gy). The most common irradiated sites included spine (24%), non-spine bones (21%), brain (18%), and lung/mediastinum (18%). COST was not associated with number of prior systemic therapies (p = 0.31), RT dose (p = 0.83), RT technique (p = 0.86), or treatment satisfaction (p = 0.34). Median follow up was 8.0 months, and median 6-month survival was 83% (95% CI 73%-95%). Inferior OS was associated with more prior systemic therapies (HR 3.43, p = 0.03), but not with COST (HR 1.01, p = 0.67).

CONCLUSION

Financial toxicity was seen in approximately half of patients receiving palliative RT. Patient-reported overall health, Medicaid coverage, and area income correlated well with financial toxicity, but the investigated clinical characteristics did not. This supports the hypothesis that financial toxicity is common and a unique factor that should be measured in cancer patients.

The LACE index and risk factors of 14-day versus 30-day readmissions in children

BACKGROUND

Risk factors for readmissions in children differ from those for adults, yet little is known about whether the LACE index (Length of stay, Acute admission, Charlson comorbidity index, Emergency department visits in the previous 6 months) developed for adults retains its validity when applied to the prediction of readmissions in children or within shorter intervals of time after discharge.

METHODS

In this retrospective cohort analysis of 4 256 patients aged≤18 hospitalized at one academic medical center in Taiwan, 2019, we first evaluated the performance of a LACE index model and the three other multivariate logistic regression models in their predictions of hospital readmissions in children using the same time intervals of 30 days. We then used multinomial logistic regression to analyze the characteristics and risk factors for readmissions that occur in the first 14 days with those that occur between 15 to 30 days after discharge.

RESULTS

The optimal cutoff of LACE index score for children in the current study was 7, which is less than the optimal score of 10 in the original derivation for adults. The predictive model with the least discriminatory power was based on LACE score alone, whereas our model that included only two variables (length of stay and the number of admissions in the past one year) was found to outperform LACE index. Multinomial logistic regression results revealed that children who had supplemental private health insurance had lower readmission rates than those insured by National Health Insurance program only, suggesting a disparity by insurance status. Some risk factors of readmission within 14 days such as acute admissions and supplemental private health insurance were not found to be relevant for longer-term predictions, while age, which was a valid predictor of readmission within 15 to 30 days, did not affect the prediction of shorter-term readmissions. Prior healthcare utilizations and a higher illness burden were found to be greater contributors to readmissions beyond 14 days.

CONCLUSION

Our simpler model outperformed the more complex LACE tool in identifying children at risk of readmission. Shorter-term readmissions can be attributed to different causes than 30-day readmissions, suggesting a need for different screening tools, interventions, and care support. There remains some socioeconomic disparity associated with readmission rates in the current healthcare system.

Early prediction of 30- and 14-day all-cause unplanned readmissions

BACKGROUND

An unplanned readmission is a dual metric for both the cost and quality of medical care.

METHODS

We employed the random forest (RF) method to build a prediction model using a large dataset from patients' electronic health records (EHRs) from a medical center in Taiwan. The discrimination abilities between the RF and regression-based models were compared using the areas under the ROC curves (AUROC).

RESULTS

When compared with standardized risk prediction tools, the RF constructed using data readily available at admission had a marginally yet significantly better ability to identify high-risk readmissions within 30 and 14 days without compromising sensitivity and specificity. The most important predictor for 30-day readmissions was directly related to the representing factors of index hospitalization, whereas for 14-day readmissions the most important predictor was associated with a higher chronic illness burden.

CONCLUSIONS

Identifying dominant risk factors based on index admission and different readmission time intervals is crucial for healthcare planning.

Comparison of Back-Propagation Neural Network, LACE Index and HOSPITAL Score in Predicting All-Cause Risk of 30-Day Readmission

Background

The main purpose of this study is to predict the all-cause risk of 30-day readmission by employing the back-propagation neural network (BPNN) in comparison with traditional risk assessment tools of LACE index and HOSPITAL scores.

Methods

This was a retrospective cohort study from January 1st, 2018 to December 31st, 2019. A total of 55,688 hospitalizations from a medical center in Taiwan were examined. The LACE index (length of stay, acute admission, Charlson comorbidity index score, emergency department visits in previous 6 months) and HOSPITAL score (hemoglobin level at discharge, discharge from an Oncology service, sodium level at discharge, procedure during hospital stay, Index admission type, number of hospital admissions during the previous year, length of stay) are calculated. We employed variables from LACE index and HOSPITAL score as the input vector of BPNN for comparison purposes.

Results

The BPNN constructed in the current study has a considerably better ability with a C statistics achieved 0.74 (95% CI 0.73 to 0.75), which is statistically significant larger than that of the other two models using DeLong’s test. Also, it was possible to achieve higher sensitivity (70.32%) without penalizing the specificity (71.76%) and accuracy (71.68%) at its optimal threshold, which is at the 20% of patients with the highest predicted risk. Moreover, it is much more informative than the other two methods because of a considerably higher LR+ and a lower LR-.

Conclusion

Our findings suggest that more attention should be paid to methods based on non-linear classification systems, as they lead to substantial differences in risk-scores.

Factors that infertile couples from mainland China may take into consideration for cross-border reproductive care - A cross-sectional questionnaire study

OBJECTIVE

Cross-border reproductive care (CBRC) has become popular in the world, including mainland China. We designed a questionnaire and aimed to determine the main factors that infertile couples from mainland China may consider for CBRC.

MATERIALS AND METHODS

In this cross-sectional questionnaire-based study, we retrospectively analyzed the data from questionnaires collected at the Reproductive Center of Beijing BaoDao Obstetrics and Gynecology Hospital from January 2018 to June 2018. The questionnaire contained 38 items that belonged to six different categories (environment and equipment, service quality, patient safety, medical quality, information acquisition channel and overseas medical services). The item scores for each factor were calculated and then weighted using principal component analysis.

RESULTS

A total of 297 infertile couples were identified. Most of the infertile women were aged 31-35 years, were married 1-3 years, and had a bachelor's degree. In the weighted factor analysis, "clean outpatient clinic and medical equipment" had the highest weight in the dimension of environment and equipment. The item with the highest weight in the dimension of service quality was "wait time for examination". In the dimension of patient safety, "health education on medication and surgery by counselors" had the highest weight. The item with the highest weight in the dimension of medical quality was "fee charged for ART treatment". The items with the three highest weights in the dimension of information acquisition channel were "other (seminar, exhibition, dissertation …)", "introduction from friends and relatives", and "telephone inquiry". In the dimension of overseas medical services, the two items with the highest weights were "cultural similarities" and "language similarities".

CONCLUSION

For CBRC, infertile couples from mainland China may take following significant factors into consideration: a high success rate and inexpensive treatment, cultural and linguistic familiarity, high-quality service and short wait time.

Natriuretic Peptide Levels and Clinical Outcomes among Patients Hospitalized with COVID-19 Infection

Purpose

There is increasing evidence of adverse cardiovascular morbidity associated with SARS-CoV-2 (COVID-19). Pro-B-type natriuretic peptide (proBNP) is a biomarker of myocardial stress associated with outcomes in various respiratory and cardiac diseases. We hypothesized that proBNP level would be associated with mortality and clinical outcomes in hospitalized COVID-19 patients.

Methods

We performed a retrospective analysis of hospitalized COVID-19 patients (n=1232) using adjusted logistic and linear regression to assess the association of admission proBNP (analyzed by both categorical cutoff >125 pg/mL and continuous log transformed proBNP) with clinical outcomes. Covariates included age, sex, race, body mass index (BMI), hypertension, coronary artery disease (CAD), diabetes, smoking history, and chronic kidney disease stage (Model 1), with Troponin I added in Model 2. We performed survival analysis by a multivariate Cox proportional hazard model, incorporating log transformed proBNP. We additionally treated BMI, a strong potential confounder of both proBNP levels and COVID-19 outcomes, as an ordinal variable ordered across tertiles.

Results

Patients were mean age 62.9±17.6, 53.8% male, and 35.9% Black. Preadmission comorbidities were hypertension (57.1%), diabetes (31.6%), CAD (9.0%) and heart failure (HF, 10.6%). In Model 1 and 2, higher proBNP level was significantly associated with death, new HF, length of stay, ICU duration and need for ventilation among hospitalized COVID-19 patients. This significance persisted after ordinal compression of BMI across tertiles. The adjusted hazard ratio of death for log[proBNP] was 1.56 (95% CI: 1.23-1.97; P<0.0001).

Conclusion

Using a relatively large and racially diverse hospitalized COVID-19 patient cohort, we find that proBNP is associated with adverse clinical outcomes, including mortality and new HF in COVID-19. Further prospective investigation is warranted on the utility of proBNP for clinical prognostication in COVID-19.

P1021Comparative efficacy of microfidelity technology vs standard ablation for atrioventricular nodal ablation

Background

Microfidelity Cateter Technology has proven efficacy in ablating atrial arrhythmias in multiple pilot studies. Closely spaced radial microelectrodes render a focused near-field electrogram. Case series suggest that this catheter design facilitates accurate ablations with fewer radiofrequency (RF) lesions. Atrioventricular junction (AVJ) ablation is regarded as a straightforward procedure, but case records show wide variance in procedure times and number of RF lesions required.

Methods

Twenty-four patients scheduled for AVJ ablation were randomized to treatment with either the Microfidelity technology or standard 8mm/8 French ablation catheter. Both groups located the AVJ by fluoroscopic landmarks and His electrograms, and the MiFi group used electroanatomical mapping to create the location of his electrograms. The primary endpoints were development of Junctional Rhythm (JR) or Complete Heart Block (CHB), and time from first RF lesion until rhythm change. Secondary endpoints included number of RF applications.

Results

Patients were randomized one-to-one to the MiFi arm or standard ablation arm. JR or CHB was achieved in all patients. Time from first RF lesion until JR/CHB was: (Median/IQR) 325 sec/250–1270 sec. vs 287 sec/101–406 sec. Number of RF applications was 5/3–15 applications vs 4.5/1–5 applications. Total procedure time in the lab was 134 min/73.5–172.5 min vs 58 min/52–146 min.

Microfidelity Technology vs Standard

Conclusion

Analysis suggests that the MiFi catheter is efficacious in ablating the AVJ, but requires greater RF duration and number of lesions, with wider case-by-case variability to achieve JR or CHB. Microfidelity technology and electroanatomical mapping did not result in faster time to completion than using fluoroscopic landmarks and His electrograms alone. Preoperative choice of sheath for catheter stability and contact may also play a role in a more efficient timely successful ablation of the AV node.

Acknowledgement/Funding

Boston Scientific

P1675Evolution of lactate dehydrogenase levels in patients with HeartMate II, HeartWare and HeartMate 3 left ventricular assist devices during first-year follow-up

Background

Lactate dehydrogenase (LDH) is considered as a biomarker of thrombotic events in patients receiving a left ventricular assist device (LVAD).

Purpose

This study aimed to investigate the evolution of LDH levels over time between patients supported with a HeartMate II (HMII), HeartMate 3 (HM3) or HeartWare (HVAD) LVAD during their first-year post implantation.

Methods

We analyzed in this multi-center retrospective study, all patients with HMII, HM3 and HVAD LVAD implanted between December 2006 and April 2017. Patients were classified into three groups based on their device type. Loess splines over time were used to depict the repeated measurements of LDH.

Results

In total, 134 patients received an LVAD (77% male, mean age 55 [46–61]), of whom 64 (48%) were HMII, 22 (16%) HM3 and 48 (36%) were HVAD. Loess splines over time indicate that there could be a considerable difference between evolution of LDH (Figure). During the first-year follow-up, 3 (5%) patients had a confirmed and 10 (16%) patients had a suspected pump thrombosis in the HMII group. For the HVAD, there were 6 (13%) patients with confirmed thrombosis and 1 (2%) case of suspected thrombosis, whereas none of the patients in the HM3 group experienced a suspected or confirmed pump thrombosis (p=0.01). The 1-year overall survival rate for HM II, HM3 and HVAD was 84%, 86% and 72% respectively (p=0.311). The overall stroke-free rate at one year was: 89%, 77% and 91% for HMII, HVAD and HM3 respectively (p=0.15).

Means of observed LDH values over time

Conclusion

During the first-year post LVAD implantation, there appear to be different evolutions of LDH levels over time in HMII device patients compared to HVAD or HM3 device patients. Given differences in baseline hemolysis levels between devices, currently used LDH thresholds for detection of impending pump thrombosis may be less sensitive and thus thresholds may be device specific.

Factors that influence infertile couples' selection of reproductive medicine centers---A cross-sectional questionnaire study

OBJECTIVE

The number of infertile women undergoing in vitro fertilization (IVF) cycles has increased annually. Due to this competitive environment, we designed a questionnaire and aimed to investigate factors affecting the choice of reproductive medicine center among infertile couples.

MATERIALS AND METHODS

This was a retrospective cross-sectional study that analyzed questionnaires provided by the reproductive medicine center of the Kaohsiung Veterans General Hospital from January 2018 to June 2018. In the questionnaire, there are six categories (environment and equipment, service quality, patient safety, medical quality, information acquisition channel and other) and 36 items. The identified factors were scored and then weighted using principal component analysis.

RESULTS

Most of the 100 identified infertile women were aged 31-35 years, were married 1-3 years, and had a university education level. In the weight analysis, "Clean outpatient clinic and medical equipment" had the greatest weight in the dimension of environment and equipment. The item with the greatest weight in the dimension of service quality was "Waiting time for registration, charging, and receiving medicine". In the dimension of patient safety, "Privacy is highly respected by medical personnel" had the highest weight. The item with the greatest weight in the dimension of medical quality was "Success rate of reproductive medicine center". The three items with the highest weights in the dimension of information acquisition channel were "Newspapers and magazines", "TV media", and "Facebook page and website of our hospital". In the other dimensions, the two with the greatest weights were "Reputation of the hospital" and "Reputation of physicians".

CONCLUSION

In the infertile couples' view, optimal reproductive medicine centers should have a high success rate and great reputation on the internet and in mass media. Additionally, a short waiting time and high levels of privacy and confidentiality are also imperative.

Efficacy and safety of brodalumab in patients with psoriasis who had inadequate responses to ustekinumab: subgroup analysis of two randomized phase III trials

BACKGROUND

Brodalumab, a fully human anti-interleukin-17 receptor A monoclonal antibody, has demonstrated superior efficacy and safety over ustekinumab as induction therapy for moderate-to-severe psoriasis.

OBJECTIVES

To evaluate the efficacy and safety of brodalumab through week 52 in patients who had inadequate responses to ustekinumab.

METHODS

A subgroup analysis of the phase III AMAGINE-2/-3 double-blind randomized controlled trials was performed. Participants were aged 18-75 years and had a Psoriasis Area and Severity Index (PASI) ≥ 12, static Physician's Global Assessment score ≥ 3 and involvement of ≥ 10% body surface area. The studies were registered at ClinicalTrials.gov: AMAGINE-2, NCT01708603; AMAGINE-3, NCT01708629.

RESULTS

At baseline, patients with or without prior biologic experience who had an adequate response at week 16 on ustekinumab or brodalumab had lower rates of involved body surface area, PASI, prior biologic use, psoriatic arthritis and body mass index than patients who experienced inadequate response at or after week 16. Among patients who experienced inadequate response to ustekinumab, those rescued with brodalumab had PASI ≥ 75%, ≥ 90% and 100% improvement response rates of 72·6%, 58·1% and 36·3%, respectively, at week 52 compared with 61·7%, 25·5% and 5·4%, respectively, in patients who continued ustekinumab. Exposure-adjusted rates of treatment-emergent adverse events were similar among patients rescued with brodalumab (377·3 adverse events per 100 patient-years) and those who remained on ustekinumab (389·9 adverse events per 100 patient-years).

CONCLUSIONS

Among patients who experienced inadequate responses to ustekinumab, rescue with brodalumab improved skin clearance outcomes compared with continuing ustekinumab.

Improvement in itch and other psoriasis symptoms with brodalumab in phase 3 randomized controlled trials

BACKGROUND

Patients with psoriasis have lesional symptoms, including itch, which can reduce quality of life. The efficacy and safety of brodalumab, an interleukin-17 receptor A antagonist, in treating moderate-to-severe psoriasis have been reported in three randomized, controlled, phase 3 trials (AMAGINE-1/-2/-3).

OBJECTIVE

The effect of brodalumab on lesional symptoms was assessed using the psoriasis symptom inventory (PSI), a validated patient-reported instrument.

METHODS

Patients were randomized to receive brodalumab (140 or 210 mg every 2 weeks [Q2W]), placebo (AMAGINE-1/-2/-3), or ustekinumab (AMAGINE-2/-3) during a 12-week induction phase, followed by a maintenance phase through week 52. Patients electronically rated the severity of PSI items (itch, burning, stinging, pain, redness, scaling, cracking and flaking) during the previous 24 h on a scale of 0 (not at all severe) to 4 (very severe). At each visit, the PSI total score responder status was assessed, with responders defined as having an average weekly total inventory score ≤8 with no item score >1 at week 12.

RESULTS

Across AMAGINE-1/-2/-3, brodalumab was associated with improvements in PSI total scores and itch scores vs. placebo from week 2 through week 12 (P < 0.001 in both domains). In AMAGINE-2/-3, brodalumab 210 mg Q2W demonstrated faster onset of PSI total score and itch responses (week 2, 22.1% and 36.4%, respectively) vs. ustekinumab (week 2, 6.9% and 17.1%, respectively) and was associated with improved itch responses vs. ustekinumab after 52 weeks of constant treatment.

CONCLUSION

Brodalumab demonstrated rapid, robust improvements in symptoms assessed by the PSI, including itch, vs. placebo and ustekinumab.

Blue Light Differentially Modulates Cell Survival and Growth

Previous studies have reported that blue light (400–500 nm) inhibits cell mitochondrial activity. We investigated the hypothesis that cells with high energy consumption are most susceptible to blue-light-induced mitochondrial inhibition. We estimated cell energy consumption by population doubling time, and cell survival and growth by succinate dehydrogenase (SDH) activity. Six cell types were exposed to 5 or 60 J/cm2 of blue light from quartz-tungsten-halogen (QTH), plasma-arc (PAC), or argon laser sources in monolayer culture. Post-light SDH activity correlated positively with population doubling time (R2 = 0.91 for PAC, 0.76 for QTH, 0.68 for laser); SDH activity increased for cell types with the longest doubling times and was suppressed for cell types with shorter doubling times. Thus, light-induced exposure differentially affects SDH activity, cell survival, and growth, depending on cell energy consumption. Blue light may be useful as a therapeutic modulator of cell growth and survival.