Investigating potential disparities by exploring time to surgical thyroid cancer treatment

(1) Delays in initial treatment have been a frequently used metric for assessing disparities in medicine; however, there has been sparse literature on treatment delays in thyroid cancer. We therefore aimed to assess disparities by investigating the association between race/ethnicity, insurance type, and socioeconomic status and time to surgical treatment of thyroid cancer. (2) A retrospective chart review was conducted to collect demographic and clinical data from 443 surgical thyroid cancer patients at Mount Sinai Hospital in 2018-2019. We investigated the time between thyroid cancer diagnosis and surgery by race/ethnicity, insurance, and income groups. (3) Univariate analysis showed that race/ethnicity, insurance type, and SES alone were not statistically significant predictors of earlier time to treatment (p = 0.766, 0.339, 0.435, respectively). On multivariable linear regression, time between diagnosis and surgical treatment was not significantly different for racial minorities compared to non-Hispanic White patients, patients with Medicare/Medicaid compared to private insurance, and patients with lowest income quartile (<$54,585) compared to those with the highest (≥$116,560). (4) Present study showed no significant delays in treatment for different racial/ethnic, insurance, and income groups.

High Dose Chemotherapy With Autologous Stem Cell Transplant for Patients With Advanced Germ Cell Tumors: Real-World Evidence From a Tertiary Cancer Center in Brazil

BACKGROUND

High-dose chemotherapy followed by stem cell transplant (HDCT) is potentially curative for patients with refractory germ cell tumors (rGCT). There is scarce real-world data supporting its implementation in low- and middle-income countries. We described the experience of our tertiary cancer center in Sao Paulo, Brazil.

METHODS

We identified male patients ≥18 years-old with rGCT referred to HDCT after board discussion. Clinical data, including delays in HDCT protocol, were extracted from medical records, and survival outcomes were estimated using the Kaplan-Meier method. The log-rank test and Cox proportional hazard were used to determine effects on overall survival (OS).

RESULTS

From January 2013 to January 2023, 34 patients were referred and considered eligible to receive 2 cycles of HDCT. Most patients had primary testicular tumors (82%), nonseminomatous histology (88%), and poor International Germ Cell Collaborative Group (IGCCCG) (79%). Twenty-three patients received HDCT (1 cycle, n = 8; 2 cycles, n = 15). Main reasons for not receiving any HDCT were death due to progressive disease (n = 1), performance deterioration (n = 7), and failure of stem cell mobilization (n = 3). OS at 2 years was 36.7% for the eligible population, 56.1% for patients who underwent at least 1 HDCT, and 77.1% for those who had ≥2 cycles. The 2-year OS rate for patients not given HDCT was 0%. All patients had delays in protocol, and poor-risk patients had longer intervals from referral to protocol initiation (0.7 vs. 1.8 month, P < .01).

CONCLUSION

Outcomes of patients who received ≥1 HDCT were encouraging; however, only 15 from 34 eligible patients were able to receive the planned 2 cycles of HDCT. Further strategies to minimize treatment delays in low- and middle-income countries are needed.

Association of Race, Ethnicity, Language, and Insurance with Time to Treatment Initiation Among Women with Breast Cancer at an Urban, Academic, Safety-Net Hospital

INTRODUCTION

Initial treatment for nonmetastatic breast cancer is resection or neoadjuvant systemic therapy, depending on tumor biology and patient factors. Delays in treatment have been shown to impact survival and quality of life. Little has been published on the performance of safety-net hospitals in delivering timely care for all patients.

METHODS

We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2019 at an academic, safety-net hospital. Time to treatment initiation was calculated for all patients. Consistent with a recently published Committee on Cancer timeliness metric, a treatment delay was defined as time from tissue diagnosis to treatment of greater than 60 days.

RESULTS

A total of 799 eligible women with stage 1-3 breast cancer met study criteria. Median age was 60 years, 55.7% were non-white, 35.5% were non-English-speaking, 18.9% were Hispanic, and 49.4% were Medicaid/uninsured. Median time to treatment was 41 days (IQR 27-56 days), while 81.1% of patients initiated treatment within 60 days. The frequency of treatment delays did not vary by race, ethnicity, insurance, or language. Diagnosis year was inversely associated with the occurrence of a treatment delay (OR: 0.944, 95% CI 0.893-0.997, p value: 0.039).

CONCLUSION

At our institution, race, ethnicity, insurance, and language were not associated with treatment delay. Additional research is needed to determine how our safety-net hospital delivered timely care to all patients with breast cancer, as reducing delays in care may be one mechanism by which health systems can mitigate disparities in the treatment of breast cancer.

Association between time from diagnosis to treatment and survival of patients with nasopharyngeal carcinoma: A population-based cohort study

BACKGROUND

Treatment delays have frequently been observed in cancer patients. Whether the treatment delays would impair the survival of patients with nasopharyngeal carcinoma (NPC) is still unclear.

METHODS

The data were derived from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015. Patients were divided into groups of timely treatment (<1 month), intermediate delay (1 and 2 months), and long delay (3-6 months). The influence of different treatment delay intervals on long-term survival was evaluated by multivariate Cox regression analysis.

RESULTS

In total, 2,048 patients with NPC were included in our study. There were 551 patients in the early stage (I, II stage: 26.9 %) and 1,497 patients in the advanced stage (III, IV stage: 73.1 %). No significant difference in overall survival (OS) or cancer-specific survival (CSS) was observed among the groups with various treatment delay intervals (p = 0.48 in OS and p = 0.43 in CSS, respectively). However, upon adjusting for covariates, a significantly improved OS probability emerged in patients with intermediate treatment delays compared to those who received timely interventions in both the entire study population (adjustedHazard Ratio (aHR)=0.86, 95 % CI: 0.74-0.99, p = 0.043) and the subgroup with advanced stage (aHR=0.85, 95 % CI: 0.72-1.00, p = 0.049). Regarding the CSS probability, similar associations were also observed in the entire study population (aHR=0.84, 95 % CI: 0.71-0.98, p = 0.030) as well as the advanced-stage patients (aHR=0.83, 95 % CI: 0.70-0.99, p =  0.038).

CONCLUSIONS

Our results revealed that treatment delays are not associated with worse survival of NPC patients. Tumor-specific characteristics and subsequent treatment modalities play more pivotal roles in the prognosis of NPC.

Sociodemographic and clinical predictors of delay to and length of stay with early intervention for psychosis service: findings from the CRIS-FEP study

PURPOSE

We investigated the influence of sociodemographic and clinical characteristics on delay to early intervention service (EIS) and the length of stay (LOS) with EIS.

METHODS

We used incidence data linked to the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) study. We followed the patients from May 2010 to March 2016. We performed multivariable Cox regression to estimate hazard ratios of delay to EIS. Negative binomial regression was used to determine LOS with EIS by sociodemographic and clinical characteristics, controlling for confounders.

RESULTS

343 patients were eligible for an EIS, 34.1% of whom did not receive the service. Overall, the median delay to EIS was 120 days (IQR; 15-1668); and the median LOS was 130.5 days (IQR 0-663). We found that women (adj.HR 0.58; 95%C I 0.42-0.78), living alone (adj.HR: 0.63; 95% CI 0.43-0.92) and ethnicity ('Other': adj.HR 0.47; 95% CI 0.23-0.98) were associated with prolonged delay to EIS. However, family involvement in help-seeking for psychosis (adj.HR 1.37; 95% CI 1.01-1.85) was strongly associated with a shorter delay to EIS. Patients who have used mental health services previously also experienced long delays to EIS.

CONCLUSIONS

Our analyses highlight the link between sociodemographic status, help-seeking behaviours, and delay to EIS. Our findings also show the vulnerability faced by those with a previous mental health problem who later develop psychosis in receiving specialist treatment for psychosis. Initiatives that ameliorate indicators of social disadvantage are urgently needed to reduce health inequalities and improve clinical outcomes.

Time to presentation and mortality outcomes among patients with diabetes and acute myocardial infarction

BACKGROUND/AIMS

Due to limited real-world evidence on the association between time to presentation (T2P) and outcomes following acute myocardial infarction and diabetes (AMI-DM), we investigated the characteristics of patients with AMI-DM and their outcomes based on their T2P.

METHODS

4,455 patients with AMI-DM from a Korean nationwide observational cohort (2011-2015) were divided into early and late presenters according to symptom-to-door time. The effects of T2P on three-year all-cause mortality were estimated using inverse probability of treatment weighting (IPTW) and survival analysis.

RESULTS

The incidence of all-cause mortality was consistently higher in late presenters than in early presenters (11.4 vs. 17.2%; p < 0.001). In the IPTW-adjusted dataset, the incidence of all-cause mortality was numerically higher in late presenters than in early presenters (9.1 vs. 12.4%; p = 0.072). In the survival analysis, the cumulative incidence of all-cause mortality was significantly higher in late presenters than in early presenters before and after IPTW. In the subgroup with ST-elevation myocardial infarction, late presenters had a higher incidence of cardiac death than early presenters before (4.8 vs. 10.5%; p < 0.001) and after IPTW (4.2 vs. 9.7%; p = 0.034). In the initial glycated hemoglobin (HbA1c)-stratified analysis, these effects were attenuated in patients with HbA1c ≥ 9.0% before (adjusted hazard ratio [HR]: 1.45, 95% confidence interval [CI]: 0.80-2.64) and after IPTW (adjusted HR: 0.82, 95% CI: 0.40-1.67).

CONCLUSION

Late presentation was associated with higher mortality in patients with AMI-DM; therefore, multifaceted and systematic interventions are needed to decrease pre-hospital delays.

Factors that contribute to patient length of stay in the emergency department: A time in motion observational study

OBJECTIVES

Increased Emergency Department length of stay impacts access to emergency care and is associated with increased patient morbidity, overcrowding, reduced patient and staff satisfaction. We sought to determine the contributing factors to increased length of stay in our mixed ED.

METHODS

A real-time observational study was conducted at Wollongong Hospital over a continuous 72-h period. Times of intervention, assessment and treatment were recorded by dedicated emergency medical or nurse observers. The time from triage to each event was calculated and descriptive analyses performed. Free text comments were analysed using inductive content analysis.

RESULTS

Data were collected on 381 of 389 eligible patients. The largest time delays were experienced by patients who required a CT, specialist review and/or an inpatient bed. Registrars and nurse practitioners were the most efficient in reaching a decision to admit or discharge. The time from triage to specialist review increased with the number requested (148 min for one, 224 min for two and 285 min for three). The longest length of stay was experienced by mental health and paediatric patients.

CONCLUSIONS

The main delays contributing to ED length of stay were CT imaging and specialist reviews. Overcrowding in ED need targeted, site-specific interventions.

Racial/ethnic and socioeconomic differences in breast cancer surgery performed and delayed treatment: mediating impact on mortality

OBJECTIVE

Although Socioeconomic status (SES), race/ethnicity, surgical type, and treatment delays are associated with breast cancer mortality outcomes, studies on these associations have been contrasting. This study examined the racial/ethnic and SES differences in surgical treatment types and treatment delays. Also, we quantified the extent to which these differences explained the racial/ethnic disparities in breast cancer mortality.

METHODS

We studied 290,066 women 40 + years old diagnosed with breast cancer between 2010 and 2017 identified from the Surveillance, Epidemiology, and End Results database. We performed logistic regression models to examine the association of SES and race/ethnicity with surgical treatment type and treatment delays. We performed mediation analysis models to quantify the extent to which mortality differences were mediated by treatment, sociodemographic, and clinicopathologic factors.

RESULTS

Non-Hispanic (NH) Black [Odds ratio (OR) = 1.16, 95% CI 1.13-1.19] and Hispanic women [OR = 1.27, 95% CI 1.24-1.31] were significantly more likely to undergo mastectomy compared to NH White women. Similarly, NH Black and Hispanic women had higher odds of delayed treatment than NH Whites. Patients in the highest SES quintile, compared to those in lowest the lowest, were less likely to experience breast cancer-specific mortality (BCSM). Variations in treatment, SES, and clinicopathological factors significantly explained 70% of the excess BCSM among NH Blacks compared to their NH White counterparts.

CONCLUSIONS

Bridging the gap of access to adequate healthcare services for all to diminish the disproportionate burden of breast cancer would require a multifactorial approach that addresses several biological and social factors that cause these differences.

Time to Curative-Intent Surgery in Gastric Cancer Shows a Bimodal Relationship with Overall Survival

BACKGROUND

Time to treatment (TTT) varies widely for patients with gastric cancer. We aimed to evaluate relationships between time to treatment, overall survival (OS), and other surgical outcomes in patients with stage I-III gastric cancer.

METHODS

We identified patients with clinical stage I-III gastric cancer who underwent curative-intent gastrectomy within the National Cancer Database (2006-2015) and grouped them by treatment sequence: neoadjuvant chemotherapy or surgery upfront. We defined TTT as weeks from diagnosis to treatment initiation (neoadjuvant chemotherapy or definitive surgical procedure, respectively). Survival differences were assessed by Kaplan-Meier estimate, Cox proportional hazard regression, and log rank test.

RESULTS

Among the 22,846 patients with stage I-III gastric cancer, most (56%) received surgery upfront. Median TTT was 5 weeks (IQR 4-7) and 6 weeks (IQR 3-9) for patients in the neoadjuvant and surgery upfront groups, respectively. In the neoadjuvant group, increasing TTT was significantly associated with increasing median OS up to TTT of 5 weeks, with no change in median OS when TTT was > 5 weeks. In the surgery group, increasing TTT was significantly associated with increasing median OS up to 6 weeks; however, increasing TTT between 14 and 21 weeks was associated with decreasing median OS.

CONCLUSIONS

The relationship between time to treatment and survival outcomes is non-linear. Among patients who underwent surgery upfront, the relationship between time to treatment and OS was bimodal, suggesting that deferring definitive surgery, up to 14 weeks, is not associated with worse OS or oncologic outcomes. The relationship between time to treatment and overall survival among patients was bimodal, suggesting that deferring definitive surgery up to 14 weeks is not associated with worse OS.

Cancer care in German centers of excellence during the first 2 years of the COVID-19 pandemic

PURPOSE

An increasing number of international studies demonstrate serious negative effects of the COVID-19 pandemic on the timely diagnosis of cancer and on cancer treatment. Our study aimed to quantitatively and qualitatively evaluate the capacities of German Comprehensive Cancer Centers (CCCs) in different areas of complex oncology care during the first 2 years of the COVID-19 pandemic.

METHODS

Prospective panel survey over 23 rounds among 18 CCCs in Germany between March 2020 and June 2022.

RESULTS

The COVID-19 pandemic substantially affected the oncological care system in Germany during the first 2 years. Persistent limitations of care in CCCs primarily affected follow-up (- 21%) and psycho-oncologic care (- 12%), but also tumor surgery (- 9%). Substantial limitations were also reported for all other areas of multidisciplinary oncological care.

CONCLUSIONS

This study documents the limitations of oncological care during the COVID-19 pandemic and highlights the need to develop strategies to avoid similar limitations in the future.

Prognostic Implications of Treatment Delays for Patients with Non-muscle-invasive Bladder Cancer

BACKGROUND

Delay in treatment is a prognostic factor in muscle-invasive bladder cancer.

OBJECTIVE

To evaluate clinical outcomes associated with delays in diagnosis and treatment for patients with non-muscle invasive bladder cancer (NMIBC).

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective study we analyzed data for patients treated at our center between November 2008 and December 2016 for intermediate risk (IR) or high risk (HR) NMIBC with an additional intravesical treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Time delays from diagnosis to first transurethral resection (TT-TUR), from resection to restaging resection (TT-reTUR), and from the last resection to first instillation (TT-INST) of bacillus Calmette-Guérin (BCG) or mitomycin C (MMC) were documented. To identify the interval of time from which recurrence rates significantly increased, we used nonparametric series regression. Recurrence-free survival (RFS) and progression-free survival for patients in each time delay category were compared using the Kaplan-Meier method. Factors associated with tumor recurrence were analyzed in a multivariable model.

RESULTS AND LIMITATIONS

A total of 434 patients were included, of whom 168 (38.7%) had IR and 266 (61.3%) had HR NMIBC. Among the patients, 34.6% had reTUR, 63.6% received BCG, and 36.4% received MMC. The median TT-TUR, TT-reTUR, and TT-INST was 4.0 wk, 6.5 wk, and 7.0 wk, respectively. At 40 mo the rate of recurrence was 28.4% and the rate of progression was 7.3%. Nonparametric analysis revealed that each week in delay increased the risk of recurrence, starting from week 6 for TT-TUR for IR and HR cases, and starting from week 7 for TT-INST for IR cases. RFS was significantly lower with TT-TUR > 6 wk among patients in the IR (p < 0.001) and HR (p = 0.04) groups, and with TT-INST >7 wk for patients in the IR group (p = 0.001). TT-reTUR >7 wk had a significant negative impact on progression (p < 0.017). Multivariable analysis revealed that for IR and HR cases, multifocality (p = 0.02 and p = 0.007) and TT-TUR >6 wk (p = 0.001 and p = 0.03) were independent predictors of recurrence, while TT-INST >7 wk predicted recurrence (p = 0.04) for IR NMIBC.

CONCLUSIONS

Our results suggest that delays of >6 wk to first TUR in IR and HR NMIBC, and >7 wk to first instillation in IR cases are associated with increases in the risk of recurrence. TT-reTUR of >7 wk is also associated with higher risk of progression.

PATIENT SUMMARY

We evaluated the impact of treatment delays on outcomes for patients with intermediate- and high-risk bladder cancer not invading the bladder wall muscle. We found that delays from diagnosis to first bladder resection, from first resection to repeat resection, and from last resection to bladder instillation treatment increase the rates of cancer recurrence and progression. The medical team should avoid delays in treatment, even for low-grade bladder cancer.

The effects of childhood adversity on treatment delays and its components in first-episode psychosis

Apart from increasing risk for psychotic disorders, childhood adversity has been associated with worse outcomes. One way in which childhood adversity may worsen outcomes is by lengthening treatment delays, which are associated with negative impacts. We tested the influence of childhood trauma on treatment delays, measured as the duration of untreated psychosis (DUP), and its help-seeking and referral components, in a first-episode psychosis cohort (N = 203). We accounted for pertinent social (e.g., migrant status) and other determinants (i.e., age at onset, diagnosis, symptoms) of treatment delays. Multiple linear regression analyses revealed that for a one-unit increase in Childhood Trauma Questionnaire (CTQ) scores, average overall DUP increased by 25%. Higher CTQ scores also significantly predicted help-seeking and referral DUPs. Patients with schizophrenia-spectrum psychosis had longer help-seeking and total DUPs than those with affective psychosis. More severe positive symptoms predicted longer help-seeking DUPs, while more severe negative symptoms predicted longer referral DUPs. Indicators of social disadvantage did not affect DUP. Our results show that childhood trauma increases DUP by prolonging the help-seeking process and delaying access to mental healthcare even after help is sought. Early identification of psychosis among populations with trauma histories seems warranted and can likely positively impact outcomes.

The influence of social determinants of health on epilepsy treatment delays in an Arizona Medicaid population

OBJECTIVE

The purpose of this study was to better understand the role of social determinants of health (SDoH) in both treatment delays and treatment gaps for individuals with epilepsy (IWE) enrolled in Arizona's Medicaid program using predictive models at the population and individual levels.

METHODS

In this retrospective cohort study, two statistical regression models were developed using Arizona Medicaid medical and pharmacy claims records from 2015-2019 and selected census tract-level SDoH data. Three treatment outcomes were defined: timely treatment (treated within thirty days); delayed treatment (treated after thirty days); and untreated. For the first model, least squares regression was used to regress the epilepsy treatment delays on selected SDoH factors at the population-level. For the second model, multinomial logistic regression was used to estimate associations between epilepsy treatment delays and individual-level sociodemographic factors.

RESULTS

Of the 5965 IWE identified with a new epilepsy diagnosis during the study period, 43.1% were treated with a mean delay of 180 days. Among the treated population, 42% received timely treatment. A treatment gap of at least 40.6% and potentially up to 56.9% was calculated. Individuals with epilepsy diagnosed in an inpatient setting or in emergency departments were more likely to be treated and receive timely treatment than those diagnosed in an office or clinic setting. Individuals with epilepsy diagnosed in "other" settings were more likely to go untreated or receive delayed treatment than a patient diagnosed in an office or clinic. Compared to IWE aged 31-50 years, IWE aged 0-30 years were more likely to receive timely treatment, IWE aged 51-64 years were more likely to receive delayed treatment, and IWE aged 65 years or older were more likely to go untreated. Widowed IWE were more likely to go untreated relative to single patients. Individuals with epilepsy experiencing homelessness were also more likely to go untreated. Unemployed IWE were more likely to go untreated or receive delayed treatment. Native American IWE were more likely to go untreated compared to White patients.

CONCLUSIONS

Treatment gaps and treatment delays are experienced by IWE in the Arizona Medicaid population. The SDoH factors predicted to impact treatment delays include care setting, age, race, marital status, homelessness, and employment.

Clinician Recognition of First Episode Psychosis

PURPOSE

Psychotic disorders develop during mid-adolescence through early adulthood, with the initial few months a "critical period" offering the greatest promise for recovery. However, the duration of untreated psychosis is typically over a year. This study aimed to identify aspects of care episodes contributing to delays in diagnosis of a first psychotic episode.

METHODS

Study subjects included 161 adolescents and young adults referred to a first episode psychosis treatment program. We captured the various ways that people who experience a severe mental illness engage in treatment using standardized interviews with patients and informants (e.g., family member) and medical record review.

RESULTS

A psychotic disorder diagnosis was not given for 38% of subjects at their initial episode of care. Time to first care episode was virtually the same for subjects that did and did not receive a psychosis diagnosis; 50% within 1 month and 84% within 6 months. Compared to initial care episodes with a psychosis diagnosis, those without a psychosis diagnosis less often involved emergency services (80% vs. 38%, respectively; p value = 1 × 10^-7) and more often outpatient primary care (6% vs. 18%; p value = .032) and mental health (32% vs. 49%; p value = .045) services. However, dangerousness indicators were similar (29% vs. 28%; p value = 1). Dangerousness indicators increased to 54% (p value = .002) by the time of eventual diagnosis for those requiring multiple care episodes.

CONCLUSIONS

Clinicians were important contributors to delays in diagnosis and treatment of psychosis. Interventions targeting outpatient health care providers may be fruitful in reducing the duration of untreated psychosis.

Patient-reported treatment delays in breast cancer care during the COVID-19 pandemic

Purpose

The coronavirus disease (COVID-19) pandemic has had a profound impact on cancer care in the US Guidelines focused on the management of COVID-19, rather than healthcare needs of breast cancer patients requiring access to crucial services. This US survey of breast cancer survivors characterizes treatment delays early period in the pandemic.

Methods

We developed a survey and administered it to 609 adult breast cancer survivors in the US. We used snowball sampling with invitations distributed via social media. We used logistic regression to select a model of delay from a pool of independent variables including race, cancer stage, site of care, health insurance, and age. We used descriptive statistics to characterize delay types.

Results

Forty-four percent of participants reported cancer care treatment delays during the pandemic. Delays in all aspects of cancer care and treatment were reported. The only variable which had a significant effect was age (97 (.95, 99), p < 0.001) with younger respondents (M = 45.94, SD = 10.31) reporting a higher incidence of delays than older respondents (M = 48.98, SD = 11.10). There was no significant effect for race, insurance, site of care, or cancer stage.

Conclusions

Our findings reveal a pervasive impact of COVID-19 on breast cancer care and a gap in disaster preparedness that leaves cancer survivors at risk for poor outcomes. Delays are critical to capture and characterize to help cancer providers and healthcare systems develop effective and patient–tailored processes and strategies to manage cases during the current pandemic wave, subsequent waves, and future disasters.

Impact of COVID-19 on Prostate Cancer Management: Guidelines for Urologists

CONTEXT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has resulted in a global health emergency, the like of which has never been seen before. Prostate cancer (PCa) services across the globe have been on hold due to changing medical and surgical priorities. There is also epidemiological evidence that PCa patients have increased incidence and mortality from SARS-CoV-2 infection due to gender differences, age, and higher propensity for risk factors (eg, respiratory disease, obesity, hypertension, and smoking status).

OBJECTIVE

To contribute to the emerging body of knowledge on the risks of SARS-CoV-2 infection to PCa patients and, in the face of PCa treatment delays, provide evidence-based recommendations for ongoing management of specific PCa patient groups.

EVIDENCE ACQUISITION

A literature search was performed using all sources (MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries, and Web of Science) as well as the media to harness emerging data on the SARS-CoV-2 pandemic and its influence on PCa. Eligibility criteria were originality of data and relevance to PCa management. The authors note that during these unprecedented times, retrospective data are constantly being updated from multiple sources globally.

EVIDENCE SYNTHESIS

A total of 72 articles and data sources were found initially. Owing to repetition, lack of originality, or nonrelevance, six articles were rejected, leaving 23 retrospective studies, seven basic science research articles, 15 societal and journal guidelines, and 21 epidemiological data sources, from countries at different stages of SARS-CoV-2 pandemic. These were analyzed qualitatively to produce evidence-based guidelines for the management of PCa patients at different stages of the patient journey, with strategies to reduce the risk of viral spread.

CONCLUSIONS

PCa patients may have an increased risk of SARS-CoV-2 infection as well as morbidity and mortality if infected. Once appropriately triaged, and to reduce viral spread, PCa patients can have surveillance by telemedicine, and institute lifestyle changes and social quarantining measures. If risk stratification suggests that treatment should be planned, androgen deprivation therapy can be started, or potentially surgery or radiation therapy is possible on a case-by-case basis.

PATIENT SUMMARY

Prostate cancer patients can be followed up remotely until the severe acute respiratory syndrome coronavirus 2 pandemic resolves, but higher-risk cases may have treatment expedited to limit any negative impact on prostate cancer outcomes.

Association of Extended Dosing Intervals or Delays in Pembrolizumab-based Regimens With Survival Outcomes in Advanced Non-small-cell Lung Cancer

Background

Besides modeling/simulation-based analysis, no post-approval studies have evaluated the optimal administration frequency of pembrolizumab in non–small-cell lung cancer (NSCLC).

Patients and Methods

We performed a multicenter retrospective cohort study to evaluate the association between survival outcomes and treatment extensions/delays of pembrolizumab-based regimens in patients with advanced NSCLC. Those who had received at least 4 cycles in routine practice were divided into 2 groups: nonstandard (Non-Std, ≥ 2 cycles at intervals > 3 weeks + 3 days) and standard (Std, all cycles every 3 weeks or 1 cycle > 3 weeks + 3 days).

Results

Among 150 patients, 92 (61%) were eligible for the study (Non-Std, 27; Std, 65). The reasons for patients with extensions/delays in the Non-Std group included: immune-related adverse events (irAEs) (33%), non–irAE-related medical issues (26%), and patient-physician preference (41%). The Non-Std group was more likely to have a higher programmed death-ligand 1 tumor proportion score, a higher number of treatment cycles, and pembrolizumab monotherapy. Univariate and 6-month landmark analyses showed longer median overall survival and progression-free survival in the Non-Std group compared with the Std group. After multivariable adjustment for confounding factors, there was no significant difference in overall survival (hazard ratio, 1.2; 95% confidence interval, 0.3-4.8; P = .824) or progression-free survival (hazard ratio, 2.6; 95% confidence interval, 0.7-9.6; P = .157) between the 2 groups.

Conclusion

Our study shows that a significant proportion of patients with advanced NSCLC receive pembrolizumab-based regimens with extended intervals or delays in routine clinical practice and with similar outcomes to those receiving treatment at label-specified 3-week intervals. Given the durability of benefit seen and the potential for cost reduction and decreased infusion frequency in these patients, this requires validation in prospective trials.

Pathways to mental health services for young people: a systematic review

PURPOSE

While early access to appropriate care can minimise the sequelae of mental illnesses, little is known about how youths come to access mental healthcare. We therefore conducted a systematic review to synthesise literature on the pathways to care of youths across a range of mental health problems.

METHODS

Studies were identified through searches of electronic databases (MEDLINE, PsycINFO, Embase, HealthSTAR and CINAHL), supplemented by backward and forward mapping and hand searching. We included studies on the pathways to mental healthcare of individuals aged 11-30 years. Two reviewers independently screened articles and extracted data.

RESULTS

Forty-five studies from 26 countries met eligibility criteria. The majority of these studies were from settings that offered services for the early stages of psychosis, and others included inpatient and outpatient settings targeting wide-ranging mental health problems. Generally, youths' pathways to mental healthcare were complex, involved diverse contacts, and, sometimes, undue treatment delays. Across contexts, family/carers, general practitioners and emergency rooms featured prominently in care pathways. There was little standardization in the measurement of pathways.

CONCLUSIONS

Except in psychosis, youths' pathways to mental healthcare remain understudied. Pathways to care research may need to be reconceptualised to account for the often transient and overlapping nature of youth mental health presentations, and the possibility that what constitutes optimal care may vary. Despite these complexities, additional research, using standardized methodology, can yield a greater understanding of the help-seeking behaviours of youths and those acting on their behalf; service responses to help-seeking; and the determinants of pathways. This understanding is critical to inform ongoing initatives to transform youth mental healthcare.

A NEET distinction: youths not in employment, education or training follow different pathways to illness and care in psychosis

PURPOSE

The early phases of psychosis, including the prodrome, often feature educational/occupational difficulties and various symptoms and signs, that can render or keep youths "Not in Employment, Education or Training" (NEET). Conversely, NEET status itself may increase risk for illness progression and impaired functioning, and impede access to appropriate services for psychosis. As these issues have not been investigated, we aimed to examine differences in the illness and care pathways and characteristics of youths with psychosis who are NEET and non-NEET.

METHODS

Youths entering a catchment-based Canadian early intervention service for psychosis (N = 416) were assessed as being NEET or non-NEET and compared on symptomatology, premorbid adjustment, prodrome and duration of untreated psychosis (DUP).

RESULTS

Thirty-nine percent of the sample was NEET. Compared to non-NEET youths, NEET youths had 34% higher negative symptoms scores, longer prodromes (median of 52 weeks vs. 24 weeks), and were more often continuously ill after their first psychiatric change until the onset of psychosis (62% vs. 45%). Both groups had similar premorbid adjustment scores until late adolescence when scores were significantly worse for NEET youths. Accounting for other predictors, NEET youths had 23% longer DUPs on average, despite having made more help-seeking attempts.

CONCLUSIONS

Despite being more narrowly defined, NEET status was thrice as prevalent in our sample as in the Canadian population. The NEET group followed a distinct trajectory of persistent symptoms and functional decline before presenting with a psychotic disorder. The systemic delays that NEET youths encountered indicate a need for better-targeted early identification efforts.

Impact of acute hematological toxicity on treatment interruptions during cranio-spinal irradiation in medulloblastoma: a tertiary care institute experience

To analyze treatment interruptions due to acute hematological toxicity in patients of medulloblastoma receiving cranio-spinal irradiation (CSI). Prospectively collected data from case records of 52 patients of medulloblastoma treated between 2011 and 2014 was evaluated. Blood counts were monitored twice a week during CSI. Spinal irradiation was interrupted for patients with ≥grade 2 hematological toxicity and resumed after recovery to grade 1 level (TLC >3000; platelet count >75,000). Treatment interruptions and hematological toxicity were analyzed. Median age was 11 years. All patients received adjuvant CSI of 36 Gy, followed by boost of 18 Gy to posterior fossa, at 1.8 Gy per fraction. Concurrent chemotherapy was not given. Adjuvant chemotherapy was given after CSI for high risk patients. Spinal fields were interrupted in 73.1% of patients. Cause of first interruption was leucopenia in 92.1%, thrombocytopenia in 2.6%, and both in 5.3%. Median number of fractions at first interruption was 8, with 25% of interruptions in first week. Median duration for hematological recovery after nadir was 5 days for leucopenia and 3 days for thrombocytopenia. Half of the patients had at least 2 interruptions, and 19% subsequently developed grade 3 toxicity. On multivariate analysis, significant correlation with duration of delay was observed for pre-treatment haemoglobin, number of fractions at first interruption, grade and duration of recovery of leucopenia. Acute hematological toxicity with CSI is frequently under-reported. Patients with low pre-treatment hemoglobin, early onset leucopenia, profound leucopenia and prolonged recovery times are at a higher risk of having protracted courses of irradiation. Frequent monitoring of blood counts and timely interruption of spinal fields of irradiation at grade 2 level of hematological toxicity minimizes the risk of grade 3 and grade 4 toxicity, while reducing the interruptions in irradiation of the gross tumour bed.

Quality Indicator for Epilepsy Treatment 15 (QUIET-15): Intervening after recurrent seizures in the elderly

In this study, we examined the provision of care to older adults with epilepsy and compliance with the "Quality Indicator for Epilepsy Treatment 15" (QUIET-15) measure. We analyzed 2008-2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African-Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27-1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57-0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57-1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22-1.51). The probability of AED change after a seizure was higher for patients with ≥4 comorbidities (OR 1.69, 95%CI 1.25-2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30-1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27-1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.

What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy?

OBJECTIVE

Disparities in epilepsy treatment are not uncommon; therefore, we examined population-based estimates of initial antiepileptic drugs (AEDs) in new-onset epilepsy among racial/ethnic minority groups of older US Medicare beneficiaries.

METHODS

We conducted retrospective analyses of 2008-2010 Medicare administrative claims for a 5% random sample of beneficiaries augmented for minority representation. New-onset epilepsy cases in 2009 had ≥1 International Classification of Diseases, Ninth Revision (ICD-9) 345.x or ≥2 ICD-9 780.3x, and ≥1 AED, AND no seizure/epilepsy claim codes or AEDs in preceding 365 days. We examined AED use and concordance with Quality Indicators of Epilepsy Treatment (QUIET) 6 (monotherapy as initial treatment = ≥30 day first prescription with no other concomitant AEDs), and prompt AED treatment (first AED within 30 days of diagnosis). Logistic regression examined likelihood of prompt treatment by demographic (race/ethnicity, gender, age), clinical (number of comorbid conditions, neurology care, index event occurring in the emergency room (ER)), and economic (Part D coverage phase, eligibility for Part D Low Income Subsidy [LIS], and ZIP code level poverty) factors.

RESULTS

Over 1 year of follow-up, 79.6% of 3,706 new epilepsy cases had one AED only (77.89% of whites vs. 89% of American Indian/Alaska Native [AI/AN]). Levetiracetam was the most commonly prescribed AED (45.5%: from 24.6% AI/AN to 55.0% whites). The second most common was phenytoin (30.6%: from 18.8% Asians to 43.1% AI/AN). QUIET 6 concordance was 94.7% (93.9% for whites to 97.3% of AI/AN). Only 50% received prompt AED therapy (49.6% whites to 53.9% AI/AN). Race/ethnicity was not significantly associated with AED patterns, monotherapy use, or prompt treatment.

SIGNIFICANCE

Monotherapy is common across all racial/ethnic groups of older adults with new-onset epilepsy, older AEDs are commonly prescribed, and treatment is frequently delayed. Further studies on reasons for treatment delays are warranted. Interventions should be developed and tested to develop paradigms that lead to better care.

Clinical impact of prolonged diagnosis to treatment interval (DTI) among patients with oropharyngeal squamous cell carcinoma

PURPOSE/OBJECTIVE(S)

We examined practice patterns using the National Cancer Data Base (NCDB) to determine risk factors for prolonged diagnosis to treatment interval (DTI) and survival outcomes in patients receiving chemoradiation for oropharyngeal squamous cell carcinoma (OPSCC).

METHODS AND MATERIALS

We identified 6606 NCDB patients with Stage III-IV OPSCC receiving chemoradiation from 2003 to 2006. We determined risk factors for prolonged DTI (>30days) using univariate and multivariable logistic regression models. We examined overall survival (OS) using Kaplan Meier and multivariable Cox proportional hazards models.

RESULTS

3586 (54.3%) patients had prolonged DTI. Race, IMRT, insurance status, and high volume facilities were significant risk factors for prolonged DTI. Patients with prolonged DTI had inferior OS compared to DTI⩽30days (Hazard Ratio (HR)=1.12, 95% CI 1.04-1.20, p=0.005). For every week increase in DTI there was a 2.2% (95% CI 1.1-3.3%, p<0.001) increase in risk of death. Patients receiving IMRT, treatment at academic, or high-volume facilities were more likely to experience prolonged DTI (High vs. Low volume: 61.5% vs. 51.8%, adjusted OR 1.38, 95% CI 1.21-1.58; Academic vs. Community: 59.5% vs. 50.6%, adjusted OR 1.26, 95% CI 1.13-1.42; non-IMRT vs. IMRT: 53.4% vs. 56.5%; adjusted OR 1.17, 95% CI 1.04-1.31).

CONCLUSIONS

Our results suggest that prolonged DTI has a significant impact on survival outcomes. We observed disparities in DTI by socioeconomic factors. However, facility level factors such as academic affiliation, high volume, and IMRT also increased risk of DTI. These findings should be considered in developing efficient pathways to mitigate adverse effects of prolonged DTI.

Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Recently developed crowding measures, such as the Emergency Department (ED) Work Index (EDWIN) score, provide a quantifiable measurement of overcrowding in the ED.

AIMS

We sought to determine the association between overcrowding, measured with the EDWIN score, and the time required to initiate percutaneous coronary intervention (PCI) for patients presenting to the ED with acute myocardial infarction (AMI).

METHODS

We retrospectively reviewed the performance improvement (PI) data on all patients presenting to the ED over a 2-month period with chest pain and whose subsequent ECG showed AMI requiring PCI. We recorded the time from patient presentation to the (1) time to first ECG, (2) time to patient arrival in the catheterization laboratory, and (3) time to catheter balloon inflation. We calculated EDWIN scores using data archived from our electronic tracking board and compared the proportion of patients who achieved our established ED goal times between patients presenting during low crowding (EDWIN < 1.5) and high crowding (EDWIN > or = 1.5) conditions.

RESULTS

Seventeen patients underwent emergent PCI in the study period. Patients presenting to the ED during periods of low crowding had shorter times to balloon inflation (median of 84 min, IQR 80 to 93 min) than patients presenting to the ED during periods of high crowding (median of 107 min, IQR 94 to 122 min), P = 0.008. Times to first ECG and to arrival in the catheterization laboratory were not significantly different between patients presenting during low and high crowding conditions.

CONCLUSION

Overcrowding appears to be associated with a decreased likelihood of timely treatment for acute AMI in our ED.