User login
The Impact of a Pharmacist-Led Oral Anticancer Clinic on Patient Outcomes
Purpose
To evaluate the impact that a pharmacistmanaged oral anticancer clinic has on patient adherence to oral anticancer therapy in regard to medication adherence and adherence to lab monitoring.
Background
Oral anticancer therapy is typically preconceived to be safer than intravenous. However, these medications have a narrow therapeutic window and significant toxicities, requiring close monitoring to ensure patient safety. Previous studies have shown that pharmacist-led oral anticancer clinics have improved adherence and decreased toxicity.
Methods
A retrospective chart review was completed for patients prescribed abiraterone, enzalutamide, or ibrutinib. The primary outcome assessed medication adherence by comparing the medication possession ratio (MPR) before (phase 1) and after (phase 2) the initiation of the pharmacist-led oral anticancer therapy clinic. The secondary outcome assessed lab monitoring adherence by patients and providers in phase 1 vs. phase 2. This study also examined descriptive outcomes in phase 2.
Data Analysis
Independent sample t tests were used to analyze primary and secondary endpoints. For descriptive endpoints, standard deviations and range of scores were assessed for continuous variables.
Results
A statistically significant increase in the mean MPR ratio was shown between phase 1 vs phase 2 (0.98 vs 1.05; P = .027). For patient adherence to lab monitoring, there was a statistically significant improvement for patients on abiraterone (21.9% vs. 67%; P < .001) and enzalutamide (35.7% vs 90.5%; P = .006). There was a decline in lab monitoring adherence for patient on ibrutinib but this effect was not statistically significant (56.2% vs. 51%; P = .283). Similar results were shown for provider adherence to lab monitoring. Descriptive outcomes showed that the pharmacist had on average 6.7 encounters per patient.
Conclusions/Implications
A pharmacist-led oral anticancer clinic can improve MPR ratios and patient adherence to oral anticancer regimens. Patient and provider lab monitoring adherence was improved for abiraterone and enzalutamide. Improvement in patient/ provider lab monitoring adherence for ibrutinib was not shown, possibly due to the impact of the COVID-19 pandemic, small sample size, and retrospective nature of this study. The results of this study supports that overall, a pharmacist-led oral anticancer clinic can significantly improve patient outcomes, which aligns with previous smaller studies.
Purpose
To evaluate the impact that a pharmacistmanaged oral anticancer clinic has on patient adherence to oral anticancer therapy in regard to medication adherence and adherence to lab monitoring.
Background
Oral anticancer therapy is typically preconceived to be safer than intravenous. However, these medications have a narrow therapeutic window and significant toxicities, requiring close monitoring to ensure patient safety. Previous studies have shown that pharmacist-led oral anticancer clinics have improved adherence and decreased toxicity.
Methods
A retrospective chart review was completed for patients prescribed abiraterone, enzalutamide, or ibrutinib. The primary outcome assessed medication adherence by comparing the medication possession ratio (MPR) before (phase 1) and after (phase 2) the initiation of the pharmacist-led oral anticancer therapy clinic. The secondary outcome assessed lab monitoring adherence by patients and providers in phase 1 vs. phase 2. This study also examined descriptive outcomes in phase 2.
Data Analysis
Independent sample t tests were used to analyze primary and secondary endpoints. For descriptive endpoints, standard deviations and range of scores were assessed for continuous variables.
Results
A statistically significant increase in the mean MPR ratio was shown between phase 1 vs phase 2 (0.98 vs 1.05; P = .027). For patient adherence to lab monitoring, there was a statistically significant improvement for patients on abiraterone (21.9% vs. 67%; P < .001) and enzalutamide (35.7% vs 90.5%; P = .006). There was a decline in lab monitoring adherence for patient on ibrutinib but this effect was not statistically significant (56.2% vs. 51%; P = .283). Similar results were shown for provider adherence to lab monitoring. Descriptive outcomes showed that the pharmacist had on average 6.7 encounters per patient.
Conclusions/Implications
A pharmacist-led oral anticancer clinic can improve MPR ratios and patient adherence to oral anticancer regimens. Patient and provider lab monitoring adherence was improved for abiraterone and enzalutamide. Improvement in patient/ provider lab monitoring adherence for ibrutinib was not shown, possibly due to the impact of the COVID-19 pandemic, small sample size, and retrospective nature of this study. The results of this study supports that overall, a pharmacist-led oral anticancer clinic can significantly improve patient outcomes, which aligns with previous smaller studies.
Purpose
To evaluate the impact that a pharmacistmanaged oral anticancer clinic has on patient adherence to oral anticancer therapy in regard to medication adherence and adherence to lab monitoring.
Background
Oral anticancer therapy is typically preconceived to be safer than intravenous. However, these medications have a narrow therapeutic window and significant toxicities, requiring close monitoring to ensure patient safety. Previous studies have shown that pharmacist-led oral anticancer clinics have improved adherence and decreased toxicity.
Methods
A retrospective chart review was completed for patients prescribed abiraterone, enzalutamide, or ibrutinib. The primary outcome assessed medication adherence by comparing the medication possession ratio (MPR) before (phase 1) and after (phase 2) the initiation of the pharmacist-led oral anticancer therapy clinic. The secondary outcome assessed lab monitoring adherence by patients and providers in phase 1 vs. phase 2. This study also examined descriptive outcomes in phase 2.
Data Analysis
Independent sample t tests were used to analyze primary and secondary endpoints. For descriptive endpoints, standard deviations and range of scores were assessed for continuous variables.
Results
A statistically significant increase in the mean MPR ratio was shown between phase 1 vs phase 2 (0.98 vs 1.05; P = .027). For patient adherence to lab monitoring, there was a statistically significant improvement for patients on abiraterone (21.9% vs. 67%; P < .001) and enzalutamide (35.7% vs 90.5%; P = .006). There was a decline in lab monitoring adherence for patient on ibrutinib but this effect was not statistically significant (56.2% vs. 51%; P = .283). Similar results were shown for provider adherence to lab monitoring. Descriptive outcomes showed that the pharmacist had on average 6.7 encounters per patient.
Conclusions/Implications
A pharmacist-led oral anticancer clinic can improve MPR ratios and patient adherence to oral anticancer regimens. Patient and provider lab monitoring adherence was improved for abiraterone and enzalutamide. Improvement in patient/ provider lab monitoring adherence for ibrutinib was not shown, possibly due to the impact of the COVID-19 pandemic, small sample size, and retrospective nature of this study. The results of this study supports that overall, a pharmacist-led oral anticancer clinic can significantly improve patient outcomes, which aligns with previous smaller studies.
Implementation of a VA Home-Infusion Program for 5-FU
Background
The VA Outpatient Chemotherapy Clinic sees approximately 870 veterans each year. Of these, 5% receive home-infusion chemotherapy. COVID-19 created staffing challenges for the contracted homeinfusion company utilized by the VA for home-infusion chemotherapy. The VA developed a self-contained home-infusion program for 5-FU to ensure needed care could be delivered to veterans without delay.
Methods
After researching private sector and VA models of providing home-infusion chemotherapy services, analyzing literature, internal VA patient safety data, and financial implications of different home-infusion pump options, including both CADD pumps and elastomeric pumps, CADD pumps were determined to be the best financial option and safest option for providing home-infusion 5-FU through the VA. Patient education documents were created from CADD pump user manuals and literature.
Results
A home-infusion program for 5-FU chemotherapy was implemented at the VA Outpatient Chemotherapy Clinic in March 2022. Veterans receive a home-infusion pump, 5-FU, education, and access to a 24-hour telephone support line staffed by an oncology registered nurse through the VA. Patient education consists of home-infusion pump training, implanted port de-accessing, chemotherapy spill management, and hazardous waste disposal.
Conclusion
Ten veterans have started their home-infusion portion of therapy through the VA, amounting to 34 completed cycles, between March 2022 and June 2022. This program is completely self-contained within the VA Outpatient Chemotherapy Clinic. It has allowed for initiation and continuation of needed chemotherapy regimens in an environment of staffing instability at the contracted home-infusion company. The home-infusion program required the acquisition of home-infusion pumps and supplies. The home-infusion pumps can be reused by another patient after completion of treatment making this program sustainable. Existing VA medical oncology staffing was utilized with the additional need for oncology nurses to take calls to provide 24-hour telephone support for any pumprelated issues that may arise during home-infusion therapy. A VA home-infusion program allows for veterans to receive seamless cancer care through one entity. This program is replicable at other VAs and can be expanded to include other forms of home-infusion therapy, such as antibiotics.
Background
The VA Outpatient Chemotherapy Clinic sees approximately 870 veterans each year. Of these, 5% receive home-infusion chemotherapy. COVID-19 created staffing challenges for the contracted homeinfusion company utilized by the VA for home-infusion chemotherapy. The VA developed a self-contained home-infusion program for 5-FU to ensure needed care could be delivered to veterans without delay.
Methods
After researching private sector and VA models of providing home-infusion chemotherapy services, analyzing literature, internal VA patient safety data, and financial implications of different home-infusion pump options, including both CADD pumps and elastomeric pumps, CADD pumps were determined to be the best financial option and safest option for providing home-infusion 5-FU through the VA. Patient education documents were created from CADD pump user manuals and literature.
Results
A home-infusion program for 5-FU chemotherapy was implemented at the VA Outpatient Chemotherapy Clinic in March 2022. Veterans receive a home-infusion pump, 5-FU, education, and access to a 24-hour telephone support line staffed by an oncology registered nurse through the VA. Patient education consists of home-infusion pump training, implanted port de-accessing, chemotherapy spill management, and hazardous waste disposal.
Conclusion
Ten veterans have started their home-infusion portion of therapy through the VA, amounting to 34 completed cycles, between March 2022 and June 2022. This program is completely self-contained within the VA Outpatient Chemotherapy Clinic. It has allowed for initiation and continuation of needed chemotherapy regimens in an environment of staffing instability at the contracted home-infusion company. The home-infusion program required the acquisition of home-infusion pumps and supplies. The home-infusion pumps can be reused by another patient after completion of treatment making this program sustainable. Existing VA medical oncology staffing was utilized with the additional need for oncology nurses to take calls to provide 24-hour telephone support for any pumprelated issues that may arise during home-infusion therapy. A VA home-infusion program allows for veterans to receive seamless cancer care through one entity. This program is replicable at other VAs and can be expanded to include other forms of home-infusion therapy, such as antibiotics.
Background
The VA Outpatient Chemotherapy Clinic sees approximately 870 veterans each year. Of these, 5% receive home-infusion chemotherapy. COVID-19 created staffing challenges for the contracted homeinfusion company utilized by the VA for home-infusion chemotherapy. The VA developed a self-contained home-infusion program for 5-FU to ensure needed care could be delivered to veterans without delay.
Methods
After researching private sector and VA models of providing home-infusion chemotherapy services, analyzing literature, internal VA patient safety data, and financial implications of different home-infusion pump options, including both CADD pumps and elastomeric pumps, CADD pumps were determined to be the best financial option and safest option for providing home-infusion 5-FU through the VA. Patient education documents were created from CADD pump user manuals and literature.
Results
A home-infusion program for 5-FU chemotherapy was implemented at the VA Outpatient Chemotherapy Clinic in March 2022. Veterans receive a home-infusion pump, 5-FU, education, and access to a 24-hour telephone support line staffed by an oncology registered nurse through the VA. Patient education consists of home-infusion pump training, implanted port de-accessing, chemotherapy spill management, and hazardous waste disposal.
Conclusion
Ten veterans have started their home-infusion portion of therapy through the VA, amounting to 34 completed cycles, between March 2022 and June 2022. This program is completely self-contained within the VA Outpatient Chemotherapy Clinic. It has allowed for initiation and continuation of needed chemotherapy regimens in an environment of staffing instability at the contracted home-infusion company. The home-infusion program required the acquisition of home-infusion pumps and supplies. The home-infusion pumps can be reused by another patient after completion of treatment making this program sustainable. Existing VA medical oncology staffing was utilized with the additional need for oncology nurses to take calls to provide 24-hour telephone support for any pumprelated issues that may arise during home-infusion therapy. A VA home-infusion program allows for veterans to receive seamless cancer care through one entity. This program is replicable at other VAs and can be expanded to include other forms of home-infusion therapy, such as antibiotics.
Close to Me: CBOC Infusion Program
Background
Currently, within the Veterans Affairs Healthcare System, anticancer therapy infusions and injections are primarily offered at VA medical centers (VAMCs) in urban areas. The time and out-of-pocket expenses related to travel present a barrier to care, often leading veterans to seek cancer care in the community. The Minneapolis VA developed a “Remote Infusion” program that deploys a chemotherapy certified RN to administer anticancer and supportive therapies at surrounding Community Based Outpatient Clinics (CBOCs). The program expanded in October 2021, and since, they have provided 259 infusions and injections to 145 veterans at 16 CBOCs. These efforts have saved at least 20,000 miles of travel for veterans in the Minneapolis/ St. Cloud catchment area. Building off the success of this program, the National Oncology Program Integrated Project Team has developed the “Close to Me” CBOC Infusion Program.
Methods
The “Close to Me” CBOC Infusion Program utilizes VAMCs to compound treatments. Then a chemotherapy certified RN is deployed to the surrounding CBOCs to administer treatments. Veterans eligible for this program must have received and tolerated their first dose of treatment at a VAMC. Medications included in this program have low risk of reaction, short infusion time, and at least 8 hours of drug stability. Treatments include immune check point inhibitors, leuprolide, octreotide, IV fluids, and iron infusions. Additional treatments continue to be evaluated and added. Telehealth modalities are utilized for patient visits with their oncology provider for treatment clearance. An implementation toolkit, including a library of standard operating procedures, note templates, and staffing models, has been developed for VAMCs interested in replicating this program.
Results
The Pittsburgh VAMC launched the first “Close to Me” CBOC Infusion Program June 8, 2022.
Conclusions
The “Close to Me” CBOC infusion program optimizes current VA infrastructure and processes to expand access to the world class oncology care VA provides by reducing travel burden for the veterans. Additional areas of novel solutions under development to provide expanded access points to anticancer therapies include mobile infusion units, mobile compounding units, and home administration.
Background
Currently, within the Veterans Affairs Healthcare System, anticancer therapy infusions and injections are primarily offered at VA medical centers (VAMCs) in urban areas. The time and out-of-pocket expenses related to travel present a barrier to care, often leading veterans to seek cancer care in the community. The Minneapolis VA developed a “Remote Infusion” program that deploys a chemotherapy certified RN to administer anticancer and supportive therapies at surrounding Community Based Outpatient Clinics (CBOCs). The program expanded in October 2021, and since, they have provided 259 infusions and injections to 145 veterans at 16 CBOCs. These efforts have saved at least 20,000 miles of travel for veterans in the Minneapolis/ St. Cloud catchment area. Building off the success of this program, the National Oncology Program Integrated Project Team has developed the “Close to Me” CBOC Infusion Program.
Methods
The “Close to Me” CBOC Infusion Program utilizes VAMCs to compound treatments. Then a chemotherapy certified RN is deployed to the surrounding CBOCs to administer treatments. Veterans eligible for this program must have received and tolerated their first dose of treatment at a VAMC. Medications included in this program have low risk of reaction, short infusion time, and at least 8 hours of drug stability. Treatments include immune check point inhibitors, leuprolide, octreotide, IV fluids, and iron infusions. Additional treatments continue to be evaluated and added. Telehealth modalities are utilized for patient visits with their oncology provider for treatment clearance. An implementation toolkit, including a library of standard operating procedures, note templates, and staffing models, has been developed for VAMCs interested in replicating this program.
Results
The Pittsburgh VAMC launched the first “Close to Me” CBOC Infusion Program June 8, 2022.
Conclusions
The “Close to Me” CBOC infusion program optimizes current VA infrastructure and processes to expand access to the world class oncology care VA provides by reducing travel burden for the veterans. Additional areas of novel solutions under development to provide expanded access points to anticancer therapies include mobile infusion units, mobile compounding units, and home administration.
Background
Currently, within the Veterans Affairs Healthcare System, anticancer therapy infusions and injections are primarily offered at VA medical centers (VAMCs) in urban areas. The time and out-of-pocket expenses related to travel present a barrier to care, often leading veterans to seek cancer care in the community. The Minneapolis VA developed a “Remote Infusion” program that deploys a chemotherapy certified RN to administer anticancer and supportive therapies at surrounding Community Based Outpatient Clinics (CBOCs). The program expanded in October 2021, and since, they have provided 259 infusions and injections to 145 veterans at 16 CBOCs. These efforts have saved at least 20,000 miles of travel for veterans in the Minneapolis/ St. Cloud catchment area. Building off the success of this program, the National Oncology Program Integrated Project Team has developed the “Close to Me” CBOC Infusion Program.
Methods
The “Close to Me” CBOC Infusion Program utilizes VAMCs to compound treatments. Then a chemotherapy certified RN is deployed to the surrounding CBOCs to administer treatments. Veterans eligible for this program must have received and tolerated their first dose of treatment at a VAMC. Medications included in this program have low risk of reaction, short infusion time, and at least 8 hours of drug stability. Treatments include immune check point inhibitors, leuprolide, octreotide, IV fluids, and iron infusions. Additional treatments continue to be evaluated and added. Telehealth modalities are utilized for patient visits with their oncology provider for treatment clearance. An implementation toolkit, including a library of standard operating procedures, note templates, and staffing models, has been developed for VAMCs interested in replicating this program.
Results
The Pittsburgh VAMC launched the first “Close to Me” CBOC Infusion Program June 8, 2022.
Conclusions
The “Close to Me” CBOC infusion program optimizes current VA infrastructure and processes to expand access to the world class oncology care VA provides by reducing travel burden for the veterans. Additional areas of novel solutions under development to provide expanded access points to anticancer therapies include mobile infusion units, mobile compounding units, and home administration.
Improving Veteran Adherence to Preadmission ERAS Protocol: Decreasing Avoidable Surgical Cancellations and Post-Operative Length of Stay (LOS)
Purpose
Improve veteran adherence of preadmission enhanced recovery after surgery (ERAS) protocol.
Background
NMVAHCS implemented the multidisciplinary Enhanced Recovery After Surgery (ERAS) protocol in 2018 to reduce postoperative morbidity and LOS utilizing evidence-based practice. Perioperative, intraoperative and postoperative practices were adopted, and well adhered. However, preadmission preparedness, the veteran’s responsibility, lacked adherence. Although detailed verbal and written instructions were provided, improvements were necessary. Patient related issues (PRI) regarding anticoagulation, drivers, anesthesia preop, COVID testing, and preparation often led to surgical cancellations.
Methods
ANNIE, an approved mobile application (app) utilizing Short Message Service (SMS) texts was identified to engage veterans. After facility and Office of Connected Care approval, an automated program was designed to text veteran’s preadmission instructions. Messages include 1-way reminders and 2-way messages providing automated instructions based on response. Veteran’s consent and enroll in the app 1 week prior to surgery and receive daily reminders for prehabilitation: daily exercise, arranging driver, and refraining from smoking, alcohol, illicit and herbal medications. Two-way messages verify anesthesia pre-op appointment and anticoagulation status. Reply messages provide information for scheduling or instructions regarding anticoagulation. Texts verify receipt and understanding of bowel preparation medications, COVID testing, “clears” diet, and assess for COVID symptoms. The day prior to admission, time sensitive reminders alert the veteran to each step of the Nichol’s preparation and carbohydrate drink consumption. Messages continue post-operatively assessing status, encouraging activity and pulmonary toilet. Messages also verify discharge education, receipt of stoma supplies, and surgical follow-up appointment.
Results
Prior to ERAS the average LOS was 11 days, which was reduced to 9 days after initial protocol implementation. Veterans enrolled in the app averaged a LOS of 7 days: a cost savings of $31,865.00 per veteran and increased bed availability for other veterans awaiting surgery. In FY19, 69 avoidable PRI led to surgical cancellations. Cancellations decrease access to care and maintain avoidable facility costs averaging $30,270.00 per case. ERAS and enrollment in ANNIE decreased cancellations by 62% (26 cases) in FY20 and 70% (21 cases) in FY21.
Conclusions
Engaging veterans with SMS messages improves preadmission ERAS adherence: improving outcomes for the veteran and facility.
Purpose
Improve veteran adherence of preadmission enhanced recovery after surgery (ERAS) protocol.
Background
NMVAHCS implemented the multidisciplinary Enhanced Recovery After Surgery (ERAS) protocol in 2018 to reduce postoperative morbidity and LOS utilizing evidence-based practice. Perioperative, intraoperative and postoperative practices were adopted, and well adhered. However, preadmission preparedness, the veteran’s responsibility, lacked adherence. Although detailed verbal and written instructions were provided, improvements were necessary. Patient related issues (PRI) regarding anticoagulation, drivers, anesthesia preop, COVID testing, and preparation often led to surgical cancellations.
Methods
ANNIE, an approved mobile application (app) utilizing Short Message Service (SMS) texts was identified to engage veterans. After facility and Office of Connected Care approval, an automated program was designed to text veteran’s preadmission instructions. Messages include 1-way reminders and 2-way messages providing automated instructions based on response. Veteran’s consent and enroll in the app 1 week prior to surgery and receive daily reminders for prehabilitation: daily exercise, arranging driver, and refraining from smoking, alcohol, illicit and herbal medications. Two-way messages verify anesthesia pre-op appointment and anticoagulation status. Reply messages provide information for scheduling or instructions regarding anticoagulation. Texts verify receipt and understanding of bowel preparation medications, COVID testing, “clears” diet, and assess for COVID symptoms. The day prior to admission, time sensitive reminders alert the veteran to each step of the Nichol’s preparation and carbohydrate drink consumption. Messages continue post-operatively assessing status, encouraging activity and pulmonary toilet. Messages also verify discharge education, receipt of stoma supplies, and surgical follow-up appointment.
Results
Prior to ERAS the average LOS was 11 days, which was reduced to 9 days after initial protocol implementation. Veterans enrolled in the app averaged a LOS of 7 days: a cost savings of $31,865.00 per veteran and increased bed availability for other veterans awaiting surgery. In FY19, 69 avoidable PRI led to surgical cancellations. Cancellations decrease access to care and maintain avoidable facility costs averaging $30,270.00 per case. ERAS and enrollment in ANNIE decreased cancellations by 62% (26 cases) in FY20 and 70% (21 cases) in FY21.
Conclusions
Engaging veterans with SMS messages improves preadmission ERAS adherence: improving outcomes for the veteran and facility.
Purpose
Improve veteran adherence of preadmission enhanced recovery after surgery (ERAS) protocol.
Background
NMVAHCS implemented the multidisciplinary Enhanced Recovery After Surgery (ERAS) protocol in 2018 to reduce postoperative morbidity and LOS utilizing evidence-based practice. Perioperative, intraoperative and postoperative practices were adopted, and well adhered. However, preadmission preparedness, the veteran’s responsibility, lacked adherence. Although detailed verbal and written instructions were provided, improvements were necessary. Patient related issues (PRI) regarding anticoagulation, drivers, anesthesia preop, COVID testing, and preparation often led to surgical cancellations.
Methods
ANNIE, an approved mobile application (app) utilizing Short Message Service (SMS) texts was identified to engage veterans. After facility and Office of Connected Care approval, an automated program was designed to text veteran’s preadmission instructions. Messages include 1-way reminders and 2-way messages providing automated instructions based on response. Veteran’s consent and enroll in the app 1 week prior to surgery and receive daily reminders for prehabilitation: daily exercise, arranging driver, and refraining from smoking, alcohol, illicit and herbal medications. Two-way messages verify anesthesia pre-op appointment and anticoagulation status. Reply messages provide information for scheduling or instructions regarding anticoagulation. Texts verify receipt and understanding of bowel preparation medications, COVID testing, “clears” diet, and assess for COVID symptoms. The day prior to admission, time sensitive reminders alert the veteran to each step of the Nichol’s preparation and carbohydrate drink consumption. Messages continue post-operatively assessing status, encouraging activity and pulmonary toilet. Messages also verify discharge education, receipt of stoma supplies, and surgical follow-up appointment.
Results
Prior to ERAS the average LOS was 11 days, which was reduced to 9 days after initial protocol implementation. Veterans enrolled in the app averaged a LOS of 7 days: a cost savings of $31,865.00 per veteran and increased bed availability for other veterans awaiting surgery. In FY19, 69 avoidable PRI led to surgical cancellations. Cancellations decrease access to care and maintain avoidable facility costs averaging $30,270.00 per case. ERAS and enrollment in ANNIE decreased cancellations by 62% (26 cases) in FY20 and 70% (21 cases) in FY21.
Conclusions
Engaging veterans with SMS messages improves preadmission ERAS adherence: improving outcomes for the veteran and facility.
Evaluating Progression Free Survival Among Veteran Population With Stage IV Non-Small Cell Immunotherapy vs Chemo- Immunotherapy
Background
Use of immune checkpoint inhibitors against advanced stage NSCLC has been associated with significant reduction in overall disease morbidity and mortality. However, despite the significant survival benefit, tumors invariably relapse. It is important to understand the pattern of progression and the progression free survival (PFS) to better predict disease outcomes and modify treatment approach.
Methods
We performed a retrospective review of 74 veterans with new diagnosis of stage IV NSCLC who received 2 or more cycles of immunotherapy with/without concurrent chemotherapy between 2015-2021 at the Stratton VA Medical Center. IRB approval was obtained. Fisher exact probability test and Kaplan-Meier estimators were used to analyze data with level of significance P < .05.
Results
Out of 74 patients, 38 patients were identified who received immunotherapy alone (Group A; n = 23, 60.5%) vs chemo-immunotherapy (Group B; n = 15, 39.5%). Baseline characteristics of Group A revealed median age 70 (IQR, 65-78), adenocarcinoma (n = 10, 43.4%), squamous cell carcinoma (n = 12, 52.1%), PD-L1 > 50% expression (n = 21, 91.3%), molecular testing positive for EGFR in 1 patient, otherwise negative for ROS, ALK, EGFR and BRAF mutations in all patients. Similarly, in Group B, median age 66 (IQR, 63-72), adenocarcinoma (n = 6, 40%), squamous cell carcinoma (n = 8, 53.3%), PD-L1 > 50% expression (n = 3, 20%), no mutations noted on molecular testing. Out of 38 patients, disease progression was noted in 19 patients, 10 in Group A (progression at initial site and new site n = 5, 50%) vs 9 in Group B (progression at initial site and new site, n = 6, 66.7%). Most common sites of progression included local and distant lymph nodes, brain, bone, and liver. Using the Kaplan-Meier analysis, median progression free survival (PFS) from start of immunotherapy till evidence of progression on imaging was 11 months in Group A and 7 months in Group B, P = .22. Our study recognized widespread metastases at the time of diagnosis (P = .03) as a possible factor affecting progression of diseases in Group A compared to Group B.
Conclusion
We conclude that although no statistically significant association was noted between the progression free survival between the two groups, the increased median PFS in immunotherapy only group is worth additional investigation. We recommend further large-scale studies to explore this association.
Background
Use of immune checkpoint inhibitors against advanced stage NSCLC has been associated with significant reduction in overall disease morbidity and mortality. However, despite the significant survival benefit, tumors invariably relapse. It is important to understand the pattern of progression and the progression free survival (PFS) to better predict disease outcomes and modify treatment approach.
Methods
We performed a retrospective review of 74 veterans with new diagnosis of stage IV NSCLC who received 2 or more cycles of immunotherapy with/without concurrent chemotherapy between 2015-2021 at the Stratton VA Medical Center. IRB approval was obtained. Fisher exact probability test and Kaplan-Meier estimators were used to analyze data with level of significance P < .05.
Results
Out of 74 patients, 38 patients were identified who received immunotherapy alone (Group A; n = 23, 60.5%) vs chemo-immunotherapy (Group B; n = 15, 39.5%). Baseline characteristics of Group A revealed median age 70 (IQR, 65-78), adenocarcinoma (n = 10, 43.4%), squamous cell carcinoma (n = 12, 52.1%), PD-L1 > 50% expression (n = 21, 91.3%), molecular testing positive for EGFR in 1 patient, otherwise negative for ROS, ALK, EGFR and BRAF mutations in all patients. Similarly, in Group B, median age 66 (IQR, 63-72), adenocarcinoma (n = 6, 40%), squamous cell carcinoma (n = 8, 53.3%), PD-L1 > 50% expression (n = 3, 20%), no mutations noted on molecular testing. Out of 38 patients, disease progression was noted in 19 patients, 10 in Group A (progression at initial site and new site n = 5, 50%) vs 9 in Group B (progression at initial site and new site, n = 6, 66.7%). Most common sites of progression included local and distant lymph nodes, brain, bone, and liver. Using the Kaplan-Meier analysis, median progression free survival (PFS) from start of immunotherapy till evidence of progression on imaging was 11 months in Group A and 7 months in Group B, P = .22. Our study recognized widespread metastases at the time of diagnosis (P = .03) as a possible factor affecting progression of diseases in Group A compared to Group B.
Conclusion
We conclude that although no statistically significant association was noted between the progression free survival between the two groups, the increased median PFS in immunotherapy only group is worth additional investigation. We recommend further large-scale studies to explore this association.
Background
Use of immune checkpoint inhibitors against advanced stage NSCLC has been associated with significant reduction in overall disease morbidity and mortality. However, despite the significant survival benefit, tumors invariably relapse. It is important to understand the pattern of progression and the progression free survival (PFS) to better predict disease outcomes and modify treatment approach.
Methods
We performed a retrospective review of 74 veterans with new diagnosis of stage IV NSCLC who received 2 or more cycles of immunotherapy with/without concurrent chemotherapy between 2015-2021 at the Stratton VA Medical Center. IRB approval was obtained. Fisher exact probability test and Kaplan-Meier estimators were used to analyze data with level of significance P < .05.
Results
Out of 74 patients, 38 patients were identified who received immunotherapy alone (Group A; n = 23, 60.5%) vs chemo-immunotherapy (Group B; n = 15, 39.5%). Baseline characteristics of Group A revealed median age 70 (IQR, 65-78), adenocarcinoma (n = 10, 43.4%), squamous cell carcinoma (n = 12, 52.1%), PD-L1 > 50% expression (n = 21, 91.3%), molecular testing positive for EGFR in 1 patient, otherwise negative for ROS, ALK, EGFR and BRAF mutations in all patients. Similarly, in Group B, median age 66 (IQR, 63-72), adenocarcinoma (n = 6, 40%), squamous cell carcinoma (n = 8, 53.3%), PD-L1 > 50% expression (n = 3, 20%), no mutations noted on molecular testing. Out of 38 patients, disease progression was noted in 19 patients, 10 in Group A (progression at initial site and new site n = 5, 50%) vs 9 in Group B (progression at initial site and new site, n = 6, 66.7%). Most common sites of progression included local and distant lymph nodes, brain, bone, and liver. Using the Kaplan-Meier analysis, median progression free survival (PFS) from start of immunotherapy till evidence of progression on imaging was 11 months in Group A and 7 months in Group B, P = .22. Our study recognized widespread metastases at the time of diagnosis (P = .03) as a possible factor affecting progression of diseases in Group A compared to Group B.
Conclusion
We conclude that although no statistically significant association was noted between the progression free survival between the two groups, the increased median PFS in immunotherapy only group is worth additional investigation. We recommend further large-scale studies to explore this association.
Blood type linked to higher risk for early onset stroke
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
FROM NEUROLOGY
Academic/Research Facility Utilization and Survival Outcomes in Osteosarcoma: An NCDB Analysis
Background
Previous studies have reported that treatment at academic/research facilities is associated with improved survival in cancer patients. The objective of this study was to investigate the impact of treatment facility type on overall survival for patients presenting with osteosarcoma.
Methods
The National Cancer Database (NCDB) was used to identify patients diagnosed with Osteosarcoma from 2004 to 2018. Facility types were identified as assigned by the Commission on Cancer Accreditation program. Data was analyzed using SPSS and statistical significance was set at P = .05.
Results
Of 2085 patients queried, 39.6% were treated at an academic/research program. The stage-adjusted difference in median survival between academic/research and non-academic programs was found to be statistically significant on log-rank comparison (P < .001). At each NCDB analytic stage (stage I-IV), academic/research programs were associated with decreased hazard and improved median survival. A Cox proportional hazards model showed a decreased likelihood of mortality in patients with osteosarcoma who underwent treatment at an academic/research program (HR, 0.882; 95% CI, .802-.969; P = .009). Chi-square testing revealed that patients at academic/research programs were more likely than those at non-academic/research centers to have private insurance, less likely to have Medicare, and more likely to live in counties of > 1 million people. These facilities were also more likely to have undergone Medicaid expansion in 2014. (P < .05). Patients at non-academic/research programs were more likely to have advanced disease (stage III and IV) and higher comorbidity scores. Additionally, they were less likely to receive surgery and/or chemotherapy at the institution in which they were diagnosed. (P < .05).
Conclusions
This study showed that Osteosarcoma patients treated in an academic/research program facility experienced increased survival compared with non-academic/research facilities. Patients at academic/research facilities tend to have less comorbidities, have private insurance, and present with more treatable disease. Despite these favorable prognostic factors, the data suggest an intrinsic benefit to being treated at an academic/research facility.
Background
Previous studies have reported that treatment at academic/research facilities is associated with improved survival in cancer patients. The objective of this study was to investigate the impact of treatment facility type on overall survival for patients presenting with osteosarcoma.
Methods
The National Cancer Database (NCDB) was used to identify patients diagnosed with Osteosarcoma from 2004 to 2018. Facility types were identified as assigned by the Commission on Cancer Accreditation program. Data was analyzed using SPSS and statistical significance was set at P = .05.
Results
Of 2085 patients queried, 39.6% were treated at an academic/research program. The stage-adjusted difference in median survival between academic/research and non-academic programs was found to be statistically significant on log-rank comparison (P < .001). At each NCDB analytic stage (stage I-IV), academic/research programs were associated with decreased hazard and improved median survival. A Cox proportional hazards model showed a decreased likelihood of mortality in patients with osteosarcoma who underwent treatment at an academic/research program (HR, 0.882; 95% CI, .802-.969; P = .009). Chi-square testing revealed that patients at academic/research programs were more likely than those at non-academic/research centers to have private insurance, less likely to have Medicare, and more likely to live in counties of > 1 million people. These facilities were also more likely to have undergone Medicaid expansion in 2014. (P < .05). Patients at non-academic/research programs were more likely to have advanced disease (stage III and IV) and higher comorbidity scores. Additionally, they were less likely to receive surgery and/or chemotherapy at the institution in which they were diagnosed. (P < .05).
Conclusions
This study showed that Osteosarcoma patients treated in an academic/research program facility experienced increased survival compared with non-academic/research facilities. Patients at academic/research facilities tend to have less comorbidities, have private insurance, and present with more treatable disease. Despite these favorable prognostic factors, the data suggest an intrinsic benefit to being treated at an academic/research facility.
Background
Previous studies have reported that treatment at academic/research facilities is associated with improved survival in cancer patients. The objective of this study was to investigate the impact of treatment facility type on overall survival for patients presenting with osteosarcoma.
Methods
The National Cancer Database (NCDB) was used to identify patients diagnosed with Osteosarcoma from 2004 to 2018. Facility types were identified as assigned by the Commission on Cancer Accreditation program. Data was analyzed using SPSS and statistical significance was set at P = .05.
Results
Of 2085 patients queried, 39.6% were treated at an academic/research program. The stage-adjusted difference in median survival between academic/research and non-academic programs was found to be statistically significant on log-rank comparison (P < .001). At each NCDB analytic stage (stage I-IV), academic/research programs were associated with decreased hazard and improved median survival. A Cox proportional hazards model showed a decreased likelihood of mortality in patients with osteosarcoma who underwent treatment at an academic/research program (HR, 0.882; 95% CI, .802-.969; P = .009). Chi-square testing revealed that patients at academic/research programs were more likely than those at non-academic/research centers to have private insurance, less likely to have Medicare, and more likely to live in counties of > 1 million people. These facilities were also more likely to have undergone Medicaid expansion in 2014. (P < .05). Patients at non-academic/research programs were more likely to have advanced disease (stage III and IV) and higher comorbidity scores. Additionally, they were less likely to receive surgery and/or chemotherapy at the institution in which they were diagnosed. (P < .05).
Conclusions
This study showed that Osteosarcoma patients treated in an academic/research program facility experienced increased survival compared with non-academic/research facilities. Patients at academic/research facilities tend to have less comorbidities, have private insurance, and present with more treatable disease. Despite these favorable prognostic factors, the data suggest an intrinsic benefit to being treated at an academic/research facility.
Financial Toxicity in Colorectal Cancer Patient Who Received Localized Treatment in the Veterans Affairs Health System
Purpose
To describe patient-reported financial toxicity for patients who received localized colorectal cancer (CRC) treatment in the Veterans Health Administration (VHA).
Background
CRC is the 2nd leading cause of cancer-related death. In the private sector, many patients suffer economic hardship from CRC and its treatment. This leads to financial toxicity, or the negative impact of medical expenses, which is a strong independent predictor of quality of life. In the VHA patients access cancer care based on a sliding fee scale; however, there is a knowledge gap regarding financial toxicity for CRC patients in the VHA whose out of pocket costs have largely been subsidized.
Methods
We performed a descriptive, retrospective analysis of a survey administered at a VHA facility to patients with colorectal cancer who received localized treatment (ie, surgery or chemoradiotherapy). The survey consisted of 49 items assessing several clinical and psychosocial domains including subjective financial burden and use of financial coping strategies. Additionally, we used the validated Confusion, Hubbub and Order Scale (CHAOS) measure, which was designed to assess the level of confusion and disorganization in homes.
Results
Between November 2015 and September 2016, we mailed surveys to 265 patients diagnosed with CRC, 133 responded, for a response rate of 50%. For financial strain, 24% (n=32) of participants reported reduced spending on basics like food or clothing to pay for their cancer treatment, 17% (n=23) reported using all or a portion of their savings to pay for their cancer care,14% (n=18) noted borrowing money or using a credit card to pay for care, and 9% (n=12) of participants noted they did not fill a prescription because it was too expensive.
Conclusions/Implications
Despite policies to reduce out-of-pocket costs for VHA patients with CRC, patients reported significant financial toxicity. In the continued movement for value-based care centered on whole person care delivery, identifying persistent financial toxicity for vulnerable cancer patients is important data as we try and improve the infrastructure to impact quality of life and healthcare delivery for this population.
Purpose
To describe patient-reported financial toxicity for patients who received localized colorectal cancer (CRC) treatment in the Veterans Health Administration (VHA).
Background
CRC is the 2nd leading cause of cancer-related death. In the private sector, many patients suffer economic hardship from CRC and its treatment. This leads to financial toxicity, or the negative impact of medical expenses, which is a strong independent predictor of quality of life. In the VHA patients access cancer care based on a sliding fee scale; however, there is a knowledge gap regarding financial toxicity for CRC patients in the VHA whose out of pocket costs have largely been subsidized.
Methods
We performed a descriptive, retrospective analysis of a survey administered at a VHA facility to patients with colorectal cancer who received localized treatment (ie, surgery or chemoradiotherapy). The survey consisted of 49 items assessing several clinical and psychosocial domains including subjective financial burden and use of financial coping strategies. Additionally, we used the validated Confusion, Hubbub and Order Scale (CHAOS) measure, which was designed to assess the level of confusion and disorganization in homes.
Results
Between November 2015 and September 2016, we mailed surveys to 265 patients diagnosed with CRC, 133 responded, for a response rate of 50%. For financial strain, 24% (n=32) of participants reported reduced spending on basics like food or clothing to pay for their cancer treatment, 17% (n=23) reported using all or a portion of their savings to pay for their cancer care,14% (n=18) noted borrowing money or using a credit card to pay for care, and 9% (n=12) of participants noted they did not fill a prescription because it was too expensive.
Conclusions/Implications
Despite policies to reduce out-of-pocket costs for VHA patients with CRC, patients reported significant financial toxicity. In the continued movement for value-based care centered on whole person care delivery, identifying persistent financial toxicity for vulnerable cancer patients is important data as we try and improve the infrastructure to impact quality of life and healthcare delivery for this population.
Purpose
To describe patient-reported financial toxicity for patients who received localized colorectal cancer (CRC) treatment in the Veterans Health Administration (VHA).
Background
CRC is the 2nd leading cause of cancer-related death. In the private sector, many patients suffer economic hardship from CRC and its treatment. This leads to financial toxicity, or the negative impact of medical expenses, which is a strong independent predictor of quality of life. In the VHA patients access cancer care based on a sliding fee scale; however, there is a knowledge gap regarding financial toxicity for CRC patients in the VHA whose out of pocket costs have largely been subsidized.
Methods
We performed a descriptive, retrospective analysis of a survey administered at a VHA facility to patients with colorectal cancer who received localized treatment (ie, surgery or chemoradiotherapy). The survey consisted of 49 items assessing several clinical and psychosocial domains including subjective financial burden and use of financial coping strategies. Additionally, we used the validated Confusion, Hubbub and Order Scale (CHAOS) measure, which was designed to assess the level of confusion and disorganization in homes.
Results
Between November 2015 and September 2016, we mailed surveys to 265 patients diagnosed with CRC, 133 responded, for a response rate of 50%. For financial strain, 24% (n=32) of participants reported reduced spending on basics like food or clothing to pay for their cancer treatment, 17% (n=23) reported using all or a portion of their savings to pay for their cancer care,14% (n=18) noted borrowing money or using a credit card to pay for care, and 9% (n=12) of participants noted they did not fill a prescription because it was too expensive.
Conclusions/Implications
Despite policies to reduce out-of-pocket costs for VHA patients with CRC, patients reported significant financial toxicity. In the continued movement for value-based care centered on whole person care delivery, identifying persistent financial toxicity for vulnerable cancer patients is important data as we try and improve the infrastructure to impact quality of life and healthcare delivery for this population.
Impact of Insurance Status on Survival in Hurthle Cell Carcinoma: A National Cancer Database (NCDB) Analysis
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Shortened radiotherapy for endometrial cancer looks safe, questions remain
Postoperative radiotherapy is a mainstay in the treatment of endometrial cancer, but the typical 5-week regimen can be time consuming and expensive. A pilot study found that delivery of approximately the same dose over just two and a half weeks, known as hypofractionation, had good short-term toxicity outcomes.
Nevertheless, shortening the duration of radiotherapy could have benefits, especially in advanced uterine cancer, where chemotherapy is employed against distant metastases. Following surgery, there is a risk of both local recurrence and distant metastasis, complicating the choice of initial treatment. “Chemo can be several months long and radiation is typically several weeks. Therefore a shortened radiation schedule may have potential benefits, especially if there is an opportunity for this to be delivered earlier without delaying or interrupting chemotherapy, for example,” said lead study author Eric Leung, MD, associate professor of radiation oncology at the University of Toronto’s Sunnybrook Health Sciences Centre.
The research was published in JAMA Oncology.
Delivery of hypofractionation is tricky, according to Dr. Leung. “Gynecological cancer patients were treated with hypofractionation radiation to the pelvis which included the vagina, paravaginal tissues and pelvic lymph nodes. With this relatively large pelvic volume with surrounding normal tissues, this requires a highly focused radiation treatment with advanced technology,” said Dr. Leung. The study protocol employed stereotactic technique to deliver 30 Gy in 5 fractions.
Hypofractionation could be beneficial in reduction of travel time and time spent in hospital, as well as reducing financial burden and increasing quality of life. These benefits have taken on a larger role in the context of the COVID-19 pandemic.
Although the findings are encouraging, they are preliminary, according to Vonetta Williams, MD, PhD, who wrote an accompanying editorial. “I would caution that all they’ve done is presented preliminary toxicity data, so we don’t have any proof yet that it is equally effective (compared to standard protocol), and their study cannot answer that at any rate because it was not designed to answer that question,” Dr. Williams said in an interview. She noted that long-term follow-up is needed to measure bowel dysfunction, sexual dysfunction, vaginal stenosis, and other side effects.
It is also uncertain whether hypofractionated doses are actually equivalent to the standard dose. “We know that they’re roughly equivalent, but that is very much a question if they are equivalent in terms of efficacy. I don’t know that I would be confident that they are. That’s probably what would give most radiation oncologists pause, because we don’t have any data to say that it is (equivalent). Although it would be nice to shorten treatment, and I think it would certainly be better for patients, I want to caution that we want to do so once we know what the toxicity and the outcomes really are,” said Dr. Williams.
The researchers enrolled 61 patients with a median age of 66 years. Thirty-nine had endometrioid adenocarcinoma, 15 had serous or clear cell, 3 had carcinosarcoma, and 4 had dedifferentiated disease. Sixteen patients underwent sequential chemotherapy, and 9 underwent additional vault brachytherapy. Over a median follow-up of 9 months, 54% had a worst gastrointestinal side effect of grade 1, while 13% had a worst side effect of grade 2. Among worst genitourinary side effects, 41% had grade 1 and 3% had grade 2. One patient had acute grade 3 diarrhea at fraction 5, but this resolved at follow-up. One patient had diarrhea scores that were both clinically and statistically significantly worse than baseline at fraction 5, and this improved at follow-up.
Patient-reported quality of life outcomes were generally good. Of all measures, only diarrhea was clinically and statistically worse by fraction 5, and improvement was seen at 6 weeks and 3 months. Global health status was consistent throughout treatment and follow-up. There was no change in sexual and vaginal symptoms.
The study authors reported grants, consulting, and personal fees from a variety of pharmaceutical companies. Dr. Williams reported having no disclosures.
Postoperative radiotherapy is a mainstay in the treatment of endometrial cancer, but the typical 5-week regimen can be time consuming and expensive. A pilot study found that delivery of approximately the same dose over just two and a half weeks, known as hypofractionation, had good short-term toxicity outcomes.
Nevertheless, shortening the duration of radiotherapy could have benefits, especially in advanced uterine cancer, where chemotherapy is employed against distant metastases. Following surgery, there is a risk of both local recurrence and distant metastasis, complicating the choice of initial treatment. “Chemo can be several months long and radiation is typically several weeks. Therefore a shortened radiation schedule may have potential benefits, especially if there is an opportunity for this to be delivered earlier without delaying or interrupting chemotherapy, for example,” said lead study author Eric Leung, MD, associate professor of radiation oncology at the University of Toronto’s Sunnybrook Health Sciences Centre.
The research was published in JAMA Oncology.
Delivery of hypofractionation is tricky, according to Dr. Leung. “Gynecological cancer patients were treated with hypofractionation radiation to the pelvis which included the vagina, paravaginal tissues and pelvic lymph nodes. With this relatively large pelvic volume with surrounding normal tissues, this requires a highly focused radiation treatment with advanced technology,” said Dr. Leung. The study protocol employed stereotactic technique to deliver 30 Gy in 5 fractions.
Hypofractionation could be beneficial in reduction of travel time and time spent in hospital, as well as reducing financial burden and increasing quality of life. These benefits have taken on a larger role in the context of the COVID-19 pandemic.
Although the findings are encouraging, they are preliminary, according to Vonetta Williams, MD, PhD, who wrote an accompanying editorial. “I would caution that all they’ve done is presented preliminary toxicity data, so we don’t have any proof yet that it is equally effective (compared to standard protocol), and their study cannot answer that at any rate because it was not designed to answer that question,” Dr. Williams said in an interview. She noted that long-term follow-up is needed to measure bowel dysfunction, sexual dysfunction, vaginal stenosis, and other side effects.
It is also uncertain whether hypofractionated doses are actually equivalent to the standard dose. “We know that they’re roughly equivalent, but that is very much a question if they are equivalent in terms of efficacy. I don’t know that I would be confident that they are. That’s probably what would give most radiation oncologists pause, because we don’t have any data to say that it is (equivalent). Although it would be nice to shorten treatment, and I think it would certainly be better for patients, I want to caution that we want to do so once we know what the toxicity and the outcomes really are,” said Dr. Williams.
The researchers enrolled 61 patients with a median age of 66 years. Thirty-nine had endometrioid adenocarcinoma, 15 had serous or clear cell, 3 had carcinosarcoma, and 4 had dedifferentiated disease. Sixteen patients underwent sequential chemotherapy, and 9 underwent additional vault brachytherapy. Over a median follow-up of 9 months, 54% had a worst gastrointestinal side effect of grade 1, while 13% had a worst side effect of grade 2. Among worst genitourinary side effects, 41% had grade 1 and 3% had grade 2. One patient had acute grade 3 diarrhea at fraction 5, but this resolved at follow-up. One patient had diarrhea scores that were both clinically and statistically significantly worse than baseline at fraction 5, and this improved at follow-up.
Patient-reported quality of life outcomes were generally good. Of all measures, only diarrhea was clinically and statistically worse by fraction 5, and improvement was seen at 6 weeks and 3 months. Global health status was consistent throughout treatment and follow-up. There was no change in sexual and vaginal symptoms.
The study authors reported grants, consulting, and personal fees from a variety of pharmaceutical companies. Dr. Williams reported having no disclosures.
Postoperative radiotherapy is a mainstay in the treatment of endometrial cancer, but the typical 5-week regimen can be time consuming and expensive. A pilot study found that delivery of approximately the same dose over just two and a half weeks, known as hypofractionation, had good short-term toxicity outcomes.
Nevertheless, shortening the duration of radiotherapy could have benefits, especially in advanced uterine cancer, where chemotherapy is employed against distant metastases. Following surgery, there is a risk of both local recurrence and distant metastasis, complicating the choice of initial treatment. “Chemo can be several months long and radiation is typically several weeks. Therefore a shortened radiation schedule may have potential benefits, especially if there is an opportunity for this to be delivered earlier without delaying or interrupting chemotherapy, for example,” said lead study author Eric Leung, MD, associate professor of radiation oncology at the University of Toronto’s Sunnybrook Health Sciences Centre.
The research was published in JAMA Oncology.
Delivery of hypofractionation is tricky, according to Dr. Leung. “Gynecological cancer patients were treated with hypofractionation radiation to the pelvis which included the vagina, paravaginal tissues and pelvic lymph nodes. With this relatively large pelvic volume with surrounding normal tissues, this requires a highly focused radiation treatment with advanced technology,” said Dr. Leung. The study protocol employed stereotactic technique to deliver 30 Gy in 5 fractions.
Hypofractionation could be beneficial in reduction of travel time and time spent in hospital, as well as reducing financial burden and increasing quality of life. These benefits have taken on a larger role in the context of the COVID-19 pandemic.
Although the findings are encouraging, they are preliminary, according to Vonetta Williams, MD, PhD, who wrote an accompanying editorial. “I would caution that all they’ve done is presented preliminary toxicity data, so we don’t have any proof yet that it is equally effective (compared to standard protocol), and their study cannot answer that at any rate because it was not designed to answer that question,” Dr. Williams said in an interview. She noted that long-term follow-up is needed to measure bowel dysfunction, sexual dysfunction, vaginal stenosis, and other side effects.
It is also uncertain whether hypofractionated doses are actually equivalent to the standard dose. “We know that they’re roughly equivalent, but that is very much a question if they are equivalent in terms of efficacy. I don’t know that I would be confident that they are. That’s probably what would give most radiation oncologists pause, because we don’t have any data to say that it is (equivalent). Although it would be nice to shorten treatment, and I think it would certainly be better for patients, I want to caution that we want to do so once we know what the toxicity and the outcomes really are,” said Dr. Williams.
The researchers enrolled 61 patients with a median age of 66 years. Thirty-nine had endometrioid adenocarcinoma, 15 had serous or clear cell, 3 had carcinosarcoma, and 4 had dedifferentiated disease. Sixteen patients underwent sequential chemotherapy, and 9 underwent additional vault brachytherapy. Over a median follow-up of 9 months, 54% had a worst gastrointestinal side effect of grade 1, while 13% had a worst side effect of grade 2. Among worst genitourinary side effects, 41% had grade 1 and 3% had grade 2. One patient had acute grade 3 diarrhea at fraction 5, but this resolved at follow-up. One patient had diarrhea scores that were both clinically and statistically significantly worse than baseline at fraction 5, and this improved at follow-up.
Patient-reported quality of life outcomes were generally good. Of all measures, only diarrhea was clinically and statistically worse by fraction 5, and improvement was seen at 6 weeks and 3 months. Global health status was consistent throughout treatment and follow-up. There was no change in sexual and vaginal symptoms.
The study authors reported grants, consulting, and personal fees from a variety of pharmaceutical companies. Dr. Williams reported having no disclosures.
FROM JAMA ONCOLOGY