Impact of care at comprehensive cancer centers on outcome: Results from a population-based study

Periprosthetic Joint Infection Centers of Excellence: Moonshot or Misstep? A Survey of the American Association of Hip and Knee Surgeons Members

BACKGROUND

Periprosthetic joint infection (PJI) centers of excellence (COE) have been discussed as an innovative model to improve healthcare quality and value in treating PJI. A national network of regional PJI centers may have the ability to improve patient outcomes, standardize treatment protocols, accelerate research, and provide economies of scale while caring for this patient population with complex needs. This study surveyed perceptions towards establishing a PJI COE among members of the American Association of Hip and Knee Surgeons (AAHKS).

METHODS

A 16-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,529 fellow-level members of AAHKS. Study results were analyzed using descriptive statistics.

RESULTS

There were 626 survey responses (24.8% response rate). More than two-thirds of survey participants (69%) reported that they would consider participation in some form of PJI COE. Most surgeons believe managing PJI is a cost to their hospital system. The top concern among respondents was that PJI COE may become a 'dumping ground' for inappropriate referrals. Participants reported financial concerns regarding the possibility that establishing such a program may trigger a re-evaluation of reimbursement for primary total joint arthroplasty (TJA) procedures.

CONCLUSION

While primary TJA is a target of national healthcare cost containment efforts, PJI has yet to be addressed. This gives AAHKS the opportunity to prospectively advocate for reform. A PJI COE designed to perform a high volume of infection revision procedures may be advantageous in providing the specialized and longitudinal care required by PJI patients. The AAHKS surgeons expressed interest and reservations in the establishment of PJI COEs that can inform future policy.

Legislation on Medical Fertility Preservation: Improved but Insufficient Access to Care in Disadvantaged Neighborhoods

Objective: To assess whether state-level legislation mandating insurance coverage for medical fertility preservation (MFP) was associated with a change in the neighborhood disadvantage of individuals accessing fertility preservation care. Methods: This is a retrospective cohort study of individuals with ovaries seen for MFP consultation from 2017 to 2020 at a large academic medical center. Neighborhood disadvantage, as measured by median area deprivation index (ADI) in those who had MFP consultation and initiated ovarian stimulation for MFP was assessed; insurance type and other demographics were also assessed. Patients who underwent ovarian stimulation in 2017-2018 (pre-legislation) were compared to those who underwent stimulation between 2019 and 2021 (post-legislation). Results: Overall, 427 individuals with ovaries were seen for MFP consultation from 2017 to 2020; 203 of which were seen prior to legislation mandating insurance coverage (2017-2018), and 224 were seen following expansion of legislation (2019-2020). Overall, 278 individuals initiated ovarian stimulation cycles for MFP, 122 pre-legislation and 156 post-legislation. More patients with Medicaid insurance coverage were seen for MFP consultation and initiated stimulation post-legislation than pre-legislation (28 versus 12 for consultation, p = 0.020; 17 versus 3 for stimulation, p = 0.007). The predicted median ADI of patients initiating stimulation was 8 points higher post-legislation, representing increased neighborhood disadvantage, though this difference did not reach statistical significance (p = 0.053). After adjusting for other sociodemographic factors, the predicted median ADI of patients initiating stimulation was 3.5 points higher post-legislation (p = 0.25). Conclusions: While the implementation of an insurance mandate for MFP increased the median ADI of those initiating stimulation, this difference was not statistically significant. Legislation alone may not be enough to expand access to care to those living in the most disadvantaged areas.

Effects of Socioeconomic Deprivation on UTUC Staging, Mortality, and Recurrence

OBJECTIVE

To determine whether the area deprivation index (ADI), a surrogate for socioeconomic status (SES) associated with patient residence, affected UTUC staging, recurrence rates, and mortality.

METHODS

Patients undergoing radical nephroureterectomy or ureterectomy for UTUC at a single institution between February 2010 and August 2021 were classified by ADI. A 50th percentile cut-off of ADI classified patients as "advantaged" or "disadvantaged. Tumor characteristics, staging, and use of neoadjuvant chemotherapy were compared between groups. Recurrence-free (RFS) and overall survival (OS) were compared among groups using Mantel-Cox log-rank testing.

RESULTS

In this cohort, 215 patients had advantaged SES, and 217 had disadvantaged SES. Neoadjuvant chemotherapy was utilized more frequently among advantaged versus disadvantaged patients (20% vs 13%, P=.035), though this difference was not significant when comparing the most advantaged and least advantaged quartiles (18% vs 14%, P=.45). No significant difference was observed in positive resection margins between groups (11% vs 13%, P=.53). Tumor characteristics, including median tumor size (P=.15), pathologic tumor stage (P=.81), and pathologic lymph node stage (P=.28), were also similar. There were no differences in median RFS or OS between SES groups.

CONCLUSION

This regional data, considering previous studies suggesting worse outcomes with increased urothelial carcinoma incidence and mortality in those with a lower socioeconomic status, may reflect efforts to improve healthcare access and adhere to evidence-based management patterns.

The Landmark Series: Surgical Oncology Care in Native Americans-The Indian Health Service

American Indian and Alaska Natives (AI/ANs) are a heterogeneous group of people living throughout the USA with some of the highest cancer incidence and highest cancer-related mortality in the country. This landmark series seeks to highlight cancer care in this population by providing a historical context of the largest healthcare delivery system serving AI/ANs, the Indian Health Service (IHS). We will highlight how the dynamic nature of this population creates unique challenges and the need for dedicated resources to help eliminate cancer care disparities.

Temporal trends in time toxicity of R-CHOP: a nationwide hospital-based database analysis in Japan

PURPOSE

While the prognosis of patients with cancer has improved, the time burden of treatment has recently been recognized as time toxicity; although, the actual clinical situation remains largely unexplored. This retrospective study aimed to elucidate the time toxicity of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in patients with B-cell lymphoma and the factors influencing it.

METHODS

We used a nationwide hospital-based database between January 2010 and November 2021 in Japan. We extracted the claims data of patients with diffuse large B-cell lymphoma and follicular lymphoma who were hospitalized and/or visited hospitals for chemotherapy.

RESULTS

Among the 7760 R-CHOP administered to 2006 patients, the rate of outpatient therapy increased over time (2010-2015: 17.9%; 2016-2021: 31.8%). In 2016, the median length of hospitalization was the shortest at 13 days (IQR 8-19), which coincided with the peak use of pegylated granulocyte colony-stimulating factor (Peg-G-CSF) during hospitalization in 2015-2016, likely driven by changes in the insurance system. In multivariate analysis, the factors associated with longer hospital stays were older age and poor activities of daily living, whereas the use of Peg-G-CSF, a reduced-dose regimen, and treatment at cancer-designated hospitals were associated with shorter stays.

CONCLUSION

The time toxicity of R-CHOP has improved and may be influenced by the patient's condition, adequate supportive care, changes in the insurance system, and center-specific treatment proficiency.

New strategies for enhancing enrollment of underrepresented minorities in lymphoma clinical trials

ABSTRACT

New lymphoma treatments, including chimeric antigen receptor T cells, bispecific antibodies, and immune checkpoint inhibitors, have significantly improved patient outcomes. Despite these therapeutic advances, only 2% to 3% of adult patients with cancer participate in clinical trials. This participation is even lower among certain groups, including ethnic and racial minorities, individuals with low socioeconomic status, rural residents, older adults, and young adults. Underrepresentation of these groups in clinical trials limits the generalizability of trial results and is detrimental to those populations that do not receive equal access to novel therapies. Although racial and ethnic minorities constitute >40% of the US population, they make up only ∼15% of clinical trial participants. The US Food and Drug Administration now requires sponsors seeking regulatory approval for therapies via registrational clinical trials to submit a plan to ensure diversity among trial participants. This article addresses strategies for enhancing enrollment of underrepresented minorities in lymphoma clinical trials.

The Requirements for Setting Up a Dedicated Structure for Adolescents and Young Adults with Cancer-A Systematic Review

Adolescents and young adults (AYAs), often defined as those aged 15-39 years, face unique challenges in oncology that are often unmet by conventional care models. This systematic review examines evidence on establishing dedicated AYA oncology units, focusing on logistical, infrastructural, and personnel-related recommendations. A PRISMA-guided search of PubMed (2000-2024) identified seven studies that emphasized early stakeholder involvement and collaboration between pediatric and adult oncology teams to ensure comprehensive care. Multidisciplinary teams (MDTs) of oncologists, nurses, and psychosocial support staff were highlighted as essential to address AYA patients' diverse needs. Care models varied, with some advocating consultation-based services and others supporting dedicated units. Priorities included increasing clinical trial enrollment, fertility counseling, and creating environments attuned to AYA patients' social and psychological needs. Key barriers included limited funding, institutional resistance, and inadequate pediatric/adult team collaboration. Despite progress, the lack of standardized guidelines and long-term data on AYA unit efficacy remains a challenge. Further research is required to develop outcome metrics, refine care models, and enhance survival and quality of life for AYA cancer patients.

A systematic review and meta-analysis of patient-relevant outcomes in comprehensive cancer centers versus noncomprehensive cancer centers

This systematic review describes difference in patient-relevant outcomes between comprehensive cancers (CCCs) versus non-CCCs. Studies were identified in PubMed, Cochrane CENTRAL, Epistemonikos, and gray literature from January 2002 to May 2024. Data were extracted and appraised by two authors. Results were narratively synthesized, and meta-analyzed where appropriate. Of 2272 records screened, 36 observational studies were included, predominantly from the United States, and focused on adults with solid cancers. Compared to non-CCCs, studies consistently or predominantly reported superior outcomes at CCCs relating to mortality and survival, quality of peri- and postoperative care, rates of cancer recurrence or progression, and impact on symptoms and health-related quality of life. Meta-analysis showed a significantly lower overall mortality risk of 23% in CCCs compared to non-CCCs (hazard ratio, 0.77; 95% confidence interval, 0.74-0.81, p < .001), with medium heterogeneity (I2 = 64.61%; Q-test = 36.29, p < .01) observed between the studies. Studies reporting on health equity and costs outcomes consistently or predominantly favored non-CCCs over CCCs. Mixed results were reported for outcomes relating to time to care, palliative and end-of-life care, and health care utilization. The literature reports CCCs are associated with superior outcomes in many areas, especially around mortality and survival. Greater focus is needed to explore outcomes that are important to people with cancer including health-related quality of life, symptoms, and treatment experience, and economic evaluation. Rather than aiming for superior outcomes, CCCs should be striving to enable equitable, high value, patient-centered outcomes for all people affected by cancer.

National Cancer Institute comprehensive cancer centers: Significant improvement in mortality and symptom control, further opportunities remain toward health equity

The article by Thamm et al. reports that studies predominantly reported superior outcomes at comprehensive cancer centers (CCCs) compared to non CCCs in metrics related to patient mortality and survival, with non‐CCCs potentially being both more accessible and lower cost. In this editorial, the authors discuss bidirectional collaborative learning opportunities between both type of cancer center that may benefit cancer patients at both types of centers.

Contemporary trends in utilization of metastasectomy in the era of targeted and immunotherapies

BACKGROUND

Metastasectomy is a useful adjunct in the management of metastatic cancer. Widespread adoption of novel targeted and immunotherapies has improved the survival profiles of multiple malignancies, which has potentially altered the role of metastasectomy. This study aimed to characterize trends in metastasectomy across five primary cancers eligible for these therapies.

METHODS

The National Inpatient Sample was used to identify patients who underwent metastasectomy in the United States (2016-2021). Patients with procedure codes for resection of the lung, liver, adrenal gland, brain, or small bowel and concurrent diagnosis codes for secondary malignant neoplasm of that site were included. Subjects were subcategorized by primary malignancy: colorectal cancer, lung cancer, breast cancer, melanoma, or renal cancer. Sample weights were used to produce national estimates, which were incidence adjusted by primary malignancy. Trends in utilization were calculated with average annual percent change (AAPC) and linear regression coefficients.

RESULTS

Colorectal cancer was the most frequent indication for metastasectomy (n = 57,644 cases), followed by lung cancer (n = 55,090 cases), breast cancer (n = 12,616 cases), renal cancer (n = 8427 cases), and melanoma (n = 5658 cases). Utilization of metastasectomy increased over the study period for breast cancer (AAPC, +10.6%; p = .013) and melanoma (AAPC, +8.3%; p = .040) but did not change for lung cancer (AAPC, -1.6%; p = .26), colorectal cancer (AAPC, +0.3%; p = .83), or renal cancer (AAPC, +2.3%; p = .36).

CONCLUSIONS

Between 2016 and 2021, utilization of metastasectomy increased significantly for melanoma and breast cancer. The role of metastasectomy will likely continue to develop as new treatment protocols improve survival profiles for patients with metastatic disease.

Is early-onset colorectal cancer an evolving pandemic? Real-world data from a tertiary cancer center

BACKGROUND

Early onset Colorectal Cancer (EOCRC), defined as those diagnosed under the age of 50, has been increasing rapidly since 1970. UK data on EOCRC are currently limited and better understanding of the condition is needed.

MATERIALS AND METHODS

A single-center retrospective study of patients with EOCRC treated over 9 years (2013-2021) at a large UK cancer center was performed. Clinicopathological features, risk factors, molecular drivers, treatment, and survival were analyzed.

RESULTS

In total, 203 patients were included. A significant increase in cases was reported from 2018-2019 (n = 33) to 2020-2021 (n = 118). Sporadic EOCRC accounted for 70% of cases and left-sided tumors represented 70.9% (n = 144). Median duration of symptoms was 3 months, while 52.7% of the patients had de-novo metastatic disease. Progression-free survival after first-line chemotherapy was 6 months (95% CI, 4.85-7.15) and median overall survival (OS) was 38 months (95% CI, 32.86-43.14). In the advanced setting, left-sided primary tumors were associated with a median OS benefit of 14 months over right-sided primaries (28 vs 14 months, P = .009). Finally, primary tumor resection was associated with median OS benefit of 21 months compared with in situ tumors (38 vs 17 months, P < .001).

CONCLUSIONS

The incidence of EOCRC is increasing, and survival outcomes remain modest. Raising public awareness and lowering the age for colorectal cancer screening are directions that could improve EOCRC clinical outcomes. There is also a need for large prospective studies to improve the understanding of the nature of EOCRC and the best therapeutic approaches.

Impact of Structural Racism and Social Determinants of Health on Disparities in Breast Cancer Mortality

The striking ethnic and racial disparities in breast cancer mortality are not explained fully by pathologic or clinical features. Structural racism contributes to adverse conditions that promote cancer inequities, but the pathways by which this occurs are not fully understood. Social determinants of health, such as economic status and access to care, account for a portion of this variability, yet interventions designed to mitigate these barriers have not consistently led to improved outcomes. Based on the current evidence from multiple disciplines, we describe a conceptual model in which structural racism and racial discrimination contribute to increased mortality risk in diverse groups of patients by promoting adverse social determinants of health that elevate exposure to environmental hazards and stress; these exposures in turn contribute to epigenetic and immune dysregulation, thereby altering breast cancer outcomes. Based on this model, opportunities and challenges arise for interventions to reduce racial and ethnic disparities in breast cancer mortality.

Impact of the Affordable Care Act on access to accredited facilities for cancer treatment

OBJECTIVE

To examine differential changes in receipt of surgery at National Cancer Institute (NCI)-designated comprehensive cancer centers (NCI-CCC) and Commission on Cancer (CoC) accredited hospitals for patients with cancer more likely to be newly eligible for coverage under Affordable Care Act (ACA) insurance expansions, relative to those less likely to have been impacted by the ACA.

DATA SOURCES AND STUDY SETTING

Pennsylvania Cancer Registry (PCR) for 2010-2019 linked with discharge records from the Pennsylvania Health Care Cost Containment Council (PHC4).

STUDY DESIGN

Outcomes include whether cancer surgery was performed at an NCI-CCC or a CoC-accredited hospital. We conducted a difference-in-differences analysis, estimating linear probability models for each outcome that control for residence in a county with above median county-level pre-ACA uninsurance and the interaction between county-level baseline uninsurance and cancer treatment post-ACA to capture differential changes in access between those more and less likely to become newly eligible for insurance coverage (based on area-level proxy). All models control for age, sex, race and ethnicity, cancer site and stage, census-tract level urban/rural residence, Area Deprivation Index, and year- and county-fixed effects.

DATA COLLECTION/EXTRACTION METHODS

We identified adults aged 26-64 in PCR with prostate, lung, or colorectal cancer who received cancer-directed surgery and had a corresponding surgery discharge record in PHC4.

PRINCIPAL FINDINGS

We observe a differential increase in receiving care at an NCI-CCC of 6.2 percentage points (95% CI: 2.6-9.8; baseline mean = 9.8%) among patients in high baseline uninsurance areas (p = 0.001). Our estimate of the differential change in care at the larger set of CoC hospitals is positive (3.9 percentage points [95% CI: -0.5-8.2; baseline mean = 73.7%]) but not statistically significant (p = 0.079).

CONCLUSIONS

Our findings suggest that insurance expansions under the ACA were associated with increased access to NCI-CCCs.

Stereotactic Body Radiation Adoption Impacts Prostate Cancer Treatment Patterns

OBJECTIVE

To investigate stereotactic body radiation (SBRT) adoption for prostate cancer. As evidence supporting SBRT mounts, its utilization and impact relative to other prostate cancer treatments is unknown.

METHODS

We used SEER-Medicare to identify patients diagnosed with localized prostate cancer from 2008 to 2017. We then identified physician networks by identifying the primary treating physician of each patient based on primary treatment, then linking each physician to a practice. We examined trends in prostate cancer treatment between networks performing SBRT or not using chi-squared tests and logistic regression models.

RESULTS

There were 35,972 patients who received treatment for prostate cancer at 234 physician networks. Of these patients, 30,635 were treated in a non-SBRT network (n = 190), while 5337 received treatment in a SBRT network (n = 44). Patients who received care in an SBRT network were more likely to live in metropolitan areas ≥1 million (70% vs 46%, P <.001), have a higher median income >$60,000 (62% vs 42%, P <.001), and live in the northeast (35% vs 12%) or west (40% vs 38%, P <.001) compared to non-SBRT networks. In SBRT networks, more patients received IMRT (31% vs 23%), and fewer patients received prostatectomy (16% vs 23%) or active surveillance (15% vs 19%) compared to non-SBRT networks. Black men were 45% less likely to receive SBRT (OR=0.55, CI: 0.36-0.85) compared to White men.

CONCLUSION

SBRT utilization is increasing relative to other prostate cancer treatments. Prostate cancer treatment mix is different in networks that offer SBRT, and SBRT is less available to some patient groups, raising concern for novel treatment inequity.

Understanding the Landscape of Cancer Care in Europe: Evaluating Clinical and Comprehensive Cancer Centers

BACKGROUND

A comparison of the operations of Clinical Cancer Centers and Comprehensive Cancer Centers across Europe provides novel data on the interrelation between different factors in care delivery.

METHOD

The analysis is based on a survey of key dimensions in care delivery, comparing routine treatment, advanced technology integration, research participation, and innovation adoption across the two types of centers.

RESULTS

Clinical Cancer Centers excel in providing routine cancer treatment through multidisciplinary teams but struggle with advanced technology integration and research participation. In contrast, Comprehensive Cancer Centers offer robust infrastructure and focus on research, advanced diagnostics, and innovative therapies, yet they face challenges in fully integrating these technologies into patient care.

CONCLUSION

Collaboration between the two types of centers could enhance overall cancer care effectiveness, leveraging the routine efficiency of Clinical Centers and the innovative capabilities of Comprehensive Centers. By addressing gaps in technology adoption, supportive care integration, and research involvement, a more holistic cancer care network can be established, ensuring that patients across Europe access both foundational care and the latest therapeutic options.

Structural Racism and Treatment Delay Among Black and White Patients With Breast Cancer

PURPOSE

Structural racism (SR) is a potential driver of health disparities, but research quantifying its impacts on cancer outcomes has been limited. We aimed to develop a multidimensional county-level SR measure and to examine the association of SR with breast cancer (BC) treatment delays among Black and White patients.

METHODS

The cohort included 32,095 individuals from the North Carolina Central Cancer Registry with stage I to III BC diagnosed between 2004 and 2017 and linked to multipayer insurance claims from the Cancer Information and Population Health Resource. County-level data were drawn from multiple public sources aggregated in the Robert Wood Johnson County Health Rankings database. Racial gaps in eight social determinants across five domains were quantified at the county level and ranked on a 0-100 minimum-maximum scale. Domain scores were averaged to create a SR Composite Index (SRCI) score. We used multilevel logistic regression with random intercepts and multiple cross-level interaction terms to evaluate the association between county-level SRCI and patient-level treatment delays, adjusting for patient-level characteristics and stratified by race.

RESULTS

The SRCI score ranged from 21 to 75 with a median (IQR) of 39.0 (31.8, 45.7). For Black patients, a 10-unit increase in SRCI score was associated with increased odds of delay (Adjusted odds ratios [aOR], 1.25; 95% confidence limits [CL], 1.08 to 1.45). No such association was found for White patients (OR, 1.05; 95% CL, 0.97 to 1.15).

CONCLUSION

Area-level SR measured by a composite index is associated with higher odds of BC treatment delays among Black, but not White patients. Increasing county-level SR is associated with increasing Black-White disparities in treatment delay. Further research is needed to refine the measurement of SR and to examine its association with other cancer care disparities.

Characteristics of Lung Cancer Patients With Asymptomatic or Undiagnosed SARS-CoV-2 Infections

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be spread by individuals unaware they are infected. Such dissemination has heightened ramifications in cancer patients, who may need to visit healthcare facilities frequently, be exposed to immune-compromising therapies, and face greater morbidity from coronavirus disease 2019 (COVID-19). We determined characteristics of (1) asymptomatic, clinically diagnosed, and (2) serologically documented but clinically undiagnosed SARS-CoV-2 infection among individuals with lung cancer.

PATIENTS AND METHODS

In a multicenter registry, individuals with lung cancer (regardless of prior SARS-CoV-2 vaccination or documented infection) underwent collection of clinical data and serial blood samples, which were tested for antinucleocapsid protein antibody (anti-N Ab) or IgG (N) levels. We used multivariable logistic regression models to investigate clinical characteristics associated with the presence or absence of symptoms and the presence or absence of a clinical diagnosis among patients with their first SARS-CoV-2 infection.

RESULTS

Among patients with serologic evidence or clinically documented SARS-CoV-2 infection, 80/142 (56%) had no reported symptoms at their first infection, and 61/149 (40%) were never diagnosed. Asymptomatic infection was more common among older individuals and earlier-stage lung cancer. In multivariable analysis, non-white individuals with SARS-CoV-2 serologic positivity were 70% less likely ever to be clinically diagnosed (P = .002).

CONCLUSIONS

In a multicenter lung cancer population, a substantial proportion of SARS-CoV-2 infections had no associated symptoms or were never clinically diagnosed. Because such cases appear to occur more frequently in populations that may face greater COVID-19-associated morbidity, measures to limit disease spread and severity remain critical.

Representativeness of Patients With Lung Cancer in an Integrated Health Care Delivery System

INTRODUCTION

Observational research is important for understanding the real-world benefits of advancements in lung cancer care. Integrated health care systems, such as Kaiser Permanente Northern California, have extensive electronic health records suitable for such research, but the generalizability of their populations is often questioned.

METHODS

Leveraging data from the California Cancer Registry, the authors compared distributions of demographic and clinical characteristics, in addition to neighborhood and environmental conditions, between patients diagnosed with lung cancer from 2015 through 2019 at Kaiser Permanente Northern California, National Cancer Institute-designated cancer centers (NCICCs), and all other non-NCICC hospitals within the same catchment area.

RESULTS

Of 20,178 included patients, 30% were from Kaiser Permanente Northern California, 8% from NCICCs, and 62% from other non-NCICC hospitals. Compared to NCICC patients, Kaiser Permanente Northern California patients were more similar to other non-NCICC patients on most characteristics. Compared to other non-NCICC patients, Kaiser Permanente Northern California patients were slightly older, more likely to be female, and less likely to be Hispanic or Asian/Pacific Islander and to reside in lower socioeconomic status (SES) neighborhoods. In contrast, NCICC patients were younger, less likely to be female or from non-Asian/Pacific Islander minoritized racial groups, and more likely to present with early-stage disease and adenocarcinoma and to reside in neighborhoods with higher SES and lower air pollution than Kaiser Permanente Northern California or other non-NCICC patients.

DISCUSSION

Patients from Kaiser Permanente Northern California, compared to NCICCs, are more broadly representative of the underlying patient population with lung cancer.

CONCLUSION

Research using electronic health record data from integrated health care systems can contribute generalizable real-world evidence to benchmark and improve lung cancer care.

Clinician-to-clinician connectedness and access to gastric cancer surgery at National Cancer Institute-designated cancer centers

BACKGROUND

For patients with gastric cancer, the pathway from primary care (PC) clinician to gastroenterologist to cancer specialist (medical oncologist or surgeons) is referral dependent. The impact of clinician connectedness on disparities in quality gastric cancer care, such as at National Cancer Institute-designated cancer centers (NCI-CC), remains underexplored. This study evaluated how clinician connectedness influences access to gastrectomy at NCI-CC.

METHODS

Maryland's All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013 to 2018. Two separate referral linkages, defined as ≥9 shared patients, were examined: (1) PC clinicians to gastroenterologists at NCI-CC and (2) gastroenterologists to cancer specialists at NCI-CC. Multiple logistic regression models determined associations between referral linkages and odds of undergoing gastrectomy at NCI-CC.

RESULTS

Only 15% of gastrectomies were performed at NCI-CC. Patients of gastroenterologists with referral links to cancer specialists at NCI-CC were more likely to be <65 years, male, White, and privately insured. Every additional referral link between PC clinician and gastroenterologist at NCI-CC and between gastroenterologist and cancer specialist at NCI-CC increased the odds of gastrectomy at NCI-CC by 71% and 26%, respectively. Black patients had half the odds as White patients in receiving gastrectomy at NCI-CC; however, adjusting for covariates including clinician-to-clinician connectedness attenuated this observation.

CONCLUSION

Patients of clinicians with low connectedness and Black patients are less likely to receive gastrectomy at NCI-CC. Enhancing clinician connectedness is necessary to address disparities in cancer care. These results are relevant to policy makers, clinicians, and patient advocates striving for health equity.

Socio-demographic determinants of myelofibrosis outcomes in an underserved center and the SEER national database

The influence of demographic characteristics and social determinants on cancer outcomes is widely recognized in various malignancies but remains understudied in myelofibrosis (MF). This study aims to investigate social and demographic variables associated with MF survival. We retrospectively reviewed data of biopsy-proven MF patients from the Surveillance, Epidemiology and End Results (SEER) database (2000-2021) and Montefiore Medical Center (2000-2023), an underserved inner-city hospital. The SEER cohort included 5,403 MF patients and was predominantly Non-Hispanic (NH) White (82%) with a median age of 69 years. The age-adjusted incidence rate of MF was 0.32 cases per 100,000 person-years, increasing annually by 1.3% from 2000 to 2021. Two- and five- year overall survival rates were 69% and 42%, respectively. Worse cause-specific survival was associated with older age, male sex, and diagnosis before 2011 (year of Ruxolitinib approval). NH-Black ethnicity, unmarried status and lower median income were independent predictors of worse overall survival. The single-center analysis included 84 cases, with a median age of 66 years. NH-White patients comprised 37% of the sample, followed by NH-Black (28.5%). Two- and five- year overall survival rates were 90% and 61%, respectively, with NH-Black patients exhibiting the lowest median survival, although the difference was not statistically significant. Age was a significant predictor of worse survival in this cohort. NH-Black and Hispanic patients lived in areas with higher socioeconomic and demographic stress compared to NH-White patients. Overall, this study highlights the association of social and demographic factors with MF survival and emphasizes the need for equitable healthcare and further exploration of social-demographic factors affecting MF survival.

If health organisations and staff engage in research, does healthcare improve? Strengthening the evidence base through systematic reviews

BACKGROUND

There is an often-held assumption that the engagement of clinicians and healthcare organizations in research improves healthcare performance at various levels. Previous reviews found up to 28 studies suggesting a positive association between the engagement of individuals and healthcare organizations in research and improvements in healthcare performance. The current study sought to provide an update.

METHODS

We updated our existing published systematic review by again addressing the question: Does research engagement (by clinicians and organizations) improve healthcare performance? The search covered the period 1 January 2012 to March 2024, in two phases. First, the formal updated search ran from 1 January 2012 to 31 May 2020, in any healthcare setting or country and focussed on English language publications. In this phase two searches identified 66 901 records. Later, a further check of key journals and citations to identified papers ran from May 2020 to March 2024. In total, 168 papers progressed to full-text appraisal; 62 were identified for inclusion in the update. Then we combined papers from our original and updated reviews.

RESULTS

In the combined review, the literature is dominated by papers from the United States (50/95) and mostly drawn from the Global North. Papers cover various clinical fields, with more on cancer than any other field; 86 of the 95 papers report positive results, of which 70 are purely positive and 16 positive/mixed, meaning there are some negative elements (i.e. aspects where there is a lack of healthcare improvement) in their findings.

CONCLUSIONS

The updated review collates a substantial pool of studies, especially when combined with our original review, which are largely positive in terms of the impact of research engagement on processes of care and patient outcomes. Of the potential engagement mechanisms, the review highlights the important role played by research networks. The review also identifies various papers which consider how far there is a "dose effect" from differing amounts of research engagement. Additional lessons come from analyses of equity issues and negative papers. This review provides further evidence of contributions played by systems level research investments such as research networks on processes of care and patient outcomes.

Cancer centers of excellence for the multidisciplinary management of urologic cancers The intersection between education, research, and healthcare

Urologic cancers are among the leading causes of morbidity and mortality in the world, representing more than 10% of the total number of new cancer cases worldwide. These complex diseases are linked to several issues related to their diagnosis, management, monitoring, and treatment - issues that require multidisciplinary solutions that encompass and manage patients as complex entities. In response to this, the so-called cancer centers of excellence (CCEs) emerged, defined as multidisciplinary institutions specialized in the diagnosis, management, monitoring, and treatment of specific diseases, including cancer. Different institutions, such as the European Association of Urology (EAU), have proposed and encouraged its consolidation, especially for the management of prostate cancer. These institutions must be composed of three areas: healthcare, education, and research, which have complementary interactions and relationships, stimulating research and problem-solving from a multidisciplinary approach and also covering elements of basic science and mental health. The implementation of these CCEs has generated positive results; therefore, it is necessary to stimulate their implementation with a uro-oncologic approach.

Impact of Severe Winter Weather on Operations of a Radiation Oncology Department

Purpose

During winter 2022, western New York faced 2 major storms with blizzard conditions and record-breaking snowfall. The severe weather resulted in power outages and travel bans. This study investigates the impact of these conditions on patient adherence to radiation therapy. Combining data from a large academic center and its satellite clinic, this single-center study sheds light on the challenges faced by cancer care facilities during severe weather and proposes suggestions to prevent and mitigate harm done by severe weather.

Methods and Materials

In this study, data were collected using the MOSAIQ Record and Verify system (v. 2.81) to generate deidentified reports of scheduled and treated patients. The treatment adherence rate was calculated by dividing the number of patients treated by the total number of patients scheduled. Data were specifically collected for patients undergoing treatment on linear accelerators at a primary academic center and a satellite facility. The study focused on working days from November 1, 2022, to March 31, 2023, excluding weekends and holidays (as treatments are not routinely scheduled). Severe weather days were identified using advisories from the National Weather Service and the local institution, including specific periods in November, December, and January.

Results

In the study, 15,010 scheduled treatment visits were recorded across the academic center and the satellite clinic. The mean daily treatment adherence rate was 91.7%. Severe weather conditions led to a significant reduction in adherence, with rates dropping to 77.8%. Adherence rates during nonsevere weather days were notably higher at 93.9%. Statistical analysis confirmed the substantial influence of severe weather on adherence (P < .001). Severe weather had a more pronounced impact on the satellite clinic during periods of severe weather, with absolute reduction in adherence rates of 21.9% versus 15% in the primary hospital. Moreover, adherence at the satellite clinic was lower than at the primary hospital site even under standard operating conditions (92.2% vs 94.0%, P < .001).

Conclusion

As a part of operational planning, it is important to be aware how severe weather can impact treatment adherence. Study findings underscore the importance of proactive measures to ensure patient access to health care services during adverse weather events and highlight the broader significance of incorporating consideration of social determinants of health into contingency planning for maintaining treatment continuity.

Impact of Financial Costs on Patients' Fertility Preservation Decisions: An Examination of Qualitative Data from Female Young Adults with Cancer and Oncology Providers

Purpose: To examine the impact of financial costs on fertility preservation decisions among female young adults (YAs) with cancer. Methods: Female YAs (N = 18; aged 21-36) with a history of cancer and oncology providers (N = 12) were recruited from an National Cancer Institute-designated comprehensive cancer center in a state without insurance coverage for fertility preservation. YAs and providers completed individual interviews and a brief online assessment. Qualitative description using thematic analysis was used to identify, analyze, and report common themes. Descriptive statistics was used to characterize the sample. Results: Female YAs and oncology providers highlighted the critical role that high out-of-pocket costs play in YAs' fertility preservation decisions along with the value that enhanced insurance coverage for fertility preservation would have for increasing female YAs' access to and utilization of fertility preservation. Although providers were concerned about preservation costs for their patients, they reported that their concerns did not impact whether they referred interested female YAs to reproductive specialists. Oncology providers expressed concern about inequities in utilization of fertility preservation for female and racially/ethnically minoritized YAs that were exacerbated by the high out-of-pocket fertility preservation costs. Conclusion: Cost is a significant barrier to fertility preservation for female YA cancer patients. Female YAs of reproductive age may benefit from decision support tools to assist with balancing the cost of fertility preservation with their values and family building goals. Policy-relevant interventions may mitigate cost barriers and improve access to care.

Outcome variation and the role of caseload in certified colorectal cancer centers - a retrospective cohort analysis of 90 000 cases

BACKGROUND

Studies have shown that surgical treatment of colorectal carcinomas in certified centers leads to improved outcomes. However, there were considerable fluctuations in outcome parameters. It has not yet been examined whether this variability is due to continuous differences between hospitals or variability within a hospital over time.

MATERIALS AND METHODS

In this retrospective observational cohort study, administrative quality assurance data of 153 German-certified colorectal cancer centers between 2010 and 2019 were analyzed. Six outcome quality indicators (QIs) were studied: 30-day postoperative mortality (POM) rate, surgical site infection (SSI) rate, anastomotic insufficiency (AI) rate, and revision surgery (RS) rate. AI and RS were also analyzed for colon (C) and rectal cancer operations (R). Variability was analyzed by funnel plots with 95% and 99% control limits and modified Cleveland dot plots.

RESULTS

In the 153 centers, 90 082 patients with colon cancer and 47 623 patients with rectal cancer were treated. Average QI scores were 2.7% POM, 6.2% SSI, 4.8% AI-C, 8.5% AI-R, 9.1% RS-C, and 9.8% RS-R. The funnel plots revealed that for every QI, about 10.1% of hospitals lay above the upper 99% and about 8.7% below the lower 99% control limit. In POM, SSI, and AI-R, a significant negative correlation with the average annual caseload was observed.

CONCLUSION

The analysis showed high variability in outcome quality between and within the certified colorectal cancer centers. Only a small number of hospitals had a high performance on all six QIs, suggesting that significant quality variation exists even within the group of certified centers.

Racial and Ethnic Disparities in Intensity of Care at the End of Life for Patients With Lung Cancer: A 13-Year Population-Based Study

PURPOSE

Lung cancer is the leading cause of cancer death in the United States. Disparities in lung cancer mortality among racial and ethnic minorities are well documented. Less is known as to whether racial and ethnic minority patients with lung cancer experience higher rates of intensity of care at the end of life (EOL) compared with non-Hispanic White (NHW) patients.

METHODS

We conducted a population-based analysis of patients 18 years and older with a lung cancer diagnosis who died between 2005 and 2018 using the California Cancer Registry linked to patient discharge data abstracts. Our primary outcome was intensity of care in the last 14 days before death (defined as any hospital admission or emergency department [ED] visit, intensive care unit [ICU] admission, intubation, cardiopulmonary resuscitation [CPR], hemodialysis, and death in an acute care setting). We used multivariable logistic regression models to evaluate associations between race and ethnicity and intensity of EOL care.

RESULTS

Among 207,429 patients with lung cancer who died from 2005 to 2018, the median age was 74 years (range, 18-107) and 106,821 (51%) were male, 146,872 (70.8%) were NHW, 1,045 (0.5%) were American Indian, 21,697 (10.5%) were Asian Pacific Islander (API), 15,490 (7.5%) were Black, and 22,325 (10.8%) were Hispanic. Compared with NHW patients, in the last 14 days before death, API, Black, and Hispanic patients had greater odds of a hospital admission, an ICU admission, intubation, CPR, and hemodialysis and greater odds of a hospital or ED death.

CONCLUSION

Compared with NHW patients, API, Black, and Hispanic patients who died with lung cancer experienced higher intensity of EOL care. Future studies should develop approaches to eliminate such racial and ethnic disparities in care delivery at the EOL.

Disparities in Cancer Stage Outcomes by Catchment Areas for a Comprehensive Cancer Center

Importance

The National Cancer Institute comprehensive cancer centers (CCCs) lack spatial and temporal evaluation of their self-designated catchment areas.

Objective

To identify disparities in cancer stage at diagnosis within and outside a CCC's catchment area across a 10-year period using spatial and statistical analyses.

Design, Setting, and Participants

This cross-sectional, population-based study conducted between 2010 and 2019 utilized cancer registry data for the Johns Hopkins Sidney Kimmel CCC (SKCCC). Eligible participants included patients with cancer in the contiguous US who received treatment for cancer, a diagnosis of cancer, or both at SKCCC. Patients were geocoded to zip code tabulation areas (ZCTAs). Individual-level variables included sociodemographic characteristics, smoking and alcohol use, treatment type, cancer site, and insurance type. Data analysis was performed between March and July 2023.

Exposures

Distance between SKCCC and ZCTAs were computed to generate a catchment area of the closest 75% of patients and outer zones in 5% increments for comparison.

Main Outcomes and Measures

The primary outcome was cancer stage at diagnosis, defined as early-stage, late-stage, or unknown stage. Multinomial logistic regression was used to determine associations of catchment area with stage at diagnosis.

Results

This study had a total of 94 007 participants (46 009 male [48.94%] and 47 998 female [51.06%]; 30 195 aged 22-45 years [32.12%]; 4209 Asian [4.48%]; 2408 Hispanic [2.56%]; 16 004 non-Hispanic Black [17.02%]; 69 052 non-Hispanic White [73.45%]; and 2334 with other or unknown race or ethnicity [2.48%]), including 47 245 patients (50.26%) who received a diagnosis of early-stage cancer, 19 491 (20.73%) who received a diagnosis of late-stage cancer , and 27 271 (29.01%) with unknown stage. Living outside the main catchment area was associated with higher odds of late-stage cancers for those who received only a diagnosis (odds ratio [OR], 1.50; 95% CI, 1.10-2.05) or only treatment (OR, 1.44; 95% CI, 1.28-1.61) at SKCCC. Non-Hispanic Black patients (OR, 1.16; 95% CI, 1.10-1.23) and those with Medicaid (OR, 1.65; 95% CI, 1.46-1.86) and no insurance at time of treatment (OR, 2.12; 95% CI, 1.79-2.51) also had higher odds of receiving a late-stage cancer diagnosis.

Conclusions and Relevance

In this cross-sectional study of CCC data from 2010 to 2019, patients residing outside the main catchment area, non-Hispanic Black patients, and patients with Medicaid or no insurance had higher odds of late-stage diagnoses. These findings suggest that disadvantaged populations and those living outside of the main catchment area of a CCC may face barriers to screening and treatment. Care-sharing agreements among CCCs could address these issues.

Health System Integration and Cancer Center Access for Rural Hospitals

BACKGROUND

Cancer centers provide superior care but are less accessible to rural populations. Health systems that integrate a cancer center may provide broader access to quality surgical care, but penetration to rural hospitals is unknown.

METHODS

Cancer center data were linked to health system data to describe health systems based on whether they included at least one accredited cancer center. Health systems with and without cancer centers were compared based on rural hospital presence. Bivariate tests and multivariable logistic regression were used with results reported as P-values and odds ratios (OR) with 95% confidence intervals (CIs).

RESULTS

Ninety percent of cancer centers are in a health system, and 72% of health systems (434/607) have a cancer center. Larger health systems (P = .03) with more trainees (P = .03) more often have cancer centers but are no more likely to include rural hospitals (11% vs 6%, P = .43; adjusted OR .69, 95% CI .28-1.70). The minority of cancer centers not in health systems (N = 95) more often serve low complexity patient populations (P = .02) in non-metropolitan areas (P = .03).

DISCUSSION

Health systems with rural hospitals are no more likely to have a cancer center. Ongoing health system integration will not necessarily expand rural patients' access to surgical care under existing health policy infrastructure and incentives.

Disparities in treatment patterns and mortality in prostate cancer: Interaction between Black race and end-stage kidney disease

BACKGROUND

Black men and men with end-stage kidney disease have lower rates of treatment and higher mortality for prostate cancer. We studied the interaction of end-stage kidney disease (ESKD) with Black race for treatment rates and mortality for men with prostate cancer.

METHODS AND RESULTS

We included 516 Black and 551 White men with ESKD before prostate cancer 22,299 Black men, and 141,821 White men without ESKD who were 40 years or older from the Surveillance, Epidemiology, and End-Results-Medicare data (2004-2016). All Black men with or without ESKD and White men with ESKD had higher prostate-specific antigen levels at diagnosis than White men without ESKD. Black men with ESKD had the lowest rates for treatment in both local and advanced stages of prostate cancer (age-adjusted risk ratio: 0.76, 95% Confidence Interval (CI): 0.71-0.82 for local stage and age-adjusted risk ratio: 0.82, 95% CI: 0.76-0.9 for advanced stages) compared to White men without ESKD. Compared to White men without ESKD, prostate cancer-specific mortality was higher in White men with ESKD for both local and advanced stages (age-adjusted hazard ratio: 1.8, 95% CI: 1.2-2.8 and HR: 1.6, 95% CI: 1.2-2.2) and it was higher for ESKD Black men only in advanced stage prostate cancer (age-adjusted hazard ratio: 2.4, 95% CI: 1.5-3.6).

CONCLUSION

Our findings suggest that having a comorbidity such as ESKD makes Black men more vulnerable to racial disparities in prostate cancer treatment and mortality.

Inherent Bias in Electronic Health Records: A Scoping Review of Sources of Bias

Objectives

1.1Biases inherent in electronic health records (EHRs), and therefore in medical artificial intelligence (AI) models may significantly exacerbate health inequities and challenge the adoption of ethical and responsible AI in healthcare. Biases arise from multiple sources, some of which are not as documented in the literature. Biases are encoded in how the data has been collected and labeled, by implicit and unconscious biases of clinicians, or by the tools used for data processing. These biases and their encoding in healthcare records undermine the reliability of such data and bias clinical judgments and medical outcomes. Moreover, when healthcare records are used to build data-driven solutions, the biases are further exacerbated, resulting in systems that perpetuate biases and induce healthcare disparities. This literature scoping review aims to categorize the main sources of biases inherent in EHRs.

Methods

1.2We queried PubMed and Web of Science on January 19th, 2023, for peer-reviewed sources in English, published between 2016 and 2023, using the PRISMA approach to stepwise scoping of the literature. To select the papers that empirically analyze bias in EHR, from the initial yield of 430 papers, 27 duplicates were removed, and 403 studies were screened for eligibility. 196 articles were removed after the title and abstract screening, and 96 articles were excluded after the full-text review resulting in a final selection of 116 articles.

Results

1.3Systematic categorizations of diverse sources of bias are scarce in the literature, while the effects of separate studies are often convoluted and methodologically contestable. Our categorization of published empirical evidence identified the six main sources of bias: a) bias arising from past clinical trials; b) data-related biases arising from missing, incomplete information or poor labeling of data; human-related bias induced by c) implicit clinician bias, d) referral and admission bias; e) diagnosis or risk disparities bias and finally, (f) biases in machinery and algorithms.

Conclusions

1.4Machine learning and data-driven solutions can potentially transform healthcare delivery, but not without limitations. The core inputs in the systems (data and human factors) currently contain several sources of bias that are poorly documented and analyzed for remedies. The current evidence heavily focuses on data-related biases, while other sources are less often analyzed or anecdotal. However, these different sources of biases add to one another exponentially. Therefore, to understand the issues holistically we need to explore these diverse sources of bias. While racial biases in EHR have been often documented, other sources of biases have been less frequently investigated and documented (e.g. gender-related biases, sexual orientation discrimination, socially induced biases, and implicit, often unconscious, human-related cognitive biases). Moreover, some existing studies lack causal evidence, illustrating the different prevalences of disease across groups, which does not per se prove the causality. Our review shows that data-, human- and machine biases are prevalent in healthcare and they significantly impact healthcare outcomes and judgments and exacerbate disparities and differential treatment. Understanding how diverse biases affect AI systems and recommendations is critical. We suggest that researchers and medical personnel should develop safeguards and adopt data-driven solutions with a "bias-in-mind" approach. More empirical evidence is needed to tease out the effects of different sources of bias on health outcomes.

Future Directions and Innovations in Venous Sinus Stenting

This review explores the future role of venous sinus stenting (VSS) in the management of idiopathic intracranial hypertension and pulsatile tinnitus. Despite its favorable safety profile and clinical outcomes compared with traditional treatments, VSS is not yet the standard of care for these conditions, lacking high-level evidence data and guidelines for patient selection and indications. Current and recently completed clinical trials are expected to provide data to support the adoption of VSS as a primary treatment option. Additionally, VSS shows potential in treating other conditions, such as dural arteriovenous fistula and cerebral venous sinus thrombosis, and it is likely that the procedure will continue to see an expansion of its approved indications. The current lack of dedicated venous stenting technology is being addressed with promising advancements, which may improve procedural ease and patient outcomes. VSS also offers potential for expansion into modulation of brain electrophysiology via endovascular routes, offering exciting possibilities for neurodiagnostics and treatment of neurodegenerative disorders.

Access to Care for Adolescents and Young Adults With Cancer in the United States: State of the Literature

Access to care remains a persistent challenge for adolescents and young adults (AYAs) with cancer. We review key findings in the science to date. (1) Location of care matters. There is survival benefit for AYAs treated either at a pediatric center or site with special status (eg, Children's Oncology Group, National Cancer Institute [NCI]-designated Comprehensive Cancer Center). (2) Socioeconomic status and insurance require further investigation. Medicaid expansion has had a moderate effect on AYA outcomes. The dependent care expansion benefit has come largely from improvements in coverage for younger populations whose parents have insurance, while some subgroups likely still face insurance gaps. (3) Clinical trial enrollment remains poor, but access may be improving. Numerous barriers and facilitators of clinical trial enrollment include those that are system level and patient level. NCI has established several initiatives over the past decade to improve enrollment, and newer collaboratives have recently brought together multidisciplinary US teams to increase clinical trial enrollment. (4) Effective AYA programs require provider and system flexibility and program reflection. With flexibility comes a need for metrics to assess program effectiveness in the context of the program model. Centers treating AYAs with cancer could submit a subset of metrics (appropriate to their program and/or services) to maintain their status; persistence would require an entity with staying power committed to overseeing the metrics and the system. Substantial clinical and biological advances are anticipated over the next 20 years that will benefit all patients with cancer. In parallel, it is crucial to prioritize research regarding access to health care and cancer care delivery; only with equitable access to care for AYAs can they, too, benefit from these advances.

Palliative Care in Adolescents and Young Adults With Cancer

Palliative care (PC) aims to improve quality of life (QOL) for patients with serious illness and their families by recognizing and alleviating the physical, emotional, social, existential, and spiritual suffering of patients and their communities. Because adolescents and young adults (AYAs, age 15-39 years) with cancer commonly report distress across all these domains and because that distress translates to their QOL during and after their cancers, PC is particularly relevant for this population. Here, we review the evidence for PC among AYAs with cancer, including its rationale, gaps, opportunities, and implications for care delivery. For example, nearly 90% of AYAs with cancer report distressing symptoms during their treatment, those who survive report ongoing unmet psychosocial and physical health needs, and those who die from their cancers are highly likely to receive medically intense care that is discordant with their goals and values. AYA communication and decision making can be challenging because of ethical and developmental considerations regarding the patient's autonomy and competing priorities of patients and caregivers. PC interventions (including primary PC delivered by oncologists, routine PC subspecialty care, symptom tracking, advance care planning, and psychosocial programs promoting AYA resilience) are all associated with improved patient-centered outcomes. However, PC is inconsistently integrated into AYA oncology care, and access to PC programs is not equitable; marginalized groups continue to experience poorer outcomes. Ongoing and future research and clinical initiatives must continue to bridge these gaps. Improving the QOL of AYAs with cancer is a shared goal of the larger clinical oncology community, and including PC in AYA cancer care delivery can help attain that goal.

Caring for older adults with cancer in Canada: Views from healthcare providers and cancer care allies in the community

BACKGROUND

Cancer is common and disproportionately impacts older adults. Moreover, cancer care of older adults is complex, and the current Canadian cancer care system struggles to address all of the dimensions. In this project, our goal was to understand the barriers and facilitators to caring for older adults with cancer from perspectives of healthcare professionals and cancer care allies, which included community groups, seniors' centers, and other community-based supports.

METHODS

In collaboration with a patient advisory board, we conducted focus groups and interviews with multiple local healthcare professionals and cancer care allies in British Columbia, Canada. We used a descriptive qualitative approach and conducted a thematic analysis using NVivo software.

RESULTS

A total of 71 participants of various disciplines and cancer care allies participated. They identified both individual and system-level barriers. Priority system-level barriers for older adults included space and staffing constraints and disconnections within healthcare systems, and between healthcare practitioners and cancer care allies. Individual-level barriers relate to the complex health states of older adults, caregiver/support person needs, and the needs of an increasingly diverse population where English may not be a first or preferable language.

CONCLUSIONS

This study identified key barriers and facilitators that demonstrate aligned priorities among a diverse group of healthcare practitioners and cancer care allies. In conjunction with perspectives from patients and caregivers, these findings will inform future improvements in cancer care. Namely, we emphasize the importance of connections among health systems and community networks, given the outpatient nature of cancer care and the needs of older adults.

The marginalization index and its association with selected services within the comprehensive care offered to breast cancer patients

PURPOSE

There is little information on the supportive care offered to breast cancer patients. We investigated the association between the marginalization index and selected services offered by health professionals.

METHODS

We used data from a cross-sectional parent study performed in Mexico from 2007 to 2009. We analyzed data from 832 women between 35 and 69 years of age with a histopathological diagnosis of breast cancer. This study was performed in hospitals in 5 states. We used frequencies, measures of central tendency, and logistic regression. We used the svy package of STATA statistical software v17.

RESULTS

Overall, 15.6% of the study population reported that health professionals offered them selected services. The offer of two or more selected services was greater among women living in states with a very high marginalization index (21.8%) than among those living in states with a very low marginalization index (13.8%). Among women living in states with high marginalization, the odds of receiving a selected service offer were 2.03 times higher than those living in states with low marginalization (Odds ratio (OR) = 2.03, 95% CI 1.08-3.83). For women in the highest tertile of the asset index, the odds of receiving a selected service offer were 2.7 times greater than the odds for women in the lowest tertile (OR = 2.66, 95% CI 1.03-6.88).

CONCLUSION

The prevalence of comprehensive care offered to breast cancer patients is low in Mexico and varies according to the marginalization index and the asset index.

Variation in Access to Palliative Radiotherapy in Prostate Cancer: A Population-Based Study in Canada

BACKGROUND

As a result of improvements in cancer therapies, patients with metastatic malignancies are living longer, and the role of palliative radiotherapy has become increasingly recognized. However, access to adequate palliative radiotherapy may continue to be a challenge, as is evident from the high proportion of patients dying of prostate cancer who never receive palliative radiotherapy. The main objective of this investigation is to identify and describe the factors associated with the receipt of palliative radiation treatment in a decedent cohort of prostate cancer patients in Ontario.

METHODOLOGY

 Population-based administrative databases from Ontario, Canada, were used to identify prostate cancer decedents, 65 years or older who received androgen deprivation therapy between January 1, 2013, and December 31, 2018. Baseline and treatment characteristics were analyzed using univariate and multivariate logistic regression models for association with receipt of radiotherapy in a two-year observation period before death.

RESULTS

We identified 3,788 prostate cancer decedents between 2013 and 2018; among these, 49.9% received radiotherapy in the two years preceding death. There were statistically significant positive associations between receipt of radiotherapy and younger age at diagnosis (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.3); higher stage at diagnosis (OR 1.3, 95% CI 1.1-1.7); receipt of care at a regional cancer center (OR 1.8, 95% CI 1.3-2.4); and involvement of radiation oncologists (OR 155.1, 95% CI 83.3-288.7) or medical oncologists (OR 1.4, 95% CI 1.1-1.8). However, there were no associations between receipt of radiotherapy and income, distance to the nearest cancer center, involvement of urologists in cancer care, healthcare administrative region, home-care involvement, or number of hospitalizations in the observation period.

CONCLUSIONS

We found the utilization of palliative radiotherapy for prostate cancer patients in Ontario varies depending on age, stage at diagnosis, number of comorbidities, registration at regional cancer centers, and involvement of oncologists. There were no differences detected based on income or distance from a cancer center. The findings of this study represent an important opportunity to facilitate better access to palliative radiotherapy and referrals to multidisciplinary regional cancer centers, to improve the quality of life of this patient population.

Strategies to decrease inequalities in cancer therapeutics, care and prevention: Proceedings on a conference organized by the Pontifical Academy of Sciences and the European Academy of Cancer Sciences, Vatican City, February 23-24, 2023

Analyses of inequalities related to prevention and cancer therapeutics/care show disparities between countries with different economic standing, and within countries with high Gross Domestic Product. The development of basic technological and biological research provides clinical and prevention opportunities that make their implementation into healthcare systems more complex, mainly due to the growth of Personalized/Precision Cancer Medicine (PCM). Initiatives like the USA-Cancer Moonshot and the EU-Mission on Cancer and Europe's Beating Cancer Plan are initiated to boost cancer prevention and therapeutics/care innovation and to mitigate present inequalities. The conference organized by the Pontifical Academy of Sciences in collaboration with the European Academy of Cancer Sciences discussed the inequality problem, dependent on the economic status of a country, the increasing demands for infrastructure supportive of innovative research and its implementation in healthcare and prevention programs. Establishing translational research defined as a coherent cancer research continuum is still a challenge. Research has to cover the entire continuum from basic to outcomes research for clinical and prevention modalities. Comprehensive Cancer Centres (CCCs) are of critical importance for integrating research innovations to preclinical and clinical research, as for ensuring state-of-the-art patient care within healthcare systems. International collaborative networks between CCCs are necessary to reach the critical mass of infrastructures and patients for PCM research, and for introducing prevention modalities and new treatments effectively. Outcomes and health economics research are required to assess the cost-effectiveness of new interventions, currently a missing element in the research portfolio. Data sharing and critical mass are essential for innovative research to develop PCM. Despite advances in cancer research, cancer incidence and prevalence is growing. Making cancer research infrastructures accessible for all patients, considering the increasing inequalities, requires science policy actions incentivizing research aimed at prevention and cancer therapeutics/care with an increased focus on patients' needs and cost-effective healthcare.

Geographic and sociodemographic access to systemic anticancer therapies for secondary breast cancer: a systematic review

BACKGROUND

The review aimed to investigate geographic and sociodemographic factors associated with receipt of systemic anticancer therapies (SACT) for women with secondary (metastatic) breast cancer (SBC).

METHODS

Included studies reported geographic and sociodemographic factors associated with receipt of treatment with SACT for women > 18 years with an SBC diagnosis. Information sources searched were Ovid CINAHL, Ovid MEDLINE, Ovid Embase and Ovid PsychINFO. Assessment of methodological quality was undertaken using the Joanna Briggs Institute method. Findings were synthesised using a narrative synthesis approach.

RESULTS

Nineteen studies published between 2009 and 2023 were included in the review. Overall methodological quality was assessed as low to moderate. Outcomes were reported for treatment receipt and time to treatment. Overall treatment receipt ranged from 4% for immunotherapy treatment in one study to 83% for systemic anticancer therapies (unspecified). Time to treatment ranged from median 54 days to 95 days with 81% of patients who received treatment < 60 days. Younger women, women of White origin, and those women with a higher socioeconomic status had an increased likelihood of timely treatment receipt. Treatment receipt varied by geographical region, and place of care was associated with variation in timely receipt of treatment with women treated at teaching, research and private institutions being more likely to receive treatment in a timely manner.

CONCLUSIONS

Treatment receipt varied depending upon type of SACT. A number of factors were associated with treatment receipt. Barriers included older age, non-White race, lower socioeconomic status, significant comorbidities, hospital setting and geographical location. Findings should however be interpreted with caution given the limitations in overall methodological quality of included studies and significant heterogeneity in measures of exposure and outcome. Generalisability was limited due to included study populations. Findings have practical implications for the development and piloting of targeted interventions to address specific barriers in a socioculturally sensitive manner. Addressing geographical variation and place of care may require intervention at a commissioning policy level. Further qualitative research is required to understand the experience and of women and clinicians.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020196490.

First-line real-world treatment patterns and survival outcomes in women younger or older than 40 years with metastatic breast cancer in the real-life multicenter French ESME cohort

AIM

To describe first-line treatment patterns, overall survival (OS) and real-world progression-free survival (rwPFS) in young women (<40) with metastatic breast cancer (mBC), as compared to women aged 40-69.

MATERIALS AND METHODS

Data on adult women diagnosed with mBC (2008-2017) were extracted from the ESME mBC database (NCT03275311) which includes consecutive patients starting first-line metastatic treatment in one of the 18 French Comprehensive cancer centers. We reported first-line therapeutic strategy and prognostic factors of OS and rwPFS for women aged < 40 and 40-69.

RESULTS

In total, 14,897 mBC women were included (1512 aged <40). HR+ /HER2- mBC was the most frequent subtype. First-line treatment differed between young patients and older ones for HR+ /HER2- and Triple Negative (TN) mBC. Median OS for women aged < 40 and 40-69, respectively, was 46.9 and 46.2 months for HR+ /HER2- mBC; 13.5 and 15.2 for TN mBC; and, 60.7 and 55.1 for HER2 + mBC. Median rwPFS under first line treatment was 11.6 and 11.9 months for HR+ /HER2- in women aged < 40 and 40-69, respectively; 5.5 and 5.9 for TN, and, 13.3 and 12.9 for HER2 + . Factors associated with shorter OS and rwPFS were similar for both women aged < 40 and 40-69 and included ≥ 3 metastatic sites, visceral metastases, and longer MFI, with time-varying effects observed for several prognostic factors.

CONCLUSION

Young women presented more frequently with TN and HER2 + subtypes and aggressive mBC than women aged 40-69 did. Prognostic factors of OS and rwPFS were quite similar between age groups and mBC subtypes.

Hospital volume and prognosis of patients with metastatic pancreatic cancer: A study using the Osaka Cancer Registry

PURPOSE

Pancreatic cancer (PC) has one of the worst prognoses among all solid cancers. Hospital volume has been shown to be significantly associated with outcomes in patients with PC undergoing surgery. Nonetheless, the association between hospital volume and prognosis in patients with metastatic PC remains unclear. This study aimed to examine the association between hospital volume and prognosis in patients with metastatic PC using large-scale population-based cancer registry data.

METHODS

This retrospective observational study was conducted using data from the Osaka Cancer Registry database. Data of patients with metastatic PC over 10 years (2009-2018) were obtained. Hospitals were categorized into high-volume hospitals (HVHs; ≥ 240 patients diagnosed with PC for 10 years), middle-volume hospitals (MVHs; 120-239 patients diagnosed with PC for 10 years), and low-volume hospitals (LVHs; < 120 patients diagnosed with PC for 10 years). Multivariate analysis was performed to identify factors associated with overall survival (OS).

RESULTS

The analysis included 8,929 patients with metastatic PC. Median OS was significantly more favorable in HVHs than in MVHs and LVHs. Multivariate analysis adjusted for hospital volume, age, primary tumor site, year of diagnosis, chemotherapy, and radiotherapy revealed that hospital volume was an independent factor associated with OS (HVHs vs. MVHs: hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.03-1.16; P = 0.003, HVHs vs. LVHs: HR, 1.20; 95% CI, 1.13-1.27; P < 0.001).

CONCLUSION

Hospital volume is an independent prognostic factor in patients with metastatic PC, suggesting an association between hospital volume and treatment outcomes.

Localized Synovial Sarcoma: A Population-Based Analysis of Treatment Patterns and Survival

Purpose: Synovial sarcoma (SS) is a rare, high-grade soft tissue tumor that requires multidisciplinary and multimodal care with surgery, radiotherapy, and chemotherapy. We examined the impact of sociodemographic and clinical factors on treatment patterns and survival in localized SS patients. Methods: Adolescents and young adults (AYAs, 15-39 years) and older adults ("adults," ≥40 years) diagnosed with localized SS from 2000 to 2018 were identified in the California Cancer Registry. Multivariable logistic regression identified clinical and sociodemographic factors associated with receipt of chemotherapy and/or radiotherapy. Cox proportional hazards regression identified factors associated with overall survival (OS). Results are reported as odds ratios (ORs) and hazard ratios (HRs), respectively, with 95% confidence intervals (CIs). Results: More AYAs (n = 346) than adults (n = 272) received chemotherapy (47.7% vs. 36.4%) and radiotherapy (62.1% vs. 58.1%). Age at diagnosis, tumor size, treatment at National Cancer Institute-Children's Oncology Group (NCI-COG)-designated facilities, insurance status, and neighborhood socioeconomic status (SES) influenced treatment patterns. Among AYAs, treatment at NCI-COG-designated facilities was associated with receiving chemotherapy (OR 2.74, CI 1.48-5.07) and low SES was associated with worse OS (HR 2.28, 1.09-4.77). In adults, high SES was associated with receiving chemoradiotherapy (OR 3.20, CI 1.40-7.31), whereas public insurance was associated with decreased odds of chemoradiotherapy (OR 0.44, CI 0.20-0.95). With regard to treatment, absence of radiotherapy (HR 1.94, CI 1.18-3.20) was associated with worse OS in adults. Conclusion: In localized SS, both clinical and sociodemographic factors influenced treatment patterns. Further research should investigate how SES-related factors produce treatment disparities and identify interventions to improve treatment equity and outcomes.

Pancreatic Adenocarcinoma: Real World Evidence of Care Delivery in AccessHope Data

BACKGROUND

Pancreatic adenocarcinoma is an aggressive disease and the delivery of comprehensive care to individuals with this cancer is critical to achieve appropriate outcomes. The identification of gaps in care delivery facilitates the design of interventions to optimize care delivery and improve outcomes in this population.

METHODS

AccessHope™ is a growing organization that connects oncology subspecialists with treating providers through contracts with self-insured employers. Data from 94 pancreatic adenocarcinoma cases (August 2019-December 2022) in the AccessHope dataset were used to describe gaps in care delivery.

RESULTS

In all but 6% of cases, the subspecialist provided guideline-concordant recommendations anticipated to improve outcomes. Gaps in care were more pronounced in patients with non-metastatic pancreatic cancer. There was a significant deficiency in germline testing regardless of the stage, with only 59% of cases having completed testing. Only 20% of cases were receiving palliative care or other allied support services. There was no difference in observed care gaps between patients receiving care in the community setting vs. those receiving care in the academic setting.

CONCLUSIONS

There are significant gaps in the care delivered to patients with pancreatic adenocarcinoma. A concurrent subspecialist review has the opportunity to identify and address these gaps in a timely manner.

Organization of Cancer Specialists in US Physician Practices and Health Systems

PURPOSE

To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers.

METHODS

Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center.

RESULTS

More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas.

CONCLUSION

Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.

Demographic disparities in receipt of care at a comprehensive cancer center

BACKGROUND

National Cancer Institute cancer centers (NCICCs) provide specialized cancer care including precision oncology and clinical treatment trials. While these centers can offer novel therapeutic options, less is known about when patients access these centers or at what timepoint in their disease course they receive specialized care. This is especially important since precision diagnostics and receipt of the optimal therapy upfront can impact patient outcomes and previous research suggests that access to these centers may vary by demographic characteristics. Here, we examine the timing of patients' presentation at Moffitt Cancer Center (MCC) relative to their initial diagnosis across several demographic characteristics.

METHODS

A retrospective cohort study was conducted among patients who presented to MCC with breast, colon, lung, melanoma, and prostate cancers between December 2008 and April 2020. Patient demographic and clinical characteristics were obtained from the Moffitt Cancer Registry. The association between patient characteristics and the timing of patient presentation to MCC relative to the patient's cancer diagnosis was examined using logistic regression.

RESULTS

Black patients (median days = 510) had a longer time between diagnosis and presentation to MCC compared to Whites (median days = 368). Black patients were also more likely to have received their initial cancer care outside of MCC compared to White patients (odds ratio [OR] and 95% confidence interval [CI] = 1.45 [1.32-1.60]). Furthermore, Hispanics were more likely to present to MCC at an advanced stage compared to non-Hispanic patients (OR [95% CI] = 1.28 [1.05-1.55]).

CONCLUSIONS

We observed racial and ethnic differences in timing of receipt of care at MCC. Future studies should aim to identify contributing factors for the development of novel mitigation strategies and assess whether timing differences in referral to an NCICC correlate with long-term patient outcomes.

Understanding inequities in precision oncology diagnostics

Advances in molecular diagnostics have enabled the identification of targetable driver pathogenic variants, forming the basis of precision oncology care. However, the adoption of new technologies, such as next-generation sequencing (NGS) panels, can exacerbate healthcare disparities. Here, we summarize data on use patterns of advanced biomarker testing, highlight the disparities in both accessing NGS testing and using this data to match patients to appropriate personalized therapies and propose multidisciplinary strategies to address inequities looking forward.

Impact of Cancer Care Regionalization on Patient Volume

BACKGROUND

Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs).

METHODS

This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution.

RESULTS

The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299).

CONCLUSIONS

The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.

Disparities in melanoma-specific mortality by race/ethnicity, socioeconomic status, and health care systems

BACKGROUND

Despite encouraging trends in survival, sociodemographic inequalities persist among patients with melanoma.

OBJECTIVE

We sought to quantify the effect of race/ethnicity, socioeconomic status, and health care systems on melanoma-specific mortality within an insured population of patients.

METHODS

Using a retrospective cohort study, we identified insured adults diagnosed with Stage I to IV melanoma from January 1, 2009, to December 31, 2014, followed through 2017, from the California Cancer Registry. We compared melanoma-specific mortality between insured patients diagnosed within the largest vertically integrated health care system in California, Kaiser Permanente Southern California, and insured patients with other private insurance (OPI).

RESULTS

Our cohort included 14,614 adults diagnosed with melanoma. Multivariable analyses demonstrated that race/ethnicity was not associated with survival disparities, while socioeconomic status was a strong predictor of melanoma-specific mortality, particularly for those with OPI. For example, hazard ratios demonstrate that the poorest patients with OPI have a 70% increased risk of dying from their melanoma compared to their wealthiest counterparts, while the poorest patients in Kaiser Permanente Southern California have no increased risk.

LIMITATIONS

Our main limitation includes inadequate data for certain racial/ethnic groups, such as Native Americans.

CONCLUSIONS

Our findings underscore the persistence of socioeconomic disparities within an insured population, specifically among those in non-integrated health care systems.

A population-based study of factors associated with systemic treatment in advanced prostate cancer decedents

INTRODUCTION

Life-prolonging therapies (LPTs) are rapidly evolving for the treatment of advanced prostate cancer, although factors associated with real-world uptake are not well characterized.

METHODS

In this cohort of prostate-cancer decedents, we analyzed factors associated with LPT access. Population-level databases from Ontario, Canada identified patients 65 years or older with prostate cancer receiving androgen deprivation therapy and who died of prostate cancer between 2013 and 2017. Univariate and multivariable analyses assessed the association between baseline characteristics and receipt of LPT in the 2 years prior to death.

RESULTS

Of 3575 patients who died of prostate cancer, 40.4% (n = 1443) received LPT, which comprised abiraterone (66.3%), docetaxel (50.3%), enzalutamide (17.2%), radium-223 (10.0%), and/or cabazitaxel (3.5%). Use of LPT increased by year of death (2013: 22.7%, 2014: 31.8%, 2015: 41.8%, 2016: 49.1%, and 2017: 57.9%, p < 0.0001), driven by uptake of all agents except docetaxel. Adjusted odds of use were higher for patients seen at Regional Cancer Centers (OR: 1.8, 95% CI: 1.5-2.1) and who received prior prostate-directed therapy (OR: 1.3, 95% CI: 1.0-1.5), but lower with advanced age (≥85: OR: 0.54, 95% CI:0.39-0.75), increased chronic conditions (≥6: OR: 0.62, 95% CI: 0.43-0.92), and long-term care residency (OR: 0.38, 95% CI: 0.17-0.89). Income, stage at presentation, and distance to the cancer center were not associated with LPT uptake.

CONCLUSION

In this cohort of prostate cancer-decedents, real-world uptake of novel prostate cancer therapies occurred at substantially higher rates for patients receiving care at Regional Cancer Centers, reinforcing the potential benefits for treatment access for patients referred to specialist centers.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.