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Huang B, Chen Q, Allison D, El Khouli R, Peh KH, Mobley J, Anderson A, Durbin EB, Goodin D, Villano JL, Miller RW, Arnold SM, Kolesar JM. Molecular Tumor Board Review and Improved Overall Survival in Non-Small-Cell Lung Cancer. JCO Precis Oncol 2021; 5:PO.21.00210. [PMID: 34622117 PMCID: PMC8492377 DOI: 10.1200/po.21.00210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/13/2021] [Accepted: 08/19/2021] [Indexed: 12/25/2022] Open
Abstract
With the introduction of precision medicine, treatment options for non-small-cell lung cancer have improved dramatically; however, underutilization, especially in disadvantaged patients, like those living in rural Appalachian regions, is associated with poorer survival. Molecular tumor boards (MTBs) represent a strategy to increase precision medicine use. UK HealthCare at the University of Kentucky (UK) implemented a statewide MTB in January 2017. We wanted to test the impact of UK MTB review on overall survival in Appalachian and other regions in Kentucky. METHODS We performed a case-control study of Kentucky patients newly diagnosed with non-small-cell lung cancer between 2017 and 2019. Cases were reviewed by the UK MTB and were compared with controls without UK MTB review. Controls were identified from the Kentucky Cancer Registry and propensity-matched to cases. The primary end point was the association between MTB review and overall patient survival. RESULTS Overall, 956 patients were included, with 343 (39%) residing in an Appalachian region. Seventy-seven (8.1%) were reviewed by the MTB and classified as cases. Cox regression analysis showed that poorer survival outcome was associated with lack of MTB review (hazard ratio [HR] = 8.61; 95% CI, 3.83 to 19.31; P < .0001) and living in an Appalachian region (hazard ratio = 1.43; 95% CI, 1.17 to 1.75; P = .004). Among individuals with MTB review, survival outcomes were similar regardless of whether they lived in Appalachia or other parts of Kentucky. CONCLUSION MTB review is an independent positive predictor of overall survival regardless of residence location. MTBs may help overcome some health disparities for disadvantaged populations.
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Affiliation(s)
- Bin Huang
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Division of Cancer Biostatistics, University of Kentucky, Lexington, KY
| | - Quan Chen
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Division of Cancer Biostatistics, University of Kentucky, Lexington, KY
| | - Derek Allison
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Radiology, University of Kentucky, Lexington, KY
| | - Riham El Khouli
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, KY
| | - Keng Hee Peh
- Department of Pharmacy, University of Kentucky, Lexington, KY
| | - James Mobley
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | | | - Eric B Durbin
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | | | - John L Villano
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Rachel W Miller
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
| | - Susanne M Arnold
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Jill M Kolesar
- Markey Cancer Center, University of Kentucky, Lexington, KY
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY
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Larson KL, Huang B, Weiss HL, Hull P, Westgate PM, Miller RW, Arnold SM, Kolesar JM. Clinical Outcomes of Molecular Tumor Boards: A Systematic Review. JCO Precis Oncol 2021; 5:PO.20.00495. [PMID: 34632252 PMCID: PMC8277300 DOI: 10.1200/po.20.00495] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/18/2021] [Accepted: 06/09/2021] [Indexed: 01/12/2023] Open
Abstract
We conducted this systematic review to evaluate the clinical outcomes associated with molecular tumor board (MTB) review in patients with cancer. METHODS A systematic search of PubMed was performed to identify studies reporting clinical outcomes in patients with cancer who were reviewed by an MTB. To be included, studies had to report clinical outcomes, including clinical benefit, response, progression-free survival, or overall survival. Two reviewers independently selected studies and assessed quality with the Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group or the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies depending on the type of study being reviewed. RESULTS Fourteen studies were included with a total of 3,328 patients with cancer. All studies included patients without standard-of-care treatment options and usually with multiple prior lines of therapy. In studies reporting response rates, patients receiving MTB-recommended therapy had overall response rates ranging from 0% to 67%. In the only trial powered on clinical outcome and including a control group, the group receiving MTB-recommended therapy had significantly improved rate of progression-free survival compared with those receiving conventional therapy. CONCLUSION Although data quality is limited by a lack of prospective randomized controlled trials, MTBs appear to improve clinical outcomes for patients with cancer. Future research should concentrate on prospective trials and standardization of approach and outcomes.
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Affiliation(s)
- Kara L. Larson
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
| | - Bin Huang
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
- Kentucky Cancer Registry, University of
Kentucky, Lexington, Kentucky
| | - Heidi L. Weiss
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
| | - Pam Hull
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
| | - Philip M. Westgate
- Department of Biostatistics, University of
Kentucky, Lexington, Kentucky
| | - Rachel W. Miller
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
- Department of Obstetrics and Gynecology,
University of Kentucky, Lexington, Kentucky
| | - Susanne M. Arnold
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
- Department of Internal Medicine,
University of Kentucky, Lexington, Kentucky
| | - Jill M. Kolesar
- Markey Cancer Center, University of
Kentucky, Lexington, Kentucky
- Department of Pharmacy Practice and
Science, University of Kentucky, Lexington, Kentucky
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3
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Becker DJ, Lee KM, Lee SY, Lynch KE, Makarov DV, Sherman SE, Morrissey CD, Kelley MJ, Lynch JA. Uptake of KRAS Testing and Anti-EGFR Antibody Use for Colorectal Cancer in the VA. JCO Precis Oncol 2021; 5:PO.20.00359. [PMID: 34250412 DOI: 10.1200/po.20.00359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/05/2021] [Accepted: 03/02/2021] [Indexed: 11/20/2022] Open
Abstract
Advances in precision oncology, including RAS testing to predict response to epidermal growth factor receptor monoclonal antibodies (EGFR mAbs) in colorectal cancer (CRC), can extend patients' lives. We evaluated uptake and clinical use of KRAS molecular testing, guideline recommended since 2010, in the Veterans Affairs Healthcare System (VA). MATERIALS AND METHODS We conducted a retrospective cohort study of patients with stage IV CRC diagnosed in the VA 2006-2015. We gathered clinical, demographic, molecular, and treatment data from the VA Corporate Data Warehouse and 29 commercial laboratories. We performed multivariable analyses of associations between patient characteristics, KRAS testing, and EGFR mAb treatment. RESULTS Among 5,943 patients diagnosed with stage IV CRC, only 1,053 (17.7%) had KRAS testing. Testing rates increased from 2.3% in 2006 to 28.4% in 2013. In multivariable regression, older patients (odds ratio, 0.17; 95% CI, 0.09 to 0.32 for ≥ age 85 v < 45 years) and those treated in the Northeast and South regions were less likely, and those treated at high-volume CRC centers were more likely to have KRAS testing (odds ratio, 2.32; 95% CI, 1.48 to 3.63). Rates of potentially guideline discordant care were high: 64.3% (321/499) of KRAS wild-type (WT) went untreated with EGFR mAb and 8.8% (401/4,570) with no KRAS testing received EGFR mAb. Among KRAS-WT patients, survival was better for patients who received EGFR mAb treatment (29.6 v 18.8 months; P < .001). CONCLUSION We found underuse of KRAS testing in advanced CRC, especially among older patients and those treated at lower-volume CRC centers. We found high rates of potentially guideline discordant underuse of EGFR mAb in patients with KRAS-WT tumors. Efforts to understand barriers to precision oncology are needed to maximize patient benefit.
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Affiliation(s)
- Daniel J Becker
- NYU Grossman School of Medicine, New York, NY.,VA-New York Harbor Health Care System, New York, NY
| | - Kyung M Lee
- VA Informatics and Computing Infrastructure, Washington, DC
| | | | - Kristine E Lynch
- VA Informatics and Computing Infrastructure, Washington, DC.,University of Utah, Salt Lake City, UT
| | - Danil V Makarov
- NYU Grossman School of Medicine, New York, NY.,VA-New York Harbor Health Care System, New York, NY
| | - Scott E Sherman
- NYU Grossman School of Medicine, New York, NY.,VA-New York Harbor Health Care System, New York, NY
| | | | - Michael J Kelley
- Durham Veteran Affairs Medical Center, Durham, NC.,Duke University, Durham, NC
| | - Julie A Lynch
- VA Salt Lake City Healthcare System, Salt Lake City, UT.,University of Massachusetts, Boston, MA
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Hung A, Lee KM, Alba PR, Li Y, Gao AZ, Hintze BJ, Efimova OV, Shenolikar R, Pavilack M, Simmons D, Kelley MJ, Lynch JA, Reed SD. EGFR mutation testing and TKI treatment patterns among veterans with stage III and IV non-small cell lung cancer. Cancer Treat Res Commun 2021; 27:100327. [PMID: 33549984 DOI: 10.1016/j.ctarc.2021.100327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) mutation testing is recommended in metastatic non-small cell lung cancer (NSCLC). The objective of this study was to assess changes in EGFR mutation testing patterns and tyrosine kinase inhibitor (TKI) use in US veterans with stage III-IV NSCLC between 2013 and 2017. PATIENTS AND METHODS Retrospective study using linked data from Department of Veterans Affairs (VA) Cancer Registry System, Corporate Data Warehouse, commercial laboratories, and clinical notes. Generalized linear mixed models accounting for clustering by VA facility were used to determine factors associated with EGFR mutation testing. RESULTS From 2013 to 2017, EGFR mutation testing increased from 29.5% to 38.4% among veterans with stage III-IV NSCLC and from 47.0% to 57.4% among veterans with stage IV non-squamous disease. Factors associated with increased odds of testing included being married, Medicare enrollment, and adenocarcinoma histology. Factors associated with decreased odds of testing included Medicaid eligibility, stage III disease, increasing age, being a current or former smoker, increasing Charlson-Deyo comorbidity score, and receiving cancer care in the South. Appropriate use of a TKI rose from 2013 to 2017 (17.2% to 74.1%). CONCLUSION EGFR mutation testing rates increased to almost 60% in the stage IV non-squamous NSCLC population in 2017, with residual opportunity for further increase. Several sociodemographic characteristics, comorbidities, and geographic regions were associated with EGFR mutation testing suggestive of inequitable testing decisions. Appropriate use of TKI improved drastically from 2013 to 2017 demonstrating rapidly changing practice patterns through the adoption phase of new treatment options.
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5
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Vashistha V, Poonnen PJ, Snowdon JL, Skinner HG, McCaffrey V, Spector NL, Hintze B, Duffy JE, Weeraratne D, Jackson GP, Kelley MJ, Patel VL. Medical oncologists' perspectives of the Veterans Affairs National Precision Oncology Program. PLoS One 2020; 15:e0235861. [PMID: 32706774 PMCID: PMC7380614 DOI: 10.1371/journal.pone.0235861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/24/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To support the rising need for testing and to standardize tumor DNA sequencing practices within the U.S. Department of Veterans Affairs (VA)'s Veterans Health Administration (VHA), the National Precision Oncology Program (NPOP) was launched in 2016. We sought to assess oncologists' practices, concerns, and perceptions regarding Next-Generation Sequencing (NGS) and the NPOP. MATERIALS AND METHODS Using a purposive total sampling approach, oncologists who had previously ordered NGS for at least one tumor sample through the NPOP were invited to participate in semi-structured interviews. Questions assessed the following: expectations for the NPOP, procedural requirements, applicability of testing results, and the summative utility of the NPOP. Interviews were assessed using an open coding approach. Thematic analysis was conducted to evaluate the completed codebook. Themes were defined deductively by reviewing the direct responses to interview questions as well as inductively by identifying emerging patterns of data. RESULTS Of the 105 medical oncologists who were invited to participate, 20 (19%) were interviewed from 19 different VA medical centers in 14 states. Five recurrent themes were observed: (1) Educational Efforts Regarding Tumor DNA Sequencing Should be Undertaken, (2) Pathology Departments Share a Critical Role in Facilitating Test Completion, (3) Tumor DNA Sequencing via NGS Serves as the Most Comprehensive Testing Modality within Precision Oncology, (4) The Availability of the NPOP Has Expanded Options for Select Patients, and (5) The Completion of Tumor DNA Sequencing through the NPOP Could Help Improve Research Efforts within VHA Oncology Practices. CONCLUSION Medical oncologists believe that the availability of tumor DNA sequencing through the NPOP could potentially lead to an improvement in outcomes for veterans with metastatic solid tumors. Efforts should be directed toward improving oncologists' understanding of sequencing, strengthening collaborative relationships between oncologists and pathologists, and assessing the role of comprehensive NGS panels within the battery of precision tests.
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Affiliation(s)
- Vishal Vashistha
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC, United States of America
- Duke Cancer Institute, Durham, NC, United states of America
- Department of Hematology and Oncology, Durham Veterans Affairs Medical Center, Durham, NC, United States of America
| | - Pradeep J. Poonnen
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC, United States of America
- Duke Cancer Institute, Durham, NC, United states of America
- Department of Hematology and Oncology, Durham Veterans Affairs Medical Center, Durham, NC, United States of America
| | | | - Halcyon G. Skinner
- College of Health, Lehigh University, Bethlehem, PA, United States of America
| | | | - Neil L. Spector
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC, United States of America
- Duke Cancer Institute, Durham, NC, United states of America
- Department of Hematology and Oncology, Durham Veterans Affairs Medical Center, Durham, NC, United States of America
| | - Bradley Hintze
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC, United States of America
| | - Jill E. Duffy
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC, United States of America
| | | | - Gretchen P. Jackson
- Watson Health, IBM, Cambridge, MA, United States of America
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael J. Kelley
- Department of Veterans Affairs, National Precision Oncology Program, Durham, NC, United States of America
- Duke Cancer Institute, Durham, NC, United states of America
- Department of Hematology and Oncology, Durham Veterans Affairs Medical Center, Durham, NC, United States of America
| | - Vimla L. Patel
- Center for Cognitive Sciences in Medicine and Public Health, The New York Academy of Medicine, New York City, NY, United States of America
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6
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Burnett-Hartman AN, Udaltsova N, Kushi LH, Neslund-Dudas C, Rahm AK, Pawloski PA, Corley DA, Knerr S, Feigelson HS, Hunter JE, Tabano DC, Epstein MM, Honda SA, Ter-Minassian M, Lynch JA, Lu CY. Clinical Molecular Marker Testing Data Capture to Promote Precision Medicine Research Within the Cancer Research Network. JCO Clin Cancer Inform 2020; 3:1-10. [PMID: 31487201 DOI: 10.1200/cci.19.00026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To evaluate health care systems for the availability of population-level data on the frequency of use and results of clinical molecular marker tests to inform precision cancer care. METHODS We assessed cancer-related molecular marker test data availability across 12 US health care systems in the Cancer Research Network. Overall, these systems provide care to a diverse population of more than 12 million people in the United States. We performed qualitative analyses of test data availability for five blood-based protein, nine germline, and 14 tissue-based tumor marker tests in each health care system's electronic health record and tumor registry using key informants, test code lists, and manual review of data types and output. We then performed quantitative analyses to estimate the proportion of patients with cancer with test utilization data and results for specific molecular marker tests. RESULTS Health systems were able to systematically capture population-level data on all five blood protein markers, six of 14 tissue-based tumor markers, and none of the nine germline markers. Successful, systematic data capture was achievable for tests with electronic data feeds for test results (blood protein markers) or through prior manual abstraction by tumor registrars (select tumor-based markers). For test results stored in scanned image files (particularly germline and tumor marker tests), information on which test was performed and test results was not readily accessible in an electronic format. CONCLUSION Even in health care systems with sophisticated electronic health records, there were few codified data elements available for evaluating precision cancer medicine test use and results at the population level. Health care organizations should establish standards for electronic reporting of precision medicine tests to expedite cancer research and facilitate the implementation of precision medicine approaches.
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Affiliation(s)
| | | | | | | | | | | | | | - Sarah Knerr
- University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | | | - David C Tabano
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Mara M Epstein
- University of Massachusetts Medical School, Worcester, MA
| | | | | | - Julie A Lynch
- Department of Veterans Affairs Salt Lake City Health System, Salt Lake City, UT
| | - Christine Y Lu
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Klein M, Scaria G, Ganti AK. Utilization of the Veterans Affairs Central Cancer Registry to evaluate lung cancer outcomes. Semin Oncol 2019; 46:321-326. [PMID: 31690464 DOI: 10.1053/j.seminoncol.2019.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/03/2019] [Indexed: 11/11/2022]
Abstract
Lung cancer is one of the most common and difficult to treat cancers. Veterans are disproportionately affected by lung cancer, as approximately 20% of all cancers diagnosed within the Veteran Affairs health system are lung cancers. Many Veterans have extensive comorbidities, and thus they are often excluded from clinical trials based on this and other eligibility criteria. Thus, while clinical trials are the gold standard to guide treatment decisions, many Veterans' clinical situations will not align with clinical trial criteria. The Department of Veterans Affairs has established a Central Cancer Registry to aid in evaluation of cancer outcomes and other studies, and data in the registry date back to 1995. This has provided a rich source of data for outcome-based and other research. Here, we highlight studies that utilized the Veterans Affairs Central Cancer Registry to analyze lung cancer outcomes in Veterans treated within the Veterans Affairs health system.
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Affiliation(s)
- Mark Klein
- Hematology/Oncology Section, Primary Care Service Line, Minneapolis VA Health Care System, Minneapolis, Minnesota; Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| | - George Scaria
- Research Service, Minneapolis VA Health Care System, Minneapolis, Minnesota.
| | - Apar Kishor Ganti
- Division of Oncology, Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Hematology/Oncology Section, Omaha VA Medical Center-VA Nebraska-Western Iowa Healthcare System, Omaha, Nebraska.
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8
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Lammers A, Slatore CG, Fromme EK, Vranas KC, Sullivan DR. Association of Early Palliative Care With Chemotherapy Intensity in Patients With Advanced Stage Lung Cancer: A National Cohort Study. J Thorac Oncol 2018; 14:176-183. [PMID: 30336324 DOI: 10.1016/j.jtho.2018.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/11/2018] [Accepted: 09/26/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Patients with advanced lung cancer have a poor prognosis, but both chemotherapy and early palliative care (EPC) have been shown to improve survival and quality of life (QOL). The relationship between palliative care and receipt of chemotherapy receipt is understudied. We sought to determine if EPC is associated with chemotherapy receipt and intensity among patients with advanced stage lung cancer. METHODS Retrospective cohort study of patients in the national Veterans Health Administration (VA) with stage IIIB or IV lung cancer diagnosed between January 2007- December 2013. EPC was defined as a specialist-delivered palliative care received within 90 days of cancer diagnosis. Outcomes included any chemotherapy receipt and high-intensity chemotherapy receipt defined as: i) more than 4 cycles of a platinum-based doublet, ii) ≥3 lines of chemotherapy, iii) Bevacizumab/Cetuximab triplet therapy, iv) Erlotinib use prior to 2011, and v) chemotherapy in the last days of life. Logistic regression was used to determine the association between EPC and chemotherapy receipt after adjustment for patient and tumor characteristics. RESULTS Among the entire cohort (N=23,566), 37% received EPC and 45% received any chemotherapy. Among those with EPC, 34% received chemotherapy compared to 51% among those without EPC (Adjusted Odds Ratio (AOR=0.55, 95% CI: 0.51-0.58). Patients who received EPC had reduced receipt of high-intensity chemotherapy including >4 cycles of platinum-based doublet (AOR=0.68, 95% CI: 0.60-0.77), ≥ 3 lines of chemotherapy (AOR=0.61, 95% CI: 0.53-0.71), triplet therapy (AOR=0.68, 95% CI: 0.56-0.82) and use of erlotinib prior to 2011 (AOR=0.66, 95% CI: 0.55-0.79). Patients with EPC were more likely to receive chemotherapy in the last 14 (AOR=1.65, 95% CI: 1.44-1.87) and 30 days (AOR=1.67, 95% CI: 1.51-1.85) of life compared to those without EPC. CONCLUSIONS EPC was associated with reduced receipt of both any chemotherapy and high-intensity chemotherapy. However, receipt of chemotherapy at the very end-of-life was increased among patients with EPC compared to those without EPC. Among patients with advanced lung cancer, EPC may optimize patient selection for chemotherapy receipt leading to reduced use of high-intensity therapy by focusing on quality of life in accordance with patients' performance, preferences and goals of care.
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Affiliation(s)
- Austin Lammers
- Department of Hematology and Medical Oncology, Kaiser Permanente, Lafayette, Colorado; Division of Hematology Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Christopher G Slatore
- VA Portland Health Care System (VAPORHCS), Health Services Research & Development, Portland, Oregon; Oregon Health and Science University, Pulmonary and Critical Care Medicine, Portland, Oregon; VAPORHCS, Section of Pulmonary and Critical Care Medicine, Portland, Oregon; Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Erik K Fromme
- Serious Illness Care Program, Ariadne Labs, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kelly C Vranas
- VA Portland Health Care System (VAPORHCS), Health Services Research & Development, Portland, Oregon; Oregon Health and Science University, Pulmonary and Critical Care Medicine, Portland, Oregon; Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Donald R Sullivan
- VA Portland Health Care System (VAPORHCS), Health Services Research & Development, Portland, Oregon; Oregon Health and Science University, Pulmonary and Critical Care Medicine, Portland, Oregon; Cancer Prevention and Control Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon.
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9
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Lynch JA, Berse B, Rabb M, Mosquin P, Chew R, West SL, Coomer N, Becker D, Kautter J. Underutilization and disparities in access to EGFR testing among Medicare patients with lung cancer from 2010 - 2013. BMC Cancer 2018; 18:306. [PMID: 29554880 PMCID: PMC5859516 DOI: 10.1186/s12885-018-4190-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 03/06/2018] [Indexed: 01/19/2023] Open
Abstract
Background Tumor testing for mutations in the epidermal growth factor receptor (EGFR) gene is indicated for all newly diagnosed, metastatic lung cancer patients, who may be candidates for first-line treatment with an EGFR tyrosine kinase inhibitor. Few studies have analyzed population-level testing. Methods We identified clinical, demographic, and regional predictors of EGFR & KRAS testing among Medicare beneficiaries with a new diagnosis of lung cancer in 2011–2013 claims. The outcome variable was whether the patient underwent molecular, EGFR and KRAS testing. Independent variables included: patient demographics, Medicaid status, clinical characteristics, and region where the patient lived. We performed multivariate logistic regression to identify factors that predicted testing. Results From 2011 to 2013, there was a 19.7% increase in the rate of EGFR testing. Patient zip code had the greatest impact on odds to undergo testing; for example, patients who lived in the Boston, Massachusetts hospital referral region were the most likely to be tested (odds ratio (OR) of 4.94, with a 95% confidence interval (CI) of 1.67–14.62). Patient demographics also impacted odds to be tested. Asian/Pacific Islanders were most likely to be tested (OR 1.63, CI 1.53–1.79). Minorities and Medicaid patients were less likely to be tested. Medicaid recipients had an OR of 0.74 (CI 0.72–0.77). Hispanics and Blacks were also less likely to be tested (OR 0.97, CI 0.78–0.99 and 0.95, CI 0.92–0.99), respectively. Clinical procedures were also correlated with testing. Patients who underwent transcatheter biopsies were 2.54 times more likely to be tested (CI 2.49–2.60) than those who did not undergo this type of biopsy. Conclusions Despite an overall increase in EGFR testing, there is widespread underutilization of guideline-recommended testing. We observed racial, income, and regional disparities in testing. Precision medicine has increased the complexity of cancer diagnosis and treatment. Targeted interventions and clinical decision support tools are needed to ensure that all patients are benefitting from advances in precision medicine. Without such interventions, precision medicine may exacerbate racial disparities in cancer care and health outcomes. Electronic supplementary material The online version of this article (10.1186/s12885-018-4190-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julie A Lynch
- Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA. .,Veterans Health Administration, 200 Springs Road, Building 70, Bedford, MA, 01730, USA.
| | - Brygida Berse
- RTI International Waltham, Waltham, MA, USA.,Boston University School of Medicine, Boston, MA, USA
| | - Merry Rabb
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Paul Mosquin
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Rob Chew
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Suzanne L West
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Nicole Coomer
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Daniel Becker
- Veterans Health Administration, New York, NY, USA.,New York University, New York, NY, USA
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10
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Efimova O, Berse B, Denhalter DW, DuVall SL, Filipski KK, Icardi M, Kelley MJ, Lynch JA. Clinical decisions surrounding genomic and proteomic testing among United States veterans treated for lung cancer within the Veterans Health Administration. BMC Med Inform Decis Mak 2017; 17:71. [PMID: 28558785 PMCID: PMC5450357 DOI: 10.1186/s12911-017-0475-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 05/23/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current clinical guidelines recommend epidermal growth factor receptor (EGFR) mutational testing in patients with metastatic non-small cell lung cancer (NSCLC) to predict the benefit of the tyrosine kinase inhibitor erlotinib as first-line treatment. Proteomic (VeriStrat) testing is recommended for patients with EGFR negative or unknown status when erlotinib is being considered. Departure from this clinical algorithm can increase costs and may result in worse outcomes. We examined EGFR and proteomic testing among patients with NSCLC within the Department of Veterans Affairs (VA). We explored adherence to guidelines and the impact of test results on treatment decisions and cost of care. METHODS Proteomic and EGFR test results from 2013 to 2015 were merged with VA electronic health records and pharmacy data. Chart reviews were conducted. Cases were categorized based on the appropriateness of testing and treatment. RESULTS Of the 69 patients with NSCLC who underwent proteomic testing, 33 (48%) were EGFR-negative and 36 (52%) did not have documented EGFR status. We analyzed 138 clinical decisions surrounding EGFR/proteomic testing and erlotinib treatment. Most decisions (105, or 76%) were concordant with clinical practice guidelines. However, for 24 (17%) decisions documentation of testing or justification of treatment was inadequate, and 9 (7%) decisions represented clear departures from guidelines. CONCLUSION EGFR testing, the least expensive clinical intervention analyzed in this study, was significantly underutilized or undocumented. The records of more than half of the patients lacked information on EGFR status. Our analysis illustrated several clinical scenarios where the timing of proteomic testing and erlotinib diverged from the recommended algorithm, resulting in excessive costs of care with no documented improvements in health outcomes.
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Affiliation(s)
- Olga Efimova
- Department of Veterans Affairs Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
| | - Brygida Berse
- Boston University School of Medicine, 715 Albany Street, Boston, MA, 02118, USA.,Veterans Healthcare Administration Bedford, 200 Springs Rd, Bedford, MA, 01730, USA.,RTI International, 307 Waverley Oaks Rd, Waltham, MA, 02452, USA
| | - Daniel W Denhalter
- Department of Veterans Affairs Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA.,University of Utah, 30 2000 E, Salt Lake City, UT, 84112, USA
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA.,University of Utah, 30 2000 E, Salt Lake City, UT, 84112, USA
| | - Kelly K Filipski
- National Cancer Institute, NIH, 9609 Medical Center Dr, Rockville, MD, 20850, USA
| | - Michael Icardi
- University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA.,Iowa City VA Medical Center, 601 Highway 6 West, Iowa City, IA, 52246-2208, USA
| | - Michael J Kelley
- Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.,Duke University School of Medicine, 2301 Erwin Rd, Durham, NC, 27710, USA
| | - Julie A Lynch
- Department of Veterans Affairs Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA. .,RTI International, 307 Waverley Oaks Rd, Waltham, MA, 02452, USA. .,University of Utah, 30 2000 E, Salt Lake City, UT, 84112, USA. .,University of Massachusetts College of Nursing & Health Sciences, 100 Morrissey Blvd, Boston, MA, 02125, USA.
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