Financial Toxicity Monitoring in a Randomized Controlled Trial of Patient-Reported Outcomes During Cancer Treatment (Alliance AFT-39)

PURPOSE

Financial toxicity (FT) affects 20% of cancer survivors and is associated with poor clinical outcomes. No large-scale programs have been implemented to mitigate FT. We evaluated the effect of monthly FT screening as part of a larger patient-reported outcomes (PROs) digital monitoring intervention.

METHODS

PRO-TECT (AFT-39) is a cluster-randomized trial of patients undergoing systemic therapy for metastatic cancer. Practices were randomly assigned 1:1 to digital symptom monitoring (PRO practices) or usual care (control practices). Digital monitoring consisted of between-visit online or automated telephone patient surveys about symptoms, functioning, and FT (single-item screening question from Functional Assessment of Chronic Illness Therapy-COmprehensive Score for financial Toxicity) for up to 1 year, with automated alerts sent to practice nurses for concerning survey scores. Clinical team actions in response to alerts were not mandated. The primary outcome of this planned secondary analysis was development or worsening of financial difficulties, assessed via the European Organisation for Research and Treatment of Cancer QLQ-C30 financial difficulties measure, at any time compared with baseline. A randomly selected subset of patients and nurses were interviewed about their experiences with the intervention.

RESULTS

One thousand one hundred ninety-one patients were enrolled (593 PRO; 598 control) at 52 US community oncology practices. Overall, 30.2% of patients treated at practices that received the FT screening intervention developed, or experienced worsening of, financial difficulties, compared with 39.0% treated at control practices (P = .004). Patients and nurses interviewed stated that FT screening identified patients for financial counseling who otherwise would be reluctant to seek, or unaware of the availability of, assistance.

CONCLUSION

In this report of a secondary outcome from a randomized clinical trial, FT screening as part of routine digital patient monitoring with PROs reduced the development, or worsening, of financial difficulties among patients undergoing systemic cancer therapy.

Abstract P6-04-13: Centralized adequacy assessment of ductal carcinoma in situ samples for the COMET study (AFT-25)

Introduction COMET (Comparing an Operation to Monitoring, with or without Endocrine Therapy) is a phase III clinical trial randomizing patients diagnosed with low-intermediate grade DCIS to either active monitoring or surgery. The study has a planned accrual goal of 1200 patients and is enrolling until 12/31/22. The protocol requires agreement between two pathologists (who do not need to be at the same institution) that a case fulfills COMET eligibility criteria. If there is disagreement, a third pathology review is required. As per protocol, tissue blocks or unstained slides of biopsies containing DCIS from enrolled patients are sent to a designated central location. While central pathology review is not a pre-requisite of the study, a retrospective review of received materials was performed to determine adequacy for correlative molecular and spatial profiling studies. Methods Sites submit either a tissue block or twenty (20) sequentially numbered, unstained, serial five-micron tissue sections from a diagnostic biopsy of DCIS to the Alliance Foundation Trials (AFT) central biorepository, a CAP-accredited biobank. All submitted biospecimens are de-identified (coded) and investigators are blinded to arm assignment and primary study outcomes. To evaluate the adequacy of specimens for subsequent correlative science studies, one unstained slide from each submitted slide set was stained with routine hematoxylin and eosin by the biobank, scanned at 40X magnification with an Aperio scanner, and provided to one of two expert breast pathologists for adequacy review. Slides were rated as “DCIS present”, “DCIS absent”, or “possible DCIS.” To conserve tissue, submitted tissue blocks are held in abeyance pending future correlative science planning. Results As of May 2022, tissue has been submitted from 789 of 856 eligible patients enrolled in the trial, demonstrating a very high level (92%) of case submission compliance. Despite the limiting size of such lesions and general clinical center hesitancy to release blocks for clinical trial research, tissue blocks were received from 376 of 789 (48%) of cases. Among 359 cases involving slide-only submissions that have been retrospectively reviewed to date, 294 were definite DCIS (82%), 25 (7%) were classified as possible DCIS, and 40 cases (11%) were classified as no DCIS present in the section reviewed. In no case was high grade DCIS or invasive breast cancer observed. Of the cases considered possible DCIS, atypical cells were present, but the lesions were too small or incomplete to confirm DCIS. The small percentage of cases that lacked DCIS or definite DCIS could be attributed to the receipt of a different block or subsequent (deeper) section from the same block used for the initial diagnosis. These cases were previously known to the submitting institutions. Conclusion Interim analysis at 71% accrual demonstrates both the feasibility of obtaining diagnostic biopsy material of limited size and the adequacy of these samples for subsequent correlative science studies that aim to improve pathology diagnostics and patient management.

Citation Format: Rachel Factor, Stuart Schnitt, Robert West, Terry Hyslop, Thomas Lynch, Deborah Collyar, Desiree Basila, Lars Grimm, Lorraine King, Jeffrey Marks, Sunil Badve, Mark Watson, Marc Ryser, Anna Weiss, Anna Rapperport, Linda McCall, H. T. Carisa Le-Petross, Ann Partridge, E Shelley Hwang, Alastair M. Thompson. Centralized adequacy assessment of ductal carcinoma in situ samples for the COMET study (AFT-25) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-04-13.

Abstract A011: Effectiveness of an online decision support tool in communicating information about treatment options and related risks for ductal carcinoma in situ (DCIS)

Introduction: Treatment options for women diagnosed with DCIS require careful consideration of the potential risks and benefits. An interactive decision support tool (DST) was developed to provide information about these options, including their potential long-term risk. The DST was implemented through the website www.dcisoptions.org in collaboration with the AFT-25 Comparing an Operation to Monitoring, with or without Endocrine Therapy (COMET), for low-risk DCIS study. Methods: The DST provides personalized prediction of the potential clinical impact of six different treatment options over a 10-year period. Women were asked to select one or more option, and to complete two surveys - one prior to interacting with the DST and one following interaction. Chi-square tests were used to compare the distribution of age group and DCIS grade among women who completed both surveys and those who completed the pre-tool survey only. Mean age was compared using the t-test and median age was compared using the Wilcoxon-Mann-Whitney test. The signed-rank test was used to compare the median age. The cohort that answered both surveys was analyzed for potential differences in response (pre- versus post-tool). The McNemar test was used to compare percentage distributions and the paired t-test was used to compare mean responses for questions using the Likert scale. A signed rank test was used to compare median changes from pre- to post-tool. Statistical significance was defined as P<0.05 in a two-sided test. The primary endpoint of the study was to evaluate the effectiveness of the DST in communicating information about DCIS treatment options and related risk predictions. Results: Data were collected from January 2019 to April 2022 for women (non-COMET participants) who completed the DST. Of those 976 women, 831 (85%) completed the pre-tool survey only and 145 (15%) completed both the pre- and post-tool survey. The mean age was 54.4 (9.8 SD) years. 73% of women had low/intermediate-grade DCIS, while 19% had high-grade DCIS. Among women who submitted both surveys, average time spent completing the DST was 10 minutes. Awareness of the treatment options prior to use of the DST was high (90%), except for active surveillance (85.2%) and bilateral mastectomy (84.3%). Awareness post-tool did not change significantly except for active surveillance (85.2% to 96.5% (p=0.004)). Among women who completed both surveys, the percentage who correctly identified that the chance of dying from DCIS is ‘Very Low’ increased from 60.0% to 73.8% (p<0.0001). The median estimated risk of dying from DCIS in 10 years decreased from 9% to 3% (p<0.0001). A total of 101/132 (76.5%) women that responded to a specific question about the DST found it to be ‘Very Helpful’ or ‘Helpful’ in making a treatment decision for DCIS. A limitation of the study is the lower response rate to the post-tool survey. Conclusion: In this study, we demonstrated that utilization of a DST by women diagnosed with DCIS may enable value-congruent decision making and potentially result in improved patient outcomes.

Citation Format: Thomas Lynch, Ann Partridge, E. Shelley Hwang, Alastair Thompson, Elizabeth Frank, Donna Pinto, Deborah Collyar, Desiree Basila, Terry Hyslop, Marc Ryser, Anna Weiss, Anna Rapperport, Rinaa Punglia, Elissa Ozanne. Effectiveness of an online decision support tool in communicating information about treatment options and related risks for ductal carcinoma in situ (DCIS) [abstract]. In: Proceedings of the AACR Special Conference on Rethinking DCIS: An Opportunity for Prevention?; 2022 Sep 8-11; Philadelphia, PA. Philadelphia (PA): AACR; Can Prev Res 2022;15(12 Suppl_1): Abstract nr A011.

A randomized controlled trial of routine financial toxicity screening via electronic patient-reported outcomes (AFT-39)

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Background: Financial toxicity affects 20% of cancer survivors and is associated with decreased treatment adherence and poor clinical outcomes. No large-scale programs have been implemented to mitigate financial toxicity among patients undergoing cancer treatment. We evaluated the effect of monthly patient-reported financial toxicity screening as part of a larger digital monitoring intervention. Methods: PRO-TECT (AFT-39) is a cluster-randomized trial of patients undergoing systemic therapy for metastatic cancer. Practices were randomized 1:1 to digital symptom monitoring with patient-reported outcomes (“PRO practices”) or usual care (“control practices”). Digital monitoring consisted of between-visit online or automated telephone patient surveys containing symptom, functioning, and financial toxicity screening questions for up to one year, with automated alerts sent to practice nurses for concerning survey scores. Clinical team actions in response to alerts were not mandated. The primary outcome of this analysis was development or worsening of financial difficulties, assessed via the EORTC QLQ-C30 (“Has your physical condition or medical treatment caused you financial difficulties?”), at any time compared to baseline. A randomly selected subset of patients and nurses were interviewed about their experiences with the intervention. Results: 1,191 patients were enrolled (593 PRO; 598 control) at 52 US community oncology practices. Overall, 30.2% of patients treated at practices that received the intervention developed, or experienced worsening of, financial difficulties, compared to 39.0% of patients treated at control practices (p = 0.01). Patients and nurses interviewed stated that financial toxicity screening identified patients for financial counseling who otherwise would be reluctant to seek, or unaware of the availability of, assistance. Conclusions: Screening for financial toxicity as part of routine digital patient monitoring with PROs reduces the development, or worsening, of financial difficulties among patients undergoing systemic cancer therapy. Clinical trial information: NCT03249090.

Antibiotic iontophoresis for the management of burned ear chondritis

A total of 11 ears in 8 patients were treated with iontophoresis utilizing either gentamicin sulfate or potassium penicillin. All patients experienced rapid healing with little or no deformity.