Oncologist Perceptions of Racial Disparity, Racial Anxiety, and Unconscious Bias in Clinical Interactions, Treatment, and Outcomes

BACKGROUND

Cancer spares no demographic or socioeconomic group; it is indeed the great equalizer. But its distribution is not equal; when structural discrimination concentrates poverty and race, zip code surpasses genetic code in predicting outcomes. Compared with White patients in the United States, Black patients are less likely to receive appropriate treatment and referral to clinical trials, genetic testing, or palliative care/hospice.

METHODS

In 2021, we administered a survey to 369 oncologists measuring differences in perceptions surrounding racial disparity, racial anxiety, and unconscious bias and adverse influence on clinical interactions, treatment, and outcomes for non-White patients. We analyzed responses by generational age group, sex/gender, race/ethnicity, US region, and selection of "decline to respond."

RESULTS

The most significant differences occurred by age group followed by race/ethnicity. Racial disparity was perceived as moderate to very high by 84% of millennial, 69% of Generation X, and 57% of baby boomer oncologists, who were also 86% more likely than millennials and 63% more likely than Generation Xers to perceive low/nonexistent levels of racial anxiety/unconscious bias.

CONCLUSIONS

Most oncologists rarely or never perceived racial anxiety/unconscious bias as adversely influencing clinical treatment or survival outcomes in non-White patients, and White oncologists were 85% more likely than non-White oncologists to perceive rare/nonexistent influence on referral of non-White patients to palliative care/hospice. The discrepancy between 62% of oncologists perceiving moderate to very high levels of racial anxiety/unconscious bias and 37% associating them with adverse influence on non-White patients shows a disconnect, especially among older oncologists (baby boomers), who were also least likely to select the decline option. Together, these factors hinder effective patient-provider communication and result in differential care and outcomes. Oncologists should uncover their own perceptions surrounding racial disparity, racial anxiety, and unconscious bias and modify their behaviors accordingly. It is this simple-and this complicated. Cancer does not discriminate, and neither should cancer care.

Real-World Use of Fedratinib for Myelofibrosis Following Prior Ruxolitinib Failure: Patient Characteristics, Treatment Patterns, and Clinical Outcomes

BACKGROUND

There is a lack of established clinical outcomes for patients with myelofibrosis (MF) receiving fedratinib following ruxolitinib failure. This study examined real-world patient characteristics, treatment patterns, and clinical outcomes of patients with MF treated with fedratinib following ruxolitinib failure in US clinical practice.

PATIENTS AND METHODS

This retrospective patient chart review included adults with a physician-reported diagnosis of MF, who initiated fedratinib after discontinuing ruxolitinib. Descriptive analyses characterized patient characteristics, clinical outcomes, and treatment patterns from MF diagnosis through ruxolitinib and fedratinib treatment.

RESULTS

Twenty-four physicians abstracted data for 150 eligible patients. Approximately 55.3% of the patients were male, 68.0% were White, and median age at MF diagnosis was 68 (range, 35-84) years. Median duration of ruxolitinib therapy was 7.6 (range, 0.7-65.5) months. At initiation of fedratinib, 88.0% of patients had palpable spleen and a mean spleen size of 16.0 (standard deviation [SD], 5.9) cm. Spleen size decreased by 19.4% to 13.2 (SD, 7.9) cm at month 3 (P = .0001) and by 53.4% to 7.2 (SD, 7.4) cm at month 6 (P = .01) of fedratinib treatment, respectively. Almost one-third (26.8%) of patients had achieved ≥ 50% spleen reduction by month 6. Mean number of symptoms also decreased significantly at month 3 (P < .0001) and month 6 (P = .01).

CONCLUSION

Fedratinib appears to deliver spleen and symptom benefits in real-world patients with MF previously treated with ruxolitinib.

Prevalence of historical medical conditions or comorbidities with potential role in clinical decision making related to suitability of immuno-oncologic plus IV antiangiogenic therapy in newly diagnosed first-line unresectable hepatocellular carcinoma in the United States

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Background: Treatment landscape in advanced/unresectable hepatocellular carcinoma (uHCC) has been rapidly changing. In June 2020, the first immuno-oncologic (I/O) + IV anti-angiogenic regimen for uHCC was approved as first line (1L) treatment in the US. As with any new therapy, it is key to understand the prevalence of medical conditions listed in patient medical history/comorbidities that could potentially influence physician choice of 1L therapy in uHCC patients. Methods: We conducted a retrospective chart review study using Cardinal Health's Oncology Provider Extended Network (OPEN). US medical oncologists identified newly diagnosed adult uHCC patients initiating 1L systemic therapy from June 2020 to April 2022. Based on the warnings and precautions section of the US FDA labels, medical conditions reported as part of patient medical history or comorbidities [including gastrointestinal (GI) bleeding risk, chronic kidney disease, autoimmune disorders, thromboembolic events] were identified from patient medical records. Less suitable was defined as the occurrence of ≥ 1 medical condition/comorbidity reported in the medical record. All patient data were deidentified. Proportions of patients with the above medical conditions or with physician-reported record of an esophagogastroduodenoscopy (EGD) procedure to assess risk of bleeding were calculated. Results: In the cohort of 433 uHCC patients initiating 1L systemic therapy, majority were male 287 (66%), Caucasian 244 (56%) with average age of 64 years. At 1L initiation, majority of the patients were 333 BCLC Stage C (77%) and 316 (73%) had ECOG performance status of 0 or 1. Approximately 160 (37%) were Child-Pugh B, 99 (23%) had non-alcoholic steatohepatitis (NASH), 176 (41%) had Hep-C etiology (among those tested), and 294 (68%) had liver cirrhosis. Prior to therapy initiation, 254 (59%) received EGD within 3 months. In the overall cohort, 221 (51%) patients were reported to have at least one condition listed as medical history/comorbidity that could make them less suitable to receive I/O + IV anti-angiogenic regimen. Upper/lower GI bleeding risk and chronic kidney disease were reported in 164 (38%) and 64 (15%) patients, respectively. History of thromboembolic events and autoimmune disorders were reported in 50 (12%) and 22 (5%) of patients, respectively. Conclusions: A significant proportion of the newly diagnosed uHCC patients were found to have at least one condition listed as medical history/comorbidity that would make them potentially less suitable for I/O + IV anti-angiogenic regimen. Our findings reinforce the importance of medical history and co-morbidity assessment in uHCC patients prior to therapy selection to optimize benefit-risk ratio for each patient.

Outcomes in patients with resected stage IIIA melanoma treated with adjuvant nivolumab or monitored with observation: A real-world study

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Background: Nivolumab is approved in the United States and other countries as an adjuvant treatment for patients with completely resected stage III–IV melanoma based on results of the phase 3 CheckMate 238 trial, though the trial enrolled a limited number of patients with stage IIIA disease (AJCC-8). The objective of this real-world study is to describe characteristics, treatment patterns, and outcomes of patients with resected stage IIIA melanoma (AJCC-8) treated with adjuvant nivolumab or monitored with observation. Methods: In this retrospective, chart-review study, physicians from Cardinal Health’s proprietary Oncology Provider Extended Network (OPEN) extracted data from electronic health records of patients who had undergone complete surgical resection of stage IIIA melanoma between Jan. 1, 2018, and Dec. 31, 2019. Recurrence-free survival (RFS) and overall survival (OS) were evaluated from the date of resection and compared between the adjuvant nivolumab and observation cohorts using log-rank tests and adjusted Cox proportional hazards models (covariates included age, sex, race, region, payer type, ECOG PS, and Charlson Comorbidity Index). Discontinuations and deaths due to adjuvant nivolumab toxicity were assessed. Results: This study included 171 patients treated with adjuvant nivolumab and 38 patients monitored with observation. In the adjuvant nivolumab and observation cohorts, respectively, mean age was 57.4 and 68.1 years; most patients were male (59% and 68%) and white (90% and 87%); and median follow-up from resection was 20.7 and 25.0 months. Sentinel lymph node tumor burden of < 1 mm was reported in 12% (n = 20) and 16% (n = 6) of patients in the adjuvant nivolumab and observation cohorts, respectively. The scheduled treatment course with adjuvant nivolumab was completed by 91% of patients (n = 155). RFS and OS rates were numerically higher with adjuvant nivolumab than with observation (Table). There was a trend toward RFS and OS benefit with adjuvant nivolumab versus observation (unadjusted RFS HR 0.53, 95% CI 0.26–1.09; adjusted RFS HR 0.62, 95% CI 0.28–1.40; unadjusted OS HR 0.55, 95% CI 0.19–1.57; adjusted OS HR 0.81, 95% CI 0.25–2.61). Discontinuation of adjuvant nivolumab due to toxicity occurred in 2% of patients (n = 4); no treatment-related deaths were reported. Conclusions: These real-world results confirm that patients with resected stage IIIA melanoma (AJCC-8) have a good prognosis. Treatment with adjuvant nivolumab may provide modest survival benefit over observation in this population, though increased sample size and additional follow-up are warranted.[Table: see text]

Real-world utilization of ctDNA in the management of colorectal cancer

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Background: The utilization of circulating tumor DNA (ctDNA) as a non-invasive biomarker for the detection of minimal residual disease, prediction of recurrence in the post-operative setting, and real-time monitoring of treatment efficacy has the potential to vastly improve the care and outcomes of patients with colorectal cancer (CRC). In August of 2020, ctDNA testing first gained approval for use in solid tumors and its prognostic benefit after curative intent surgery has been demonstrated to exceed that of prior standard of care clinicopathological criteria in CRC patients. The comprehensive integration of validated ctDNA approaches into the routine clinical care of patients with CRC would not only fundamentally change how risk of recurrence is assessed but could also reduce treatment with unneeded/unwarranted toxic therapies and allow for earlier recognition and treatment in cases with a high risk of relapse. This survey-based study aimed to evaluate the utilization of ctDNA testing in the management of CRC among practicing community oncologists in the U.S. Methods: Questions related to ctDNA utilization for patients with CRC were presented to community oncologists during a virtual meeting held in July 2021. Descriptive statistics were used to analyze the results. Results: Of 55 participating oncologists geographically distributed across the U.S., 49% indicated not using ctDNA to make treatment decisions in CRC. A proportion of physicians reported using ctDNA to detect recurrence (27% of physicians); make decisions around post-resection adjuvant therapy (25%); monitor disease progression/relapse (18%); and track tumor resistance during treatment (9%). The most frequently cited barriers to ordering ctDNA testing for patients with metastatic CRC were reimbursement issues (reported by 56% of oncologists), insufficient clinical evidence (46%), and limited familiarity with ctDNA use (28%). Oncologists reported that the following would increase their utilization of ctDNA testing: more clinical evidence of the utility of ctDNA (reported by 66% of physicians), increased education on methodology (60%), more education on the use of ctDNA (57%), more financial aid and reimbursement support for patients (49%), more decision support tools (47%), and better communication between physicians and vendors (26%). Conclusions: These findings demonstrate limited adoption of ctDNA testing by community oncologists in the care of CRC patients. Insufficient demonstration of clinical utility, limited familiarity with methodology, and reimbursement issues were cited as barriers to uptake. Education for community oncology providers about ctDNA testing and its demonstrated clinical utility, and increased financial support for patients may improve its utilization and adoption in CRC to improve patient outcomes and care.

Mental health care for oncology patients in community settings

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Background: Research suggests that between thirty and fifty percent of patients with cancer experience psychiatric disorders across the cancer trajectory. As part of standard cancer care, mental health care can reduce distress and psychological morbidity for patients and improve their quality of life. Mental health treatment may even improve cancer survival rates.Considering the mental health issues relevant to cancer, implementation of mental health care into routine clinical care remains a challenge among community-based hematologists/oncologists (cH/O). Methods: Practicing U.S. cH/O completed a cross-sectional, web-based survey from September through November 2021. The survey collected demographic information and assessed physicians’ experiences and awareness regarding mental health diagnosis, frequency, severity, and management among their patients. Data were summarized using descriptive statistics. Results: Participants (N = 243) specialized in hematology/oncology (63%), medical oncology (36%) (1% other). The majority practiced in community-based settings unaffiliated with an academic center or hospital (73%). The majority (92%) agreed that mental health can significantly impact the health outcomes of patients with cancer. The majority (80%) frequently see patients coping with mental illness or distress. More than a quarter of the participants reported that their practice has clinical psychologists (27%), and nearly half (46%) have social workers on staff. About half (51%) occasionally refer patients for mental health services/treatment while 15% rarely or never refer. Nearly half (49%) indicated they do not have adequate resources to support the mental health needs of their patients with cancer. Conclusions: Our findings that oncologists have high levels of awareness about mental health issues among their patients with cancer is encouraging as is their incorporation of professionals on the care team to address this need. However, oncologists indicated that their available mental health resources are inadequate to meet patients’ needs and external referrals are limited. These findings suggest that additional resources and referrals are needed to ensure that patients will consistently receive the mental health care they need. Future research to assess the impact of mental health care on clinical outcomes including quality of life in patients with cancer is warranted.

Racial differences in treatment patterns and outcomes of first-line (1L) therapies for advanced renal cell carcinoma (aRCC) in the real-world (RW) setting

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Background: In 1L therapy for aRCC, nivolumab plus ipilimumab (NIVO+IPI) and pembrolizumab plus axitinib (PEM+AXI) have demonstrated significantly improved clinical outcomes versus sunitinib in phase III trials. African American/Black (AA) patients are grossly underrepresented in all aRCC trials. Little is known about the impact of racial differences on the use of 1L therapies and clinical outcomes in the RW setting. Methods: This retrospective chart review included AA and White American (WA) patients diagnosed with International Metastatic Renal Cell Carcinoma Database Consortium (IMDC)/Memorial Sloan Kettering Cancer Center (MSKCC) intermediate/poor (I/P)-risk aRCC who initiated on 1L NIVO+IPI, PEM+AXI, or tyrosine kinase inhibitor (TKI) monotherapy with sunitinib, pazopanib, or cabozantinib. Patients’ demographic/clinical characteristics and outcomes were abstracted from medical charts by treating oncologists. Use of 1L therapy, treatment discontinuation, and clinical outcomes including disease response, landmark progression-free survival (PFS), landmark overall survival (OS), and treatment-related adverse event (TRAE) rates were assessed descriptively by race. Results: Of 473 patients, 95 (20.1%) were AA, and 378 (79.9%) were WA patients. Median follow-up was 10.9 months. A higher proportion of AA vs. WA patients had received 1L TKI monotherapy (21.1% vs. 16.1%). Treatment discontinuation rate was higher in AA vs. WA patients (49.5% vs. 43.4%). Treatment response was lower in AA than WA patients (overall response rate [ORR]: 58.8% vs. 74.8%; complete response [CR]: 8.2% vs. 11.4%). The TRAE rate was slightly lower in AA vs. WA patients (25.3% vs. 32.5%). Stratified clinical outcomes including landmark PFS and OS rates at 6 and 9 months are shown in the Table. Conclusions: In this RW I/P-risk aRCC cohort, fewer AA patients were treated with standard of care immune-oncology (IO)-based therapy vs. WA patients, which may contribute to differences in therapy discontinuation and survival outcomes. Also, even with short follow-up, clinically meaningful ORR differences are noted in AA and WA patients. [Table: see text]

Monitoring and management of interstitial lung disease/pneumonitis among patients with metastatic breast cancer treated with trastuzumab deruxtecan

1036

Background: Trastuzumab Deruxtecan (T-DXd) was associated with an increased risk of interstitial lung disease (ILD)/pneumonitis (P) in metastatic breast cancer (mBC) patients (pts) in clinical trials, leading to ILD/P monitoring and management guidelines in the product label. This study aims to describe the monitoring and management of ILD/P during T-DXd therapy among US community oncology practices. Methods: Oncologists in the Cardinal Health Oncology Provider Extended Network (OPEN) participated in a cross-sectional survey on monitoring approaches for ILD/P among mBC pts. Participating physicians provided data from medical charts of up to 10 pts who were treated with T-DXd regarding presence of ILD/P symptoms, management, and outcomes of ILD/P symptoms. Results: Twenty-eight physicians from across the U.S participated and provided data on 149 T-DXd pts. Nearly all physicians reported they were monitoring ILD/P after T-DXd initiation by physical examination (n = 27), symptoms checklist (n = 25) and pulse oximetry (n = 23) at every visit, whereas fewer reported performing lung CT scan (n = 18), echocardiogram (n = 13), chest X-ray (n = 12), lung PET scan (n = 10), pulmonary function tests (n = 8) and diffusion testing (n = 7) on a less frequent basis. Among 149 T-DXd pts, 4 pts were diagnosed with ILD/P over an average T-DXd treatment duration of 5.5 months. All 4 cases initiated T-DXd treatment at 5.4mg/kg every 3 weeks, experienced ILD/P within the first 5 cycles of T-DXd, were diagnosed with lung CT scan and initially presented with Grade 2 symptomology (2 cases progressed to Grade 3). For both cases that remained as Grade 2, ILD/P completely resolved within 23 days. One case received IV methylprednisolone (1000mg daily; duration of therapy (DOT): 3 days) during hospitalization, oxygen therapy and T-DXd was permanently discontinued; whereas the other one received oral prednisone (started at 40mg daily and tapered to 5mg daily; DOT: 7 days) and T-DXd dose was held. For the two grade 3 cases, one received IV methylprednisolone (125mg daily; DOT: 7 days) during hospitalization, T-DXd dose was held, and ILD/P completely resolved within 11 days; whereas the other case received oral prednisone (started at 80mg daily and tapered to 5mg daily; DOT: 63 days), oxygen therapy, T-DXd was permanently discontinued, and ILD/P resolved with sequela within 46 days. Conclusions: ILD/P incidence in this small study sample of patients receiving T-DXd treatment was 2.7%. Although general awareness of ILD and routine screening by pulse oximetry and physical exam were common, management approaches for ILD/P were not always consistent with T-DXd prescribing information. Further physician education may be needed to improve appropriate management of ILD/P and outcomes for T-DXd pts.

US physician perceptions of treatment decision making for advanced renal cell carcinoma

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Background: The immuno-oncology (IO) therapy combination nivolumab + ipilimumab, and the IO-tyrosine kinase inhibitor (TKI) combination pembrolizumab + axitinib, received US FDA approvals in 2018 and 2019, respectively, as first-line (1L) therapy for advanced renal cell carcinoma (aRCC). We examined physician perceptions of concerns about and barriers to 1L treatment by class of regimen (IO-IO, IO-TKI, and single-agent TKI [SA-TKI]) in the United States. Methods: US-based oncologists treating ≥ 5 aRCC patients in the prior 12 months were identified from the Cardinal Health network, a community of > 800 oncologists. Physicians were surveyed about concerns in prescribing and barriers to treating by class (scale of 1–5; 1 = no concern/not a barrier, 5 = most concerning/major barrier); mean scores are reported. Adverse events (AEs) of concern were selected from a prespecified list and respondents rank-ordered from most to least concerning by class. Physicians were also asked to gauge affordability and to rank-order 13 characteristics to identify key factors in prescribing preference. The impact of COVID-19 on aRCC care in practice was also assessed. Results: A total of 49 providers (84% community, 16% academic) treating a median of 20 (IQR 14–30) aRCC patients from across the United States participated. For IO-IO, the top 3 concerns in prescribing were AEs (4.3), patient out-of-pocket costs (OOP; 3.7), and unexpected late AEs (3.6), whereas patient OOP (4.3), AEs (4.1), and patient adherence (3.9) were of most concern for IO-TKI. For SA-TKIs, the top 3 concerns were patient adherence (3.9), patient OOP (3.9), and AEs (3.6). High patient OOP and impact on quality of life were the top 2 barriers in using IO-TKI therapy. The most concerning AEs were colitis, pneumonitis, and hypertension for IO-IO or IO-TKI, and diarrhea, fatigue, hand-foot syndrome, and hypertension for SA-TKI. Overall survival (OS), progression-free survival (PFS), and complete response (CR) were ranked 1st, 2nd, and 3rd factors in prescribing preferences while patient compliance, patient preference, and practice reimbursement ranked 11th, 12th, and 13th. Patient OOP and drug acquisition costs (DAC) were the most important factors when considering the affordability of treatment, with the perception that IO-IO was the most expensive among the classes of therapy. The overall impact of COVID-19 on caring for aRCC patients was very limited, with a moderate increased use of telemedicine and a slight impact on the timing and number of routine care visits. Conclusions: OS, PFS, and CR ranked highest among the most important factors influencing selection of 1L treatment for aRCC. Factors of concern and barriers varied by class of treatment, with patient adherence and OOP affecting use of TKI or IO-TKI therapies, and AEs affecting the use of IO-based therapy. This study revealed perceptions of high patient OOP and DAC of IO-IO therapy, in contrast to our expectations.

Community oncologists’ perceptions of and barriers to access for 177LU-PSMA-617 in metastatic castration-resistant prostate cancer

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Background: Metastatic castration-resistant prostate cancer (mCRPC) is a difficult-to-treat cancer with poor patient outcomes. In June 2021, 177Lu-PSMA-617 was granted U.S. FDA breakthrough designation for the treatment of mCRPC based on results from the phase III VISION trial showing a 4-month increased median overall survival (15.3 v 11.3 m; HR 0.62 [0.52-0.74], P < 0.001) and a 5.3-month increased radiographic progression-free survival (8.7 v 3.4 m; HR 0.40 [0.29-0.57] for 177Lu-PSMA-617 versus standard of care (SOC). If approved, 177Lu-PSMA-617 has the potential to improve patient outcomes, but its impact will depend significantly on how community-based medical oncologists (cbMO) plan to integrate it into patient management. The present study surveyed cbMO regarding their perceptions of the VISION trial data and potential barriers to 177Lu-PSMA-617 use in mCRPC. Methods: Between June and October 2021, practicing U.S.-based cbMO were invited to attend a virtual meeting and were presented with the VISION trial data. Their reactions to the data and preferences were collected using audience response technology. Results are presented using descriptive statistics. Results: Among the 287 participating cbMO, median years in practice was 17 (1-45), and median time spent in direct patient care was 90% (20-100%). In the past year, 46% of cbMO managed 6-15 patients with mCRPC, and 27% managed 16 or more. CbMO reported that at the time of referral, their patients with mCRPC had commonly been treated with androgen deprivation therapy (77%) and one (49%) or two plus (20%) novel hormonal agents. After reviewing the recent data from the VISION trial showing improved survival outcomes in mCRPC, 51% of cbMO reported that both the safety and efficacy data were compelling, and they were very likely to prescribe 177Lu-PSMA-617 if approved; 33% indicated that the efficacy data alone was compelling and were likely to prescribe 177Lu-PSMA-617. The top 2 limitations of the VISION trial were identified as PSMA gallium positivity for eligibility (54%) and the disallowance of radium-223 on the SOC arm (48%). Regarding perceived barriers to future use of 177Lu-PSMA-617, 68% and 64% of cbMO reported availability of a PSMA-gallium scan and availability/access of the therapy itself, respectively, would be the greatest barriers. Additional barriers included cost (42%) and difficulty with reimbursement (30%), highlighting the importance of addressing access and financial considerations associated with 177Lu-PSMA-617. Conclusions: Most cbMO found the VISION trial data of 177Lu-PSMA-617 in mCRPC compelling and indicated that they are likely to incorporate it into their patient management, if approved. However, major barriers such as the incorporation of PSMA-gallium scans, 177Lu-PSMA-617 availability, and cost will need to be addressed to encourage widespread adoption of this new therapy.

Economic and clinical impact of a novel, light-based, at-home antiviral treatment on mild-to-moderate COVID-19

OBJECTIVES

Antiviral treatments for early intervention in patients with mild-to-moderate COVID-19 are needed as a complement to vaccination. We sought to estimate the impact on COVID-19 cases, deaths, and direct healthcare costs over 12 months following introduction of a novel, antiviral treatment, RD-X19, a light-based, at-home intervention designed for the treatment of mild-to-moderate COVID-19 infection.

METHODS

A time-dependent, state transition (semi-Markov) cohort model was developed to simulate infection progression in individuals with COVID-19 in 3 US states with varying levels of vaccine uptake (Alabama, North Carolina, and Massachusetts) and at the national level between 1 June 2020 and 31 May 2021. The hypothetical cohort of patients entering the model progressed through subsequent health states after infection. Costs were assigned to each health state. Number of infections/vaccinations per day were incorporated into the model. Simulations were run to estimate outcomes (cases by severity, deaths, and direct healthcare costs) at various levels of adoption of RD-X19 (5%, 10%, 25%) in eligible infected individuals at the state and national levels and across three levels of clinical benefit based on the results from an early feasibility study of RD-X19. The clinical benefit reflects a decline in the duration of symptomatic disease by 1.2, 2.4 (base case), and 3.6 days.

RESULTS

In the base case analysis with 10% adoption, simulated infections/deaths/direct healthcare costs were reduced by 10,059/275/$69 million in Alabama, 21,092/545/$135 million in North Carolina, and 16,670/415/$102 million in Massachusetts over 12 months. At the national level, 10% adoption reduced total infections/deaths/direct healthcare costs by 686,722/17,748/$4.41 billion.

CONCLUSION

At-home, antiviral treatment with RD-X19 or other interventions with similar efficacy that decrease both symptomatic days and transmission probabilities can be used in concert with vaccines to reduce COVID-19 cases, deaths, and direct healthcare costs.

Impact of social determinants of health on cancer care: a survey of community oncologists

OBJECTIVE

Cancer survival rates have improved over the past few decades, yet socioeconomic disparities persist. Social determinants of health (SDOH) have consistently been shown to correlate with health outcomes. The objective of this study was to characterise oncologists' perceptions of the impact of SDOH on their patients, and their opinions on how these effects could be remediated.

DESIGN

Cross-sectional survey of physicians.

SETTING

Web-based survey completed prior to live meetings held between February and April 2020.

PARTICIPANTS

Oncologists/haematologists from across the USA.

EXPOSURE

Clinical practice in a community-based or hospital-based setting.

MAIN OUTCOME AND MEASURE

Physician responses regarding how SDOH affected their patients, which factors represented the most significant barriers to optimal health outcomes and how the impact of SDOH could be mitigated through assistance programmes.

RESULTS

Of the 165 physicians who completed the survey, 93% agreed that SDOH had a significant impact on their patients' health outcomes. Financial security/lack of insurance and access to transportation were identified most often as the greatest barriers for their patients (83% and 58%, respectively). Eighty-one per cent of physicians indicated that they and their staff had limited time to spend assisting patients with social needs, and 76% reported that assistance programmes were not readily accessible. Government organisations, hospitals, non-profit organisations and commercial payers were selected by 50% or more of oncologists surveyed as who should be responsible for delivering assistance programmes to patients with social needs; 42% indicated that pharmaceutical manufacturers should also be responsible.

CONCLUSION

Our survey found that most oncologists were aware of the impact of SDOH on their patients but were constrained in their time to assist patients with social needs. The physicians in our study identified a need for more accessible assistance programmes and greater involvement from all stakeholders in addressing SDOH to improve health outcomes.

Interaction with patients of color or ethnic minority (PCEM): Oncologist perceptions of racial anxiety and/or implicit bias (RA/IB)

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Background: Oncologists interacting with PCEM may be unaware of RA/IB, yet data show lower-quality care. Helping oncologists recognize this may improve quality of patient-provider interaction, care, and outcomes. We conducted a descriptive study of medical/hematologic oncologists to assess perceptions of RA/IB impact on PCEM interaction. Methods: From February to April 2021, U.S.-based medical/hematologic oncologists participated in an online survey of perceptions on cancer care and outcomes in PCEM (part of broader survey of various clinical and practice-related concerns). Questions used a modified 5-point Likert scale with an option of declining to answer, and respondents were aware data would be anonymized and aggregated. Results: Among 369 physicians surveyed, median years in practice were 17 (range 2-49). Most (72.4%) were in community settings; 64.0% were age 40 to 59 years; 20.6% identified as female, 70.5% male, and 8.7% declined to disclose. Racial distribution was 32.0% White, 33.1% Asian, 7.0% Black, 4.1% Hispanic/Latinx, and 18.7% declined to disclose. When asked the degree of RA/IB White providers had toward PCEM, 39.6% chose low/none, 33.3% moderate, 14.9% high/very high, and 12.2% declined. When asked whether RA/IB among White providers adversely affects PCEM, 37.1% somewhat/strongly agreed, 29.3% somewhat/strongly disagreed, 23.6% neither agreed nor disagreed, and 10.0% declined. Also, 7.9% declined to estimate percent of non-White patients managed. Perceived frequency of scenarios involving RA/IB impacting PCEM interaction at their practices was also assessed (Table). Notably, 12.0% to 14.0% declined to answer regarding their own practices. Although most oncologists (76.4%) perceived RA/IB among White providers toward PCEM, only 37.1% agreed it had adverse effects. Conclusions: Discrepancy in perception of RA/IB among White providers and its effect on PCEM suggests a need to show causality, and declining to respond suggests mistrust/apprehension in expressing true views. Findings suggest oncologists may benefit from improved education and awareness regarding RA/IB in PCEM interaction, treatment, and outcomes. Provider responses (N=369).[Table: see text]

Physician satisfaction with electronic medical records (EMRs): Time for an intelligent health record?

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Background: EMRs are devised to improve the quality and efficiency of healthcare delivery and to reduce medical errors. Despite the widespread use of EMRs, various factors can limit their effectiveness in improving healthcare quality. General EMR use has been cited as a factor contributing to increased workload and clinician burnout in oncology and other specialties. The objective of this qualitative research study was to identify barriers perceived by medical oncologists and hematologists (mO/H) in utilizing EMR software and factors associated with levels of satisfaction. Methods: Between January and April 2021, mO/H from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 369 mO/H completed the survey: 72% practice in a community setting; 47% identified as a hospital employee; they have an average of 19 years of clinical experience and spend on average 86% of their working time in direct patient care, seeing 17 patients per day on average on clinic days. Most (99%) of mO/H surveyed use an EMR software at their practice, with Epic (45%) and OncoEMR (16%) being the most common. Regarding satisfaction, 16% and 50% reported feeling highly satisfied and satisfied, respectively, with their current EMR, and 3% and 11% reported feeling very dissatisfied or dissatisfied, respectively. Some (19%) stated that they have considered changing their EMR, and 68% are unsure how EMR licensing fees for their practice are paid. EMR pain points most commonly experienced were: time-consuming, e.g., too many steps/click (70%); interoperability, e.g., difficulty sharing information across institutions or other EMR software (45%); data entry issues, e.g., difficulty entering clinical information, scheduling patient visits and reminders, or ordering multiple labs (38%); and poor workflow support (31%). The most useful aspects/features of their EMR software reported were availability of information, e.g., preloaded protocols, chemotherapy regimens and pathways (64%); data access (64%); and multiple access points, including remote access (37%). Conclusions: Satisfaction with EMR were generally positive among the mO/H surveyed. However, there are multiple deterrents to the efficient use of current EMR systems. This information is essential in the design of next-generation EMR (an Intelligent Medical Records system) to allow for incorporation of aspects most useful to the end-users, such as pathway access, preloaded information on cancer management as well as ease of access and portability, and a user experience that minimizes clicks and reduces physician time with EMR.

Impact of COVID-19 pandemic on oncologists’ professional and personal lives: A pre-vaccine study

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Background: The COVID-19 pandemic has adversely impacted healthcare workers globally, leading to high rates of burnout, especially among frontline workers. We conducted a study to assess the pandemic’s impact on community-based medical oncologists and hematologists (mO/H) in the U.S. before the widespread distribution of vaccines. Methods: Between October and December 2020, mO/H participated in a compensated, online survey addressing the impact of COVID-19 on oncologists’ professional and personal lives and other issues in oncology; demographic, clinical, and practice-based questions were also asked. Results are presented using descriptive statistics. Results: A total of 259 geographically diverse mO/H, with a median of 18 (1-42) years in practice, completed the survey. At the time of the study, local trends in COVID-19 cases were reported as increasing, stable, or decreasing by 29%, 51%, and 20%, respectively. The summative view of the pandemic was “proud of my work as a physician in the frontlines” (37%), “a challenge to get through” (35%), and “no significant impact” (23%). Over half reported a moderate to severe impact on their professional (60%) and personal lives (65). The top 3 factors adversely impacting professional life were: concern of transmitting COVID-19 to patients or staff (52%), difficulty providing patient care (45%), and loss of income (41%). The top 4 factors adversely impacting personal life were: concerns of safety for self and family (84%), a sense of anxiety (50%), loss of family income (24%), and a sense of depression/doom (22%). Fifty percent agreed or strongly agreed that they had increased burnout at work since the beginning of the pandemic. However, workload was assessed as stable (51%) or reduced (33%) during the pandemic. The top 3 factors contributing to burnout were: loss of face-to-face patient interaction (46%), financial loss by practice (42%), and reduced patient volume (35%). The factors thought to impact income were: use of virtual patients visits (38%), pay cuts from the employer (33%), and cancellation of elective procedures (31%). Overall, 41% reported receiving funds from government-based programs (e.g., CARES act) during the pandemic. While about half (52%) did not believe that the pandemic would impact their retirement, some felt that the pandemic would likely hasten (17%) or delay (17%) their plans to retire. Conclusions: This study confirms greater feelings of burnout among U.S. community-based mO/H in the wake of the pandemic and offers insight into drivers of professional and personal dissatisfaction. While mO/H have concerns about loss of income, notably, loss of in-person patient interaction is also a key factor impacting their professional satisfaction. Given the high baseline rate of burnout among mO/H, it is critical to prevent, mitigate and control additional risks imposed by pandemic-related factors.

Barriers to participation and success in value-based care (VBC) models

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Background: The enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 initiated the transition from a fee-for-service to a fee-for-value payment system in healthcare. Two government-sponsored VBC models (Oncology Care Model [OCM] and Merit-Based Incentive Payment System [MIPS]) were introduced in 2016 and 2017. Several commercial payers followed suit with similar value-based contracts. Implementing and complying with the performance metrics of these models comes with challenges. This qualitative research study sought to assess participation in both government-sponsored and commercial-insurance-sponsored VBC models among oncology providers and their perceptions regarding the ability to perform successfully. Methods: Between February and April 2021, medical oncologists/hematologists (mO/H) from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 307 mO/H across the U.S. completed the survey: 73% practice in a community setting; 47% identify as hospital employees. The participants spend a median of 90% of their working time in direct patient care, have a median of 16 years of clinical experience, and see a median of 20 patients per day on clinic days. Half participate in a government-sponsored VBC model (21% MIPS and 28% OCM), and 20% participate in a commercial VBC model. A third reported that it is difficult to perform favorably in VBC models (37% government and 35% commercial). Primary challenges deterring favorable performance were navigating the payer landscape and reimbursements (27%), identifying cost-reduction opportunities (20%), tracking costs across an episode (18%), and clinical decision support and compliance (17%). One-third are not satisfied with currently available technology to effectively support their performance in VBC models. Almost half would like to see more seamless integration into practice workflows (49%) and interoperability across platforms including EHRs (42%), and 24% would like artificial intelligence or machine learning features integrated into solutions tools. Conclusions: Oncology practices find it challenging to perform favorably in government and private payer-sponsored VBC models. They are generally dissatisfied with current technology and see an unmet need for interoperability and artificial intelligence to better support their performance in these programs. Further research is needed to determine how best to design and implement VBC programs.

Adoption of telemedicine (Telemed) by medical oncologists/hematologists (mO/H) during the COVID-19 pandemic

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Background: The COVID-19 pandemic has dramatically impacted access to and delivery of healthcare in the U.S. At the height of the pandemic, many practices began initiating or increasing telemed visits to meet care demands in a quarantined environment. The objective of this descriptive study was to assess mO/H perceptions of benefits and barriers to current and post-pandemic use of telemed in oncology. Methods: Web-based surveys were fielded to mO/H before virtual meetings held between September and November 2020. Participants submitted their demographic information and responses to questions about pandemic impacts on their practice and patients. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 259 mO/H across the U.S. completed the survey; 73% practice in a community setting; 44% identify as hospital employees. The participants spend a median of 90% of their working time in direct patient care, have a median of 18 years of clinical experience, and see a median of 20 patients per day on clinic days. Before the pandemic, 92% of the participants’ practices had telemed capabilities but of those, 77% were not utilizing telemed for any visits. During the pandemic, almost all the participants’ practices were offering telemed, with 97% reporting some patient visits being conducted via telemed. Most (78%) anticipate continuing to offer or conduct some patient visits via telemed. Two-thirds stated that up to 25% of their patient visits could be converted to telemed outside of a pandemic environment. The types of visits that most believe are suitable for telemed include reviewing test/lab results, routine surveillance of chronic conditions, and survivorship care visits. Most (60%) stated that their patients view telemed favorably. About half reported a positive overall experience with telemed, with 47% reporting a better-than-expected experience. Most (79%) estimated that pivoting to telemed equates to a revenue loss of up to 50% for that visit; 53% feel that telemed has had an overall negative financial impact on their practice. Two-thirds have experienced challenges getting reimbursed for telemed claims. The most common challenges with telemed reported were reluctance or inability of patients to participate in telemed (39%) and technology challenges (37%). The most common benefit of telemed reported was safety, i.e., less potential exposure to COVID-19 for providers and staff (65%). Conclusions: Telemed use was infrequent before the pandemic, but utilization has dramatically increased during the pandemic. Despite favorable experiences with telemed, mO/H expect telemed use to decline significantly post-pandemic. This prediction may be driven by the perceived loss of revenue when an in-person visit is converted to telemed visit. Further research is needed in identifying factors that may allow for the long-term adoption of telemed for appropriate patients.

Awareness and utilization of tumor mutation burden (TMB) as a biomarker for administration of immuno-oncology (I-O) therapeutics by practicing community oncologists in the United States (U.S.)

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Background: TMB, a measurement of the number of mutations carried by tumor cells, is emerging as a biomarker for the identification of patients who may benefit from certain I-O-based therapies. TMB-high (TMB-H) tumors, defined by the detection of ≥10 mutations/megabase (mut/Mb) in tumor cells using a tissue-based assay such as the FoundationOneCDx (F1CDx) assay (Foundation Medicine, Inc.), may be more likely to respond to some I-O therapies. Higher neoantigen loads of TMB-H tumors have been proposed to contribute to increased responsiveness of TMB-H tumors to certain I-O therapeutics. Pembrolizumab was approved by the FDA on June 16, 2020 for the treatment of adult and pediatric patients with unresectable or metastatic TMB-H tumors, as determined by F1CDx, based on results from the KEYNOTE-158 trial (NCT02628067), which demonstrated that 50% of patients with TMB-H tumors had response durations of ≥24 months, with objective response rates in TMB-H vs. non-TMB-H patients of 29% and 6%, respectively (Marabelle et al, The Lancet Oncology, 2020). This survey-based study aimed to evaluate awareness and utilization of TMB as a biomarker for I-O therapeutics among practicing community oncologists in the U.S. Methods: Questions related to awareness and utilization of TMB as a biomarker for I-O therapeutics were developed by two medical oncologists (AG and BF) and presented to community oncologists in a web-based survey prior to virtual meetings held between October and November 2020. Descriptive statistics were used to analyze the results. Results: Of the 193 participating providers geographically distributed across the U.S., 15% reported being unaware of either the concept of TMB in I-O therapy or how to use the information clinically. 39% of these providers reported testing ≤25% of patients with advanced cancer for TMB, including 8% who do not test for TMB at all. Misconceptions regarding TMB identified among participating providers included the belief that high TMB is considered to be > 5 mut/Mb among 20% of providers, that TMB is essentially the same as MSI-high among 8% of providers, and that there are no therapies with FDA approval based on TMB among 15% of providers. Further, 37% of the participants did not identify pembrolizumab as an agent approved for the treatment of solid tumors based on TMB-H status. Conclusions: These findings demonstrate that there is a knowledge gap regarding the definition of TMB, testing for TMB, as well as implementation of TMB status in clinical decision making. Education directed towards community oncology providers regarding TMB and its use as a predictive biomarker for I-O therapy may improve its utilization and adoption in solid tumors to improve patient outcomes.

Cooperative group and pharmaceutical sponsored clinical trials: Perceptions of U.S. community oncologists

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Background: Many community-based oncologists in the US participate in clinical trials. These trials largely fall into two categories: trials run by cooperative (co-op) groups, funded and supported by the National Cancer Institute and trials developed, and supported by the pharmaceutical (pharma) industry. This study aimed to assess participation in, and perceptions regarding, co-op versus pharma trials among US community oncologists. Methods: We invited healthcare providers (HCP) across the continental US to attend 4 virtual meetings held between September and November 2020. Participants submitted their demographic information and responses to targeted questions regarding their opinions about co-op- and pharma-sponsored trials via a web-based pre-meeting survey. We evaluated participant HCP practice demographics and survey responses using descriptive statistics. Results: Of 259 surveyed participants, HCPs specialized in hematology-oncology (57%) and medical oncology (40%) with mean (median) 19 (18) years’ clinical experience. Most HCPs (178; 69%) reported participating in clinical research, and of these, 137 (77%) participated in co-op-led and 156 (88%) participated in pharma-led clinical research. HCPs preferred participating in both pharma and co-op (49%), pharma only (22%), and co-op only (11%) trials, while 18% preferred not to participate. Co-op trials were considered more prestigious to lead (86%), less likely to imply a conflict of interest (59%), and to address more pertinent questions (58%), while pharma trials had perceived advantages of better compensation (61%) and superior efficiency (48%). Co-op trials were perceived as not being financially sustainable (69%) and slower to accrue patients (85%) than pharma-led trials. Relatedly, in a hypothetical scenario of competing trials with identical design, the majority (60%) of HCPs preferred enrolling a loved one in a co-op trial. HCPs practicing in facilities with academic affiliation (34%) and in non-academic (66%) settings reported similar perceptions about co-op- and pharma-led trials; though, HCPs in academic settings were more likely to participate in clinical research compared to those in non-academic settings (82% vs. 62% [ P=0.001], respectively). Conclusions: In our survey of experienced HCPs, co-op-led clinical trials were perceived generally more favorably than pharma-led trials, even with concerns regarding cost, feasibility, and slower recruitment. However, despite their preference for co-op trials, HCPs were more likely to participate in pharma-led trials. Almost a third of surveyed HCPs are not participating in clinical trials and a fifth do not wish to. These findings can inform stakeholders (co-op trial leadership, pharma drug development teams, and patient advocacy groups) regarding appropriate education, design, and messaging regarding future clinical trials in oncology.

Assessment of objective response rate (ORR) by investigator versus blinded independent central review in pivotal trials of drugs approved for solid tumor indications

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Background: Objective response rate (ORR), defined as the proportion of patients with a complete response or partial response to treatment according to Response Evaluation Criteria in Solid Tumors (RECIST), is the most common endpoint used in pivotal trials supporting FDA approval of cancer drugs for solid tumor indications. Blinded independent central review (BICR) is frequently employed in clinical trials to minimize bias in evaluation of response rate, as historically, assessment of response by investigators (INV) has been shown to overestimate treatment effect. In this study, we analyzed the variability in assessment of ORR between INV and BICR in trials supporting recent Food and Drug Administration (FDA) approvals of drugs for solid tumor indications. Methods: The FDA’s novel drug approvals (2015-2019) were reviewed to identify drugs receiving primary approval for solid tumor indications. Drug approval packages accessed via the Drugs@FDA database and primary publications for the pivotal trials accessed via PubMed were reviewed for investigator-assessed and BICR-assessed ORR. For trials reporting both assessments, the difference between INV and BICR ORR was determined across all study arms. Data are presented using descriptive statistics. Results: A total of 36 drugs received primary approval for the treatment of solid tumors between 2015 and 2019. Of the 40 supporting trials, ORR was the primary endpoint for 21 (52.5%), progression-free survival for 13 (32.5%), and overall survival for 2 (5.0%). ORR was evaluated in 35 of the 40 trials (87.5%). Eight (22.9%) of the 35 trials evaluated INV ORR only, 5 (14.3%) evaluated BICR ORR only, and 22 (62.9%) evaluated both INV and BICR ORR. Among the 22 trials (29 arms in total), the mean difference between BICR- and INV-assessed ORR was -4.3% (95% CI: -6.4, -2.3); the range was -13.1 to 5. INV-assessed ORR was greater than BICR-assessed ORR in 22 of 29 arms (75.9%). The mean difference between BICR- and INV-assessed ORR among the 6 arms representing placebo or active control was -6.0 (95% CI: -11.0, -0.9), compared with -3.9 (95% CI: -6.3, -1.5) among the 23 experimental arms. Conclusions: Compared with BICR, INV overestimated ORR in three-quarters of the trial arms, including those representing control and experimental treatments. Despite this variability, for one fifth of the trials supporting approval of drugs to treat solid tumors, INV was the only method used to assess ORR. For consistency, and the ability to make relative cross-trial comparisons of ORR between agents, BICR should be considered for evaluation of tumor response in all registrational trials.

Postmarketing requirements for drugs approved by the Food and Drug Administration for the treatment of solid tumor cancers, 2010-2019

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Background: In recent years, efforts to improve the efficiency and speed of drug development and approval have driven a surge of Food and Drug Administration (FDA) approvals for cancer drugs. For many cancer therapies, the serious or life-threatening nature of the condition and unmet medical need confers eligibility for expedited programs. Many cancers are also rare diseases, and the increasing use of precision medicine principles to define cancer types further contributes to smaller trial sizes. With limited clinical evidence at the time of approval, cancer drugs may be subject to a greater burden of postmarketing requirements (PMRs). We analyzed PMRs for solid tumor therapies approved by the FDA over the past decade. Methods: The FDA’s novel drug approvals (2010-2019) were reviewed to identify drugs receiving primary approval for solid tumor indications. Approval letters were accessed via the Drugs@FDA database and analyzed for PMRs required under accelerated approval (AA), the Pediatric Research Equity Act (PREA) and the FDA Amendments Act of 2007 Section 505(o) (505(o)). Data are presented using descriptive statistics. Results: A total of 60 drugs received primary approval from the FDA for solid tumor indications between 2010 and 2019 (20 [33.3%] received AA, 33 [55.0%] received orphan designation, and 45 [75.0%] received Fast Track or Breakthrough Therapy designation). The proportion of drugs receiving AA doubled between the period 2010-2014 and 2015-2019 (Table). Of the 60 drugs approved, 52 (86.7%) received a total of 180 PMRs. All 20 drugs approved under AA received PMRs, with a total of 25 PMRs issued under AA. Data from new clinical trials were required for 22 (88.0%) of the 25 PMRs. No PMRs were issued under PREA. Additional safety data required under 505(o) comprised the largest proportion of PMRs; 155 total PMRs (86.1% of all PMRs) were issued for 45 (75.0%) of the drug approvals. Pharmacokinetic or other clinical safety data were required for 96 (61.9%) of the 155 PMRs. Conclusions: More than three-quarters of the cancer drugs approved for the treatment of solid tumors in the past 10 years were issued PMRs, with the majority requiring new safety data. The results of this study indicate that PMRs represent a critical mechanism by which FDA collects safety and efficacy for solid tumor therapies, and underscore the importance of PMR fulfillment. Post-marketing requirements (PMRs) for solid tumor drugs approved 2010-2019.[Table: see text]

Real-world clinical effectiveness of eribulin in metastatic breast cancer patients with visceral metastases in the United States

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Background: Eribulin mesylate was approved in the United States (US) in 2010 for the treatment of metastatic breast cancer (mBC) after at least two prior chemotherapeutic regimens, which should have included an anthracycline and a taxane in either the adjuvant or metastatic setting. Visceral metastases, including those to the lung and brain, have been identified as poor prognostic features for patients with mBC. The objective of this analysis was to assess the real-world clinical effectiveness of eribulin in mBC patients with visceral metastases when treated in accordance with the US label. Methods: Patients with mBC initiating eribulin consistent with the US label between 2011-2017 were identified through a retrospective, multi-site chart review study conducted in US oncology practices. De-identified, patient-level demographics, clinical characteristics, treatment patterns, and outcomes were entered into an electronic case report form by the patients’ treating physicians. Sites of metastases at initiation of eribulin were indicated by providers. Clinical outcomes assessed included best overall response to eribulin as recorded in the patient’s chart, progression-free survival (PFS), and overall survival (OS). The proportion of patients with either a complete or partial response as their best overall response was calculated. PFS and OS were calculated by the Kaplan-Meier method from the initiation of eribulin for all patients with visceral metastases and subsets reporting lung or brain metastases site, respectively. Results: The analysis included 470 patients with visceral metastases, including 342 with lung metastases and 22 with brain metastases at the time of eribulin initiation. Eribulin was third-line therapy for approximately three quarters of patients in these subgroups, and the remainder received eribulin in fourth line or later. Mean age was 59 years in general (59 and 54 years in those with lung and brain metastases, respectively). Over half of patients (53.6%) had either a complete or partial response to eribulin. Median PFS was estimated at 6.0 months, and median OS was estimated at 10.5 months. Results for the subgroups of patients with lung and brain metastases are shown in the table. Conclusions: The results of this retrospective analysis affirm clinical effectiveness of eribulin in mBC patients with visceral metastases, when used consistent with the US label.[Table: see text]

Effectiveness of Eribulin in Metastatic Breast Cancer: 10 Years of Real-World Clinical Experience in the United States

Introduction

Eribulin was approved in the United States (US) in 2010 for patients with metastatic breast cancer (MBC) who previously received at least two chemotherapeutic regimens, including anthracycline and taxane in the adjuvant or metastatic setting. With significant changes to the treatment landscape over the past decade, assessment of the real-world effectiveness of eribulin in clinical practice when used according to the approved US indication is valuable.

Methods

Patients with MBC were identified by community oncologists through a retrospective, multi-site patient chart review; de-identified data were abstracted into electronic case report forms. Eligible patients initiated eribulin consistent with approved US indication between 1 January 2011 and 31 December 2017. Clinical outcomes assessed included objective response rate (ORR), progression-free survival (PFS) and overall survival (OS) in all patients and those with triple negative breast cancer (TNBC).

Results

The analysis included 513 patients (median 59.0 years; 38.8% with Eastern Cooperative Oncology Group status ≥ 2). Eribulin was third-line therapy for 78.0% of patients, and fourth-line or later for the remainder. ORR was 54.4%, median PFS was 6.1 months (95% CI: 5.8, 6.6), and median OS was 10.6 months (95% CI 9.9, 11.7) in all patients. Among the 49.9% of patients with TNBC, ORR was 55.1%, median PFS was 5.8 months (95% CI 5.1, 6.4), and median OS was 9.8 months (95% CI 8.6, 11.0).

Conclusion

The current retrospective chart review study reinforces the clinical effectiveness of eribulin in patients with MBC, including those with TNBC, when used according to the approved US indication in real-world clinical practice.

Expanded Access and Right To Try Requests: The Community Oncologist's Experience

PURPOSE:

For patients with cancer who have exhausted approved treatment options and for whom appropriate clinical trials are not available, access to investigational drugs through the US Food and Drug Administration's Expanded Access (EA) program has been an alternative since the program's inception more than 30 years ago. In 2018, federal Right To Try legislation was passed in the United States, creating a second pathway—one that bypasses the US Food and Drug Administration—to obtain unapproved drugs outside of clinical trials. The use of the two programs by community medical oncologists and hematologist-oncologists has not been studied.

METHODS:

Between October 2019 and February 2020, community oncologists-hematologists from across the United States completed web-based surveys about EA and Right To Try pathways for accessing unapproved drugs for their patients. Physicians were asked about their utilization of, and perceptions of, the two programs.

RESULTS:

Of the 238 physicians who completed the survey, 46% indicated that they had attempted to gain access to an investigational drug for a patient using the EA program, whereas 14% reported attempting to use Right To Try pathway to obtain an unapproved drug for a patient. Eighty-nine percent of those who tried to use the EA program reported success in obtaining the investigational drug versus 73% of those who attempted to use the Right To Try pathway.

CONCLUSION:

Our survey found that most community oncologists-hematologists were aware of both the EA and Right To Try pathways, but there is room for improvement in understanding and utilization of the programs.

Referral patterns and treatment preferences in patients with advanced prostate cancer (aPC): Differences between medical oncologists and urologists

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Background: With the advent of newer non-cytotoxic therapies for aPC, early integration of hormonal therapies (HT), and expansion of services within urology practices [e.g., radiation therapy (RT) and immunotherapy], urology practices are playing a larger role in the management of patients with aPC. In this descriptive study, we sought to assess the differences between medical oncologists (oncs) and urologists (uros) as they pertain to referral patterns and treatment decisions of men with aPC. Methods: Virtual meetings held in August 2020 convened oncs and uros of diverse US regions and practice types with experience treating prostate cancer (PC) to better understand perceptions around the management of patients with PC. Participants submitted responses via web-based pre-meeting surveys and real-time polling. All responses are summarized using descriptive statistics. Results: 66 oncs and 69 uros participated. The advisors were mostly community-based and see on average 20+ patients per day. 75% of uros estimated they refer ≤25% of all of their patients with PC to oncs and 75% of oncs reported that > 50% of their patients with PC referrals are from uros. Other referring physicians identified include primary care (76%), radiation oncs (46%), or hospitalists (40%). Uros perceive oncs as co-managers (86%) for their patients with aPC and rarely (9%) transfer the care of their patients completely to oncs. Referrals from uros to oncs are driven by the need for chemotherapy (chemo) (52%) or progression to metastatic castration-resistant PC (mCRPC) (22%). Oncs reported that upon referral, these patients with PC have already been exposed to HT (75%), RT (66%), and/or surgery (43%). For second-line treatment of asymptomatic patients with mCRPC, oncs most commonly prescribe HT (60%) and chemo (23%), while uros most commonly prescribe sipuleucel-T (45%) and HT (38%). For second-line treatment of patients with mCRPC and symptomatic bony disease, oncs most commonly prescribe chemo (44%) and radium-223 (34%), while uros most commonly prescribe radium-223 (47%) and HT (22%). Conclusions: Uros refer patients with aPC to oncs for chemo. Uros prefer to treat with non-chemo options when possible and retain oncologic care for most of the patients’ cancer journey. The need for chemo is a major reason for referral from uros to oncs. The impact of these provider preferences upon patient outcomes in the real world needs further research. [Table: see text]

Abstract PS13-37: Effectiveness of eribulin in poor prognosis subgroups of metastatic breast cancer (mBC) patients (elderly, African Americans, and patients with liver metastases) in the United States

Background: Eribulin mesylate was approved in the United States (US) in 2010 as third-line or later treatment (after an anthracycline and a taxane) of mBC. Multiple patient demographic and clinical characteristics have been reported to impact clinical outcomes in mBC patients. The objective of these analyses was to assess real-world clinical outcomes of eribulin therapy in three subgroups that generally have poorer prognoses: elderly (≥65 years), African American, and those with liver metastases in clinical practice in the US. Methods: A retrospective chart review study was conducted across community oncology practices in the US. Adult female patients with mBC who initiated treatment with eribulin as per US prescribing information between 2011 and 2017 were included. Data were extracted by prescribing physicians from individual patient’s electronic health records and captured via an electronic case report form. All patient data were de-identified prior to analyses. Clinical outcomes including objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) were assessed in patients who were elderly, African American, or who had liver metastases. Results: Current analyses were based on data from 278 patients including 175 (63%) patients with liver metastases, 98 (35%) elderly patients, and 73 (26%) African American patients. Mean age at initiation of eribulin in each group was: liver metastases, 59; elderly, 71; and African American, 58. Proportion of patients with ECOG-PS ≥2 at initiation of eribulin was: liver metastases, 46%; elderly, 52%; and African American, 47%. The majority of patients received eribulin in 3rd line: liver metastases, 80%; elderly, 87%; and African American, 85%. ORR to eribulin was 34% in patients with liver metastases, 35% in elderly, and 48% in African Americans. Median PFS from initiation of eribulin was 5.2 months in patients with liver metastases, 5.8 months in elderly, and 7.6 months in African Americans. Landmark OS from initiation of eribulin at 6, 12 and 24 months were 71%, 36% and 18%, respectively, in patients with liver metastases, 72%, 35% and 23% in elderly, and 78%, 46%, and 28% in African Americans. Conclusion: Effectiveness of eribulin in clinical practice in patients with liver metastases, elderly, and African Americans was confirmed within this real-world study in the US.

Citation Format: Sarah S. Mougalian, Jonathan K. Kish, Jingchuan Zhang, Djibril Liassou, Bruce A. Feinberg. Effectiveness of eribulin in poor prognosis subgroups of metastatic breast cancer (mBC) patients (elderly, African Americans, and patients with liver metastases) in the United States [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-37.

Comparison of Solid Tumor Treatment Response Observed in Clinical Practice With Response Reported in Clinical Trials

IMPORTANCE

In clinical trials supporting the regulatory approval of oncology drugs, solid tumor response is assessed using Response Evaluation Criteria in Solid Tumors (RECIST). Calculation of RECIST-based responses requires sequential, timed imaging data, which presents challenges to the method's application in real-world evidence research.

OBJECTIVE

To evaluate the feasibility and validity of a novel real-world RECIST method in assessing tumor burden associated with therapy for a large heterogeneous patient population undergoing treatment in routine clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used physician-abstracted data pooled from retrospective, multisite electronic health record (EHR) review studies of patients treated with anticancer drugs at US oncology practices from 2014 through 2017. Included patients were receiving first-line treatment for thyroid cancer, breast cancer, or metastatic melanoma. Data were analyzed from March through August 2020.

EXPOSURES

Undergoing treatment with immunotherapy or targeted therapy.

MAIN OUTCOMES AND MEASURES

Tumor response was classified according to RECIST guidelines (ie, change in sum diameter of target lesions) post hoc with measurements derived from imaging scans and reports.

RESULTS

Among 1308 completed electronic case report forms, 956 forms (73.1%) had adequate data to classify real-world RECIST response. The greatest difference between physician-recorded responses and real-world RECIST-based responses was found in the proportion of complete responses: 118 responses (12.3%) vs 46 responses (4.8%) (P < .001). Among 609 patients in the metastatic melanoma population, complete responses were reported in 112 physician-recorded responses (18.4%) vs 44 real-world RECIST-based responses (7.2%) (P < .001), compared with 11 of 247 responses (4.5%) to 31 of 192 responses (16.1%) across pivotal trials of the same melanoma therapies.

CONCLUSIONS AND RELEVANCE

These findings suggest that comparing tumor lesion sizes and categorizing treatment response according to RECIST guidelines may be feasible using real-world data. This study found that physician-recorded assessments were associated with overestimation of treatment response, with the largest overestimation among complete responses. Real-world RECIST-based assessments were associated with better approximations of tumor response reported in clinical trials compared with those reported in EHRs.

Patient-reported outcomes in routine oncology care: Perceptions, execution, and barriers

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Background: There has been an increased emphasis on patient-reported outcomes (PROs) in recent oncology trials, and the benefits of incorporating PRO assessments during routine care have been established. The aim of the present study was to assess the perceptions, adoption and barriers to implementation of PROs in community practices during routine care. Methods: A live meeting in September 2019 surveyed US-based community oncology health care providers (HCPs), including medical oncologists/hematologists and advanced practice providers (APPs; defined as nurse practitioners and physician assistants) regarding their perceptions of PROs and their adoption of PROs during routine patient care. Participants completed both a web-based premeeting survey and live queries captured via audience response system. Data were summarized using descriptive statistics. Results: 71 HCPs (51 medical oncologists/hematologists and 20 APPs) participated. HCPs described their practices as: urban 50%, suburban 37%, and rural 13%. Over 80% reported having collected PRO data from their patients. Over 90% indicated that PROs are important to guide their treatment of patients, irrespective of the data sources (clinical studies or in real-world). Commonly collected PRO data included disease symptoms (66%), activities of daily living (62%), physical function (61%) and adverse events (59%). The NCCN Distress Thermometer (41%) was reported as the most common PRO instrument used during routine oncology care (Table). Despite understanding the importance of implementing PROs, 54% indicated that more resources (software and incentive systems) are needed, and 53% said that discussing PRO results with each patient is critical to facilitate the collection and utilization of PRO data. 84% were unaware of results of a seminal study which demonstrated that PROs improve quality of life and survival (Basch et al 2016, 2017). Conclusions: Most of the community oncology providers surveyed collected PRO data and acknowledged its value. However, more resources are needed to increase collection and use of PROs during routine care. Education directed towards community oncology providers is needed to highlight the value that PROs can add in cancer care. [Table: see text]

The use of validated geriatric assessment instruments among U.S. community oncologists

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Background: Older adults are disproportionately affected by cancer and may be under-treated due to concerns for adverse events or may suffer excessive toxicity from standard cancer treatments due to comorbidity and diminished physiologic reserve. A geriatric assessment (GA) can assist with risk stratification, inform treatment decisions and improve outcomes in older adults with cancer. This descriptive study aimed to assess knowledge, perceptions, and utilization of GA instruments among community oncologists/hematologists (cOH) with an overall goal to identify actionable disparities in the management of older adults with cancer. Methods: Questions about GA in the care of older adults with cancer were developed by two medical oncologists (AG and BAF) and presented to cOH with diverse geographic representation at live meetings and a preceding web-based survey between September 2019 and February 2020. Descriptive statistics were used to analyze the results. Results: Of the 349 participants, the response rate was 100%. The cut-off age used to define older adults by cOH was: ≥ 65 years (22%), ≥ 70 years (39%), and ≥75 (32%). The proportion of patients aged ≥ 70 years in their practices was reported as: 26-50% (48%) and > 50% (22%). Most cOH (60%) performed no formal GA to inform treatment decisions. The two most common reasons for not performing GA were: “Too cumbersome to incorporate into routine practice” (44%), and “Adds no value beyond the comprehensive history and physical exam” (36%). cOH awareness of validated GA/related instruments was: Mini-Mental State Exam (MMSE; 63%), Comprehensive GA (CGA; 37%) and CARG (Cancer and Aging Research Group) GA tool (22%); 22% were not aware of any validated instruments. Outside of clinical trials, the most frequently used validated GA instruments were: MMSE (54%), CGA (23%), CARG (12%), and CRASH (9%). For older adults with cancer, ECOG performance status and comorbidities were the two GA-related surrogate factors utilized in treatment decisions (88% and 73%, respectively). Conclusions: A majority of US community oncologists do not incorporate formal GA with validated instruments in the decision-making for older patients with cancer due to lack of time, resources and awareness. Education directed towards community oncologists may change perception and practice.

Knowledge and evaluation of geriatric assessment (GA) domains among U.S. community oncologists/hematologists (cOH)

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Background: GA is a multidisciplinary assessment consisting of the following domains: physical function, comorbidity, cognition, mood, social support, nutrition and medication review. Conducting a GA with validated instruments to assess these domains has been shown to improve outcomes in older adults with cancer [Soo, et al ASCO 2020]. The utilization of validated GA tools and its domains versus use of other surrogates from history and physical exam (HPE) for risk-stratification in older adults in the community practice setting is unclear. In this survey-based study, we assessed the knowledge of GA and the methods used to evaluate GA domains among cOH. Methods: Questions pertaining to GA and the care of older adults with cancer were developed by two medical oncologists (AG and BAF) and presented to cOH with diverse US geographic representation at live meetings and via web-based questionnaire between September 2019 and March 2020. Results were analyzed using descriptive statistics. Results: Of the 173 participants surveyed, 59% reported performing no GA, while 13% and 28% reported performing GA on all and selected older adults, respectively. When presented with a list of daily living activities, over half of cOH were unable to correctly identify all activities of daily living (ADLs) and instrumental ADLs (56% and 70%, respectively). The top 2 methods used by cOH to assess physical functional were the ECOG performance status (82%) and HPE (42%). For assessment of cognition, most cOH used HPE (78%) or the Mini Mental State Exam (MMSE; 12%). Social support was assessed via HPE (44%) or GA (27%). cOH reported that medication review is performed by an office staff (medical assistant 31%, nurse 12%, pharmacist 5%), with the physician signing off on the information reported in the chart irrespective of who entered the medication information (50%). Regarding chemotherapy dosing in older adults with cancer, only 7% utilized GA to inform chemotherapy dose; 48% reported starting at a lower chemotherapy dose with intent to escalate, while 33% reported starting at the standard dose with intent to de-escalate if toxicity is encountered. Lastly, 27% stated that oncologists are not adequately equipped to care for older adults with cancer given the complexity involved. Conclusions: Many cOH do not utilize validated instruments to assess the domains of GA. There also appear to be knowledge gaps regarding individual domains of GA. There is a need to further the education of cOH regarding the components and value of GA in older adults with cancer.

Treatment patterns of advanced or recurrent endometrial cancer following platinum-based therapy in the U.S. real-world setting

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Background: Patient (pt) prognosis is poor following disease progression on or after primary (1L) platinum-based therapy (PBT) for advanced/recurrent (A/R) endometrial cancer (EC), and no consensus on standard second-line (2L) therapy exists. This retrospective analysis aimed to understand real-world (RW) treatment patterns of pts with A/R mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) EC who progressed after 1L PBT. Methods: Physicians in Cardinal Health’s Oncology Provider Extended Network submitted retrospective data by abstracting outpatient electronic medical records of pts who received systemic treatment for A/R EC following PBT from 2016 to 2018. Demographics, clinical characteristics, treatments, and outcomes were summarized descriptively. Results: This study included 84 pts with A/R dMMR/MSI-H EC (table). The majority of participating physicians were hematologists/medical oncologists (80%) and practiced in the community setting (70%). Median duration of therapy (mDOT) in 1L was 4.9 months (95% CI, 4.47–5.57); 64% of pts discontinued treatment due to completion and 35% due to disease progression. In contrast, mDOT in 2L was 6.2 months (95% CI, 5.40–6.37); 37% of pts discontinued treatment due to completion and 44% due to disease progression. The most common MMR/MSI testing modalities were next-generation sequencing (NGS) only, immunohistochemistry (IHC) only, and polymerase chain reaction (PCR) only (table). Conclusions: RW treatment patterns in pts with A/R dMMR/MSI-H EC show that most will undergo PBT retreatment. However, progression is the main reason for discontinuation during retreatment. An urgent need exists for durable therapies that improve prognosis. Opportunities to improve timely testing of MMR/MSI exist. Funding: GlaxoSmithKline, Waltham, MA, USA. [Table: see text]

Linking reimbursement to patient-reported quality of life: Provider perspectives

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Background: In the value-based era, policymakers have begun incorporating quality of life (QoL) components into payment models, such as the Merit-based Incentive Payment System (MIPs), Oncology Care Model (OCM), and Accountable Care Organization (ACO), to increase accountability. This qualitative research study sought to understand how providers address their patients’ QoL issues in a value-based environment. Methods: A live meeting in September 2019 brought together community oncology healthcare providers (HCPs) from across the United States. Participants submitted their demographic information via a web-based pre-meeting survey and their responses pertaining to patient QoL via an audience response system during the live meeting. Participant responses and their practice demographics were analyzed using descriptive statistics. Results: 71 HCPs participated in this live market research program: 51 medical oncologists/hematologists (herein referred to as physicians) and 20 nurse practitioners or physician assistants (herein referred to as APPs). 50% of physicians and 25% of APPs were from privately owned community practices. Half of HCPs indicated that their practices are collecting and reporting QoL data through value-based programs: 28% of physicians and 60% of APPs were in OCM-participating practices. Regarding accountability, over 80% of HCPs strongly agreed that they have a role in improving patients’ QoL. However, 32% of physicians and 25% of APPs agreed that their payment should be tied to patients’ QoL improvement. According to HCPs, the top factor impacting patients’ QoL was symptom and symptom burden (83%). To address QoL in their patients, HCPs reported addressing patients’ psychosocial needs (78%), implementing survivorship care planning (76%), and using nurse navigators (69%). 70% of physicians and 95% of APPs were confident that their patients have reliable resources for managing their QoL issues. Conclusions: HCPs recognize their role in improving patients’ QoL, and their practices have made several transformations to improve patients’ QoL; they are confident that their patients have resources for managing QoL issues. However, many HCPs disagree with linking QoL improvements to their payment. Further studies are needed to understand QoL from patients’ perspectives in the value-based environment.

Real-world utilization of quality-of-life data: Perspectives from community oncology providers

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Background: Quality of life (QoL) is commonly assessed in oncology clinical trials. However, it is unclear if oncology healthcare providers (HCPs) perceive value in these metrics or if they impact clinical practice. We sought to assess the real-world utilization of QoL data and barriers to its adoption among US community oncology providers. Methods: Medical oncologists/hematologists, and advanced practice providers (APPs) participated in a survey to assess their perceptions and the utility of QoL data for routine practice during a live meeting in September 2019. Responses were captured via a web-based premeeting survey and an audience response system during the live meeting. Participant characteristics and responses were summarized using descriptive statistics. Results: A total of 71 HCPs (51 physicians and 20 APPs) participated. Regarding perceptions of QoL in oncology, 50% of physicians and 32% of APPs reported aligning with the sentence “It is important to have QoL, but efficacy is obviously the most critical endpoint.” HCPs reported that QoL may outweigh overall survival (OS) in certain clinical scenarios, such as in end-of-life (81%), frail patients (67%), or metastatic tumors (62%). When selecting between two agents with similar efficacy, safety was the most important factor (78%), followed by QoL (40%). 64% of physicians utilized aggregate QoL data from registrational trials or real-world studies to keep informed about QoL of different treatments, while 69% of APPs relied on their personal or practice experiences. 85% of physicians and 84% of APPs responded that it is important to perform formal QoL assessments during routine patient visits. 88% of HCPs expected that QoL/patient-reported outcomes (PRO) collection will increase their workload. Patient burden (58%) and provider resources (43%) were other barriers for QoL/PRO collection. HCPs were largely split regarding their understanding of QoL versus PRO, with 34% reporting that PRO was a subset of QoL and 28% reporting that QoL was a subset of PRO. Conclusions: Efficacy and safety are prioritized as clinical endpoints among oncology HCPs; however, there are certain clinical scenarios where QoL may provide more impactful data for HCPs in managing patients. Barriers remain to successful collection of QoL, and there is a need for further education among HCPs regarding PROs and QoL.

Use of Real-World Evidence to Support FDA Approval of Oncology Drugs

OBJECTIVES

Real-world evidence (RWE) has gained increased attention in recent years as a complement to traditional clinical trials. The use of RWE to establish the efficacy of oncology drugs for Food and Drug Administration (FDA) approval has not been described. In this paper, we review 5 recent examples where RWE was submitted in support of the FDA approvals of original or supplementary indications for oncology drugs.

METHODS

To identify cases where RWE was used, we reviewed drug approval packages available at Drugs@FDA for oncology drugs approved between 2017 and 2019. Five cases were selected to present a broad overview of different types of RWE, different circumstances under which RWE has been used for regulatory approvals, and how FDA evaluated the data in each case. The type of RWE submitted, the indication, limitations identified by FDA reviewers, and the outcome of the submission are discussed.

RESULTS

RWE, particularly historical controls for rare or orphan indications, has been used to support both original and supplementary oncology drug approvals. Types of RWE included data from electronic health records, claims, post-marketing safety reports, retrospective medical record reviews, and expanded access studies. Small sample sizes, data quality, and methodological issues were among concerns cited by FDA reviewers.

CONCLUSION

By bridging the gap between the constraints of the trial setting and the realities of clinical practice, RWE can add value to a regulatory submission. These early examples provide insight into how regulators evaluated RWE submitted as evidence of efficacy for oncology drugs.

Neurological adverse events following CAR T-cell therapy: a real-world analysis

Aim: To characterize real-world neurological adverse events (AEs) associated with chimeric antigen receptor T-cell therapies in patients with refractory/relapsed large B-cell lymphomas. Materials & methods: Postmarketing case reports from the US FDA AEs reporting system involving axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) for large B-cell lymphomas were analyzed. Results: Of 804 AE cases identified (637 axi-cel, 167 tisa-cel), 428 (67%) of axi-cel cases and 43 (26%) of tisa-cel cases reported neurological AEs. Compared with cases without neurological AEs, significant associations were observed between neurological AEs and use of axi-cel, age ≥65 years, and the outcome of hospitalization. Conclusion: Neurological AEs were common with chimeric antigen receptor T-cell therapy in the real world and largely reflected those reported in clinical trials.

Real-world adverse events associated with CAR T-cell therapy among adults age ≥ 65 years

INTRODUCTION

Chimeric antigen receptor (CAR) T-cell therapy has emerged as a promising treatment for relapsed or refractory large B-cell lymphoma (LBCL) with the Food and Drug Administration (FDA) approvals of axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tis-cel). Although the incidence of LBCL is highest among patients age ≥ 65, clinical trials supporting approval of these 2 products primarily enrolled younger patients. Safety data for axi-cel and tis-cel in older patients is limited.

METHODS

In this analysis, we queried the FDA Adverse Events Reporting System (FAERS) database for cases associated with axi-cel or tis-cel from the FDA approval dates for the LBCL indication for each product through December 31, 2019, and compared adverse events (AEs) reported for cases involving patients aged <65 and ≥ 65.

RESULTS

A total of 804 cases were retrieved, with 333 (41%) involving patients age ≥ 65. Cytokine release syndrome (CRS) was the most common AE reported in both age groups. Cases involving older patients had a significantly higher proportion of neurological AEs, including CAR T-cell-related encephalopathy syndrome (8% vs. 4%, p = 0.03). Some individual clinical features of CRS were significantly more common among younger age group cases, including pyrexia (33% vs. 23%, p < 0.01), tachycardia (10% vs. 5%, p < 0.01), and thrombocytopenia (4% vs. 2%, p = 0.03).

DISCUSSION

In this age-based analysis of FAERS reports for patients treated with axi-cel or tis-cel, we identified differences in patterns of AEs experienced. This large-scale post-marketing study complements clinical trial safety data and may help inform clinicians' decision making when treating adult patients with CAR-T cell therapy.

Lenvatinib and Subsequent Therapy for Radioactive Iodine-Refractory Differentiated Thyroid Cancer: A Real-World Study of Clinical Effectiveness in the United States

Introduction

Lenvatinib has become the most commonly prescribed first-line (1L) agent for the treatment of radioactive iodine-refractory differentiated thyroid cancer (RAI-r DTC) since its approval in 2015. With no real-world studies describing clinical outcomes of 1L lenvatinib and subsequent therapy, the current study aimed to assess treatment sequencing and related clinical outcomes in patients treated with 1L lenvatinib in the USA

Methods

We conducted a multisite, retrospective chart review of US patients with a diagnosis of RAI-r DTC who had initiated 1L therapy with lenvatinib from January 1, 2016 through May 31, 2017 with follow-up through October 17, 2018. Physicians completed electronic case report forms for two patient cohorts: patients still receiving 1L lenvatinib (cohort 1) and those who had initiated second-line (2L) therapy prior to data cutoff (cohort 2). Real-world objective response rate (ORR) was assessed for both cohorts. Progression-free survival (PFS) and overall survival (OS) were assessed for cohort 2.

Results

A total of 252 patients met the study criteria with 71 in cohort 1 and 181 in cohort 2. Patients were predominantly female, had papillary DTC, and had lung metastases. The ORR was 64.8% for cohort 1 and 53.6% for cohort 2. In cohort 2, median PFS from 1L lenvatinib initiation was 14.0 months (95% CI 12.7–15.0). Second-line treatments included sorafenib (49.7%), cabozantinib (19.3%), and other targeted/chemotherapy/immuno-oncology agents. The ORR in 2L therapy was 15.5%. For cohort 2, the 12-, 18-, and 24-month OS from initiation of 1L lenvatinib was 92.8%, 81.5%, and 66.9%, respectively.

Conclusions

In this first real-world examination of clinical effectiveness of 1L lenvatinib and subsequent therapy among patients in the US, the results demonstrated that treatment with 1L lenvatinib followed by another 2L therapy may deliver a clinical benefit, thus allowing a number of potential 2L options following 1L lenvatinib for patients with RAI-r DTC.

Physician treatment preferences for metastatic triple negative breast cancer (mTNBC) in an era of immunotherapy

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Background: TNBC accounts for 10-20% of all breast cancer and has poor prognosis. Guidelines now list atezolizumab with nab-paclitaxel (ANP) as preferred for mTNBC w/ PD-L1 expression > 1%. We sought to assess current mTNBC prescribing and sequencing preferences for first-line (1L), second-line (2L), and third-line (3L) therapy among U.S. community oncologists (c-oncs). Methods: C-oncs were presented 4 hypothetical mTNBC clinical scenarios (CS 1-4) via web-based survey. CS differed by PD-L1 expression, menopausal status, prior adjuvant therapy and nature of metastases (bulky liver, lung, bone) but were otherwise uniform in terms of being asymptomatic, BRCA negative, with identical response extent and duration of each line of therapy. Respondents selected their preferred treatment for 1L, 2L, and 3L in each CS in the following categories: single agent (SA) chemotherapy, combination chemotherapy (CC), or ANP. The proportion of c-oncs selecting each treatment approach per CS for each line of therapy was calculated. We describe these preference patterns and how these may deviate from current guidelines. Results: 47 c-oncs participated from across the U.S. (northeast = 23%, midwest = 28%, south = 32%, west = 17%): mean years in practice was 22.7 and mean number of mTNBC patients under treatment was 18.8. The proportion of c-oncs preferring SA, CC or ANP per CS per line of therapy is listed in the table. Deviations from guidelines include preferences for: 1L ANP despite PD-L1 < 1% (26% in CS 1 and 4); 1L CC (45%) in asymptomatic bone only disease (CS1); 2L CC (19-34%) in asymptomatic visceral metastases (CS 2, 3 and 4). The SA 2L (74%)/3L (90%) preferences: capecitabine (36% 2L; 18% 3L) and eribulin (24% 2L; 35% 3L). Gemcitabine + carboplatin was the preferred CC regimen in 2L (50%) and 3L (28%). Conclusions: There is deviation from current guidelines in the treatment preferences for mTNBC patients among c-oncs, specifically the preference for ANP in PD-L1 negative patients and CC in 2L and 3L for asymptomatic patients. [Table: see text]

Treatment patterns of advanced or recurrent endometrial cancer following platinum-based therapy in the US real-world setting

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Background: Following disease progression on or after primary (1L) platinum-based therapy (PBT) for advanced/recurrent (A/R) endometrial cancer (EC), patient (pt) prognosis is poor and no consensus on standard second-line therapy exists. This retrospective analysis aimed to understand real-world (RW) treatment patterns of pts with A/R mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) EC who progressed after 1L PBT. Methods: Physicians in Cardinal Health’s Oncology Provider Extended Network submitted retrospective data by abstracting outpatient electronic medical records of pts who received systemic treatment for A/R EC following PBT from 2016 to 2018. Demographics, clinical characteristics, treatments received, and outcomes were summarized descriptively. Results: This study included 84 pts with A/R dMMR/MSI-H EC (table). The majority of participating physicians were hematologists/medical oncologists (80%) and practiced in the community setting (70%). Median duration of therapy (mDOT) in 1L was 4.9 months (95% CI, 4.47–5.57); 64% of pts discontinued treatment due to therapy completion and 35% due to disease progression. In contrast, mDOT in 2L was 6.2 months (95% CI, 5.40–6.37); 37% of pts discontinued treatment due to therapy completion and 44% due to disease progression. The most common MMR/MSI testing modalities were next-generation sequencing (NGS) only, immunohistochemistry (IHC) only, and polymerase chain reaction (PCR) only (table). Conclusions: RW treatment patterns in pts with A/R dMMR/MSI-H EC show that most will undergo PBT retreatment. However, progression is the main reason for discontinuation during retreatment. An urgent need exists for durable therapies that improve prognosis. Opportunities to improve timely testing of MMR/MSI exist. [Table: see text]

Gender-based disparities in clinical trials supporting FDA approval of oncology drugs

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Background: Adequate gender representation in clinical trials of new drugs is critical in order to accurately detect possible differences in response and toxicity (Özdemir et al, JCO 2018). The under-representation of women in oncology clinical trials has been previously described, however data on registrational trials, which are the basis for drug approval and inform the prescribing information, is lacking. We conducted an analysis of the trials supporting Food and Drug Administration approval of oncology drugs over a 5-year period to evaluate the representation of women vs. men. Methods: Prescribing information for novel new drugs approved from 2014-2018 was reviewed for the proportions of men and women in the evaluable population of the supporting clinical trials. Sex-specific cancers were excluded. Prevalence estimates for the indications were obtained from the Surveillance, Epidemiology and End Results database and the published literature. A participation to prevalence ratio (PPR) was calculated for each trial by dividing the percentage of women in the trial by the percentage of women in the disease population. A PPR value closer to unity represents even gender distribution and the range 0.8-1.2 is considered to reflect an acceptable representation of women. Data are presented using descriptive statistics. Results: A total of 46 oncology drugs were approved based on 56 trials enrolling 13,862 patients (7941 [57%] men; 5,921 [43%] women). Of the 56 trials, 38 (68%) had a PPR within the 0.8-1.2 range, 15 (27%) fell between 0.4-0.7, and 3 (5%) had a PPR of 1.3. The proportion of trials with unbalanced gender representation was comparable for hematological malignancy and solid tumor indications and did not improve over time. Fewer unbalanced trials were Phase III or employed a randomized design. Nine of the 18 (50%) unbalanced trials enrolled <100 subjects, compared to 3 of the 38 (8%) balanced trials. Conclusions: A third of registrational trials for oncology drugs lacked balanced gender distribution. Of the trials lacking balance, the vast majority (80%) had under-representation of women. Phase I-II trials and smaller trials had greater gender disparity, a concerning finding in a precision medicine environment where an increasing number of registration trials have double digit accrual. Further research is needed to understand the implications of unbalanced gender accrual in registrational trials, and to develop strategies for preventing disparities.

Prescribing preferences for hormone sensitive (HR+) metastatic breast cancer (mBC) in the CDK 4/6 inhibitor (CDK 4/6i) era

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Background: CDK 4/6i is a category 1 guideline-recommended therapy for HR+/HER2- mBC in both first-line (1L) with an aromatase inhibitor and second-line (2L) with fulvestrant and without prior CDK 4/6i. We sought to understand community oncologists’ (c-oncs) prescribing preferences and sequencing for 1L, 2L, and third-line (3L) HR+/HER2- mBC patients across several common clinical scenarios (CS). Methods: C-oncs were presented 4 hypothetical HR+/HER2- mBC clinical scenarios (CS 1-4) via web-based survey. CS differed by menopausal status, prior adjuvant therapy and nature of metastases (mets) (i.e., bulky liver, lung, bone), but otherwise uniform: asymptomatic presentation, PI3K negative, identical response extent and duration in 1L, 2L, and 3L. Treatment preferences: hormonal (H), single agent (SA) or combination chemotherapy (CC) for 1L, 2L, and 3L in each CS were queried. We describe these preference patterns. Results: 47 U.S. c-oncs participated: mean years in practice was 22.7 and mean mBC patients under active treatment was 23.3. Preference for treatment and sequence, regardless of CS, per LOT were: 1L = 71% H, 14% SA, 16% CC; 2L = 51% H, 31% SA, 16% CC; and 3L = 35% H, 59% SA, 6% CC (Table). Of the 71% who preferred 1L H, the CDK4/6i % were: 73% overall, 58% when mets described as bulky liver, 94% when described as bone and or lung. The preference for pre-planned sequential chemo-hormonal therapy in 1L resulted in 63% of initial chemotherapy followed immediately by H; of which CDK 4/6i was preferred in 47%. In total, the initial and post-chemo CDK4/6i 1L preference was 80%. 2L hormonal preferences by frequency were: everolimus + exemestane = 38%, CDK 4/6i + fulvestrant = 20%, fulvestrant = 19%. SA preferences: 2L = capecitabine 46%, taxane 25%; 3L = capecitabine 40%, eribulin 32%. CC preferences included atezolizumab + nab-paclitaxel 24% in 1L and 16% in 2L. Conclusions: 1L HR+/HER2- mBC treatment is highly variable and preferences that warrant further research include: the role of CC, specifically atezolizumab + nab-paclitaxel; repeated CDK4/6i line of therapy; H therapy post CDK4/6i progression; and optimal SA sequencing. [Table: see text]

RE-MIND study: A propensity score-based 1:1 matched comparison of tafasitamab + lenalidomide (L-MIND) versus lenalidomide monotherapy (real-world data) in transplant-ineligible patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL)

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Background: Patients with R/R DLBCL ineligible for autologous stem cell transplant (ASCT) have a poor prognosis. In these patients, tafasitamab (anti-CD19 antibody) plus lenalidomide (LEN) has shown encouraging results in the open-label, single-arm, phase II L-MIND study (n = 81; NCT02399085). To evaluate the contribution of tafasitamab to the activity of this doublet, we conducted a global, real-world study of patients treated with LEN monotherapy (RE-MIND; NCT04150328). Here we present the primary analysis of a 1:1 patient-level matched comparison between the L-MIND and RE-MIND cohorts. Methods: Patients treated with LEN monotherapy for R/R DLBCL were enrolled in the observational, retrospective RE-MIND cohort. As in L-MIND, patients had 1–3 prior systemic therapies, including ≥1 CD20-targeting regimen; were aged ≥18 years; and were not eligible for ASCT. A 1:1 estimated propensity score (ePS) matching methodology ensured balancing of nine pre-specified baseline covariates. The primary analysis set, Matched Analysis Set 25 (MAS25), included patients who received a LEN starting dose of 25 mg/day. The primary endpoint was investigator-assessed best objective response rate (ORR). Key secondary endpoints included overall survival (OS) and complete response (CR) rate. Results: 490 patients were enrolled in RE-MIND across 58 centers in the US and Europe, of which 140 fulfilled the ePS matching criteria. The MAS25 included 76 patients each from the two cohorts. Baseline characteristics between cohorts were comparable. The primary endpoint was met with a significantly better ORR of 67.1% (95% CI: 55.4–77.5) for the L-MIND cohort versus 34.2% (95% CI: 23.7–46.0) for the RE-MIND cohort (odds ratio 3.89; 95% CI: 1.90–8.14; p < 0.0001). The CR rate was 39.5% (95% CI: 28.4–51.4) in the L-MIND cohort and 13.2% (95% CI: 6.5–22.9) in the RE-MIND cohort. A significant difference in OS favored the L-MIND cohort (HR = 0.499; 95% CI: 0.317–0.785). ORR and CR outcomes in the RE-MIND cohort were similar to the published literature for LEN monotherapy in R/R DLBCL. Conclusions: Significantly better ORR, CR and OS indicate potential synergistic effects of the tafasitamab + LEN combination in ASCT-ineligible R/R DLBCL. ePS-based 1:1 matching allows robust estimation of the treatment effect of tafasitamab when added to LEN. RE-MIND demonstrates the utility of real-world data in interpreting non-randomized trials. Clinical trial information: NCT04150328 .

Real-world incidence and cost of pneumonitis post-chemoradiotherapy for Stage III non-small-cell lung cancer

Aim: To estimate the real-world incidence and timing of radiation pneumonitis following chemoradiotherapy for Stage III non-small-cell lung cancer and compare costs between patients with and without radiation pneumonitis. Methods: Retrospective analysis using the Symphony Health Integrated Dataverse. Results: Pneumonitis incidence was 12.4% with a 177-day mean time to onset. Patients with versus without pneumonitis were more frequently admitted to the hospital (33.8 vs 19.2%, p < 0.0001) and seen in the emergency room (51.9 vs 35.8%, p < 0.0001) and had higher mean total healthcare costs (US$4251 vs US$3969 per-patient per-month; p = 0.0163). Conclusion: Although pneumonitis significantly increased healthcare resource utilization and costs in chemoradiotherapy-treated Stage III non-small-cell lung cancer, the per-patient per-month differential was <10%. Such financial assessments are critical for cost–benefit analysis.

Observational study of clinical outcomes of eribulin mesylate in metastatic breast cancer after cyclin-dependent kinase 4/6 inhibitor therapy

Aim: To examine the effectiveness of eribulin mesylate for metastatic breast cancer post cyclin-dependent kinase inhibitor (CDKi) 4/6 therapy. Materials & methods: US community oncologists reviewed charts of patients who had received eribulin from 3 February 2015 to 31 December 2017 after prior CDKi 4/6 therapy and detailed their clinical/treatment history, clinical outcomes (lesion measurements, progression, death) and toxicity. Results: Four patient cohorts were created according to eribulin line of therapy: second line, third line, per US label and fourth line with objective response rates/clinical benefit rates of 42.2%/58.7%, 26.1%/42.3%, 26.7%/54.1% and 17.9%/46.4%, respectively. Median progression-free survival/6-month progression-free survival (79.5% of all patients censored) by cohort was: 9.7 months/77.3%, 10.3 months/71.3%, not reached/70.4% and 4.0 months/0.0%, respectively. Overall occurrence of neutropenia = 23.5%, febrile neutropenia = 1.3%, peripheral neuropathy = 10.1% and diarrhea = 11.1%. Conclusion: Clinical outcome and adverse event rates were similar to those in clinical trials and other observational studies. Longer follow-up is required to confirm these findings.

Real-world outcomes among patients with early rapidly progressive rheumatoid arthritis

OBJECTIVES

To characterize treatment patterns, healthcare resource utilization (HRU), and disease activity among patients with early rapidly progressive rheumatoid arthritis (eRPRA) in the United States when treated with a first-line biologic disease-modifying antirheumatic drug (bDMARD) tumor necrosis factor-α (TNF) inhibitor or first-line abatacept.

STUDY DESIGN

Observational, multicenter, retrospective, longitudinal, medical records-based, cohort study.

METHODS

Patients with eRPRA were identified by anti-citrullinated protein antibody positivity, 28-joint Disease Activity Score-C-reactive protein of 3.2 or greater, symptomatic synovitis in 2 or more joints for at least 8 weeks prior to the index date, and onset of symptoms within 2 years or less of the index date. Patients received abatacept or a TNF inhibitor as first-line treatment. Patient characteristics, treatment patterns, HRU, and disease activity following bDMARD initiation were compared across the 2 groups. Odds ratios (ORs) of HRU in the first 6 months of bDMARD treatment were estimated using multivariable logistic regression to adjust for patient mix.

RESULTS

There were 60 patients treated with abatacept and 192 treated with a TNF inhibitor in the first line. Those treated with first-line abatacept had lower adjusted odds of hospitalization (OR, 0.42; 95% CI, 0.18-0.95), emergency department (ED) visits (OR, 0.39; 95% CI, 0.16-0.93), and magnetic resonance imaging (MRI) (OR, 0.45; 95% CI, 0.21-0.97) than those treated with a first-line TNF inhibitor (all P <.05). Adjusted odds of achieving low disease activity as measured by clinical disease activity index within 100 days of bDMARD initiation favored first-line abatacept versus a first-line TNF inhibitor (OR, 4.37; 95% CI, 1.34-13.94; P = .01).

CONCLUSIONS

Adjusting for disease severity, patients with eRPRA who were treated with first-line abatacept were less likely to have hospitalizations, ED visits, and MRI use during the first 6 months of bDMARD treatment and more likely to achieve low disease activity within 100 days of bDMARD start compared with those who received a first-line TNF inhibitor.

Community oncologists' perceptions three years after the Oncology Care Model

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Background: The Oncology Care Model (OCM) is a Medicare-sponsored delivery and payment innovation pilot under the broader concept of value-based care (VBC). OCM aims to provide better quality and coordinated cancer care at reduced cost. The OCM participants, 176 practices and 10 payers who provide care to nearly half of Medicare beneficiaries, entered into payment arrangements based on financial and performance accountability for episodes of care surrounding chemotherapy administration. We sought to understand the impact of OCM adoption on community physicians 3 years into the pilot. Methods: A live meeting in April 2019 convened a sample of US-based community oncologists to discuss “The OCM Experience”. Audience response survey methodology addressed: participation in OCM and/or related commercial programs, implementation, operation and perceptions of outcomes to patient care and practice. Results: Regarding VBC initiatives at the practices (n = 48) of 57 providers: 61% identified their practice participated in OCM, 31% in other commercial payer pathway program, and 17% in other commercial payer VBC reimbursement (not mutually exclusive). Regarding impact of OCM on improving access to care: 60% indicated having same-day appointments, 45% 24/7 HCP access, 22% weekend hours and 18% evening clinic hours. Regarding changes to patient care: 58% stated OCM driven initiatives reduced ER visits, 48% reduced hospitalizations, 62% increased palliative care referrals, and 54% increased hospice referrals. Regarding impact on practice: 41% felt an increased administrative burden with 50% hiring administrative staff, advanced practice providers, and patient navigators, but only 11% hiring physicians. The 13-component oncology care plan was reported by 53% as “not easy” to devise. The “most challenging” components included estimating total out of pocket expenses (61%) and creating a plan to address psychosocial needs (16%). 49% respondents found their practices’ OCM transformation meaningful and 46% found it not very/not at all meaningful. Conclusions: The impact of OCM/VBC transformation upon community oncologists and their practices appear to be quite profound, while the precise impact on their patients remains to be determined.

Biosimilars in Oncology in the United States: A Review

Importance

Biosimilars are biological medicines that contain a highly similar version of the active substance of an already approved biologic reference product. The availability of biosimilars might provide an opportunity to lower health care expenditures as a result of the inherent price competition with their reference product. Understanding how biosimilar cancer drugs are regulated, approved, and paid for, as well as their impact in a value-based care environment, is essential for physicians and other stakeholders in oncology.

Observations

Important structural and regulatory differences exist between biosimilar and generic medications. Minor differences in clinically inactive components with no clinically meaningful differences between biosimilars and their reference biologic are allowed. A biosimilar uses the same mechanism of action as the reference biologic, and its condition of use is the same as the approved indication, although extrapolation is permitted across indications under regulatory guidance. A biosimilar has to have a similar route of administration, dosage, and strength as the reference biologic. As patent expiration of multiple cancer biologics will occur in the next few years, more biosimilars might enter the market. Whether the approval and use of biosmilars as replacements for these heavily prescribed reference biologics will ultimately lead to cost savings is unknown and requires longer follow-up. Two biosimilars with an oncology supportive care indication are currently approved in the United States; both are myeloid growth factors.

Conclusions and Relevance

The financial impact of generic drug competition can be dramatic, but significant differences in regulatory and development processes between generics and biosimilars limit such comparisons and likely present significant challenges for biosimilar approval and adoption in the US market. However, a value-based care environment and their cost-savings potential make biosimilars an attractive option for the therapeutic arsenal. Oncologists' understanding of biosimilars is critical to moving forward.

Scope of practice of advanced practice providers (APP) in US community oncology

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Background: Oncology practices are increasingly employing nurse practitioners (NPs) and physician assistants (PAs) known collectively as advanced practice providers (APPs) to improve practice workflow, increase efficiency, and enable physicians to focus on complex patient care. Understanding variations in scope of practice for APPs may help establish a benchmark against which future changes are measured. Methods: US community physicians responded to a web-based survey from Sep to Nov 2018. Physicians were asked how frequently their APPs performed certain tasks on a 5-point scale (i.e., never, occasionally, sometimes, frequently, and always). Responses have been summarized using descriptive statistics. Results: In this study, 163 physicians were surveyed, most (81.0%, n = 132) used APPs in their practice. Among physicians using APPs, 91.7% (n = 121) used NPs and 49.2% (n = 65) used PAs. Most physicians stated that APPs were frequently/always involved in providing patient education (84.1%), ordering imaging and laboratory studies (68.9%), and/or making supportive care decisions (62.1%). Over 85% (57.6%-59.8% occasionally/sometimes; 28.0%-28.8% frequently/always) of physicians agreed that APPs discussed imaging reports and end of life (EOL) care (57.6% occasionally/sometimes, 28.8% frequently/always) with patients. Regarding procedures: 51.9% (28.0% occasionally/sometimes; 24.1% frequently/always) responded that APPs performed bone marrow biopsies and intrathecal chemotherapy. Regarding systemic therapy: 68.2% (58.3% occasionally/ sometimes; 9.8% frequently) allowed APPs to modify existing regimen e.g., dose/schedule change; 39.4% responded that APPs made decisions about new therapy selection. Conclusions: While substantial variation in the role of APPs in community oncology practices was observed, similar themes emerged. APPs appear to be integral in patient education, ordering laboratory and imaging studies, and discussing EOL care. Fewer are involved in managing and selecting supportive care and systemic therapy. Longitudinal and longer follow up are warranted to ascertain whether the scope of these practices change over time.