Integrating electronic geriatric assessment and frailty screening for adults with acute myeloid leukemia to drive personalized treatment decisions

PURPOSE

Evidenced based guidelines for patients with Acute Myeloid Leukemia (AML) acknowledge increasing importance of frailty assessment when deciding on treatment, yet comprehensive geriatric assessment (GA) results are not easily incorporated into clinic workflows and the electronic health record. This study assessed the feasibility of electronic GA use in a real-world environment.

METHODS

Patients with AML, ≥ 60 years and at a treatment decision-making point were recruited at three academic institutions. An electronic GA (eGA) was completed by patients prior to starting treatment. Results were immediately available on a dashboard. Data on feasibility, useability and acceptability of the intervention were collected immediately after the clinical visit. Patients completed follow up surveys at 3 months and chart reviews were done to capture treatment and toxicities.

RESULTS

77 patients were enrolled with a median age of 71 years (range=61-88). The eGA results were 25 fit (31.0 %), 22 (32.0 %) intermediate, and 23 (31.0 %) frail. There was 62.7 % (n = 47) provider concordance with the eGA result and 27 (36.0 %) post visit reports indicated that the eGA results influenced the treatment decision. On average, patients completed the surveys unassisted in 16.24 min and providers reviewed the dashboard in 3.5 min.

CONCLUSION

Patients easily completed an eGA prior to starting treatment. Results were reviewed by the physician and considered in the decision for optimal treatment. One third of physician reports indicated the results were used to inform the treatment decision. Feasibility of completing the eGA in the clinic without workflow disruption and utility of the results was demonstrated.

Goals, preferences, and concerns of patients with acute myeloid leukemia at time of treatment decision

INTRODUCTION

Current cancer value-based models require documentation of patient goals of care and an evidence-based treatment course commensurate with patient goals. This feasibility study assessed the utility of an electronic tablet-based questionnaire to elicit patient goals, preferences, and concerns at a treatment decision making time point in patients with acute myeloid leukemia.

MATERIALS AND METHODS

Seventy-seven patients were recruited from three institutions prior to seeing the physician for treatment decision-making visit. Questionnaires included demographics, patient beliefs, and decision-making preferences. Analyses included standard descriptive statistics appropriate for the level of measurement.

RESULTS

Median age was 71 (range = 61-88), 64.9% female, 87.0% white, and 48.6% college educated. On average, patients completed the surveys unassisted in 16.24 min and providers reviewed the dashboard in 3.5 min. All but one patient completed the survey prior to starting treatment (98.7%). Providers reviewed the survey results prior to seeing the patient 97.4% of the time. When asked their goals of care, 57 (74.0%) patients agreed with the statement "my cancer is curable" and 75 (97.4%) agreed that the treatment goal was to get rid of all cancer. Seventy-seven (100%) agreed the goal of care is to feel better and 76 (98.7%) agreed the goal of care is live longer. Forty-one (53.9%) indicated they wanted to make treatment decisions together with the provider. The top two concerns were understanding treatment options (n = 24; 31.2%) and making the right decision (n = 22; 28.6%).

DISCUSSION

This pilot demonstrated the feasibility of using technology for decision-making at the point of care. Eliciting patient goals of care, treatment outcomes expectations, decision-making preferences, and top concerns may provide clinicians with information to inform the treatment discussion. A simple electronic tool may provide valuable insight into patient understanding of disease to better tailor patient-provider discussion and treatment decision-making.

A Study Design to Harmonize Patient-Reported Outcomes Across Data Sets

PURPOSE

Using patient-reported outcomes (PROs) provides important insights from the patient's perspective and can be valuable to monitor and manage treatment-related adverse events during cancer treatment. Additionally, the digital administration of PROs (electronic PROs [ePROs]) provides real-time updates to clinical care teams on treatment-related symptoms in-between clinic visits. However, given the variability in the methodology and timing of the data collection, using and harmonizing these data across different systems remains challenging. Identifying data elements to capture and operating procedures for harmonization across ePRO tools will expedite efforts to generate relevant and robust data on use of ePRO data in clinical care.

METHODS

Friends of Cancer Research assembled a consortium of project partners from key health care sectors to align on a framework for ePRO data capture across ePRO tools and assessment of the impact of ePRO data capture on patient outcomes.

RESULTS

We identified challenges and opportunities to align ePRO data capture across ePRO tools and aligned on key data elements for assessing the impact of ePRO data capture on patient care and outcomes. Ultimately, we proposed a study protocol to leverage ePRO data for symptom and adverse event management to measure real-world effectiveness of ePRO tool implementation on patient care and outcomes.

CONCLUSION

This work provides considerations for harmonizing ePRO data sets and a common framework to align across multiple ePRO tools to assess the value of ePROs for improving patient outcomes. Future efforts to interpret evidence and evaluate the impact of ePRO tools on patient outcomes will be aided by improved alignment across studies.

Improving supportive care for patients with thoracic cancer

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Background: Improving lung cancer care among Veterans is a priority within the Veterans Affairs due to higher rates of lung cancer incidence, morbidity, and mortality among Veterans compared to non-veterans. Unaddressed symptom burden is common due to many factors including complex comorbidities, psychosocial challenges, smoking history and limited social support networks. Additionally, complications from social determinants of health can obstruct successful discussions of symptom-burden between Veterans and their clinical care teams which can limit compliance with recommended symptom management strategies. To overcome these barriers, we conducted a randomized controlled trial to test the effectiveness of a lay volunteer-led proactive symptom assessment and symptom intervention. The objective was to determine if the intervention improved clinician documentation from baseline to 6-months post-enrollment compared to usual care. Secondary outcomes included change in patient activation, health-related quality of life (HrQOL), and symptom-burden. Methods: Patients were randomized into the lay volunteer proactive symptom assessment intervention plus usual cancer care (intervention group) or usual cancer care alone (control group). We conducted electronic health record review to assess primary cancer-clinician symptom documentation of Veterans’ symptoms identified as moderate-to-severe at baseline and 6-months using the Edmonton Symptom Assessment Scale. Patient surveys with validated assessments were used to assess patient activation, HrQOL and symptom burden at baseline (time of enrollment) and 6-months post-enrollment. We used regression models to evaluate differences in our primary and secondary outcomes. Results: 60 Veterans were consented and randomized into the study (29 control; 31 intervention). There were no differences in demographic or clinical factors across groups. The median age was 70 years (range 56-85), 95% were male, 70% identified their race as White, 53% were married and 48% had a 2-year or 4-year college degree. The majority had at least 3 comorbidities (54%), diagnosed with stage 3 or 4 (62%) and received systemic treatment with chemotherapy and/or radiation (77%). At 6-months post-enrollment as compared to baseline, the intervention group had greater improvements in symptom documentation (56% from 12.5% vs. 29% from 43%, p = 0.01), greater improvements in patient activation (p<0.001), HrQOL (<0.001), and lower symptom burden (p<0.001) than the control group. Conclusions: Integration of proactive symptom assessment by lay volunteers has a significant and meaningful effect on symptom documentation, patient activation, quality of life, and reducing symptom burden among Veterans with lung cancer. Clinical trial information: NCT03216109.

Electronic Patient Symptom Management Program to Support Patients Receiving Cancer Treatment at Home During the COVID-19 Pandemic

OBJECTIVES

Remote patient monitoring became critical for patients receiving cancer treatment during the COVID-19 pandemic. We sought to test feasibility of an electronic patient symptom management program implemented during a pandemic. We collected and analyzed the real-world data to inform practice quality improvement and understand the patient experience.

METHODS

Eligible patients had breast, lung, or ovarian cancers, multiple myeloma, or acute myeloid leukemia and 12 weeks of planned chemotherapy. Patients were notified that a symptom survey with common symptoms derived from the National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events was available to complete using a smart phone, tablet, or computer. Patients recorded their symptoms and results were sent to the provider. Patients received care guidelines for mild/moderate severity symptoms and a phone call from the provider for severe reports.

RESULTS

A total of 282 patients generated > 119 088 data points. Patients completed 2860 of 3248 assigned surveys (88%), and 152 of 282 patients (54%) had symptom reports that generated an immediate notification to the provider. Longitudinal data were analyzed to determine whether previous reports predicted a notification alert and whether symptoms resolved after the alert was addressed.

CONCLUSIONS

An electronic patient symptom management program was implemented in the midst of the COVID-19 pandemic. Enrollment of 282 patients and a high survey completion (88%) demonstrated feasibility/acceptance. Patients reported symptoms at severe levels of 54% of the time and received self-management instructions and provider phone calls that resolved or decreased the severity of the symptom. A standard approach and validated instrument provide opportunities for improving and benchmarking outcomes.

Shared Decision-Making in Managing Breakthrough Cancer Pain in Patients With Advanced Cancer

Background: Pain is a significant problem in patients with cancer. Breakthrough cancer pain contributes to the pain experience, but it is often underassessed and underrecognized. Shared decision-making (SDM), where patient preferences, goals, and concerns are discussed and integrated into a shared decision, can potentially foster earlier identification of pain, including breakthrough cancer pain, and improve pain management. Objectives: To explore the use of SDM to evaluate its impact on cancer pain management. Methods: This prospective, multisite study engaged patients with advanced cancer to explore the use of SDM in managing cancer pain using a digital platform with an expanded pain assessment. Decision preferences were noted and incorporated into care. Outcomes included pain and patient-perceived pain care quality. Results: 51 patients with advanced cancer enrolled in the study. The mean pain score was 5 out of 10 throughout the three study time points. 88% of patients experienced breakthrough cancer pain of severe intensity at baseline and approximately 70% at visits two and three. The majority of breakthrough cancer pain episodes lasted longer than 30 minutes. The majority (86%) of participating patients desired shared decision-making or patient-driven decision-making. Most patients expressed satisfaction with the level of shared decision-making in managing their cancer pain. Breakthrough cancer pain remained significant for most patients. Conclusions: SDM incorporated into pain discussions has the potential to improve pain outcomes, but significant challenges remain in managing breakthrough cancer pain.

Patient responses to weekly electronic patient-reported outcomes

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Background: Home-based symptom monitoring using patient reported outcomes has been shown to reduce symptom burden and hospitalizations, while improving quality of life and overall. The primary goal of this study was to evaluate the early feasibility of home-based symptom monitoring. Methods: This prospective single-arm pilot study evaluated a two-part education and technology intervention (home-based symptom monitoring) for clinicians treating Multiple Myeloma (MM) and Acute Myeloid Leukemia (AML) patients. Inclusion criteria included patients ≥ 60 who were anticipating a treatment decision. Participants completed a baseline survey and then enrolled into the PROmpt® symptom monitoring platform, which used text or email to prompt weekly symptom surveys. Patients receive an auto-generated self-management plan based on electronic patient reported outcomes (ePRO). If severe symptoms were reported (score of > 7/10), alerts were sent to clinical nurses. Outcomes for this study included proportion of patient approach who agreed to participate, patient completion rates (completion of weekly surveys), compliance rate (completion of total surveys), number of alerts generated, and type of alert. Feasibility was defined as a completion rate of > 70%. Results: Between September 1, 2020 –May 19, 2021; 114 patients were screened, 77 were approached, and 35 were enrolled (18) MM, (17) AML patients. Of non-participants, 11 were not seeking care at the institution, 10 patients were uninterested or did not have a smartphone, 9 patients were ineligible, and 9 were unsure and left with information about the study, 3 declined enrollment. The majority (80%) or participants were ages 60-74; 20% of patients were ages 75+. Over the 13-week period, AML patients completed 195/220 (compliance rate of 89%). The average completion rate was 92%. For MM, 192/233 surveys were completed (82% compliance rate). The average completion rate was 94%. For AML, 9 was the average number of completed surveys and the average number for MM was 8. Over 3 months, there were 294 moderate to severe alerts generated for AML and MM patients. For AML patients, there were 40 fatigue, 25 constipation, 21 pain, 17 decreased appetite, 11 insomnia, 11 rash, 6 anxiety, 7 dyspnea/cough, 7 diarrhea, 5 depression/sadness, 4 nausea/ vomiting, 4 mouth/ throat sores, 3 neuropathy, 3 fever, and 2 alerts for other symptoms. Within a 3 month time span for MM patients, there was 35 pain, 21 constipation, 18 fatigue, 11 rash, 10 neuropathy, 9 anxiety, 7 insomnia, 6 depression/sadness, 4 decreased appetite, 4 other symptom, and 1 nausea/vomiting alert. Conclusions: This study demonstrated early feasibility with over 80% of patient completing their surveys with a high compliance rate. Future analysis will include both final implementation outcomes as well as patient outcomes for all patients within the study.

Integrating touchscreen-based geriatric assessment and frailty screening for adults with acute myelogenous leukemia to drive personalized treatment decisions

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Background: AML is a disease of older adults, with median age of 68 years at presentation. NCCN guidelines suggest comprehensive geriatric assessments (GA) be included in clinical practice to guide treatment decisions. Utility of GA in older AML patients in a real-world environment is not yet established. We tested the feasibility of using a modified GA (mGA), administered by patient self-report on a touchscreen computer, real-time use and utility by clinicians and the correlation of mGA results on treatment decision-making. Methods: Sixty-two patients were recruited from three sites to complete a tablet-based mGA screening at a treatment decision-making time point. The mGA consists of the Frailty Index (FI) that includes four domains: age, activities of daily living, instrumental ADLs, and comorbidities. Falls within the past 6 months and patient reported health interference with function are also assessed. Results are displayed for the clinician to inform the treatment discussion. Results: Participants were mean age 73 years (range 61-88), 63% male, and 90% white. Frailty Index result was 32% fit, 40% intermediate, and 28% frail. Providers were asked the fit/frailty status prior to seeing the results of the mGA. Of 53 provider responses, there was 57% (n=30) provider concordance with the mGA result; 9% (n=5) said fit when mGA said intermediate and 17% (n=9) said intermediate when mGA said frail. When asked their goals of care, nearly all (n=60, 97%) patients agreed with the statement “my cancer is curable”, yet 30% (n=19) disagreed the treatment goal was to get rid of all the cancer. Nearly half (n=30) indicated they want to make treatment decisions together with the provider rather than provider or patient making decision alone. 73% (45/62) of patients were satisfied with the ease of using the survey and took an average 16.3 minutes to complete. Patient self-reported presence/severity of eight symptoms at baseline (see Table). Conclusions: A simple electronic tool may provide valuable insight into patient understanding of disease to better tailor patient-provider discussion and treatment decision-making. Providers overestimated fitness 26% of the time. Final results will be presented to include the outcome at 3 months by Frailty Index. [Table: see text]

Use of a patient-preferences shared-decision-making encounter tool in clinical practice for patients with non-Hodgkin’s lymphoma

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Background: Non-Hodgkin lymphoma (NHL) is the fourth leading cause of cancer in the United States with 77,240 new cases and 19,940 deaths annually. Treatment options are numerous and driven by patient’s molecular profile, risk, preferences/goals, and ability to tolerate treatment. Aligning physician-patient goals of care and integrating patient preferences into a shared-decision making (SDM) model allows patients and providers to select treatment consistent with medical science and personalized to each patient. This project evaluates feasibility of a patient preferences (PP) SDM encounter tool using technology to facilitate SDM at treatment decision (TD) for patients with NHL. Methods: To date, 45 patients with NHL at a TD making point were recruited from two sites to complete a tablet-based PPSDM encounter tool. The tool includes questions about needs, decision making preferences, values and goals of care. Results are reviewed by the provider and used to facilitate SDM in treatment selection during the clinical encounter. Patients also completed measures to assess satisfaction with the TD, patient activation, and perceived achievement of desired role in SDM at 3 weeks and 3 months post TD. Results: Participants are mean age 66 years (range 23-86), 53% male, and 98% white. 47% (n = 45) preferred that their doctor share responsibility with them when deciding which treatment was best for them. 69% said they would like to make the TD together with family and close friends and 69% agreed that their spouse was the most important person in helping make a TD. 51% said spirituality did not play a part in their TD. When asked how they liked to get medical information, 67% said they wanted all the facts, but not the prognosis. 87% said they had identified a medical surrogate to make decisions, yet 31% had an advanced directive on file. 64% agreed their cancer was curable and 84% agreed that a treatment goal was to get rid of all cancer. 73% of providers used the PPSDM results in conversation with the patient and 53% indicated their patient management changed based on the PPSDM results. There was 24% concordance between patient and provider perception of how TD were made. Conclusions: Collecting patient preferences, values, and care goals prior to the clinical visit using technology is feasible in busy clinics. Although most providers used the PPSDM results and over half changed their management plan, there was low concordance between patient and provider perceptions. Final analysis will include 3 week and 3 month measures of patient activation and satisfaction.

Understanding Barriers to Oral Therapy Adherence in Adults With Acute Myeloid Leukemia

Acute myeloid leukemia (AML) is a disease of older adults, with a median age at diagnosis of 68 years. The availability of oral anticancer medications has increased, although the standard treatment for AML remains in intravenous form. We aim to identify barriers to adherence to oral medications in patients with AML and proposed solutions for improvements. Following institutional review board approval, patients with AML and their caregivers were recruited to participate in focus groups. Sessions were digitally recorded, transcribed verbatim, and analyzed for thematic content using Dedoose qualitative software. 11 patients (five < 65 years; six ≥ 65 years) and 4 caregivers participated in these sessions. Three central themes emerged: 1) medication adherence challenges, 2) managing an oral adherence plan, and 3) strategies to improve oral adherence. Participants recommended written schedules, taking medications around meals, and using pillboxes and alarms. We believe that patients are an important source of insight into barriers and solutions to oral medication adherence.

Integrating Touchscreen-Based Geriatric Assessment and Frailty Screening for Adults With Multiple Myeloma to Drive Personalized Treatment Decisions

PURPOSE

Geriatric assessment (GA) results predict toxicity/survival in older adults, yet GA is not routinely used in care for patients with multiple myeloma (MM). We tested a tablet-based modified GA (mGA) providing real-time results to clinicians.

METHODS

One hundred sixty-five patients with MM aged ≥ 65 years facing a treatment decision from 4 sites completed a tablet-based mGA with Katz Activities of Daily Living (ADL), Lawton Instrumental ADL, Charlson Comorbidity Index, and variables from the Cancer and Aging Research Group's Chemotherapy Toxicity Calculator. Providers reviewed the assessment results at the treatment visit.

RESULTS

Patients were white (72%; n = 86), mean age was 72 years (range, 65-85 years), and averaged 7.71 minutes (range, 2-17 minutes) for survey completion. Providers averaged 3.2 minutes (range, 1-10 minutes) to review mGA results. Using International Myeloma Working Group frailty score, patients were fit (39%; n = 64), intermediate fit (33%; n = 55), or frail (28%; n = 46). Providers selected more aggressive treatments in 16.3% of patients and decreased treatment intensity in 34% of patients; treatment intensification was more common for fit patients and milder treatments for frail patients (χ² = 20.02; P < .0001). Transplant eligibility significantly correlated with fit status and transplant ineligibility with frail status (P = .004). Outcomes on 144 patients 3 months post study visit showed 19.4% (n = 28) had grade ≥ 3 hematologic toxicities, 38.9% (n = 56) had dose modifications, and 18% (n = 26) had early therapy cessation.

CONCLUSION

Limited patient time required for survey completion and provider time for results review show mGA can be easily incorporated into clinical workflow. Real-time mGA results indicating fit/frailty status influenced treatment decisions.

Oral adherence in adults with acute myeloid leukemia (AML): Results of a mixed methods study

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Background: The incidence of AML is increasing, in part due to an aging population. Amid established intravenous (IV) or subcutaneous chemotherapies , recent drug approvals have ushered in an era of oral medication (OM) approaches to treating AML, shifting the burden of daily adherence from clinicians to patients. We aimed to identify and summarize adherence to oral therapy in this population. Methods: Our mixed methods study design used focus groups (FG) and patient surveys. After IRB approval, 11 patients and 4 caregivers participated in 4 focus groups. Results were used to develop a 37-item OM adherence needs assessment. Subsequently, AML patients were recruited and consented at three cancer centers to complete surveys (online, at the clinic, hospital, or from home). Results: 100 patients completed the OM survey. Most were male (62%), racial/ethnic diversity (33%), < 65 years (59%), and college-educated (52%). The to be taken was the most frequent and troublesome challenge. Loss of appetite was the most commonly reported and problematic side effect. Although half of the patients stated, “no side effect would cause them to stop taking OM”, another 25% indicated nausea would cause non-adherence. The best strategy to support taking OM was to make it part of the daily routine. Directions for taking OM were most commonly found on medication bottles or received from the health care team (HCT); patients felt HCTs were the best source of directions. Nearly 1/3 of patients indicated they skip the OM dose altogether when they forget to take it. When asked what would help improve adherence: smaller pills, easier packaging, and scheduling assistance were most frequently reported. Older individuals (>65 years) had a slightly more positive attitude towards oral medication (p =.51). Younger patients (<65 years) were more accepting of taking oral vs IV meds, (p = .03). Conclusions: This study represents the first assessment of OM adherence in patients with AML. Three themes emerged in FG transcript analysis that informed the development of a 37-item survey that was subsequently completed by 100 patients. Findings provide the basis for further exploration of interventions to enhance and increase adherence to OM regimens.

Oncology practice changes during a multistep Oncology Care Model practice transformation project

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Background: Treatment of lung cancer has seen a paradigm shift in recent years. While the availability of newer treatment options such as targeted therapy and immunotherapy have provided new hope for better outcomes, this has added to the cost of care. Participation in the Center for Medicare Services’ Oncology Care Model (OCM) provides opportunities for oncology practices to identify practice transformation (PT) change strategies that result in improved quality of care (QOL) and cost savings. Methods: A lung cancer PT team convened to facilitate changes that improve patient outcomes and decrease costs at an OCM organization. The year-long project included clinical treatment updates, quantitative and qualitative assessments, and data sharing. Practice changes focused on biomarker driven treatment selection, nurse navigation to better manage symptoms and decrease emergency department (ED) visits and hospitalizations, and earlier advanced care planning (ACP) discussions. Surveys were completed by oncology physicians and nurse practitioners at baseline (n = 9) and end of the project (n = 7). Results: After education, there were more correct responses in 3 of 6 knowledge questions and providers noted less concern about performance status or co-morbidities when prescribing immunotherapy. Providers noted fewer barriers with biomarker documentation; self-reported confidence in 4 questions of biomarker selection was unchanged. Providers reported increased participation of nurse navigators to impact ED visits and hospitalizations over time. Documentation of ACP discussions increased, 42% (8/19) to 56% (13/23), but did not reach statistical significance due to sample size. Although providers reported changes toward earlier ACP discussions, 1 in 3 still wait until performance status declines to initiate discussion. Conclusions: Systematic PT can improve quality of patients care and measures used in value-based care reimbursement models. Providers need ongoing education, practice feedback, and organizational support to effect positive practice changes. In addition, new strategies to increase provider ability to initiate end of life discussions need to be explored.

Understanding barriers to oral medication adherence in adults with acute myeloid leukemia (AML)

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Background: AML is a disease of older adults (median age 67 years). Although standard AML treatment is intravenous (IV) chemotherapy, availability of oral anti-cancer medications has increased , providing benefits and risks to patients. Patients prefer their convenience, absence of IV infusions, potential for fewer clinic visits, and increased subjective feeling of control over their disease. Poor adherence can increase toxicity risk and compromise treatment effectiveness. We aim to identify barriers to adherence to oral medications in patients with AML and proposed solutions for improvements. Methods: Following IRB approval, patients with AML and their caregivers were recruited to participate in focus groups. An experienced moderator conducted the groups using an interview guide developed by AML experts. Participants received gift cards for their participation. Sessions were digitally recorded, transcribed verbatim, and analyzed for thematic content using Dedoose qualitative software. Results: 11 patients (5 <65 years; 6 >65 years) and 4 caregivers participated in sessions lasting 60-75 minutes. Three central themes emerged: medication adherence challenges, managing an oral adherence plan, and strategies to improve oral adherence. Adherence challenges: number and size of pills, different directions, cost, availability, and side effects. An adherence plan was recommended: written schedules, take medications around meals, and use of pillboxes and alarms. Main sources of information: health care team and bottle directions. Recommendations for providing adherence assistance included better instructions, assistance with scheduling, making pills smaller, and consistency in packaging. Conclusions: Patients are an important source of insight into barriers and solutions to oral medication adherence. These responses were used to develop a survey to be administered to 100 patients with AML. Results will inform development of an intervention to improve oral medication adherence in the AML population.

Meeting lung cancer value based care requirements with documentation of patient goals and preferences

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Background: Non-small cell lung cancer (NSCLC) accounts for 25% of all cancer deaths with 5-year survival of 6%. Recent scientific advances in molecular based treatments and immunotherapy and insurers’ emphasis on patient-centered care is changing patient care. This study sought to incorporate patients’ perceptions, goals, and preferences into treatment planning. Methods: After provider education and using electronic care planning software (CPS), a pilot of 50 patients with advanced NSCLC from two academic centers completed tablet-based surveys addressing treatment goals, decision-making preferences, and interest in clinical trials. Results were shared with the provider during the visit. Once treatment was selected, the CPS generated a personalized care management plan. Results: Participants were mean age 65 (range 41-86), 52% female, and 78% white. 60% (12/20) Stage IV patients believed that their cancer was curable. 62% (31/50) were not interested in clinical trial participation. 48% (24/50) wanted to share treatment decision making; 34% (12/50) wanted to make the final decision after seriously considering the doctor’s opinion; 6% (3/ 50) wanted the provider to make the final decision but consider their opinion, and 10% (5/50) wanted to leave all decisions to the provider. Conclusions: Patient perception of curability and decision-making preferences were important domains identified by personalized-care management planning in this Lung Cancer pilot study. Pre-visit CPS use provided the opportunity for the provider to address treatment intent and decision-making at the point-of-care. Academic centers generally expect their patients to have strong interest in clinical trials; Investigation for the reasons for disinterest warrants further exploration.

A practice transformation model to improve lung cancer care

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Background: Lung cancer has the highest cause of cancer death, treatment of which is both complicated and expensive. Emerging actionable biomarkers and treatments provide both opportunity and treatment challenges. Adherence to evidence-based treatment and advanced care discussions add value to care. Oncology practices need to document the above to participate in value-based care reimbursement models. A Practice Transformation (PT) model was implemented to address quality and cost issues. Methods: After IRB approval, baseline data on lung cancer patients diagnosed during a 6-month period (Jul-Dec 2017) were collected through chart abstraction and treatment planning surveys. Rates of molecular testing ordered, results available at time of treatment decision-making, guideline concordant treatment decisions, and documentation of advanced care discussions were presented to the PT team. After education on recent clinical trial results and NCCN treatment guidelines, the PT team determined strategies for change. The PT team met after two 3-month periods of PT for education updates and progress reports. Data was compared on newly diagnosed patients during a 6-month period (Jul-Dec 2018), one year after the baseline period. Results: A total of forty-two patients were diagnosed in two 6-month periods, baseline and study period. Average age was 65 years, 57% male, 71% Caucasian, 95% ever smokers, 71% adenocarcinoma histology. Rate of ordering any molecular testing was (16/19) 84% in the baseline period vs (20/23) 86% in the study period. However, extended molecular testing increased from 16% (3/19) to 60% (12/20), p = .05 Fishers exact test. At treatment initiation, evidence-based treatment selections went from 47% to 52%. Documentation of advanced care discussions, 42% (8/19) to 56% (13/23), did not change significantly. Conclusions: A PT model that included education, and two cycles of implementation and feedback, resulted in increased molecular testing to inform evidence-based treatment selections. Increased awareness of the lack of documentation of advanced care discussions provides opportunity for continued improvement to effect quality care.

Real-world practice patterns of providers managing older patients with non-small cell lung cancer

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Background: Most patients with non-small cell lung cancer (NSCLC) have advanced disease at diagnosis and are older with median age 72 years. Evidence-based treatment (EBT) selection requires availability of molecular testing (MT) results at time of treatment decision and geriatric assessment (GA) helps determine a patient’s ability to tolerate therapy. This study describes practice patterns and evidence based treatment selections of providers managing older patients with NSCLC. Methods: After provider education and using care planning software (CPS), 50 patients with advanced NSCLC from two academic centers completed surveys regarding treatment goals and decision-making preferences, and patients ≥ 65 completed a modified GA that included activities of daily living and comorbidity assessment. Once treatment was selected, a personalized care plan was generated. Comparison treatment data from 17 community patients was obtained. Results: Participants were mean age 65, 52% female, and 78% white. Of 28 stage IV patients, 79% had MT and results available at time of treatment decision, and 100% met EBT guidelines. The community cohort had 47% testing, 29% results available, and 65% met guidelines. GA results in 24 patients were 46% frail, 29% intermediate fit, and 25% fit. Two patients (8%) were frail and had a plan change due to GA results. Conclusions: Obtaining timely MT results remains challenging. Continued strategies to ensure MT and timely results should be explored, including quality assurance monitoring given the increasing importance of MT in treatment selection. GA was less impactful in this setting, likely due to later stage patients, presumed frailty, and treatment goal being palliation. We believe GA would have greater impact in early stage NSCLC where aggressive treatments are offered with curative intent.

Shared decision-making preferences and pain characterization in patients with cancer

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Background: Cancer pain prevalence is high (52%-77%) with breakthrough pain flares and end-of-dose failure adding to patient suffering and increased health care utilization. Shared decision-making (SDM), incorporating patient-stated preferences, goals, and concerns, can foster comprehensive pain assessment (CPA) and improve pain outcomes. Methods: This study will evaluate SDM and CPA in patients with cancer to manage chronic and breakthrough pain. Eligible patients have pain or are taking opioids to manage chronic cancer pain. Patients complete a tablet-based survey at enrollment to record baseline pain and activity levels, pain flare severity and length, end-of-dose pain, and SDM preferences. Results are presented on an electronic dashboard and the provider and patient collaboratively establish a pain care plan. The effectiveness of SDM on pain outcomes will be measured with the Pain Care Quality Survey. Results: Pain characterization is described for the first 43 patients enrolled, of which 42% (n=18) desire to share decision-making with the provider, while 35% (n=15) prefer to make the final decision after considering provider input. Patients are 57% (n=26) female with a mean age of 56 (range 20-93); baseline mean pain scores were 5.4, and overall distress scores were 5.43, (scale 0-10); 91% had a pain flare in the last seven days with mean severity of 5.53; 72% of flares lasted longer than 30 minutes. All patients had end-of-dose pain. Less than half (42%) have restricted activity and 23% manage self-care but cannot work. Participants reported incident pain associated with certain activity (63%) as well as insidious pain not associated with activity (65%). Enrolled patients selected 143 pain descriptors: burning (16), achy (24), sharp and stabbing (21), pins and needles (15), cramping (14) radiating (14), intermittent (19), and continuous (20). Conclusions: The majority (77%) of patients desire SDM. Although most patients were already taking opioids at presentation, they had moderate pain and distress, frequent flares and end of dose pain, and limitations on activity level due to the pain. Baseline pain characterization with a drill down CPA offers opportunity to use SDM to develop effective pain care plans and measure outcomes. Clinical trial information: NCT03304145.

Barriers and solutions to conducting patient-reported outcomes (PRO) research in patients with pain

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Background: Cancer pain prevalence ranges from 52-77%. Poorly controlled pain contributes to patient suffering and increased health care utilization. Shared decision making (SDM), where patient preferences, goals, and concerns are discussed, can foster earlier identification and improved pain management. A study was proposed to determine if incorporating SDM into a pain care plan is feasible and effective. Methods: Patients with metastatic cancer reported their pain and symptom experiences on an electronic patient-reported outcome (ePRO) platform. A drill down pain assessment included questions on chronic and breakthrough pain and end of dose failure. The patient and provider jointly discussed ePROs; an individualized care plan was printed for each patient. One academic and two community sites planned to recruit 105 patients over 6 months. Accrual quickly fell behind predicted rates (1 vs 15 patients per month). Study teams met to identify and mitigate accrual barriers. Results: Using an implementation science framework, barriers were identified in study design, and patient, provider, and environmental issues. Literature reports challenges in accruing/ retaining patients with metastatic disease, such as uncontrolled symptoms, inability to complete measures, missed visits, hospice admission, and death. Researchers broadened eligibility requirements to include all cancer stages; study team members were re-educated to clarify the operational definition of pain (experiencing pain or controlled on opioids). Some patient-related barriers were solved with workflow modifications (pre-visit survey completion). Environmental issues such as privacy to complete ePRO measures and internet connection reliability were solved with clinical staff. Conclusions: Study accrual improved 500% (from 6 to 36 in 3 months) following design and process changes. While examining patients with metastatic disease is important, expanding eligibility allows researchers to still include these patients and yet answer research questions timelier with the expanded population. Applying implementation science principles during study design is relevant to broader studies of pain and symptom ePROs and SDM in cancer care. Clinical trial information: NCT03304145.

Overcoming suvivorship care planning implementation challenges through decentralization

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Background: To meet Commission on Cancer accreditation requirements, cancer programs must implement processes to monitor the dissemination of survivorship care plans (SCP) for patients with Stages I-III cancers who were treated with curative intent and completed active therapy. Challenges of SCP delivery across disease sites include lack of designated/trained staff, time burden, knowledge of current evidence-based guidelines, and sustainability. We describe the challenges NorthShore University HealthSystem Kellogg Cancer Center (NKCC) and their Living in the Future (LIFE) Cancer Survivorship Program faced in meeting this standard and how evolving the SCP delivery process has resulted in a sustainable model. Methods: LIFE implemented a technology-based SCP tool using a centralized consultative model led by a nurse practitioner (NP) with specialized survivorship training. Physicians referred eligible patients to the survivorship clinic for an education visit where they received a SCP from the NP. Since the centralized model was dependent on one person for delivery, a more sustainable model was needed. NKCC transitioned to a decentralized process, moving SCP creation and delivery responsibility to all oncology care providers (OCPs). Although not all OCPs had specialized survivorship training, care quality was supported by automated SCP creation based on evidence-based care recommendations embedded in the technology. Results: To date, 143 evidence-based SCPs have been delivered since tool implementation in April 2017. During the centralized model (April 25– June 30) 67 SCPs were created by the lead LIFE NP; 76 were created during the decentralized process while the lead NP was on leave (July 3 – Oct 1). By using a technology-based SCP, OCPs incorporated SCP delivery into their workflow and no longer had to refer patients to a separate clinic. Conclusions: This project demonstrates the feasibility of a sustainable, decentralized process using a technology-based SCP as an option for augmenting centralized SCP delivery. A comparable number of patients received a SCP during both processes with an equivalent number of SCPs being delivered via the decentralized model by OCPs supported by evidence-based technology.

Abstract P4-11-05: Improving neoadjuvant breast cancer therapy rates uptake with education and technology

Background: Recent studies show that treating aggressive subtypes of breast cancer (BC) with neoadjuvant chemotherapy (NAC) improves clinical outcomes in addition to breast conservation therapy (BCT) rates. Yet a large multi-site population-level analysis shows that only 5.5% of NCCN-guideline eligible patients receive NAC (Ontilo et al, 2013). Multi-level interventions are needed to improve concordance with NCCN guidelines for NAC consideration in women who meet criteria for BCT (clinical stage IIA, IIB, and IIIA BC). Methods: A 2-part intervention was undertaken to improve adherence to NAC guidelines. Certified medical education (CME) was first provided on BC diagnostics and treatment (Tx), including NAC. Next patients were recruited to a point of care technology-based intervention. Eligibility included a new diagnosis of invasive BC, clinical stage T1c and/or N1 or greater, and no prior Tx. Patients interact with an electronic care planning system (CPS) at the time of surgical consultation to report preferences for decision-making and concerns, such as distress over losing a breast. The CPS displays these findings along with a draft care plan (CP) that suggests guideline based referrals and provides patient education about BC diagnosis and Tx options. After editing, surgeons finalize and deliver CPs at the visit. The goal is to describe referral rates to medical oncology for discussion of and receipt of NAC. Outcomes from chart abstraction are compared to historical rates in the literature and where available, the institution. Results: Data on 39 of 75 women are mature (remaining to be presented at meeting). Median age is 60 years (range 37-92) and clinical stage is IA=41% (N=16), IIA= 41% (N=16), IIB=8% (N=3), and III=10% (N=4). Of 39 patients, 44% were HR+HER2+, 10% were HR+HER2-, 13% had triple negative BC, and 33% had incomplete data. Per NCCN stage, 59% (N =23) were eligible for NAC evaluation. 96% (N=22) of those eligible were referred to MO. Follow up 2 months post-surgical appointment revealed 91% (N=21) of referred patients had completed a MO consultation. 39% (N=9) of those referred for evaluation (N=23) had a prescription for NAC and all prescriptions were guideline adherent, including regimens combining chemotherapy with trastuzumab and pertuzumab for HER2+ disease. Overall, 30.4% of women eligible for referral went on to receive NAC. Distress related to loss of breast was moderate (0-10 scale, M=4.83) and was significantly related to whether patients received a referral for NAC (B= -.304, Wald's=4.61, p=.03). Most of participating providers (80%, N=5) felt the CP was valuable to help with Tx decision-making. Conclusions: Preliminary results show CME and an electronic CPS may improve NAC uptake. Rates of prescription were clearly higher in this analysis than in a 4-center population database study, both overall (23.1% vs. 3.8%) and by NCCN eligibility (30.4% vs. 5.5%), and compared to baseline in 1 (of 3 planned) centers in the study who had a baseline rate of overall NAC prescription of 8.7% in the year prior to the study. The higher the distress over the loss of a breast, the more likely the patient received a referral for NAC. These data provide preliminary support for improving NAC uptake and warrant investigation in a RCT.

Citation Format: Gary M, Keeler V, Rush S, Parsons P, Zhong X, Stricker CT, Wujcik D, DiGiovanni L, Davis A, Han LK. Improving neoadjuvant breast cancer therapy rates uptake with education and technology [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-11-05.

Integrating a touchscreen-based brief geriatric assessment in older adults with multiple myeloma

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Background: Multiple myeloma (MM) is a disease of older adults (OAs) with > 60% of diagnoses and nearly 75% of deaths occurring in patients > 65 years old (YO). Geriatric Assessment (GA) is associated with toxicity and survival in OAs with MM, but not routinely used in practice. This project pilot tests a tablet-based modified Geriatric Assessment (mGA) that presents compiled GA results, including (the Palumbo) frailty score, to clinicians at a treatment decision-making visit in a single screen dashboard. Methods: In this multisite ongoing study, 210 patients with MM ≥65 YO facing a decision point for care will complete a mGA that includes the Charlson Comorbidity Index (CCI), Katz Activity of Daily Living (ADL) Score, and Lawton Instrumental Activity of Daily Living (IADL) Score prior to meeting with a physician. mGA results, including composite frailty score, are provided to physicians at the start of a visit. Results: Thirty-six patients have been enrolled to date; enrollment continues. Participants are 69% (n = 25) white, 64% (n = 23) male, and mean age of 72 YO (range 65-87). Most (74%, n = 20) currently receive ≥1 therapy and have few co-morbidities (CCI median 1, SD 1.95, range 0-8); 57% require assistance with IADLs and 37% require assistance with ADLs. Based on Palumbo score, 36% of participants were frail (n = 13), 33% intermediate (n = 12), and 31% fit (n = 11). Providers report mGA results influenced treatment decision (54%, n = 28) and frailty score was the most frequently cited result to impact treatment decision-making (61%, n = 39). The most common way the mCGA influenced decision-making was to reduce dose/dose intensity (25%, N = 8). Clinicians on average spent 5 minutesreviewing the mGA results. Patients reported an average of 7 minutes to complete the survey, most independently (83%, n = 30), and were satisfied with the electronic program overall (80%, n = 29), including how easy it was to use (88%, n = 32). Conclusions: Preliminary data support feasibility, usability, and acceptability of the tablet-based mGA and that frailty score influences provider decision-making ≥50% of the time. Future analyses will explore the relationship of the mGA with toxicity, dose modification and/or treatment discontinuation in OAs with MM.

Abstract P5-11-04: Technology as a change agent for improving breast cancer quality care

Background: With rapid advances in research, clinicians often struggle to remain current with evolving care guidelines and to implement current national quality standards (NQS) relevant to breast cancer management. Adherence to NQS is driving reimbursement for cancer services, but clinical workflow processes and IT solutions are lacking to effectively document adherence. The Carevive Care Planning SystemTM (CPS), an evidence-based, patient assessment and care planning software, is designed to close gaps in quality cancer care by marrying clinical and patient-reported data with evidence-based algorithms to help centers improve and document their adherence rates to quality care standards.

Methods: This study enrolled 30 non-metastatic breast cancer patients presenting to an NCI-designated comprehensive cancer center for no greater than their second medical oncology visit, and compared provider adherence to quality metrics for these patients with 30 matched historical controls who were seen prior to the study intervention. All were planned for chemotherapy treatment. The two part study intervention included 1) Provider participation in certified continuing medical education (CME) on evidence-based assessment, decision-making, and management strategies for breast cancer and 2) Use of the Carevive CPS with intervention subjects, each of whom who completed a electronic survey assessing current symptoms and concerns prior to their visit, and then received a provider-approved care plan including tailored recommendations for symptom management and referrals. The primary aim was to compare provider adherence to select quality metrics between historical controls (pre-test) and post-intervention subjects.

Analysis/Results:

Patient enrollment began in July 2015 and an earlier report of control data showed improved provider knowledge post-CME and opportunities to improve adherence. Median age and distribution of race, ethnicity, breast cancer stage, and HER2/ER status was not statistically different between the groups. Provider adherence to quality standards from pre to post-test is shown below:

Quality Standard MetricsQuality StandardNPrePostChi-squarepAssessed emotional well being6020%50%6.190.045Addressed emotional well being2133.3%93.3%8.510.004Pain quantified by second visit60100%100%N/AN/APain plan documented1137.533.3%&lt;10.90Opioid assesssed post treatment2791.0%100%1.510.22Opioid induced constipation assessed2718.2%9.3%&lt;10.33      

Conclusions:Provider adherence to quality metrics for emotional wellbeing increased from pre- to post- intervention, but did not for pain assessment and management. This was largely due to ceiling effect, but opportunities exist for continued improvement in pain management, at least in documentation. The Carevive CPS plus CME has the potential to allow institutions an patient-centered and user-friendly approach to both improve and document adherence to quality metrics.

Citation Format: Hathaway A, Stricker C, Halilova KI, Hammelef KJ, Wujcik D, Dudley WN, Rocque G. Technology as a change agent for improving breast cancer quality care [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-04.

Automated home monitoring and management of patient-reported symptoms during chemotherapy: results of the symptom care at home RCT

Technology‐aided remote interventions for poorly controlled symptoms may improve cancer symptom outcomes. In a randomized controlled trial, the efficacy of an automated symptom management system was tested to determine if it reduced chemotherapy‐related symptoms. Prospectively, 358 patients beginning chemotherapy were randomized to the Symptom Care at Home (SCH) intervention (n = 180) or enhanced usual care (UC) (n = 178). Participants called the automated monitoring system daily reporting severity of 11 symptoms. SCH participants received automated self‐management coaching and nurse practitioner (NP) telephone follow‐up for poorly controlled symptoms. NPs used a guideline‐based decision support system. Primary endpoints were symptom severity across all symptoms, and the number of severe, moderate, mild, and no symptom days. A secondary endpoint was individual symptom severity. Mixed effects linear modeling and negative binominal regressions were used to compare SCH with UC. SCH participants had significantly less symptom severity across all symptoms (P < 0.001). On average, the relative symptom burden reduction for SCH participants was 3.59 severity points (P < 0.001), roughly 43% of UC. With a very rapid treatment benefit, SCH participants had significant reductions in severe (67% less) and moderate (39% less) symptom days compared with UC (both P < 0.001). All individual symptoms, except diarrhea, were significantly lower for SCH participants (P < 0.05). Symptom Care at Home dramatically improved symptom outcomes. These results demonstrate that symptoms can be improved through automated home monitoring and follow‐up to intensify care for poorly controlled symptoms.

Scientific Advances Shaping the Future Roles of Oncology Nurses

OBJECTIVES

To discuss the recent scientific advances that influence current oncology care and explore the implications of these advances for the future of oncology nursing.

DATA SOURCES

Current nursing, medical and basic science literature; Clinicaltrials.gov.

CONCLUSION

The future of oncology care will be influenced by an aging population and increasing number of patients diagnosed with cancer. The advancements in molecular sequencing will lead to more clinical trials, targeted therapies, and treatment decisions based on the genetic makeup of both the patient and the tumor. Nurses must stay current with an ever changing array of targeted therapies and developing science. Nurses will influence cancer care quality, value, cost, and patient satisfaction.

IMPLICATIONS FOR NURSING PRACTICE

It is critical for oncology nurses and nursing organizations to engage with all oncology care stakeholders in identifying the future needs of oncology patients and the environment in which care will be delivered. Nurses themselves must identify the roles that will be needed to ensure a workforce that is adequate in number and well trained to meet the future challenges of care delivery.

Abstract C37: “Oh happy day”: A pilot study of a culturally tailored depression intervention for African American female cancer survivors

Almost 1 million African Americans are now identified as cancer survivors. Despite this growth, African Americans' long-term survivorship lags behind national survival rates. Given that cancer survivorship starts with diagnosis and continues throughout life, improving cancer survival outcomes for African Americans is important. Cancer survivors are at increased risk of experiencing psychosocial distress and depression as a result of cancer. Because of discrimination and multiple systemic barriers, African American cancer survivors may not have access to high quality healthcare treatment and services nor seek services in mainstream facilities. Thus their survivorship, including access to high quality, culturally competent behavioral health supports, may be compromised.

While current research suggests racial and cultural differences in cancer experiences, coping strategies and survivorship among different racial/ethnic groups, little is known about effective behavioral health resources African American female cancer survivors use to cope with depression. Even less is known about culturally tailored interventions that could potentially aid African American female cancer survivors by reducing depressive symptoms and supporting improved mental health.

A Culturally Tailored Depression Intervention for African American Female Cancer Survivors Study, a community-engaged research project attempts to determine the feasibility of a culturally tailored depression intervention called “Oh Happy Day Class.” Using group therapy and psycho-educational supports, including yoga, this study determines whether a 4-week modified version of this class, offered in a community setting, is acceptable to African American female cancer survivors. The class, coupled with other mixed methods (surveys, key informant interviews) provides important information about the benefits of offering culturally tailored depression interventions for African American female cancer survivors. As a community-engaged research project including African American female cancer survivors, Public Health researchers, & health professionals, this study further underscores why engaging community in the work of supporting cancer survivorship for African Americans is needed.

Citation Format: Elizabeth A. Williams, Earlise Ward, Debra Wujcik, Robin Oatis-Ballew, Cheryl Green, Navita Gunter, Brea Bond. “Oh happy day”: A pilot study of a culturally tailored depression intervention for African American female cancer survivors. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C37. doi:10.1158/1538-7755.DISP13-C37

Abstract C36: Psychosocial outcomes in cancer survivors treated at a comprehensive cancer center or a minority-serving institution

Background: Cancer health disparities are well described for incidence, diagnosis and treatment. Little is known about disparities among long-term survivors.

Methods: At Vanderbilt-Ingram Cancer Center (VICC), an NCI-designated comprehensive cancer center and Meharry Medical College (MMC), minority serving institutional partner, we evaluated quality of life (QOL) using the FACT-G, FACT-B, FACT-L, and FACT-P; posttraumatic stress disorder (PTSD) using the PTSD Checklist (PCL); and posttraumatic growth (PTG) using the PTG Inventory (PTGI) among breast, lung or prostate cancer survivors. We used linear regression to compare the scale mean values by institution while adjusting for confounding variables.

Results: Among 111 breast, 53 lung and 68 prostate cancer survivors, mean age was 62 years, 61% were female, 33% were black, 65% were married, 22% and 67% respectively had a high school degree or some college/higher education, 36% were employed and 94% were insured. MMC survivors were younger (p = 0.0005), more likely to be black (p &lt;0.0001), less likely to be married (p &lt; 0.0001), less educated (p&lt;0.0001) and more likely to be uninsured (p &lt; 0.0001). After adjusting for race, insurance status and educational level, there were no significant differences in cancer-related QOL between VICC and MMC survivors. MMC survivors did score significantly higher than VICC survivors on the PCL (33.9 vs. 28.3; p = 0.01) and the PTGI (75.9 vs. 62.5; p = 0.002). A total of 19 (8.3%) survivors met criteria for PTSD with a score of 50 or more (18.1% MMC, 3.8% VICC, p =0.003). Scores were significantly increased for MMC survivors relative to VICC survivors on all PTG subscales, especially the appreciation for life subscale (p = 0.0005).

Conclusion: Cancer health disparities extend into the survivorship period. Although overall QOL did not differ, survivors treated at an underserved institution had significantly higher PTSD than those treated at a comprehensive cancer center. Underserved survivors also exhibited higher degrees of PTG. Further evaluation will identify the most significant sources of stress and resilience in order to design interventions to improve psychosocial wellbeing and decrease disparities.

Citation Format: Debra L. Friedman, Maureen Sanderson, Pamela Hull, Debra Wujcik, Dira R. Ashworth, Amaka Okafor, Jane Kennedy, Paula Hill, David Shen-Miller. Psychosocial outcomes in cancer survivors treated at a comprehensive cancer center or a minority-serving institution. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C36. doi:10.1158/1538-7755.DISP13-C36

Psychosocial outcomes in cancer survivors treated at a comprehensive cancer center or a minority-serving institution

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Background: Cancer health disparities are well described for incidence, diagnosis and treatment. Little is known about disparities among long-term survivors. Methods: At Vanderbilt-Ingram Cancer Center (VICC), an NCI-designated comprehensive cancer center and Meharry Medical College (MMC), minority serving institutional partner, we evaluated quality of life (QOL) using the FACT-G, FACT-B, FACT-L, and FACT-P; posttraumatic stress disorder (PTSD) using the PTSD Checklist (PCL); and posttraumatic growth (PTG) using the PTG Inventory (PTGI) among breast, lung or prostate cancer survivors. We used linear regression to compare the scale mean values by institution while adjusting for confounding variables. Results: Among 111 breast, 53 lung and 68 prostate cancer survivors, mean age was 62 years, 61% were female, 33% were black, 65% were married, 22% and 67% respectively had a high school degree or some college/higher education, 36% were employed and 94% were insured. MMC survivors were younger (p = 0.0005), more likely to be black (p <0.0001), less likely to be married (p < 0.0001), less educated (p<0.0001) and more likely to be uninsured (p < 0.0001). After adjusting for race, insurance status and educational level, there were no significant differences in cancer-related QOL between VICC and MMC survivors. MMC survivors did score significantly higher than VICC survivors on the PCL (33.9 vs. 28.3; p = 0.01) and the PTGI (75.9 vs. 62.5; p = 0.002). A total of 19 (8.3%) survivors met criteria for PTSD with a score of 50 or more (18.1% MMC, 3.8% VICC, p =0.003). Scores were significantly increased for MMC survivors relative to VICC survivors on all PTG subscales, especially the appreciation for life subscale (p = 0.0005). Conclusions: Cancer health disparities extend into the survivorship period. Although overall QOL did not differ, survivors treated at an underserved institution had significantly higher PTSD than those treated at a comprehensive cancer center. Underserved survivors also exhibited higher degrees of PTG. Further evaluation will identify the most significant sources of stress and resilience in order to design interventions to improve psychosocial wellbeing and decrease disparities.

An IT-integrated, computer-based telephone system for monitoring patient-reported symptoms: Result of two trials

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Background: An automated remote monitoring system of patient reported symptoms was tested in two separate trials to determine if it improved unrelieved symptoms after outpatient chemotherapy. Methods: In Study 1,250 patients and Study 2,335 patients beginning a chemotherapy course were randomized to Telephone Care (TC) (n 129/174) or usual care (UC) (n 121/162). All called daily reporting presence, severity, and distress (0-10 scale) for 11 common symptoms. Those in the Study 1 TC group had reports of moderate to severe symptoms emailed to their oncologist and oncology nurse. Those in Study 2 TC group had similar moderate to severe symptom reports sent to a study Nurse Practitioner (NP) who responded by telephone utilizing evidence based guidelines to intensify symptom care. These patients also received automated tailored self-care messages based on their specific symptoms. Results: The majority of participants in both studies were white (91%; 84%) and female (76%; 77%). The mean age was 56 years, with breast cancer most common (40%; 45%). Mean study days were 45 (Study 1) and 73 (Study 2) with 66% and 87% call completion days respectively. Fatigue, pain, poor sleep, nausea and depressed mood were reported as moderate to severe by over 50% of patients in both studies. In Study 1 no difference was found in symptom severity between TC and UC. Oncology providers found the TC symptom alerts useful but rarely initiated symptom care intensification. In Study 2 the TC group mean symptom score was significantly lower than UC, p < .001. Poisson regression showed TC had fewer Severe symptom days than UC (est. means and SE) 3.16 (0.44) vs. 10.24 (1.84), p < .001; and fewer Moderate days 8.91 (1.04) vs. 19.06 (2.22), p < .001. TC had somewhat higher Mild days 19.85 (2.81) vs. 13.75 (1.85), p = .06; and more no symptom days 66.06 (3.82) vs 52.02 (4.15), p = .01. Conclusions: Remote monitoring of patient reported symptoms after chemotherapy is effective in identifying unrelieved symptoms. It can be used to track quality improvement as well as augment symptom care. Follow up to intensify symptom treatment utilizing guidelines is necessary to achieve significant reductions in symptom severity, distress and days of moderate or severe symptoms.

Outpatient chemotherapy supportive care: Trial of an IT-integrated, NP-delivered system for unrelieved symptoms

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Background: We tested an automated computer based remote monitoring system paired with nurse practitioner (NP) follow up using a case management system to address unrelieved symptoms. Methods: Prospectively 336 patients beginning a course of chemotherapy were randomized to the Telephone Care NP (TC) intervention (n 174) or usual care (UC) (n 162). All called daily reporting presence, severity, and distress (0-10 scale) for 11 common symptoms. Those in the TC intervention also received automated tailored symptom self-care messages and, based on automated alerts for unrelieved symptoms at moderate or higher levels, NP calls to further treat symptoms utilizing national guidelines. Results: There were no differences between groups on any demographics: 84% White, 56 years old, female (77%), breast (45%) or lung (17%) cancer. Average study days were 73 with 87% call completion. Prevalence of participants reporting moderate to severe symptoms were fatigue (86%), pain (80%), sleep (78%), nausea (60%), depressed mood (52%), anxious (49%), trouble thinking (48%), numbness (43%), sore mouth (38%), diarrhea (38%), and appearance concerns (35%). Mixed modeling with intention to treat was used to compare overall symptom scores by treatment condition (TC/UC) while accounting for individuals. Results indicate the TC group mean symptom score was significantly lower than UC (mean difference = .30, p < .001). Also, each symptom was significantly lower for the TC group except for diarrhea. Poisson regression showed TC had lower Severe days than UC (est. means and SE) 3.16 (0.44) vs 10.24 (1.84), p < .001; and lower Moderate days 8.91 (1.04) vs 19.06 (2.22), p < .001. TC had somewhat higher Mild days than UC 19.85 (2.81) vs 13.75 (1.85), p = .06; and more No symptom days 66.06 (3.82) vs 52.02 (4.15), p = .01. Mixed modeling was used to explore TC intervention impact following NP calls for alerts. TC reduced symptom scores compared to UC over a 4 day period (mean difference = 1.28, p< .001). Conclusions: Remote telephone monitoring of symptoms after chemotherapy with nurse practitioner follow up on moderate and severe symptoms results in decreased symptom severity, distress, fewer severe and moderate days and more no symptom days.

Obesity, gynecological factors, and abnormal mammography follow-up in minority and medically underserved women

BACKGROUND

The relationship between obesity and screening mammography adherence has been examined previously, yet few studies have investigated obesity as a potential mediator of timely follow-up of abnormal (Breast Imaging Reporting and Data System [BIRADS-0]) mammography results in minority and medically underserved patients.

METHODS

We conducted a retrospective cohort study of 35 women who did not return for follow-up >6 months from index abnormal mammography and 41 who returned for follow-up < or =6 months in Nashville, Tennessee. Patients with a BIRADS-0 mammography event in 2003-2004 were identified by chart review. Breast cancer risk factors were collected by telephone interview. Multivariate logistic regression was performed on selected factors with return for diagnostic follow-up.

RESULTS

Obesity and gynecological history were significant predictors of abnormal mammography resolution. A significantly higher frequency of obese women delayed return for mammography resolution compared with nonobese women (64.7% vs. 35.3%). A greater number of hysterectomized women returned for diagnostic follow-up compared with their counterparts without a hysterectomy (77.8% vs. 22.2%). Obese patients were more likely to delay follow-up >6 months (adjusted OR 4.09, p = 0.02). Conversely, hysterectomized women were significantly more likely to return for timely mammography follow-up < or =6 months (adjusted OR 7.95, p = 0.007).

CONCLUSIONS

Study results suggest that weight status and gynecological history influence patients' decisions to participate in mammography follow-up studies. Strategies are necessary to reduce weight-related barriers to mammography follow-up in the healthcare system including provider training related to mammography screening of obese women.

A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence

BACKGROUND

Early-stage diagnosis of colorectal cancer is associated with high survival rates; screening prevalence, however, remains suboptimal.

PURPOSE

This study seeks to test the hypothesis that participants receiving telephone-based tailored education or motivational interviewing had higher colorectal cancer screening completion rates compared to usual care.

METHODS

Primary care patients not adherent with colorectal cancer screening and with no personal or family history of cancer (n = 515) were assigned by block randomization to control (n = 169), tailored education (n = 168), or motivational interview (n = 178). The response rate was 70%; attrition was 24%.

RESULTS

Highest screening occurred in the tailored education group (23.8%, p < .02); participants had 2.2 times the odds of completing a post-intervention colorectal cancer screening than did the control group (AOR = 2.2, CI = 1.2-4.0). Motivational interviewing was not associated with significant increase in post-intervention screening.

CONCLUSIONS

Tailored education showed promise as a feasible strategy to increase colorectal cancer screening.

Abstract 1822: Decision making and cancer clinical trial participation among African Americans

INTRODUCTION: Although the disparity in clinical trial participation is well documented, the main reason why African Americans and the medically underserved do not participate in cancer clinical trials (CCT) has not been agreed upon. It is apparent that new policies and initiatives are required to ensure minority access to CCT and applicability of subsequent results from CCT.

METHODS: In-depth interviews were conducted to explore issues of fear and mistrust in CCT participation. Participants were asked questions regarding their perceptions of cancer, research, cancer clinical trials; attitudes toward participation in clinical trials; and the effect of trust in decision-making. Afterward, participants completed a survey, a modification of the Wake Forest Physician Trust Scale to assess trust in medical research study. One field expert and one medical student independently reviewed the tapes, transcripts, and surveys from the interviews for themes, trends, and congruence. Saturation was achieved at eight interviews.

RESULTS: Eight African Americans, 7 female and 1 male, participated. Three themes emerged related to decision making and CCT participation: 1) Motivation to participate comes from believing what they were doing would help those coming after them; 2) Trusted sources for CCT information include the research team, primary care providers, and trusted individuals; 3) Final decision making, based on all of the advice and information given, would be theirs to make.

CONCLUSION: Potential African American participants in CCT have many trusted sources to turn to and receive advice regarding their decision to participate or not. However, they will listen to the CCT research team and their primary care providers, especially if what they perceive is a trusting and open relationship is established. Given that these potential participants are the ones who make the final decisions, just as much of an effort should be placed on making sure that they have all of the information that they want, whether these conversations are with researchers or primary care providers who know about CCT. An emphasis on how potential African American participants can contribute to CCT and positively affect the lives of other African Americans with the same diagnoses should also be made. Results from this study and a previous study will form the basis for an intervention study.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1822. doi:10.1158/1538-7445.AM2011-1822

Psychosocial determinants of mammography follow-up after receipt of abnormal mammography results in medically underserved women

This article targets the relationship between psychosocial determinants and abnormal screening mammography follow-up in a medically underserved population. Health belief scales were modified to refer to diagnostic follow-up versus annual screening. A retrospective cohort study design was used. Statistical analyses were performed examining relationships among sociodemographic factors, psychosocial determinants, and abnormal mammography follow-up. Women with lower mean internal health locus of control scores (3.14) were two times more likely than women with higher mean internal health locus of control scores (3.98) to have inadequate follow-up (OR=2.53, 95% CI=1.12-5.36). Women with less than a high school education had lower cancer fatalism scores than women who had completed high school (47.5 vs. 55.2, p-value=.02) and lower mean external health locus of control scores (3.0 vs. 5.3) (p-value<.01). These constructs have implications for understanding mammography follow-up among minority and medically underserved women. Further comprehensive study of these concepts is warranted.

Recruitment of African Americans to National Oncology Clinical Trials through a clinical trial shared resource

In 2000, using National Institutes of Health/National Cancer Institute (NIH/NCI) U54 funds, a clinical trials shared resource was established at Nashville General Hospital at Meharry to attract more African Americans to national cancer clinical trials. This Report from the Field describes the model used to achieve this end.

Delay in diagnostic testing after abnormal mammography in low-income women

PURPOSE/OBJECTIVES

To identify factors associated with diagnostic delay after an incomplete or abnormal mammogram among women participating in a state mammography screening program.

RESEARCH APPROACH

Retrospective case-control design using bivariate and multivariate logistic regression analyses to explore the associations between age, race, ethnicity, marital status, breast cancer history, and self-reported breast symptoms and delay.

SETTING

A statewide program of free screening mammography for women who are under- or uninsured.

PARTICIPANTS

11,460 women enrolled in a free, statewide screening program from 2002-2006.

METHODOLOGIC APPROACH

Using the Tennessee Breast and Cervical Cancer Screening Program database, further analyses were conducted.

MAIN RESEARCH VARIABLES

The outcome measure was delay in completion of all diagnostic tests and was defined as women who did not complete testing within 60 days.

FINDINGS

Thirty-seven percent of women required follow-up, and of a subset used in the analysis, 30% experienced delay of more than 60 days. Controlling for marital status, age, and breast cancer history, women who experienced delay were more likely to be African American versus Caucasian (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.13, 1.85) or Hispanic (OR = 0.72, 95% CI = 0.55, 0.93) and to have self-reported breast symptoms (OR = 1.50, 95% CI = 1.27, 1.77).

CONCLUSIONS

In a sample of women with low income needing mammography follow-up, delay was associated with three intrapersonal variables, potentially reducing the effectiveness of mammography screening for women who were African American, or Hispanic, or had self-reported breast symptoms.

INTERPRETATION

Nurses providing cancer screening examinations are uniquely positioned to assess the knowledge, beliefs, and resources of women using the program and to navigate women through barriers to completion. Knowledge of factors associated with delay is valuable for planning interventions and allocating program resources.

Timing is everything: methodologic issues locating and recruiting medically underserved women for abnormal mammography follow-up research

OBJECTIVES

Recruiting underserved women in breast cancer research studies remains a significant challenge. We present our experience attempting to locate and recruit minority and medically underserved women identified in a Nashville, Tennessee public hospital for a mammography follow-up study.

STUDY DESIGN

The study design was a retrospective hospital-based case-control study.

METHODS

We identified 227 women (88 African-American, 65 Caucasian, 36 other minority, 38 race undocumented in the medical record) who had undergone screening mammography and received an abnormal result during 2003-2004. Of the 227 women identified, 159 women were successfully located with implementation of a tracking protocol and more rigorous attempts to locate the women using online directory assistance and public record search engines. Women eligible for the study were invited to participate in a telephone research survey. Study completion was defined as fully finishing the telephone survey.

RESULTS

An average of 4.6 telephone calls (range 1-19) and 2.7 months (range 1-490 days) were required to reach the 159 women contacted. Within three contact attempts, more cases were located than controls (61% cases vs. 49% controls, p=0.03). African-American women cases were four times likely to be recruited than African-American controls, (OR, 4.07; 95% CI, 1.59-10.30) (p=0.003). After 3 months of effort, we located 67% of African-American women, 63% of Caucasian women, and 56% of other minorities. Ultimately, after a maximum of 12 attempts to contact women, 77% of African-American women and 71% of Caucasian women were eventually found. Of these, 59% of African-American women, 69% Caucasian women, and 50% other minorities were located and completed the study survey for an overall response rate of 59%, 71%, and 47% respectively.

CONCLUSIONS

Data collection and study recruitment efforts were more challenging in racial and ethnic minorities. Continuing attempts to contact women may increase minority group study participation but does not guarantee retention or study completion.

Pain-Related Distress and Interference With Daily Life of Ambulatory Patients With Cancer With Pain

PURPOSE/OBJECTIVES

To examine the unique and combined effects of pain intensity, pain-related distress, analgesic prescription, and negative mood on interference with daily life because of pain.

DESIGN

Descriptive, cross-sectional.

SETTING

Two cancer clinics in academic medical centers in the southeastern United States.

SAMPLE

64 ambulatory patients with cancer who had pain that required analgesics.

METHOD

Participants completed a number of self-report instruments during a regularly scheduled clinic visit. Standard instruments were selected to measure the main research variables.

MAIN RESEARCH VARIABLES

Worst pain intensity, pain-related distress, analgesic adequacy, negative mood, and interference with daily life.

FINDINGS

Patients with higher levels of worst pain, pain-related distress, and negative mood and inadequately prescribed analgesics reported greater interference with daily life because of pain. Multiple regression analysis indicated that interference with daily life was explained by the combination of these four predictors. All variables except negative mood were significant predictors of interference. The unique variance explained by pain-related distress exceeded that explained by worst pain intensity or inadequately prescribed analgesics.

CONCLUSIONS

Data suggest that pain-related distress may be an important factor when investigating interference with daily life caused by pain. In addition, pain-related distress may provide a target for future intervention studies aimed at improving the impact of cancer-related pain on daily life.

IMPLICATIONS FOR NURSING

Assessment of pain-related distress may be important in planning interventions. Common nursing interventions may be employed to reduce pain intensity and pain-related distress, which may result in enhanced physical and emotional well-being.

EGFR as a Target: Rationale for Therapy

OBJECTIVES

To review the biology of the EGFR, its structure, and the associated signal transduction pathways. To provide an overview of the role of EGFR in normal physiology and the pathophysiology of malignancy. Current anti-EGFR treatments are also discussed.

DATA SOURCES

Research articles.

CONCLUSION

EGFR is a valid target in the treatment of solid tumors. EGFR abnormalities and dysfunction are involved in various aspects of carcinogenesis and tumor progression, and EGFR is overexpressed in several tumor types. The development of anti-EGFR therapies represents an important advance in cancer therapy.

IMPLICATIONS FOR NURSING PRACTICE

Anti-EGFR therapy is currently available in the clinical setting. Nurses involved in the care of patients with cancer can benefit from an increased understanding of the normal and abnormal function of EGFR in the body and the mechanisms by which anti-EGFR therapies act.