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Patel TA, Jain B, Vapiwala N, Chino F, Tringale KR, Mahal BA, Yamoah K, McBride SN, Lam MB, Hubbard A, Nguyen PL, Dee EC. Trends in Utilization and Medicare Spending on Short-Course Radiation Therapy for Breast and Prostate Cancer: An Episode-Based Analysis From 2015 to 2019. Int J Radiat Oncol Biol Phys 2024; 119:17-22. [PMID: 38072324 DOI: 10.1016/j.ijrobp.2023.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE Evidence supports the value of shorter, similarly efficacious, and potentially more cost-effective hypofractionated radiation therapy (RT) regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in RT cost and practice patterns among episodes of BC and PC. METHODS AND MATERIALS We performed a retrospective cohort analysis of all external beam RT episodes for BC and PC from 2015 to 2019 to assess predictors of short-course RT (SCRT) use and calculated spending differences. Multivariable logistic regression defined adjusted odds ratios of receipt of SCRT over longer-course RT (LCRT) by treatment modality, age, year of diagnosis, type of practice, and the interaction between year and treatment setting. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs LCRT) in addition to the above covariables. RESULTS Of 143,729 BC episodes and 114,214 PC episodes, 63,623 (44.27%) and 25,955 (22.72%) were SCRT regimens, respectively. Median total spending for SCRT regimens among BC episodes was $9418 (interquartile range [IQR], $7966-$10,983) versus $13,602 (IQR, $11,814-$15,499) for LCRT. Among PC episodes, median total spending was $6924 (IQR, $4,509-$12,905) for stereotactic body RT, $18,768 (IQR, $15,421-$20,740) for moderate hypofractionation, and $27,319 (IQR, $25,446-$29,421) for LCRT. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes as well as treatment at hospital-affiliated over freestanding sites (P < .001 for all). CONCLUSIONS In this evaluation of BC and PC RT episodes from 2015 to 2019, we found that shorter-course RT resulted in lower costs than longer-course RT. SCRT was also more common in hospital-affiliated sites. Future research focusing on potential payment incentives encouraging SCRT when clinically appropriate in the 2 most common cancers treated with RT will be valuable as the field continues to prospectively evaluate cost-effective hypofractionation in other disease sites.
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Affiliation(s)
- Tej A Patel
- Department of Healthcare Management and Policy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bhav Jain
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiation Medicine and Applied Sciences, University of California, San Diego, School of Medicine, San Diego, California
| | - Brandon A Mahal
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Sean N McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miranda B Lam
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anne Hubbard
- Department of Health Policy, American Society for Radiation Oncology, Arlington, Virgnia
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Hart NH, Nekhlyudov L, Smith TJ, Yee J, Fitch MI, Crawford GB, Koczwara B, Ashbury FD, Lustberg MB, Mollica M, Smith AL, Jefford M, Chino F, Zon R, Agar MR, Chan RJ. Survivorship Care for People Affected by Advanced or Metastatic Cancer: MASCC-ASCO Standards and Practice Recommendations. JCO Oncol Pract 2024:OP2300716. [PMID: 38684036 DOI: 10.1200/op.23.00716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/19/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE People with advanced or metastatic cancer and their caregivers may have different care goals and face unique challenges compared with those with early-stage disease or those nearing the end of life. These Multinational Association for Supportive Care in Cancer (MASCC)-ASCO standards and practice recommendations seek to establish consistent provision of quality survivorship care for people affected by advanced or metastatic cancer. METHODS A MASCC-ASCO expert panel was formed. Standards and recommendations relevant to the provision of quality survivorship care for people affected by advanced or metastatic cancer were developed through conducting (1) a systematic review of unmet supportive care needs; (2) a scoping review of cancer survivorship, supportive care, and palliative care frameworks and guidelines; and (3) an international modified Delphi consensus process. RESULTS A systematic review involving 81 studies and a scoping review of 17 guidelines and frameworks informed the initial standards and recommendations. Subsequently, 77 experts (including eight people with lived experience) across 33 countries (33% were low- to middle-resource countries) participated in the Delphi study and achieved ≥94.8% agreement for seven standards, (1) Person-Centered Care; (2) Coordinated and Integrated Care; (3) Evidence-Based and Comprehensive Care; (4) Evaluated and Communicated Care; (5) Accessible and Equitable Care; (6) Sustainable and Resourced Care; and (7) Research and Data-Driven Care, and ≥84.2% agreement across 45 practice recommendations. CONCLUSION Standards of survivorship care for people affected by advanced or metastatic cancer are provided. These MASCC-ASCO standards support optimization of health outcomes and care experiences by providing guidance to stakeholders (health care professionals, leaders, and administrators; governments and health ministries; policymakers; advocacy agencies; cancer survivors and caregivers). Practice recommendations may be used to facilitate future research, practice, policy, and advocacy efforts.Additional information is available at www.mascc.org, www.asco.org/standards and www.asco.org/survivorship-guidelines.
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Affiliation(s)
- Nicolas H Hart
- Human Performance Research Centre, INSIGHT Research Institute, Faculty of Health, University of Technology Sydney (UTS), Sydney, NSW, Australia
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, SA, Australia
- Exercise Medicine Research Institute, School of Medical and Health Science, Edith Cowan University, Perth, WA, Australia
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Institute for Health Research, The University of Notre Dame Australia, Perth, WA, Australia
| | - Larissa Nekhlyudov
- Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Thomas J Smith
- Division of General Internal Medicine and Sidney Kimmel Comprehensive Cancer Center, John Hopkins Medical Institutions, Baltimore, MD
| | - Jasmine Yee
- Centre for Medical Psychology and Evidence-Based Decision-Making, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Margaret I Fitch
- School of Graduate Studies, Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Gregory B Crawford
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Bogda Koczwara
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Flinders Cancer and Innovation Centre, Flinders Medical Centre, Adelaide, SA, Australia
| | - Fredrick D Ashbury
- VieCure, Clinical and Scientific Division, Greenwood Village, CO
- Department of Oncology, University of Calgary, Calgary, ON, Canada
| | - Maryam B Lustberg
- Department of Medicine, School of Medicine, Yale University, New Haven, CT
- Medical Oncology Division, Yale Cancer Centre, New Haven, CT
| | - Michelle Mollica
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Andrea L Smith
- The Daffodil Centre and University of Sydney: a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michael Jefford
- Australian Cancer Survivorship Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robin Zon
- Michiana Hematology-Oncology, Mishawaka, IN
- Cincinnati Cancer Advisors, Norwood, OH
| | - Meera R Agar
- IMPACCT Research Centre, Faculty of Health, University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, SA, Australia
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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3
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Hart NH, Nekhlyudov L, Smith TJ, Yee J, Fitch MI, Crawford GB, Koczwara B, Ashbury FD, Lustberg MB, Mollica M, Smith AL, Jefford M, Chino F, Zon R, Agar MR, Chan RJ. Survivorship care for people affected by advanced or metastatic cancer: MASCC-ASCO standards and practice recommendations. Support Care Cancer 2024; 32:313. [PMID: 38679639 PMCID: PMC11056340 DOI: 10.1007/s00520-024-08465-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE People with advanced or metastatic cancer and their caregivers may have different care goals and face unique challenges compared to those with early-stage disease or those nearing the end-of-life. These MASCC-ASCO standards and practice recommendations seek to establish consistent provision of quality survivorship care for people affected by advanced or metastatic cancer. METHODS An expert panel comprising MASCC and ASCO members was formed. Standards and recommendations relevant to the provision of quality survivorship care for people affected by advanced or metastatic cancer were developed through conducting: (1) a systematic review of unmet supportive care needs; (2) a scoping review of cancer survivorship, supportive care, and palliative care frameworks and guidelines; and (3) an international modified Delphi consensus process. RESULTS A systematic review involving 81 studies and a scoping review of 17 guidelines and frameworks informed the initial standards and recommendations. Subsequently, 77 experts (including 8 people with lived experience) across 33 countries (33% were low-to-middle resource countries) participated in the Delphi study and achieved ≥ 94.8% agreement for seven standards (1. Person-Centred Care; 2. Coordinated and Integrated Care; 3. Evidence-Based and Comprehensive Care; 4. Evaluated and Communicated Care; 5. Accessible and Equitable Care; 6. Sustainable and Resourced Care; 7. Research and Data-Driven Care) and ≥ 84.2% agreement across 45 practice recommendations. CONCLUSION Standards of survivorship care for people affected by advanced or metastatic cancer are provided. These MASCC-ASCO standards will support optimization of health outcomes and care experiences by providing guidance to stakeholders in cancer care (healthcare professionals, leaders, and administrators; governments and health ministries; policymakers; advocacy agencies; cancer survivors and caregivers. Practice recommendations may be used to facilitate future research, practice, policy, and advocacy efforts.
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Affiliation(s)
- Nicolas H Hart
- Human Performance Research Centre, INSIGHT Research Institute, Faculty of Health, University of Technology Sydney (UTS), Sydney, NSW, Australia.
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, SA, Australia.
- Exercise Medicine Research Institute, School of Medical and Health Science, Edith Cowan University, Perth, WA, Australia.
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia.
- Institute for Health Research, The University of Notre Dame Australia, Perth, WA, Australia.
| | - Larissa Nekhlyudov
- Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas J Smith
- Division of General Internal Medicine and Sidney Kimmel Comprehensive Cancer Center, John Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jasmine Yee
- Centre for Medical Psychology and Evidence-Based Decision-Making, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Margaret I Fitch
- School of Graduate Studies, Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Gregory B Crawford
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Northern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Bogda Koczwara
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Flinders Cancer and Innovation Centre, Flinders Medical Centre, Adelaide, SA, Australia
| | - Fredrick D Ashbury
- VieCure, Clinical and Scientific Division, Greenwood Village, CO, USA
- Department of Oncology, University of Calgary, Calgary, ON, Canada
- Internal Medicine-Medical Oncology, College of Medicine, The Ohio State University, Columbus , OH, USA
| | - Maryam B Lustberg
- Department of Medicine, School of Medicine, Yale University, New Haven, CT, USA
- Medical Oncology Division, Yale Cancer Centre, New Haven, CT, USA
| | - Michelle Mollica
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Andrea L Smith
- The Daffodil Centre and University of Sydney: a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Michael Jefford
- Australian Cancer Survivorship Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robin Zon
- Michiana Hematology-Oncology, Mishawaka, IN, USA
- Cincinnati Cancer Advisors, Norwood, OH, USA
| | - Meera R Agar
- IMPACCT Research Centre, Faculty of Health, University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, SA, Australia
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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Yabroff KR, Doran JF, Zhao J, Chino F, Shih YCT, Han X, Zheng Z, Bradley CJ, Bryant MF. Cancer diagnosis and treatment in working-age adults: Implications for employment, health insurance coverage, and financial hardship in the United States. CA Cancer J Clin 2024. [PMID: 38652221 DOI: 10.3322/caac.21837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/19/2024] [Accepted: 03/05/2024] [Indexed: 04/25/2024] Open
Abstract
The rising costs of cancer care and subsequent medical financial hardship for cancer survivors and families are well documented in the United States. Less attention has been paid to employment disruptions and loss of household income after a cancer diagnosis and during treatment, potentially resulting in lasting financial hardship, particularly for working-age adults not yet age-eligible for Medicare coverage and their families. In this article, the authors use a composite patient case to illustrate the adverse consequences of cancer diagnosis and treatment for employment, health insurance coverage, household income, and other aspects of financial hardship. They summarize existing research and provide nationally representative estimates of multiple aspects of financial hardship and health insurance coverage, benefit design, and employee benefits, such as paid sick leave, among working-age adults with a history of cancer and compare them with estimates among working-age adults without a history of cancer from the most recently available years of the National Health Interview Survey (2019-2021). Then, the authors identify opportunities for addressing employment and health insurance coverage challenges at multiple levels, including federal, state, and local policies; employers; cancer care delivery organizations; and nonprofit organizations. These efforts, when informed by research to identify best practices, can potentially help mitigate the financial hardship associated with cancer.
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Affiliation(s)
- K Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia, USA
| | | | - Jingxuan Zhao
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ya-Chen Tina Shih
- Department of Radiation Oncology, University of California-Los Angeles Jonsson Comprehensive Cancer Center, School of Medicine, Los Angeles, California, USA
| | - Xuesong Han
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia, USA
| | - Zhiyuan Zheng
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia, USA
| | - Cathy J Bradley
- University of Colorado Comprehensive Cancer Center and Colorado School of Public Health, Aurora, Colorado, USA
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5
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Ragavan MV, Swartz S, Clark M, Chino F. Pharmacy Assistance Programs for Oral Anticancer Drugs: A Narrative Review. JCO Oncol Pract 2024; 20:472-482. [PMID: 38241597 DOI: 10.1200/op.23.00295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/20/2023] [Accepted: 11/28/2023] [Indexed: 01/21/2024] Open
Abstract
Oral anticancer medications (OAMs) are high priced with a significant cost-sharing burden to patients, which can lead to catastrophic financial, psychosocial, and clinical repercussions. Cost-conscious prescribing and inclusion of low-cost alternatives can help mitigate this burden, but cost transparency at the point of prescribing remains a major barrier to doing so. Pharmacy assistance programs, including co-payment cards and patient assistance programs administered by manufacturers and foundation-based grants, remain an essential resource for patients facing prohibitive co-payments for OAMs. However, access to these programs is fraught with complexities, including lack of trained financial navigators, limited transparency on eligibility criteria, onerous documentation burdens, and limits in available funding. Despite these drawbacks and the potential for such programs to incentivize manufacturers to keep list prices high, assistance programs have been demonstrated to improve financial well-being for patients with cancer. The increasing development of integrated specialty pharmacies with dedicated, trained pharmacy staff can help improve and standardize access to such programs, but these services are disproportionately available to patients seen at tertiary care centers. Multistakeholder interventions are needed to mitigate the burden of cost sharing for OAMs, including increased clinician knowledge of financial resources and novel assistance mechanisms, investment of institutions in trained financial navigation services and centralized platforms to identify assistance programs, and policies to cap out-of-pocket spending and improve transparency of rates charged by pharmacy benefit managers to a health plan.
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Affiliation(s)
- Meera V Ragavan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Scott Swartz
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Mackenzie Clark
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA
| | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
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Lu S, Rakovitch E, Hannon B, Zimmermann C, Dharmarajan KV, Yan M, De Almeida JR, Yao CMKL, Gillespie EF, Chino F, Yerramilli D, Goonaratne E, Abdel-Rahman F, Othman H, Mheid S, Tsai CJ. Palliative Care as a Component of High-Value and Cost-Saving Care During Hospitalization for Metastatic Cancer. JCO Oncol Pract 2024:OP2300576. [PMID: 38442311 DOI: 10.1200/op.23.00576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/06/2023] [Accepted: 12/20/2023] [Indexed: 03/07/2024] Open
Abstract
PURPOSE Randomized controlled trials have demonstrated that palliative care (PC) can improve quality of life and survival for outpatients with advanced cancer, but there are limited population-based data on the value of inpatient PC. We assessed PC as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer and identified hospitalization characteristics significantly associated with high costs. METHODS Hospitalizations of patients 18 years and older with a primary diagnosis of metastatic cancer from the National Inpatient Sample from 2010 to 2019 were analyzed. We used multivariable mixed-effects logistic regression to assess medical services, patient demographics, and hospital characteristics associated with higher charges billed to insurance and hospital costs. Generalized linear mixed-effects models were used to determine cost savings associated with provision of PC. RESULTS Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in US dollars (USD) to $56,098 USD, whereas the median hospital cost remained stable at $14,300 USD. Receipt of inpatient PC was associated with significantly lower charges (odds ratio [OR], 0.62 [95% CI, 0.61 to 0.64]; P < .001) and costs (OR, 0.59 [95% CI, 0.58 to 0.61]; P < .001). Factors associated with high charges were receipt of invasive medical ventilation (P < .001) or systemic therapy (P < .001), Hispanic patients (P < .001), young age (18-49 years, P < .001), and for-profit hospitals (P < .001). PC provision was associated with a $1,310 USD (-13.6%, P < .001) reduction in costs per hospitalization compared with no PC, independent of the receipt of invasive care and age. CONCLUSION Inpatient PC is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Integration of inpatient PC may de-escalate costs incurred through low-value inpatient interventions.
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Affiliation(s)
- Sifan Lu
- SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Eileen Rakovitch
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, ON, Canada
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Kavita V Dharmarajan
- Department of Radiation Oncology and the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Yan
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - John R De Almeida
- Department of Otolaryngology Head and Neck Surgery, University Health Network, Toronto, ON, Canada
| | - Christopher M K L Yao
- Department of Otolaryngology Head and Neck Surgery, University Health Network, Toronto, ON, Canada
| | - Erin F Gillespie
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Fadwa Abdel-Rahman
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Hiba Othman
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Sara Mheid
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Chiaojung Jillian Tsai
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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7
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Wu VS, Shen X, de Moor J, Chino F, Klein J. Financial Toxicity in Radiation Oncology: Impact for Our Patients and for Practicing Radiation Oncologists. Adv Radiat Oncol 2024; 9:101419. [PMID: 38379894 PMCID: PMC10876607 DOI: 10.1016/j.adro.2023.101419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 11/16/2023] [Indexed: 02/22/2024] Open
Abstract
With rising costs of diagnosis, treatment, and survivorship, financial burdens on patients with cancer and negative effects from high costs, called financial toxicity (FT), are growing. Research suggests that FT may be experienced by more than half of working-age cancer survivors and a similar proportion may incur debt or avoid recommended prescription medications due to treatment costs. As FT can lead to worse physical, psychological, financial, and survival outcomes, there is a discrete need to identify research gaps around this issue that constrain the development and implementation of effective screening and innovative care delivery interventions. Prior research, including within a radiation oncology-specific context, has sought to identify the scope of FT among patients with cancer, develop assessment tools to evaluate patient risk, quantify financial sacrifices, and qualify care compromises that occur when cancer care is unaffordable. FT is a multifactorial problem and potential solutions should be pursued at all levels of the health care system (patient-provider, institutional, and systemic) with specific regard for patients' individual/local contexts. Solutions may include selecting alternative treatment schedules, discussing financial concerns with patients, providing financial navigation services, low-cost transportation options, and system-wide health policy shifts. This review summarizes existing FT research, describes tools developed to measure FT, and suggests areas for intervention and study to help improve FT and outcomes for radiation oncology patients.
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Affiliation(s)
- Victoria S. Wu
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Xinglei Shen
- Department of Radiation Oncology, University of Kansas Cancer Medical Center, Kansas City, Kansas
| | - Janet de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan Klein
- Department of Radiation Oncology, Maimonides Medical Center and State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, New York
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8
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Patel TA, Jain B, Cho HL, Corti C, Vapiwala N, Chino F, Leeman JE, Dee EC. Second Malignancy Probabilities in Patients With Breast Cancer Treated With Conventional Versus Hypofractionated External Beam Radiation Therapy in the Adjuvant Setting. Clin Oncol (R Coll Radiol) 2024; 36:183-192. [PMID: 38184401 DOI: 10.1016/j.clon.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/12/2023] [Accepted: 12/05/2023] [Indexed: 01/08/2024]
Abstract
AIMS For women with breast cancer, seminal studies have shown that adjuvant hypofractionated external beam radiation therapy (hEBRT) maintains similar outcomes and may reduce overall costs compared with conventionally fractionated external beam radiation therapy (cEBRT). However, it is unclear whether hEBRT may be associated with differential risk of development of radiation-induced second malignancies compared with cEBRT. Because the occurrence of second malignancies is small, large databases may improve our understanding of the relative risk of second malignancies between hEBRT and cEBRT. MATERIALS AND METHODS Using the National Cancer Database, we carried out a retrospective cohort analysis of women diagnosed with non-metastatic, stage 0-III breast cancer from 2004 to 2017. All patients had a lumpectomy or mastectomy and a follow-up time of at least 60 months after diagnosis. The probability of second malignancies in women receiving adjuvant cEBRT or hEBRT was compared using multivariable logistic regression adjusting for sociodemographic, geographical, clinical and treatment factors, allowing for relative (but not absolute) comparison of second malignancy risk. Temporal sensitivity analyses stratified by year of diagnosis and length of follow-up time were also conducted. RESULTS Of the 125 228 women in our study, 115 576 (92.3%) received cEBRT and 9652 (7.71%) received hEBRT. The median age of the cohort was 60 (interquartile range 51-68) years at diagnosis and the median follow-up time was 99.61 (interquartile range 77.5-128.49) months. Upon adjusting for sociodemographic and clinical factors, patients who received hEBRT had no difference in relative risk than patients who received cEBRT (odds ratio 0.937, 95% confidence interval 0.869-1.010, P = 0.091). In analyses stratified by year of diagnosis, and stratified by length of follow-up, there was no difference in second malignancy probability between patients who completed hEBRT and patients who completed cEBRT. CONCLUSIONS In this analysis of over 120 000 women with non-metastatic breast cancer, hEBRT was not associated with different odds of developing second malignancies compared with cEBRT. Our findings may inform patient counselling in the choice of radiation regimens for breast cancer and further support the safety of hypofractionated regimens for breast cancer.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - B Jain
- Stanford School of Medicine, Stanford, CA, USA
| | - H L Cho
- Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C Corti
- Breast Oncology Program, Dana-Farber Cancer Centre, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hematology-Oncology (DIPO), University of Milan, Milan, Italy
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - E C Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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9
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Salazar MM, Khera N, Chino F, Johnston E. Financial hardship for patients with cancer and caregivers at end of life in the USA: narrative review. BMJ Support Palliat Care 2024; 14:25-35. [PMID: 38123962 DOI: 10.1136/spcare-2023-004556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients and their families face financial hardship during cancer treatment, which may intensify at end of life (EOL) due to increased symptoms and care needs. We undertook a narrative literature review to describe the current understanding of the causes, impacts and factors associated with financial hardship at EOL. We identify gaps in research, policy and clinical practice and propose steps to mitigate financial hardship for patients and caregivers at EOL. METHODS We conducted a Medline search to identify US studies since 2000 that examined EOL financial hardship for patients with cancer and their caregivers. RESULTS Twenty-seven adult and four paediatric studies met review criteria. Adults with cancer and their caregivers face significant financial hardship at EOL and in bereavement, especially due to employment changes and informal caregiving time costs. Financial hardship may be higher for younger caregivers and for patients who are uninsured, low income, rural, with high symptom burdens or with certain cancer types. The few paediatric studies showed high financial hardship and employment impact lasting well beyond a child's death. CONCLUSIONS There is limited literature examining financial hardship at EOL in the USA, especially in paediatrics. Priorities for future research include longitudinal studies in diverse populations of patients with cancer and informal caregivers using standardised financial hardship measures. Policies to address financial hardship at EOL, especially with hospice care, should include insurance coverage for family caregiving and medical leave policies. There is need for increased financial hardship screening at EOL and in bereavement and a need for financial navigation interventions.
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Affiliation(s)
- Marisa Martinez Salazar
- School of Medicine, Mayo Clinic School of Medicine-Scottsdale Campus, Scottsdale, Arizona, USA
| | - Nandita Khera
- Mayo Clinic School of Medicine, Phoenix, Arizona, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Emily Johnston
- Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
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10
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Ragavan MV, Swartz S, Clark M, Lo M, Gupta A, Chino F, Lin TK. Access to Financial Assistance Programs and Their Impact on Overall Spending on Oral Anticancer Medications at an Integrated Specialty Pharmacy. JCO Oncol Pract 2024; 20:291-299. [PMID: 38175987 DOI: 10.1200/op.23.00446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/23/2023] [Accepted: 11/15/2023] [Indexed: 01/06/2024] Open
Abstract
PURPOSE Financial assistance (FA) programs are increasingly used to help patients afford oral anticancer medications (OAMs), but access to such programs and their impact on out-of-pocket (OOP) spending has not been well explored. This study aimed to (1) characterize the impact of receipt of FA on both OOP spending and likelihood of catastrophic spending on OAMs and (2) evaluate racial/ethnic disparities in access to FA programs. METHODS Patients with a cancer diagnosis prescribed an OAM anytime between January 1, 2021, and December 31, 2021 were included in this retrospective, single-center study at an integrated specialty pharmacy affiliated with a tertiary academic cancer center. Fixed-effect regression models were used to characterize the impact of receipt of FA on overall spending and likelihood of catastrophic spending on OAMs, as well as explore the association of race/ethnicity with receipt of FA. RESULTS Across 1,186 patients prescribed an OAM, 37% received FA. Receipt of FA was associated with lower annual spending on OAMs (β = -$1,236 US dollars [USD; 95% CI, -$1,841 to -$658], P < .001) but not reduced risk of catastrophic spending (odds ratio [OR], 0.442 [95% CI, 0.755 to 3.199], P = .23). Non-White patients (OR, 0.60 [95% CI, 0.43 to 0.85], P = .004) and patients who spoke English as a second language (OR, 0.46 [95% CI, 0.23 to 0.90], P = .02) were less likely to receive FA compared with White and English-speaking patients, respectively. CONCLUSION FA programs can mitigate high OOP spending but not for patients who spend at catastrophic levels. There are racial/ethnic and language disparities in access to such programs. Future studies should evaluate access to FA programs across diverse delivery settings.
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Affiliation(s)
- Meera V Ragavan
- University of California, San Francisco, Department of Medicine, Division of Hematology/Oncology, San Francisco, CA
| | - Scott Swartz
- University of California, San Francisco, School of Medicine, San Francisco, CA
| | - Mackenzie Clark
- University of California, San Francisco, School of Pharmacy, San Francisco, CA
| | - Mimi Lo
- University of California, San Francisco, School of Pharmacy, San Francisco, CA
| | - Arjun Gupta
- University of Minnesota, Department of Internal Medicine, Minneapolis, MN
| | - Fumiko Chino
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY
| | - Tracy Kuo Lin
- University of California, San Francisco, Institute for Health and Aging, School of Nursing, San Francisco, CA
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11
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O'Brien DR, Boe L, Montagna G, Mueller B, Chino F, Cuaron J, Choi JI, Xu A, Bernstein M, McCormick B, Powell S, Khan AJ, Braunstein LZ. Accelerated Partial Breast Irradiation for HER2-Positive Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 118:468-473. [PMID: 37791937 DOI: 10.1016/j.ijrobp.2023.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE HER2-positive (HER2+) breast cancer historically exhibited the most adverse local outcomes and, consequently, has had limited representation among trials of partial breast irradiation (PBI). We hypothesized that with contemporary HER2-targeted agents, patients may now exhibit excellent disease control outcomes after adjuvant PBI. METHODS AND MATERIALS Using a prospectively maintained institutional database, we identified patients with HER2+ breast cancer treated with breast conserving surgery (BCS) and PBI from 2000 to 2022. Salient clinicopathologic and treatment parameters were collected. All patients received external beam PBI to 40 Gy in 10 daily fractions. Cumulative incidence functions were calculated to estimate the incidence of local recurrence (LR) with the competing risk of death. RESULTS We identified 1248 patients who underwent PBI at our institution, of whom the study cohort comprised 52 (4%) with HER2+ breast cancer (median age, 64 years; range, 44-87). Nearly all had T1 tumors (98%; median size, 12 mm [range, 1-21 mm]). Most had estrogen receptor positive disease (88%), and all patients had negative surgical margins. Nearly all underwent sentinel node biopsy (94%), with the remainder undergoing no surgical axillary evaluation. Forty-two (81%) received chemotherapy; 40 (77%), hormone therapy; and 42 (81%), HER2-directed therapy, most commonly trastuzumab. At 143.8 person-years of follow-up (range, 7-226 months for each patient), we observed 2 LR events at 14 and 26 months, respectively, yielding a 2-year LR rate of 3.8%. No regional or distant recurrences were observed, nor were any breast-specific mortality events. Two deaths were observed, both without evidence of disease. CONCLUSIONS Among a cohort of patients with HER2+ early-stage breast cancer managed with BCS and PBI, we observed a 2-year LR rate of 3.8%, with no regional or distant recurrences and excellent overall survival. These findings require confirmation with longer follow-up among larger cohorts but appear consistent with the excellent results of contemporary randomized trials of PBI unselected for HER2 status.
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Affiliation(s)
| | | | - Giacomo Montagna
- Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | - Amy Xu
- Departments of Radiation Oncology
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12
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Barnes JM, Yabroff KR, Chino F. Unwinding of Medicaid Continuous Enrollment Exposes Millions to Disrupted Care-"Be Kind, Rewind". JAMA Oncol 2024; 10:157-158. [PMID: 38095902 DOI: 10.1001/jamaoncol.2023.5725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
This Viewpoint discusses the causes and consequences of Medicaid unwinding and disenrollment and proposes solutions to minimize disenrollment and improve coverage uptake and health care access.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - K Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
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13
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Mathew A, Jain B, Patel TA, Hammond A, Dee EC, Chino F. Trends in Location of Death for Individuals With Ovarian Cancer in the United States. Obstet Gynecol 2024; 143:101-103. [PMID: 37944156 PMCID: PMC10842215 DOI: 10.1097/aog.0000000000005439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023]
Abstract
Using the publicly available Centers for Disease Control and Prevention's WONDER (Wide-ranging Online Data for Epidemiologic Research) database from 2003 to 2019, we evaluated associations between decedent characteristics and location of death for patients with ovarian malignancy. We found that Black, Native American, Asian American, and Hispanic patients were more likely to die in hospitals than White patients, despite an overall reduction in hospital deaths and an overall increase in hospice facility deaths. Additionally, patients with lesser educational attainment were more likely to die in nursing facilities and less likely to die in hospice facilities. Although there may be some contribution from cultural preferences, these findings may represent disparities in access to palliative care affecting people with cancer from racial and ethnic minoritized groups.
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Affiliation(s)
| | - Bhav Jain
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
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14
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Pompa IR, Qi D, Ghosh A, Goldberg SI, Chino F, Efstathiou JA, Kamran SC. Longitudinal Analysis of Bladder Cancer-Specific Mortality Trends in the United States. Bladder Cancer 2023; 9:345-353. [PMID: 38174126 PMCID: PMC10759801 DOI: 10.3233/blc-230062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Bladder cancer is the tenth leading cause of cancer death in the United States (US). Advances in diagnosis, imaging, and treatments have led to improvements in bladder cancer management. OBJECTIVE To evaluate longitudinal bladder cancer mortality trends from 1999-2020 in the US by gender, race, ethnicity, age, geographic region, and urbanization category. METHODS Age-adjusted bladder cancer death and incidence rates of individuals in the US of all ages between 1999-2020 were obtained using the CDC WONDER and NAACCR databases. Trends and average annual percent changes (AAPC) in age-adjusted Bladder Cancer-Specific Mortality (BCSM) and incidence rates were estimated. Data were analyzed from May 2023 to October 2023. RESULTS From 1999-2020, overall BCSM decreased by 0.4% annually, with a dramatic decrease in deaths between 2015-2020 (AAPC: -2.0% [95% CI: -2.6,-1.3]). However, BCSM rates and metastatic malignant bladder cancer incidence rates from 1999-2020 increased for individuals≥85 years old (AAPC for BCSM: 0.8% [95% CI:0.5,1.1]; AAPC for metastatic malignant incidence: 2.5% [95% CI: 2.0,2.9]). Increases in BCSM were found for certain years in the South, in rural areas, and for Non-Hispanic White and Asian or Pacific Islander individuals. CONCLUSIONS Overall mortality from bladder cancer has been decreasing in the US over two decades. Upon disaggregation, increasing trends were found for BCSM and for metastatic malignant bladder cancer incidence for individuals≥85 years old from 1999-2020. Further evaluation of these trends is essential to understand how to target specific populations to improve patient outcomes.
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Affiliation(s)
- Isabella R. Pompa
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - David Qi
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Anushka Ghosh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Saveli I. Goldberg
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sophia C. Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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15
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Thom B, Friedman DN, Aviki EM, Benedict C, Watson SE, Zeitler MS, Chino F. The long-term financial experiences of adolescent and young adult cancer survivors. J Cancer Surviv 2023; 17:1813-1823. [PMID: 36472761 PMCID: PMC9734817 DOI: 10.1007/s11764-022-01280-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cancer-related financial hardship can negatively impact financial well-being and may prevent adolescent and young adult (AYA) cancer survivors (ages 15-39) from gaining financial independence. This analysis explored the financial experiences following diagnosis with cancer among AYA survivors. METHODS We conducted a cross-sectional, anonymous survey of a national sample of AYAs recruited online. The Comprehensive Score for Financial Toxicity (COST) and InCharge Financial Distress/Financial Well-Being Scale (IFDFW) assessed financial hardship (cancer-related and general, respectively), and respondents reported related financial consequences and financial coping behaviors (both medical and non-medical). RESULTS Two hundred sixty-seven AYA survivors completed the survey (mean 8.3 years from diagnosis). Financial hardship was high: mean COST score was 13.7 (moderate-to-severe financial toxicity); mean IFDFW score was 4.3 (high financial stress). Financial consequences included post-cancer credit score decrease (44%), debt collection contact (39%), spending more than 10% of income on medical expenses (39%), and lacking money for basic necessities (23%). Financial coping behaviors included taking money from savings (55%), taking on credit card debt (45%), putting off major purchases (45%), and borrowing money (42%). In logistic regression models, general financial distress was associated with increased odds of experiencing financial consequences and engaging in both medical- and non-medical-related financial coping behaviors. DISCUSSION AYA survivors face long-term financial hardship after cancer treatment, which impacts multiple domains, including their use of healthcare and their personal finances. Interventions are needed to provide AYAs with tools to navigate financial aspects of the healthcare system; connect them with resources; and create systems-level solutions to address healthcare affordability. IMPLICATIONS FOR CANCER SURVIVORS Survivorship care providers, particularly those who interact with AYA survivors, must be attuned to the unique risk for financial hardships facing this population and make efforts to increase access available interventions.
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Affiliation(s)
- Bridgette Thom
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Danielle N Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emeline M Aviki
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Catherine Benedict
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA, USA
| | | | | | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Thom B, Arora N, Benedict C, Aviki EM, Chino F, Friedman DN, Watson SE, Zeitler MS. Using Real-World Data to Explore the Impact of One-Time Financial Grants Among Young Adult Cancer Survivors. J Adolesc Young Adult Oncol 2023; 12:912-917. [PMID: 37852000 PMCID: PMC10739788 DOI: 10.1089/jayao.2022.0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
Young adult (YA) cancer survivors experience worse financial outcomes than older survivors. This analysis used data from Expect Miracles Foundation to explore the impact of one-time financial grants on financial well-being and access to health care. Among 300 respondents, the average grant was $1526 (standard deviation = $587; range $300-$3000). Respondents reported improved ability to pay expenses (t = 4.45, p < 0.001), increased financial decision-making power (t = 2.79, p = 0.06), decreased medical debt impact (t = 2.1, p = 0.04), improved transportation access (t = 2.38, p = 0.02), and fewer challenges in accessing care (t = 3.0, p = 0.005) 6 months after receiving a financial grant. Financial assistance offers YAs an opportunity to meet medical and nonmedical expenses.
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Affiliation(s)
- Bridgette Thom
- Thom, Aviki, Friedman, Chino: Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Neha Arora
- Texas A&M School of Medicine, College Station, Texas, USA
| | - Catherine Benedict
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, California, USA
| | - Emeline M. Aviki
- Thom, Aviki, Friedman, Chino: Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Fumiko Chino
- Thom, Aviki, Friedman, Chino: Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Danielle N. Friedman
- Thom, Aviki, Friedman, Chino: Memorial Sloan Kettering Cancer Center, New York, New York, USA
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17
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Girda E, Randall LM, Chino F, Monk BJ, Farley JH, O'Cearbhaill RE. Cervical cancer treatment update: A Society of Gynecologic Oncology clinical practice statement. Gynecol Oncol 2023; 179:115-122. [PMID: 37980766 PMCID: PMC11001261 DOI: 10.1016/j.ygyno.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/21/2023]
Abstract
Cervical cancer is the most commonly diagnosed gynecologic cancer worldwide. Although the incidence has declined with increased screening and higher uptake of human papillomavirus (HPV) vaccination in high-income countries, this disease remains the second highest cause of cancer mortality among women in low- and middle-income countries. In this clinical practice statement, we describe therapies for cervical cancer by treatment setting, as well as quality of life, financial toxicity, and disparities associated with this disease. In addition to chemotherapy and radiation, therapeutic strategies for cervical cancer include immune checkpoint blockade, antiangiogenics, and antibody-drug conjugates. Optimal treatment for recurrent cervical cancer remains an area of unmet need, necessitating further exploration of rational and innovative treatment approaches, including cell and immune-based therapies. Importantly, development of effective therapies for cervical cancer must incorporate strategies to ensure universal equitable access to HPV vaccination, screening, and treatment. Important consequences of the disease and treatment that impact quality of life must also be addressed. Patients with cervical cancer are at increased risk for financial toxicity, which can lead to downstream detrimental effects on physical, financial, and career outcomes. Underrepresentation of racial and ethnic minorities in gynecologic oncology clinical trials highlights the urgent need for collaborative and focused initiatives to bridge the significant divide and alleviate inequalities in the prevention and treatment of cervical cancer.
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Affiliation(s)
- Eugenia Girda
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States of America
| | - Leslie M Randall
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology and Massey Cancer Center, Virginia Commonwealth University Health, Richmond, VA, United States of America
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Bradley J Monk
- Arizona Oncology (US Oncology Network), University of Arizona, Creighton University, Phoenix, AZ, United States of America
| | - John H Farley
- Department of Obstetrics and Gynecology, St Joseph's Hospital and Medical Center, Phoenix, AZ, United States of America
| | - Roisin E O'Cearbhaill
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America.
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18
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Chino F, Baez A, Elkins IB, Aviki EM, Ghazal LV, Thom B. The Patient Experience of Prior Authorization for Cancer Care. JAMA Netw Open 2023; 6:e2338182. [PMID: 37851442 PMCID: PMC10585404 DOI: 10.1001/jamanetworkopen.2023.38182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/04/2023] [Indexed: 10/19/2023] Open
Abstract
Importance Prior authorization (PA) requires clinicians and patients to navigate a complex approval pathway. Resultant delays and denials can be particularly problematic for patients with cancer, who often need urgent treatment or symptom management. Objective To investigate the patient perspective of PA for cancer-related care, including perceptions about the process, outcomes (including delays and denials), and patient administrative burden. Design, Setting, and Participants This cross-sectional, anonymous survey used a convenience sample of patients with PA experience. Participants were recruited using social media and email lists of US-based cancer advocacy organizations from July 1 to October 6, 2022. Exposure Prior authorization for any cancer-related service. Main Outcomes and Measures Delays to care, outcome of PA, communication, and changes in anxiety (measured on a scale of 0-100, with 0 indicating no anxiety and higher scores indicating higher levels of anxiety) and trust. Results Of 178 respondents (158 women [88%], 151 non-Hispanic White respondents [84%], 164 respondents [92%] <65 years), 112 (63%) reported that their cancer care was approved and given as recommended, and 39 (22%) did not receive recommended care due to delays or denials. Most respondents (123 [69%]) reported a PA-related delay in care; of those with delayed care, 90 (73%) reported a delay of 2 or more weeks. Most respondents (119 [67%]) had to personally become involved in the PA process; 35 (20%) spent 11 or more hours dealing with PA issues. Overall, the PA experience was rated as bad (70 [40%]) or horrible (55 of 174 [32%]); ratings were associated with the length of delay (ρ = 0.36; P < .001) and the time spent on PA (ρ = 0.42; P < .001). Self-reported PA-related anxiety was higher than usual anxiety (mean [SD] score, 74.7 [20.2] vs 37.5 [22.6]; P < .001) and was correlated with delay length (ρ = 0.16; P = .04), time spent on PA (ρ = 0.27; P < .001), and overall PA experience (ρ = 0.34; P < .001). After PA, 159 respondents (89%) trusted their insurance company less, and 148 respondents (83%) trusted the health care system less. Patient involvement in the PA process was associated with increased odds of distrusting their insurance company (β = 6.0; 95% CI, 1.9-19.2) and the health care system (β = 3.3; 95% CI, 1.4-8.1) and of having a negative experience (β = 6.6; 95% CI, 3.1-14.3). Conclusions and Relevance This survey-based cross-sectional study of the patient experience with PA highlights an adverse outcome of PA: 22% of patients did not receive the care recommended by their treatment team because of PA. Most respondents experienced a delay in recommended oncology care, and delays were associated with increased anxiety, a negative perception of the PA process, and patient administrative burden.
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Affiliation(s)
- Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Emeline M. Aviki
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Surgery, Gynecology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Bridgette Thom
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Patel TA, Jain B, Vapiwala N, Chino F, Tringale KR, Mahal BA, Yamoah K, McBride S, Hubbard A, Nguyen PL, Dee EC. Trends in Utilization and Medicare Spending on Shorter vs. Longer Radiotherapy Courses for Breast and Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e614. [PMID: 37785845 DOI: 10.1016/j.ijrobp.2023.06.1990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Evidence based research supports shorter, similarly efficacious, and potentially more cost-effective hypofractionated treatment regimens in many clinical scenarios for breast cancer (BC) and prostate cancer (PC). However, practice patterns of hospital-affiliated and standalone facilities vary considerably. We used the most recent Centers for Medicare and Medicaid Services data to assess trends in radiotherapy (RT) costs and practice patterns among episodes of BC and PC. MATERIALS/METHODS We performed a retrospective cohort analysis of all external beam episodes for BC and PC from 2015-2019. For patients with BC, receipt of shorter-course RT (SCRT) was defined as receiving 11-20 fractions of external beam radiation therapy (including IMRT), and conventional RT as >20 fractions. For patients with PC, SBRT was defined as receipt of <10 fractions and moderate hypofractionation as 10-30 fractions (SCRT defined as SBRT and moderate hypofractionation), and >30 fractions for conventional RT. Total Medicare spending were defined as the sum of winsorized payment for professional and technical services furnished during the episode in 2019 dollars. Multivariable logistic regression defined adjusted odds ratios (ORs) of receipt of SCRT over conventional RT by treatment modality, age, year of diagnosis, type of practice, as well as a time*treatment setting interaction term. Medicare spending was evaluated using multivariable linear regression controlling for duration of RT regimen (SCRT vs conventional) in addition to the covariables above. RESULTS Of 47,283 BC episodes and 45,917 PC episodes, 23,705 (50.13%) and 9,125 (19.87%) were SCRT, respectively. Median total spending for SCRT among BC episodes was $9,324 (IQR, $7,916-$10,921) vs. $13,372 (IQR, $11,511-$15,283) for conventional RT. Among PC episodes, median total spending was $12,917 (IQR, $9,551-$15,271) for SBRT, $18,944 (IQR, $16,530-$20,615) for moderate hypofractionation, and $26,935 (IQR, $25,062-$28,959) for conventional RT. For both cancers, total episode spending was reduced with SCRT utilization [(BC adjusted β, -$4,200; p<0.001), (PC adjusted β, -$8,747; p<0.001)], older age, and non-IMRT-based treatment. On logistic regression, receipt of SCRT was associated with older age among both BC and PC episodes (p<0.001), as well as treatment at hospital-affiliated over freestanding sites [(BC OR [95% CI], 1.41 [1.29-1.54], p<0.001), (PC OR, 1.64 [1.39-1.94], p<0.001)]. CONCLUSION In this evaluation of all BC and PC RT episodes from 2015-2019, we found that shorter-course RT resulted in increased cost-savings vs. conventional RT. SCRT was also more common in hospital-affiliated sites. Further research is needed to devise payment incentives that encourage SCRT when clinically applicable in the two most common sites treated with RT, and to prospectively study cost-effective hypofractionation in other disease sites.
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Affiliation(s)
- T A Patel
- University of Pennsylvania, Philadelphia, PA
| | - B Jain
- Massachusetts Institute of Technology, Cambridge, MA
| | - N Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K R Tringale
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - B A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - K Yamoah
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
| | - S McBride
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Hubbard
- American Society for Radiation Oncology, Arlington, VA
| | - P L Nguyen
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - E C Dee
- Memorial Sloan Kettering Cancer Center, New York, NY
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Affiliation(s)
- Howard Jack West
- Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
- AccessHope, Los Angeles, CA, USA.
| | - Erin Bange
- Department of Medical Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
- Affordability Working Group, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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Malapati SJ, Idossa D, Singh SRK, Wei Z, Kiel L, Chino F, Patel MA, Bruno XJ, Florez N. Parent Penalty: Parental Leave Experiences of Trainees and Early-Career Faculty in Oncology Subspecialties. JCO Oncol Pract 2023; 19:899-906. [PMID: 37708434 DOI: 10.1200/op.23.00242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/08/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
PURPOSE Prime childbearing years occur during medical training and early career, leaving physicians with tough choices between family planning and career growth. Restrictive workplace parental leave (PL) policies may negatively affect physician well-being. We evaluate existing PL and lactation policies, as well as return-to-work experiences, among oncology trainees and early-career faculty. METHODS An anonymous 43-question cross-sectional survey was distributed via e-mail and social media channels between May and June 2021 to oncology trainees and physicians within 5 years of terminal training in the United States. The survey was administered through SurveyMonkey. Descriptive statistics were used to analyze data. Two hundred seventy-five participants were recruited via social media and outreach to program directors and coordinators in adult hematology/oncology and radiation oncology program directors. RESULTS The average duration of PL was <6 weeks for most participants. Among those who used PL, 50% felt pressured to work while on PL, 60% felt guilty asking coworkers for help, and 79% were overwhelmed with demands of work and home, whereas only 27% had resources available at workplace to assist with transition back to work. Among those who breastfed at return to work, 31% did not have access to a lactation room, 56% did not have adequate pumping breaks, and 66% did not have pumping breaks mandated in contract. CONCLUSION Our findings underline the immense magnitude of problems surrounding inadequate PL and support for lactating mothers among trainees and early-career physicians in oncology subspecialities. Policies and practices around PL and lactation should be restructured to meet the needs of the evolving oncology workforce.
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Affiliation(s)
| | | | - Sunny R K Singh
- University of Arkansas for Medical Sciences, Little Rock, AR
| | - Zihan Wei
- Dana-Farber Cancer Institute, Boston, MA
| | | | - Fumiko Chino
- Memorial Sloan Kettering Cancer Center, New York, NY
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Gold BO, Ghosh A, Goldberg SI, Chino F, Efstathiou JA, Kamran SC. Disparities in testicular cancer incidence, mortality, and place of death trends from 1999 to 2020: A comprehensive cohort study. Cancer Rep (Hoboken) 2023; 6:e1880. [PMID: 37584159 PMCID: PMC10598251 DOI: 10.1002/cnr2.1880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/13/2023] [Accepted: 07/17/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Testicular cancer (TC) mortality rates have decreased over time, however it is unclear whether these improvements are consistent across all communities. AIMS The aim of this study was to analyze trends in TC incidence, mortality, and place of death (PoD) in the United States between 1999-2020 and identify disparities across race, ethnicity, and geographic location. METHODS AND RESULTS This cross-sectional study used CDC WONDER and NAACCR, to calculate age-adjusted rates of TC incidence and mortality, respectively. PoD data for individuals who died of TC were collected from CDC WONDER. Using Joinpoint analysis, longitudinal mortality trends were evaluated by age, race, ethnicity, US census region, and urbanization category. TC stage (localized vs metastatic) trends were also evaluated. Univariate and multivariate regression analysis identified demographic disparities for PoD. A total of 8,456 patients died of TC from 1999-2020. Average annual percent change (AAPC) of testicular cancer-specific mortality (TCSM) remained largely stable (AAPC, 0.4; 95% CI -0.2 to 0.9; p = 0.215). Men ages 25-29 experienced a significant increase in TCSM (AAPC, 1.3, p = 0.003), consistent with increased metastatic testicular cancer-specific incidence (TCSI) trend for this age group (AAPC, 1.6; p < 0.01). Mortality increased for Hispanic men (AAPC, 1.7, p < 0.001), with increased metastatic TCSI (AAPC, 2.5; p < 0.001). Finally, younger (<45), single, and Hispanic or Black men were more likely to die in medical facilities (all p < 0.001). The retrospective study design is a limitation. CONCLUSION Significant increases in metastatic TC were found for Hispanic men and men aged 25-29 potentially driving increasing testicular cancer specific mortality in these groups. Evidence of racial and ethnic differences in place of death may also highlight treatment disparities.
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Affiliation(s)
- Beck O. Gold
- Department of Radiation OncologyMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anushka Ghosh
- Department of Radiation OncologyMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Saveli I. Goldberg
- Department of Radiation OncologyMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Fumiko Chino
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Jason A. Efstathiou
- Department of Radiation OncologyMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Sophia C. Kamran
- Department of Radiation OncologyMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Barnes JM, Yabroff R, Chino F. Association of Managed Medicaid Plans and Cancer Stage at Diagnosis. Int J Radiat Oncol Biol Phys 2023; 117:S91. [PMID: 37784603 DOI: 10.1016/j.ijrobp.2023.06.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Managed care organizations provide insurance to many Medicare (Advantage) and Medicaid beneficiaries and seek to maintain quality while controlling provider networks, utilization, and costs. In prior research, patients with Medicare Advantage plans had restricted access to care, including at cancer centers, and had higher mortality after cancer surgery than patients with traditional Medicare. Over 80% of Medicaid patients nationally are enrolled in managed care plans; despite their prevalence, there is a paucity of evidence regarding the quality of cancer care provided by these plans. We examined associations of state-level managed Medicaid rates and cancer stage at diagnosis. MATERIALS/METHODS Adults ages 18-64 years with Medicaid coverage diagnosed with cancer from 2007-2016 were identified from Surveillance, Epidemiology, and End Results program data covering 12 states. Note that 2016 was the last year with unsuppressed insurance status data. Year-varying state-level rates of types of managed Medicaid plans (comprehensive risk-based managed care, limited benefit plans, and primary care case management) were obtained from the Medicaid and CHIP Payment and Access Commission and categorized in quartiles. The association of state levels of each type of managed Medicaid plan with localized stage diagnoses was evaluated using multivariable linear probability models with cluster-robust standard errors (state clusters) accounting for state fixed effects, year fixed effects, age, sex, race, metropolitan residence, marital status, county-level income and education, state Medicaid expansion status, and cancer type. RESULTS A total of 229,227 Medicaid patients were identified. The average state-level rates of comprehensive managed care, limited benefit, and primary care case management plans were 47%, 47%, and 5.6%, respectively. In adjusted analyses, relative to states with <20% of Medicaid recipients enrolled in comprehensive managed care plans, states with 40-80% (-2.07 percentage points, 95% CI = -3.31 to -0.83, P = .001) and >80% (-1.49, 95% CI = -2.49 to -0.50, P = .003) had fewer localized stage diagnoses. States with >2% relative to 0-1% of recipients enrolled in primary care case management plans had more localized stage diagnoses (1.02, 95% CI = 0.27 to 1.77, P = .008). States with higher levels of limited benefit plans had more localized stage diagnoses (P = .011), though associations were attenuated with increasing levels (20-40%: 1.22; 40-80%: 0.53; >80%: 0.40). Patterns were similar across most cancer types. CONCLUSION The prevalence and type of Medicaid managed care plans are associated with early-stage cancer diagnoses. Higher levels of comprehensive managed care plans were associated with fewer early diagnoses, raising concerns about barriers to symptom evaluation and diagnostic workup. In contrast, higher levels of primary care case management plans were associated with more early diagnoses, potentially through streamlined care coordination.
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Affiliation(s)
- J M Barnes
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, Saint Louis, MO
| | - R Yabroff
- American Cancer Society, Kennesaw, GA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Shenker RF, Johnson TL, Ribeiro MR, Karukonda P, Brizel DM, Chino F, Chino JP, Mowery YM. Environmental Toxicity of Driving Distance to External Beam Radiotherapy (EBRT) for Head and Neck Cancer Patients. Int J Radiat Oncol Biol Phys 2023; 117:e625. [PMID: 37785869 DOI: 10.1016/j.ijrobp.2023.06.2013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) For many patients undergoing external beam radiotherapy (EBRT), distance from home to treatment center is significant and require housing in closer proximity to minimize this travel burden. Patient transport also contributes significantly to the carbon footprint of EBRT. We sought to define the difference of carbon dioxide (CO2) emissions from commuting for patients who stay at a charity housing (CH) facility during treatment for head and neck cancer (HNC) versus a commute from home. MATERIALS/METHODS Patients with HNC were enrolled in an IRB-approved prospective protocol from 2019-2021. A distance of 3 miles (mi) was calculated from CH to our facility using Google Maps. Driving distance from home was indicated by patient self-report. Distance traveled per day Mon-Fri was doubled to account for driving to and from treatment. It was assumed that patients staying at CH returned home on weekends and that all used a standard, gasoline powered automobile for transportation to and from home. Transportation from CH to treatment was via a gasoline powered, 6-person shuttle. Both forms of transport were considered light-duty vehicles (LDV) with mileage and tailpipe emissions corresponding to the US on-road average (23.7 mi per gallon and 0.84 lb CO2/mi). For estimation of CH emissions, conversions were made from the reported electricity bill multiplied by the North Carolina grid emissions rate of 0.698 lb CO2/kWh. Natural gas used by CH for heating (prorated per patient) was estimated using the Piedmont Natural Gas rate (located in NC) and the monthly gas bill. Emissions from patient homes were assumed to be similar for patients commuting and making use of CH and therefore ignored. RESULTS Forty-nine patients enrolled in the study: 38 drove themselves to treatment daily, and 2 stayed at CH. The remaining 9 patients indicated that they stayed with friends/family or in a hotel where travel distance to DCI was unknown. CH electricity emissions were estimated to be 8,823 lb CO2/month. CH gas emissions were estimated to be 2,210.6 lb CO2/month. Emissions at CH were calculated as 137.9 lb CO2 per patient per month. The median emissions of those who drove daily per course of EBRT was 1205.4 lb CO2 (IQR 366.0 - 2221.2). For the 2 patients who stayed at the CH, total mi per course were 650 and 774. Including emissions of CH, emissions per patient were 1305.6 and 1523.2 lb CO2. If these patients were to have driven daily from their home, emissions would have been doubled (2368.8 and 2646 lb CO2, respectively). CH was estimated to result in fewer emissions for those that live ≥ 12 miles from the treatment facility. CONCLUSION Affordable and safe housing, such as charity housing is not only convenient for patients, but also reduces the environmental impact of travel for care for HNC. Patients who stayed at the charity housing in this study reduced their emissions from travel by nearly a half compared to driving daily in a personal vehicle. Further studies are imperative to continue to measure and mitigate the environmental toxicity of cancer care.
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Affiliation(s)
- R F Shenker
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - T L Johnson
- Duke University Nicholas School of the Environment, Durham, NC
| | - M R Ribeiro
- Duke University Nicholas School of the Environment, Durham, NC
| | - P Karukonda
- Duke University Medical Center, Department of Radiation Oncology, Durham, NC
| | - D M Brizel
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, NC
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - J P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Y M Mowery
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC
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Santos P, Shah K, Barnes JM, Tao A, Tsai CJ, Chino F. Disparities in Inpatient Care Including Receipt of Radiotherapy and Mortality in Unhoused Adults with Cancer in the United States. Int J Radiat Oncol Biol Phys 2023; 117:e53-e54. [PMID: 37785645 DOI: 10.1016/j.ijrobp.2023.06.765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Cancer is the second leading cause of death among unhoused individuals in the United States. This study aims to assess inpatient care and outcomes of unhoused vs. housed adults with cancer. We hypothesize that unhoused patients receive less intensive care than housed patients during hospitalization. MATERIALS/METHODS All hospitalized adults age ≥18 with a principal cancer diagnosis were identified in the 2016-2020 National Inpatient Sample (NIS). Logistic regression models tested for associations between housing status and primary outcomes: care management (i.e., receipt of invasive procedures, systemic therapy, or radiation therapy [RT]) and inpatient death. Adjusted analyses accounted for patient demographics, socioeconomic status, comorbidities, and potential interactions between housing status and length of stay (LOS). RESULTS A total of 9,030 unhoused and 2,758,693 housed hospitalized adults with cancer were included in this study. At baseline, there were significant (p<0.05) differences in age <65 years (77% unhoused vs. 41% housed), male sex (75% vs. 53%), race (Black, 25% vs. 13%; White, 58% vs. 71%), and insurance type (Private, 6% vs. 27%; Medicaid, 53% vs. 11%) between groups. There were also differences in the prevalence of certain cancer histologies, including lung (17% vs. 14%) and liver (8% vs. 3%) cancer. Additionally, while comorbidities such as congestive heart failure (18% vs. 15%) and HIV (10% vs. 1%) were more common among unhoused patients, other conditions such as autoimmune disease (21% vs. 26%) and diabetes mellitus (38% vs. 43%) were more common among housed patients. Compared to housed patients, unhoused patients had longer LOS (median 6 vs. 4 days), with 62% hospitalized for ≥5 days (vs. 46%). On adjusted analysis, unhoused patients were less likely to undergo invasive procedures (48% vs. 58%; aOR [95% CI], 0.34 [0.27-0.42]) or receive systemic therapy (6% vs. 8%; 0.41 [0.20-0.85]) while inpatient. There were no significant differences in odds of receipt of RT (2% vs. 1%; 0.85 [0.21-3.41]) or odds of inpatient death (4% vs. 6%; 0.78 [0.52-1.15]) between groups. CONCLUSION In this first nationally representative analysis of housing status among hospitalized adults with cancer, unhoused adults were significantly less likely to receive invasive procedures or systemic therapy while inpatient, despite a higher prevalence of certain aggressive cancers and serious comorbidities compared to housed adults. Although there were no significant differences in the receipt of RT or death, disparities in inpatient management among unhoused patients highlight missed opportunities to promote equitable cancer care in this vulnerable population.
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Affiliation(s)
- P Santos
- Harvard T.H. Chan School of Public Health, Boston, MA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - K Shah
- Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY
| | - J M Barnes
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, Saint Louis, MO
| | - A Tao
- Tufts University School of Medicine, Boston, MA
| | - C J Tsai
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
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Lu S, Rakovitch E, Hannon B, Zimmermann C, Yan M, de Almeida J, Yao CM, Gillespie EF, Chino F, Yerramilli D, Abdel-Rahman F, Othman H, Mheid S, Tsai CJ. Palliative Care as a Component of High Value and Cost-Saving Care During Hospitalization for Metastatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e602-e603. [PMID: 37785818 DOI: 10.1016/j.ijrobp.2023.06.1967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Randomized controlled trials have demonstrated that palliative care can improve both quality of life and survival for outpatients with advanced cancer, but there is limited population-based data on the value of inpatient palliative care. We assessed palliative care as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer. We further identified care, patient, and hospital characteristics significantly associated with high costs. MATERIALS/METHODS This study analyzed hospitalizations of patients ≥18 years with a primary diagnosis of metastatic cancer from the National Inpatient Sample (covering 97% of the U.S. population) from 2010-2019. We utilized multivariable mixed-effects logistic regression to assess medical services (receipt of palliative care, invasive medical ventilation [IMV], systemic therapy), patient demographics, and hospital characteristics that were associated with high charges billed to insurance and hospital costs. We utilized generalized linear mixed-effects models to determine cost savings associated with provision of palliative care. RESULTS Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in 2010 to $56,098 in 2019, while the median cost remained stable at $14,300. Receipt of inpatient palliative care was associated with significantly lower charges (Odds Ratio [OR], 0.62; 95% CI, 0.61-0.64; P <.001) and costs (OR, 0.59; 95% CI, 0.58-0.61; P<.001). Factors associated with high charges were receipt of invasive medical ventilation (P<.001) or systemic therapy (P<.001), Hispanic patients (P<.001), and young age (18-49 years, P<.001). For-profit hospitals were more likely to bill high charges (OR, 5.05; 95% CI, 4.78-5.33, P<.001) but less likely to incur high hospital costs (OR, 0.51; 95% CI, 0.48-0.54, P<.001) than public hospitals. In adjusted generalized linear mixed effects regression, palliative care provision was associated with a $1,293 (-13.4%, P<.001) reduction in costs per hospitalization compared to no palliative care, independent of receipt of invasive care and age. Significant interactions were observed between receipt of palliative care and patient age group (-9.6% for 18-49 years; -14.7% for ≥70 years), receipt of IMV (-6.4% for IMV receipt; -14.0% for no IMV), hospital ownership (-19.6% for for-profit; -10.5% for public), and year of hospitalization (-15.4% for 2010; -8.9% for 2019). CONCLUSION Inpatient palliative care is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Assuming inpatient palliative care receipt increases by 50%, we estimate $4,045,000 in annual national savings. Integration of inpatient palliative care may de-escalate costs incurred through low-value inpatient interventions.
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Affiliation(s)
- S Lu
- SUNY Downstate College of Medicine, Brooklyn, NY
| | - E Rakovitch
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - B Hannon
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - C Zimmermann
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - M Yan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - J de Almeida
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - C M Yao
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - E F Gillespie
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - F Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - D Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - H Othman
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - S Mheid
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - C J Tsai
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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Barnes JM, Johnston KJ, Johnson KJ, Chino F, Osazuwa-Peters N. State Public Assistance Spending and Survival Among Adults With Cancer. JAMA Netw Open 2023; 6:e2332353. [PMID: 37669050 PMCID: PMC10481229 DOI: 10.1001/jamanetworkopen.2023.32353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/29/2023] [Indexed: 09/06/2023] Open
Abstract
Importance Social determinants of health contribute to disparities in cancer outcomes. State public assistance spending, including Medicaid and cash assistance programs for socioeconomically disadvantaged individuals, may improve access to care; address barriers, such as food and housing insecurity; and lead to improved cancer outcomes for marginalized populations. Objective To determine whether state-level public assistance spending is associated with overall survival (OS) among individuals with cancer, overall and by race and ethnicity. Design, Setting, and Participants This cohort study included US adults aged at least 18 years with a new cancer diagnosis from 2007 to 2013, with follow-up through 2019. Data were obtained from the Surveillance, Epidemiology, and End Results program. Data were analyzed from November 18, 2021, to July 6, 2023. Exposure Differential state-level public assistance spending. Main Outcome and Measure The main outcome was 6-year OS. Analyses were adjusted for age, race, ethnicity, sex, metropolitan residence, county-level income, state fixed effects, state-level percentages of residents living in poverty and aged 65 years or older, cancer type, and cancer stage. Results A total 2 035 977 individuals with cancer were identified and included in analysis, with 1 005 702 individuals (49.4%) aged 65 years or older and 1 026 309 (50.4%) male. By tertile of public assistance spending, 6-year OS was 55.9% for the lowest tertile, 55.9% for the middle tertile, and 56.6% for the highest tertile. In adjusted analyses, public assistance spending at the state-level was significantly associated with higher 6-year OS (0.09% [95% CI, 0.04%-0.13%] per $100 per capita; P < .001), particularly for non-Hispanic Black individuals (0.29% [95% CI, 0.07%-0.52%] per $100 per capita; P = .01) and non-Hispanic White individuals (0.12% [95% CI, 0.08%-0.16%] per $100 per capita; P < .001). In sensitivity analyses examining the roles of Medicaid spending and Medicaid expansion including additional years of data, non-Medicaid spending was associated with higher 3-year OS among non-Hispanic Black individuals (0.49% [95% CI, 0.26%-0.72%] per $100 per capita when accounting for Medicaid spending; 0.17% [95% CI, 0.02%-0.31%] per $100 per capita Medicaid expansion effects). Conclusions and Relevance This cohort study found that state public assistance expenditures, including cash assistance programs and Medicaid, were associated with improved survival for individuals with cancer. State investment in public assistance programs may represent an important avenue to improve cancer outcomes through addressing social determinants of health and should be a topic of further investigation.
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Affiliation(s)
- Justin M. Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Kenton J. Johnston
- General Medical Sciences Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | | | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
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Patel TA, Jain B, Dee EC, Gomez SL, Vapiwala N, Chino F, Fayanju OM. Delays in Time to Surgery Among Asian and Pacific Islander Women with Breast Cancer. Ann Surg Oncol 2023; 30:5337-5340. [PMID: 37365415 PMCID: PMC10869161 DOI: 10.1245/s10434-023-13806-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Scarlett Lin Gomez
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Neha Vapiwala
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oluwadamilola M Fayanju
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Rena Rowan Breast Center, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation (PC3I), Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA.
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Salz T, Meza AM, Chino F, Mao JJ, Raghunathan NJ, Jinna S, Brens J, Furberg H, Korenstein D. Cannabis use among recently treated cancer patients: perceptions and experiences. Support Care Cancer 2023; 31:545. [PMID: 37650961 PMCID: PMC10585595 DOI: 10.1007/s00520-023-07994-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE To characterize cannabis use among cancer patients, we aimed to describe 1) patterns of cannabis use across multiple cancer sites; 2) perceived goals, benefits, harms of cannabis; and 3) communication about cannabis. METHODS Patients with 9 different cancers treated at Memorial Sloan Kettering Cancer Center between March and August 2021 completed an online or phone survey eliciting cannabis use, attitudes, and communication about cannabis. Multivariable logistic regression estimated the association of cancer type and cannabis use, adjusting for sociodemographic characteristics and prior cannabis use. RESULTS Among 1258 respondents, 31% used cannabis after diagnosis, ranging from 25% for lung cancer to 59% for testicular cancer. Characteristics associated with cannabis use included younger age, lower education level, and cancer type. In multivariable analysis, compared to lung cancer patients, gastrointestinal cancer patients were more likely to use cannabis (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.25-5.43). Cannabis use in the year prior to diagnosis was strongly associated with cannabis use after diagnosis (OR 19.13, 95% CI 11.92-30.72). Among users, reasons for use included difficulty sleeping (48%); stress, anxiety, or depression (46%); and pain (42%). Among respondents who used cannabis to improve symptoms, 70-90% reported improvement; < 5% reported that any symptom worsened. Only 25% discussed cannabis with healthcare providers. CONCLUSIONS Almost a third of cancer patients use cannabis, largely for symptom management. Oncologists may not know about their patients' cannabis use. To improve decision making about cannabis use during cancer care, research is needed to determine benefits and harms of cannabis use.
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Affiliation(s)
- Talya Salz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA.
| | - Akriti Mishra Meza
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jun J Mao
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nirupa J Raghunathan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sankeerth Jinna
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Jessica Brens
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Helena Furberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY, 10065, USA
| | - Deborah Korenstein
- Department of Internal Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
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Barnes JM, Kirchhoff AC, Yabroff KR, Chino F. State policies regulating short-term limited duration insurance plans and cancer stage at diagnosis. JNCI Cancer Spectr 2023; 7:pkad060. [PMID: 37572315 PMCID: PMC10471520 DOI: 10.1093/jncics/pkad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023] Open
Abstract
Short-term limited duration insurance plans, which proliferated following 2018 federal regulations, may not provide adequate protections for patients with suspected or newly diagnosed cancer and can destabilize insurance markets for comprehensive insurance plan enrollees. Individuals aged 18-64 years with newly diagnosed cancer from 11 states during 2016-2017 and 2019 were identified from the Surveillance, Epidemiology, and End Results program. Difference-in-differences analyses were used to compare changes in early-stage cancer diagnoses from 2016-2017 to 2019 in states that prohibited vs did not regulate short-term limited duration insurance plans. In adjusted difference-in-differences analyses, early-stage diagnoses increased 0.95 percentage points (95% confidence interval = 0.53 to 1.38, P < .001) in states that prohibited short-term limited duration insurance plans vs did not regulate short-term limited duration insurance plans. State policies resulting in unavailability of short-term limited duration insurance plans were associated with an increased percentage of early-stage diagnoses.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Anne C Kirchhoff
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Barnes JM, Johnson KJ, Osazuwa-Peters N, Yabroff KR, Chino F. Changes in cancer mortality after Medicaid expansion and the role of stage at diagnosis. J Natl Cancer Inst 2023; 115:962-970. [PMID: 37202350 PMCID: PMC10407703 DOI: 10.1093/jnci/djad094] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Medicaid expansion is associated with improved survival following cancer diagnosis. However, little research has assessed how changes in cancer stage may mediate improved cancer mortality or how expansion may have decreased population-level cancer mortality rates. METHODS Nationwide state-level cancer data from 2001 to 2019 for individuals ages 20-64 years were obtained from the combined Surveillance, Epidemiology, and End Results National Program of Cancer Registries (incidence) and the National Center for Health Statistics (mortality) databases. We estimated changes in distant stage cancer incidence and cancer mortality rates from pre- to post-2014 in expansion vs nonexpansion states using generalized estimating equations with robust standard errors. Mediation analyses were used to assess whether distant stage cancer incidence mediated changes in cancer mortality. RESULTS There were 17 370 state-level observations. For all cancers combined, there were Medicaid expansion-associated decreases in distant stage cancer incidence (adjusted odds ratio = 0.967, 95% confidence interval = 0.943 to 0.992; P = .01) and cancer mortality (adjusted odds ratio = 0.965, 95% confidence interval = 0.936 to 0.995; P = .022). This translates to 2591 averted distant stage cancer diagnoses and 1616 averted cancer deaths in the Medicaid expansion states. Distant stage cancer incidence mediated 58.4% of expansion-associated changes in cancer mortality overall (P = .008). By cancer site subgroups, there were expansion-associated decreases in breast, cervix, and liver cancer mortality. CONCLUSIONS Medicaid expansion was associated with decreased distant stage cancer incidence and cancer mortality. Approximately 60% of the expansion-associated changes in cancer mortality overall were mediated by distant stage diagnoses.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Nosayaba Osazuwa-Peters
- Department of Otolaryngology-Head and Neck Surgery, Duke University, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Pompa IR, Ghosh A, Bhat S, Ragala S, Nwiloh A, Rasheed N, Chino F, Willers H, Goldberg S, Kamran SC. US Cancer Mortality Trends Among Hispanic Populations From 1999 to 2020. JAMA Oncol 2023; 9:1090-1098. [PMID: 37382965 PMCID: PMC10311425 DOI: 10.1001/jamaoncol.2023.1993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/23/2023] [Indexed: 06/30/2023]
Abstract
Importance Advances in cancer research and treatment access have led to decreasing cancer mortality in the US; however, cancer remains the leading cause of death among Hispanic individuals. Objective To evaluate longitudinal cancer mortality trends from 1999 to 2020 among Hispanic individuals by demographic characteristics and to compare age-adjusted cancer death rates between the Hispanic population and other racial and ethnic populations during 2000, 2010, and 2020. Design, Setting, and Participants This cross-sectional study obtained age-adjusted cancer death rates among Hispanic individuals of all ages between January 1999 and December 2020, using the Centers for Disease Control and Prevention WONDER database. Cancer death rates in other racial and ethnic populations were extracted for 2000, 2010, and 2020. Data were analyzed from October 2021 to December 2022. Exposures Age, gender, race, ethnicity, cancer type, and US census region. Main Outcomes and Measures Trends and average annual percent changes (AAPCs) in age-adjusted cancer-specific mortality (CSM) rates among Hispanic individuals were estimated by cancer type, age, gender, and region. Results From 1999 to 2020, 12 644 869 patients died of cancer in the US, of whom 690 677 (5.5%) were Hispanic; 58 783 (0.5%) were non-Hispanic American Indian or Alaska Native; 305 386 (2.4%), non-Hispanic Asian or Pacific Islander; 1 439 259 (11.4%), non-Hispanic Black or African American; and 10 124 361 (80.1%), non-Hispanic White. For 26 403 patients (0.2%), no ethnicity was stated. The overall CSM rate among Hispanic individuals decreased by 1.3% (95% CI, 1.2%-1.3%) annually. Overall CSM rate decreased more for Hispanic men (AAPC, -1.6%; 95% CI, -1.7% to -1.5%) compared with women (AAPC, -1.0%; 95% CI, -1.0% to -0.9%). While death rates among Hispanic individuals decreased for most cancer types, mortality rates for liver cancer (AAPC, 1.0%; 95% CI, 0.6%-1.4%) increased among Hispanic men, and rates of liver (AAPC, 1.0%; 95% CI, 0.8%-1.3%), pancreas (AAPC, 0.2%; 95% CI, 0.1%-0.4%), and uterine (AAPC, 1.6%; 95% CI, 1.0%-2.3%) cancers increased among Hispanic women. Overall CSM rates increased for Hispanic men aged 25 to 34 years (AAPC, 0.7%; 95% CI, 0.3%-1.1%). By US region, liver cancer mortality rates increased significantly in the West for both Hispanic men (AAPC, 1.6%; 95% CI, 0.9%-2.2%) and Hispanic women (AAPC, 1.5%; 95% CI, 1.1%-1.9%). There were differential findings in mortality rates when comparing Hispanic individuals with individuals belonging to other racial and ethnic populations. Conclusions and Relevance In this cross-sectional study, despite overall CSM decreasing over 2 decades among Hispanic individuals, disaggregation of data demonstrated that rates of liver cancer deaths among Hispanic men and women and pancreas and uterine cancer deaths among Hispanic women increased from 1999 to 2020. There were also disparities in CSM rates among age groups and US regions. The findings suggest that sustainable solutions need to be implemented to reverse these trends among Hispanic populations.
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Affiliation(s)
- Isabella R. Pompa
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anushka Ghosh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shamik Bhat
- Yale School of Medicine, New Haven, Connecticut
| | - Siri Ragala
- University of Missouri–Kansas City School of Medicine, Kansas City
| | | | - Nabeel Rasheed
- University of Missouri–Kansas City School of Medicine, Kansas City
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Saveli Goldberg
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sophia C. Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Thom B, Sokolowski S, Abu-Rustum NR, Allen-Dicker J, Caramore A, Chino F, Doyle S, Fitzpatrick C, Gany F, Liebhaber A, Newman T, Rao N, Tappen J, Aviki EM. Financial Toxicity Order Set: Implementing a Simple Intervention to Better Connect Patients With Resources. JCO Oncol Pract 2023; 19:662-668. [PMID: 37319394 PMCID: PMC10424913 DOI: 10.1200/op.22.00669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/24/2023] [Accepted: 04/24/2023] [Indexed: 06/17/2023] Open
Abstract
PURPOSE Financial toxicity of cancer treatment is well described in the literature, including characterizations of its risk factors, manifestations, and consequences. There is, however, limited research on interventions, particularly those at the hospital level, to address the issue. METHODS From March 1, 2019, to February 28, 2022, a multidisciplinary team conducted a three-cycle Plan-Do-Study-Act (PDSA) process to develop, test, and implement an electronic medical record (EMR) order set to directly refer patients to a hospital-based financial assistance program. The cycles included an assessment of the efficacy of our current practice in connecting patients experiencing financial hardship with assistance, the development and piloting of the EMR referral order, and the broad implementation of the order set across our institution. RESULTS In PDSA cycle 1, we found that approximately 25% of patients at our institution experienced some form of financial hardship, but most patients were not connected to available resources because of our referral mechanism. In PDSA cycle 2, the pilot referral order set was deemed feasible and received positive feedback. Over the 12-month study period (March 1, 2021-February 28, 2022) of PDSA cycle 3, 718 orders were placed for 670 unique patients across interdisciplinary providers from 55 treatment areas. These referrals resulted in at least $850,000 in US dollars (USD) in financial aid in 38 patients (mean = $22,368 USD). CONCLUSION The findings from our three-cycle PDSA quality improvement project demonstrate the feasibility and efficacy of interdisciplinary efforts to develop a hospital-level financial toxicity intervention. A simple referral mechanism can empower providers to connect patients in need with available resources.
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Affiliation(s)
- Bridgette Thom
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stefania Sokolowski
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nadeem R. Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of OB/GYN, Weill Cornell Medical College, New York, NY
| | - Joshua Allen-Dicker
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amy Caramore
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephanie Doyle
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Patient Financial Services, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Francesca Gany
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Allison Liebhaber
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tiffanny Newman
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nisha Rao
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Johanna Tappen
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Social Work, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emeline M. Aviki
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Wu VS, Benedict C, Friedman DN, Watson SE, Anglade E, Zeitler MS, Chino F, Thom B. Do discussions of financial burdens decrease long-term financial toxicity in adolescent and young adult cancer survivors? Support Care Cancer 2023; 31:434. [PMID: 37395811 DOI: 10.1007/s00520-023-07822-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE This study aims to evaluate the associations between patient-provider cost discussions with patient-reported out-of-pocket (OOP) spending and long-term financial toxicity (FT) among adolescent and young adult (AYA; 15-39 years old) cancer survivors. METHODS Using a cross-sectional survey, we assessed the themes and quality of patient discussions with providers about financial needs and general survivorship preparation, quantified patients' levels of FT, and evaluated patient-reported OOP spending. We determined the association between cancer treatment cost discussion and FT using multivariable analysis. In a subset of survivors (n = 18), we conducted qualitative interviews and used thematic analysis to characterize responses. RESULTS Two hundred forty-seven AYA survivors completed the survey at a mean of 7 years post treatment and with a median COST score of 13. 70% of AYA survivors did not recall having any cost discussion about their cancer treatment with a provider. Having any cost discussion with a provider was associated with decreased FT (β = 3.00; p = 0.02) but not associated with reduced OOP spending (χ2 = 3.77; p = 0.44). In a second adjusted model, with OOP spending included as a covariate, OOP spending was a significant predictor of FT (β = - 1.40; p = 0.002). Key qualitative themes included survivors' frustration about the lack of communication related to financial issues throughout treatment and in survivorship, feeling unprepared, and reluctance to seek help. CONCLUSION AYA patients are not fully informed about the costs of cancer care and FT; the dearth of cost discussions between patients and providers may represent a missed opportunity to reduce costs.
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Affiliation(s)
- Victoria S Wu
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Catherine Benedict
- Stanford University School of Medicine, Stanford Cancer Institute, Palo Alto, CA, USA
| | - Danielle N Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | - Fumiko Chino
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bridgette Thom
- Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Ranganathan S, Tomar V, Chino F, Jain B, Patel TA, Dee EC, Mathew A. A burden shared: the financial, psychological, and health-related consequences borne by family members and caregivers of people with cancer in India. Support Care Cancer 2023; 31:420. [PMID: 37354234 DOI: 10.1007/s00520-023-07886-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/13/2023] [Indexed: 06/26/2023]
Abstract
In India, approximately 1.4 million new cases of cancer are recorded annually, with 26.7 million people living with cancer in 2021. Providing care for family members with cancer impacts caregivers' health and financial resources. Effects on caregivers' health and financial resources, understood as family and caregiver "financial toxicity" of cancer, are important to explore in the Indian context, where family members often serve as caregivers, in light of cultural attitudes towards family. This is reinforced by other structural issues such as grave disparities in socioeconomic status, barriers in access to care, and limited access to supportive care services for many patients. Effects on family caregivers' financial resources are particularly prevalent in India given the increased dependency on out-of-pocket financing for healthcare, disparate access to insurance coverage, and limitations in public expenditure on healthcare. In this paper, we explore family and caregiver financial toxicity of cancer in the Indian context, highlighting the multiple psychosocial aspects through which these factors may play out. We suggest steps forward, including future directions in (1) health services research, (2) community-level interventions, and (3) policy changes. We underscore that multidisciplinary and multi-sectoral efforts are needed to study and address family and caregiver financial toxicity in India.
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Affiliation(s)
| | | | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology and Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bhav Jain
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Tej A Patel
- University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Aju Mathew
- Department of Oncology, MOSC Medical College, Ernakulam, Kerala, 682311, India
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Alcorn SR, Chino F. Current Trends for Diversity, Equity, and Inclusion Among Medical Faculty and Clinical Trial Participation. Int J Radiat Oncol Biol Phys 2023; 116:207-211. [PMID: 37179079 DOI: 10.1016/j.ijrobp.2023.03.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Sara R Alcorn
- Department of Radiation Oncology, University of Minnesota Medical School, Minneapolis, Minnesota.
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Sukumar S, Wasfy JH, Januzzi JL, Peppercorn J, Chino F, Warraich HJ. Financial Toxicity of Medical Management of Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2043-2055. [PMID: 37197848 DOI: 10.1016/j.jacc.2023.03.402] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 05/19/2023]
Abstract
Optimal medical management of heart failure (HF) improves quality of life, decreases mortality, and decreases hospitalizations. Cost may contribute to suboptimal adherence to HF medications, especially angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors. Patients' experiences with HF medication cost include financial burden, financial strain, and financial toxicity. Although there has been research studying financial toxicity in patients with some chronic diseases, there are no validated tools for measuring financial toxicity of HF, and very few data on the subjective experiences of patients with HF and financial toxicity. Strategies to decrease HF-associated financial toxicity include making systemic changes to minimize cost sharing, optimizing shared decision-making, implementing policies to lower drug costs, broadening insurance coverage, and using financial navigation services and discount programs. Clinicians may also improve patient financial wellness through various strategies in routine clinical care. Future research is needed to study financial toxicity and associated patient experiences for HF.
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Affiliation(s)
- Smrithi Sukumar
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/SmrithiSukumar
| | - Jason H Wasfy
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James L Januzzi
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey Peppercorn
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fumiko Chino
- Memorial Sloan Kettering, New York, New York, USA
| | - Haider J Warraich
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, Massachusetts, USA.
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Roy E, Chino F, King B, Madu C, Mattes M, Morrell R, Pollard-Larkin J, Siker M, Takita C, Ludwig M. Increasing Diversity of Patients in Radiation Oncology Clinical Trials. Int J Radiat Oncol Biol Phys 2023; 116:103-114. [PMID: 36526234 PMCID: PMC10414211 DOI: 10.1016/j.ijrobp.2022.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/21/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
Radiation oncology clinical trials lack full representation of the ethnic and racial diversity present in the general United States and in the cancer patient population. There are low rates of both recruitment and enrollment of individuals from underrepresented ethnic and racial backgrounds, especially Black and Hispanic patients, people with disabilities, and patients from underrepresented sexual and gender groups. Even if approached for enrollment, barriers such as mistrust in medical research stemming from historical abuse and contemporary biased systems, low socioeconomic status, and lack of awareness prohibit historically marginalized populations from participating in clinical trials. In this review, we reflect on these specific barriers and detail approaches to increase diversity of the patient population in radiation oncology clinical trials to better reflect the communities we serve. We hope that implementation of these approaches will increase the diversity of clinical trials patient populations in not only radiation oncology but also other medical specialties.
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Affiliation(s)
- Emily Roy
- Baylor College of Medicine, Houston, Texas
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin King
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chika Madu
- Department of Radiation Oncology, Staten Island University Hospital, Staten Island, New York
| | - Malcolm Mattes
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Rosalyn Morrell
- Advanced Radiation Center of Beverly Hills, Beverly Hills, California
| | | | - Malika Siker
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christiane Takita
- Department of Radiation Oncology, Miami University School of Medicine, Miami, Florida
| | - Michelle Ludwig
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas.
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Swami N, Dee EC, Mahal BA, Chino F, Florez N. Prevalence of Financial Toxicity Among Hispanic Cancer Survivors: A Nationally Representative Pan-Cancer Analysis. J Gen Intern Med 2023; 38:1334-1337. [PMID: 36720765 PMCID: PMC10110788 DOI: 10.1007/s11606-022-08016-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/29/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Nishwant Swami
- University of Massachusetts Chan Medical School, Worcester, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Narjust Florez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
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Affiliation(s)
- Patricia Mae G Santos
- From the Department of Radiation Oncology (P.M.G.S., F.C.), the Immigrant Health and Cancer Disparities Service (F.M.G.), and the Affordability Working Group (F.C.), Memorial Sloan Kettering Cancer Center, and the Department of Internal Medicine, New York University Grossman School of Medicine (K.S.) - both in New York
| | - Kanan Shah
- From the Department of Radiation Oncology (P.M.G.S., F.C.), the Immigrant Health and Cancer Disparities Service (F.M.G.), and the Affordability Working Group (F.C.), Memorial Sloan Kettering Cancer Center, and the Department of Internal Medicine, New York University Grossman School of Medicine (K.S.) - both in New York
| | - Francesca M Gany
- From the Department of Radiation Oncology (P.M.G.S., F.C.), the Immigrant Health and Cancer Disparities Service (F.M.G.), and the Affordability Working Group (F.C.), Memorial Sloan Kettering Cancer Center, and the Department of Internal Medicine, New York University Grossman School of Medicine (K.S.) - both in New York
| | - Fumiko Chino
- From the Department of Radiation Oncology (P.M.G.S., F.C.), the Immigrant Health and Cancer Disparities Service (F.M.G.), and the Affordability Working Group (F.C.), Memorial Sloan Kettering Cancer Center, and the Department of Internal Medicine, New York University Grossman School of Medicine (K.S.) - both in New York
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Abstract
Abstract
People with cancer spend more out of pocket for medical care than others with chronic diseases, a pattern that persists years after initial cancer diagnosis and treatment. Patients and their families are at risk for financial toxicity including problems paying medical bills, increased stress and/or symptom burden, and delaying or forgoing care due to costs. In this talk, Dr. Fumiko Chino provides an overview of financial toxicity in cancer care and its real-life impact on people with cancer. Factors contributing to financial toxicity are addressed as well potential solutions.
1. Define financial toxicity as a negative consequence of cancer diagnosis/treatment
2. Describe effects of financial toxicity on quality of life, adherence, and outcomes
3. Name potential solutions to financial toxicity on a health system, provider, and patient level
Citation Format: Fumiko Chino. Financial toxicity [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr ED5-3.
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Affiliation(s)
- Fumiko Chino
- 1Memorial Sloan Kettering Cancer Center, New York, New York
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42
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Barnes JM, Chino JP, Chino F. Racial and Ethnic Disparities in Coexisting Cancer and COVID-19 Mortality. J Gen Intern Med 2023; 38:1344-1347. [PMID: 36750506 PMCID: PMC9904866 DOI: 10.1007/s11606-023-08069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/27/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Center for Advanced Medicine, Washington University School of Medicine, 4921 Parkview Place, Lower Level, St. Louis, MO, 63110, USA.
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Affordability Working Group, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Hussaini SMQ, Chen KY, Blackford AL, Chino F, Gupta A. Food insecurity and gastrointestinal (GI) cancer mortality in the United States, 2015 to 2019. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
788 Background: Food insecurity is a crucial but under-appreciated social determinant of health in GI cancers given high rates of cachexia where nutritional status may adversely impact functional status and outcomes. We investigated the impact of county-level food insecurity on age-adjusted mortality rates (AAMRs) from GI cancer. Methods: GI cancer-related deaths (ICD C15-26) were linked across US counties from 2015-2019 in the CDC WONDER database to county-level food insecurity measures from Feeding America and Census County Business Patterns databases. These included percent of individuals with food insecurity or on Supplemental Nutrition Assistance Program (SNAP) benefits, and the average cost/meal (USD) and density of local fast food/take-out restaurants. All measures were classified into quartiles based on distribution. AAMRs per 100,000 were compared between 1st and 4th quartiles for each measure using robust linear regression models with log scale and including the population size as weights. Results: There were 790,624 GI cancer deaths with overall AAMR 43.0 (68.5% age >65y, 57.8% male, 12.9% non-Hispanic Black, 8.9% Hispanic, 82.4% urban, 33.6% colorectal, 27.7% pancreatic, 19.6% liver/biliary cancer). Highest AAMRs were noted for age >65y, men, non-Hispanic White, and rural areas. AAMRs increased when moving from least to most insecure counties as defined by overall food insecurity, higher proportion of population on SNAP, or by higher local fast food density. AAMRs were lower in counties where cost per meal was higher. Association between AAMRs and all measures were strongest in younger adults (<65y), men, and rural counties, while association between AAMR and fast food density was strong among non-Hispanic Black individuals. Conclusions: Our study highlights the most food insecure US counties also have higher GI cancer mortality with significant sociodemographic variation. Food insecurity may be a helpful proxy for county-level social vulnerability in driving GI cancer mortality. Our findings recognize an important relationship between nutrition and cancer mortality and should inform ongoing congressional policy on food insecurity and assistance.[Table: see text]
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Affiliation(s)
- S. M. Qasim Hussaini
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, MD
| | | | | | - Fumiko Chino
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Arjun Gupta
- University of Minnesota Masonic Cancer Center, Minneapolis, MN
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Peterson J, Wilson TF, Watt MH, Gruhl J, Davis S, Olsen J, Parsons MW, Kann BH, Swire-Thompson B, Fagerlin A, Warner EL, King AJ, Chino F, Johnson SB. International medical tourism of US cancer patients for alternative cancer treatments: Financial, demographic, and clinical profiles of online crowdfunding campaigns. Cancer Med 2023; 12:8871-8879. [PMID: 36659856 PMCID: PMC10134261 DOI: 10.1002/cam4.5636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/29/2022] [Accepted: 01/08/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Previous research has found that individuals may travel outside their home countries in pursuit of alternative cancer therapies (ACT). The goal of this study is to compare individuals in the United States who propose plans for travel abroad for ACT, compared with individuals who seek ACT domestically. METHODS Clinical and treatment data were extracted from campaign descriptions of 615 GoFundMe® campaigns fundraising for individuals in the United States seeking ACT between 2011 and 2019. We examined treatment modalities, treatment location, fundraising metrics, and online engagement within campaign profiles. Clinical and demographic differences between those who proposed international travel and those who sought ACT domestically were examined using two-sided Fisher's exact tests. Differences in financial and social engagement data were examined using two-sided Mann-Whitney tests. RESULTS Of the total 615 campaigns, 237 (38.5%) mentioned plans to travel internationally for ACT, with the majority (81.9%) pursuing travel to Mexico. Campaigns that proposed international treatment requested more money ($35,000 vs. $22,650, p < 0.001), raised more money ($7833 vs. $5035, p < 0.001), had more donors (57 vs. 45, p = 0.02), and were shared more times (377 vs. 290.5, p = 0.008) compared to campaigns that did not. The median financial shortfall was greater for campaigns pursuing treatments internationally (-$22,640 vs. -$13,436, p < 0.003). CONCLUSIONS Campaigns proposing international travel for ACT requested and received more money, were shared more online, and had more donors. However, there was significantly more unmet financial need among this group, highlighting potential financial toxicity on patients and families.
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Affiliation(s)
- John Peterson
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Trevor F Wilson
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Melissa H Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Josh Gruhl
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Sydney Davis
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Jaxon Olsen
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Matthew W Parsons
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Benjamin H Kann
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Briony Swire-Thompson
- Network Science Institute, Northeastern University, Boston, Massachusetts, USA.,Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, Utah, USA
| | - Echo L Warner
- College of Nursing, University of Utah, Salt Lake City, Utah, USA.,Cancer Control & Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Andy J King
- Cancer Control & Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA.,Department of Communication, University of Utah, Salt Lake City, Utah, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Skyler B Johnson
- Department of Radiation Oncology, University of Utah, Huntsman Cancer Institute, Salt Lake City, Utah, USA.,Cancer Control & Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA
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Jimenez RB, Pinnix CC, Juang T, Franco I, Sim AJ, Siker M, Vapiwala N, Chino F, Shinohara ET, Metz J, Winkfield KM, Suneja G, Deville C, Gibbs IC. Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration. Int J Radiat Oncol Biol Phys 2023; 116:334-347. [PMID: 36669542 DOI: 10.1016/j.ijrobp.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023]
Abstract
Disproportionate gender, racial, and ethnic diversity remains in the radiation oncology physician workforce despite widespread awareness and longitudinal efforts to improve representation. In this collaborative review, we define the rationale and components of holistic review and how it can be best utilized to provide a comprehensive evaluation of applicants to residency programs in radiation oncology. We initially discuss the current state of diversity in the field of radiation oncology and highlight the components of the residency selection process that may serve to perpetuate existing biases. Subsequently, the ACGME and AAMC holistic review framework is reviewed in detail to demonstrate the balanced assessment of potential applicants. The implementation of holistic review in medical school and residency selection to-date are examined to underscore the potential value of holistic review in the radiation oncology residency selection process. Finally, recommendations for the practical implementation of holistic review in radiation oncology trainee selection are outlined.
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Affiliation(s)
- Rachel B Jimenez
- Massachusetts General Hospital, Department of Radiation Oncology, Boston, MA.
| | - Chelsea C Pinnix
- MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | - Titania Juang
- University of California, San Diego, Department of Radiation Medicine and Applied Science, San Diego, CA
| | - Idalid Franco
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Department of Radiation Oncology, Boston, MA
| | - Austin J Sim
- James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Department of Radiation Oncology, Columbus, OH
| | - Malika Siker
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, WI
| | - Neha Vapiwala
- University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA
| | - Fumiko Chino
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY
| | - Eric T Shinohara
- Vanderbilt University Medical Center, Department of Radiation Oncology, Nashville, TN
| | - James Metz
- University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA
| | - Karen M Winkfield
- Meharry-Vanderbilt Alliance and Vanderbilt University Medical Center, Department of Radiation Oncology, Nashville, TN
| | - Gita Suneja
- University of Utah, Department of Radiation Oncology, Salt Lake City, UT
| | - Curtiland Deville
- Johns Hopkins University, Department of Radiation Oncology and Molecular Radiation Sciences, Baltimore, MD
| | - Iris C Gibbs
- Stanford University, Department of Radiation Oncology, Palo Alto, CA
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Chino F, Sadigh G. Introduction to Financial Toxicity and the Growing Affordability Crisis. J Am Coll Radiol 2023; 20:6-7. [PMID: 36513261 DOI: 10.1016/j.jacr.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Fumiko Chino
- Affordability Working Group and the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; is a member of the Health Equity, Diversity and Inclusion Counsel, American Society for Radiation Oncology; is on the steering committee of ASCO Quality; and a director of the Costs of Care group.
| | - Gelareh Sadigh
- Department of Radiological Sciences, University of California, Irvine, Irvine, California; is an Associate Editor of the Journal of American College of Radiology; and Director of Health Services and Comparative Effectiveness Outcome Research at the University of California, Irvine, Irvine, California
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47
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Bell L, Thom B, Chino F. Value-Based Health Care: Evaluating the Education of Future Radiation Oncologists on Costs and Affordability. J Am Coll Radiol 2023; 20:59-62. [PMID: 36496086 PMCID: PMC9898151 DOI: 10.1016/j.jacr.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/31/2022] [Accepted: 11/05/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Lauren Bell
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bridgette Thom
- Affordability Working Group and the Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fumiko Chino
- Affordability Working Group and the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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Swami N, Nguyen T, Dee EC, Franco I, Baez YA, Lapen K, Wang L, Goel N, Mahal BA, Fayanju OM, Duma N, Chino F. Disparities in Primary Breast Cancer Stage at Presentation Among Hispanic Subgroups. Ann Surg Oncol 2022; 29:7977-7987. [PMID: 35953743 DOI: 10.1245/s10434-022-12302-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although the United States (US) Hispanic population consists of diverse communities, prior breast cancer studies often analyze this group in aggregate. Our aim was to identify differences in breast cancer stage at presentation in the US population, with a particular focus on Hispanic subgroups. METHODS Data from the National Cancer Database (NCDB) from 2004 to 2017 were used to select women with primary breast cancer; individuals were disaggregated by racial and ethnic subgroup and Hispanic country of origin. Ordinal logistic regression was used to create adjusted odds ratios (aORs) with 95% confidence intervals (CIs), with higher odds representing presentation at later-stage breast cancer. Subgroup analysis was conducted based on tumor receptor status. RESULTS Overall, among 2,282,691 women (5.2% Hispanic), Hispanic women were more likely to live in low-income and low-educational attainment neighborhoods, and were also more likely to be uninsured. Hispanic women were also more likely to present at later-stage primary breast cancer when compared with non-Hispanic White women (aOR 1.19, 95% CI 1.18-1.21; p < 0.01). Stage disparities were demonstrated when populations were disaggregated by country of origin, particularly for Mexican women (aOR 1.55, 95% CI 1.51-1.60; p < 0.01). Disparities worsened among both racial and country of origin subgroups in women with triple-negative disease. CONCLUSION Later breast cancer stage at presentation was observed among Hispanic populations when disaggregated by racial subgroup and country of origin. Socioeconomic disparities, as well as uncaptured disparities in access and/or differential care, may drive these observed differences. Future studies with disaggregated data are needed to characterize outcomes in Hispanic communities and develop targeted interventions.
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Affiliation(s)
- Nishwant Swami
- University of Massachusetts Chan Medical School, Worcester, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tiffany Nguyen
- University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Idalid Franco
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA
| | - Yefri A Baez
- Department of Urology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lora Wang
- Department of Radiation Oncology, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Neha Goel
- Department of Surgical Oncology, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Oluwadamilola M Fayanju
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA.,Rena Rowan Breast Center, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA.,Penn Center for Cancer Care Innovation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Narjust Duma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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49
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Swami N, Nguyen T, Dee EC, Franco I, Baez YA, Lapen K, Wang L, Goel N, Mahal BA, Fayanju OM, Duma N, Chino F. ASO Visual Abstract: Disparities in Primary-Stage Breast Cancer at Presentation Among Hispanic Subgroups. Ann Surg Oncol 2022; 29:7990-7991. [PMID: 35933540 DOI: 10.1245/s10434-022-12375-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Nishwant Swami
- University of Massachusetts Medical School, Worcester, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tiffany Nguyen
- University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue Box #33, New York, NY, USA
| | - Idalid Franco
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA
| | - Yefri A Baez
- Department of Urology, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue Box #33, New York, NY, USA
| | - Lora Wang
- Department of Radiation Oncology, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Neha Goel
- Department of Surgical Oncology, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami Miller School of Medicine/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Oluwadamilola M Fayanju
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
- Rena Rowan Breast Center, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Narjust Duma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue Box #33, New York, NY, USA.
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50
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Lee S, Weil C, Boyd L, Burt L, Chino F, Gaffney D, Shaikh F, Suneja G. Trends in IMRT Utilization for Definitive Treatment of Cervical Cancer, 2004-2018. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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