A proactive financial navigation intervention in patients with newly diagnosed gastric and gastroesophageal junction adenocarcinoma

PURPOSE

Many cancer patients and caregivers experience financial hardship, leading to poor outcomes. Gastric and gastroesophageal junction (GEJ) cancer patients are particularly at risk for financial hardship given the intensity of treatment. This pilot randomized study among gastric/GEJ cancer patients and caregivers tested a proactive financial navigation (FN) intervention to obtain a signal of efficacy to inform a larger, more rigorous randomized study.

METHODS

We tested a 3-month proactive FN intervention among gastric/GEJ cancer patients and caregivers compared to usual care. Caregiver participation was optional. The primary endpoint was incidence of financial hardship, defined as follows: accrual of debt, income decline of ≥ 20%, or taking loans to pay for treatment. Data from participant surveys and documentation by partner organizations delivering the FN intervention was analyzed and outcomes were compared between study arms.

RESULTS

Nineteen patients and 12 caregivers consented. Primary FN resources provided included insurance navigation, budget planning, and help with out-of-pocket medical expenses. Usual care patients were more likely to experience financial hardship (50% vs 40%) and declines in quality of life (37.5% vs 0%) compared to intervention patients. Caregivers in both arms reported increased financial stress and poorer quality of life over the study period.

CONCLUSIONS

Proactive financial navigation has potentially positive impacts on financial hardship and quality of life for cancer patients and more large-scale randomized interventions should be conducted to rigorously explore the impact of similar interventions. Interventions that have the potential to lessen caregiver financial stress and burden need further exploration.

TRIAL REGISTRATION

TRN: NCT03986502, June 14, 2019.

A pilot study of a comprehensive financial navigation program in cancer patients and caregivers

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Background: Few studies have reported on interventions to alleviate financial toxicity (FT) in cancer patients (pts) and informal caregivers (cgs). We developed a financial navigation program in collaboration with Consumer Education and Training Services (CENTS), Patient Advocate Foundation (PAF), and Family Reach Foundation (FRF), to offer financial coaching, insurance navigation, and assistance with unpaid non-medical bills. We conducted a pilot study to assess feasibility of enrolling cgs with pts and to describe the assistance provided. Methods: Pts with any stage solid tumor actively receiving treatment (tx) at the Seattle Cancer Care Alliance were asked to identify a cg who could participate. Pts or pt/cg dyads received an online financial education course and monthly contact for 6 months (mo) with CENTS and PAF. Subjects were referred to FRF for assistance in paying non-medical bills. We describe pt and cg characteristics, and assistance provided by the program. Results: Of 54 pts approached, 30 (median age 59.5, 61% white, 97% stage III/IV disease) were consented. Most pts (53%) had income ≤ $25,000, and all were insured (48% commercial, 28% Medicare, 21% Medicaid). 18 cgs (67% spouse/partner) were consented. At consent, 55% of pts reported debt in the prior 3 mo. Mean score using the COST PRO FT measure (range 0-44, lower score = higher FT) was 17.4 at baseline. After pts’ physical health, out-of-pocket costs were the most stressful aspects of tx for cgs. Cgs with high financial burden from caregiving more often reported taking on new debt, dipping into retirement accounts, or changing their jobs or hours. CENTS coaches assisted with budgeting, updating wills, and employment rights counsel. PAF case managers assisted with financial assistance for drugs, cost of living (e.g. transportation), disability applications, and secured $6,950 in debt relief. FRF dispersed $4,133, primarily for housing expenses. Conclusions: Implementing a financial navigation program that engages both pts and cgs is feasible. This lower income, financially stressed population received $11,000 in financial assistance. Future work will focus on evaluating the impact of this program on financial and psychosocial outcomes in pts and cgs.

Pilot Feasibility Study of an Oncology Financial Navigation Program

BACKGROUND

Few studies have reported on interventions to alleviate financial toxicity in patients with cancer. We developed a financial navigation program in collaboration with our partners, Consumer Education and Training Services (CENTS) and Patient Advocate Foundation (PAF), to improve patient knowledge about treatment costs, provide financial counseling, and to help manage out-of-pocket expenses. We conducted a pilot study to assess the feasibility and impact of this program.

METHODS

Patients with cancer received a financial education course followed by monthly contact with a CENTS financial counselor and a PAF case manager for 6 months. We measured program adherence, self-reported financial burden and anxiety, program satisfaction, and type of assistance provided.

RESULTS

Thirty-four patients (median age, 60.5 years) were consented (85% white and 50% commercially insured). Debt, income declines, and loans were reported by 55%, 55%, and 30% of patients, respectively. CENTS counselors assisted most often with budgeting, retirement planning, and medical bill questions. PAF case managers assisted with applications for appropriate insurance coverage, cost of living issues (eg, housing, transportation), and disability applications. High financial burden and anxiety about costs (4 or 5 on a Likert scale) were reported at baseline by 37% and 47% of patients, respectively. Anxiety about costs decreased over time in 33% of patients, whereas self-reported financial burden did not substantially change.

CONCLUSION

Implementing an oncology financial navigation program is feasible, provides concrete assistance in navigating the cost of care, and mitigates anxiety about costs in a subset of patients. Future work will focus on measuring the program's impact on financial and clinical outcomes.

A pilot study of a comprehensive financial navigation program in cancer survivors

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Background: Although financial toxicity is associated with poorer clinical outcomes in cancer survivors, few studies have attempted to address this toxicity. We developed a financial navigation program in collaboration with our partners (Consumer Education and Training Services (CENTS) and Patient Advocate Foundation (PAF)) to improve patients’ knowledge about cancer treatment costs, provide financial counseling, and help with out-of-pocket expenses. We conducted a pilot study to assess feasibility and early impact of this program. Methods: Patients (pts) within 1 year of a solid tumor diagnosis and 6 months of chemotherapy and/or radiation were recruited at the Seattle Cancer Care Alliance. Pts received a financial education course followed by monthly contact with a CENTS financial counselor and PAF case manager for 6 months. We measured program adherence, self-reported financial burden, anxiety about costs, program satisfaction, and type and amount of assistance provided. Results: We consented 34 pts (median age 60.5), the majority of whom were white (85%) and commercially insured (50%). Participants (n = 20) and non-participants (n = 14 who withdrew or were lost to follow up early on) did not differ in age, race, gender, education, income, or insurance type. Debt, income declines, and loans were reported by 55%, 55%, and 30% of pts. High financial burden and anxiety about costs (4 or 5; Likert scale) were reported by 37% and 47% of pts. High satisfaction with the education course, CENTS counselors, and PAF case managers were reported by 73%, 80%, and 91% of pts. CENTS counselors assisted pts most often with budgeting, retirement planning, and medical bill questions. PAF case managers assisted pts with gaps in insurance, debt or cost of living issues, and employment rights and disability applications. A total of $7,667 ($1,267 for pts and $6,400 for institutions) was obtained through charitable entities. Conclusions: Our findings confirm that a financial navigation program is feasible to implement, associated with high satisfaction, and provides concrete assistance to pts in navigating the cost of cancer care. Future work will focus on improving program adherence and measuring its impact on financial and clinical outcomes.

Development of a financial literacy course for patients with newly diagnosed cancer

OBJECTIVES

Although patients with cancer often face serious financial hardships, few studies have reported on strategies to mitigate this burden. Improving literacy about the financial aspects of cancer care may decrease the negative financial impact of cancer diagnosis and treatment. We obtained input from patient stakeholders on the perceived value and optimal design of a financial literacy program in the advanced cancer setting.

STUDY DESIGN

Prospective cohort survey.

METHODS

A series of semi-structured interviews were conducted, during which patients with either colorectal or breast cancer were asked to describe the impact of cancer on their finances and employment, to state their preferences about discussing costs with their providers, and to give input on development of a financial literacy course.

RESULTS

Twenty-one patients (76% Caucasian) completed interviews, the majority of whom had Medicare or commercial insurance (71%). Lost income from early retirement or disability was the most financially burdensome experience for 67% of patients. The majority of patients (76%) reported that a financial literacy course would be helpful in navigating the cost of cancer care. Most preferred the course be administered at diagnosis in a live group format.

CONCLUSIONS

Feedback from patients with cancer supported the development of a group financial literacy course that addresses barriers to discussing cost concerns, employment changes during cancer, and available resources for financial assistance.

Cerebellar c9RAN proteins associate with clinical and neuropathological characteristics of C9ORF72 repeat expansion carriers

Clinical and neuropathological characteristics associated with G₄C₂ repeat expansions in chromosome 9 open reading frame 72 (C9ORF72), the most common genetic cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia, are highly variable. To gain insight on the molecular basis for the heterogeneity among C9ORF72 mutation carriers, we evaluated associations between features of disease and levels of two abundantly expressed “c9RAN proteins” produced by repeat-associated non-ATG (RAN) translation of the expanded repeat. For these studies, we took a departure from traditional immunohistochemical approaches and instead employed immunoassays to quantitatively measure poly(GP) and poly(GA) levels in cerebellum, frontal cortex, motor cortex, and/or hippocampus from 55 C9ORF72 mutation carriers [12 patients with ALS, 24 with frontotemporal lobar degeneration (FTLD) and 19 with FTLD with motor neuron disease (FTLD-MND)]. We additionally investigated associations between levels of poly(GP) or poly(GA) and cognitive impairment in 15 C9ORF72 ALS patients for whom neuropsychological data were available. Among the neuroanatomical regions investigated, poly(GP) levels were highest in the cerebellum. In this same region, associations between poly(GP) and both neuropathological and clinical features were detected. Specifically, cerebellar poly(GP) levels were significantly lower in patients with ALS compared to patients with FTLD or FTLD-MND. Furthermore, cerebellar poly(GP) associated with cognitive score in our cohort of 15 patients. In the cerebellum, poly(GA) levels similarly trended lower in the ALS subgroup compared to FTLD or FTLD-MND subgroups, but no association between cerebellar poly(GA) and cognitive score was detected. Both cerebellar poly(GP) and poly(GA) associated with C9ORF72 variant 3 mRNA expression, but not variant 1 expression, repeat size, disease onset, or survival after onset. Overall, these data indicate that cerebellar abnormalities, as evidenced by poly(GP) accumulation, associate with neuropathological and clinical phenotypes, in particular cognitive impairment, of C9ORF72 mutation carriers.

Neurodegeneration. C9ORF72 repeat expansions in mice cause TDP-43 pathology, neuronal loss, and behavioral deficits

The major genetic cause of frontotemporal dementia and amyotrophic lateral sclerosis is a G4C2 repeat expansion in C9ORF72. Efforts to combat neurodegeneration associated with "c9FTD/ALS" are hindered by a lack of animal models recapitulating disease features. We developed a mouse model to mimic both neuropathological and clinical c9FTD/ALS phenotypes. We expressed (G4C2)66 throughout the murine central nervous system by means of somatic brain transgenesis mediated by adeno-associated virus. Brains of 6-month-old mice contained nuclear RNA foci, inclusions of poly(Gly-Pro), poly(Gly-Ala), and poly(Gly-Arg) dipeptide repeat proteins, as well as TDP-43 pathology. These mouse brains also exhibited cortical neuron and cerebellar Purkinje cell loss, astrogliosis, and decreased weight. (G4C2)66 mice also developed behavioral abnormalities similar to clinical symptoms of c9FTD/ALS patients, including hyperactivity, anxiety, antisocial behavior, and motor deficits.

Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis

Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood. We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995-2009. We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2-5 times higher rates of bankruptcy than cancer patients age sixty-five or older, which indicates that Medicare and Social Security may mitigate bankruptcy risk for the older group. The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.

Phosphorylated neurofilament heavy subunit (pNF-H) in peripheral blood and CSF as a potential prognostic biomarker in amyotrophic lateral sclerosis

BACKGROUND

The phosphorylated neurofilament heavy subunit (pNF-H), a major structural component of motor axons, is a promising putative biomarker in amyotrophic lateral sclerosis (ALS) but has been studied mainly in CSF. We examined pNF-H concentrations in plasma, serum and CSF as a potential biomarker for disease progression and survival in ALS.

METHODOLOGY

We measured pNF-H concentration by monoclonal sandwich ELISA in plasma (n=43), serum and CSF (n=20) in ALS patients collected at the Mayo Clinic Florida and Emory University. We included plasma from an ALS cohort (n=20) from an earlier pilot study in order to evaluate baseline pNF-H levels in relation to disease progression using the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R), survival and anatomical region of ALS onset.

RESULTS

Higher pNF-H levels in plasma, serum and CSF showed evidence of association with faster decline in ALSFRS-R. There was evidence for a relationship of higher serum and plasma pNF-H levels with shorter survival, although evidence was weaker for CSF. pNF-H concentration in plasma (n=62) may be higher in patients with bulbar onset than in patients with spinal onset.

CONCLUSIONS

In ALS, increased pNF-H concentration in plasma, serum and CSF appears to be associated with faster disease progression. Factors affecting pNF-H levels or their detection in serum and plasma in relation to disease course may differ from those in CSF. Data raising the possibility that site of ALS onset (bulbar vs spinal) may influence pNF-H levels in peripheral blood seems noteworthy but requires confirmation. These data support further study of pNF-H in CSF, serum and plasma as a potential ALS biomarker.

Immunoreactivity of the phosphorylated axonal neurofilament H subunit (pNF-H) in blood of ALS model rodents and ALS patients: evaluation of blood pNF-H as a potential ALS biomarker

Levels of neurofilament subunits, potential biomarkers of motor axon breakdown, are increased in amyotrophic lateral sclerosis (ALS) patient's CSF but data on blood are not available. We measured blood levels of the phosphorylated axonal form of neurofilament H (pNF-H) by ELISA in transgenic rodent models of superoxide dismutase 1 (SOD1) ALS, and in 20 ALS patients and 20 similar aged controls monthly for 4 months. All symptomatic rodent ALS models showed robust levels of blood pNF-H, while control rodents or mice transgenic for unmutated SOD1 showed no detectable blood pNF-H. Average pNF-H levels in the G93A SOD1 mouse progressively increased from day 74 through death (day approximately 130). Median blood pNF-H level in ALS patients was 2.8-fold higher than controls (p < 0.001). Median ALSFRS-R declined a median of 0.8 pt/month (p < 0.001); higher baseline pNF-H level appeared to be associated with faster ALSFRS-R decline over 4 months (p = 0.087). The median rate of decline in ALSFRS-R was 1.9 pt/month in patients with baseline pNF-H levels above the median pNF-H value of 0.53 ng/mL; ALSFRS-R declined at a median of 0.6 pt/month in patients below this level. The pNF-H levels were relatively stable month to month in individual patients, raising questions regarding the molecular pathogenesis of ALS. Baseline control human pNF-H levels were higher in men than women and increased minimally over time. These data suggest that blood pNF-H can be used to monitor axonal degeneration in ALS model rodents and support further study of this protein as a potential biomarker of disease prognosis in ALS patients.

Multiple scattering and the density distribution of a Cs MOT

Multiple scattering is studied in a Cs magneto-optical trap (MOT). We use two Abel inversion algorithms to recover density distributions of the MOT from fluorescence images. Deviations of the density distribution from a Gaussian are attributed to multiple scattering.

Urothelial and prostate carcinoma metastasizing to the same lymph node: a case report and review of the literature

We report herein a case of a collision tumor composed of high-grade urothelial carcinoma and a Gleason grade 3+4 prostate adenocarcinoma metastasizing to the same lymph node. After the patient underwent cystoprostatectomy for known urothelial carcinoma, he was incidentally discovered to have a second primary prostate tumor. Lymph node examination revealed that one node appeared to have metastatic foci from both primary tumors. The presence of 2 tumor types colliding in the same lymph node was confirmed using immunohistochemical stains, including monoclonal carcinoembryonic antigen, prostate-specific antigen, prostatic acid phosphatase, cytokeratins 7 and 20, and CD57. We also stained both primary tumors with the same panel as an internal control. Although 2 similar collision tumors have been reported in the literature in the past, neither used a battery of immunohistochemical stains to definitively distinguish one tumor from the other. Herein, we review the literature on urothelial and prostate collision tumors and some of the special stains used to distinguish them.