Incidentally Detected Lung Cancer in Persons Too Young or Too Old for Lung Cancer Screening in a Mississippi Delta Cohort

INTRODUCTION

Lung cancer risk in screening age-ineligible persons with incidentally detected lung nodules is poorly characterized. We evaluated lung cancer risk in two age-ineligible Lung Nodule Program (LNP) cohorts.

METHODS

Prospective observational study comparing 2-year cumulative lung cancer diagnosis risk, lung cancer characteristics, and overall survival between low-dose computed tomography (LDCT) screening participants aged 50 to 80 years and LNP participants aged 35 to younger than 50 years (young) and older than 80 years (elderly).

RESULTS

From 2015 to 2022, lung cancer was diagnosed in 329 (3.43%), 39 (1.07%), and 172 (6.87%) LDCT, young, and elderly LNP patients, respectively. The 2-year cumulative incidence was 3.0% (95% confidence intervals [CI]: 2.6%-3.4%) versus 0.79% (CI: 0.54%-1.1%) versus 6.5% (CI: 5.5%-7.6%), respectively, but lung cancer diagnosis risk was similar between young LNP and Lung CT Screening Reporting and Data System (Lung-RADS) 1 (adjusted hazard ratio [aHR] = 0.88 [CI: 0.50-1.56]) and Lung-RADS 2 (aHR = 1.0 [0.58-1.72]). Elderly LNP risk was greater than Lung-RADS 3 (aHR = 2.34 [CI: 1.50-3.65]), but less than 4 (aHR = 0.28 [CI: 0.22-0.35]). Lung cancer was stage I or II in 62.92% of LDCT versus 33.33% of young (p = 0.0003) and 48.26% of elderly (p = 0.0004) LNP cohorts; 16.72%, 41.03%, and 29.65%, respectively, were diagnosed at stage IV. The aggregate 5-year overall survival rates were 57% (CI: 48-67), 55% (CI: 39-79), and 24% (CI: 15-40) (log-rank p < 0.0001). Results were similar after excluding persons with any history of cancer.

CONCLUSIONS

LNP modestly benefited persons too young or old for screening. Differences in clinical characteristics and outcomes suggest differences in biological characteristics of lung cancer in these three patient cohorts.

Disparities in electronic health record portal access and use among patients with cancer

BACKGROUND

Electronic health record-linked portals may improve health-care quality for patients with cancer. Barriers to portal access and use undermine interventions that rely on portals to reduce cancer care disparities. This study examined portal access and persistence of portal use and associations with patient and structural factors before the implementation of 3 portal-based interventions within the Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium.

METHODS

Portal use data were extracted from electronic health records for the 12 months preceding intervention implementation. Sociodemographic factors, mode of accessing portals (web vs mobile), and number of clinical encounters before intervention implementation were also extracted. Rurality was derived using rural-urban commuting area codes. Broadband access was estimated using the 2015-2019 American Community Survey. Multiple logistic regression models tested the associations of these factors with portal access (ever accessed or never accessed) and persistence of portal use (accessed the portal ≤20 weeks vs ≥21 weeks in the 35-week study period).

RESULTS

Of 28 942 eligible patients, 10 061 (35%) never accessed the portal. Male sex, membership in a racial and ethnic minority group, rural dwelling, not working, and limited broadband access were associated with lower odds of portal access. Younger age and more clinical encounters were associated with higher odds of portal access. Of those with portal access, 25% were persistent users. Using multiple modalities for portal access, being middle-aged, and having more clinical encounters were associated with persistent portal use.

CONCLUSION

Patient and structural factors affect portal access and use and may exacerbate disparities in electronic health record-based cancer symptom surveillance and management.

Effects of a change in recall period on reporting severe symptoms: an analysis of a pragmatic multisite trial

BACKGROUND

Optimal methods for deploying electronic patient-reported outcomes (ePROs) to manage symptoms in routine oncologic practice remain uncertain. The eSyM symptom management program asks chemotherapy and surgery patients to self-report 12 symptoms regularly. Feedback from nurses and patients led to changing the recall period from the past 7 days to the past 24 hours.

METHODS

Using questionnaires submitted during the 16-weeks surrounding the recall period change, we assessed the likelihood of reporting a severe, or a moderate-severe, symptom across all 12 symptoms and separately for the 5 most prevalent symptoms. Interrupted time series analyses modeled the effects of the change using generalized linear mixed-effects models. Surgery and chemotherapy cohorts were analyzed separately. Study-wide effects were estimated using a meta-analysis method.

RESULTS

In total, 1,692 patients from 6 institutions submitted 7,823 eSyM assessments during the 16-weeks surrounding the recall period change. Shortening the recall period was associated with lower odds of severe symptom reporting in the surgery cohort (OR 0.65; 95% CI 0.46 to 0.93; p = .02) and lower odds of moderate-severe symptom reporting in the chemotherapy cohort (OR 0.83, 95% CI 0.71 to 0.97; p = .02). Among the most prevalent symptoms, 24-hour recall was associated with lower rate of reporting post-operative constipation, but no differences in reporting rates for other symptoms.

CONCLUSION

A shorter recall period was associated with a reduction in the proportion of patients reporting moderate-severe symptoms. The optimal recall period may vary depending on whether ePROs are collected for active symptom management, as a clinical trial endpoint, or another purpose. (Clinicaltrails.gov (NCT03850912).

Two Interventions on Pathologic Nodal Staging in a Population-Based Lung Cancer Resection Cohort

BACKGROUND

Despite its prognostic importance, poor pathologic nodal staging of lung cancer prevails. We evaluated the impact of 2 interventions to improve pathologic nodal staging.

METHODS

We implemented a lymph node specimen collection kit to improve intraoperative lymph node collection (surgical intervention) and a novel gross dissection method for intrapulmonary node retrieval (pathology intervention) in nonrandomized stepped-wedge fashion, involving 12 hospitals and 7 pathology groups. We used standard statistical methods to compare surgical quality and survival of patients who had neither intervention (group 1), pathology intervention only (group 2), surgical intervention only (group 3), and both interventions (group 4).

RESULTS

Of 4019 patients from 2009 to 2021, 50%, 5%, 21%, and 24%, respectively, were in groups 1 to 4. Rates of nonexamination of lymph nodes were 11%, 9%, 0%, and 0% and rates of nonexamination of mediastinal lymph nodes were 29%, 35%, 2%, and 2%, respectively, in groups 1 to 4 (P < .0001). Rates of attainment of American College of Surgeons Operative Standard 5.8 were 22%, 29%, 72%, and 85%; and rates of International Association for the Study of Lung Cancer complete resection were 14%, 21%, 53%, and 61% (P < .0001). Compared with group 1, adjusted hazard ratios for death were as follows: group 2, 0.93 (95% CI, 0.76-1.15); group 3, 0.91 (0.78-1.03); and group 4, 0.75 (0.64-0.87). Compared with group 2, group 4 adjusted hazard ratio was 0.72 (0.57-0.91); compared with group 3, it was 0.83 (0.69-0.99). These relationships remained after exclusion of wedge resections.

CONCLUSIONS

Combining a lymph node collection kit with a novel gross dissection method significantly improved pathologic nodal evaluation and survival.

Program-Based Lung Cancer Care: A Prospective Observational Tumor Registry Linkage Study

Introduction

Low-dose computed tomography screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordant care. The impact of such program-based care on "real-world" lung cancer survival is unquantified. We evaluated outcomes of lung cancer care delivered through structured programs in a community health care system.

Methods

We conducted a cohort study linking institutional prospective observational LDCT, LNP and MDC databases with Tumor Registry of Baptist Cancer Center facilities. We categorized all patients diagnosed with lung cancer between 2011 and 2021 into program-based care versus non-program-based care cohorts. We compared patient characteristics, stage distribution, treatment modalities, survival and mortality in each pathway of care.

Results

Of 12,148 patients, 237, 1,165, 1,140 and 9,606 were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96.3% to 66.5%, diagnosis through LDCT increased from 0.5% to 7.1%, LNP from 3.5% to 20.8%; and MDC alone decreased from a high of 12.8% in 2014 to 5.6% in 2021. Program-based care was associated with earlier stage (p < 0.001), higher surgical resection rates (p < 0.001), greater use of adjuvant therapy (p < 0.001), better aggregate and stage-stratified survival (p < 0.001), and lower all-cause and lung cancer-specific mortality (p < 0.001). Recipients of non-program-based care were considerably less likely to receive lung cancer treatment; results remained consistent when patients receiving no treatment were excluded.

Conclusions

Program-based care was associated with substantially better survival. Increasing access to program-based care should be explored as a matter of urgent public policy.

Strategies for Implementing an Electronic Patient-Reported Outcomes-Based Symptom Management Program Across Six Cancer Centers

Background

Electronic patient-reported outcome (ePRO)-based symptom management improves cancer patients' outcomes. However, implementation of ePROs is challenging, requiring technical resources for integration into clinical systems, substantial buy-in from clinicians and patients, novel workflows to support between-visit symptom management, and institutional investment.

Methods

The SIMPRO Research Consortium developed eSyM, an electronic health record-integrated, ePRO-based symptom management program for medical oncology and surgery patients and deployed it at six cancer centers between August 2019 and April 2022 in a type II hybrid effectiveness-implementation cluster randomized stepped-wedge study. Sites documented implementation strategies monthly using REDCap, itemized them using the Expert Recommendations for Implementation Change (ERIC) list and mapped their target barriers using the Consolidated Framework for Implementation Research (CFIR) to inform eSyM program enhancement, facilitate inter-consortium knowledge sharing and guide future deployment efforts.

Results

We documented 226 implementation strategies: 35 'foundational' strategies were applied consortium-wide by the coordinating center and 191 other strategies were developed by individual sites. We consolidated these 191 site-developed strategies into 64 unique strategies (i.e., removed duplicates) and classified the remainder as either 'universal', consistently used by multiple sites (N=29), or 'adaptive', used only by individual sites (N=35). Universal strategies were perceived as having the highest impact; they addressed eSyM clinical preparation, training, engagement of patients/clinicians, and program evaluation. Across all documented SIMPRO strategies, 44 of the 73 ERIC strategies were addressed and all 5 CFIR barriers were addressed.

Conclusion

Methodical collection of theory-based implementation strategies fostered the identification of universal, high-impact strategies that facilitated adoption of a novel care-delivery intervention by patients, clinicians, and institutions. Attention to the high-impact strategies identified in this project could support implementation of ePROs as a component of routine cancer care at other institutions.

Current and Future Perspectives on Computed Tomography Screening for Lung Cancer: A Roadmap From 2023 to 2027 From the International Association for the Study of Lung Cancer

Low-dose computed tomography (LDCT) screening for lung cancer substantially reduces mortality from lung cancer, as revealed in randomized controlled trials and meta-analyses. This review is based on the ninth CT screening symposium of the International Association for the Study of Lung Cancer, which focuses on the major themes pertinent to the successful global implementation of LDCT screening and develops a strategy to further the implementation of lung cancer screening globally. These recommendations provide a 5-year roadmap to advance the implementation of LDCT screening globally, including the following: (1) establish universal screening program quality indicators; (2) establish evidence-based criteria to identify individuals who have never smoked but are at high-risk of developing lung cancer; (3) develop recommendations for incidentally detected lung nodule tracking and management protocols to complement programmatic lung cancer screening; (4) Integrate artificial intelligence and biomarkers to increase the prediction of malignancy in suspicious CT screen-detected lesions; and (5) standardize high-quality performance artificial intelligence protocols that lead to substantial reductions in costs, resource utilization and radiologist reporting time; (6) personalize CT screening intervals on the basis of an individual's lung cancer risk; (7) develop evidence to support clinical management and cost-effectiveness of other identified abnormalities on a lung cancer screening CT; (8) develop publicly accessible, easy-to-use geospatial tools to plan and monitor equitable access to screening services; and (9) establish a global shared education resource for lung cancer screening CT to ensure high-quality reading and reporting.

Assessing Patient Readiness for an Electronic Patient-Reported Outcome-Based Symptom Management Intervention in a Multisite Study

PURPOSE

While the use of electronic patient-reported outcomes (ePROs) in routine clinical practice is increasing, barriers to patient engagement limit adoption. Studies have focused on technology access as a key barrier, yet other characteristics may also confound readiness to use ePROs including patients' confidence in using technology and confidence in asking clinicians questions.

METHODS

To assess readiness to use ePROs, adult patients from six US-based health systems who started a new oncology treatment or underwent a cancer-directed surgery were invited to complete a survey that assessed access to and confidence in the use of technology, ease of asking clinicians questions about health, and symptom management self-efficacy. Multivariable ordinal logistic regression models were fit to assess the association between technology confidence, ease of asking questions, and symptom management self-efficacy.

RESULTS

We contacted 3,212 individuals, and 1,043 (33%) responded. The median age was 63 years, 68% were female, and 75% reported having access to patient portals. Over 80% had two or more electronic devices. Most patients reported high technology confidence, higher ease of asking clinicians questions, and high symptom management self-efficacy (n = 692; 66%). Patients with high technology confidence also reported higher ease of asking nurses about their health (adjusted odds ratio [AOR], 4.58 [95% CI, 2.36 to 8.87]; P ≤ .001). Those who reported higher ease of asking nurses questions were more likely to report higher confidence in managing symptoms (AOR, 30.54 [95% CI, 12.91 to 72.30]; P ≤ .001).

CONCLUSION

Patient readiness to use ePROs likely depends on multiple factors, including technology and communication confidence, and symptom management self-efficacy. Future studies should assess interventions to address these factors.

The Longitudinal Implementation Strategy Tracking System (LISTS): feasibility, usability, and pilot testing of a novel method

BACKGROUND

Systematic approaches are needed to accurately characterize the dynamic use of implementation strategies and how they change over time. We describe the development and preliminary evaluation of the Longitudinal Implementation Strategy Tracking System (LISTS), a novel methodology to document and characterize implementation strategies use over time.

METHODS

The development and initial evaluation of the LISTS method was conducted within the Improving the Management of SymPtoms during And following Cancer Treatment (IMPACT) Research Consortium (supported by funding provided through the NCI Cancer MoonshotSM). The IMPACT Consortium includes a coordinating center and three hybrid effectiveness-implementation studies testing routine symptom surveillance and integration of symptom management interventions in ambulatory oncology care settings. LISTS was created to increase the precision and reliability of dynamic changes in implementation strategy use over time. It includes three components: (1) a strategy assessment, (2) a data capture platform, and (3) a User's Guide. An iterative process between implementation researchers and practitioners was used to develop, pilot test, and refine the LISTS method prior to evaluating its use in three stepped-wedge trials within the IMPACT Consortium. The LISTS method was used with research and practice teams for approximately 12 months and subsequently we evaluated its feasibility, acceptability, and usability using established instruments and novel questions developed specifically for this study.

RESULTS

Initial evaluation of LISTS indicates that it is a feasible and acceptable method, with content validity, for characterizing and tracking the use of implementation strategies over time. Users of LISTS highlighted several opportunities for improving the method for use in future and more diverse implementation studies.

CONCLUSIONS

The LISTS method was developed collaboratively between researchers and practitioners to fill a research gap in systematically tracking implementation strategy use and modifications in research studies and other implementation efforts. Preliminary feedback from LISTS users indicate it is feasible and usable. Potential future developments include additional features, fewer data elements, and interoperability with alternative data entry platforms. LISTS offers a systematic method that encourages the use of common data elements to support data analysis across sites and synthesis across studies. Future research is needed to further adapt, refine, and evaluate the LISTS method in studies with employ diverse study designs and address varying delivery settings, health conditions, and intervention types.

Lung Cancer Patients' and Caregivers' Satisfaction With Multidisciplinary Versus Serial Care in a Community Healthcare Setting: A Prospective Comparative-Effectiveness Cohort Study

BACKGROUND

Multidisciplinary Care is recommended for complex oncologic conditions. We compared lung cancer patients' and caregivers' satisfaction with Multidisciplinary Care to routine, serial care.

MATERIALS AND METHODS

We analyzed validated surveys administered at baseline, 3 and 6 months to patients and their caregivers enrolled in a prospective cohort comparative-effectiveness study of Multidisciplinary versus Serial Care (clinicaltrials.gov NCT02123797). Multivariate mixed linear models examined the cross-group differences, time-related variances, and how interaction between groups and time-periods influenced satisfaction.

RESULTS

Compared to serial care (N = 297), the Multidisciplinary Care cohort (N = 159), was older (69 vs. 66 years), had earlier clinical stage (41% vs. 33% stage I/II), and less severe symptoms (45% vs. 35% asymptomatic). Demographic and social-economic characteristics of caregivers (N = 99 for Multidisciplinary and 123 for Serial Care, respectively) were similar. Multidisciplinary Care patients and caregivers were more likely to perceive their care to be better than that of other patients (p < .01). Although Serial Care patients and caregivers expressed greater satisfaction with their treatment plan (p < .01 patients, p = 0.04 caregivers), Multidisciplinary Care patients showed greater improvement at 6-months (p < .01). Multidisciplinary Care patients and caregivers reported better overall satisfaction with team members (p < .01) while Serial Care patients had greater improvement in their satisfaction with team members at 6-months (p = .04). Multidisciplinary Care patients perceived more financial burden at 6-months compared to Serial Care patients (p = .04).

CONCLUSION

Patient-caregiver dyads had mixed perceptions of their care experience. Recipients of Multidisciplinary Care perceived better experience with care and team members; Serial Care recipients expressed greater satisfaction with their treatment plan.

Systematic symptom management in the IMPACT Consortium: rationale and design for 3 effectiveness-implementation trials

Cancer and its treatment produce deleterious symptoms across the phases of care. Poorly controlled symptoms negatively affect quality of life and result in increased health-care needs and hospitalization. The Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium was created to develop 3 large-scale, systematic symptom management systems, deployed through electronic health record platforms, and to test them in pragmatic, randomized, hybrid effectiveness and implementation trials. Here, we describe the IMPACT Consortium's conceptual framework, its organizational components, and plans for evaluation. The study designs and lessons learned are highlighted in the context of disruptions related to the COVID-19 pandemic.

The International Association for the Study of Lung Cancer Staging Project for Lung Cancer: Proposals for the Revision of the N Descriptors in the Forthcoming Ninth Edition of the TNM Classification for Lung Cancer

INTRODUCTION

The accurate assessment of nodal (N) status is crucial to the management and prognostication of nonmetastatic NSCLC. We sought to determine whether the current N descriptors should be maintained or revised for the upcoming ninth edition of the international TNM lung cancer staging system.

METHODS

Data were assembled by the International Association for the Study of Lung Cancer on patients with NSCLC, detailing both clinical and pathologic N status, with information about anatomical location and individual station-level identification. Survival was calculated by the Kaplan-Meier method and prognostic groups were assessed by a Cox regression analysis.

RESULTS

Data for clinical N and pathologic N status were available in 45,032 and 35,009 patients, respectively. The current N0 to N3 descriptors for both clinical N and pathologic N categories reflect prognostically distinct groups. Furthermore, single-station N2 involvement (N2a) exhibited a better prognosis than multistation N2 involvement (N2b) in both clinical and pathologic classifications, and the differences between all neighboring nodal subcategories were highly significant. The prognostic differences between N2a and N2b were robust and consistent across resection status, histologic type, T category, and geographic region.

CONCLUSIONS

The current N descriptors should be maintained, with the addition of new subdescriptors to N2 for single-station involvement (N2a) and multiple-station involvement (N2b).

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer

PURPOSE

The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care.

PATIENTS AND METHODS

Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes.

RESULTS

From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively.

CONCLUSION

Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Institution-Level Evolution of Lung Cancer Resection Quality With Implementation of a Lymph Node Specimen Collection Kit

INTRODUCTION

Lung cancer surgery with a lymph node kit improves patient-level outcomes, but institution-level impact is unproven.

METHODS

Using an institutional stepped-wedge implementation study design, we compared lung cancer resection quality between institutions in preimplementation and postimplementation phases of kit deployment and, within implementing institutions, resections without versus with the kit. Benchmarks included rates of nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and attainment of American College of Surgeons Operative Standard 5.8. We report institution-level adjusted ORs (aORs) for attaining quality benchmarks.

RESULTS

From 2009 to 2020, three preimplementing hospitals had 953 resections; 11 implementing hospitals had 4013 resections, 58% without and 42% with the kit. Quality was better in implementing institutions and with kit cases. Compared with preimplementing institutions, the aOR for nonexamination of lymph nodes was 0.62 (0.49-0.8, p = 0.002), nonexamination of mediastinal lymph nodes was 0.56 (0.47-0.68, p < 0.0001), and attainment of Operative Standard 5.8 was 7.3 (5.6-9.4, p < 0.0001); aORs for kit cases were 0.01 (0.001-0.06), 0.08 (0.06-0.11), and 11.6 (9.9-13.7), respectively (p < 0.0001 for all). Surgical quality was persistently poor in preimplementing institutions but sequentially improved in implementing institutions in parallel with kit adoption. In implementing institutions, resections with the kit had a uniformly high level of quality, whereas nonkit cases had a low level of quality, approximating that of preimplementing institutions. Within implementing institutions, 5-year overall survival was 61% versus 51% after surgery with versus without the kit (p < 0.001).

CONCLUSIONS

Surgery with a lymph node specimen collection kit improved institution-level quality of curative-intent lung cancer resection.

Abstract 3216: Comparative characteristics of stage I non-small cell lung cancer (NSCLC) patients segregated by quality of surgery and survival in a population-based cohort

Introduction. Poor quality NSCLC resection impairs survival, but some patients survive irrespective. We explored characteristics of patients in 4 cohorts defined by surgery quality and survival.

Methods. We analyzed stage I resections in a population-based cohort surviving &gt;120 days post-op from 2009-2018. Using the International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’ and 3-year survival as ‘good’, we categorized patients into 4 dyads: 1) Good surgery/good survival; 2) Good surgery/poor survival; 3) Poor surgery/good survival (reference); 4) Poor surgery/poor survival. We used Chi-square and Kruskal-Wallis test for description, multivariable multinomial logistic regression to estimate Odds Ratio (OR) of surgery quality and survival.

Results. Of 1,515 patients, 31%, 7%, 51%, and 12% were in Groups 1-4, respectively. In the ‘mis-match dyads’ (Groups 2 and 3), Group 2 was more likely to be elderly (70 vs. 66, p&lt;0.01), on Medicaid (p=0.01), have ever smoked (96% vs. 85%, p&lt;0.01), have squamous cell carcinoma.

Older (OR=1.06), male (OR=1.78), Medicaid patients (OR=2.16) with smoking history (OR=3.25) had poorer survival despite good surgery rather than survival despite bad surgery. With poor surgery, male (OR=2.01) patients tumor 2-3 and &gt;3 cm (OR=1.77 and 1.64) had poorer survival; commercially insured patients had 36% reduced risk of poor survival. Compared to open thoracotomy, patients with robotic-assisted surgery were &gt;4-fold more likely to have good surgery rather than poor surgery but good survival.

Conclusion. Differentiating characteristics associated with good/bad survival after good/bad quality lung cancer surgery provide opportunity to compare biomarker profiles between dyads.

Citation Format: Huibo Shao, Yu-Sheng Lee, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha T. Matthews, Nicholas R. Faris, Matthew Smeltzer, Meredith A. Ray, Raymond U. Osarogiagbon. Comparative characteristics of stage I non-small cell lung cancer (NSCLC) patients segregated by quality of surgery and survival in a population-based cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3216.

Abstract 4372: Hierarchy of prognostic quality markers after curative-intent resection of stage IA non-small cell lung cancer

Introduction. 5-year disease-free survival after curative-intent resection of stage IA NSCLC approximates 65%. The quality of resection and differences in cancer biology probably account for most curative-intent treatment failure. We evaluated the hazard associated with markers of surgical quality.

Methods. Using the population-based Mid-South Quality of Surgical Resection cohort, we compared outcomes of pathologic IA NSCLC resections from 2009 to 2021. With the stringent International Association for the Study of Lung Cancer complete (R0) resection for reference, we evaluated eight quality benchmarks: wedge resection; resections with positive margins; non-examination of lymph nodes (LN) from anywhere (pNX), mediastinal (pNXmed), intrapulmonary, hilar, low paratracheal and subcarinal stations. We evaluated hazard ratios (HR), adjusted for age, sex, insurance, histology, comorbidity, preoperative staging and technique of resection (95% CI) from Proportional Hazards models.

Results. Of 2,243 resections, 906 (41%) were R0; 1,333 were non-R0, including 3% R1/R2, 13% pNX, 15% wedge resections, 15% pNXmed, 45% without subcarinal, 41% without hilar, 47% without low paratracheal, and 36% without intrapulmonary LNs.Compared to IASLC-R0, adjusted HRs were: 2.04 (1.21-3.44) for R1/R2; 1.75 (1.33-2.31) for pNX; 1.64 (1.26-2.14) for wedge resections; 1.35 (1.12-1.63) for non-examination of intrapulmonary LN; 1.33 (1.03-1.72), pNXmed; 1.25 (1.02-1.53), non-examination of hilar LN; 1.15 (0.95 - 1.39) missing station 4; and 1.11 (0.90-1.37) missing station 7 LNs.

Conclusion. Surgical quality, indicated by markers of LN evaluation, have significant impact on long-term survival and should be required selection criteria or stratification factors in lung cancer surgery trials.

Citation Format: Huibo Shao, Yu-Sheng Lee, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha T. Matthews, Nicholas R. Faris, Meredith A. Ray, Matthew Smeltzer, Raymond U. Osarogiagbon. Hierarchy of prognostic quality markers after curative-intent resection of stage IA non-small cell lung cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4372.

Abstract 4382: Evolution of curative-intent lung cancer surgery in a 4 eras in the population-based mid-south quality of surgical resection (MS-QSR) cohort

Background. Most patients die within 5 years of curative-intent lung cancer surgery

Differences in surgical quality and cancer biology drive long-term overall survival (OS) differences after curative-intent resection. From 2009 onward, we implemented a sequence of interventions to improve surgical quality and pathologic evaluation in a regional population. We evaluated population-level surgical quality and OS in the MS-QSR cohort.

Methods. We categorized the MS-QSR into 4 (approximately) 5-year eras: 1) 2004-08, baseline; 2) 2009-13 (quality feedback and pilot intervention studies); 3) 2014-18 (surgical intervention with a lymph node collection kit); 4) 2019-22 (dual surgical and pathology intervention with novel gross dissection method). We compared surgical quality and OS across eras using standard statistical methods.

Results. Of 6,701 resections, 15%, 33%, 32%, and 20% were in Eras 1-4, respectively. American College of Surgeons Operative Standard 5.8 quality was attained in 4%, 22%, 45%, and 65% of resections in Eras 1-4, respectively; the International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’ was achieved in 0%, 9%, 20%, and 31%, respectively; 120-Day mortality rates were 10%, 9%, 7%, and 4%; 3-year OS rates were 49%, 64%, 71%, and 84%; 5-year OS, 34%, 52%, and 61%, in Eras 1-3 (too early for Era 4); p&lt;0.0001 for all comparisons.

Conclusion. Population-level surgical quality and OS have improved sequentially in parallel with implementation of interventions to surgical and pathology practices. The higher OS threshold in the MS-QSR creates a platform to interrogate the biologic drivers of surgical outcomes differences.

Citation Format: Olawale Akinbobola, Meredith A. Ray, Carrie Fehnel, Andrea Saulsberry, Kourtney Dortch, Anberitha T. Matthews, Nicholas R. Faris, Caroline M. Godfrey, Matthew Smeltzer, Raymond U. Osarogiagbon. Evolution of curative-intent lung cancer surgery in a 4 eras in the population-based mid-south quality of surgical resection (MS-QSR) cohort. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4382.

Abstract 4359: Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study

Introduction. Despite its importance, pathologic nodal (pN) staging of lung cancer remains poor. We evaluated the quality and survival impact of two interventions to improve pN staging.

Methods. Using a non-randomized stepped-wedge design, we implemented use of a lymph node (LN) specimen collection kit to improve intraoperative LN collection (surgical intervention) and a novel gross dissection method for intrapulmonary LN retrieval (pathology intervention) in 12 hospitals in five contiguous Hospital Referral Regions in AR, MS and TN (2009-2021). With appropriate statistical methods we compared surgical quality and survival of patients among: neither (Group 1), pathology only (Group 2), surgical only (Group 3), and both (Group 4) interventions.

Results. Of 4,019 patients, 50%, 5%, 21% and 24%, were in Groups 1-4 respectively. Rates of non-examination of LNs and non-examination of mediastinal LNs: 11%, 9%, 0% and 0%; 29%, 35%, 2% and 2% respectively in Groups 1-4 (p&lt;0.0001). Attainment of American College of Surgeons Operative Standard 5.8: 22%, 29%, 72%, 85%; International Association for the Study of Lung Cancer’s stringent definition of ‘complete resection’: 14%, 21%, 53%, 61% (p&lt;0.0001). Compared to Group 1, adjusted hazard ratios, aHR (95% CI), were: Group 2, 0.93 (0.76-1.15); Group 3, 0.91 (0.78-1.03); Group 4, 0.75 (0.64-0.87). Compared to Group 2, Group 4 aHR- 0.72 (0.57-0.91); compared to Group 3, was 0.83 (0.69-0.99). These relationships remained after excluding wedge resections.

Discussion. Combining a LN collection kit and novel gross dissection method significantly improved pN evaluation and survival in a population-based cohort.

Citation Format: Meredith A. Ray, Carrie Fehnel, Olawale Akinbobola, Andrea Saulsberry, Kourtney Dortch, Anberitha Matthews, Amal Anga, Christopher Giampapa, Elizabeth Sales, Sherry Okun, Edward T. Robbins, Bradley Wolf, Paul Levy, Horace L. Wiggins, Thomas Ng, Vishal Sachdev, Ganpat Valaulikar, Hetal D. Patel, Nicholas R. Faris, Matthew Smeltzer, Raymond U. Osarogiagbon. Interventions to improve pathologic nodal staging of curatively resected lung cancer: A population-based implementation study. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4359.

Acquiring tissue for advanced lung cancer diagnosis and comprehensive biomarker testing: A National Lung Cancer Roundtable best-practice guide

Advances in biomarker-driven therapies for patients with nonsmall cell lung cancer (NSCLC) both provide opportunities to improve the treatment (and thus outcomes) for patients and pose new challenges for equitable care delivery. Over the last decade, the continuing development of new biomarker-driven therapies and evolving indications for their use have intensified the importance of interdisciplinary communication and coordination for patients with or suspected to have lung cancer. Multidisciplinary teams are challenged with completing comprehensive and timely biomarker testing and navigating the constantly evolving evidence base for a complex and time-sensitive disease. This guide provides context for the current state of comprehensive biomarker testing for NSCLC, reviews how biomarker testing integrates within the diagnostic continuum for patients, and illustrates best practices and common pitfalls that influence the success and timeliness of biomarker testing using a series of case scenarios.

Evaluation of Lung Cancer Risk Among Persons Undergoing Screening or Guideline-Concordant Monitoring of Lung Nodules in the Mississippi Delta

IMPORTANCE

Guideline-concordant management of lung nodules promotes early lung cancer diagnosis, but the lung cancer risk profile of persons with incidentally detected lung nodules differs from that of screening-eligible persons.

OBJECTIVE

To compare lung cancer diagnosis hazard between participants receiving low-dose computed tomography screening (LDCT cohort) and those in a lung nodule program (LNP cohort).

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included LDCT vs LNP enrollees from January 1, 2015, to December 31, 2021, who were seen in a community health care system. Participants were prospectively identified, data were abstracted from clinical records, and survival was updated at 6-month intervals. The LDCT cohort was stratified by Lung CT Screening Reporting and Data System as having no potentially malignant lesions (Lung-RADS 1-2 cohort) vs those with potentially malignant lesions (Lung-RADS 3-4 cohort), and the LNP cohort was stratified by smoking history into screening-eligible vs screening-ineligible groups. Participants with prior lung cancer, younger than 50 years or older than 80 years, and lacking a baseline Lung-RADS score (LDCT cohort only) were excluded. Participants were followed up to January 1, 2022.

MAIN OUTCOMES AND MEASURES

Comparative cumulative rates of lung cancer diagnosis and patient, nodule, and lung cancer characteristics between programs, using LDCT as a reference.

RESULTS

There were 6684 participants in the LDCT cohort (mean [SD] age, 65.05 [6.11] years; 3375 men [50.49%]; 5774 [86.39%] in the Lung-RADS 1-2 and 910 [13.61%] in the Lung-RADS 3-4 cohorts) and 12 645 in the LNP cohort (mean [SD] age, 65.42 [8.33] years; 6856 women [54.22%]; 2497 [19.75%] screening eligible and 10 148 [80.25%] screening ineligible). Black participants constituted 1244 (18.61%) of the LDCT cohort, 492 (19.70%) of the screening-eligible LNP cohort, and 2914 (28.72%) of the screening-ineligible LNP cohort (P < .001). The median lesion size was 4 (IQR, 2-6) mm for the LDCT cohort (3 [IQR, 2-4] mm for Lung-RADS 1-2 and 9 [IQR, 6-15] mm for Lung-RADS 3-4 cohorts), 9 (IQR, 6-16) mm for the screening-eligible LNP cohort, and 7 (IQR, 5-11) mm for the screening-ineligible LNP cohort. In the LDCT cohort, lung cancer was diagnosed in 80 participants (1.44%) in the Lung-RADS 1-2 cohort and 162 (17.80%) in the Lung-RADS 3-4 cohort; in the LNP cohort, it was diagnosed in 531 (21.27%) in the screening-eligible cohort and 447 (4.40%) in the screening-ineligible cohort. Compared with Lung-RADS 1-2, the fully adjusted hazard ratios (aHRs) were 16.2 (95% CI, 12.7-20.6) for the screening-eligible cohort and 3.8 (95% CI, 3.0-5.0) for the screening-ineligible cohort; compared with Lung-RADS 3-4, the aHRs were 1.2 (95% CI, 1.0-1.5) and 0.3 (95% CI, 0.2-0.4), respectively. The stage of lung cancer was I to II in 156 of 242 patients (64.46%) in the LDCT cohort, 276 of 531 (52.00%) in the screening-eligible LNP cohort, and 253 of 447 (56.60%) in the screening-ineligible LNP cohort.

CONCLUSIONS AND RELEVANCE

In this cohort study, the cumulative lung cancer diagnosis hazard of screening-age persons enrolled in the LNP was higher than that in a screening cohort, irrespective of smoking history. The LNP provided access to early detection for a higher proportion of Black persons.

A biopsychosocial model to understand racial disparities in the era of cancer immunotherapy

The approval and wide uptake of immune checkpoint inhibitors (ICIs) in oncology practice raise the concerns of possibly worsened racial disparities in cancer treatment due to biological and psychosocial reasons. We propose a multilevel biopsychosocial model to understand the opportunities and challenges to racial disparities in the era of cancer immunotherapy.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System

PURPOSE

Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic.

METHODS

We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age.

RESULTS

A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms.

CONCLUSION

The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Expanding the Reach and Grasp of Lung Cancer Screening

Low-dose computer tomographic (LDCT) lung cancer screening reduces lung cancer-specific and all-cause mortality among high-risk individuals, but implementation has been challenging. Despite health insurance coverage for lung cancer screening in the United States since 2015, fewer than 10% of eligible persons have participated; striking geographic, racial, and socioeconomic disparities were already evident, especially in the populations at greatest risk of lung cancer and, therefore, most likely to benefit from screening; and adherence to subsequent testing is significantly lower than that reported in clinical trials, potentially reducing the realized benefit. Lung cancer screening is a covered health care benefit in very few countries. Obtaining the full population-level benefit of lung cancer screening will require improved participation of already eligible persons (the grasp of screening) and improved eligibility criteria that more closely match up with the full spectrum of persons at risk (the reach of screening), irrespective of smoking history. We used the socioecological framework of health care to systematically review implementation barriers to lung cancer screening and discuss multilevel solutions. We also discussed guideline-concordant management of incidentally detected lung nodules as a complementary approach to early lung cancer detection that can extend the reach and strengthen the grasp of screening. Furthermore, we discussed ongoing efforts in Asia to explore the possibility of LDCT screening in populations in whom lung cancer risk is relatively independent of smoking. Finally, we summarized innovative technological solutions, including biomarker selection and artificial intelligence strategies, to improve the safety, effectiveness, and cost-effectiveness of lung cancer screening in diverse populations.

Severe symptom reporting in medical oncology patients at community cancer centers assessed through eSyM

242

Background: Among cancer patients (pts) treated with chemotherapy, electronic patient reported outcome (ePRO)-based symptom management programs at quaternary cancer care institutions have improved outcomes. Uptake of ePRO programs in the real-world setting, where less is known about severe symptom reporting, is often complicated by perceptions of increased workload and erroneous severe symptom reporting. The SIMPRO study group, which includes 6 diverse health systems, are implementing an integrated electronic symptom management (eSyM) program to address these challenges. Methods: SIMPRO sites deployed the Epic-embedded eSyM program for thoracic (THOR), gastrointestinal (GI), and gynecologic (GYN) medical oncology (MO) pts, who received PRO-CTCAE-based questionnaires via the patient portal twice weekly for 6 months after starting a new chemotherapy regimen. Symptoms were scored 0 (none), 1 (mild), 2 (moderate), and 3 (severe) and automatically transmitted to care teams within Epic. The distribution and predictors of severe symptom reporting were assessed using descriptive statistics and logistic regression modeling. Results: From September 2019 – March 2022, 47% of eligible pts (2679/5716) submitted 27,062 questionnaires (median age of 67 years, 55% female, 78% white, 53% married, and 49% retired). 17% of eSyM questionnaires included at least 1 severe symptom (15% for GI, 14% for GYN, and 18% for THOR). Table displays the frequencies of all symptoms reported with fatigue, general pain, and constipation being most common. Among respondents, older, black, and employed pts reported significantly fewer severe symptoms (p < 0.03); cancer type was not associated with a greater likelihood of severe symptom reporting. Conclusions: Only approximately 1 of every 6 eSyM responses included a severe symptom, suggesting that routine monitoring in the real-world could help identify patients experiencing bothersome symptoms with minimal disruption to clinical workload. The mix of symptoms commonly reported as severe are challenging to treat with medications alone, arguing that symptom management strategies should provide multidisciplinary supportive care. Interventions that aide both patients and care teams and are embedded within eSyM or Epic could help address these symptoms without overburdening care teams. Clinical trial information: NCT03850912. [Table: see text]

Evaluating the use of web versus mobile devices for ePRO reporting and severe symptom responses at 6 cancer centers

241

Background: Monitoring electronic patient-reported outcomes (ePROs) improves quality of life, reduces acute care, and extends survival in cancer patients. Different modalities for collecting ePROs exist. Many efforts focus on mobile apps, but optimal methods for reporting are not well established. We sought to determine whether patient engagement and symptom reporting patterns differed by submission modality. Methods: Through the SIMPRO Consortium, ePRO questionnaires (eSyM) were collected from medical oncology (MO) and surgical (SUR) patients at six health systems between September 2019-March 2022. Questionnaires assessing 12 symptoms plus functional status and overall wellbeing were sent 2-3 times per week via patient portal and made accessible through two modalities: a web platform or mobile device app (mobile). Patterns and predictors of reporting modality were ascertained using descriptive statistics and logistic regression. Results: In total, 6460 patients submitted 47,736 questionnaires: 74% via web and 26% via mobile. Of 2679 MO responders, 53% reported via web, 0.7% via mobile only, and 43% via both. Older, black, and unemployed MO patients were more likely to report via web only. Of 3781 SUR responders, 55% reported via web, 0.3% via mobile only, and 45% via both. Older and unemployed SUR patients were more likely to report via web only; disabled SUR patients were less likely to use web only. Patients utilizing both modalities reported significantly more moderate-severe symptoms than web only responders [Table]. Conclusions: Very few patients reported via mobile only, which was unexpected in the context of trends toward mobile-based patient engagement. Moderate-severe symptoms were reported more frequently by dual-modality responders. Patients with access to both modalities may be more likely to report symptoms in real-time compared to web-users who may delay reporting until they have access to a device. The resulting difference between web and mobile reporting modalities could be due to age, race, and employment; future studies should assess other factors, such as locality and cellular coverage. This work emphasizes the importance of deploying ePROs via multiple modalities to maximize accessibility and response rates. Clinical trial information: NCT03850912. [Table: see text]

Severe symptom reporting in surgical patients assessed through an EHR-integrated ePRO questionnaire at 6 cancer centers

243

Background: Patients (pts) undergoing surgery for suspected malignancy may experience burdensome post-operative symptoms which can compromise outcomes and necessitate acute care. In prior randomized controlled trials at academic medical centers, patient-reported outcome (PRO)-based symptom management solutions improved clinical outcomes. Attempts to generalize this approach to real-world surgical pts have been challenged by perceptions that severe symptoms rarely occur, responding to severe symptoms can be burdensome, and uncertainty about which symptoms are likely to be severe and need interventions. Methods: Six US-based healthcare systems deployed eSyM, an EHR-integrated symptom management program. Pts undergoing surgery for suspected or confirmed thoracic (THOR), gastrointestinal (GI), and gynecologic (GYN) malignancies received automated questionnaires via MyChart portal 1-3 times weekly for up to 3 months after discharge. Questionnaires based on the PRO-CTCAE included 10 required and 20 optional symptoms, all scored as 0 (no symptoms), 1 (mild), 2 (moderate), or 3 (severe). Additional questions assessed functional status, overall wellbeing, wound discharge, and wound redness. Frequency and predictors of severe reporting were assessed using descriptive statistics and logistic regression modeling. Results: 21,012 surgical eSyM questionnaires were submitted between October 2019 - March 2022 by 3,781 unique pts (median age 63 years, 66.9% female, 92.1% white, 57.9% married, and 37.5% retired). 17% of questionnaires (16% of GI, 14% of GYN, and 21% of THOR) included at least 1 severe symptom. Frequencies of severe symptom reporting appear in Table with physical function impairment, general pain, and fatigue as the top three. Severe symptoms were more likely to be reported by younger, female, or unemployed pts(p < 0.01). In comparison to GI pts, GYN pts reported fewer and THOR pts reported more severe symptoms (p < 0.03). Conclusions: A meaningful minority of pts reported severe symptoms, suggesting that symptom monitoring could benefit pts without over-taxing clinicians. There were few strong patient-level predictors of severe symptoms, arguing that population surveillance may be preferable to targeted surveillance. Interventions are needed to address common severe symptoms and future studies should define most effective mitigation strategies for these symptoms. Clinical trial information: NCT03850912. [Table: see text]

Rural-Urban Disparities in Cancer Outcomes: Opportunities for Future Research

Cancer care disparities among rural populations are increasingly documented and may be worsening, likely because of the impact of rurality on access to state-of-the-art cancer prevention, diagnosis, and treatment services, as well as higher rates of risk factors such as smoking and obesity. In 2018, the American Society of Clinical Oncology undertook an initiative to understand and address factors contributing to rural cancer care disparities. A key pillar of this initiative was to identify knowledge gaps and promote the research needed to understand the magnitude of difference in outcomes in rural vs nonrural settings, the drivers of those differences, and interventions to address them. The purpose of this review is to describe continued knowledge gaps and areas of priority research to address them. We conducted a comprehensive literature review by searching the PubMed (Medline), Embase, Web of Science, and Cochrane Library databases for studies published in English between 1971 and 2021 and restricted to primary reports from populations in the United States and abstracted data to synthesize current evidence and identify continued gaps in knowledge. Our review identified continuing gaps in the literature regarding the underlying causes of rural-urban disparities in cancer outcomes. Rapid advances in cancer care will worsen existing disparities in outcomes for rural patients without directed effort to understand and address barriers to high-quality care in these areas. Research should be prioritized to address ongoing knowledge gaps about the drivers of rurality-based disparities and preventative and corrective interventions.

Implementation of patient-reported outcomes for symptom management in oncology practice through the SIMPRO research consortium: a protocol for a pragmatic type II hybrid effectiveness-implementation multi-center cluster-randomized stepped wedge trial

Background

Many cancer patients experience high symptom burden. Healthcare in the USA is reactive, not proactive, and doctor-patient communication is often suboptimal. As a result, symptomatic patients may suffer between clinic visits. In research settings, systematic assessment of electronic patient-reported outcomes (ePROs), coupled with clinical responses to severe symptoms, has eased this symptom burden, improved health-related quality of life, reduced acute care needs, and extended survival. Implementing ePRO-based symptom management programs in routine care is challenging. To study methods to overcome the implementation gap and improve symptom control for cancer patients, the National Cancer Institute created the Cancer-Moonshot funded Improving the Management of symPtoms during And following Cancer Treatment (IMPACT) Consortium.

Methods

Symptom Management IMplementation of Patient Reported Outcomes in Oncology (SIMPRO) is one of three research centers that make up the IMPACT Consortium. SIMPRO, a multi-disciplinary team of investigators from six US health systems, seeks to develop, test, and integrate an electronic symptom management program (eSyM) for medical oncology and surgery patients into the Epic electronic health record (EHR) system and associated patient portal. eSyM supports real-time symptom tracking for patients, automated clinician alerts for severe symptoms, and specialized reports to facilitate population management. To rigorously evaluate its impact, eSyM is deployed through a pragmatic stepped wedge cluster-randomized trial. The primary study outcome is the occurrence of an emergency department treat-and-release event within 30 days of starting chemotherapy or being discharged following surgery. Secondary outcomes include hospitalization rates, chemotherapy use (time to initiation and duration of therapy), and patient quality of life and satisfaction. As a type II hybrid effectiveness-implementation study, facilitators and barriers to implementation are assessed throughout the project.

Discussion

Creating and deploying eSyM requires collaboration between dozens of staff across diverse health systems, dedicated engagement of patient advocates, and robust support from Epic. This trial will evaluate eSyM in routine care settings across academic and community-based healthcare systems serving patients in rural and metropolitan locations. This trial’s pragmatic design will promote generalizable results about the uptake, acceptability, and impact of an EHR-integrated, ePRO-based symptom management program.

Trial registration

ClinicalTrials.gov NCT03850912. Registered on February 22, 2019. Last updated on November 9, 2021.

Strategies for implementing an ePRO-based symptom management program (eSyM) across six cancer centers

12017

Background: Electronic patient-reported outcome (ePRO)-based symptom management can improve cancer care outcomes. However, implementation is challenging as it requires 1) tremendous technical resources to integrate ePROs into the electronic health record (EHR), 2) substantial buy-in from clinicians and patients, 3) between visit symptom management, and 4) institutional investment to support engagement. Methods: The SIMPRO Consortium developed and deployed eSyM, an EHR-integrated ePRO-based symptom management program for medical oncology and surgery patients, at 6 cancer centers between September 2019-March 2022. Site teams document new and changes to implementation strategies monthly using REDCap (data collection is ongoing). Strategies are itemized using the Expert Recommendations for Implementation Change (ERIC) list and mapped to the Consolidated Framework for Implementation Research (CFIR) list of barriers. The SIMPRO Coordinating Center (Dana-Farber) reviews all ERIC-CFIR classifications for consistency. Results: To date, 162 distinct strategies have been documented. On average, sites have implemented 23 strategies, 5 preparing for go-live and 18 remaining active beyond go-live. Preparation of clinical staff, training, and routine program evaluation are consistent high impact strategies. Other adaptive strategies have varied across sites, including various approaches to patient and provider engagement. Foundational strategies have been deployed by the coordinating center to support the multi-center initiative. Conclusions: Methodical deployment using theory-based implementation strategies may foster adoption of novel health care delivery systems by patients, clinicians, and institutions. Attention to the specific high-value strategies identified by the SIMPRO Consortium could support similar ePRO deployment at other institutions. [Table: see text]

Lung cancer risk in persons enrolled in low-dose CT screening (LDCT) versus incidental lung nodule programs (ILNP)

8553

Background: LDCT screening saves lives, but <10% of eligible persons participate; eligibility criteria are imperfect; geographic, racial and socio-economic disparities have emerged. ILNP may expand access to early detection. We compared rates of lung cancer diagnosis in LDCT and ILNP population subsets. Methods: Prospective observational cohort study of enrollees in LDCT and ILNP in a community healthcare system in AR, MS and TN. We compared LDCT vs 4 ILNP cohorts (C) based on USPSTF 2021 LDCT eligibility criteria: <50 years (C1, too young); >80 years (C2, too old); 50 – 80 years (C3, ineligible smoking history); 50 – 80 years (C4, eligible). For certain analyses, we stratified the LDCT cohort by baseline (T0) Lung-RADS score (0-2 v 3-4). We used a Cox model to calculate crude and adjusted hazard ratios (aHR) for lung cancer diagnosis within 24 months of enrollment. Results: From 2015-2021, 7050 persons were in LDCT- 6073 (86%) Lung-RADS 0-2 (no/benign lesions), 977 (14%) Lung-RADS 3 or 4 (possibly malignant lesion) on T0 scan; 17,579 were in ILNP, 16%, 10%, 57% and 16% respectively in C1-4. Demographics and tobacco use history of the ILNP cohorts differed strikingly; C4 was very similar to LDCT (Table). Black persons were significantly more in C1 (too young) and C3 (insufficient tobacco use). Diagnosis of lung cancer at 36 months ranged from 1% in C1 to 15% in C4, compared to 3% in LDCT; aHR for lung cancer diagnosis within 2 years ranged from 0.23 to 5.12 (all LDCT ref), but ranged from 0.04 to 1.02 with reference to LDCT Lung-RADS 3-4. Most patients in LDCT and ILNP C2-4 had early stage. There were proportionately more Black lung cancer patients in C1-4, and 3 times more Black patients in C3 and 4 than in LDCT. Conclusions: ILNP provides early-detection access to a larger, more diverse population than LDCT, potentially alleviating race and socio-economics-based outcomes disparities. [Table: see text]

Incidental pulmonary nodules, lung cancer screening, and lung cancer in the Medicare population

6536

Background: Low-dose CT lung cancer screening (LDCT) saves lives, but only 5%-10% of eligible persons in the US have participated. Management of indeterminate pulmonary nodules (IPNs) identified on CT scans may also reduce lung cancer mortality. We assessed the frequency of IPNs, estimated cumulative lung cancer rates following IPNs, and compared characteristics of lung cancers diagnosed following IPNs versus LDCT screens. Methods: We defined 2 cohorts in the SEER-Medicare database: persons with 12+ months of Medicare Part A&B coverage during 2014-2019 comprised the 5% sample cohort; persons in SEER-Medicare diagnosed with lung cancer during 2015-2017 with Part A&B coverage for the prior 18-month period comprised the lung cancer cohort. We defined IPNs as chest CTs with ICD-10 codes of R91.1 (solitary pulmonary nodule) or R91.8 (other nonspecific abnormal finding of lung field) on the same date as the CT; we used corresponding ICD-9 codes through September 2015. We classified lung cancer cohort cases by whether they had an LDCT (LDCT group), an IPN without an LDCT screen (IPN-only), or neither (Referent) within 18 months before diagnosis. We compared cancer stage and survival between these groups. Results: Of 627,547 subjects in the 5% sample cohort, 58.6% were women; 85.6% were non-Hispanic White (NH-Whites) and 7.7% non-Hispanic Black (NH-Blacks). Over median 5.0 years follow-up, 26.3% had chest CTs and 12.0% had IPNs. The IPN rate was similar by sex but significantly higher in NH-Whites (12.7%) than NH-Blacks (9.7%). The cumulative lung cancer rate following initial IPNs was 2.27% at two years. Of the 44,194 lung cancer cohort cases (85.8% NH-White, 8.2% NH-Black), 26.9%, 2.9% and 70.2% were in the IPN-only, LDCT, and Referent groups, respectively. NH-Whites comprised a higher proportion of LDCT than of IPN-only cases (90.1% vs. 88.4%), while for NH-Blacks, the reverse was true (5.4% vs. 6.5%). The ratio of LDCT:IPN lung cancer cases was 1:9. Among IPN-only and LDCT group cases, 52.0% and 50.3%, respectively, were localized stage, compared to 21.5% for the Referent group. Among all localized cases, 45.4% and 4.9% were in the IPN-only and LDCT groups, respectively. Comparing 3-year survival between IPN vs LDCT vs Referent groups, respectively: aggregate overall survival rates were 53.5% v 59.2% v 29.2%; aggregate lung cancer-specific survival, 71.1% v 75.3% v 46.6%; overall survival for localized cases, 73.2% v 80.7% v 62.9%; lung cancer-specific survival rates for localized cases, 88.2%, 91.8% and 81.4%. Conclusions: Subjects with IPNs had similar stage distribution and survival as LDCT-screened subjects. Almost half of localized cases had prior IPNs, compared to a < 5% of LDCT-screened cases. IPN programs, by circumventing implementation barriers to LDCT, may expand access to early lung cancer detection, including to African American patients and in places where LDCT coverage is not available.

Associations between biomarker testing and characteristics of patients with metastatic non–small cell lung cancer (mNSCLC): An analysis of CancerLinQ Discovery (CLQD) data

9127

Background: Guidelines have evolved from 2011-2019; there are now 23 approved therapies targeting various predictive biomarkers in mNSCLC. 2021 NCCN Guidelines advocate for a minimum of ALK, EGFR, BRAF, METex14, NTRK1/2/3, RET, KRAS, and ROS1 testing before determining a treatment regimen. The study objective was to estimate the association between the presence of biomarker testing and smoking status, age, sex, race, ethnicity, histology, and diagnosis year in patients with mNSCLC. Methods: CLQD is a real-world data source that provides de-identified electronic health record (EHR) data from more than 60 U.S. oncology practices utilizing 10 different EHRs. This retrospective analysis included patients initially diagnosed with mNSCLC from January 1, 2011, to December 31, 2019. Standard logistic regression models were fit separately by practice to estimate practice-specific odds ratios to assess variability across practices in associations between covariates (smoking status, age, race, etc.) and the primary outcome of biomarker testing, defined as documented testing for EGFR, ALK, ROS1, BRAF, KRAS, MET, RET, ERBB2, and/or PD-L1 within -60 to +365 days of mNSCLC diagnosis. Random effects logistic regression was then used to estimate associations with random intercepts, accounting for clustering by practices. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Results: 8704 patients from 31 practices were eligible. Testing rates increased from 31.5% in 2011 to a peak of 62.3% in 2017. Patients with a smoking history were half as likely to receive testing than patients without a smoking history (OR = 0.50, 95% CI: 0.41, 0.60); patients with unknown smoking history were 0.66 times as likely (95% CI: 0.52, 0.84). Females were more likely to be tested than males (OR = 1.19, 95% CI: 1.07, 1.32). After adjusting for other covariates, Asian patients were 1.51 times more likely to be tested than patients of other races (95% CI: 1.05, 2.17); Hispanic patients were 1.33 times more likely to be tested than patients without Hispanic ethnicity (95% CI: 0.99, 1.78). The odds of receiving biomarker testing were 6x greater for patients with non-squamous mNSCLC versus squamous mNSCLC (95% CI: 5.45, 7.20). Patients > 70 years old were less likely to be tested (OR = 0.83, 95% CI: 0.75, 0.93) than younger patients. Conclusions: Our data demonstrate annual increases in testing rates, reflecting guideline changes. However, in this cohort of patients with mNSCLC, biomarker testing was more likely for non-squamous mNSCLC patients, females, Asians, Hispanics, or those who did not have a history of smoking. Patient characteristics should no longer factor into obtaining biomarker testing. Non-discriminant, broad panel-based reflex molecular testing in mNSCLC can reduce treatment choice ambiguity and enhance patient opportunities.

Rates of Guideline-Concordant Surgery and Adjuvant Chemotherapy Among Patients With Early-Stage Lung Cancer in the US ALCHEMIST Study (Alliance A151216)

Importance

Standard treatment for resectable non-small cell lung cancer (NSCLC) includes anatomic resection with adequate lymph node dissection and adjuvant chemotherapy for appropriate patients. Historically, many patients with early-stage NSCLC have not received such treatment, which may affect the interpretation of the results of adjuvant therapy trials.

Objective

To ascertain patterns of guideline-concordant treatment among patients enrolled in a US-wide screening protocol for adjuvant treatment trials for resected NSCLC.

Design, Setting, and Participants

This retrospective cohort study included 2833 patients with stage IB to IIIA NSCLC (per American Joint Committee on Cancer 7th edition criteria) who enrolled in the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial (ALCHEMIST) screening study (Alliance for Clinical Trials in Oncology A151216) from August 18, 2014, to April 1, 2019, and who did not enroll in a therapeutic adjuvant clinical trial; patients had tumors of at least 4 cm and/or with positive lymph nodes. Statistical analysis was conducted from June 1, 2020, through October 1, 2021.

Exposures

Care patterns were ascertained overall and by sociodemographic and clinical factors, including age, sex, race and ethnicity, educational level, marital status, geography, histologic characteristics, stage, genomic variant status, smoking history, and comorbidities.

Main Outcomes and Measures

Five outcomes are reported: whether patients (1) had anatomic surgical resection, (2) had adequate lymph node dissection (≥1 N1 nodal station plus ≥3 N2 nodal stations), (3) received any adjuvant chemotherapy, (4) received any cisplatin-based adjuvant chemotherapy, and (5) received at least 4 cycles of adjuvant chemotherapy.

Results

Of the 2833 patients (1505 women [53%]; mean [SD] age, 66.5 [9.2] years) included in this analysis, 2697 (95%) had anatomic surgical resection, 1513 (53%) had adequate lymph node dissection, 1617 (57%) received any adjuvant chemotherapy, 1237 (44%) received at least 4 cycles of adjuvant platinum-based chemotherapy, and 965 (34%) received any cisplatin-based adjuvant chemotherapy. Rates were similar across race and ethnicity.

Conclusions and Relevance

This cohort study found that among participants in a screening protocol for adjuvant clinical trials for resected early-stage NSCLC, just 53% underwent adequate lymph node dissection, and 57% received adjuvant chemotherapy, despite indications for such treatment. These results may affect the interpretation of adjuvant trials. Efforts are needed to optimize the use of proven therapies for early-stage NSCLC.

Trial Registration

ClinicalTrials.gov Identifier: NCT02194738.

Lung Cancer Diagnosed Through Screening, Lung Nodule, and Neither Program: A Prospective Observational Study of the Detecting Early Lung Cancer (DELUGE) in the Mississippi Delta Cohort

PURPOSE

Lung cancer screening saves lives, but implementation is challenging. We evaluated two approaches to early lung cancer detection-low-dose computed tomography screening (LDCT) and program-based management of incidentally detected lung nodules.

METHODS

A prospective observational study enrolled patients in the early detection programs. For context, we compared them with patients managed in a Multidisciplinary Care Program. We compared clinical stage distribution, surgical resection rates, 3- and 5-year survival rates, and eligibility for LDCT screening of patients diagnosed with lung cancer.

RESULTS

From 2015 to May 2021, 22,886 patients were enrolled: 5,659 in LDCT, 15,461 in Lung Nodule, and 1,766 in Multidisciplinary Care. Of 150, 698, and 1,010 patients diagnosed with lung cancer in the respective programs, 61%, 60%, and 44% were diagnosed at clinical stage I or II, whereas 19%, 20%, and 29% were stage IV (P = .0005); 47%, 42%, and 32% had curative-intent surgery (P < .0001); aggregate 3-year overall survival rates were 80% (95% CI, 73 to 88) versus 64% (60 to 68) versus 49% (46 to 53); 5-year overall survival rates were 76% (67 to 87) versus 60% (56 to 65) versus 44% (40 to 48), respectively. Only 46% of 1,858 patients with lung cancer would have been deemed eligible for LDCT by US Preventive Services Task Force (USPSTF) 2013 criteria, and 54% by 2021 criteria. Even if all eligible patients by USPSTF 2021 criteria had been enrolled into LDCT, the Nodule Program would have detected 20% of the stage I-II lung cancer in the entire cohort.

CONCLUSION

LDCT and Lung Nodule Programs are complementary, expanding access to early lung cancer detection and curative treatment to different-risk populations. Implementing Lung Nodule Programs may alleviate emerging disparities in access to early lung cancer detection.

eSyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems

PURPOSE

Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available.

METHODS

As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes.

RESULTS

eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts.

CONCLUSION

eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

Defining comprehensive biomarker-related testing and treatment practices for advanced non-small-cell lung cancer: Results of a survey of U.S. oncologists

BACKGROUND

An ASCO taskforce comprised of representatives of oncology clinicians, the American Cancer Society National Lung Cancer Roundtable (NLCRT), LUNGevity, the GO2 Foundation for Lung Cancer, and the ROS1ders sought to: characterize U.S. oncologists' biomarker ordering and treatment practices for advanced non-small-cell lung cancer (NSCLC); ascertain barriers to biomarker testing; and understand the impact of delays on treatment decisions.

METHODS

We deployed a survey to 2374 ASCO members, targeting U.S. thoracic and general oncologists.

RESULTS

We analyzed 170 eligible responses. For non-squamous NSCLC, 97% of respondents reported ordering tests for EGFR, ALK, ROS1, and BRAF. Testing for MET, RET, and NTRK was reported to be higher among academic versus community providers and higher among thoracic oncologists than generalists. Most respondents considered 1 (46%) or 2 weeks (52%) an acceptable turnaround time, yet 37% usually waited three or more weeks to receive results. Respondents who waited ≥3 weeks were more likely to defer treatment until results were reviewed (63%). Community and generalist respondents who waited ≥3 weeks were more likely to initiate non-targeted treatment while awaiting results. Respondents <5 years out of training were more likely to cite their concerns about waiting for results as a reason for not ordering biomarker testing (42%, vs. 19% with ≥6 years of experience).

CONCLUSIONS

Respondents reported high biomarker testing rates in patients with NSCLC. Treatment decisions were impacted by test turnaround time and associated with practice setting and physician specialization and experience.

Knowledge and Practice Patterns Among Pulmonologists for Molecular Biomarker Testing in Advanced Non-small Cell Lung Cancer

BACKGROUND

Targeted therapies for advanced non-small cell lung cancer (NSCLC) with oncogenic drivers have caused a paradigm shift in care. Biomarker testing is needed to assess eligibility for these therapies. Pulmonologists often perform bronchoscopy, providing tissue for both pathologic diagnosis and biomarker analysis. We performed this survey to define the existing knowledge and practices regarding the pulmonologists' role in biomarker testing for advanced NSCLC.

RESEARCH QUESTION

What is the current knowledge and practice of pulmonologists regarding biomarker testing and targeted therapies in advanced NSCLC?

STUDY DESIGN AND METHODS

This cross-sectional study was performed using an electronic survey of a random sample of 7,238 pulmonologists. Questions focused on diagnostic steps and biomarker analyses for NSCLC.

RESULTS

A total of 453 pulmonologists responded. Respondents vary by reported lung cancer patient volume, ranging from 51% evaluating one to four new cases per month to 19% evaluating > 10 cases per month. Interventional training, academic practice setting, and higher volume of endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) were associated with increased knowledge of practice guidelines for the number of recommended passes during EBUS-TBNA (P < .05). Academic pulmonologists more commonly performed or referred for EBUS-TBNA than community pulmonologists (96% and 83%, respectively; P < .0005). Higher testing rates were associated with interventional training, academic setting, and the presence of an institutional policy, whereas lower testing rates were associated with general pulmonologists, practice in community settings, and lack of a guiding institutional policy (P < .05).

INTERPRETATION

Substantial differences among pulmonologists' evaluation of advanced NSCLC, variation in knowledge of available biomarkers and the importance of targeted therapies, and differences in institutional coordination likely lead to underutilization of biomarker testing. Interventional training appears to drive improved knowledge and practice for biomarker testing more than practice setting. Improvements are needed in tissue acquisition and interdisciplinary coordination to ensure universal and comprehensive testing for eligible patients.

Comparing U.S. Preventive Services Task Force 2013 versus 2021 lung cancer screening eligibility

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Background: Early detection of lung cancer provides the best opportunity for long-term survival. In 2021 US Preventive Services Task Force (USPSTF) expanded the 2013 risk-based Low-dose CT (LDCT) screening criteria, in part to reduce unintended race and gender disparities in lung cancer detection. We evaluated the impact of the updated USPSTF criteria in a cohort of patients from an incidental lung nodule program (ILNP). Methods: We implemented an ILNP in a community healthcare system in the mid-south US. Patients with lung lesions on routinely-performed radiologic studies were triaged using evidence-based guidelines. We prospectively tracked patient demographics, clinical characteristics, procedures, complications, and health outcomes. We classified all patients in the ILNP cohort based on USPSTF 2013 and 2021 screening criteria. Statistical analysis used the chi-square test. Results: The ILNP cohort included 14,642 patients from 2015-2021. This cohort was 56% female, 65% White, 29% Black, with a median age of 64 years. Overall 1,581 (10.8%) met 2013 and 2,051 (14.0%) met 2021 USPSTF criteria. 1.9% of subjects eligible by 2013 criteria were diagnosed with lung cancer compared to 2.2% by 2021 criteria. 470 additional patients met screening criteria when we expanded from USPSTF 2013 to 2021. As expected, these patients were younger and less likely to have Medicare insurance. These additional eligible patients were significantly more likely to be female (58% v 49%, p = 0.0011) or Black (28% vs. 18%, p < 0.0001) compared to those eligible by 2013 criteria. 44 of the 470 (9%) were diagnosed with cancer: 36% adenocarcinoma, 18% squamous, and 11% small cell, 11% non-lung primary, 9% non-small cell lung cancer NOS, and 15% other or unknown histology. The median tumor size was 3 cm with an interquartile range from 1.7 to 4.2 cm. The clinical stage distribution was 34% I, 4.5% II, 15.9% III, and 31.8% IV. Conclusions: In this selective community-based cohort, USPSTF 2021 criteria identified a higher percentage of subjects with lung cancer and were more inclusive of women and minorities compared to USPSTF 2013 criteria.

A disease-based evaluation of lung cancer care quality in a community healthcare system

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Background: Lung cancer care is complex, but, for quality improvement, can be simplified into five ‘nodal points’: lesion detection, diagnostic biopsy, radiologic staging, invasive staging, and treatment. We previously demonstrated great heterogeneity in passage through these nodal points in patients who received surgical resection for lung cancer in our healthcare system. However, examining only surgical patients may underestimate the enormity of the opportunity for quality improvement. With the aim of identifying quality gaps in pre-treatment evaluation for lung cancer, we evaluated the flow of care through these nodal points within a community-based healthcare system. Methods: We classified lung cancer care procedures received by all suspected lung cancer patients treated within the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN between 2014 and 2019, into five nodal points. We compared the frequency of, and time intervals between, nodal points among patients receiving surgical, nonsurgical (chemotherapy/radiation), or no definitive treatment, using Chi-square or Kruskal Wallis tests, where appropriate. Results: Of 1304 eligible patients: 11% had no pre-treatment diagnostic procedure, 20% no PET/CT, and 39% no invasive staging. 39% of patients underwent surgical resection, 51% received non-surgical treatment, and 10% received no treatment. Patients who had surgery were less likely than those who had non-surgical treatment to get a diagnostic test, radiologic staging, and invasive staging (Table). Patients who had non-surgical treatment were more likely to pass through all five nodal points (50% v 68%, p<0.0001). The median (IQR) duration from initial lesion identification to treatment (n=1126) was 77 days (45-190); 27 days (10-90) from lesion identification to diagnostic biopsy (n=1115); and 38 days (26-63) from diagnostic biopsy to treatment (n=1041). Patients who had surgery received less timely care than those who had non-surgical or no treatment: median 122 v 66 v 68 days from lesion identification to treatment; 40 v 21 v 29 days from lesion identification to diagnostic biopsy; 46 v 38 v 31 days from diagnostic biopsy to treatment (p<0.0001 all comparisons). Conclusions: Quality improvement initiatives within our healthcare system, such as the establishment of a coordinated multidisciplinary program, enhanced care quality over previous benchmarks. Despite improvements, lung cancer patients who had surgery received less frequent and less timely pre-treatment evaluation than those without surgery. Implementing a standardized cancer care pathway from diagnosis to surgery could help to reduce variations in optimal care delivery.[Table: see text]

Patient and caregiver’s satisfaction with multidisciplinary vs. serial lung cancer care in a community setting

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Background: Few existing studies examined lung cancer patients and caregivers’ satisfaction with the team-based multidisciplinary care (MD) in comparison to the usual serial care (SC). We hypothesized that MD, by providing early and concurrent input from key specialists collaborating as a team with patients and caregivers to develop a consensus care plan, can improve patients and caregivers’ satisfaction with care, compared to SC, in which multiple specialists independently screen, diagnose, and treat patients through a fragmented sequence of referrals. Methods: Data on newly diagnosed lung cancer patients, enrolled in a prospective matched cohort comparative effectiveness trial of MD or SC between Oct. 9th, 2014 and July 5th, 2017 in a Mid-South community hospital system, were collected at baseline, 3- and 6-month periods to assess patient and caregiver’s satisfaction with these two care-delivery models. Measures of satisfaction were adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Multivariate mixed linear models were used to examine the cross-group differences, the time-related variances, and how the interaction between groups and time-periods influenced patients’ and caregivers’ satisfaction. Results: Compared with SC (N = 297), patients in MD (N = 159) were older (66 vs. 69 years), more in an early cancer stage (33% vs. 41% in stage I or II), and lower in performance score (35% vs. 45% asymptomatic). Demographic and social-economic characteristics of caregivers in MD (N = 97) and SC (N = 122) were not significantly different. Patients and caregivers in MD were more likely than those in SC to perceive their care to be better than that received by other patients (p =.003 and p <.001 respectively). Greater satisfaction with their treatment plan at 6-month was observed among the MD patients (p =.004). Also, MD patients reported better overall satisfaction with team members (p =.038). Consistent with the findings among the patients in MD, caregivers in MD were more satisfied with the quality of care (p <.001) and with care received from team members (p <.001) than that reported by caregivers in SC. Conclusions: Coordinated MD care improved patients and caregivers’ satisfaction with lung cancer care in a community healthcare system. Further research will compare the quality of life and financial burden on patients in the MD and SC treatment models to provide more evidence for stakeholders to refine cancer care models.

Survival Impact of an Enhanced Multidisciplinary Thoracic Oncology Conference in a Regional Community Health Care System

INTRODUCTION

We compared NSCLC treatment and survival within and outside a multidisciplinary model of care from a large community health care system.

METHODS

We implemented a rigorously benchmarked "enhanced" Multidisciplinary Thoracic Oncology Conference (eMTOC) and used Tumor Registry data (2011-2017) to evaluate guideline-concordant care. Because eMTOC was located in metropolitan Memphis, we separated non-MTOC patient by metropolitan and regional location. We categorized National Comprehensive Cancer Network guideline-concordant treatment as "preferred," or "appropriate" (allowable under certain circumstances). We compared demographic and clinical characteristics across cohorts using chi-square tests and survival using Cox regression, adjusted for multiple testing. We also performed propensity-matched and adjusted survival analyses.

RESULTS

Of 6259 patients, 14% were in eMTOC, 55% metropolitan non-MTOC, and 31% regional non-MTOC cohorts. eMTOC had the highest rates of African Americans (34% versus 28% versus 22%), stages I to IIIB (63 versus 40 versus 50), urban residents (81 versus 78 versus 20), stage-preferred treatment (66 versus 57 versus 48), guideline-concordant treatment (78 versus 70 versus 63), and lowest percentage of nontreatment (6 versus 21 versus 28); all p values were less than 0.001. Compared with eMTOC, hazard for death was higher in metropolitan (1.5, 95% confidence interval: 1.4-1.7) and regional (1.7, 1.5-1.9) non-MTOC; hazards were higher in regional non-MTOC versus metropolitan (1.1, 1.0-1.2); all p values were less than 0.05 after adjustment. Results were generally similar after propensity analysis with and without adjusting for guideline-concordant treatment.

CONCLUSIONS

Multidisciplinary NSCLC care planning was associated with significantly higher rates of guideline-concordant care and survival, providing evidence for rigorous implementation of this model of care.

Trends in Accuracy and Comprehensiveness of Pathology Reports for Resected NSCLC in a High Mortality Area of the United States

Introduction:

Complete and accurate pathology reports are vital to postoperative prognostication and management. We evaluated the impact of three interventions across a diverse group of hospitals on pathology reports of postresection NSCLC.

Methods:

We evaluated pathology reports for patients who underwent curative-intent surgical resection for NSCLC, at 11 institutions within four contiguous Dartmouth Hospital Referral Regions in Arkansas, Mississippi, and Tennessee from 2004 to 2020, for completeness and accuracy, before and after the following three quality improvement interventions: education (feedback to heighten awareness); synoptic reporting; and a lymph node specimen collection kit. We compared the proportion of pathology reports with the six most important items for postoperative management (specimen type, tumor size, histologic type, pathologic [p] T-category, pN-category, margin status) across the following six patient cohorts: preintervention control, postintervention with four different combinations of interventions, and a contemporaneous nonintervention external control.

Results:

In the postintervention era, the odds of reporting all key items were eight times higher than those in the preintervention era (OR = 8.3, 95 % confidence interval [CI]: 6.7–10.2, p < 0.0001). There were sixfold and eightfold increases in the odds of accurate pT- and pN-category reporting in the postintervention era compared with the preintervention era (pT OR = 5.7, 95 % CI: 4.7–6.9; pN OR = 8.0, 95 % CI: 6.5–10.0, both p < 0.0001). Within the intervention groups, the odds of reporting all six key items, accurate pT category, and accurate pN-category were highest in patients who received all three interventions.

Conclusions:

Gaps in the quality of NSCLC pathologic reportage can be identified, quantified, and corrected by rationally designed interventions.

Interest in Cessation Treatment Among People Who Smoke in a Community-Based Multidisciplinary Thoracic Oncology Program

INTRODUCTION

To evaluate the need for tobacco cessation services within a multidisciplinary clinic (MDC), we surveyed patients on their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program. We further evaluated the association between interest in cessation or willingness to participate in a cessation program and overall survival (OS).

METHODS

From 2014 to 2019, all new patients with lung cancer in the MDC at Baptist Cancer Center (Memphis, TN) were administered a social history questionnaire to evaluate their demographic characteristics, smoking status, tobacco dependence, interest in quitting, and willingness to participate in a cessation program. We used chi-square tests and logistic regression to compare characteristics of those who would participate to those who would not or were unsure and Kaplan-Meier curves and Cox regression to evaluate the association between cessation interest or willingness to quit and OS.

RESULTS

Of 641 total respondents, the average age was 69 years (range: 32-95), 47% were men, 64% white, 34% black, and 17% college graduates. A total of 90% had ever smoked: 34% currently and 25% quit within the past year. Among the current smokers, 60% were very interested in quitting and 37% would participate in a cessation program. Willingness to participate in a cessation program was associated with greater interest in quitting (p < 0.0001), better OS (p = 0.02), and reduced hazard of death (hazard ratio = 0.52, 95% confidence interval: 0.30-0.88), but no other characteristics.

CONCLUSIONS

Patients with lung cancer in an MDC expressed considerable interest in tobacco cessation services; patients willing to participate in a clinic-based cessation program had improved survival.

Early detection of lung cancer with an incidental lung nodule program (ILNP)

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Background: Lung cancer early detection improves survival, but risk-based low-dose CT screening (LDCT) only identifies a minority of patients. We implemented an ILNP in a community healthcare system, and evaluated its risks and benefits. Methods: Patients with lung lesions on routinely-performed radiologic studies were flagged by radiologists and triaged using evidence-based guidelines. We tracked demographics, clinical characteristics, procedures, complications, and health outcomes. We analyzed ILNP subjects’ eligibility for LDCT by National Lung Screening Trial (NLST), Center for Medicaid Services (CMS), NEderlands Leuvens Screening ONderzoek (NELSON), National Comprehensive Cancer Network (NCCN) Risk Groups 1 and 2 (screening recommended), NCCN Risk Group 3 (screening not currently recommended), and US Preventive Services Task Force (USPSTF) criteria from 2013 and 2020. Statistical analysis used the chi-square test and Kaplan Meier method. Results: From 2015-2020, 13,710 patients were evaluated in the ILNP program: median age, 64 years; 42% male; 65% White, 29% Black; 667 (4.9%) were diagnosed with lung cancer. Lung cancers diagnosed from ILNP were 39% adenocarcinoma / 20% Squamous Cell with clinical stage distribution 49% I, 8% II, 17% III, and 16% IV. 832 (6.1%) had invasive diagnostic testing- CT-guided biopsy (50%), bronchoscopy (30%), and/or EBUS (26%); 11% of the 832 had >1 invasive diagnostic test. The most common complications from invasive testing were pneumothorax and chest tube placement. Only 11%-20% of all ILNP patients would have been eligible for LDCT. In ILNP patients diagnosed with lung cancer, only 33% were eligible for screening by NLST criteria; the proportion increased substantially when USPSTF 2020 or NCCN Group 2 criteria were applied (Table). Compared to NLST, NCCN Group 2 criteria increased screening eligibility among cancer patients by 22% (from 33% to 55%), while only increasing screening eligibility by 6% (from 8% to 14%) in non-cancer patients. Aggregate 1-year and 3-year survival rates for lung cancer patient diagnosed through ILNP were 76% (95% CI: 73, 80) and 64% (95% CI: 59, 69). Conclusions: The ILNP identified early-stage lung cancer more frequently than most LDCT programs, with promising survival rates. The majority of subjects with lung cancer were not eligible for LDCT, we still need to optimize risk-based screening criteria. Even with new, expanded criteria for LDCT, structured ILNP is necessary to expand early detection of lung cancer.[Table: see text]