Developing national cancer survivorship standards to inform quality of care in the United States using a consensus approach

PURPOSE

To develop United States (US) standards for survivorship care that informs (1) essential health system policy and process components and (2) evaluation of the quality of survivorship care.

METHODS

The National Cancer Institute and the Department of Veterans Affairs led a review to identify indicators of quality cancer survivorship care in the domains of health system policy, process, and evaluation/assessment. A series of three virtual consensus meetings with survivorship care and research experts and advocates was conducted to rate the importance of the indicators and refine the top indicators. The final set of standards was developed, including ten indicators in each domain.

RESULTS

Prioritized items were survivor-focused, including processes to both assess and manage physical, psychological, and social issues, and evaluation of patient outcomes and experiences. Specific indicators focused on developing a business model for sustaining survivorship care and collecting relevant business metrics (e.g., healthcare utilization, downstream revenue) to show value of survivorship care to health systems.

CONCLUSIONS

The National Standards for Cancer Survivorship Care can be used by health systems to guide development of new survivorship care programs or services or to assess alignment and enhance services in existing survivorship programs. Given the variety of settings providing care to survivors, it is necessary for health systems to adapt these standards based on factors including age-specific needs, cancer types, treatments received, and health system resources.

IMPLICATIONS FOR CANCER SURVIVORS

With over 18 million cancer survivors in the United States, many of whom experience varied symptoms and unmet needs, it is essential for health systems to have a comprehensive strategy to provide ongoing care. The US National Standards for Survivorship Care should serve as a blueprint for what survivors and their families can anticipate after a cancer diagnosis to address their needs.

Alterations in Cancer Treatment During the First Year of the COVID-19 Pandemic in the US

Importance

The COVID-19 pandemic created challenges to the evaluation and treatment of cancer, and abrupt resource diversion toward patients with COVID-19 put cancer treatment on hold for many patients. Previous reports have shown substantial declines in cancer screening and diagnoses in 2020; however, the extent to which the delivery of cancer care was altered remains unclear.

Objective

To assess alterations in cancer treatment in the US during the first year of the COVID-19 pandemic.

Design, Setting, and Participants

This retrospective cohort study used data from the National Cancer Database (NCDB) on patients older than 18 years with newly diagnosed cancer from January 1, 2018, to December 31, 2020.

Main Outcomes and Measures

The main outcomes were accessibility (time to treatment, travel distance, and multi-institutional care), availability (proportional changes in cancer treatment between years), and utilization (reductions by treatment modality, hospital type) of cancer treatment in 2020 compared with 2018 to 2019. Autoregressive models forecasted expected findings for 2020 based on observations from prior years.

Results

Of 1 229 654 patients identified in the NCDB in 2020, 1 074 225 were treated for cancer, representing a 16.8% reduction from what was expected. Patients were predominately female (53.8%), with a median age of 66 years (IQR, 57-74 years), similar to demographics in 2018 and 2019. Median time between diagnosis and treatment was 26 days (IQR, 0-36 days) in 2020, and median travel distance for care was 11.1 miles (IQR, 5.0-25.3 miles), similar to 2018 and 2019. In 2020, fewer patients traveled longer distances (20.2% reduction of patients traveling >35 miles). The proportions of patients treated with chemotherapy (32.0%), radiation (29.5%), and surgery (57.1%) were similar to those in 2018 and 2019. Overall, 146 805 fewer patients than expected underwent surgery, 80 480 fewer received radiation, and 68 014 fewer received chemotherapy. Academic hospitals experienced the greatest reduction in cancer surgery and treatment, with a decrease of approximately 484 patients (-19.0%) per hospital compared with 99 patients (-12.6%) at community hospitals and 110 patients (-12.8%) at integrated networks.

Conclusions and Relevance

This study found that among patients diagnosed with cancer in 2020, access and availability of treatment remained intact; however, reductions in treated patients varied across treatment modalities and were greater at academic hospitals than at community hospitals and integrated networks compared with expected values. These results suggest the resilience of cancer service lines and frame the economic losses from reductions in cancer treatment during the pandemic.

Getting ready for prime time: Recommended adaptations of an Empathic Communication Skills training intervention to reduce lung cancer stigma for a national multi-center trial

Building upon prior work developing and pilot testing a provider-focused Empathic Communication Skills (ECS) training intervention, this study sought feedback from key invested partners who work with individuals with lung cancer (i.e. stakeholders including scientific and clinical advisors and patient advocates) on the ECS training intervention. The findings will be used to launch a national virtually-delivered multi-center clinical trial that will examine the effectiveness and implementation of the evidence-based ECS training intervention to reduce patients' experience of lung cancer stigma. A 1-day, hybrid, key invested partners meeting was held in New York City in Fall 2021. We presented the ECS training intervention to all conference attendees (N = 25) to seek constructive feedback on modifications of the training content and platform for intervention delivery to maximize its impact. After participating in the immersive training, all participants engaged in a group discussion guided by semi-structured probes. A deductive thematic content analysis was conducted to code focus group responses into 12 distinct a priori content modification recommendations. Content refinement was suggested in 8 of the 12 content modification themes: tailoring/tweaking/refining, adding elements, removing elements, shortening/condensing content, lengthening/extending content, substituting elements, re-ordering elements, and repeating elements. Engagement and feedback from key invested multi-sector partner is a valuable resource for intervention content modifications. Using a structured format for refining evidence-based interventions can facilitate efforts to understand the nature of modifications required for scaling up interventions and the impact of these modifications on outcomes of interest. ClinicalTrials.gov Identifier: NCT05456841.

Disruption of National Cancer Database Data Models in the First Year of the COVID-19 Pandemic

Importance

Each year, the National Cancer Database (NCDB) collects and analyzes data used in reports to support research, quality measures, and Commission on Cancer program accreditation. Because data models used to generate these reports have been historically stable, year-to-year variances have been attributed to changes within the cancer program rather than data modeling. Cancer submissions in 2020 were anticipated to be significantly different from prior years because of the COVID-19 pandemic. This study involved a validation analysis of the variances in observed to expected 2020 NCDB cancer data in comparison with 2019 and 2018.

Observations

The NCDB captured a total of 1 223 221 overall cancer cases in 2020, a decrease of 14.4% (Δ = -206 099) compared with 2019. The early months of the COVID-19 pandemic (March-May 2020) coincided with a nadir of cancer cases in April 2020 that did not recover to overall prepandemic levels through the remainder of 2020. In the early months of the COVID-19 pandemic, the proportion of early-stage disease decreased sharply overall, while the proportion of late-stage disease increased. However, differences in observed to expected stage distribution in 2020 varied by primary disease site. Statistically significant differences in the overall observed to expected proportions of race and ethnicity, sex, insurance type, geographic location, education, and income were identified, but consistent patterns were not evident.

Conclusions and Relevance

Historically stable NCDB data models used for research, administrative, and quality improvement purposes were disrupted during the first year of the COVID-19 pandemic. NCDB data users will need to carefully interpret disease- and program-specific findings for years to come to account for pandemic year aberrations when running models that include 2020.

Palliative care use and utilization determinants among patients treated for advanced stage lung cancer care in the community and academic medical setting

PURPOSE

Despite clinical guidelines, palliative care is underutilized during advanced stage lung cancer treatment. To inform interventions to increase its use, patient-level barriers and facilitators (i.e., determinants) need to be characterized, especially among patients living in rural areas or those receiving treatment outside academic medical centers.

METHODS

Between 2020 and 2021, advanced stage lung cancer patients (n = 77; 62% rural; 58% receiving care in the community) completed a one-time survey assessing palliative care use and its determinants. Univariate and bivariate analyses described palliative care use and determinants and compared scores by patient demographic (e.g., rural vs. urban) and treatment setting (e.g., community vs. academic medical center) factors.

RESULTS

Roughly half said they had never met with a palliative care doctor (49.4%) or nurse (58.4%) as part of cancer care. Only 18% said they knew what palliative care was and could explain it; 17% thought it was the same as hospice. After palliative care was distinguished from hospice, the most frequently cited reasons patients stated they would not seek palliative care were uncertainty about what it would offer (65%), concerns about insurance coverage (63%), difficulty attending multiple appointments (60%), and lack of discussion with an oncologist (59%). The most common reasons patients stated they would seek palliative care were a desire to control pain (62%), oncologist recommendation (58%), and coping support for family and friends (55%).

CONCLUSION

Interventions should address knowledge and misconceptions, assess care needs, and facilitate communication between patients and oncologists about palliative care.

Neoadjuvant Versus Adjuvant Chemotherapy for Resectable Metastatic Colon Cancer in Non-academic and Academic Programs

BACKGROUND

Overall survival advantage of chemotherapy before versus after metastasectomy of liver or lung lesion is not clear for colon cancer with synchronous liver or lung metastasis.

MATERIALS AND METHODS

Adults 20 years or older with primary colon cancer and single organ metastatic disease either in the liver or lung at diagnosis were identified between 2010 and 2015 through the National Cancer Database (NCDB). Patients were categorized into 2 cohorts: pre-operative/peri-operative chemotherapy (neoadjuvant -[NAC]) or post-operative chemotherapy (adjuvant [AC]). Survivals and factors associated with were compared between the 2 groups.

RESULTS

A total of 3038 patients with colon cancer with liver or lung metastases were identified. The percentage of patients receiving NAC had steadily increased from 12.29% to 28.31%, mostly in academic programs. On multivariate analysis, patients who received NAC had an overall survival advantage in the non-academic setting whereas no advantage is seen in the patients treated in the academic settings. The median overall survival for patients receiving NAC and AC was 47.24 months and 38.08 months, respectively. Factors associated with overall survival advantage in NAC patients treated in non-academic programs included age 20-49 years, CEA value of >30, right-sided colon primary, liver metastasis, and clear resection margins.

CONCLUSIONS

Metastatic colon cancer with single organ liver or lung lesions benefits from neoadjuvant chemotherapy, especially in -non-academic settings. The overall survival advantage in this setting has not been shown before.

Lung Cancer in Young Adults: A Single-Center Experience

OBJECTIVE

This single-center retrospective review examines the unique characteristics of young patients (ages 18 to 40 years) who were diagnosed as having non-small-cell lung cancer (NSCLC) at Markey Cancer Center, the only National Cancer Institute-designated cancer center in the state of Kentucky.

METHODS

This retrospective study examines adult patients with NSCLC who were between ages 18 and 40 at diagnosis. Patients diagnosed between 2012 and 2018 were included. The final cohort consisted of 35 patients. The data collected included patient demographic information, tumor topography, clinical stage, cell type, treatment information/dates, metastasis, and survival data.

RESULTS

In total, 36 of 3246 total NSCLC cases treated at Markey Cancer Center from 2012 to 2018 were diagnosed in adults aged 18 to 40 (1.11%); 35 of these 36 patients were included in our cohort. The majority (22; 62.86%) presented at an advanced stage of disease (stage III or IV). Furthermore, our cohort consisted of a strong majority of female patients (24; 68.57%). The most common histological type was adenocarcinoma (14; 40.00%). The 5-year survival rate was 47% (standard error 9%).

CONCLUSIONS

Lung cancer is rare in young patients; when present, often it presents at the advanced stage. Despite many diagnostic tools and treatment modalities available, long-term survival remains poor. Our experience showed a small proportion of patients with NSCLC aged 18 to 40 at diagnosis; among this unique patient population, there is a predominance of smokers, women, adenocarcinoma, and advanced disease.

Effectiveness of tunneled pleural catheter placement in patients with malignant pleural effusions

Pleural effusions (PE) occur frequently among patients with various types of advanced malignancies, resulting in remarkably decreased quality of life. Treatment of malignant PE includes placement of a chest tube with subsequent placement of a tunneled pleural catheter. We reviewed our experience with tunneled pleural catheter use to assess outcomes and resource utilization of this intervention. A retrospective study of consecutive patients (n = 163, including 41 outpatients) who were treated between July 2001 and April 2008 with tunneled pleural catheters was performed to evaluate operative and discharge outcomes. The average age of the patients was 59.32 years (range: 24 to 89). Lung cancer, breast cancer, and ovarian cancer were common primary diseases in this patient population. The mean hospital stay after tunneled pleural catheter placement was 3.19 days (range: 0 to 56), with 41 patients treated as outpatients. Thirteen inpatient deaths were related to the patients' primary diseases, but no deaths were due to drain placement itself. Eight patients (4.91%) required reoperation to replace a nonfunctioning drain or to add an additional drain, and six patients underwent a second procedure to place a contralateral drain. One hundred twenty-six patients (77.30%) were discharged home following the procedure and hospital stay. Fifty-five people achieved spontaneous pleurodesis. Tunneled pleural catheter placement is a safe and effective approach to the treatment of PE. The advantages of tunneled pleural catheter placement include symptomatic relief and improved quality of life. This method allows patients to spend time at home with their family and avoid prolonged hospitalization.

Treatment of respiratory syncytial virus pneumonia in a lung transplant recipient: case report and review of the literature

A 61-year-old woman who underwent lung transplantation developed severe respiratory syncytial virus (RSV) pneumonia and experienced respiratory failure requiring mechanical ventilation. She was treated initially with aerosolized ribavirin monotherapy; RSV hyperimmune globulin was later added to her regimen. Lung transplant recipients are acutely susceptible to respiratory infections, including community-acquired respiratory viruses. Respiratory syncytial virus is particularly difficult to treat in immunocompromised patients because of the lack of proved pharmaceutical agents and solid scientific evidence by which to guide therapy. The most important factor appears to be the early start of therapy; immunocompromised patients who develop RSV pneumonia and subsequent respiratory failure requiring mechanical ventilation have a mortality rate approaching 100%. This case report demonstrates the successful treatment of RSV pneumonia with the combination of aerosolized ribavirin and RSV hyperimmune globulin in a severely ill lung transplant recipient who required mechanical ventilation.

Administration of prenatal betamethasone suppresses the adrenal-hypophyseal axis in newborns with congenital diaphragmatic hernia

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a condition that is characterized by pulmonary hypoplasia and pulmonary hypertension. Prenatal betamethasone often is administered to fetuses with CDH to improve pulmonary function. In this study, the authors investigate the possible role of the adrenal-hypophyseal axis in CDH in an animal model and subsequently in human infants with CDH.

METHODS

Twin fetal sheep underwent creation of DH or a sham thoracotomy, and levels of plasma and lung ACTH and plasma cortisol were compared. For the human studies, plasma levels of ACTH, cortisol, and DHEA were measured in cord blood samples collected from 9 CDH (5 that received prenatal betamethasone) and compared with those of 14 normal newborns. In both studies, ACTH and cortisol levels were determined by radioimmunoassay (RIA). Human (DHEA) levels were determined by ELISA.

RESULTS

Plasma ACTH and cortisol levels were elevated in fetal DH sheep compared with sham-operated controls; however, levels of ACTH in lung tissues were not different. Human newborns with CDH who have been exposed to prenatal steroids have significantly lower plasma ACTH, cortisol, and DHEA levels than normal newborns and CDH newborns not exposed to prenatal betamethasone.

CONCLUSIONS

In an ovine model of CDH, the adrenal-hypophyseal axis appears up-regulated in DH fetuses compared with sham-operated animals. Conversely, the adrenal-hypophyseal axis in human CDH newborns appears normal but is suppressed by the administration of prenatal betamethasone.

Fatal hydrofluoric acid cutaneous exposure with refractory ventricular fibrillation

A patient with hydrofluoric acid burns involving only 8% of his body surface area died from intractable cardiac arrhythmia secondary to the depletion of ionized calcium by fluoride ion. For burns of this type, immediate subcutaneous injection of 10% calcium gluconate into the burn wound is recommended and the dose given should be titrated to the relief of local pain. Immediate debridgement of the burn wound also can decrease the treacherous aspect of the circulating fluoride ion, which binds to calcium to form an insoluble salt, effectively removing the calcium ion from any physiologic interaction.

The nucleus tractus solitarii of the cat: a comparison of Golgi impregnated neurons with methionine-enkephalin- and substance P-immunoreactive neurons

Golgi-impregnated and methionine-enkephalin (ME)- and substance P (SP)-immunoreactive neurons were studied throughout the feline nucleus tractus solitarii. The majority of Golgi-impregnated neurons in the NTS range in size from 5 to 18 micron. A noticeable exception is the large (15-30 micron) neurons of the ventrolateral subdivision. The Golgi-impregnated neurons possess dendritic trees which remain within the nucleus and even at times within the particular subdivisions. Golgi-impregnated neurons had a variety of spine forms: pedunculated, sessile, filiform, and complex. A number of neurons exhibited axons originating from the cell and they could be followed for distances up to 100 micron. ME- and SP-immunoreactive neurons were found in commissural, medial, lateral, and parvocellular subdivisions while ME-immunoreactive neurons were situated additionally in the intermediate and ventrolateral subdivisions. Both types of immunostained neurons were similar in size (6-20 micron) and shape of dendritic arbor. One population of ME-immunoreactive neurons resembled the large ventrolateral neurons of the Golgi impregnations. Neither type of immunostained neuron possessed the extensive dendritic arbor, numbers of spines, or axons of the Golgi-impregnated neurons. The presence of ME- and SP-immunoreactive neurons in regions which are associated with autonomic regulation suggests that these two peptides are involved in this process.