Oncologist Perceptions of Racial Disparity, Racial Anxiety, and Unconscious Bias in Clinical Interactions, Treatment, and Outcomes

BACKGROUND

Cancer spares no demographic or socioeconomic group; it is indeed the great equalizer. But its distribution is not equal; when structural discrimination concentrates poverty and race, zip code surpasses genetic code in predicting outcomes. Compared with White patients in the United States, Black patients are less likely to receive appropriate treatment and referral to clinical trials, genetic testing, or palliative care/hospice.

METHODS

In 2021, we administered a survey to 369 oncologists measuring differences in perceptions surrounding racial disparity, racial anxiety, and unconscious bias and adverse influence on clinical interactions, treatment, and outcomes for non-White patients. We analyzed responses by generational age group, sex/gender, race/ethnicity, US region, and selection of "decline to respond."

RESULTS

The most significant differences occurred by age group followed by race/ethnicity. Racial disparity was perceived as moderate to very high by 84% of millennial, 69% of Generation X, and 57% of baby boomer oncologists, who were also 86% more likely than millennials and 63% more likely than Generation Xers to perceive low/nonexistent levels of racial anxiety/unconscious bias.

CONCLUSIONS

Most oncologists rarely or never perceived racial anxiety/unconscious bias as adversely influencing clinical treatment or survival outcomes in non-White patients, and White oncologists were 85% more likely than non-White oncologists to perceive rare/nonexistent influence on referral of non-White patients to palliative care/hospice. The discrepancy between 62% of oncologists perceiving moderate to very high levels of racial anxiety/unconscious bias and 37% associating them with adverse influence on non-White patients shows a disconnect, especially among older oncologists (baby boomers), who were also least likely to select the decline option. Together, these factors hinder effective patient-provider communication and result in differential care and outcomes. Oncologists should uncover their own perceptions surrounding racial disparity, racial anxiety, and unconscious bias and modify their behaviors accordingly. It is this simple-and this complicated. Cancer does not discriminate, and neither should cancer care.

Reducing Avoidable Emergency Visits and Hospitalizations With Patient Risk-Based Prescriptive Analytics: A Quality Improvement Project at an Oncology Care Model Practice

PURPOSE

Cancer-related emergency department (ED) visits and hospitalizations that would have been appropriately managed in the outpatient setting are avoidable and detrimental to patients and health systems. This quality improvement (QI) project aimed to leverage patient risk-based prescriptive analytics at a community oncology practice to reduce avoidable acute care use (ACU).

METHODS

Using the Plan-Do-Study-Act (PDSA) methodology, we implemented the Jvion Care Optimization and Recommendation Enhancement augmented intelligence (AI) tool at an Oncology Care Model (OCM) practice, the Center for Cancer and Blood Disorders practice. We applied continuous machine learning to predict risk of preventable harm (avoidable ACU) and generated patient-specific recommendations that nurses implemented to avert it.

RESULTS

Patient-centric interventions included medication/dosage changes, laboratory tests/imaging, physical/occupational/psychologic therapy referral, palliative care/hospice referral, and surveillance/observation. Nurses contacted patients every 1-2 weeks after initial outreach to assess and maintain adherence to recommended interventions. Per 100 unique OCM patients, monthly ED visits dropped from 13.7 to 11.5 (18%), a sustained month-over-month improvement. Quarterly admissions dropped from 19.5 to 17.1 (13%), a sustained quarter-over-quarter improvement. Overall, the practice realized potential annual savings of $2.8 million US dollars (USD) on avoidable ACU.

CONCLUSION

The AI tool has enabled nurse case managers to identify and resolve critical clinical issues and reduce avoidable ACU. Effects on outcomes can be inferred from the reduction; targeting short-term interventions toward patients most at-risk translates to better long-term care and outcomes. QI projects involving predictive modeling of patient risk, prescriptive analytics, and nurse outreach may reduce ACU.

Abstract P1-11-05: Provider perceptions of DESTINY-Breast04, HER2-low directed treatment, and interstitial lung disease

Background: Human epidermal growth factor receptor 2 (HER2)-targeted therapies are an established treatment for patients with HER2-positive breast cancer, however, these therapies have not proven effective in the HER2-negative setting. Until recently, HER2 status was used to guide treatment decisions based on a binary classification of positive or negative. A new pathological category, HER2-low, has emerged as a subtype of interest within the breast cancer treatment landscape. HER2-low status is defined as a HER2 immunohistochemistry score of 1+ or 2+ and a negative in-situ hybridization result. DESTINY-Breast04 (DB04) was the first trial to evaluate a HER2-targeted agent within the metastatic HER2-low breast cancer setting. The anti-HER2 agent trastuzumab deruxtecan (T-DXd) demonstrated promising clinical activity in HER2-low expressing tumors. However, development of T-DXd-related interstitial lung disease (ILD) remains a concern when using this therapy. This survey-based study aimed to evaluate community oncologists’ perceptions of the DB04 data, HER2-low directed treatment, and management of ILD. Methods: U.S.-based oncologists (n=83) convened at two live meetings in June 2022 to review clinical updates presented at ASCO 2022. Participant characteristics and demographic data were collected via an online survey prior to the respective meetings. Perceptions/reactions to clinical updates were captured in real-time via electronic keypad. Data were summarized using descriptive statistics. Results: Among respondents, 83.1% identified as community providers, with an average experience of 20.7 years in practice. On average, participants reported that 88.2% of their time is allocated towards direct patient care, with roughly 18 patients seen per clinic day. Nearly half of respondents (49.4%) reported awareness of HER2-low as a distinct pathological category prior to the presentation of DB04 at ASCO 2022, however, less than 10% of respondents had previously used this sub-category to determine therapy. Increased T-DXd-related ILD, which occurred in 12% of trial participants, was cited as the greatest limitation of the DB04 trial by over one-third (37.3%) of respondents. After reviewing real-world evidence data of ILD incidence in metastatic breast cancer, nearly one-third (31%) of respondents reported that their observed ILD rates are less than DB04, but more (36%) said that ILD can be hard to quantify because patients are not always symptomatic. When asked if the ILD rate associated with T-DXd would limit their selection of this agent for their patients with breast cancer, approximately one-quarter (24.1%) of respondents indicated that they would reserve T-DXd use for patients without symptomatic pulmonary disease. However, the majority of respondents (60.2%) indicated that they would not limit their use of T-DXd based on ILD rates, with most (55.4%) opting for a risk-management approach involving increased monitoring for the development of ILD-related adverse events. Conclusions: Advancements in assay interpretation have made it possible to differentiate gradients of HER2 expression, creating a space for pathological sub-categories within a formerly binary paradigm. Among providers who reported awareness of HER2-low as a distinct pathological sub-category, few had used this as a benchmark to guide their treatment decisions prior to the presentation of DB04 at ASCO 2022. Newer anti-HER2 agents, such as T-DXd, provide a potential new standard of care for patients with HER2-low expressing tumors. Despite the concern of ILD rates associated with T-DXd use, the majority of providers do not view this as a limiting factor due to the ability to closely monitor patients for the development of adverse events coupled with appropriate provider/patient education.

Citation Format: Brooke Leon, Robert Bone, Yolaine Jeune-Smith, Bruce Feinberg. Provider perceptions of DESTINY-Breast04, HER2-low directed treatment, and interstitial lung disease [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-11-05.

Real-world utilization of ctDNA in the management of colorectal cancer

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Background: The utilization of circulating tumor DNA (ctDNA) as a non-invasive biomarker for the detection of minimal residual disease, prediction of recurrence in the post-operative setting, and real-time monitoring of treatment efficacy has the potential to vastly improve the care and outcomes of patients with colorectal cancer (CRC). In August of 2020, ctDNA testing first gained approval for use in solid tumors and its prognostic benefit after curative intent surgery has been demonstrated to exceed that of prior standard of care clinicopathological criteria in CRC patients. The comprehensive integration of validated ctDNA approaches into the routine clinical care of patients with CRC would not only fundamentally change how risk of recurrence is assessed but could also reduce treatment with unneeded/unwarranted toxic therapies and allow for earlier recognition and treatment in cases with a high risk of relapse. This survey-based study aimed to evaluate the utilization of ctDNA testing in the management of CRC among practicing community oncologists in the U.S. Methods: Questions related to ctDNA utilization for patients with CRC were presented to community oncologists during a virtual meeting held in July 2021. Descriptive statistics were used to analyze the results. Results: Of 55 participating oncologists geographically distributed across the U.S., 49% indicated not using ctDNA to make treatment decisions in CRC. A proportion of physicians reported using ctDNA to detect recurrence (27% of physicians); make decisions around post-resection adjuvant therapy (25%); monitor disease progression/relapse (18%); and track tumor resistance during treatment (9%). The most frequently cited barriers to ordering ctDNA testing for patients with metastatic CRC were reimbursement issues (reported by 56% of oncologists), insufficient clinical evidence (46%), and limited familiarity with ctDNA use (28%). Oncologists reported that the following would increase their utilization of ctDNA testing: more clinical evidence of the utility of ctDNA (reported by 66% of physicians), increased education on methodology (60%), more education on the use of ctDNA (57%), more financial aid and reimbursement support for patients (49%), more decision support tools (47%), and better communication between physicians and vendors (26%). Conclusions: These findings demonstrate limited adoption of ctDNA testing by community oncologists in the care of CRC patients. Insufficient demonstration of clinical utility, limited familiarity with methodology, and reimbursement issues were cited as barriers to uptake. Education for community oncology providers about ctDNA testing and its demonstrated clinical utility, and increased financial support for patients may improve its utilization and adoption in CRC to improve patient outcomes and care.

Mental health care for oncology patients in community settings

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Background: Research suggests that between thirty and fifty percent of patients with cancer experience psychiatric disorders across the cancer trajectory. As part of standard cancer care, mental health care can reduce distress and psychological morbidity for patients and improve their quality of life. Mental health treatment may even improve cancer survival rates.Considering the mental health issues relevant to cancer, implementation of mental health care into routine clinical care remains a challenge among community-based hematologists/oncologists (cH/O). Methods: Practicing U.S. cH/O completed a cross-sectional, web-based survey from September through November 2021. The survey collected demographic information and assessed physicians’ experiences and awareness regarding mental health diagnosis, frequency, severity, and management among their patients. Data were summarized using descriptive statistics. Results: Participants (N = 243) specialized in hematology/oncology (63%), medical oncology (36%) (1% other). The majority practiced in community-based settings unaffiliated with an academic center or hospital (73%). The majority (92%) agreed that mental health can significantly impact the health outcomes of patients with cancer. The majority (80%) frequently see patients coping with mental illness or distress. More than a quarter of the participants reported that their practice has clinical psychologists (27%), and nearly half (46%) have social workers on staff. About half (51%) occasionally refer patients for mental health services/treatment while 15% rarely or never refer. Nearly half (49%) indicated they do not have adequate resources to support the mental health needs of their patients with cancer. Conclusions: Our findings that oncologists have high levels of awareness about mental health issues among their patients with cancer is encouraging as is their incorporation of professionals on the care team to address this need. However, oncologists indicated that their available mental health resources are inadequate to meet patients’ needs and external referrals are limited. These findings suggest that additional resources and referrals are needed to ensure that patients will consistently receive the mental health care they need. Future research to assess the impact of mental health care on clinical outcomes including quality of life in patients with cancer is warranted.

Impact of an augmented intelligence-based tool upon the timeliness of referrals to palliative care and hospice in patients with advanced cancer in the real-world setting

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Background: Timely integration of palliative care (PC) and hospice management for patients with advanced cancer requires informed clinical decision-making and expectation-setting to help patients realize their end-of-life (EOL) goals. Longer stay with hospice is a quality indicator in oncology care that requires earlier referral to PC and hospice. We have previously demonstrated that an augmented intelligence (AI) tool used to predict 30-day mortality can assist with an increase in referrals to PC and hospice. In this secondary analysis, we report on the impact of the AI tool on the timeliness of referral to PC and hospice prior to death. However, calculating days with hospice across multiple hospice providers and geographies can be challenging. Thus, we used a real-world (RW) measure of 14 to 90 days prior to death as a surrogate for timeliness for hospice and 90 to 180 days prior to death for a PC referral. Methods: Medical records of patients at a large community-based hematology/oncology practice in the Pacific Northwest who experienced a mortality event pre-deployment (January 2017 to April 2018) or post-deployment (May 2018 to June 2021) of the AI tool were electronically reviewed for evidence of a PC or hospice referral. Patients were included if the referral was between 14 to 90 days of the mortality event for hospice care or between 90 to 180 days prior to death for PC. Outcomes for additional timepoints (1-3 days and 4-13 days and >90 days) will be provided at the final presentation. Data were analyzed using a statistical process control chart. Results: Of the patients who experienced a mortality event, the following percentages had been referred pre- and post-deployment of the AI tool: PC 7.1% pre- and 15.0% post-deployment; hospice 11.5% pre- and 32.1% post-deployment. A system shift (≥6 points in a row steadily increasing or decreasing) occurred early after deployment, in June 2018. The overall improvements were 111.0% in PC referrals and 179.1% in hospice referrals within the respective timeframes. Conclusions: Deployment of an AI tool at a hematology/oncology practice substantially increased the proportions of patients referred to PC 90-180 days prior to death and hospice between 14 -90 days prior to death, suggesting a favorable impact on timeliness of referrals. If confirmed in additional studies, the AI-based tool can be utilized to integrate PC early in the management of patients with advanced cancer.[Table: see text]

The Use and Knowledge of Validated Geriatric Assessment Instruments Among US Community Oncologists

PURPOSE

The use of a standardized geriatric assessment (GA) to inform treatment decisions in older adults with cancer improves quality of life, reduces treatment-related toxicity, and is guideline-recommended. This study aimed to assess community oncologists' knowledge and utilization of GAs.

METHODS

Between September 2019 and February 2020, practicing US-based oncologists were invited to attend live meetings and complete web-based surveys designed to collect information on treatment decision making and various practice-based challenges in oncology care.

RESULTS

Among the 349 oncologists surveyed, 74% practiced in a community setting. Sixty percent did not use a formal GA to inform treatment decisions for any of their older patients; the most common reasons for not using a GA were "Too cumbersome to incorporate into routine practice" (44%) and "Adds no value beyond the comprehensive history and physical exam" (36%). Validated GA instruments used in routine clinical practice included: Mini-Mental State Exam (54%), Comprehensive Geriatric Assessment (23%), Cancer and Aging Research Group toxicity tool (12%), and Chemotherapy Risk Assessment Scale for High-Age Patients tool (9%). Nineteen percent of oncologists were not aware of any validated GA instruments. Eastern Cooperative Oncology Group performance status and comorbidities were the most frequently used assessment factors to inform treatment decisions (88% and 73%, respectively).

CONCLUSION

Many oncologists have not incorporated GA tools because of perceptions that GAs are difficult to implement or do not add any value. Increasing education of the benefits of GA-directed therapy could help to increase GA utilization among community oncologists.

Assessing physician prescribing behaviors in first-line (1L) advanced renal cell carcinoma (aRCC): A case-based study

355

Background: Over the past decade, immune checkpoint inhibitors (ICIs) have become foundational to aRCC management. Tyrosine kinase inhibitors (TKIs) remain a mainstay, resulting in the potential for ICI/TKI combination regimens. Four ICI/TKI combinations (pembrolizumab/axitinib [PA], nivolumab/cabozantinib [NC], pembrolizumab/lenvatinib [PL], and avelumab/axitinib [AA]) have shown promising results compared to single-agent sunitinib in randomized clinical trials (KEYNOTE-426 [KN426], CheckMate 9ER [CM9ER], CLEAR, and JAVELIN RENAL 101 [JR101], respectively); national guidelines recommend them as 1L options. Further, an ICI-based regimen of nivolumab/ipilumumab (NI) is a treatment option for poor-risk RCC based on CheckMate 214 (CM214) results. We sought to understand how community oncologists perceive data from these trials and what aspects influence their clinical decisions. Methods: In May 2021, medical oncologists experienced in treating aRCC were presented with key results from these trials and 2 clinical vignettes. Treatment preferences and reasons for decisions were captured via an audience response system. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 103 U.S. medical oncologists participated; most risk-stratify their patients with either IMDC (44%), MSKCC (34%), or both (14%). When presented with simulated case studies, most (76%) indicated they are not likely to order PD-L1 testing, yet 81% will treat with an ICI-based regimen. Participants are more likely to prescribe ICI/TKI over ICI/ICI (65% vs 47%) in favorable-risk aRCC. Yet in poor-risk RCC, they are more likely to prescribe ICI/ICI over ICI/TKI (52% vs 15%). Among ICI/TKI regimen, participants showed a small preference toward PA over NC for both the poor-risk (21% vs 20%) and intermediate-risk (30% vs 23%) patient case. In the favorable-risk case, PA was significantly preferred over NC, 46% vs 19%. Most participants were aware of the trial data (91% KN426, 82% CM9ER, 57% CLEAR, 96% CM214); and more found the data from CM9ER most compelling compared to KN426 and CM214 (32%, 29%, and 23%, respectively). The participants viewed trials that met primary or survival endpoints as strong. Major limitations in each trial commonly identified were trial design (KN426, 27%); short follow-up (CM9ER, 48%); short follow-up and no OS data (CLEAR, 39% and 38%, respectively), and high discontinuation rate (CM214, 42%). Conclusions: Providers typically will treat aRCC patients with ICI-based regimens regardless of PD-L1 status and are more likely to prescribe an ICI/TKI regimen for favorable-risk and an ICI/ICI regimen for poor-risk aRCC. Meeting primary endpoints is a strong influencer in providers’ decision-making. Given the nonsignificant difference in preference for PA over NC, further research is needed to assess factors influencing providers’ decisions.

Community oncologists’ perceptions of and barriers to access for 177LU-PSMA-617 in metastatic castration-resistant prostate cancer

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Background: Metastatic castration-resistant prostate cancer (mCRPC) is a difficult-to-treat cancer with poor patient outcomes. In June 2021, 177Lu-PSMA-617 was granted U.S. FDA breakthrough designation for the treatment of mCRPC based on results from the phase III VISION trial showing a 4-month increased median overall survival (15.3 v 11.3 m; HR 0.62 [0.52-0.74], P < 0.001) and a 5.3-month increased radiographic progression-free survival (8.7 v 3.4 m; HR 0.40 [0.29-0.57] for 177Lu-PSMA-617 versus standard of care (SOC). If approved, 177Lu-PSMA-617 has the potential to improve patient outcomes, but its impact will depend significantly on how community-based medical oncologists (cbMO) plan to integrate it into patient management. The present study surveyed cbMO regarding their perceptions of the VISION trial data and potential barriers to 177Lu-PSMA-617 use in mCRPC. Methods: Between June and October 2021, practicing U.S.-based cbMO were invited to attend a virtual meeting and were presented with the VISION trial data. Their reactions to the data and preferences were collected using audience response technology. Results are presented using descriptive statistics. Results: Among the 287 participating cbMO, median years in practice was 17 (1-45), and median time spent in direct patient care was 90% (20-100%). In the past year, 46% of cbMO managed 6-15 patients with mCRPC, and 27% managed 16 or more. CbMO reported that at the time of referral, their patients with mCRPC had commonly been treated with androgen deprivation therapy (77%) and one (49%) or two plus (20%) novel hormonal agents. After reviewing the recent data from the VISION trial showing improved survival outcomes in mCRPC, 51% of cbMO reported that both the safety and efficacy data were compelling, and they were very likely to prescribe 177Lu-PSMA-617 if approved; 33% indicated that the efficacy data alone was compelling and were likely to prescribe 177Lu-PSMA-617. The top 2 limitations of the VISION trial were identified as PSMA gallium positivity for eligibility (54%) and the disallowance of radium-223 on the SOC arm (48%). Regarding perceived barriers to future use of 177Lu-PSMA-617, 68% and 64% of cbMO reported availability of a PSMA-gallium scan and availability/access of the therapy itself, respectively, would be the greatest barriers. Additional barriers included cost (42%) and difficulty with reimbursement (30%), highlighting the importance of addressing access and financial considerations associated with 177Lu-PSMA-617. Conclusions: Most cbMO found the VISION trial data of 177Lu-PSMA-617 in mCRPC compelling and indicated that they are likely to incorporate it into their patient management, if approved. However, major barriers such as the incorporation of PSMA-gallium scans, 177Lu-PSMA-617 availability, and cost will need to be addressed to encourage widespread adoption of this new therapy.

Impact of social determinants of health on cancer care: a survey of community oncologists

OBJECTIVE

Cancer survival rates have improved over the past few decades, yet socioeconomic disparities persist. Social determinants of health (SDOH) have consistently been shown to correlate with health outcomes. The objective of this study was to characterise oncologists' perceptions of the impact of SDOH on their patients, and their opinions on how these effects could be remediated.

DESIGN

Cross-sectional survey of physicians.

SETTING

Web-based survey completed prior to live meetings held between February and April 2020.

PARTICIPANTS

Oncologists/haematologists from across the USA.

EXPOSURE

Clinical practice in a community-based or hospital-based setting.

MAIN OUTCOME AND MEASURE

Physician responses regarding how SDOH affected their patients, which factors represented the most significant barriers to optimal health outcomes and how the impact of SDOH could be mitigated through assistance programmes.

RESULTS

Of the 165 physicians who completed the survey, 93% agreed that SDOH had a significant impact on their patients' health outcomes. Financial security/lack of insurance and access to transportation were identified most often as the greatest barriers for their patients (83% and 58%, respectively). Eighty-one per cent of physicians indicated that they and their staff had limited time to spend assisting patients with social needs, and 76% reported that assistance programmes were not readily accessible. Government organisations, hospitals, non-profit organisations and commercial payers were selected by 50% or more of oncologists surveyed as who should be responsible for delivering assistance programmes to patients with social needs; 42% indicated that pharmaceutical manufacturers should also be responsible.

CONCLUSION

Our survey found that most oncologists were aware of the impact of SDOH on their patients but were constrained in their time to assist patients with social needs. The physicians in our study identified a need for more accessible assistance programmes and greater involvement from all stakeholders in addressing SDOH to improve health outcomes.

Interaction with patients of color or ethnic minority (PCEM): Oncologist perceptions of racial anxiety and/or implicit bias (RA/IB)

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Background: Oncologists interacting with PCEM may be unaware of RA/IB, yet data show lower-quality care. Helping oncologists recognize this may improve quality of patient-provider interaction, care, and outcomes. We conducted a descriptive study of medical/hematologic oncologists to assess perceptions of RA/IB impact on PCEM interaction. Methods: From February to April 2021, U.S.-based medical/hematologic oncologists participated in an online survey of perceptions on cancer care and outcomes in PCEM (part of broader survey of various clinical and practice-related concerns). Questions used a modified 5-point Likert scale with an option of declining to answer, and respondents were aware data would be anonymized and aggregated. Results: Among 369 physicians surveyed, median years in practice were 17 (range 2-49). Most (72.4%) were in community settings; 64.0% were age 40 to 59 years; 20.6% identified as female, 70.5% male, and 8.7% declined to disclose. Racial distribution was 32.0% White, 33.1% Asian, 7.0% Black, 4.1% Hispanic/Latinx, and 18.7% declined to disclose. When asked the degree of RA/IB White providers had toward PCEM, 39.6% chose low/none, 33.3% moderate, 14.9% high/very high, and 12.2% declined. When asked whether RA/IB among White providers adversely affects PCEM, 37.1% somewhat/strongly agreed, 29.3% somewhat/strongly disagreed, 23.6% neither agreed nor disagreed, and 10.0% declined. Also, 7.9% declined to estimate percent of non-White patients managed. Perceived frequency of scenarios involving RA/IB impacting PCEM interaction at their practices was also assessed (Table). Notably, 12.0% to 14.0% declined to answer regarding their own practices. Although most oncologists (76.4%) perceived RA/IB among White providers toward PCEM, only 37.1% agreed it had adverse effects. Conclusions: Discrepancy in perception of RA/IB among White providers and its effect on PCEM suggests a need to show causality, and declining to respond suggests mistrust/apprehension in expressing true views. Findings suggest oncologists may benefit from improved education and awareness regarding RA/IB in PCEM interaction, treatment, and outcomes. Provider responses (N=369).[Table: see text]

Physician satisfaction with electronic medical records (EMRs): Time for an intelligent health record?

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Background: EMRs are devised to improve the quality and efficiency of healthcare delivery and to reduce medical errors. Despite the widespread use of EMRs, various factors can limit their effectiveness in improving healthcare quality. General EMR use has been cited as a factor contributing to increased workload and clinician burnout in oncology and other specialties. The objective of this qualitative research study was to identify barriers perceived by medical oncologists and hematologists (mO/H) in utilizing EMR software and factors associated with levels of satisfaction. Methods: Between January and April 2021, mO/H from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 369 mO/H completed the survey: 72% practice in a community setting; 47% identified as a hospital employee; they have an average of 19 years of clinical experience and spend on average 86% of their working time in direct patient care, seeing 17 patients per day on average on clinic days. Most (99%) of mO/H surveyed use an EMR software at their practice, with Epic (45%) and OncoEMR (16%) being the most common. Regarding satisfaction, 16% and 50% reported feeling highly satisfied and satisfied, respectively, with their current EMR, and 3% and 11% reported feeling very dissatisfied or dissatisfied, respectively. Some (19%) stated that they have considered changing their EMR, and 68% are unsure how EMR licensing fees for their practice are paid. EMR pain points most commonly experienced were: time-consuming, e.g., too many steps/click (70%); interoperability, e.g., difficulty sharing information across institutions or other EMR software (45%); data entry issues, e.g., difficulty entering clinical information, scheduling patient visits and reminders, or ordering multiple labs (38%); and poor workflow support (31%). The most useful aspects/features of their EMR software reported were availability of information, e.g., preloaded protocols, chemotherapy regimens and pathways (64%); data access (64%); and multiple access points, including remote access (37%). Conclusions: Satisfaction with EMR were generally positive among the mO/H surveyed. However, there are multiple deterrents to the efficient use of current EMR systems. This information is essential in the design of next-generation EMR (an Intelligent Medical Records system) to allow for incorporation of aspects most useful to the end-users, such as pathway access, preloaded information on cancer management as well as ease of access and portability, and a user experience that minimizes clicks and reduces physician time with EMR.

Cancer treatment and outcomes in patients of color or ethnic minority (PCEM): Oncologist perceptions of racial anxiety and/or implicit bias (RA/IB)

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Background: Healthcare disparities are prevalent in cancer, with patients of color or ethnic minority (PCEM) at greatest risk for poor outcomes due to limited access to care, low health literacy and socioeconomic status, and potentially, racial anxiety and/or implicit bias (RA/IB) among oncologists. We conducted a descriptive study of medical/hematologic oncologists to assess perceptions of impact of RA/IB on treatment decisions and outcomes in PCEM. Methods: From February to April 2021, U.S.-based medical/hematologic oncologists participated in an online survey of perceptions regarding cancer care and outcomes in PCEM as part of a broader survey of various clinical and practice-related concerns. Questions used a modified 5-point Likert scale with an option of declining to answer, and respondents were aware that data would be anonymized and aggregated. Results: Among the 369 physicians surveyed, median years in practice were 17 (range 2-49). Most (72%) worked in community oncology; 64% were age 40 to 59 years; 21% identified as female, 70% as male, and 9% declined to disclose gender. Racial distribution was 32% White, 33% Asian, 7% Black, 4% Hispanic/Latinx, and 19% declined to disclose. Regarding perception of the degree of racial/ethnic healthcare disparity experienced by PCEM, 33% chose moderate, 29% very high/high, 29% low/none, and 8% declined to answer. Regarding how often RA/IB adversely affected survival among PCEM at their own practice, a majority (58%) chose rarely or never, 33% very often/almost always, often, or sometimes, and 9% declined to answer. Perceived frequency of specific scenarios involving RA/IB as adversely influencing treatment decisions at their practice (referral/recommendation for oncologic standard-of-care [SOC] modalities/services) was also assessed. The combinations of very often/almost always, often, and sometimes responses were: clinical trial referral (35%); palliative/hospice care (31%); novel therapeutic regimen vs. SOC selection (e.g., chemo/targeted/radiation therapy) (28%); surgical treatment recommendation (26%); and genetic/genomic testing referral (24%). Notably, 10% to 12% declined to answer. Conclusions: A majority of the medical/hematologic oncologists surveyed recognized the role of RA/IB in substandard treatment and outcomes among PCEM, but were less likely to perceive it within their own practice, suggesting a need for better identification. Notably, 24% to 35% recognized its adverse influence on SOC treatment decisions for PCEM. Further, 19% declined to identify their own race/ethnicity and 10% consistently declined to answer all treatment decision-making questions related to disparity, suggesting mistrust or apprehension in expressing true views. Findings suggest that oncologists may benefit from improved education regarding RA/IB and healthcare disparities in PCEM.

Impact of COVID-19 pandemic on oncologists’ professional and personal lives: A pre-vaccine study

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Background: The COVID-19 pandemic has adversely impacted healthcare workers globally, leading to high rates of burnout, especially among frontline workers. We conducted a study to assess the pandemic’s impact on community-based medical oncologists and hematologists (mO/H) in the U.S. before the widespread distribution of vaccines. Methods: Between October and December 2020, mO/H participated in a compensated, online survey addressing the impact of COVID-19 on oncologists’ professional and personal lives and other issues in oncology; demographic, clinical, and practice-based questions were also asked. Results are presented using descriptive statistics. Results: A total of 259 geographically diverse mO/H, with a median of 18 (1-42) years in practice, completed the survey. At the time of the study, local trends in COVID-19 cases were reported as increasing, stable, or decreasing by 29%, 51%, and 20%, respectively. The summative view of the pandemic was “proud of my work as a physician in the frontlines” (37%), “a challenge to get through” (35%), and “no significant impact” (23%). Over half reported a moderate to severe impact on their professional (60%) and personal lives (65). The top 3 factors adversely impacting professional life were: concern of transmitting COVID-19 to patients or staff (52%), difficulty providing patient care (45%), and loss of income (41%). The top 4 factors adversely impacting personal life were: concerns of safety for self and family (84%), a sense of anxiety (50%), loss of family income (24%), and a sense of depression/doom (22%). Fifty percent agreed or strongly agreed that they had increased burnout at work since the beginning of the pandemic. However, workload was assessed as stable (51%) or reduced (33%) during the pandemic. The top 3 factors contributing to burnout were: loss of face-to-face patient interaction (46%), financial loss by practice (42%), and reduced patient volume (35%). The factors thought to impact income were: use of virtual patients visits (38%), pay cuts from the employer (33%), and cancellation of elective procedures (31%). Overall, 41% reported receiving funds from government-based programs (e.g., CARES act) during the pandemic. While about half (52%) did not believe that the pandemic would impact their retirement, some felt that the pandemic would likely hasten (17%) or delay (17%) their plans to retire. Conclusions: This study confirms greater feelings of burnout among U.S. community-based mO/H in the wake of the pandemic and offers insight into drivers of professional and personal dissatisfaction. While mO/H have concerns about loss of income, notably, loss of in-person patient interaction is also a key factor impacting their professional satisfaction. Given the high baseline rate of burnout among mO/H, it is critical to prevent, mitigate and control additional risks imposed by pandemic-related factors.

Barriers to participation and success in value-based care (VBC) models

70

Background: The enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 initiated the transition from a fee-for-service to a fee-for-value payment system in healthcare. Two government-sponsored VBC models (Oncology Care Model [OCM] and Merit-Based Incentive Payment System [MIPS]) were introduced in 2016 and 2017. Several commercial payers followed suit with similar value-based contracts. Implementing and complying with the performance metrics of these models comes with challenges. This qualitative research study sought to assess participation in both government-sponsored and commercial-insurance-sponsored VBC models among oncology providers and their perceptions regarding the ability to perform successfully. Methods: Between February and April 2021, medical oncologists/hematologists (mO/H) from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 307 mO/H across the U.S. completed the survey: 73% practice in a community setting; 47% identify as hospital employees. The participants spend a median of 90% of their working time in direct patient care, have a median of 16 years of clinical experience, and see a median of 20 patients per day on clinic days. Half participate in a government-sponsored VBC model (21% MIPS and 28% OCM), and 20% participate in a commercial VBC model. A third reported that it is difficult to perform favorably in VBC models (37% government and 35% commercial). Primary challenges deterring favorable performance were navigating the payer landscape and reimbursements (27%), identifying cost-reduction opportunities (20%), tracking costs across an episode (18%), and clinical decision support and compliance (17%). One-third are not satisfied with currently available technology to effectively support their performance in VBC models. Almost half would like to see more seamless integration into practice workflows (49%) and interoperability across platforms including EHRs (42%), and 24% would like artificial intelligence or machine learning features integrated into solutions tools. Conclusions: Oncology practices find it challenging to perform favorably in government and private payer-sponsored VBC models. They are generally dissatisfied with current technology and see an unmet need for interoperability and artificial intelligence to better support their performance in these programs. Further research is needed to determine how best to design and implement VBC programs.

Adoption of telemedicine (Telemed) by medical oncologists/hematologists (mO/H) during the COVID-19 pandemic

285

Background: The COVID-19 pandemic has dramatically impacted access to and delivery of healthcare in the U.S. At the height of the pandemic, many practices began initiating or increasing telemed visits to meet care demands in a quarantined environment. The objective of this descriptive study was to assess mO/H perceptions of benefits and barriers to current and post-pandemic use of telemed in oncology. Methods: Web-based surveys were fielded to mO/H before virtual meetings held between September and November 2020. Participants submitted their demographic information and responses to questions about pandemic impacts on their practice and patients. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 259 mO/H across the U.S. completed the survey; 73% practice in a community setting; 44% identify as hospital employees. The participants spend a median of 90% of their working time in direct patient care, have a median of 18 years of clinical experience, and see a median of 20 patients per day on clinic days. Before the pandemic, 92% of the participants’ practices had telemed capabilities but of those, 77% were not utilizing telemed for any visits. During the pandemic, almost all the participants’ practices were offering telemed, with 97% reporting some patient visits being conducted via telemed. Most (78%) anticipate continuing to offer or conduct some patient visits via telemed. Two-thirds stated that up to 25% of their patient visits could be converted to telemed outside of a pandemic environment. The types of visits that most believe are suitable for telemed include reviewing test/lab results, routine surveillance of chronic conditions, and survivorship care visits. Most (60%) stated that their patients view telemed favorably. About half reported a positive overall experience with telemed, with 47% reporting a better-than-expected experience. Most (79%) estimated that pivoting to telemed equates to a revenue loss of up to 50% for that visit; 53% feel that telemed has had an overall negative financial impact on their practice. Two-thirds have experienced challenges getting reimbursed for telemed claims. The most common challenges with telemed reported were reluctance or inability of patients to participate in telemed (39%) and technology challenges (37%). The most common benefit of telemed reported was safety, i.e., less potential exposure to COVID-19 for providers and staff (65%). Conclusions: Telemed use was infrequent before the pandemic, but utilization has dramatically increased during the pandemic. Despite favorable experiences with telemed, mO/H expect telemed use to decline significantly post-pandemic. This prediction may be driven by the perceived loss of revenue when an in-person visit is converted to telemed visit. Further research is needed in identifying factors that may allow for the long-term adoption of telemed for appropriate patients.

Awareness and utilization of tumor mutation burden (TMB) as a biomarker for administration of immuno-oncology (I-O) therapeutics by practicing community oncologists in the United States (U.S.)

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Background: TMB, a measurement of the number of mutations carried by tumor cells, is emerging as a biomarker for the identification of patients who may benefit from certain I-O-based therapies. TMB-high (TMB-H) tumors, defined by the detection of ≥10 mutations/megabase (mut/Mb) in tumor cells using a tissue-based assay such as the FoundationOneCDx (F1CDx) assay (Foundation Medicine, Inc.), may be more likely to respond to some I-O therapies. Higher neoantigen loads of TMB-H tumors have been proposed to contribute to increased responsiveness of TMB-H tumors to certain I-O therapeutics. Pembrolizumab was approved by the FDA on June 16, 2020 for the treatment of adult and pediatric patients with unresectable or metastatic TMB-H tumors, as determined by F1CDx, based on results from the KEYNOTE-158 trial (NCT02628067), which demonstrated that 50% of patients with TMB-H tumors had response durations of ≥24 months, with objective response rates in TMB-H vs. non-TMB-H patients of 29% and 6%, respectively (Marabelle et al, The Lancet Oncology, 2020). This survey-based study aimed to evaluate awareness and utilization of TMB as a biomarker for I-O therapeutics among practicing community oncologists in the U.S. Methods: Questions related to awareness and utilization of TMB as a biomarker for I-O therapeutics were developed by two medical oncologists (AG and BF) and presented to community oncologists in a web-based survey prior to virtual meetings held between October and November 2020. Descriptive statistics were used to analyze the results. Results: Of the 193 participating providers geographically distributed across the U.S., 15% reported being unaware of either the concept of TMB in I-O therapy or how to use the information clinically. 39% of these providers reported testing ≤25% of patients with advanced cancer for TMB, including 8% who do not test for TMB at all. Misconceptions regarding TMB identified among participating providers included the belief that high TMB is considered to be > 5 mut/Mb among 20% of providers, that TMB is essentially the same as MSI-high among 8% of providers, and that there are no therapies with FDA approval based on TMB among 15% of providers. Further, 37% of the participants did not identify pembrolizumab as an agent approved for the treatment of solid tumors based on TMB-H status. Conclusions: These findings demonstrate that there is a knowledge gap regarding the definition of TMB, testing for TMB, as well as implementation of TMB status in clinical decision making. Education directed towards community oncology providers regarding TMB and its use as a predictive biomarker for I-O therapy may improve its utilization and adoption in solid tumors to improve patient outcomes.

Cooperative group and pharmaceutical sponsored clinical trials: Perceptions of U.S. community oncologists

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Background: Many community-based oncologists in the US participate in clinical trials. These trials largely fall into two categories: trials run by cooperative (co-op) groups, funded and supported by the National Cancer Institute and trials developed, and supported by the pharmaceutical (pharma) industry. This study aimed to assess participation in, and perceptions regarding, co-op versus pharma trials among US community oncologists. Methods: We invited healthcare providers (HCP) across the continental US to attend 4 virtual meetings held between September and November 2020. Participants submitted their demographic information and responses to targeted questions regarding their opinions about co-op- and pharma-sponsored trials via a web-based pre-meeting survey. We evaluated participant HCP practice demographics and survey responses using descriptive statistics. Results: Of 259 surveyed participants, HCPs specialized in hematology-oncology (57%) and medical oncology (40%) with mean (median) 19 (18) years’ clinical experience. Most HCPs (178; 69%) reported participating in clinical research, and of these, 137 (77%) participated in co-op-led and 156 (88%) participated in pharma-led clinical research. HCPs preferred participating in both pharma and co-op (49%), pharma only (22%), and co-op only (11%) trials, while 18% preferred not to participate. Co-op trials were considered more prestigious to lead (86%), less likely to imply a conflict of interest (59%), and to address more pertinent questions (58%), while pharma trials had perceived advantages of better compensation (61%) and superior efficiency (48%). Co-op trials were perceived as not being financially sustainable (69%) and slower to accrue patients (85%) than pharma-led trials. Relatedly, in a hypothetical scenario of competing trials with identical design, the majority (60%) of HCPs preferred enrolling a loved one in a co-op trial. HCPs practicing in facilities with academic affiliation (34%) and in non-academic (66%) settings reported similar perceptions about co-op- and pharma-led trials; though, HCPs in academic settings were more likely to participate in clinical research compared to those in non-academic settings (82% vs. 62% [ P=0.001], respectively). Conclusions: In our survey of experienced HCPs, co-op-led clinical trials were perceived generally more favorably than pharma-led trials, even with concerns regarding cost, feasibility, and slower recruitment. However, despite their preference for co-op trials, HCPs were more likely to participate in pharma-led trials. Almost a third of surveyed HCPs are not participating in clinical trials and a fifth do not wish to. These findings can inform stakeholders (co-op trial leadership, pharma drug development teams, and patient advocacy groups) regarding appropriate education, design, and messaging regarding future clinical trials in oncology.

Racial disparity in uterine cancer treatment and survival: A matter of Black women’s lives

6550

Background: Despite similar incidence rates of uterine cancer (UC) in Black and White women, the former have worse prognosis and survival. Absence of denominator correction for UC hysterectomy (prevalence varies within the United States [US] by race/region) may underestimate incidence. The objective of this study is to compare treatment and survival of patients with UC by race in a large, contemporary, population-based study with at least 5 years of follow-up. Methods: With the latest available data from the Surveillance, Epidemiology, and End Results database, comparisons between Black and White patients were made using chi-square and Mann-Whitney tests. Cox proportional hazards regression estimated the adjusted risk of mortality by including age at diagnosis, race, US region, tumor histology/stage/grade, and receipt of hysterectomy as covariates. Results: A total of 105,036 women (11,028 Black and 94,008 White) newly diagnosed with UC in 2000-2013 and followed through 2018 were identified. Median age at diagnosis was 62 years, and more patients in the South were Black (41% vs 17%, P<.0001). Higher rates of type 2 (15% vs 6%), late-stage (44% vs 28%), and high-grade (48% vs 25%) tumors at diagnosis were also found in Black women (all Ps<.0001; Table). Compared with White women, Black women had lower 5-year survival rate (18% vs 37%, P<.0001), shorter survival (median 49 vs 78 months, P<.0001), and higher adjusted mortality risk (hazard ratio [HR]: 1.3, 95% CI: [1.3, 1.4], P<.0001). Lack or unknown status of hysterectomy was also associated with higher death risk (HR: 3.6, 95% CI: [3.4, 3.9], P<.0001). Conclusions: Correcting for hysterectomy attenuates racial disparity in incidence; however, black women have inferior outcomes primarily due to increased aggressive histology, late-stage, and high-grade tumors as well as decreased use of hysterectomy. Underestimation of at-risk populations may be misdirecting cancer control efforts, highlighting the importance of accurate reporting to inform potential treatment adaptations. Next steps are to assess cancer-specific mortality with Fine-Gray competing risk models.[Table: see text]

Postmarketing requirements for drugs approved by the Food and Drug Administration for the treatment of solid tumor cancers, 2010-2019

e13597

Background: In recent years, efforts to improve the efficiency and speed of drug development and approval have driven a surge of Food and Drug Administration (FDA) approvals for cancer drugs. For many cancer therapies, the serious or life-threatening nature of the condition and unmet medical need confers eligibility for expedited programs. Many cancers are also rare diseases, and the increasing use of precision medicine principles to define cancer types further contributes to smaller trial sizes. With limited clinical evidence at the time of approval, cancer drugs may be subject to a greater burden of postmarketing requirements (PMRs). We analyzed PMRs for solid tumor therapies approved by the FDA over the past decade. Methods: The FDA’s novel drug approvals (2010-2019) were reviewed to identify drugs receiving primary approval for solid tumor indications. Approval letters were accessed via the Drugs@FDA database and analyzed for PMRs required under accelerated approval (AA), the Pediatric Research Equity Act (PREA) and the FDA Amendments Act of 2007 Section 505(o) (505(o)). Data are presented using descriptive statistics. Results: A total of 60 drugs received primary approval from the FDA for solid tumor indications between 2010 and 2019 (20 [33.3%] received AA, 33 [55.0%] received orphan designation, and 45 [75.0%] received Fast Track or Breakthrough Therapy designation). The proportion of drugs receiving AA doubled between the period 2010-2014 and 2015-2019 (Table). Of the 60 drugs approved, 52 (86.7%) received a total of 180 PMRs. All 20 drugs approved under AA received PMRs, with a total of 25 PMRs issued under AA. Data from new clinical trials were required for 22 (88.0%) of the 25 PMRs. No PMRs were issued under PREA. Additional safety data required under 505(o) comprised the largest proportion of PMRs; 155 total PMRs (86.1% of all PMRs) were issued for 45 (75.0%) of the drug approvals. Pharmacokinetic or other clinical safety data were required for 96 (61.9%) of the 155 PMRs. Conclusions: More than three-quarters of the cancer drugs approved for the treatment of solid tumors in the past 10 years were issued PMRs, with the majority requiring new safety data. The results of this study indicate that PMRs represent a critical mechanism by which FDA collects safety and efficacy for solid tumor therapies, and underscore the importance of PMR fulfillment. Post-marketing requirements (PMRs) for solid tumor drugs approved 2010-2019.[Table: see text]

Expanded Access and Right To Try Requests: The Community Oncologist's Experience

PURPOSE:

For patients with cancer who have exhausted approved treatment options and for whom appropriate clinical trials are not available, access to investigational drugs through the US Food and Drug Administration's Expanded Access (EA) program has been an alternative since the program's inception more than 30 years ago. In 2018, federal Right To Try legislation was passed in the United States, creating a second pathway—one that bypasses the US Food and Drug Administration—to obtain unapproved drugs outside of clinical trials. The use of the two programs by community medical oncologists and hematologist-oncologists has not been studied.

METHODS:

Between October 2019 and February 2020, community oncologists-hematologists from across the United States completed web-based surveys about EA and Right To Try pathways for accessing unapproved drugs for their patients. Physicians were asked about their utilization of, and perceptions of, the two programs.

RESULTS:

Of the 238 physicians who completed the survey, 46% indicated that they had attempted to gain access to an investigational drug for a patient using the EA program, whereas 14% reported attempting to use Right To Try pathway to obtain an unapproved drug for a patient. Eighty-nine percent of those who tried to use the EA program reported success in obtaining the investigational drug versus 73% of those who attempted to use the Right To Try pathway.

CONCLUSION:

Our survey found that most community oncologists-hematologists were aware of both the EA and Right To Try pathways, but there is room for improvement in understanding and utilization of the programs.

Referral patterns and treatment preferences in patients with advanced prostate cancer (aPC): Differences between medical oncologists and urologists

71

Background: With the advent of newer non-cytotoxic therapies for aPC, early integration of hormonal therapies (HT), and expansion of services within urology practices [e.g., radiation therapy (RT) and immunotherapy], urology practices are playing a larger role in the management of patients with aPC. In this descriptive study, we sought to assess the differences between medical oncologists (oncs) and urologists (uros) as they pertain to referral patterns and treatment decisions of men with aPC. Methods: Virtual meetings held in August 2020 convened oncs and uros of diverse US regions and practice types with experience treating prostate cancer (PC) to better understand perceptions around the management of patients with PC. Participants submitted responses via web-based pre-meeting surveys and real-time polling. All responses are summarized using descriptive statistics. Results: 66 oncs and 69 uros participated. The advisors were mostly community-based and see on average 20+ patients per day. 75% of uros estimated they refer ≤25% of all of their patients with PC to oncs and 75% of oncs reported that > 50% of their patients with PC referrals are from uros. Other referring physicians identified include primary care (76%), radiation oncs (46%), or hospitalists (40%). Uros perceive oncs as co-managers (86%) for their patients with aPC and rarely (9%) transfer the care of their patients completely to oncs. Referrals from uros to oncs are driven by the need for chemotherapy (chemo) (52%) or progression to metastatic castration-resistant PC (mCRPC) (22%). Oncs reported that upon referral, these patients with PC have already been exposed to HT (75%), RT (66%), and/or surgery (43%). For second-line treatment of asymptomatic patients with mCRPC, oncs most commonly prescribe HT (60%) and chemo (23%), while uros most commonly prescribe sipuleucel-T (45%) and HT (38%). For second-line treatment of patients with mCRPC and symptomatic bony disease, oncs most commonly prescribe chemo (44%) and radium-223 (34%), while uros most commonly prescribe radium-223 (47%) and HT (22%). Conclusions: Uros refer patients with aPC to oncs for chemo. Uros prefer to treat with non-chemo options when possible and retain oncologic care for most of the patients’ cancer journey. The need for chemo is a major reason for referral from uros to oncs. The impact of these provider preferences upon patient outcomes in the real world needs further research. [Table: see text]

Patient-reported outcomes in routine oncology care: Perceptions, execution, and barriers

162

Background: There has been an increased emphasis on patient-reported outcomes (PROs) in recent oncology trials, and the benefits of incorporating PRO assessments during routine care have been established. The aim of the present study was to assess the perceptions, adoption and barriers to implementation of PROs in community practices during routine care. Methods: A live meeting in September 2019 surveyed US-based community oncology health care providers (HCPs), including medical oncologists/hematologists and advanced practice providers (APPs; defined as nurse practitioners and physician assistants) regarding their perceptions of PROs and their adoption of PROs during routine patient care. Participants completed both a web-based premeeting survey and live queries captured via audience response system. Data were summarized using descriptive statistics. Results: 71 HCPs (51 medical oncologists/hematologists and 20 APPs) participated. HCPs described their practices as: urban 50%, suburban 37%, and rural 13%. Over 80% reported having collected PRO data from their patients. Over 90% indicated that PROs are important to guide their treatment of patients, irrespective of the data sources (clinical studies or in real-world). Commonly collected PRO data included disease symptoms (66%), activities of daily living (62%), physical function (61%) and adverse events (59%). The NCCN Distress Thermometer (41%) was reported as the most common PRO instrument used during routine oncology care (Table). Despite understanding the importance of implementing PROs, 54% indicated that more resources (software and incentive systems) are needed, and 53% said that discussing PRO results with each patient is critical to facilitate the collection and utilization of PRO data. 84% were unaware of results of a seminal study which demonstrated that PROs improve quality of life and survival (Basch et al 2016, 2017). Conclusions: Most of the community oncology providers surveyed collected PRO data and acknowledged its value. However, more resources are needed to increase collection and use of PROs during routine care. Education directed towards community oncology providers is needed to highlight the value that PROs can add in cancer care. [Table: see text]

The use of validated geriatric assessment instruments among U.S. community oncologists

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Background: Older adults are disproportionately affected by cancer and may be under-treated due to concerns for adverse events or may suffer excessive toxicity from standard cancer treatments due to comorbidity and diminished physiologic reserve. A geriatric assessment (GA) can assist with risk stratification, inform treatment decisions and improve outcomes in older adults with cancer. This descriptive study aimed to assess knowledge, perceptions, and utilization of GA instruments among community oncologists/hematologists (cOH) with an overall goal to identify actionable disparities in the management of older adults with cancer. Methods: Questions about GA in the care of older adults with cancer were developed by two medical oncologists (AG and BAF) and presented to cOH with diverse geographic representation at live meetings and a preceding web-based survey between September 2019 and February 2020. Descriptive statistics were used to analyze the results. Results: Of the 349 participants, the response rate was 100%. The cut-off age used to define older adults by cOH was: ≥ 65 years (22%), ≥ 70 years (39%), and ≥75 (32%). The proportion of patients aged ≥ 70 years in their practices was reported as: 26-50% (48%) and > 50% (22%). Most cOH (60%) performed no formal GA to inform treatment decisions. The two most common reasons for not performing GA were: “Too cumbersome to incorporate into routine practice” (44%), and “Adds no value beyond the comprehensive history and physical exam” (36%). cOH awareness of validated GA/related instruments was: Mini-Mental State Exam (MMSE; 63%), Comprehensive GA (CGA; 37%) and CARG (Cancer and Aging Research Group) GA tool (22%); 22% were not aware of any validated instruments. Outside of clinical trials, the most frequently used validated GA instruments were: MMSE (54%), CGA (23%), CARG (12%), and CRASH (9%). For older adults with cancer, ECOG performance status and comorbidities were the two GA-related surrogate factors utilized in treatment decisions (88% and 73%, respectively). Conclusions: A majority of US community oncologists do not incorporate formal GA with validated instruments in the decision-making for older patients with cancer due to lack of time, resources and awareness. Education directed towards community oncologists may change perception and practice.

Knowledge and evaluation of geriatric assessment (GA) domains among U.S. community oncologists/hematologists (cOH)

206

Background: GA is a multidisciplinary assessment consisting of the following domains: physical function, comorbidity, cognition, mood, social support, nutrition and medication review. Conducting a GA with validated instruments to assess these domains has been shown to improve outcomes in older adults with cancer [Soo, et al ASCO 2020]. The utilization of validated GA tools and its domains versus use of other surrogates from history and physical exam (HPE) for risk-stratification in older adults in the community practice setting is unclear. In this survey-based study, we assessed the knowledge of GA and the methods used to evaluate GA domains among cOH. Methods: Questions pertaining to GA and the care of older adults with cancer were developed by two medical oncologists (AG and BAF) and presented to cOH with diverse US geographic representation at live meetings and via web-based questionnaire between September 2019 and March 2020. Results were analyzed using descriptive statistics. Results: Of the 173 participants surveyed, 59% reported performing no GA, while 13% and 28% reported performing GA on all and selected older adults, respectively. When presented with a list of daily living activities, over half of cOH were unable to correctly identify all activities of daily living (ADLs) and instrumental ADLs (56% and 70%, respectively). The top 2 methods used by cOH to assess physical functional were the ECOG performance status (82%) and HPE (42%). For assessment of cognition, most cOH used HPE (78%) or the Mini Mental State Exam (MMSE; 12%). Social support was assessed via HPE (44%) or GA (27%). cOH reported that medication review is performed by an office staff (medical assistant 31%, nurse 12%, pharmacist 5%), with the physician signing off on the information reported in the chart irrespective of who entered the medication information (50%). Regarding chemotherapy dosing in older adults with cancer, only 7% utilized GA to inform chemotherapy dose; 48% reported starting at a lower chemotherapy dose with intent to escalate, while 33% reported starting at the standard dose with intent to de-escalate if toxicity is encountered. Lastly, 27% stated that oncologists are not adequately equipped to care for older adults with cancer given the complexity involved. Conclusions: Many cOH do not utilize validated instruments to assess the domains of GA. There also appear to be knowledge gaps regarding individual domains of GA. There is a need to further the education of cOH regarding the components and value of GA in older adults with cancer.

Linking reimbursement to patient-reported quality of life: Provider perspectives

75

Background: In the value-based era, policymakers have begun incorporating quality of life (QoL) components into payment models, such as the Merit-based Incentive Payment System (MIPs), Oncology Care Model (OCM), and Accountable Care Organization (ACO), to increase accountability. This qualitative research study sought to understand how providers address their patients’ QoL issues in a value-based environment. Methods: A live meeting in September 2019 brought together community oncology healthcare providers (HCPs) from across the United States. Participants submitted their demographic information via a web-based pre-meeting survey and their responses pertaining to patient QoL via an audience response system during the live meeting. Participant responses and their practice demographics were analyzed using descriptive statistics. Results: 71 HCPs participated in this live market research program: 51 medical oncologists/hematologists (herein referred to as physicians) and 20 nurse practitioners or physician assistants (herein referred to as APPs). 50% of physicians and 25% of APPs were from privately owned community practices. Half of HCPs indicated that their practices are collecting and reporting QoL data through value-based programs: 28% of physicians and 60% of APPs were in OCM-participating practices. Regarding accountability, over 80% of HCPs strongly agreed that they have a role in improving patients’ QoL. However, 32% of physicians and 25% of APPs agreed that their payment should be tied to patients’ QoL improvement. According to HCPs, the top factor impacting patients’ QoL was symptom and symptom burden (83%). To address QoL in their patients, HCPs reported addressing patients’ psychosocial needs (78%), implementing survivorship care planning (76%), and using nurse navigators (69%). 70% of physicians and 95% of APPs were confident that their patients have reliable resources for managing their QoL issues. Conclusions: HCPs recognize their role in improving patients’ QoL, and their practices have made several transformations to improve patients’ QoL; they are confident that their patients have resources for managing QoL issues. However, many HCPs disagree with linking QoL improvements to their payment. Further studies are needed to understand QoL from patients’ perspectives in the value-based environment.

Real-world utilization of quality-of-life data: Perspectives from community oncology providers

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Background: Quality of life (QoL) is commonly assessed in oncology clinical trials. However, it is unclear if oncology healthcare providers (HCPs) perceive value in these metrics or if they impact clinical practice. We sought to assess the real-world utilization of QoL data and barriers to its adoption among US community oncology providers. Methods: Medical oncologists/hematologists, and advanced practice providers (APPs) participated in a survey to assess their perceptions and the utility of QoL data for routine practice during a live meeting in September 2019. Responses were captured via a web-based premeeting survey and an audience response system during the live meeting. Participant characteristics and responses were summarized using descriptive statistics. Results: A total of 71 HCPs (51 physicians and 20 APPs) participated. Regarding perceptions of QoL in oncology, 50% of physicians and 32% of APPs reported aligning with the sentence “It is important to have QoL, but efficacy is obviously the most critical endpoint.” HCPs reported that QoL may outweigh overall survival (OS) in certain clinical scenarios, such as in end-of-life (81%), frail patients (67%), or metastatic tumors (62%). When selecting between two agents with similar efficacy, safety was the most important factor (78%), followed by QoL (40%). 64% of physicians utilized aggregate QoL data from registrational trials or real-world studies to keep informed about QoL of different treatments, while 69% of APPs relied on their personal or practice experiences. 85% of physicians and 84% of APPs responded that it is important to perform formal QoL assessments during routine patient visits. 88% of HCPs expected that QoL/patient-reported outcomes (PRO) collection will increase their workload. Patient burden (58%) and provider resources (43%) were other barriers for QoL/PRO collection. HCPs were largely split regarding their understanding of QoL versus PRO, with 34% reporting that PRO was a subset of QoL and 28% reporting that QoL was a subset of PRO. Conclusions: Efficacy and safety are prioritized as clinical endpoints among oncology HCPs; however, there are certain clinical scenarios where QoL may provide more impactful data for HCPs in managing patients. Barriers remain to successful collection of QoL, and there is a need for further education among HCPs regarding PROs and QoL.

Perceptions of community hematologists/oncologists on barriers to chimeric antigen receptor T-cell therapy for the treatment of diffuse large B-cell lymphoma

Objective: To determine the perceptions of US community-based hematologists/oncologists regarding approved CAR-T therapies in relapsed/refractory large B-cell lymphoma and barriers to their adoption in practice. Materials & methods: In February and November 2019, US physicians with diverse geographic representation submitted responses via a web-based survey prior to or via an audience response system at the live meetings. Results: In February and November, 46 and 29% of physicians indicated that they had not referred any patients for CAR-T therapy, respectively. Cumbersome logistics, high cost and toxicity were defined as major barriers to prescribing CAR-T therapy. Conclusions: These findings highlight a need to improve processes, and address costs, to ensure timely access to this potentially curative therapy for relapsed/refractory large B-cell lymphoma patients.

Physician treatment preferences for metastatic triple negative breast cancer (mTNBC) in an era of immunotherapy

e13095

Background: TNBC accounts for 10-20% of all breast cancer and has poor prognosis. Guidelines now list atezolizumab with nab-paclitaxel (ANP) as preferred for mTNBC w/ PD-L1 expression > 1%. We sought to assess current mTNBC prescribing and sequencing preferences for first-line (1L), second-line (2L), and third-line (3L) therapy among U.S. community oncologists (c-oncs). Methods: C-oncs were presented 4 hypothetical mTNBC clinical scenarios (CS 1-4) via web-based survey. CS differed by PD-L1 expression, menopausal status, prior adjuvant therapy and nature of metastases (bulky liver, lung, bone) but were otherwise uniform in terms of being asymptomatic, BRCA negative, with identical response extent and duration of each line of therapy. Respondents selected their preferred treatment for 1L, 2L, and 3L in each CS in the following categories: single agent (SA) chemotherapy, combination chemotherapy (CC), or ANP. The proportion of c-oncs selecting each treatment approach per CS for each line of therapy was calculated. We describe these preference patterns and how these may deviate from current guidelines. Results: 47 c-oncs participated from across the U.S. (northeast = 23%, midwest = 28%, south = 32%, west = 17%): mean years in practice was 22.7 and mean number of mTNBC patients under treatment was 18.8. The proportion of c-oncs preferring SA, CC or ANP per CS per line of therapy is listed in the table. Deviations from guidelines include preferences for: 1L ANP despite PD-L1 < 1% (26% in CS 1 and 4); 1L CC (45%) in asymptomatic bone only disease (CS1); 2L CC (19-34%) in asymptomatic visceral metastases (CS 2, 3 and 4). The SA 2L (74%)/3L (90%) preferences: capecitabine (36% 2L; 18% 3L) and eribulin (24% 2L; 35% 3L). Gemcitabine + carboplatin was the preferred CC regimen in 2L (50%) and 3L (28%). Conclusions: There is deviation from current guidelines in the treatment preferences for mTNBC patients among c-oncs, specifically the preference for ANP in PD-L1 negative patients and CC in 2L and 3L for asymptomatic patients. [Table: see text]

Prescribing preferences for hormone sensitive (HR+) metastatic breast cancer (mBC) in the CDK 4/6 inhibitor (CDK 4/6i) era

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Background: CDK 4/6i is a category 1 guideline-recommended therapy for HR+/HER2- mBC in both first-line (1L) with an aromatase inhibitor and second-line (2L) with fulvestrant and without prior CDK 4/6i. We sought to understand community oncologists’ (c-oncs) prescribing preferences and sequencing for 1L, 2L, and third-line (3L) HR+/HER2- mBC patients across several common clinical scenarios (CS). Methods: C-oncs were presented 4 hypothetical HR+/HER2- mBC clinical scenarios (CS 1-4) via web-based survey. CS differed by menopausal status, prior adjuvant therapy and nature of metastases (mets) (i.e., bulky liver, lung, bone), but otherwise uniform: asymptomatic presentation, PI3K negative, identical response extent and duration in 1L, 2L, and 3L. Treatment preferences: hormonal (H), single agent (SA) or combination chemotherapy (CC) for 1L, 2L, and 3L in each CS were queried. We describe these preference patterns. Results: 47 U.S. c-oncs participated: mean years in practice was 22.7 and mean mBC patients under active treatment was 23.3. Preference for treatment and sequence, regardless of CS, per LOT were: 1L = 71% H, 14% SA, 16% CC; 2L = 51% H, 31% SA, 16% CC; and 3L = 35% H, 59% SA, 6% CC (Table). Of the 71% who preferred 1L H, the CDK4/6i % were: 73% overall, 58% when mets described as bulky liver, 94% when described as bone and or lung. The preference for pre-planned sequential chemo-hormonal therapy in 1L resulted in 63% of initial chemotherapy followed immediately by H; of which CDK 4/6i was preferred in 47%. In total, the initial and post-chemo CDK4/6i 1L preference was 80%. 2L hormonal preferences by frequency were: everolimus + exemestane = 38%, CDK 4/6i + fulvestrant = 20%, fulvestrant = 19%. SA preferences: 2L = capecitabine 46%, taxane 25%; 3L = capecitabine 40%, eribulin 32%. CC preferences included atezolizumab + nab-paclitaxel 24% in 1L and 16% in 2L. Conclusions: 1L HR+/HER2- mBC treatment is highly variable and preferences that warrant further research include: the role of CC, specifically atezolizumab + nab-paclitaxel; repeated CDK4/6i line of therapy; H therapy post CDK4/6i progression; and optimal SA sequencing. [Table: see text]

Frequency and Causes of Burnout in US Community Oncologists in the Era of Electronic Health Records

BACKGROUND:

Physician burnout, characterized by exhaustion of physical or emotional strength, cynicism, and lack of achievement, has become a worsening phenomenon in medicine, contributing to higher health care costs and patient/physician dissatisfaction. How burnout has affected hematologists and oncologists is not well studied.

METHODS:

US community oncologists/hematologists were queried via a Web-based survey from September-November 2018. Physicians were asked about frequency of burnout symptoms, drivers of work-related stress, and their perceptions on management of workload.

RESULTS:

Among the 163 physicians surveyed, 46% felt a substantial amount of stress at work. Most physicians felt emotionally (85%) and physically (87%) exhausted. A majority of physicians felt lethargic (67%), ineffective (64%), and/or detached (63%). In a typical workweek, 93% needed time beyond time allocated to clinical care to complete work responsibilities. Electronic health record (EHR) responsibilities caused moderate to excessive stress at work for 67% of physicians; 79% of physicians worked on EHRs outside of clinic hours. Other sources of excessive stress were changing reimbursement models (33%), interactions with payers (31%), and increasing patient and caregiver demands (31%). A third of physicians have considered retiring early or changing their career path to cope. To combat burnout, physicians’ practices have used advanced practice providers, invested in information technology, and/or hired additional administrative staff. However, the majority of physicians stated they had optimal or good control over their workload.

CONCLUSION:

Most oncologists experience burnout symptoms and require additional time beyond that allocated to clinical care to complete their workload. The discordance between oncologists’ admission of stress and exhaustion while claiming good control over those same burdens warrants exploration in future research.

Real-time ultrasound-guided needle injection of the mouse jugular vein

This unit describes a novel method for direct venous injection into mice that offers potentially significant advantages over commonly used mouse vein injection techniques. This is achieved via percutaneous needle placement into the mouse jugular vein under real-time B-mode ultrasound (US) imaging. Real-time US imaging of the injection process allows for immediate determination of the overall success of injection. Unique, and potentially significant, advantages of this technique over others include: (1) direct visual confirmation of needle tip placement in the lumen of the vein, (2) immediate visual detection of extravascular extravasation of injectate, when compared to blinded techniques, such as tail vein injections, and (3) reduced morbidity and mortality compared to surgical vascular access techniques (i.e., jugular vein cannulation). This technique may lead to more accurate determination of the success of the injection procedure for each mouse, thus improving the quality of acquired data in dependent mouse experiments.

In vivo and in silico pharmacokinetics and biodistribution of a melanocortin receptor 1 targeted agent in preclinical models of melanoma

The melanocortin 1 receptor (MC1R) is overexpressed in most melanoma metastases, making it a promising target for imaging of melanomas. In this study, the expression of MC1R in a large fraction of patients with melanoma was confirmed using mRNA and tissue microarray. Here, we have characterized the in vivo tumor and tissue distribution and pharmacokinetics (PK) of uptake and clearance of a MC1R specific peptidomimetic ligand conjugated to a near-infrared fluorescent dye. We propose an interdisciplinary framework to bridge the different time and space scales of ligand-tumor-host interactions: intravital fluorescence microscopy to quantify probe internalization at the cellular level, a xenograft tumor model for whole body pharmacokinetics, and a computational pharmacokinetic model for integration and interpretation of experimental data. Administration of the probe into mice bearing tumors with high and low MC1R expression demonstrated normalized image intensities that correlated with expression levels (p < 0.05). The biodistribution study showed high kidney uptake as early as 30 min postinjection. The PK computational model predicted the presence of receptors in the kidneys with a lower affinity, but at higher numbers than in the tumors. As the mouse kidney is known to express the MC5R, this hypothesis was confirmed by both coinjection of a ligand with higher MC5R affinity compared to MC1R and by injection of lower probe concentrations (e.g., 1 nmol/kg), both leading to decreased kidney accumulation of the MC1R ligand. In addition, through this interdisciplinary approach we could predict the rates of ligand accumulation and clearance into and from organs and tumors, and the amount of injected ligand required to have maximum specific retention in tumors. These predictions have potential to aid in the translation of a targeted agent from lab to the clinic. In conclusion, the characterized MC1R-specific probe has excellent potential for in vivo detection of melanoma metastases. The process of cell-surface marker validation, targeted imaging probe development, and in vitro, in vivo, and in silico characterization described in this study can be generally applied to preclinical development of targeted agents.

Modeling negative cooperativity in streptavidin adsorption onto biotinylated microtubules

The nanoscale architecture of binding sites can result in complex binding kinetics. Here, the adsorption of streptavidin and neutravidin to biotinylated microtubules is found to exhibit negative cooperativity due to electrostatic interactions and steric hindrance. This behavior is modeled by a newly developed kinetic analogue of the Fowler-Guggenheim adsorption model. The complex adsorption kinetics of streptavidin to biotinylated structures needs to be considered when these intermolecular bonds are employed in self-assembly and nanobiotechnology.

Cargo loading onto kinesin powered molecular shuttles

Cells have evolved sophisticated molecular machinery, such as kinesin motor proteins and microtubule filaments, to support active intracellular transport of cargo. While kinesins tail domain binds to a variety of cargoes, kinesins head domains utilize the chemical energy stored in ATP molecules to step along the microtubule lattice. The long, stiff microtubules serve as tracks for long-distance intracellular transport. These motors and filaments can also be employed in microfabricated synthetic environments as components of molecular shuttles. In a frequently used design, kinesin motors are anchored to the track surface through their tails, and functionalized microtubules serve as cargo carrying elements, which are propelled by these motors. These shuttles can be loaded with cargo by utilizing the strong and selective binding between biotin and streptavidin. The key components (biotinylated tubulin, streptavidin, and biotinylated cargo) are commercially available. Building on the classic inverted motility assay, the construction of molecular shuttles is detailed here. Kinesin motor proteins are adsorbed to a surface precoated with casein; microtubules are polymerized from biotinylated tubulin, adhered to the kinesin and subsequently coated with rhodamine-labeled streptavidin. The ATP concentration is maintained at subsaturating concentration to achieve a microtubule gliding velocity optimal for loading cargo. Finally, biotinylated fluorescein-labeled nanospheres are added as cargo. Nanospheres attach to microtubules as a result of collisions between gliding microtubules and nanospheres adhering to the surface. The protocol can be readily modified to load a variety of cargoes such as biotinylated DNA, quantum dots or a wide variety of antigens via biotinylated antibodies.