Overuse of Diagnostic Brain Imaging Among Patients With Stage IA Non-Small Cell Lung Cancer

BACKGROUND

Among patients diagnosed with stage IA non-small cell lung cancer (NSCLC), the incidence of occult brain metastasis is low, and several professional societies recommend against brain imaging for staging purposes. The goal of this study was to characterize the use of brain imaging among Medicare patients diagnosed with stage IA NSCLC.

METHODS

Using data from linked SEER-Medicare claims, we identified patients diagnosed with AJCC 8th edition stage IA NSCLC in 2004 through 2013. Patients were classified as having received brain imaging if they underwent head CT or brain MRI from 1 month before to 3 months after diagnosis. We identified factors associated with receipt of brain imaging using multivariable logistic regression.

RESULTS

Among 13,809 patients with stage IA NSCLC, 3,417 (25%) underwent brain imaging at time of diagnosis. The rate of brain imaging increased over time, from 23.5% in 2004 to 28.7% in 2013 (P=.0006). There was significant variation in the use of brain imaging across hospital service areas, with rates ranging from 0% to 64.0%. Factors associated with a greater likelihood of brain imaging included older age (odds ratios [ORs] of 1.16 for 70-74 years, 1.13 for 75-79 years, 1.31 for 80-84 years, and 1.46 for ≥85 years compared with 65-69 years; all P<.05), female sex (OR, 1.09; P<.05), black race (OR 1.23; P<.05), larger tumor size (ORs of 1.23 for 11-20 mm and 1.28 for 21-30 mm tumors vs 1-10 mm tumors; all P<.05), and higher modified Charlson-Deyo comorbidity score (OR, 1.28 for score >1 vs score of 0; P<.05).

CONCLUSIONS

Roughly 1 in 4 patients with stage IA NSCLC received brain imaging at the time of diagnosis despite national recommendations against the practice. Although several patient factors are associated with receipt of brain imaging, there is significant geographic variation across the United States. Closer adherence to clinical guidelines is likely to result in more cost-effective care.

Variation in Use of High-Cost Technologies for Palliative Radiation Therapy by Radiation Oncologists

BACKGROUND

Understanding the sources of variation in the use of high-cost technologies is important for developing effective strategies to control costs of care. Palliative radiation therapy (RT) is a discretionary treatment and its use may vary based on patient and clinician factors.

METHODS

Using data from the SEER-Medicare linked database, we identified patients diagnosed with metastatic lung, prostate, breast, and colorectal cancers in 2010 through 2015 who received RT, and the radiation oncologists who treated them. The costs of radiation services for each patient over a 90-day episode were calculated, and radiation oncologists were assigned to cost quintiles. The use of advanced technologies (eg, intensity-modulated radiation, stereotactic RT) and the number of RT treatments (eg, any site, bone only) were identified. Multivariable random-effects models were constructed to estimate the proportion of variation in the use of advanced technologies and extended fractionation (>10 fractions) that could be explained by patient fixed effects versus physician random effects.

RESULTS

We identified 37,361 patients with metastatic lung cancer, 3,684 with metastatic breast cancer, 5,323 with metastatic prostate cancer, and 8,726 with metastatic colorectal cancer, with 34%, 27%, 22%, and 9% receiving RT within the first year, respectively. The use of advanced technologies and extended fractionation was associated with higher costs of care. Compared with the patient case-mix, physician variation accounted for a larger proportion of the variation in the use of advanced technologies for palliative RT and the use of extended fractionation.

CONCLUSIONS

Differences in radiation oncologists' practice and choices, rather than differences in patient case-mix, accounted for a greater proportion of the variation in the use of advanced technologies and high-cost radiation services.

Association between the 21-gene recurrence score and isolated locoregional recurrence in stage I-II, hormone receptor-positive breast cancer

Background

Although the 21-gene recurrence score (RS) assay is widely used to predict distant recurrence risk and benefit from adjuvant chemotherapy among women with hormone receptor-positive (HR+) breast cancer, the relationship between the RS and isolated locoregional recurrence (iLRR) remains poorly understood. Therefore, we examined the association between the RS and risk of iLRR for women with stage I-II, HR+ breast cancer.

Methods

We identified 1758 women captured in the national prospective Breast Cancer-Collaborative Outcomes Research Database who were diagnosed with stage I-II, HR+ breast cancer from 2006 to 2012, treated with mastectomy or breast-conserving surgery, and received RS testing. Women who received neoadjuvant therapy were excluded. The association between the RS and risk of iLRR was examined using competing risks regression.

Results

Overall, 19% of the cohort (n = 329) had a RS ≥25. At median follow-up of 29 months, only 22 iLRR events were observed. Having a RS ≥25 was not associated with a significantly higher risk of iLRR compared to a RS < 25 (hazard ratio 1.14, 95% confidence interval 0.39–3.36, P = 0.81). When limited to women who received adjuvant endocrine therapy without chemotherapy (n = 1199; 68% of the cohort), having a RS ≥25 (n = 74) was significantly associated with a higher risk of iLRR compared to a RS < 25 (hazard ratio 3.66, 95% confidence interval 1.07–12.5, P = 0.04). In this group, increasing RS was associated with greater risk of iLRR (compared to RS < 18, hazard ratio of 1.66, 3.59, and 7.06, respectively, for RS 18–24, 25–30, and ≥ 31; P_trend = 0.02).

Conclusions

The RS was significantly associated with risk of iLRR in patients who did not receive adjuvant chemotherapy. The utility of the RS in identifying patients who have a low risk of iLRR should be further studied.

Performance of Cancer Recurrence Algorithms After Coding Scheme Switch From International Classification of Diseases 9th Revision to International Classification of Diseases 10th Revision

PURPOSE

We previously developed and validated informatic algorithms that used International Classification of Diseases 9th revision (ICD9)-based diagnostic and procedure codes to detect the presence and timing of cancer recurrence (the RECUR Algorithms). In 2015, ICD10 replaced ICD9 as the worldwide coding standard. To understand the impact of this transition, we evaluated the performance of the RECUR Algorithms after incorporating ICD10 codes.

METHODS

Using publicly available translation tables along with clinician and other expertise, we updated the algorithms to include ICD10 codes as additional input variables. We evaluated the performance of the algorithms using gold standard recurrence measures associated with a contemporary cohort of patients with stage I to III breast, colorectal, and lung (excluding IIIB) cancer and derived performance measures, including the area under the receiver operating curve, average absolute prediction error, and correct classification rate. These values were compared with the performance measures derived from the validation of the original algorithms.

RESULTS

A total of 659 colorectal, 280 lung, and 2,053 breast cancer cases were identified. Area under the receiver operating curve derived from the updated algorithms was 89.0% (95% CI, 82.3% to 95.7%), 88.9% (95% CI, 79.3% to 98.2%), and 80.5% (95% CI, 72.8% to 88.2%) for the colorectal, lung, and breast cancer algorithms, respectively. Average absolute prediction errors for recurrence timing were 2.7 (SE, 11.3%), 2.4 (SE, 10.4%), and 5.6 months (SE, 21.8%), respectively, and timing estimates were within 6 months of actual recurrence for more than 80% of colorectal, more than 90% of lung, and more than 50% of breast cancer cases using the updated algorithm.

CONCLUSION

Performance measures derived from the updated and original algorithms had overlapping confidence intervals, suggesting that the ICD9 to ICD10 transition did not affect the RECUR Algorithm performance.

Interactive or static reports to guide clinical interpretation of cancer genomics

Objective

Misinterpretation of complex genomic data presents a major challenge in the implementation of precision oncology. We sought to determine whether interactive genomic reports with embedded clinician education and optimized data visualization improved genomic data interpretation.

Materials and Methods

We conducted a randomized, vignette-based survey study to determine whether exposure to interactive reports for a somatic gene panel, as compared to static reports, improves physicians’ genomic comprehension and report-related satisfaction (overall scores calculated across 3 vignettes, range 0–18 and 1–4, respectively, higher score corresponding with improved endpoints).

Results

One hundred and five physicians at a tertiary cancer center participated (29% participation rate): 67% medical, 20% pediatric, 7% radiation, and 7% surgical oncology; 37% female. Prior to viewing the case-based vignettes, 34% of the physicians reported difficulty making treatment recommendations based on the standard static report. After vignette/report exposure, physicians’ overall comprehension scores did not differ by report type (mean score: interactive 11.6 vs static 10.5, difference = 1.1, 95% CI, −0.3, 2.5, P = .13). However, physicians exposed to the interactive report were more likely to correctly assess sequencing quality (P < .001) and understand when reports needed to be interpreted with caution (eg, low tumor purity; P = .02). Overall satisfaction scores were higher in the interactive group (mean score 2.5 vs 2.1, difference = 0.4, 95% CI, 0.2-0.7, P = .001).

Discussion and Conclusion

Interactive genomic reports may improve physicians’ ability to accurately assess genomic data and increase report-related satisfaction. Additional research in users’ genomic needs and efforts to integrate interactive reports into electronic health records may facilitate the implementation of precision oncology.

Mortality After Invasive Second Breast Cancers Following Prior Radiotherapy for DCIS

BACKGROUND

Women with a history of ductal carcinoma in situ (DCIS) are at increased risk for developing a second breast cancer (SBC). A prior meta-analysis of randomized studies of radiotherapy (RT) for DCIS has shown a trend toward increased breast cancer-specific mortality after SBC, but it did not have the power needed to detect a significant difference, due to a limited number of recurrences. This study sought to evaluate the impact of RT for DCIS on mortality after SBC in a larger cohort.

PATIENTS AND METHODS

Using the SEER database, 3,407 patients were identified who received breast-conserving therapy with or without RT for primary DCIS in 2000 through 2013 and subsequently developed a stage I-III invasive SBC within the same time period. Fine-Gray competing risk models were used to study the association between receipt of RT and mortality after SBC.

RESULTS

Prior RT was found to be associated with higher rates of breast cancer-specific mortality (hazard ratio [HR], 1.70; 95% CI, 1.18-2.45; P=.005), even after controlling for cancer stage. Interaction analysis suggested that this risk trended higher in patients with ipsilateral versus contralateral SBC (HR, 2.07 vs 1.26; P=.16). Furthermore, compared with patients who developed contralateral SBC, those with ipsilateral SBC were younger (P<.001) and more often lacked estrogen receptor expression (P<.001).

CONCLUSIONS

Patients who previously received RT for DCIS had higher mortality after developing an invasive SBC than those who did not receive RT. This finding may have implications for initial treatment decisions in the management of DCIS.

Determining the Time of Cancer Recurrence Using Claims or Electronic Medical Record Data

PURPOSE

Data from claims and electronic medical records (EMRs) are frequently used to identify clinical events (eg, cancer diagnosis, stroke). However, accurately determining the time of clinical events can be challenging, and the methods used to generate time estimates are underdeveloped. We sought to develop an approach to determine the time of a clinical event-cancer recurrence-using high-dimensional longitudinal structured data.

METHODS

Manual chart abstraction provided information regarding the actual time of cancer recurrence. These data were linked to claims from Medicare or structured EMR data from the Cancer Research Network, which were used to determine time of recurrence for patients with lung or colorectal cancer. We analyzed the longitudinal profile of codes that could help determine the time of recurrence, adjusted for systematic differences between code dates and recurrence dates, and integrated time estimates from different codes to empirically derive an optimal algorithm.

RESULTS

We identified twelve code groups that could help determine the time of recurrence. Using claims data for patients with lung cancer, the optimal algorithm consisted of three code groups and provided an average prediction error of 4.8 months. Using EMR data or applying this approach to patients with colorectal cancer yielded similar results.

CONCLUSION

Time estimates were improved by selecting codes not necessarily the same as those used to identify recurrence, combining time estimates from multiple code groups, and adjusting for systematic bias between code dates and recurrence dates. Improving the accuracy of time estimates for clinical events can facilitate research, quality measurement, and process improvement.

Unrealistic parental expectations for cure in poor-prognosis childhood cancer

BACKGROUND

Many parents of children with advanced cancer pursue curative goals when cure is no longer possible. To the authors' knowledge, no pediatric studies to date have prospectively evaluated prognosis communication or influences on decision making in poor-prognosis childhood cancer.

METHODS

The authors conducted a prospective cohort study at 9 pediatric cancer centers that enrolled 95 parents of children with recurrent or refractory, high-risk neuroblastoma (63% of those who were approached), a condition for which cure rarely is achieved. Parents were surveyed regarding the child's likelihood of cure; their primary goal of care; the child's symptoms, suffering, and quality of life; and regret concerning the last treatment decision. Medical records identified care and treatment decisions.

RESULTS

Only 26% of parents recognized that the chance of cure was <25%. When asked to choose a single most important goal of care, approximately 72% chose cure, 10% chose longer life, and 18% chose quality of life. Parents were more likely to prioritize quality of life when they recognized the child's poor prognosis (P = .002). Approximately 41% of parents expressed regret about the most recent treatment decision. Parents were more likely to experience regret if the child had received higher intensity medical care (odds ratio [OR], 3.14; 95% CI, 1.31-7.51), experienced suffering with limited benefit from the most recent treatment (OR, 4.78; 95% CI, 1.16-19.72), or experienced suffering from symptoms (OR, 2.91; 95% CI, 1.18-7.16).

CONCLUSIONS

Parents of children with poor-prognosis cancer frequently make decisions based on unrealistic expectations. New strategies for effective prognosis communication are needed.

Psychological outcomes related to exome and genome sequencing result disclosure: a meta-analysis of seven Clinical Sequencing Exploratory Research (CSER) Consortium studies

PURPOSE

As exome and genome sequencing (ES/GS) enters the clinic, there is an urgent need to understand the psychological effects of test result disclosure. Through a Clinical Sequencing Exploratory Research (CSER), phase 1 (CSER1) Consortium collaboration, we evaluated participants' psychological outcomes across multiple clinical settings.

METHODS

We conducted a random effects meta-analysis of state anxiety (Hospital Anxiety and Depression Scale [HADS]/Generalized Anxiety Disorder 7-item), depressive symptoms (HADS/Personal Health Questionnaire 9-item), and multidimensional impact (i.e., test-related distress, uncertainty and positive impact: modified Multidimensional Impact of Cancer Risk Assessment/Feelings About Genomic Testing Results scale).

RESULTS

Anxiety and depression did not increase significantly following test result disclosure. Meta-analyses examining mean differences from pre- to postdisclosure revealed an overall trend for a decrease in participants' anxiety. We observed low levels of test-related distress and perceptions of uncertainty in some populations (e.g., pediatric patients) and a wide range of positive responses.

CONCLUSION

Our findings across multiple clinical settings suggest no clinically significant psychological harms from the return of ES/GS results. Some populations may experience low levels of test-related distress or greater positive psychological effects. Future research should further investigate the reasons for test-related psychological response variation.

Spending for Advanced Cancer Diagnoses: Comparing Recurrent Versus De Novo Stage IV Disease

PURPOSE

Spending for patients with advanced cancer is substantial. Past efforts to characterize this spending usually have not included patients with recurrence (who may differ from those with de novo stage IV disease) or described which services drive spending.

METHODS

Using SEER-Medicare data from 2008 to 2013, we identified patients with breast, colorectal, and lung cancer with either de novo stage IV or recurrent advanced cancer. Mean spending/patient/month (2012 US dollars) was estimated from 12 months before to 11 months after diagnosis for all services and by the type of service. We describe the absolute difference in mean monthly spending for de novo versus recurrent patients, and we estimate differences after controlling for type of advanced cancer, year of diagnosis, age, sex, comorbidity, and other factors.

RESULTS

We identified 54,982 patients with advanced cancer. Before diagnosis, mean monthly spending was higher for recurrent patients (absolute difference: breast, $1,412; colorectal, $3,002; lung, $2,805; all P < .001), whereas after the diagnosis, it was higher for de novo patients (absolute difference: breast, $2,443; colorectal, $4,844; lung, $2,356; all P < .001). Spending differences were driven by inpatient, physician, and hospice services. Across the 2-year period around the advanced cancer diagnosis, adjusted mean monthly spending was higher for de novo versus recurrent patients (spending ratio: breast, 2.39 [95% CI, 2.05 to 2.77]; colorectal, 2.64 [95% CI, 2.31 to 3.01]; lung, 1.46 [95% CI, 1.30 to 1.65]).

CONCLUSION

Spending for de novo cancer was greater than spending for recurrent advanced cancer. Understanding the patterns and drivers of spending is necessary to design alternative payment models and to improve value.

How Do Blood Cancer Doctors Discuss Prognosis? Findings from a National Survey of Hematologic Oncologists

Background: Although blood cancers are accompanied by a high level of prognostic uncertainty, little is known about when and how hematologic oncologists discuss prognosis. Objectives: Characterize reported practices and predictors of prognostic discussions for a cohort of hematologic oncologists. Design: Cross-sectional mailed survey in 2015. Setting/Subjects: U.S.-based hematologic oncologists providing clinical care for adult patients with blood cancers. Measurements: We conducted univariable and multivariable analyses assessing the association of clinician characteristics with reported frequency of initiation of prognostic discussions, type of terminology used, and whether prognosis is readdressed. Results: We received 349 surveys (response rate = 57.3%). The majority of respondents (60.3%) reported conducting prognostic discussions with "most" (>95%) of their patients. More than half (56.8%) preferred general/qualitative rather than specific/numeric terms when discussing prognosis. Although 91.3% reported that they typically first initiate prognostic discussions at diagnosis, 17.7% reported routinely never readdressing prognosis or waiting until death is imminent to revisit the topic. Hematologic oncologists with ≤15 years since medical school graduation (odds ratio [OR] 0.51; confidence interval (95% CI) 0.30-0.88) and those who considered prognostic uncertainty a barrier to quality end-of-life care (OR 0.57; 95% CI 0.35-0.90) had significantly lower odds of discussing prognosis with "most" patients. Conclusions: Although the majority of hematologic oncologists reported discussing prognosis with their patients, most prefer general/qualitative terms. Moreover, even though prognosis evolves during the disease course, nearly one in five reported never readdressing prognosis or only doing so near death. These findings suggest the need for structured interventions to improve prognostic communication for patients with blood cancers.

Development, Validation, and Dissemination of a Breast Cancer Recurrence Detection and Timing Informatics Algorithm

Background

This study developed, validated, and disseminated a generalizable informatics algorithm for detecting breast cancer recurrence and timing using a gold standard measure of recurrence coupled with data derived from a readily available common data model that pools health insurance claims and electronic health records data.

Methods

The algorithm has two parts: to detect the presence of recurrence and to estimate the timing of recurrence. The primary data source was the Cancer Research Network Virtual Data Warehouse (VDW). Sixteen potential indicators of recurrence were considered for model development. The final recurrence detection and timing models were determined, respectively, by maximizing the area under the ROC curve (AUROC) and minimizing average absolute error. Detection and timing algorithms were validated using VDW data in comparison with a gold standard recurrence capture from a third site in which recurrences were validated through chart review. Performance of this algorithm, stratified by stage at diagnosis, was compared with other published algorithms. All statistical tests were two-sided.

Results

Detection model AUROCs were 0.939 (95% confidence interval [CI] = 0.917 to 0.955) in the training data set (n = 3370) and 0.956 (95% CI = 0.944 to 0.971) and 0.900 (95% CI = 0.872 to 0.928), respectively, in the two validation data sets (n = 3370 and 3961, respectively). Timing models yielded average absolute prediction errors of 12.6% (95% CI = 10.5% to 14.5%) in the training data and 11.7% (95% CI = 9.9% to 13.5%) and 10.8% (95% CI = 9.6% to 12.2%) in the validation data sets, respectively, and were statistically significantly lower by 12.6% (95% CI = 8.8% to 16.5%, P < .001) than those estimated using previously reported timing algorithms. Similar covariates were included in both detection and timing algorithms but differed substantially from previous studies.

Conclusions

Valid and reliable detection of recurrence using data derived from electronic medical records and insurance claims is feasible. These tools will enable extensive, novel research on quality, effectiveness, and outcomes for breast cancer patients and those who develop recurrence.

Duality of purpose: Participant and parent understanding of the purpose of genomic tumor profiling research among children and young adults with solid tumors

PURPOSE

Increasing use of genomic tumor profiling may blur the line between research and clinical care. We aimed to describe research participants' perspectives on the purpose of genomic tumor profiling research in pediatric oncology.

METHODS

We surveyed 45 participants (response rate 85%) in a pilot study of genomic profiling in pediatric solid tumors at four academic cancer centers following return of sequencing results. We defined understanding according to a one-item ("basic") definition (recognizing that the primary purpose was not to improve the patient's treatment) and a four-item ("comprehensive") definition (primary purpose was not to improve patient's treatment; primary purpose was to improve treatment of future patients; there may not be direct medical benefit; most likely result of participation was not increased likelihood of cure).

RESULTS

Sixty-eight percent of respondents (30/44) demonstrated basic understanding of the study purpose; 55% (24/44) demonstrated comprehensive understanding. Understanding was more frequently seen in those with higher education and greater genetic knowledge according to basic (81% vs 50%, p=0.05; and 82% vs 46%, p=0.03, respectively) and comprehensive definitions (73% vs 28%, p=0.01; 71% vs 23%, p=0.01). Ninety-three percent of respondents who believed the primary purpose was to improve the patient's care simultaneously stated that the research also aimed to benefit future patients.

CONCLUSIONS

Most participants in pediatric tumor profiling research understand that the primary goal of this research is to improve care for future patients, but many express dual goals when participating in sequencing research. Some populations demonstrate increased rates of misunderstanding. Nuanced participant views suggest further work is needed to assess and improve participant understanding, particularly as tumor sequencing moves beyond research into clinical practice.

Medical Care Costs for Recurrent versus De Novo Stage IV Cancer by Age at Diagnosis

OBJECTIVE

To address the knowledge gap regarding medical care costs for advanced cancer patients, we compared costs for recurrent versus de novo stage IV breast, colorectal, and lung cancer patients.

DATA SOURCES/STUDY SETTING

Virtual Data Warehouse (VDW) information from three Kaiser Permanente regions: Colorado, Northwest, and Washington.

STUDY DESIGN

We identified patients aged ≥21 with de novo or recurrent breast (nde novo  = 352; nrecurrent  = 765), colorectal (nde novo  = 1,072; nrecurrent  = 542), and lung (nde novo  = 4,041; nrecurrent  = 340) cancers diagnosed 2000-2012. We estimated average total monthly and annual costs in the 12 months preceding, month of, and 12 months following the index de novo/recurrence date, stratified by age at diagnosis (<65, ≥65). Generalized linear repeated-measures models controlled for demographics and comorbidity.

PRINCIPAL FINDINGS

In the pre-index period, monthly costs were higher for recurrent than for de novo breast (<65: +$2,431; ≥65: +$1,360), colorectal (<65: +$3,219; ≥65: +$2,247), and lung cancer (<65: +$3,086; ≥65: +$2,260) patients. Conversely, during the index and post-index periods, costs were higher for de novo patients. Average total annual pre-index costs were five- to ninefold higher for recurrent versus de novo patients <65.

CONCLUSIONS

Cost differences by type of advanced cancer and by age suggest heterogeneous patterns of care that merit further investigation.

Parental distress and desire for information regarding long-term implications of pediatric cancer treatment

BACKGROUND

Parents of children with cancer have unmet information needs regarding future limitations resulting from cancer or its treatment. Prior research has demonstrated that, in early care discussions, clinicians focus on the acute effects of therapy rather than long-term limitations, partly due to worries of causing distress. The validity of concerns regarding distress is unknown. In the current study, the authors evaluated parental distress associated with information regarding future limitations, and the extent to which distress is associated with information preferences.

METHODS

The authors surveyed 355 parents of children with cancer within 3 months of diagnosis, and the children's physicians at Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and the Children's Hospital of Philadelphia. The primary outcome was parental distress associated with information regarding long-term limitations.

RESULTS

Approximately 46% of parents found information regarding future limitations to be extremely or very upsetting. In multivariate analysis, parents were more likely to consider information regarding future limitations distressing if they also found prognostic information upsetting (odds ratio [OR], 5.36; P<.001), struggled to accept their child's illness (OR, 2.57; P<.001), or had depression (OR, 1.79; P=.01). However, approximately 92% of parents considered information regarding potential future limitations to be extremely/very important. Those who found information regarding future limitations distressing were more likely to consider it important (96% vs 89%; P=.03) and to desire a precise understanding of their child's risks (92% vs 80%; P=.001).

CONCLUSIONS

Although information regarding future limitations caused by cancer treatment is upsetting to many parents, the majority of them desire this information, and those who are distressed are more likely to value this information.

Impact of pre-diagnosis depressive symptoms and health-related quality of life on treatment choice for ductal carcinoma in situ and stage I breast cancer in older women

PURPOSE

To examine whether pre-diagnosis patient-reported health-related quality of life (HRQOL) and depressive symptoms are associated with local treatment for older women with ductal carcinoma in situ (DCIS) and stage I breast cancer (BC).

METHODS

Using the SEER-MHOS dataset, we identified women ≥ 65 years old with DCIS or stage I BC diagnosed 1998-2011 who completed surveys ≤ 24 months before diagnosis. Depressive symptoms were measured by major depressive disorder (MDD) risk and HRQOL was measured by Physical and Mental Component Summary scores (PCS and MCS, respectively) of the SF-36/VR-12. Associations with treatment choice (breast-conserving surgery [BCS] and radiation therapy [RT], BCS alone, mastectomy) were assessed with multivariable multinomial logistic regression, controlling for patient characteristics.

RESULTS

We identified 425 women with DCIS and 982 with stage I BC. Overall, 20.4% endorsed depressive symptoms placing them at risk for MDD pre-diagnosis; mean MCS and PCS scores were 52.3 (SD = 10.1) and 40.5 (SD = 11.5), respectively. Among women with DCIS, those at risk for MDD were more likely to receive BCS (adjusted odds ratio [AOR] 2.04, 95% CI 1.04-4.00, p = 0.04) or mastectomy (AOR 1.88, 95% CI 0.91-3.86, p = 0.09) compared to BCS + RT. For DCIS, MCS score was not associated with treatment; higher PCS score was associated with decreased likelihood of receiving mastectomy versus BCS + RT (AOR 0.71 per 10-point increase, 95% CI 0.54-0.95, p = 0.02). For BC, none of the measures were significantly associated with treatment.

CONCLUSION

Older women at risk for MDD before DCIS diagnosis were less likely to receive RT after BCS, compared to BCS alone or mastectomy.

Hospital variation in outcomes after surgery for prostate cancer

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Background: Surgery for prostate cancer can lead to adverse outcomes, such as incontinence and erectile dysfunction. Studies have identified hospital variation in survival after surgery for other types of cancer; few studies have assessed hospital variation in outcomes after prostate cancer surgery. We sought to characterize hospital variation in incontinence/erectile dysfunction (IED) and overall survival (OS) after prostate surgery. Methods: Using SEER-Medicare claims, we identified men > 65 years old who had surgery for prostate cancer from 2009-13, excluding those with metastatic disease, chemotherapy, or radiation therapy. We computed the difference in the number of days with claims for incontinence or erectile dysfunction in the year after versus the year before prostate surgery (IED score). Then, we assigned each patient to the hospital where prostate surgery was performed, and derived the mean IED score for hospitals that treated ≥10 patients (n = 239). Hierarchical linear and cox regression models were used to assess the association of patient, tumor, and hospital factors with the IED score and OS, respectively. The Kaplan-Meier method was used to estimate 3-year OS. Results: Among 10,850 Medicare-insured men with prostate cancer, the mean difference in claim-days for incontinence or erectile dysfunction during the year after versus before prostate surgery was +2.34 (standard deviation [SD] 3.72, minimum -18, maximum 54). After rescaling the IED score using a 0 (worst) to 100 (best) scale, the mean unadjusted hospital performance was 52.7 (SD 8.0). Controlling for other factors, hospital, NCI-cancer center designation (comprehensive vs. none), region in the US (south or west vs. northeast), and type of prostate surgery (open vs. not) were associated with a higher IED score. The mean 3-year OS across all hospitals was 98% (SD 3%). Conclusions: This claims-based analysis identified significant variation in incontinence/erectile dysfunction after prostate cancer surgery by hospital, but not by patient socio-demographic factors. The IED score may help identify opportunities to improve outcomes. Efforts to validate claims as indicators of patient-centric outcomes and to explore the reasons for hospital-level variation are needed.

Parental distress and desire for information regarding long-term implications of pediatric cancer treatment

BACKGROUND

Parents of children with cancer have unmet information needs regarding future limitations resulting from cancer or its treatment. Prior research has demonstrated that, in early care discussions, clinicians focus on the acute effects of therapy rather than long-term limitations, partly due to worries of causing distress. The validity of concerns regarding distress is unknown. In the current study, the authors evaluated parental distress associated with information regarding future limitations, and the extent to which distress is associated with information preferences.

METHODS

The authors surveyed 355 parents of children with cancer within 3 months of diagnosis, and the children's physicians at Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and the Children's Hospital of Philadelphia. The primary outcome was parental distress associated with information regarding long-term limitations.

RESULTS

Approximately 46% of parents found information regarding future limitations to be extremely or very upsetting. In multivariate analysis, parents were more likely to consider information regarding future limitations distressing if they also found prognostic information upsetting (odds ratio [OR], 5.36; P<.001), struggled to accept their child's illness (OR, 2.57; P<.001), or had depression (OR, 1.79; P=.01). However, approximately 92% of parents considered information regarding potential future limitations to be extremely/very important. Those who found information regarding future limitations distressing were more likely to consider it important (96% vs 89%; P=.03) and to desire a precise understanding of their child's risks (92% vs 80%; P=.001).

CONCLUSIONS

Although information regarding future limitations caused by cancer treatment is upsetting to many parents, the majority of them desire this information, and those who are distressed are more likely to value this information.

Parent understanding of the risk of future limitations secondary to pediatric cancer treatment

BACKGROUND

Parents and physicians may have different understandings of a child's risk of future limitations due to cancer or cancer treatment. We evaluated alignment between parent- and physician-estimated risk of late effects.

METHODS

We surveyed 352 parents of children with cancer within 12 weeks of diagnosis, and the children's oncologists, at Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Children's Hospital of Philadelphia. We assessed parent and physician estimations of the child's risk of future limitations in physical abilities, intelligence, or quality of life (QOL) due to cancer treatment. Physician-estimated risk of limitations ≥50% was considered high risk.

RESULTS

Physicians considered 22% of children at high risk of physical impairments, 9% at high risk for impaired intelligence, and 6% at high risk for impaired QOL. Among high-risk children, 38% of parents recognized this risk in physical abilities, 21% in intelligence, and 5% in QOL. In multivariable analysis, parental understanding of risk, defined as concordant parent and physician estimates, was greater among parents of children at lower risk of future limitations (odds ratio 2.59; 95% confidence interval 1.35-4.96). Regardless of risk, 92% of parents considered it very/extremely important to receive information about potential health implications of cancer treatment.

CONCLUSIONS

Although most parents want information about life after cancer, most parents of children at high risk of future impairment do not recognize this risk. Strategies to improve communication about late effects throughout pediatric cancer treatment should prioritize meeting information needs and improving parent understanding of the risk of impairment.

Comparing Survival After Recurrent vs De Novo Stage IV Advanced Breast, Lung, and Colorectal Cancer

The treatments provided to and survival of patients with recurrent vs de novo stage IV advanced breast, lung, and colorectal cancer may differ but have not been well studied. Using population-based data from the Cancer Research Network for 4510 patients with advanced breast, lung, or colorectal cancer, we matched recurrent/de novo patients on demographic factors. We found longer survival for recurrent vs de novo lung cancer (182 matched pairs); no significant difference for colorectal cancer (332 matched pairs); and shorter survival for recurrent vs de novo breast cancer (219 matched pairs). Compared with recurrent cases, chemotherapy use and radiation therapy use were more common among de novo cases. Differences in treatment and survival between recurrent and de novo advanced cancer patients could inform prognostic estimates and clinical trial design.

Meaningful changes in end-of-life care among patients with myeloma

Patients with advanced myeloma experience a high symptom burden particularly near the end of life, making timely hospice use crucial. Little is known about the quality and determinants of end-of-life care for this population, including whether potential increases in hospice use are also accompanied by “late” enrollment (≤ 3 days before death). Using the Surveillance, Epidemiology, and End-Results-Medicare database, we identified patients ≥ 65 years diagnosed with myeloma between 2000 and 2013 who died by December 31, 2013. We assessed prevalence and trends in hospice use, including late enrollment. We also examined six established measures of potentially aggressive medical care at the end of life. Independent predictors of late hospice enrollment and aggressive end-of-life care were assessed using multivariable logistic regression analyses. Of 12,686 myeloma decedents, 48.2% enrolled in hospice. Among the 6111 who enrolled, 17.2% spent ≤ 3 days there. There was a significant trend in increasing hospice use, from 28.5% in 2000 to 56.5% by 2013 (P_trend <0.001), no significant rise in late enrollment (12.2% in 2000 to 16.3% in 2013, P_trend =0.19), and a slight decrease in aggressive end-of-life care (59.2% in 2000 to 56.7% in 2013, P_trend =0.01). Patients who were transfusion-dependent, on dialysis, or survived for less than one year were more likely to enroll late in hospice and experience aggressive medical care at the end of life. Gains in hospice use for myeloma decedents were not accompanied by increases in late enrollment or aggressive medical care. These findings suggest meaningful improvements in end-of-life care for this population.

Intended and unintended consequences: Ethics, communication, and prognostic disclosure in pediatric oncology

BACKGROUND

The majority of patients desire all available prognostic information, but some physicians hesitate to discuss prognosis. The objective of the current study was to examine outcomes of prognostic disclosure among the parents of children with cancer.

METHODS

The authors surveyed 353 parents of children with newly diagnosed cancer at 2 tertiary cancer centers, and each child's oncologist. Using multivariable logistic regression, the authors assessed associations between parental report of elements of prognosis discussions with the oncologist (quality of information/communication and prognostic disclosure) and potential consequences of these discussions (trust, hope, peace of mind, prognostic understanding, depression, and anxiety). Analyses were stratified by oncologist-reported prognosis.

RESULTS

Prognostic disclosure was not found to be associated with increased parental anxiety, depression, or decreased hope. Among the parents of children with less favorable prognoses (<75% chance of cure), the receipt of high-quality information from the oncologist was associated with greater peace of mind (odds ratio [OR], 5.23; 95% confidence interval [95% CI], 1.81-15.16) and communication-related hope (OR, 2.54; 95% CI, 1.00-6.40). High-quality oncologist communication style was associated with greater trust in the physician (OR, 2.45; 95% CI, 1.09-5.48) and hope (OR, 3.01; 95% CI, 1.26-7.19). Accurate prognostic understanding was less common among the parents of children with less favorable prognoses (OR, 0.39; 95% CI, 0.17-0.88). Receipt of high-quality information, high-quality communication, and prognostic disclosure were not found to be significantly associated with more accurate prognostic understanding.

CONCLUSIONS

The results of the current study demonstrate no evidence that disclosure is associated with anxiety, depression, or decreased hope. Communication processes may increase peace of mind, trust, and hope. It remains unclear how best to enhance prognostic understanding. Cancer 2018;124:1232-41. © 2017 American Cancer Society.

Insurance status and cancer treatment mediate the association between race/ethnicity and cervical cancer survival

Cervical cancer outcomes remain poor among disadvantaged populations, including ethnic minorities, low-income, and underinsured women. The aim of this study was to evaluate the mechanisms that underlie the observed association between race/ethnicity and cervical cancer survival. We identified 13,698 women, ages 21 to 64 years, diagnosed with stages I-III primary cervical cancer between 2007-2013 in Surveillance, Epidemiology, and End Results (SEER). Multivariable Cox proportional hazards regression models evaluated associations between race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other) and cervical cancer-specific mortality. We conducted mediation analysis to calculate the mediation proportion and its 95% confidence interval. Non-Hispanic black women had an increased risk of cervical cancer-specific mortality (HR: 1.23, 95% CI: 1.08-1.39), and Hispanic women a decreased risk of dying from their disease (HR: 0.82, 95% CI: 0.72-0.93), compared with non-Hispanic white. The estimated proportion of excess cervical cancer mortality for non-Hispanic black women relative to non-Hispanic white women that was mediated by insurance was 18.6% and by treatment was 47.2%. Furthermore, non-Hispanic black women were more likely to receive radiation and less likely to receive surgery for early-stage disease. In this population-based study we found that some of the excess cervical cancer-specific mortality for non-Hispanic black women is mediated by factors such as insurance status and treatment. These findings suggest that enhancing existing insurance coverage and ensuring equal and adequate treatment in all women may be a key strategy for improving cervical cancer outcomes.

Use and Effectiveness of Neoadjuvant Chemotherapy for Treatment of Ovarian Cancer

Purpose In 2010, a randomized clinical trial demonstrated noninferior survival for patients with advanced ovarian cancer who were treated with neoadjuvant chemotherapy (NACT) compared with primary cytoreductive surgery (PCS). We examined the use and effectiveness of NACT in clinical practice. Patients and Methods A multi-institutional observational study of 1,538 women with stages IIIC to IV ovarian cancer who were treated at six National Cancer Institute-designated cancer centers. We examined NACT use in patients who were diagnosed between 2003 and 2012 (N = 1,538) and compared overall survival (OS), morbidity, and postoperative residual disease in a propensity-score matched sample of patients (N = 594). Results NACT use increased from 16% during 2003 to 2010 to 34% during 2011 to 2012 in stage IIIC disease ( P_trend < .001), and from 41% to 62% in stage IV disease ( P_trend < .001). Adoption of NACT varied by institution, from 8% to 30% for stage IIIC disease (P < .001) and from 27% to 61% ( P = .007) for stage IV disease during this time period. In the matched sample, NACT was associated with shorter OS in stage IIIC disease (median OS: 33 v 43 months; hazard ratio [HR], 1.40; 95% CI, 1.11 to 1.77) compared with PCS, but not stage IV disease (median OS: 31 v 36 months; HR, 1.16; 95% CI, 0.89 to 1.52). Patients with stages IIIC and IV disease who received NACT were less likely to have ≥ 1 cm postoperative residual disease, an intensive care unit admission, or a rehospitalization (all P ≤ .04) compared with those who received PCS treatment. However, among women with stage IIIC disease who achieved microscopic or ≤ 1 cm postoperative residual disease, NACT was associated with decreased OS (HR, 1.49; 95% CI, 1.01 to 2.18; P = .04). Conclusion Use of NACT increased significantly between 2003 and 2012. In this observational study, PCS was associated with increased survival in stage IIIC, but not stage IV disease. Future studies should prospectively consider the efficacy of NACT by extent of residual disease in unselected patients.

A comparison of cancer risk assessment and testing outcomes in patients from underserved vs. tertiary care settings

In cancer genetics, technological advances (next generation sequencing) and the expansion of genetic test options have resulted in lowered costs and increased access to genetic testing. Despite this, the majority of patients utilizing cancer genetics services lack diversity of gender, ethnicity, and socioeconomic status. Through retrospective chart review, we compared outcomes of cancer genetics consultations at a tertiary cancer center and a Federally Qualified Health Center (FQHC) (58 tertiary and 23 FQHC patients) from 2013 to 2015. The two groups differed in race, ethnicity, use of translator services, and type of insurance coverage. There were also significant differences in completeness of family history information, with more missing information about relatives in the FQHC group. In spite of these differences, genetic testing rates among those offered testing were comparable across the two groups with 74% of tertiary patients and 60% of FQHC patients completing testing. Implementation of community-based cancer genetics outreach clinics represents an opportunity to improve access to genetic counseling services, but more research is needed to develop effective counseling models for diverse patient populations.

Does prognostic uncertainty affect discussions of prognosis? Lessons from a survey of hematologic oncologists

45

Background: Although recent advances in cancer therapy have improved survival for patients with solid tumors, they have also increased the complexity of prognostication (Temel, JCO 2016). Prognostic uncertainty is particularly prevalent in hematologic oncology (LeBlanc, JOP 2014) and potentially a barrier to timely end-of-life (EOL) communication (Odejide, JCO 2016). Methods: In 2015, we mailed a 30-item survey to a national sample of hematologic oncologists randomly selected from the American Society of Hematology directory. The survey was developed through focus groups (n = 20) and cognitive debriefing (n = 5). We aimed to characterize respondents’ reports of prognostic discussions, as well as their timeliness and content. Results: We received 349 surveys from 48 states (response rate: 57%). Median time in practice was 25 years and 57% practiced in community settings. Overall, 60% reported discussing prognosis with “most” ( > 95%) of their patients. Those with < 15 years clinical experience (AOR = 0.54, 95% CI 0.31, 0.94) and those considering prognostic uncertainty to be a barrier to EOL care (AOR = 0.57, 95% CI 0.35, 0.92) were less likely to have prognostic discussions with “most” of their patients. When discussing prognosis, almost all (98%) reported typically having an initial discussion at diagnosis or during a period of stability; however, 18% reported either never readdressing prognosis or doing so only when death is clearly imminent. In terms of preferred terminology, 57% reported routinely having “general discussions of potentially curable disease,” while 43% preferred providing specific data such as percent chance of survival or median survival. Conclusions: The majority of hematologic oncologists in this large cohort reported discussing prognosis with their patients, but doing so qualitatively, focusing on whether cure is possible. About one-fifth reported not readdressing prognosis in a timely manner. These suggest that the prognostic uncertainty common with blood cancers fosters missed opportunities to convey what is known about prognosis. Given the growing difficulty in solid tumor prognostication, these data may foreshadow coming communication gaps for oncology as a whole.

The association between germline BRCA2 variants and sensitivity to platinum-based chemotherapy among men with metastatic prostate cancer

BACKGROUND

Breast cancer 2 (BRCA2)-associated breast and ovarian cancers are sensitive to platinum-based chemotherapy. It is unknown whether BRCA2-associated prostate cancer responds favorably to such treatment.

METHODS

A retrospective analysis of a single-institution cohort of men with castration-resistant, metastatic prostate cancer was performed to determine the association between carrier status of pathogenic BRCA2 germline variants and prostate-specific antigen response to carboplatin-based chemotherapy. From 2001 through 2015, 8081 adult men with prostate cancer who had a consultation and/or underwent treatment at Dana-Farber Cancer Institute provided blood samples and consented to analyses of biologic material and clinical records. A subgroup of 141 men received at least 2 doses of carboplatin and docetaxel for castration-resistant disease (94% were also taxane refractory). These patients were categorized according to the absence or presence of pathogenic germline mutations in BRCA2 based on DNA sequencing from whole blood. The primary outcome was the response rate to carboplatin/docetaxel chemotherapy, defined according to a decline in prostate-specific antigen that exceeded 50% within 12 weeks of initiating this regimen. Associations between BRCA2 mutation status and response to carboplatin-based chemotherapy were tested using the Fisher exact test, with a 2-sided P value < .05 as the threshold for significance.

RESULTS

Pathogenic germline BRCA2 variants were observed in 8 of 141 men (5.7%; 95% confidence interval, 2.5%-10.9%). Six of 8 BRCA2 carriers (75%) experienced prostate-specific antigen declines >50% within 12 weeks, compared with 23 of 133 noncarriers (17%; absolute difference, 58%; 95% confidence interval, 27%-88%; P < .001). Prostate cancer cell lines functionally corroborated these clinical findings.

CONCLUSIONS

BRCA2-associated, castration-resistant prostate cancer is associated with a higher likelihood of response to carboplatin-based chemotherapy than non-BRCA2-associated prostate cancer. Cancer 2017;123:3532-9. © 2017 American Cancer Society.

Estimating Costs of Care Attributable to Cancer: Does the Choice of Comparison Group Matter?

OBJECTIVE

To compare alternative strategies for specifying cancer-free control cohorts for estimating cancer-attributable costs of care.

DATA SOURCE, STUDY DESIGN, DATA EXTRACTION

Secondary data analysis of Surveillance, Epidemiology, and End Results data linked to Medicare claims among patients diagnosed with colorectal, lung, breast, and prostate cancers, 2007-2011. We estimated cancer-attributable costs using three alternative reference cohorts: (1) noncancer Medicare patients individually matched by demographic characteristics, (2) noncancer patients individually matched on demographic factors and comorbidity score, (3) cancer patients as their own control, using prediagnosis costs.

PRINCIPAL FINDINGS

Among 44,266 colorectal, 61,584 lung, 55,921 breast, and 67,733 prostate patients, mean total Medicare spending in the first year of diagnosis was $59,496, $54,261, $31,895, and $26,305, respectively. Estimates of cancer-attributable costs ranged from 79 percent to 82 percent of spending for colorectal, 76 percent-79 percent for lung, 65 percent-74 percent for breast, and 60 percent-75 percent for prostate cancers, depending on the reference cohort used. For all cancers, estimates were higher when patients were used as their own control, compared to demographic and comorbidity-matched controls.

CONCLUSIONS

Choice of reference group can have a substantial impact on proportion of total costs attributed to cancer and should be clearly defined in analyses of the costs of cancer care.

Survival after recurrence of stage I-III breast, colorectal, or lung cancer

BACKGROUND

The experiences of patients with recurrent cancer are assumed to reflect those of patients with de novo stage IV disease; yet, little is truly known because most registries lack recurrence status. Using two databases with excellent recurrence and death information, we examined determinants of survival duration after recurrence of breast (BC), colorectal (CRC), and lung cancers (LC).

METHODS

Recurrence status was abstracted from the medical records of patients who participated in the Cancer Care Outcomes Research and Surveillance study and who received care at two Cancer Research Network sites-the Colorado and Northwest regions of Kaiser Permanente. The analysis included 1653 patients who developed recurrence after completing definitive therapy for stages I-III cancer. Multivariable modeling identified independent determinants of survival duration after recurrence, controlling for other factors.

RESULTS

Through 60 months' average follow-up, survival after recurrence for BC, CRC, and LC were 28.4, 23.1 and 16.1 months, respectively. Several factors were independently associated with shorter survival for all three cancers, including higher initial stage (III vs. I: BC -9.9 months; CRC -6.9 months; LC -7.4 months; P≤0.01). Factors associated with shorter survival for selected cancers included: distant/regional recurrence for BC and CRC; current/former smoker for LC; high grade for CRC; and <4-year time-to-recurrence for BC.

CONCLUSIONS

Initial stage predicts survival duration after recurrence, whereas time-to-recurrence usually does not. The impact of biologic characteristics (e.g., grade, hormone-receptor status) on survival duration after recurrence needs further study. Predictors of survival duration after recurrence may help facilitate patient decision-making.

Why are patients with blood cancers more likely to die without hospice?

BACKGROUND

Although patients with blood cancers have significantly lower rates of hospice use than those with solid malignancies, data explaining this gap in end-of-life care are sparse.

METHODS

In 2015, we conducted a mailed survey of a randomly selected sample of hematologic oncologists in the United States to characterize their perspectives regarding the utility and adequacy of hospice for blood cancer patients, as well as factors that might impact referral patterns. Simultaneous provision of care for patients with solid malignancies was permitted.

RESULTS

We received 349 surveys (response rate, 57.3%). The majority of respondents (68.1%) strongly agreed that hospice care is helpful for patients with hematologic cancers; those with practices including greater numbers of solid tumor patients (at least 25%) were more likely to strongly agree (odds ratio, 2.10; 95% confidence interval, 1.26-3.52). Despite high levels of support for hospice in general, 46.0% felt that home hospice is inadequate for their patients' needs (as compared to inpatient hospice with round-the-clock care). Although more than half of the respondents reported that they would be more likely to refer patients to hospice if red cell and/or platelet transfusions were available, those who considered home hospice inadequate were even more likely to report that they would (67.3% vs 55.3% for red cells [P = .03] and 52.9% vs 39.7% for platelets [P = .02]).

CONCLUSIONS

These data suggest that although hematologic oncologists value hospice, concerns about the adequacy of services for blood cancer patients limit hospice referrals. To increase hospice enrollment for blood cancer patients, interventions tailoring hospice services to their specific needs are warranted. Cancer 2017;123:3377-84. © 2017 American Cancer Society.

Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity

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Background: Most parents of children with cancer say they want detailed prognostic information about their child’s cancer. However, prior work has been conducted in populations of limited diversity. We sought to evaluate the impact of parental race/ethnicity on prognosis communication experiences amongst parents of children with cancer. Methods: We surveyed 357 parents of children with cancer, and the children’s physicians at Dana-Farber Cancer Institute/Boston Children’s Hospital and Children’s Hospital of Philadelphia. Our outcome measures were parental preferences for prognostic information, physician beliefs about parental preferences, prognosis communication processes and communication outcomes. Except where noted, associations were assessed by logistic regression with generalized estimating equations to correct for physician clustering. Results: 87% of parents wanted as much detail as possible about their child’s prognosis, with no significant differences by race/ethnicity (P = .50). Physician beliefs about parental preferences for prognosis communication varied based on parent race/ethnicity. 60% of physicians for White parents reported they believed parents wanted as much detail as possible about their child’s prognosis, versus 36%, 38%, and 64% of physicians, respectively, for Black, Hispanic, and Asian/Other parents (P = .04). Parent race/ethnicity was not associated with actual prognostic disclosure as reported by parents (P = .79) or by physicians (P = .61). Accurate understanding of prognosis was higher amongst White (51%) versus non-White parents (range 22%-29%), although this difference was not statistically significant (P = .13, unadjusted). Conclusions: The majority of parents, regardless of racial and ethnic background, want detailed prognostic information about their child’s cancer. However, physicians rarely recognize the information needs of Black and Hispanic parents. Despite this discrepancy, prognosis communication outcomes were largely equivalent. Our findings suggest that in order to meet parents’ information needs, physicians should ask about the information preferences of parents of children with cancer prior to prognosis discussions.

Determinants of spending for metastatic breast, lung, and colorectal cancer in SEER-Medicare

6621

Background: A substantial proportion of cancer spending is directed towards patients with metastatic disease. Past efforts to characterize spending for metastatic cancer have been limited, because they have not included patients with recurrent disease or analyzed spending across the entire episode of care. Spending for stage IV and recurrent metastatic cancer patients may differ. Methods: Using SEER-Medicare data from 2008-13, we identified breast (BC), colorectal (CRC), and lung (LC) cancer patients who were continuously enrolled in parts A, B and D, and had either stage IV or recurrent disease (i.e., return of cancer after resection of stage I-III disease). Mean total Medicare spending/patient per month and per year (2012$US) were estimated from 12 months prior to 12 months after diagnosis, and described for relevant patient sub-groups. Results: In a cohort of 27,847 patients, total spending for stage IV vs. recurrent cancer was 61-73% lower in the year before diagnosis ($11,339 vs. $28,796 for BC; $13,359 and $49,804 for CRC; $15,118 and $49,555 for LC), and 28-88% higher in the year after diagnosis ($68,787 and $42,091 for BC; $111,304 and $58,657 for CRC; $92,181 and $72,354 for LC). When considering the 2 year-period spanning the diagnosis, spending was similar (≤14%) between groups. The primary drivers of spending differences between patients with stage IV and recurrent disease were cancer type and time from diagnosis (Table). Younger age, higher comorbidity, and SEER region were also drivers of higher spending, especially after diagnosis. Conclusions: Spending patterns differ for patients with stage IV vs. recurrent cancer, suggesting different patterns of care that warrant further investigation. Spending differences after diagnosis were driven largely by part B spending, which was due in part to differential chemotherapy use. [Table: see text]

Optimizing somatic genomic reporting and physician interpretation with web-based, interactive technologies

1517

Background: The increased availability of tumor genomic profiling is revolutionizing oncology. However, the promise of precision care will not be realized if providers misinterpret complex genomic data. Methods: We created web-based, interactive reports with enhanced data visualization elements and embedded decision support for > 300 gene panels. We conducted a randomized vignette-based survey study to determine whether exposure to the interactive reports, as compared to static reports, improves physicians’ genomic understanding and report-based satisfaction. Overall comprehension and satisfaction scores were calculated across three vignettes (possible range 0-18 and 1-4 respectively, higher score correspond to improved endpoints). Results: 105 physicians at a major cancer center participated (29% participation rate); 67% medical, 20% pediatric, 7% radiation and 7% surgical oncology; 37% female. Prior to viewing the case-based vignette reports, 34% of physicians reported that they found it difficult to make treatment recommendations based on the standard report in their routine practice. After viewing the case-based vignettes, physicians’ overall comprehension scores did not differ significantly by report type (mean score interactive 11.6 vs. static 10.5, difference = 1.1, 95% CI -0.3, 2.5, p = 0.13). However, physicians who viewed the interactive report were more likely to correctly assess sequencing quality (p < 0.001) and understand when reports needed to be interpreted with caution (e.g., if low tumor purity, p = 0.02). Overall satisfaction scores were significantly higher in the interactive group than the static group (mean score 2.5 vs. 2.1, difference = 0.4, 95% CI 0.2, 0.7, p = 0.001). Of the 92 physicians who endorsed the need for additional genomic support for providers, 66% reported that interactive genomic reports would be helpful. Conclusions: Interactive, genomic reports may improve physicians’ ability to accurately assess genomic data and increase physician satisfaction. To advance the field, further research in representative provider populations is warranted and efforts to integrate interactive genomic reports into electronic health records are needed.

Prevalence and complications associated with off-label use of lenalidomide in older patients with myelodysplastic syndromes (MDS)

7054

Background: Lenalidomide (LEN) is approved for patients with lower-risk MDS with del5q who are transfusion-dependent (TD). We aimed to assess the prevalence and complications associated with LEN use in non-TD older patients with MDS. Methods: Using the SEER-Medicare database we identified Medicare enrollees diagnosed with MDS from 2007-2011. Medicare part D claims were analyzed for evidence of LEN use. CPT, HCPCS, and ICD-9 codes were used to characterize TD MDS (claims for ≥ 2 RBC transfusions within 8 weeks prior to LEN), complications, and baseline risk per SEER-Medicare MDS Risk Score (SMMRS; Uno, Leuk Res 2014). Incident complications during LEN were noted if there were no prior claims for the same within a 1-yr look-back window. Results: Among 469 patients initiating LEN (median age 78 years), 77% received it first-line, and 23% after a hypomethylating agent. Among all, 19% had del5q, 37% had non-del5q MDS, and 44% no histology specified (MDS NOS). SMMRS risk was evenly distributed between low (36%), intermediate (30%), and high (34%). Only 42% of patients were TD at the time of first LEN prescription, and 26% had not been transfused within six months prior to LEN. Non-TD patients receiving LEN were more likely to have lower-risk disease (p = .004), and less likely to have pre-treatment thrombocytopenia (p = .005) or neutropenia (p = .003); they did not differ significantly in age (p = .85), documentation of del5q (p = .51), comorbidity (p = .65) or treatment center volume (p = .80). Median days on LEN for the non-TD was 121. Incident complications post-LEN among the non-TD are shown. Conclusions:These data suggest there is widespread off-label use of LEN in older patients with MDS, as many receive the drug who are not TD. Moreover, off-label exposure to LEN in these patients is associated with a sizable risk of incident complications, which is difficult to justify given they are already living free of transfusion dependence. [Table: see text]

Differences in medical care costs for recurrent versus de novo stage IV cancer by age at diagnosis

6611

Background: To address the paucity of data on costs of cancer recurrence, this study estimated medical care costs of patients diagnosed with recurrent breast, colorectal or lung cancer, and compared costs to patients diagnosed with de novo stage IV disease. Methods: Data from patients enrolled in three health plans who were diagnosed with de novo stage IV or recurrent breast (nstage IV = 352; nrecurrent= 765), colorectal (nstage IV = 1072 and nrecurrent= 542) and lung (nstage IV = 4042 and nrecurrent= 339) cancers between 2000-2012 were used to estimate total medical care costs in the 12 months preceding (pre-index), month of index, and 12 months following (post-index) diagnosis/recurrence date. Cancer patients were identified using tumor registry data. Recurrent cancers were validated by medical record abstraction and the RECUR algorithms –innovative tools to detect recurrence using claims and electronic health record data. We used generalized linear repeated measures regression models controlling for demographic and comorbidity variables to estimate costs (2012 US$), stratified by age at diagnosis (ages < 65, ≥65). Results: Medical care cost differences in the pre-index period indicate higher costs for recurrent cancer patients than for stage IV breast (Age < 65:+$2550; Age ≥65: +$1254), colorectal (Age < 65:+$3295; Age ≥65: +$1653), and lung cancer patients (Age < 65:+$3232; Age ≥65: +$2340). Conversely, in the index and post-index periods, costs for stage IV cancers were higher than recurrent cancer costs. Specifically, post-index period cost differences indicate higher costs for stage IV patients than for recurrent breast (Age < 65:+$683; Age ≥65: +$1172), colorectal (Age < 65:+$3104; Age ≥65: +$1557), and lung cancer patients (Age < 65:+$1136; Age ≥65: +$1103). Conclusions: Our study provides medical care cost estimates of recurrent and de novo stage IV cancers. Cost differences between recurrent and stage IV cancers reveal heterogeneity in care patterns that merits further investigation. The reported study costs, measured in capitated care systems using standardized fee-for-service reimbursement coefficients, may serve as a benchmark for stage-specific phase-of-care oncology episode payment models.

What does the general population think about chemotherapy shortages?

6530

Background: Chemotherapy shortages have been increasingly recognized, and most oncologists report their patients have been at least intermittently affected. Despite their potential impact, little is known about the perspectives of the general population regarding shortages. Methods: In October 2016, we conducted a survey using the GfK KnowledgePanel, an online probability-based sample representative of adults in the United States. We assessed awareness of shortages, and provided vignettes in which a substitute chemotherapy drug had either a major or minor difference in side effects or effectiveness. We asked respondents whether they would want to be informed of a substitution, and, if the original drug were available elsewhere, would transfer care to receive it. We also asked if cancer centers were to publish drugs in shortage at their center, if such data would affect decisions about where to seek care. Analyses applied post-stratification sampling weights to draw national inferences. Results: Of 737 potential participants, 420 (57%) responded; 16% had heard of chemotherapy shortages. Respondents with a personal history of cancer were more likely to have heard of shortages (31% vs 14%, p = 0.03), as were those with greater education (p = 0.01) and those who reported more sources of health information (p = 0.01). Most desired to be informed about a chemotherapy substitution in the setting of both major (87%) and minor (83%) differences in side effects, as well as both major (87%) and minor (82%) differences in effectiveness. In contrast, only 61% reported they would transfer care if a substitute drug had major differences in side effects, and even fewer (40%) for minor differences. Similarly, 72% and 46% reported they would transfer care if a substitute had major or minor differences in effectiveness respectively. Finally, 57% reported that publically-reported shortage data would be a “big factor” in deciding where to be treated. Conclusions: Our data suggest that the general population is largely unaware of chemotherapy shortages. Moreover, in the setting of even minor changes in effectiveness or side effects, respondents wanted to be made aware of substitutions. With major differences, many would seek care elsewhere.

Self-reported sleep disturbance and survival in myelodysplastic syndromes

Neither the prevalence of sleep disturbance nor its association with fatigue and overall survival (OS) are well understood for patients with myelodysplastic syndromes (MDS). New patients at our institution (n = 251; 2006-2014) completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, which includes questions about sleep and fatigue. Fifty-three per cent reported at least 'a little' trouble sleeping. In multivariable models, anaemia and sleep disturbance were associated with fatigue (both P < 0·001). Additionally, in separate models, sleep disturbance (P = 0·002) and fatigue (P = 0·04) both predicted OS. Our data suggest that improving sleep quality may impact MDS-related fatigue and OS.

Use of CA-125 Tests and Computed Tomographic Scans for Surveillance in Ovarian Cancer

Importance

A 2009 randomized clinical trial demonstrated that using cancer antigen 125 (CA-125) tests for routine surveillance in ovarian cancer increases the use of chemotherapy and decreases patients' quality of life without improving survival, compared with clinical observation. The Society of Gynecologic Oncology guidelines categorize CA-125 testing as optional and discourage the use of radiographic imaging for routine surveillance. To date, few studies have examined the use of CA-125 tests in clinical practice.

Objectives

To examine the use of CA-125 tests and computed tomographic (CT) scans in clinical practice before and after the 2009 randomized clinical trial and to estimate the economic effect of surveillance testing.

Design, Setting, and Participants

A prospective cohort of 1241 women with ovarian cancer in clinical remission after completion of primary cytoreductive surgery and chemotherapy at 6 National Cancer Institute-designated cancer centers between January 1, 2004, and December 31, 2011, was followed up through December 31, 2012, to study the use of CA-125 tests and CT scans before and after 2009. Data analysis was conducted from April 9, 2014, to March 28, 2016.

Main Outcomes and Measures

The use of CA-125 tests and CT scans before and after 2009. Secondary outcomes included the time from CA-125 markers doubling to retreatment among women who experienced a rise in CA-125 markers before and after 2009, and the costs associated with surveillance testing using 2015 Medicare reimbursement rates.

Results

Among 1241 women (mean [SD] age 59 [12] years; 1112 white [89.6%]), the use of CA-125 testing and CT scans was similar during the study period. During 12 months of surveillance, the cumulative incidence of patients undergoing 3 or more CA-125 tests was 86% in 2004-2009 vs 91% in 2010-2012 (P = .95), and the cumulative incidence of patients undergoing more than 1 CT scan was 81% in 2004-2009 vs 78% in 2010-2012 (P = .50). Among women whose CA-125 markers doubled (n = 511), there was no significant difference in the time to retreatment with chemotherapy before and after 2009 (median, 2.8 vs 3.5 months; P = .40). During a 12-month period, there was a mean of 4.6 CA-125 tests and 1.7 CT scans performed per patient, resulting in a US population surveillance cost estimate of $1 999 029 per year for CA-125 tests alone and $16 194 647 per year with CT scans added.

Conclusions and Relevance

CA-125 tests and CT scans are still routinely used for surveillance testing in patients with ovarian cancer, although their benefit has not been proven and their use may have significant implications for patients' quality of life as well as costs.

Association of Regional Intensity of Ductal Carcinoma In Situ Treatment With Likelihood of Breast Preservation

Importance

Large regional variation exists in the use of radiotherapy after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Although patients who do not receive initial radiotherapy for DCIS are candidates for subsequent BCS if they experience a second breast event, many undergo mastectomy instead.

Objective

To examine whether regional practice patterns of radiotherapy for DCIS affect the use of mastectomy in these patients.

Design, Setting, and Participants

A retrospective analysis of population-based databases (Surveillance, Epidemiology, and End Results [SEER] and SEER-Medicare). Data were obtained for 2679 women in SEER with a diagnosis of DCIS between 1990 and 2011 and for 757 women in SEER-Medicare with a DCIS diagnosis between 1991 and 2009 who had not undergone radiotherapy for DCIS and experienced a subsequent breast cancer or DCIS diagnosis.

Exposures

Treatment intensity for primary DCIS (high, medium, low), as defined by separating health service areas (HSAs) into 3 clusters based on radiotherapy use.

Main Outcomes and Measures

Mastectomy vs BCS at a second breast event defined as DCIS recurrence or new invasive cancer.

Results

The median (SD) ages of the participants was 64 (13) years for the 2679 SEER population and 79 (6) years for the SEER-Medicare cohort. Residence in an HSA characterized by greater radiotherapy use for DCIS increased the likelihood of receiving mastectomy vs BCS at a subsequent breast event, even among women who had not previously received radiotherapy for DCIS. Adjusted odds ratios for receiving mastectomy were 1.43 (95% CI, 1.10-1.85) and 1.90 (95% CI, 1.27-2.84) in SEER and SEER-Medicare databases, respectively, among women residing in an HSA with the greatest radiotherapy use vs the least, corresponding to an adjusted increase from 40.8% to 49.6%, and from 38.6% to 54.5%.

Conclusions and Relevance

Areas with more radiotherapy use for DCIS had increased use of mastectomy at the time of a second breast event even among patients eligible for breast conservation. This association suggests that physician-related factors are affecting the likelihood of breast preservation.

Decisional Regret Among Parents of Children With Cancer

Purpose Decision making is one of the ways in which parents serve as stewards of their children with cancer, but barriers to informed decision making among parents of children with cancer have been identified. We sought to evaluate the extent to which parents feel satisfied with, or regretful of, decisions made for their child's cancer treatment and to identify factors associated with heightened regret. Methods We surveyed 346 parents of children with cancer within 12 weeks of their initial cancer treatment decision and the children's physicians at Dana-Farber Cancer Institute/Boston Children's Hospital and the Children's Hospital of Philadelphia. Our main outcome measure was heightened regret as measured by the Decisional Regret Scale. Results Sixteen percent of parents (N = 54) met our definition of heightened decisional regret. In a multivariable logistic regression model, race/ethnicity was associated with regret, with black (odds ratio [OR], 6.55; 95% CI, 2.30 to 18.7), Hispanic (OR, 2.15; 95% CI, .69 to 6.65), and other race parents (OR, 4.68; 95% CI, 1.58 to 13.8) at increased risk for regret relative to whites ( P = .001 across all categories). In contrast, parents who reported receiving high-quality information (OR, .45; 95% CI, .23 to .91; P = .03) and detailed prognostic information (OR, .48; 95% CI, .24 to .96; P = .04), who trusted the oncologist completely (OR, .32; 95% CI, .17 to .63; P = .001), and who held their ideal role in decision making (OR, .49; 95% CI, .25 to .95; P = .04) were less likely to experience regret. Conclusion Although many parents are satisfied with decisions made for their children with cancer, racial and ethnic minority parents are at heightened risk for regret. Clinicians may be able to reduce this risk by providing high-quality information, including prognostic information, involving parents in decision making in the ways they wish, and serving as trusted providers.

Barriers to Quality End-of-Life Care for Patients With Blood Cancers

Purpose

Patients with blood cancers have been shown to receive suboptimal care at the end of life (EOL) when assessed with standard oncology quality measures (eg, no chemotherapy ≤ 14 days before death). As they were developed primarily for solid tumors, it is unclear if these measures are appropriate for patients with hematologic malignancies. Moreover, barriers to high-quality EOL care for this specific patient population are largely unknown.

Methods

In 2015, we asked a national cohort of hematologic oncologists about the acceptability of eight standard EOL quality measures. Building on prior qualitative work, we prespecified that measures achieving agreement among at least 55% of respondents would be considered acceptable. We also explored perspectives regarding barriers to quality EOL care.

Results

We received 349 surveys (response rate = 57.3%). Six of the standard measures met the threshold of acceptability, and four were acceptable to > 75% of respondents: hospice admission > 7 days before death, no chemotherapy ≤ 14 days before death, no intubation in the last 30 days of life, and no cardiopulmonary resuscitation in the last 30 days of life. The highest-ranked barriers to quality EOL care reported were “unrealistic patient expectations” (97.3%), “clinician concern about taking away hope” (71.3%), and “unrealistic clinician expectations” (59.0%).

Conclusion

In this large national cohort of hematologic oncologists, standard EOL quality measures were highly acceptable. The top barrier to quality EOL care reported was unrealistic patient expectations, which may be best addressed with more timely and effective advance care discussions.

Parental preparedness for late effects and long-term quality of life in survivors of childhood cancer

BACKGROUND

Parents of children with cancer desire information regarding the late effects of treatment. In the current study, the authors assessed parents' preparedness for late effects at least 5 years after their child's diagnosis.

METHODS

A cross-sectional survey was conducted of all eligible parents of children with cancer between April 2004 and September 2005 at Dana-Farber/Boston Children's Cancer and Blood Disorders Center within 1 year of diagnosis, and a follow-up questionnaire was administered at least 5 years later.

RESULTS

Approximately 66% of parents of children who were still living, and who were able to be contacted, completed the follow-up questionnaire (91 of 138 parents). Approximately 77% of respondents (70 of 91 respondents) were parents of disease-free survivors and 23% (21 of 91 respondents) were parents of children with recurrent disease. The majority of parents believed they were well prepared for their child's oncology treatment (87%), but fewer felt prepared for future limitations experienced by their children (70%; P = .003 using the McNemar test) or for life after cancer (62%; P<.001). On bivariable analysis among parents of disease-free survivors, parents were more likely to believe themselves to be prepared for future limitations when they also reported that communication with the oncologist helped to address worries regarding the future (odds ratio, 4.50; P = .01). At the time of diagnosis, both parents and physicians underestimated a child's risk of future limitations; 45% of parents and 39% of clinicians predicted future limitations in physical abilities, intelligence, or quality of life, but at the time of the follow-up questionnaire >5 years later, 72% of children experienced limitations in at least 1 domain.

CONCLUSIONS

Parents believe themselves to be less prepared for survivorship than for treatment. High-quality communication may help parents to feel more prepared for life after cancer therapy. Cancer 2016;122:2587-94. © 2016 American Cancer Society.