Immunotherapy utilization patterns in patients with advanced cancer and autoimmune disease

PURPOSE

Immunotherapy has been shown to improve cancer survival, but there are no consensus guidelines to inform use in patients with both cancer and autoimmune disease (AD). We sought to examine immunotherapy utilization patterns between cancer patients with and without AD.

PATIENTS AND METHODS

This retrospective cohort study utilized data from a de-identified nationwide oncology database. Patients diagnosed with advanced melanoma, non-small cell lung cancer, and renal cell carcinoma were included. Outcomes of interest included first-line immunotherapy, overall immunotherapy, and number of immunotherapy cycles. We used logistic and Poisson regression models to examine associations between AD and immunotherapy utilization patterns.

RESULTS

A total of 25,076 patients were included (796 with AD). Patients with AD were more likely to be female, White, receive care at academic centers, and have ECOG ≥ 3. Controlling for demographic and clinical variables, AD was associated with lower odds of receiving first-line (odds ratio [OR] = 0.68, 95% confidence interval [CI] 0.56-0.82) and overall (OR = 0.80, 95% CI 0.67-0.94) immunotherapy. Among patients who received at least one cycle of immunotherapy, there was no difference in mean number of cycles received between patients with and without AD (11.3 and 10.5 cycles respectively). The incident rate of immunotherapy cycles received for patients with AD was 1.03 times that of patients without AD (95% CI 1.01-1.06).

DISCUSSION

Patients with AD were less likely to receive immunotherapy as first-line and overall therapy for treatment of their advanced cancer. However, among those who did receive at least one cycle of immunotherapy, patients with AD received a similar number of cycles compared to patients without AD. This not only indicates that AD is not an absolute contraindication for immunotherapy in clinical practice but may also demonstrate overall treatment tolerability and net benefit in patients with AD.

Integrating 4 methods to evaluate physical function in patients with cancer (In4M): protocol for a prospective cohort study

INTRODUCTION

Accurate, patient-centred evaluation of physical function in patients with cancer can provide important information on the functional impacts experienced by patients both from the disease and its treatment. Increasingly, digital health technology is facilitating and providing new ways to measure symptoms and function. There is a need to characterise the longitudinal measurement characteristics of physical function assessments, including clinician-reported outcome, patient-reported ported outcome (PRO), performance outcome tests and wearable data, to inform regulatory and clinical decision-making in cancer clinical trials and oncology practice.

METHODS AND ANALYSIS

In this prospective study, we are enrolling 200 English-speaking and/or Spanish-speaking patients with breast cancer or lymphoma seen at Mayo Clinic or Yale University who will receive intravenous cytotoxic chemotherapy. Physical function assessments will be obtained longitudinally using multiple assessment modalities. Participants will be followed for 9 months using a patient-centred health data aggregating platform that consolidates study questionnaires, electronic health record data, and activity and sleep data from a wearable sensor. Data analysis will focus on understanding variability, sensitivity and meaningful changes across the included physical function assessments and evaluating their relationship to key clinical outcomes. Additionally, the feasibility of multimodal physical function data collection in real-world patients with breast cancer or lymphoma will be assessed, as will patient impressions of the usability and acceptability of the wearable sensor, data aggregation platform and PROs.

ETHICS AND DISSEMINATION

This study has received approval from IRBs at Mayo Clinic, Yale University and the US Food and Drug Administration. Results will be made available to participants, funders, the research community and the public.

TRIAL REGISTRATION NUMBER

NCT05214144; Pre-results.

Estradiol- and progesterone-associated changes in microRNA-induced silencing and reduced anti-seizure efficacy of an antagomir in female mice

About one third of individuals living with epilepsy have treatment-resistant seizures. Alternative therapeutic strategies are thus urgently needed. One potential novel treatment target is microRNA-induced silencing, which is differentially regulated in epilepsy. Inhibitors (antagomirs) of specific microRNAs have shown therapeutic promise in preclinical epilepsy studies; however, these studies were mainly conducted in male rodent models, and research into microRNA regulation in females and by female hormones in epilepsy is scarce. This is problematic because female sex and the menstrual cycle can affect the disease course of epilepsy and may, therefore, also alter the efficacy of potential microRNA-targeted treatments. Here, we used the proconvulsant microRNA miR-324-5p and its target, the potassium channel Kv4.2, as an example to test how microRNA-induced silencing and the efficacy of antagomirs in epilepsy are altered in female mice. We showed that Kv4.2 protein is reduced after seizures in female mice similar to male mice; however, in contrast to male mice, microRNA-induced silencing of Kv4.2 is unchanged, and miR-324-5p activity, as measured by the association with the RNA-induced silencing complex, is reduced in females after seizure. Moreover, a miR-324-5p antagomir does not consistently reduce seizure frequency or increase Kv4.2 in female mice. As a possible underlying mechanism, we found that miR-324-5p activity and silencing of Kv4.2 in the brain were differentially correlated with plasma levels of 17β-estradiol and progesterone. Our results suggest that hormonal fluctuations in sexually mature female mice influence microRNA-induced silencing and could alter the efficacy of potential future microRNA-based treatments for epilepsy in females.Significance StatementMicroRNA-induced silencing is currently investigated in preclinical studies as a potential novel class of treatment target for epilepsy; however, surprisingly little is known about if and how microRNA-induced silencing is regulated by biological sex and if microRNA therapeutics are as effective in females as they are in males. This study shows that microRNA silencing of the potassium channel Kv4.2 and the functional activity of its targeting microRNA, miR-324-5p, change with plasma levels of estrogens and progesterone and that an inhibitor of miR-324-5p is less effective in female mice to suppress seizures. These findings are significant as they suggest microRNA-induced silencing as a novel molecular mechanism contributing to sex differences in epilepsy that could impact future therapy development.

Metrics, baseline scores, and a tool to improve sponsor performance on clinical trial diversity: retrospective cross sectional study

Objective

To develop a measure for fair inclusion in pivotal trials by assessing transparency and representation of enrolled women, older adults (aged 65 years and older), and racially and ethnically minoritized patients.

Design

Retrospective cross sectional study.

Population

Sponsors of novel oncology therapeutics that were approved by the US Food and Drug Administration over 1 January 2012 to 31 December 2017.

Data sources

Trial data from Drugs@FDA, ClinicalTrials.gov, and corresponding publications; cancer incidence demographics from US Cancer Statistics and the American Cancer Society.

Main outcome measures

Transparency measures assess whether trials publicly report participant sex, age, and racial and ethnic identity. Representation measures assess whether trial participant demographics represent more than 80% of the US patient population for studied conditions, calculated by dividing the percentage of study participants in each demographic subgroup by the percentage of the US cancer population with the studied condition per group. Composite fair inclusion measures assess average transparency and representation scores, overall and for each demographic group. Results are reported at the trial, product, and sponsor levels.

Results

Between 1 January 2012 and 31 December 2017, the FDA approved 59 novel cancer therapeutics, submitted by 25 sponsors (all industry companies) on the basis of 64 pivotal trials. All 25 sponsors (100%) reported participant sex, 10 (40%) reported age, and six (24%) reported race and ethnicity. Although 14 (56%) sponsors had adequate representation of women in trials, only six (24%) adequately represented older adults, and four (16%) adequately represented racially and ethnically minoritized patients (black, Asian, Hispanic or Latinx). On overall fair inclusion, one sponsor scored 100% and the median sponsor score was 81% (interquartile range 75-87%). More than half of sponsors (13 (56%) of 25) fairly included women, 20% (n=5) fairly included older adults, and 4% (n=1) fairly included racially and ethnically minoritized patients in trials. 80% of product had pivotal trials that fairly included women, 24% fairly included older adults, and 5% fairly included racially and ethnically minoritized patients.

Conclusions

This novel approach evaluates trials, products, and sponsors on their fair inclusion of demographic groups in research. For oncology trials, substantial room was noted for improved inclusion of older adults and patients who identify as black or Latinx and transparency around the number of participants identifying as Native Hawaiian, Pacific Islander, American Indian, and Alaska Native. These measures can be used by sponsors, ethics committees, among others, to set and evaluate trial diversity goals to help spur progress toward greater research equity in the US.

Old known and possible new biomarkers of ANCA-associated vasculitis

Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) comprises a group of multisystem disorders involving severe, systemic, small-vessel vasculitis with short- and long term serious and life-threating complications. Despite the simplification of treatment, fundamental aspects concerning assessment of its efficacy and its adaptation to encountered complications or to the relapsing/remitting/subclinical disease course remain still unknown. The pathogenesis of AAV is complex and unique, and despite the progress achieved in the last years, much has not to be learnt. Foremost, there is still no accurate marker enabling us to monitoring disease and guide therapy. Therefore, the disease management relays often on clinical judgment and follows a" trial and error approach". In the recent years, an increasing number of new molecules s have been explored and used for this purpose including genomics, B- and T-cell subpopulations, complement system factors, cytokines, metabolomics, biospectroscopy and components of our microbiome. The aim of this review is to discuss both the role of known historical and clinically established biomarkers of AAV, as well as to highlight potential new ones, which could be used for timely diagnosis and monitoring of this devastating disease, with the goal to improve the effectiveness and ameliorate the complications of its demanding therapy.

NCCN Guidelines® Insights: Older Adult Oncology, Version 1.2021

The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.

Clinical trial transparency and data sharing among biopharmaceutical companies and the role of company size, location and product type: a cross-sectional descriptive analysis

OBJECTIVES

To examine company characteristics associated with better transparency and to apply a tool used to measure and improve clinical trial transparency among large companies and drugs, to smaller companies and biologics.

DESIGN

Cross-sectional descriptive analysis.

SETTING AND PARTICIPANTS

Novel drugs and biologics Food and Drug Administration (FDA) approved in 2016 and 2017 and their company sponsors.

MAIN OUTCOME MEASURES

Using established Good Pharma Scorecard (GPS) measures, companies and products were evaluated on their clinical trial registration, results dissemination and FDA Amendments Act (FDAAA) implementation; companies were ranked using these measures and a multicomponent data sharing measure. Associations between company transparency scores with company size (large vs non-large), location (US vs non-US) and sponsored product type (drug vs biologic) were also examined.

RESULTS

26% of products (16/62) had publicly available results for all clinical trials supporting their FDA approval and 67% (39/58) had public results for trials in patients by 6 months after their FDA approval; 58% (32/55) were FDAAA compliant. Large companies were significantly more transparent than non-large companies (overall median transparency score of 95% (IQR 91-100) vs 59% (IQR 41-70), p<0.001), attributable to higher FDAAA compliance (median of 100% (IQR 88-100) vs 57% (0-100), p=0.01) and better data sharing (median of 100% (IQR 80-100) vs 20% (IQR 20-40), p<0.01). No significant differences were observed by company location or product type.

CONCLUSIONS

It was feasible to apply the GPS transparency measures and ranking tool to non-large companies and biologics. Large companies are significantly more transparent than non-large companies, driven by better data sharing procedures and implementation of FDAAA trial reporting requirements. Greater research transparency is needed, particularly among non-large companies, to maximise the benefits of research for patient care and scientific innovation.

Incarceration and Cancer-Related Outcomes (ICRO) study protocol: using a mixed-methods approach to investigate the role of incarceration on cancer incidence, mortality and quality of care

INTRODUCTION

Incarceration is associated with decreased cancer screening rates and a higher risk for hospitalisation and death from cancer after release from prison. However, there is a paucity of data on the relationship between incarceration and cancer outcomes and quality of care. In the Incarceration and Cancer-Related Outcomes Study, we aim to develop a nuanced understanding of how incarceration affects cancer incidence, mortality and treatment, and moderates the relationship between socioeconomic status, structural racism and cancer disparities.

METHODS AND ANALYSIS

We will use a sequential explanatory mixed-methods study design. We will create the first comprehensive linkage of data from the Connecticut Department of Correction and the statewide Connecticut Tumour Registry. Using the linked dataset, we will examine differences in cancer incidence and stage at diagnosis between individuals currently incarcerated, formerly incarcerated and never incarcerated in Connecticut from 2005 to 2016. Among individuals with invasive cancer, we will assess relationships among incarceration, quality of cancer care and mortality, and will assess the degree to which incarceration status moderates relationships among race, socioeconomic status, quality of cancer care and cancer mortality. We will use multivariable logistic regression and Cox survival models with interaction terms as appropriate. These results will inform our conduct of in-depth interviews with individuals diagnosed with cancer during or shortly after incarceration regarding their experiences with cancer care in the correctional system and the immediate postrelease period. The results of this qualitative work will help contextualise the results of the data linkage.

ETHICS AND DISSEMINATION

The Yale University Institutional Review Board (#2000022899) and the Connecticut Department of Public Health Human Investigations Committee approved this study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. Access to the deidentified quantitative and qualitative datasets will be made available on review of the request.

Predictors of Unplanned Hospitalizations Among Older Adults Receiving Cancer Chemotherapy

PURPOSE

Hospitalizations during cancer treatment are costly, can impair quality of life, and negatively affect therapy completion. Our objective was to identify risk factors for unplanned hospitalization among older adults receiving chemotherapy.

METHODS

This is a secondary analysis of a multisite cohort study (N = 750) of patients ≥ 65 years of age evaluated with a geriatric assessment (GA) to predict chemotherapy toxicity. The primary outcome of this analysis was unplanned hospitalizations during treatment; the secondary outcome was length of stay (LOS) of the first hospitalization. Independent variables included pretreatment GA measures, laboratory values, cancer type and stage, and treatment intensity characteristics. We used logistic regression to estimate the odds of hospitalization and generalized linear models for LOS in multivariable analyses.

RESULTS

The sample median age was 72 years (range, 65-94 years); 59% had stage IV disease. At least one unplanned hospitalization occurred in 193 patients (25.7%) during receipt of chemotherapy. In multivariable analyses controlling for cancer type, the following baseline characteristics were significantly associated with increased odds of hospitalization: needing help bathing or dressing (odds ratio [OR], 1.8; 95% CI, 1.0 to 3.1), polypharmacy (≥ 5 meds) (OR, 1.6; 95% CI, 1.1 to 2.4), more comorbid conditions (OR, 1.1; 95% CI, 1.0 to 1.3), availability of someone to take them to the doctor (OR, 2.0; 95% CI, 1.0 to 4.1), CrCl < 60 mL/min (OR, 1.7; 95% CI, 1.1 to 2.4), and albumin < 3.5 g/dL (OR, 1.8; 95% CI, 1.2 to 2.8). In multivariable analyses, older age, self-reported presence of liver or kidney disease, living alone and depressive symptoms were associated with longer LOS.

CONCLUSION

Readily available GA variables and laboratory data, but not age, were associated with unplanned hospitalizations among older adults receiving chemotherapy. If validated, these data can inform prediction models and the design of interventions to decrease unplanned hospitalizations.

Is there variation in private payor payments to cancer surgeons? A cross-sectional study in the USA

OBJECTIVES

Although demand for price transparency in healthcare is growing, variation in private payors' payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors' payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators.

SETTING

Fair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation's largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA.

PARTICIPANTS

We performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

To assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments.

RESULTS

Median allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to $1380 in the costliest region. For MRM, the range was $842-$1760, for lobectomy $326-$3066, for VATS $317-$3307 and for prostatectomy $1716-$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to $1132 (75th percentile); MRM $850-$1620; lobectomy $861-$2767; VATS $1024-$3122; and prostatectomy $2286-$3563.

CONCLUSIONS

There is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care.

Abstract P5-07-08: Development and validation of the “radiotherapy for older women” risk calculator

BACKGROUND: For many older women with early-stage breast cancer, radiotherapy (RT) reduces local recurrence but does not improve overall survival. Risk calculators provide individualized risk estimation; however, there is a paucity of risk calculators specific to the elderly, in whom competing mortality is an important consideration. This study aimed to develop and validate a risk calculator to provide older patients with accurate, personalized risk estimates for local recurrence and mortality.

METHODS: We used two existing prediction models, the Early Breast Cancer Trialist Collaboration Group prediction model for breast cancer specific outcomes and ePrognosis for life expectancy, to construct a simulation model to predict individual patient risk. This new model was used to create the “Radiotherapy for Older Women (ROW)” risk calculator. ROW predicts 5-year and 10-year risks of local recurrence and mortality, according to age, comorbidities, functional status, tumor characteristics, and RT receipt. To validate the risk calculator, we collected clinical data from all women older than 65, with newly diagnosed stage I/II breast cancer between 2001 and 2010 at our institution. Discrimination was assessed using c-statistics. Calibration was examined graphically by plotting observed versus predicted probabilities and Hosmer-Lemeshow tests (H-L tests; a p-value &lt;0.05 indicating poor calibration).

RESULTS: Based on our simulation, the 5-year all-cause mortality estimated by ROW ranged from 2% to 79%. ROW also projected the 5-year local recurrence, from 1% to 57% for patients not undergoing RT, and from 0% to 26% for patients undergoing RT. Among the 487 patients we identified in the validation study, the predicted 5-year mortality was 20%, compared to observed 5-year mortality of 16%. The predicted 5-year local recurrence rate was 3.9%, compared to observed 5-year local recurrence rate of 3.1%. The c-statistics were 0.761 for 5-year mortality and 0.775 for 5-year local recurrence. The calibration plot for 5-year local recurrence reflected good agreement between the observed outcomes and predictions; however, the model seemed to over-estimate 5-year all cause-mortality (H-L test; p=0.01). The performance for 10-year outcomes was similar (Table). A beta-version of this risk calculator can be accessed online at https://rtbreastcancer.org.

CONCLUSIONS: Based on simulation modeling without cohort data collection, the authors developed an online individualized risk calculator. The outcome estimates projected by the tool were compatible with the observed estimates from real-world data. Such individualized risk provision could facilitate shared decision-making between provider and patient. Future research collecting prospective data to validate our estimates is needed.

MortalityLocal recurrencec-statistics95% CIc-statistics95% CI5-year0.761(0.700, 0.822)0.775(0.664, 0.887)10-year0.769(0.722, 0.817)0.721(0.594, 0.849)CI: Confidence interval

Citation Format: Shi-Yi Wang, Sarah Mougalian, Brigid Killelea, Jeph Herrin, Liana Fraenkel, Cary Gross, Suzanne Evans. Development and validation of the “radiotherapy for older women” risk calculator [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-07-08.

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

[Longterm Homecare Augmentation Program in Alpha-1-Antitrypsin Deficient Patients]

BACKGROUND

Augmentation with human alpha-1 proteinase inhibitor is the only specific treatment for Alpha-1-Antitrypsin Deficiency (AATD), a rare genetic disease with symptoms of progressive COPD.

OBJECTIVES

A prospective long-term exploration of outcomes during the "Alpha-1-Mobile" home care AAT augmentation program in seven advanced-stage patients.

METHODS

Patients received weekly i. v. AAT augmentation and COPD therapy. Symptoms, lung function, health status, quality-of-life aspects, and safety were documented continuously. Outcomes during six years of home care augmentation therapy were observed and evaluated on an inter- and intraindividual basis. FEV1 profiles were compared to pre-program data.

RESULTS

The seven patients had a mean age of 56.7 (40-68) years and had previously received augmentation for 8.8 (1-19) years. Compared to the three-year preprogram period, functional decline of FEV1 (ΔFEV1 0.47 L vs 0.17 L) slowed. Mean QoL scores showed seasonal fluctuations in the first three years of observation, and then stabilized. All blood samples tested exceeded the protective threshold of 50 mg/dL with a dose of 60 mg AAT/kg/week. Less than one exacerbation-related hospitalization occurred per patient-year. No adverse events of related to augmentation therapy were observed.

CONCLUSIONS

Home care with i. v. augmentation therapy by medical professionals contributes to optimum care through consistent treatment and close health-status monitoring in our collective. Exacerbation-related hospitalizations were largely avoided. "Alpha-1-Mobile" was well accepted, practical, and safe.

Association Between Guideline-Discordant Prostate Cancer Imaging Rates and Health Care Service Among Veterans and Medicare Recipients

Importance

Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare.

Objective

To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting.

Design, Setting, and Participants

This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018.

Exposures

Patient utilization of different health care delivery systems.

Main Outcomes and Measures

Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer.

Results

Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P < .001). Imaging rates for men with high-risk prostate cancer were not significantly different among the 3 groups. Multivariable analysis showed that individuals in the VA and Medicare group (risk ratio [RR], 0.87; 95% CI, 0.76-0.98) and VA-only group (RR, 0.79; 95% CI, 0.67-0.92) were less likely to receive guideline-discordant imaging than those in the Medicare-only group.

Conclusions and Relevance

The results of this study suggest that patients with prostate cancer who use Medicare rather than the VA for health care could experience more utilization of health care services without an improvement in the quality of care.

Information Needs of Older Women With Early-Stage Breast Cancer When Making Radiation Therapy Decisions

PURPOSE

To identify the information older women with early-stage breast cancer need when making radiation therapy decisions, and who patients identify as the main decision maker.

METHODS AND MATERIALS

We surveyed (through face-to-face interview, telephone, or mail) women aged ≥65 years who received lumpectomy and were considering or receiving adjuvant radiation therapy for early-stage breast cancer. The survey instrument was constructed with input from patient and professional advisory committees, including breast cancer survivors, advocates of breast cancer care and aging, clinicians, and researchers. Participants rated the importance (on a 4-point scale) of 24 statements describing the benefits, side effects, impact on daily life, and other issues of radiation therapy in relation to radiation therapy decision making. Participants also designated who was considered the key decision maker.

RESULTS

The response rate was 56.4% (93 of 165). Mean age was 72.5 years, ranging from 65 to 93 years. More than 96% of participants indicated they were the main decision maker on receiving radiation therapy. There was wide variation in information needs regarding radiation therapy decision making. Participants rated a mean of 18 (range, 3-24) items as "essential." Participants rated items related to benefits highest, followed by side effects. Participants who were older than 75 years rated 13.9 questions as essential, whereas participants aged ≤74 years rated 18.7 as essential (P=.018).

CONCLUSIONS

Older women desire information and have more agency and input in the decision-making process than prior literature would suggest. The variation in information needs indicates that future decision support tools should provide options to select what information would be of interest to the participants.

Exercise adherence in a randomized trial of exercise on aromatase inhibitor arthralgias in breast cancer survivors: the Hormones and Physical Exercise (HOPE) study

PURPOSE

Up to 50 % of postmenopausal breast cancer survivors taking aromatase inhibitors (AIs) experience AI-associated arthralgias, or joint pain, which causes many to stop taking AIs and may inhibit exercise, despite known health benefits. We thus evaluated exercise adherence and factors associated with better exercise adherence in breast cancer survivors experiencing AI-induced arthralgia in the (HOPE) year long randomized controlled trial.

METHODS

We included 61 HOPE women randomized to exercise (150 min/week of moderate-intensity aerobic exercise and twice-weekly supervised strength training). Our main outcomes were aerobic exercise measured with daily activity logs, attendance at supervised exercise sessions, and changes in cardiorespiratory fitness, measured maximal oxygen consumption (VO2max). We examined means and standard deviations (SDs) for exercise adherence by demographic and medical characteristics and used the t test for mean differences. We also examined predictors of adherence using linear regression.

RESULTS

On average, at the end of the year long trial, women reported 119 (SD 78) min/week of moderate-intensity aerobic exercise and participated in 70 % of supervised exercise training sessions. After adjustment for other factors that influence adherence, at 6 months postrandomization, only baseline VO2max was associated with higher aerobic exercise levels and at 12 months, only older age predicted better supervised exercise training attendance.

CONCLUSIONS

Breast cancer survivors taking AIs and experiencing arthralgia are able to initiate and maintain a year long exercise program, regardless of other factors that influence activity levels.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivors can exercise at levels that have been shown to improve AI-associated arthralgia.

Early Clinical Outcome of Patients with Ruptured Cerebral Aneurysms Treated by Endovascular (GDC) or Microsurgical Techniques

Over the past 3.5 years 220 patients with aneurysmal subarachnoid hemorrhage were treated in the Department of Neurosurgery University of Vienna Medical School using either endovascular techniques (Guglielmi Detachable Coils) or open craniotomy with aneurysm clipping.

A retrospective analysis was undertaken to assess whether any difference in outcome could be correlated with the treatment choice.

The patients were stratified as to 1) Hunt and Hess grade at time of treatment, 2) method of treatment, and 3) clinical outcome at 2–4 weeks following treatment.

The outcomes in this population of patients were consistent with recent published series regardless of whether the aneurysms were treated with microvascular surgery or endovascular surgery.

There was a trend toward better outcome in a relatively small sub-group of patients presenting as Hunt and Hess grade III who were treated by the endovascular method. Guglielmi detachable coils have been available for a relatively short time, and although early results are promising, the ultimate long-term efficacy of the coils will have to be assessed.

The impact of emergency department observation units on United States emergency department admission rates

OBJECTIVE

Prior studies suggesting that the presence of emergency department (ED) observation units decrease overall ED hospital admissions have been either single-center studies or based on model simulations. The objective of this preliminary national study is to determine if the presence of ED observation units is associated with hospitals having lower ED admission rates.

METHODS

We conducted a retrospective cross-sectional analysis using the 2010 National Hospital Ambulatory Care Survey and estimated ED risk-standardized hospital admission rates (RSHAR) for each center. The following were excluded from the study: ages <18 years, leaving prior to completion of ED visit, died in the ED, transferred to another facility, and missing disposition. Hospitals with less than 30 ED visits or unknown observation unit status were also excluded. We used linear regression analysis to determine the association between ED RSHAR and presence of observation units.

RESULTS

There were 24,232 ED visits in 315 hospitals in the United States. Of these, 82 (20.6%) hospitals had an ED observation unit. The average ED risk-standardized hospital admission rates for hospitals with observation units and without hospital observation units were 13.7% (95% confidence interval [CI]: 11.3-16.0) and 16.0% (95% CI: 14.1-17.7), respectively. The difference of 2.3% was not statistically significant.

CONCLUSIONS

In this preliminary study, we did not find an association between the presence of observation units and ED hospital admission rates. Further studies with larger sample sizes should be performed to further evaluate the impact of ED observation units on ED hospital admission rates.

Abstract 107: Cardiovascular Events, Early Discontinuation of Trastuzumab, and Their Impact on Survival

Background: Trastuzumab increases risk of cardiovascular (CV) events such as heart failure (HF) in clinical trials. However, it is unknown how often trastuzumab therapy is ended early (i.e. early discontinuation), which CV events are associated with early discontinuation, and how CV events and early discontinuation affect overall survival among older women with breast cancer.

Methods: Using the Surveillance, Epidemiology, and End Results-Medicare dataset, we identified women age 67-94 with stage I-III breast cancer diagnosed 2005-2009 who received trastuzumab adjuvant chemotherapy and followed them through 2011. Completed trastuzumab treatment was defined as ≥11 months of continuous trastuzumab treatments with no delay between trastuzumab treatments >45 days. We identified therapy-associated CV events as those occurring within 45 days before or after the last trastuzumab treatment. We compared CV events between the completed and early discontinuation groups using chi-squared statistics. We used Cox proportional hazard models to examine the association of overall survival with early discontinuation of trastuzumab treatment and CV events.

Results: Our cohort consisted of 585 women (mean age: 71.6 years), with a median follow-up of 4.2 years. Approximately 41% (239) of women did not complete trastuzumab therapy. Patients with early discontinuation of trastuzumab treatment were more likely to have HF/cardiomyopathy (18.8% vs. 4.0%; p<.001), atrial fibrillation (5.4% vs. <3.2%, p=.006), and other cardiovascular events (7.9% vs. 3.5%; p=.017) within 45 days before or after the last trastuzumab treatment. These cardiovascular events were strongly associated with worse survival (adjusted hazard ratio [AHR] 3.54; 95% CI 1.87 to 6.68). Women with early discontinuation of trastuzumab treatment were also more likely to have worse overall survival, but the results were not statistically significant (AHR: 1.74; 95% CI 0.94 to 3.23).

Conclusion: Early discontinuation of trastuzumab treatment is common among older women with breast cancer, and associated with higher rates of CV events. Reducing CV complications from trastuzumab therapy will likely improve overall survival in patients with breast cancer