Cluster-randomized trial to evaluate the implementation of reproductive health care in cancer care delivery in community oncology practices: Results from ECOG-ACRIN E1Q11

1519

Background: Reproductive health (RH) needs of women newly diagnosed with cancer have been poorly addressed. RH management must be aligned with cancer treatment to optimize cancer survivorship. The primary objective of the EROS trial is to evaluate the effectiveness of implementing RH programming to improve RH care among reproductive aged women with cancer. Methods: E1Q11 used a cluster randomized design with 17 NCI Community Oncology Research Program (NCORP) Sites randomized to intervention (n = 8) or usual care (n = 9). Intervention sites received study-specific training delivered via webinar and tools to support RH care implementation. Pre-menopausal women aged 15-55 years newly diagnosed with cancer and pre-initiation of treatment were eligible. The primary endpoint was defined as the delivery of RH goal-concordant management within the first 3 months since enrollment. Data were obtained through patient completed questionnaires and medical record abstraction forms at baseline and 3 months. The management rate was analyzed using generalized estimating equations (GEEs) method. Results: From 7/2016 - 4/2021, 434 women enrolled (156 intervention, 278 usual care) and 392 were analyzable. The median age was 41 years. Patients self-identified as White 67.5%; Black 21.1%; Hispanic 15.9%. Most patients had breast cancer (83.5%) and local/regional disease (69.5%). A higher proportion of patients at intervention sites (77.1%, 108/140, 90% CI: 0.71-0.83) received goal-concordant RH care compared to patients enrolled from usual care sites (61.5%; 155/252, 90% CI: 0.56, 0.67). A total of 263/392 (67.1%) patients received goal-concordant RH care within the first 3 months of enrollment. The GEE analysis demonstrated patients enrolled from intervention sites were approximately twice more likely to receive goal- concordant RH care than patients at usual care sites (odds ratio, OR = 2.11, 95% CI: 1.30, 3.44, p = 0.003). Younger age (< / = 35 years vs. > 35 years) and better ECOG performance status (PS 0 vs. PS 1-3) were statistically associated with the adoption of RH goal-concordant management (OR = 2.85, 95% CI: 1.59, 5.12, p = 0.0004 and OR = 1.94, 95% CI: 1.04, 3.63, p = 0.04, respectively). The intervention effect on the primary endpoint remained after age and PS were adjusted in the model (adjusted OR = 2.23, 95% CI: 1.30, 3.84, p = 0.004). Conclusions: The EROS trial demonstrated significant improvement of goal-concordant reproductive health management amongst racially diverse women newly diagnosed with cancer treated in community oncology practices. Sites randomized to intervention more frequently delivered reproductive care compared to usual care sites. Findings support wider implementation of this intervention to improve reproductive health care delivery, improving cancer care quality for pre-menopausal women diagnosed with cancer. Clinical trial information: NCT01806129.

Reproductive health in cancer

TPS6649

Background: Reproductive health needs of females ages 15 to 55 with cancer are poorly understood and overlooked, despite their importance to patients. Uncertainties regarding fertility and pregnancy are intricate and challenging for a patient and a cancer care team. The goals of reproductive health care may come in conflict with the primary objective of cancer care. However, with appropriate counseling and preventive measures, this conflict can be absolved to unify objectives. The primary objective of this trial is to evaluate the success of the implementation of reproductive health programming among reproductive aged females with cancer. To expand knowledge on this subject, the NCI approved the ECOG-ACRIN EROS trial: Engendering Reproductive Health within Cancer Survivorship, with two ancillary studies: Endocrine Disruption in Cancer Care and Sexuality in the first 5 years after Cancer Diagnosis. Methods: The primary study is a multicenter, cluster randomized control trial, with NCI Community Oncology Research Programs randomized to either the non-intervention arm (usual standard practice related to reproductive health) or the intervention arm (using study-specific training and tools). The accrual goal is 668 patients based on the expectation that the intervention can increase the adoption of appropriate reproductive health management within 3 months from the baseline visit from 50% to 80%, with the first 200 to consent to the endocrine disruption substudy. All patients participate in the sexuality part. Pre-menopausal female patients ages 15 to 55 with an initial diagnosis of any type of cancer who have not initiated treatment of any type are eligible to participate. Patients are asked to complete 2 questionnaires at 8 timepoints regarding their reproductive health interests. Providers are also asked to complete questionnaires regarding their healthcare practice in general as well as specific to patients enrolled in this study. The reproductive health management rate at each time point will be summarized, by arm, with frequency and percentage along with its 95% confidence interval. The comparison between the two arms, using a GEE model, can evaluate the intervention effect. EROS was activated in September 2015. To date, 264 patients have been enrolled to the main study and half of these patients are participating in the endocrine disruption correlative. Outcomes pertaining to management and treatment implementation and modification are the cornerstones of this study. It should inform organizations in cancer care to improve guidelines and to include a reproductive health assessment for all young females with cancer. Clinical trial information: NCT01806129.

Looking Through the Lens of a Family Planner to Prioritize Reproductive Health Among Women With Cancer

PURPOSE

Prioritization of cancer treatment initiation in women of reproductive age may underscore potential implications on reproductive health. This study describes a family planning quotient (FPQ) and reproductive life index (RepLI) tool designed to help providers to discuss effectively reproductive health with women with cancer.

METHODS

We tailored the FPQ/RepLI tool for patients with cancer after development in the family planning setting and piloted it with 36 oncology patients referred to our family planning clinic. Each patient completed the FPQ/RepLI with a health educator or medical student and then met with a physician to create a reproductive life plan. A subsample evaluated the tool by rating satisfaction using a Likert scale. Summary statistics were calculated overall and by childbearing status.

RESULTS

Of the 36 women, 22 did not desire additional children and received contraception. One third (n = 14) had not completed childbearing, four of whom continued with fertility preservation counseling. Women who desired childbearing were less likely to already have children ( P = .02), and more than one half were using long-term contraception. All agreed that the FPQ/RepLI helped them to talk to their provider about their reproductive goals. Only 44.4% agreed that their oncologist knew how many children they desired, and 88.9% found the tool helpful and would use it for future tracking of their reproductive goals.

CONCLUSION

The FPQ/RepLI is useful for assessing the reproductive health of young women with a new cancer diagnosis, understanding desires of future childbearing, and providing effective contraception. We recommend the incorporation of this tool into practice to better understand patients' reproductive needs.

Results of implementing a novel supportive oncology screening tool for comprehensive evaluation of distress and other supportive care needs

61

Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. Screening tools are not standardized and often address only a portion of patients’ supportive oncology needs. Methods: A collaborative of 100+ clinicians, funded by The Coleman Foundation, developed a patient-centric screening tool adapted from NCCN Distress Problem List, IOM report and CoC standards, with validated sub-tools: PHQ-4 for anxiety and depression and PROMIS short forms for pain, fatigue and physical function. Novel treatment/care and other concerns were included. The screening tool was implemented at 4 cancer centers (2 academic, 1 public & 1 safety-net). End points included correlation of PHQ-4 score with other supportive oncology needs. Descriptive statistics, Fisher’s exact test were used. Results: 2805 patients were screened. Average scores were: PHQ4 – Anxiety and Depression 1.8 (mild > 3), Pain 4.5 (mild > 4), Fatigue 8.8 (mild > 6), Physical Function 20.2 (mild < 20), see table for additional items. Higher scores on the PHQ-4 were significantly associated with each of the following: greater pain, fatigue, , nutritional and specific treatment/care concerns, and lower physical function (p<.0001). (See Table). Conclusions: Patients with higher anxiety and depression also have many other supportive oncology concerns. Our results support the use of a comprehensive tool capturing a spectrum of each patient’s unique concerns. This may enable earlier interventions and personalized delivery of supportive care. [Table: see text]

Oncocontraception in cancer care

e18018

Background: Focus on fertility preservation has overshadowed other aspects of reproductive health including sexuality and contraception in cancer care. Regardless of future childbearing interest, the first 18-months post-diagnosis of cancer are considered suboptimal for childbearing. We have coined the term, oncocontraception, for the application of contraception in cancer care. To address this need at our institution, we used the novel Family Planning Quotient/Reproductive Life Index (FPQ/RepLI) which allows providers to better understand patients’ reproductive health goals and counsel them towards appropriate family planning services. These tools aid providers in implementing clinical care to prevent pregnancy during this critical time. They are routinely utilized at Stroger Hospital in the Family Planning Clinic for women within the reproductive age, between the ages of 18 and 55. Methods: FPQ and RepLI were adapted for use with oncology patients. They were used to visually depict and quantify a woman’s reproductive life plan and assist health care providers in speaking to a woman regarding family planning as it pertains to and aligns with her cancer treatment. Results: During our study period, 36 reproductive aged women were seen in our family planning clinic after a cancer diagnosis. Our study population was comprised of mostly Hispanic/Latino women (58.3.0%) and 50.0% were between the ages of 31-40. The majority of the study group had breast cancer (77.8%) and were being treated with chemotherapy (52.8%). Among the study population, 80.6% received a form of contraception (44.8% short-term, 55.2% long-term). Conclusions: We established a link between the Oncology and Family Planning Clinics to incorporate contraceptive counseling as an essential piece of comprehensive cancer care. Approximately 45% of the women newly diagnosed with cancer are in the reproductive age range. With improvements in treatments and prognosis, quality of life factors are of increasing importance for these women. With this essential clinical relationship, patient counseling and provider-patient communication regarding contraceptive care in the context of cancer diagnosis will continue to grow and improve.

Results of implementing a novel supportive oncology screening tool for comprehensive evaluation of distress and other supportive care needs

e21644

Background: The Institute of Medicine (IOM) 2013 Report recommends that supportive oncology care start at cancer diagnosis; the Commission on Cancer (CoC) Standard 3.2 requires distress screening and indicated action. Screening tools are not standardized and often address only a portion of patients’ supportive oncology needs. Methods: A collaborative of 100+ clinicians, funded by The Coleman Foundation, developed a patient-centric screening tool adapted from NCCN Distress Problem List, IOM report and CoC standards, with validated sub-tools: PHQ-4 for anxiety and depression and PROMIS short forms for pain, fatigue and physical function. Novel treatment/care and other concerns were included. The screening tool was implemented at 4 cancer centers (2 academic, 1 public & 1 safety-net). End points included correlation of PHQ-4 score with other supportive oncology needs. Descriptive statistics, Fisher’s exact test were used. Results: 2805 patients were screened. Average scores were: PHQ4 – Anxiety and Depression 1.8 (mild > 3), Pain 4.5 (mild > 4), Fatigue 8.8 (mild > 6), Physical Function 20.2 (mild < 20), see table for additional items. Higher scores on the PHQ-4 were significantly associated with each of the following: greater pain, fatigue, nutritional and specific treatment/care concerns, and lower physical function (p<.0001). Conclusions: Patients with higher anxiety and depression also have many other supportive oncology concerns. Our results support the use of a comprehensive tool capturing a spectrum of each patient’s unique concerns. This may enable earlier interventions and personalized delivery of supportive care. [Table: see text]

Reproductive health assessment for women with cancer: a pilot study

OBJECTIVE

The purpose of this study was to pilot a survey instrument and to develop descriptive data about the reproductive goals of reproductive-aged women (15-44 years) with cancer.

STUDY DESIGN

This was a cross-sectional pilot survey study of 20 women who were diagnosed with various types of cancers at the oncology clinic of Stroger Hospital of Cook County, Chicago, from January-July 2006.

RESULTS

Of the 20 patients whose cases were surveyed, the mean age was 36.6 years, and 90% of the women had breast cancer. Ten percent of patients would continue pregnancy, if they became pregnant while receiving treatment. Contraception was used by 55% of patients (n = 11), of whom 55% of the women (n = 6) were using abstinence.

CONCLUSION

The result of this pilot study demonstrates the need for reproductive health counseling in women with cancer; the range of discussion must include fertility interest, contraception, and fertility preservation.