Association between oral targeted cancer drug net health benefit, uptake, and spending

BACKGROUND

Targeted cancer drugs (TCDs) have revolutionized oncology but vary in clinical benefit and patient out-out-pocket (OOP) costs. The ASCO Value Framework uses survival, toxicity, and symptom palliation data to quantify the net health benefit (NHB) of cancer drugs. We evaluated associations between NHB, uptake, and spending on oral TCDs.

METHODS

We conducted a retrospective cohort study of patients aged 18-64 years with an incident oral TCD pharmacy claim in 2012-2020 in a nationwide de-identified commercial claims dataset. TCDs were categorized as having high (>60), medium (40-60), and low (<40) NHB scores. We plotted the uptake of TCDs by NHB category and used standard descriptive statistics to evaluate patient OOP and total spending. Generalized linear models evaluated the relationship between spending and TCD NHB, adjusted for cancer indication.

RESULTS

We included 8,524 patients with incident claims for eight oral TCDs with nine first-line indications in advanced melanoma, breast, lung, and pancreatic cancer. Medium- and high-NHB TCDs accounted for most TCD prescriptions. Median OOP spending was $18.78 for the first 28-day TCD supply (IQR $0.00-$87.57); 45% of patients paid $0 OOP. Median total spending was $10,118.79 (IQR $6,365.95-$10,600.37) for an incident 28-day TCD supply. Total spending increased $1,083.56 for each 10-point increase in NHB score (95% CI $1,050.27-$1,116.84, p < .01 for H0=$0).

CONCLUSION

Low-NHB TCDs were prescribed less frequently than medium- and high-NHB TCDs. Total spending on oral TCDs was high and positively associated with NHB. Commercially insured patients were largely shielded from high OOP spending on oral TCDs.

Pilot Study of a Mobile Phone Chatbot for Medication Adherence and Toxicity Management Among Patients With GI Cancers on Capecitabine

PURPOSE

Capecitabine is an oral chemotherapy used to treat many gastrointestinal cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality care.

METHODS

We conducted a pilot study of PENNY-GI, a mobile phone text messaging-based chatbot that leverages algorithmic surveys and natural language processing to promote medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine. Eligibility initially included all capecitabine-containing regimens but was subsequently restricted to capecitabine monotherapy because of challenges in integrating PENNY-GI with radiation and intravenous chemotherapy schedules. We used design thinking principles and real-time data on safety, accuracy, and usefulness to make iterative refinements to PENNY-GI with the goal of minimizing the proportion of text messaging exchanges with incorrect medication or symptom management recommendations. All patients were invited to participate in structured exit interviews to provide feedback on PENNY-GI.

RESULTS

We enrolled 40 patients (median age 64.5 years, 52.5% male, 62.5% White, 55.0% with colorectal cancer, 50.0% on capecitabine monotherapy). We identified 284 of 3,895 (7.3%) medication-related and 13 of 527 (2.5%) symptom-related text messaging exchanges with incorrect recommendations. In exit interviews with 24 patients, participants reported finding the medication reminders reliable and user-friendly, but the symptom management tool was too simplistic to be helpful.

CONCLUSION

Although PENNY-GI provided accurate recommendations in >90% of text messaging exchanges, we identified multiple limitations with respect to the intervention's generalizability, usefulness, and scalability. Lessons from this pilot study should inform future efforts to develop and implement digital health interventions in oncology.

Development of an Electronic Health Record-Based Clinical Decision Support Tool for Patients With Lynch Syndrome

PURPOSE

To develop an electronic health record (EHR)-based clinical decision support (CDS) tool to promote guideline-recommended cancer risk management among patients with Lynch syndrome (LS), an inherited cancer syndrome that confers an increased risk of colorectal and other cancer types.

MATERIALS AND METHODS

We conducted a cross-sectional study to determine the baseline prevalence and predictors of guideline-recommended colonic surveillance and annual genetics program visits among patients with LS. Multivariable log-binomial regressions estimated prevalence ratios (PRs) of cancer risk management adherence by baseline sociodemographic and clinical characteristics. These analyses provided rationale for the development of an EHR-based CDS tool to support patients and clinicians with LS-related endoscopic surveillance and annual genetics program visits. The CDS leverages an EHR platform linking discrete genetic data to LS Genomic Indicators, in turn driving downstream clinician- and patient-facing CDS.

RESULTS

Among 323 patients with LS, cross-sectional adherence to colonic surveillance and annual genetics program visits was 69.3% and 55.4%, respectively. Patients with recent electronic patient portal use were more likely to be adherent to colonic surveillance (PR, 1.67; 95% CI, 1.11 to 2.52). Patients more recently diagnosed with LS were more likely to be adherent to annual genetics program visits (PR, 0.58; 95% CI, 0.44 to 0.76 for 2-4 years; PR, 0.62; 95% CI, 0.51 to 0.75 for ≥4 compared with <2 years). Our EHR-based CDS tool is now active for 421 patients with LS throughout our health system.

CONCLUSION

We have successfully developed an EHR-based CDS tool to promote guideline-recommended cancer risk management among patients with LS.

Nationwide Trends and Determinants of Germline BRCA1/2 Testing in Patients With Breast and Ovarian Cancer

BACKGROUND

Germline genetic testing (GT) for BRCA1/2 is instrumental in identifying patients with breast and ovarian cancers who are eligible for PARP inhibitors (PARPi). Little is known about recent trends and determinants of GT since PARPi were approved for these patients.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients in a nationwide electronic health record (EHR)-derived oncology-specific database with the following GT eligibility criteria: breast cancer diagnosed at age ≤45 years, triple-negative breast cancer diagnosed at age ≤60 years, male breast cancer, or ovarian cancer. GT within 1 year of diagnosis was assessed and stratified by tumor type. Multivariable log-binomial regressions estimated adjusted relative risks (RRs) of GT by patient and tumor characteristics.

RESULTS

Among 2,982 eligible patients with breast cancer, 56.4% underwent GT between January 2011 and March 2020, with a significant increase in GT over time (RR, 1.08; 95% CI, 1.05-1.11, for each year), independent of when PARPi were approved for BRCA1/2-mutated metastatic breast cancer in January 2018. In multivariable analyses, older age (RR, 0.93; 95% CI, 0.90-0.96, for every 5 years) and Medicare coverage (RR, 0.69; 95% CI, 0.49-0.96 vs commercial insurance) were associated with less GT. Among 5,563 eligible patients with ovarian cancer, 35.4% underwent GT between January 2011 and March 2020, with a significant increase in GT over time (RR, 1.11; 95% CI, 1.07-1.14, for each year) that accelerated after approval of PARPi for BRCA1/2-mutated, chemotherapy-refractory ovarian cancer in December 2014 (RR, 1.42; 95% CI, 1.19-1.70). Older age (RR, 0.95; 95% CI, 0.93-0.97, for every 5 years) and Black or African American race (RR, 0.80; 95% CI, 0.65-0.98 vs White race) were associated with less GT.

CONCLUSIONS

GT remains underutilized nationwide among patients with breast and ovarian cancers. Although GT has increased over time, significant disparities by age, race, and insurance status persist. Additional work is needed to design, implement, and evaluate strategies to ensure that all eligible patients receive GT.

Impact of integrating genomic data into the electronic health record on genetics care delivery

PURPOSE

Integrating genomic data into the electronic health record (EHR) is key for optimally delivering genomic medicine.

METHODS

The PennChart Genomics Initiative (PGI) at the University of Pennsylvania is a multidisciplinary collaborative that has successfully linked orders and results from genetic testing laboratories with discrete genetic data in the EHR. We quantified the use of the genomic data within the EHR, performed a time study with genetic counselors, and conducted key informant interviews with PGI members to evaluate the effect of the PGI's efforts on genetics care delivery.

RESULTS

The PGI has interfaced with 4 genetic testing laboratories, resulting in the creation of 420 unique computerized genetic testing orders that have been used 4073 times to date. In a time study of 96 genetic testing activities, EHR use was associated with significant reductions in time spent ordering (2 vs 8 minutes, P < .001) and managing (1 vs 5 minutes, P < .001) genetic results compared with the use of online laboratory-specific portals. In key informant interviews, multidisciplinary collaboration and institutional buy-in were identified as key ingredients for the PGI's success.

CONCLUSION

The PGI's efforts to integrate genomic medicine into the EHR have substantially streamlined the delivery of genomic medicine.

An augmented intelligence mobile phone chatbot for medication adherence and toxicity management among patients with gastrointestinal cancers on capecitabine

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Background: Capecitabine (cape), an oral chemotherapy, is the treatment backbone for many GI cancers. Its complex dosing and narrow therapeutic index make medication adherence and toxicity management crucial for quality patient care. Methods: We conducted a feasibility study of “Penny,” an augmented intelligence mobile phone chatbot that leverages algorithmic surveys and natural language processing (NLP) to engage with patients in conversational, bi-directional text messages. Penny provides patients with medication reminders tailored to their prescribed doses and schedules, sends weekly check-in messages, manages low-grade symptoms in real time, and escalates high-grade symptoms for resolution by the clinical team. Patients ≥18 years old receiving cape for the treatment of a GI cancer were accrued in sequential cohorts of 20 for participation over a three-month period. Feasibility was assessed during planned interim analyses and was predefined as the completion of a 20-patient cohort without a safety event, defined as the communication of incorrect medication or symptom management recommendations as ascertained by two independent clinician reviewers (Κ = 0.89). Secondary outcomes included patient-reported adherence and engagement with the chatbot’s weekly check-in messages. At study completion, all patients were invited to participate in structured interviews to provide feedback on the platform. Results: The first cohort of 20 patients was enrolled from 8/2021 to 4/2022; the median age was 57 years, and patients were primarily female (55%), white (65%), commercially insured (55%), and had colorectal cancer (55%). Chemotherapy regimens included cape with oxaliplatin (50%), concurrent RT (30%), temozolomide (5%), and monotherapy (15%). A total of 2,149 text messaging exchanges were reviewed with 150 (7%) medication-related and 9 (0.4%) symptom-related safety events identified. Most medication-related safety events were due to misalignment with prescribed chemotherapy schedules (55%) and doses (32%). Symptom-related safety events were primarily due to the misinterpretation of patient messages by Penny’s NLP functionality (89%). Average patient-reported adherence was 67% (SD 27%), and patients engaged with 27% (SD 24%) of the chatbot’s weekly check-in messages. In post-study interviews with 12 patients, participants reported that the medication reminders were reliable and user-friendly, whereas the symptom management tool was too simplistic to be helpful. Conclusions: Although Penny has not yet met its feasibility endpoint, the lessons learned from this first cohort have informed further refinements to the platform. Ongoing efforts aim to integrate Penny with the electronic health record and further train the chatbot’s NLP functionality to minimize medication- and symptom-related safety events, respectively. Clinical trial information: NCT05113264.

Implementing Pharmacogenetic Testing in Gastrointestinal Cancers (IMPACT-GI): Study Protocol for a Pragmatic Implementation Trial for Establishing DPYD and UGT1A1 Screening to Guide Chemotherapy Dosing

Background

Fluoropyrimidines (fluorouracil [5-FU], capecitabine) and irinotecan are commonly prescribed chemotherapy agents for gastrointestinal (GI) malignancies. Pharmacogenetic (PGx) testing for germline DPYD and UGT1A1 variants associated with reduced enzyme activity holds the potential to identify patients at high risk for severe chemotherapy-induced toxicity. Slow adoption of PGx testing in routine clinical care is due to implementation barriers, including long test turnaround times, lack of integration in the electronic health record (EHR), and ambiguity in test cost coverage. We sought to establish PGx testing in our health system following the Exploration, Preparation, Implementation, Sustainment (EPIS) framework as a guide. Our implementation study aims to address barriers to PGx testing.

Methods

The Implementing Pharmacogenetic Testing in Gastrointestinal Cancers (IMPACT-GI) study is a non-randomized, pragmatic, open-label implementation study at three sites within a major academic health system. Eligible patients with a GI malignancy indicated for treatment with 5-FU, capecitabine, or irinotecan will undergo PGx testing prior to chemotherapy initiation. Specimens will be sent to an academic clinical laboratory followed by return of results in the EHR with appropriate clinical decision support for the care team. We hypothesize that the availability of a rapid turnaround PGx test with specific dosing recommendations will increase PGx test utilization to guide pharmacotherapy decisions and improve patient safety outcomes. Primary implementation endpoints are feasibility, fidelity, and penetrance. Exploratory analyses for clinical effectiveness of genotyping will include assessing grade ≥3 treatment-related toxicity using available clinical data, patient-reported outcomes, and quality of life measures.

Conclusion

We describe the formative work conducted to prepare our health system for DPYD and UGT1A1 testing. Our prospective implementation study will evaluate the clinical implementation of this testing program and create the infrastructure necessary to ensure sustainability of PGx testing in our health system. The results of this study may help other institutions interested in implementing PGx testing in oncology care.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04736472, identifier [NCT04736472].

Trends in and determinants of germline BRCA1/2 testing in patients with breast and ovarian cancer

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Background: Germline BRCA1/2 testing (GT) is instrumental in identifying patients with breast and ovarian cancer who may be eligible for biomarker-driven poly ADP ribose polymerase inhibitor (PARPi) therapy. Little is known about recent trends and determinants of GT since PARPi were approved for these patients. Methods: We performed a retrospective cohort study of patients with breast and ovarian cancer who were eligible for GT (diagnosed with breast cancer under age 45, triple negative breast cancer under age 60, male breast cancer or ovarian cancer) between 1/2011 and 3/2020 in the nationwide Flatiron Health EHR-derived deidentified database. Duration of follow-up was at least one year for each patient. Spline regressions estimated the annual prevalence of GT within one year of diagnosis. Multivariable log binomial regressions estimated adjusted relative risks (RR) of GT by patient and tumor characteristics. Multiple imputation with chained equations was conducted for missing data. Results: Among 2,982 eligible patients with breast cancer, 1,682 (56%) underwent GT within one year of diagnosis with a median time of 42 days. GT increased from 37% in 2011 to 68% in 2020, with a significantly higher RR after PARPi were approved for breast cancer in 1/2018 (RR 1.35, 95% CI 1.20-1.51). In multivariable analyses, there were no appreciable differences by sex, race or ethnicity, but there was a negative linear relationship between GT and age (RR 0.93, 95% CI 0.90-0.96 for every 5 years). After adjusting for age, the 87 breast cancer patients with Medicare were also less likely to undergo GT despite being eligible (RR 0.67, 95% CI 0.48-0.95 vs commercial insurance). Among 5,563 eligible patients with ovarian cancer, 1,968 (35%) underwent GT within one year of diagnosis with a median time of 101 days. GT increased from 23% in 2011 to 53% in 2020, with a significantly higher RR after PARPi were approved for ovarian cancer in 12/2014 (RR 2.25, 95% CI 2.01-2.52). Although insurance status was not a significant determinant of GT in patients with ovarian cancer, older age (RR 0.95, 95% CI 0.93-0.97 for every 5 years) and Black race (RR 0.80, 95% CI 0.66-0.98 vs white race) were associated with a lower likelihood of GT in multivariable analyses. All results remained similar in pre-planned sensitivity analyses restricted to the post-PARPi approval period, limiting to patients who remained alive one year after diagnosis and using the non-imputed dataset. Conclusions: GT remains underutilized in patients with breast and ovarian cancer. Although GT has increased since PARPi were approved for this population, significant disparities by age, race and insurance status persist but differ by tumor type. This study is limited by potential misclassification due to missing GT performed outside the Flatiron Health network. Multifaceted patient-, clinician- and system-level strategies are needed to ensure that all eligible patients receive GT.

Association between timely targeted treatment and outcomes in patients with metastatic HER2-overexpressing gastroesophageal adenocarcinoma

BACKGROUND

Timely targeted treatment initiation can be challenging because additional biomarker testing is needed for eligibility. The authors hypothesized that timely targeted treatment improves survival relative to nontimely initiation in metastatic HER2+ gastroesophageal adenocarcinoma (GEA).

METHODS

The authors performed a retrospective cohort study of metastatic HER2+ GEA treated with first-line (1L) systemic therapy from January 2011 to December 2017 using a nationwide electronic health record-derived deidentified database. Timely targeted treatment-trastuzumab initiation within 14 days after starting 1L chemotherapy-was assessed as a time-varying exposure. Nontimely targeted treatment included patients who initiated trastuzumab after 14 days or who lacked documentation of receiving trastuzumab. Extended Cox regressions compared overall survival (OS) and progression-free survival (PFS) between timely and nontimely groups.

RESULTS

A total of 320 patients were included; 59.1% received timely trastuzumab. Relative to nontimely initiation, timely trastuzumab was associated with significantly higher OS (2-year OS, 32.1% vs 15.3%; adjusted hazard ratio [HR], 0.67; 95% CI, 0.51-0.88) and PFS (2-year PFS, 9.2% vs 3.7%; adjusted HR, 0.71; 95% CI, 0.55-0.93). Results remained similar in sensitivity analyses 1) using alternative "timeliness" definitions up to 70 days after starting 1L chemotherapy, 2) comparing any trastuzumab, regardless of timing of initiation, to no trastuzumab, and 3) excluding patients lacking documentation of receiving trastuzumab.

CONCLUSIONS

Improved survival was observed among metastatic HER2+ GEA patients treated with trastuzumab versus those who were not, regardless of timing of initiation. Although these results reassure clinicians that modest targeted treatment delays may not be detrimental to outcomes, efforts should still ensure that all metastatic HER2+ GEA patients receive trastuzumab.

Preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies: a qualitative study of barriers to implementation

Background

Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice.

Methods

We conducted a qualitative study of oncology clinicians to identify barriers to using preemptive PGx testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a semi-structured interview informed by the Consolidated Framework for Implementation Research (CFIR). Interviews were analyzed using an inductive content analysis approach.

Results

Participants included sixteen medical oncologists and nine oncology pharmacists from one academic medical center and two community hospitals in Pennsylvania. Barriers to the use of preemptive PGx testing to guide chemotherapy dosing mapped to four CFIR domains: intervention characteristics, outer setting, inner setting, and characteristics of individuals. The most prominent themes included 1) a limited evidence base, 2) a cumbersome and lengthy testing process, and 3) a lack of insurance coverage for preemptive PGx testing. Additional barriers included clinician lack of knowledge, difficulty remembering to order PGx testing for eligible patients, challenges with PGx test interpretation, a questionable impact of preemptive PGx testing on clinical care, and a lack of alternative therapeutic options for some patients found to have actionable PGx variants.

Conclusions

Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multifaceted effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09171-6.

Adherence to and determinants of guideline-recommended biomarker testing and targeted therapy in patients with gastroesophageal adenocarcinoma: Insights from routine practice

BACKGROUND

Anti human epidermal growth factor receptor 2 (anti-HER2) therapy with trastuzumab improves overall survival in patients with advanced, HER2-positive gastroesophageal adenocarcinoma (GEA) and is now incorporated into national guidelines. However, little is known about adherence to and determinants of timely HER2 testing and trastuzumab initiation in routine practice.

METHODS

The authors performed a cross-sectional study of patients who had advanced GEA diagnosed between January 2011 and June 2019 in a nationwide electronic health record-derived database. The annual prevalences of both timely HER2 testing (defined within 21 days after advanced diagnosis) and timely trastuzumab initiation (defined within 14 days after a positive HER2 result) were calculated. Log-binomial regressions estimated adjusted prevalence ratios comparing timely HER2 testing and trastuzumab initiation by patient and tumor characteristics.

RESULTS

In total, the cohort included 6032 patients with advanced GEA of whom 1007 were HER2-positive. Between 2011 and 2019, timely HER2 testing increased from 22.4% to 44.5%, whereas timely trastuzumab initiation remained stable at 16.3%. No appreciable differences in timely testing or trastuzumab initiation were noted by age, sex, race, or insurance status. Compared with patients who had metastatic disease at diagnosis, patients who had early stage GEA who did not undergo surgery were less likely to receive timely HER2 testing and trastuzumab initiation (testing prevalence ratio, 0.69; 95% CI, 0.64-0.75; treatment prevalence ratio, 0.32; 95% CI, 0.18-0.56), as were patients with early stage disease who subsequently developed a distant recurrence (testing prevalence ratio, 0.56; 95% CI, 0.47-0.65; treatment prevalence ratio, 0.61; 95% CI, 0.24-1.55).

CONCLUSIONS

In patients with advanced GEA, guideline-recommended HER2 testing and anti-HER2 therapy remain underused. Uptake may improve with universal HER2 testing regardless of stage.

Association between timely targeted therapy initiation and clinical outcomes in patients with advanced HER2+ gastroesophageal adenocarcinoma

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Background: Delayed treatment initiation is associated with increased mortality in early-stage cancers. Few studies have examined the impact of timely initiation in advanced cancers. Timely targeted therapy initiation can be especially challenging due to the additional biomarker testing required to identify patients eligible for these treatments. We examined the impact of timely targeted therapy initiation on survival among patients with metastatic HER2+ gastroesophageal adenocarcinoma (GEA). Methods: We performed a retrospective cohort study of patients with metastatic HER2+ GEA treated with first line systemic therapy between 1/2011 and 12/2017 using the nationwide Flatiron Health EHR-derived deidentified database. Timely targeted therapy, defined as initiation of the anti-HER2 monoclonal antibody trastuzumab up to 14 days after first line chemotherapy initiation, was entered as a time-varying exposure on the day of initiation. Patients who initiated trastuzumab after the 14-day cut point or who lacked documentation of having received trastuzumab were classified as having non-timely targeted therapy initiation. Extended Cox regression models were used to compare progression-free (PFS) and overall survival (OS) from the date of first line treatment initiation, adjusted for potential confounders. Pre-planned sensitivity analyses assessed alternative “timeliness” definitions as well as the impact of any trastuzumab administration, regardless of the timing of initiation. Results: We included 459 patients with metastatic HER2+ GEA; 293 (63.8%) received trastuzumab, of whom 223 (76.1%) initiated in a timely manner. The median age was 65.0 years, and patients were predominantly male (82.4%) and non-Hispanic White (78.2%) with an ECOG performance status of 0-1 (85.9%). Relative to non-timely initiation, timely targeted therapy was associated with significantly higher OS (2-year OS 29.6% vs 14.6%; adjusted HR 0.72, 95% CI 0.57-0.91, p = 0.006) and PFS (2-year PFS 8.3% vs 3.9%; adjusted HR 0.78, 95% CI 0.62-0.98, p = 0.030). Results remained similar in sensitivity analyses 1) using alternative “timeliness” definitions (up to 70 days after chemotherapy initiation), and 2) comparing any trastuzumab administration, regardless of the timing of initiation, to no trastuzumab administration (OS - adjusted HR 0.75, 95% CI 0.60-0.95, p = 0.018; PFS - adjusted HR 0.81, 95% CI 0.64-1.02, p = 0.069). Conclusions: OS and PFS were higher among patients with metastatic HER2+ GEA treated with trastuzumab, regardless of the timing of targeted therapy initiation. Although our results provide reassurance to clinicians that delays in targeted therapy may not be detrimental to patient outcomes, efforts should still be made to ensure that all patients with metastatic HER2+ GEA receive first line trastuzumab.

Clinician perspectives on preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies

54

Background: Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice. Methods: We conducted a multi-site mixed-methods study to understand clinician attitudes toward PGx testing and to identify facilitators and barriers to using preemptive testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a demographic survey and semi-structured interview informed by the Consolidated Framework for Implementation Research. Interviews were analyzed using a modified grounded theory approach. Results: A total of 16 medical oncologists and 9 oncology pharmacists from one academic medical center and two community hospitals participated. Fifteen (60%) participants reported feeling comfortable or very comfortable with interpreting PGx test results. While clinicians expressed generally favorable attitudes toward PGx testing, many were hesitant to use it to preemptively guide chemotherapy dosing due to a perceived lack of evidence for this practice. They cited a lack of consensus chemotherapy dosing recommendations in response to PGx test results, as well as concerns about decreased drug efficacy, especially in patients treated with curative intent. Additional barriers included 1) a low prevalence of actionable PGx variants; 2) lengthy PGx test turnaround time; 3) concerns about testing costs and lack of insurance coverage; and 4) burdensome integration of PGx testing into clinical workflows. The electronic health record emerged as a potential tool for the unobtrusive integration of PGx testing into clinical practice–suggested applications included default PGx test orders for eligible patients, discrete reporting of PGx variant results, and clinical decision support to guide subsequent chemotherapy dosing. Conclusions: Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multi-level effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study. The electronic health record should be explored as a tool to integrate PGx testing into routine practice.

DPYD and UGT1A1 Pharmacogenetic Testing in Patients with Gastrointestinal Malignancies: An Overview of the Evidence and Considerations for Clinical Implementation

Gastrointestinal (GI) malignancies are among the most commonly diagnosed cancers worldwide. Despite the introduction of targeted and immunotherapy agents in the treatment landscape, cytotoxic agents, such as fluoropyrimidines and irinotecan, remain as the cornerstone of chemotherapy for many of these tumors. Pharmacogenetics (PGx) is a rapidly evolving field that accounts for interpatient variability in drug metabolism to predict therapeutic response and toxicity. Given the significant incidence of severe treatment-related adverse events associated with cytotoxic agents, utilizing PGx can allow clinicians to better anticipate drug tolerability while minimizing treatment interruptions or delays. In this review, the PGx profiles of drug-gene pairs with potential impact in GI malignancy therapy - DPYD-5-fluorouracil/capecitabine and UGT1A1-irinotecan - and the available clinical evidence of their roles in reducing severe adverse events are discussed. Considerations for clinical implementation, such as optimal laboratory workflows, electronic health record integration, and stakeholder engagement, as well as provider education, are addressed. Last, exploratory PGx markers in GI malignancy treatment are described. As the PGx knowledge base rapidly evolves, pharmacists will be vital in leveraging their pharmacology knowledge and clinical skills to implement PGx testing in the clinic.

Adherence to and determinants of guideline-recommended biomarker testing and targeted therapy in patients with gastroesophageal adenocarcinoma: Insights from routine practice

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Background: Precision oncology has transformed care for patients with advanced HER2+ gastroesophageal adenocarcinoma (GEA), where the addition of anti-HER2 therapy with trastuzumab improves overall survival and is now incorporated into national guidelines. However, little is known about adherence to and determinants of timely HER2 testing and trastuzumab initiation in routine care. Methods: We performed a retrospective study of advanced GEA diagnosed between 1/2011 and 6/2019 in the nationwide Flatiron Health EHR-derived deidentified database. We calculated annual prevalence and identified determinants of timely HER2 testing (defined within 21 days after advanced diagnosis) and timely first-line trastuzumab initiation (defined within 14 days after a HER2+ result). Log binomial regressions estimated adjusted prevalence ratios (PR) comparing timely HER2 testing and trastuzumab initiation by patient and tumor characteristics. Multiple imputation was conducted for missing data. Results: We included 6,479 patients with advanced GEA; 973 were HER2+ of whom 585 (60.1%) initiated trastuzumab. Prevalence of timely HER2 testing increased from 22.4% in 2011 to 44.5% in 2019; timely trastuzumab initiation remained stable at 18.0% over the same period. No appreciable differences in timely testing or trastuzumab initiation by age, sex, race or payer category were noted. Patients with early-stage GEA who subsequently developed metastatic disease were less likely to undergo timely HER2 testing and trastuzumab initiation than those with metastatic disease at diagnosis (PR 0.69, 95% CI 0.64-0.75 for testing; PR 0.44, 95% CI 0.28-0.69 for therapy). Similar findings were seen for patients who did not receive surgery (PR 0.56, 95% CI 0.47-0.65 for testing; PR 0.57, 95% CI 0.22-1.46 for therapy). Patients who started chemotherapy before learning their HER2 status (PR 1.42, 95% CI 1.05-1.90) and those with concordant HER2 immunohistochemistry and FISH results (PR 1.76, 95% CI 0.99-3.13) were more likely to initiate timely trastuzumab. Conclusions: Among patients with advanced GEA, guideline-recommended HER2 testing and anti-HER2 therapy initiation remain underutilized. Misclassification due to missing testing or treatment performed outside the Flatiron Network is a study limitation. Uptake of precision oncology may improve with implementation of universal HER2 testing of GEA patients regardless of stage and reflex multidisciplinary review of discordant HER2 test results.

Outcomes among minority patients with stage IV colorectal cancer in the Harris County Health System

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Background: Colorectal cancer (CRC) mortality has declined over the last three decades, but significant racial disparities in CRC survival continue to be reported, especially for stage IV disease. Hypothesizing that these disparities arise from differences in access to care rather than tumor biology, we examined treatment patterns and outcomes among minority patients evaluated and treated for stage IV CRC in an academic safety net health system. Methods: The Harris Health System is an integrated health delivery network that utilizes tax revenue to care for predominantly minority and uninsured residents of Harris County, Texas. As the largest Harris Health facility and an affiliate of the Dan L. Duncan Comprehensive Cancer Center at Baylor College of Medicine, Ben Taub Hospital delivers cancer care through multidisciplinary subspecialty clinics and a robust patient assistance program. We performed a retrospective analysis of minority patients diagnosed with stage IV CRC between 1/2010 and 12/2012 who were evaluated and treated at Ben Taub Hospital. Results: We identified 103 patients of whom 40% were black, 49% were Hispanic, and 12% were Asian or Middle Eastern. 65% spoke English as their preferred language; 74% were uninsured and covered by the Harris Health Plan, a financial assistance program for individuals with incomes under 300% of the federal poverty level. 85% of patients received cancer-directed therapy, of whom 99% received standard chemotherapy with a best response rate of 67% and a disease control rate of 87%. Median overall survival was 20.7 months for all patients and 23.0 months for patients who received chemotherapy. Conclusions: The Harris Health System provides the health delivery infrastructure through which minority patients with significant socioeconomic challenges obtain financial assistance and access to quality cancer care in an academic setting, thereby leading to clinical outcomes comparable to those of the predominantly Caucasian and insured populations studied in randomized control trials. Efforts to resolve disparities in CRC outcomes should focus on improving access of at-risk populations to comprehensive cancer care.

Code status transitions from full code to do-not-resuscitate (DNR) among hospitalized patients with advanced cancer

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Background: Code status discussions ensure the delivery of preference-concordant care. However, the processes by which hospitalized patients with advanced cancer change their code status from full code to DNR are unknown. Methods: We conducted a mixed-methods study on a prospective cohort of patients with advanced cancer who were hospitalized from 9/14-10/15. Two physicians used a consensus-driven medical record review to characterize processes leading to code status transitions from full code to DNR. We explored factors associated with these processes using χ2 and Kruskal-Wallis tests. Results: We reviewed 1,047 hospitalizations among 728 patients. Admitting physicians did not address code status in 52.1% of these hospitalizations, leading code status orders to be “presumed full.” 273 patients (37.5%) transitioned from full code to DNR; 132 (48.4%) of them had erroneous “presumed full” code status orders on admission. We identified three additional processes leading to transitions from full code to DNR: acute clinical deterioration (15.4%), discontinuation of cancer-directed therapy (17.2%), and hypothetical discussions regarding the futility of CPR (15.4%). Among these processes, code status transitions due to acute clinical deterioration were associated with less patient involvement, shorter time to death, and higher likelihood of inpatient death. Changes due to hypothetical discussions were more likely to involve palliative care. Conclusions: Half of code status transitions among hospitalized patients with advanced cancer were due to erroneous full code orders, underscoring a greater need to discuss patient CPR preferences. Transitions due to acute clinical deterioration were associated with less patient engagement and higher likelihood of inpatient death. [Table: see text]