Panel Interview of ONcology practices with Emergent Experience of teclistamab in the Real world: The TecPIONEER Study

OBJECTIVE

To understand providers' current teclistamab step-up dosing (SUD) model and how they envision future administration models, as well as perceived barriers and facilitators to these models in day-to-day clinical practice.

METHODS

Interviews of clinicians with RW experience administering teclistamab, with a subsequent roundtable discussion to discuss interview findings. Topics of interest included managing adverse events (AE), and handling logistics of SUD and transition of care (ToC).

RESULTS

20 clinicians representing 19 practices participated. Of 14 practices administering inpatient teclistamab SUD, 12 (86%) utilized a single admission. A day 1-3-5 dosing schedule with a 7-day length of stay was planned in 10/14 (71%). The remaining 5 practices employed outpatient or hybrid SUD. SUD models depended on cellular therapy experience, patient volume, and monitoring capabilities. Clinicians desired to administer SUD outpatient for convenience and reduced healthcare resource use. 11% of practices reported using tocilizumab for cytokine release syndrome (CRS) prophylaxis, whilst it was uniformly used to treat grade 2+ CRS. Corticosteroids were the preferred treatment for neurotoxicity. Infection prophylaxis with intravenous immunoglobulin was reported by 89% of practices. Patient- and institution-level factors affected decision-making of transitioning patients back to referring sites after SUD.

CONCLUSION

The results consolidated practice-based experiences and indicated diverse RW SUD models and patient management strategies in practices with familiarity with teclistamab AE management and ToC protocols. Inpatient SUD is common, with expectations that approaches will evolve toward outpatient or community-based administration. Further research is needed to investigate outcomes of different care models and AE management strategies.

Disarming Intimate Partner Violence Offenders: An In-Depth Descriptive Analysis of Federal and State Firearm Prohibitor Laws in the United States, 1991-2016

Intimate partner violence is a preventable public health problem affecting more than 12 million people in the United States annually. The immense burden of victimization is most often borne by women. Nearly one in two female homicide victims are killed by current or former partners (more than 50% of which involve firearms). Firearm-related morbidity and mortality are concentrated where firearm ownership is most prevalent and firearm laws are least restrictive, indicating the potential for law to serve as an intervention. Understanding intricacies within laws and how they vary is critical to studying their influence on health. This study is the first to use the scientific legal mapping technique of policy surveillance to create legal data by systematically collecting and coding laws that authorize or require courts to prohibit offenders subject to domestic violence restraining orders (DVROs) and temporary restraining orders (TROs) from purchasing and possessing firearms ("firearm prohibitor" laws). These data measure key provisions of federal and state laws from 1991 to 2016, including whether the law includes a firearm prohibition, who qualifies as an intimate partner, notice and hearing requirements, whether the prohibition occurs automatically or through judicial discretion, and if the law permits or requires the relinquishment or removal of firearms. The federal law, enacted in 1994 (and reauthorized in 2022), only protects qualifying victims that obtain final DVROs. States can mirror or go beyond federal measures. From 1991 to 2016, 38 states enacted a firearm prohibitor law through DVROs (37 states), TROs (20 states), or both (19 states). Today, survivors suffer from a sluggish and fragmented legal system leading to the unequal protection of victims based on where they happen to live. This research provides an in-depth descriptive analysis of this complex and nuanced legal system, recommendations to spur policy reform, and longitudinal data for future research.

Patient perspectives on colorectal cancer care delivery during the COVID-19 pandemic: A qualitative interview study

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Background: The COVID-19 pandemic generated unprecedented interruptions and impacts on healthcare services across the US, including cancer care delivery. Patient perspectives on navigating colorectal cancer (CRC) care throughout the pandemic have not been well documented. This study explored patient experiences and perspectives around CRC care delivery throughout the pandemic by examining the impacts of COVID-19 on planned treatment, healthcare access, and quality of care. Methods: Patients diagnosed with CRC prior to January 2020 and who received treatment for CRC during 2019 participated in this qualitative study. Semi-structured interviews explored treatment experiences before and during the pandemic and were conducted between December 2021 and March 2022. Thematic analysis was used to identify key themes. Results: Twenty-four patients with CRC (mean age 45.4 years [SD=9.7]; 75% female; 62.5% current stage IV) completed an interview. Participants reported diminished mental health as the most salient impact of the pandemic related to their CRC care. Participants expressed how difficult, isolating, and lonely they felt navigating cancer treatment, particularly as a result of visitor restriction policies that did not allow their support person (e.g., spouse) to be present during visits or stays. Increased anxiety, fear, and worry over how the pandemic may affect their planned cancer care, including fear of contracting the virus themselves, were major concerns. Other impacts experienced included barriers to physically accessing care facilities (e.g., reduced appointment availability, staffing shortages), delays to patients’ planned treatment (e.g., canceled surgery), and increased access to and use of telehealth, which was perceived as being more convenient and safer than in-person visits. Participant perspectives on the quality of care they received throughout the pandemic were based on frequency and personalization of patient-provider communication, ability to access their usual care and support services (e.g., care navigators, support groups), and provider attention to their mental health. To improve the quality of cancer care in a pandemic setting, participants recommended personalized and frequent communications from the oncology care team, holistic care that includes mental health support, and streamlined insurance preauthorization processes. Conclusions: While the long-term impacts of COVID-19 on CRC care delivery have yet to be fully understood, this study highlights the key challenges patients experienced while receiving CRC care during the pandemic. Recognizing the strain of the pandemic on patients’ mental health and well-being will help to ensure patient-provider communication and support services consider the short and long-term effects of the pandemic for cancer patients as well as help contribute to improved treatment-related outcomes.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation’s epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18–35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky

BACKGROUND

Though overdose rates have been increasing in US rural areas for two decades, little is known about the rural risk environment for overdoses. This qualitative study explored the risk environment for overdoses among young adults in Eastern Kentucky, a rural epicenter of the US opioid epidemic.

METHODS

Participants were recruited via community-based outreach. Eligibility criteria included living in one of five rural Eastern Kentucky counties; being aged 18-35; and using opioids to get high in the past 30 days. Semi-structured interviews explored the rural risk environment, and strategies to prevent overdose and dying from an overdose. Interviews were transcribed verbatim and analyzed using constructivist grounded-theory methods.

RESULTS

In this sample (N = 19), participants reported using in a range of locations, including homes and outdoor settings; concerns about community stigma and law enforcement shaped the settings where participants used opioids and the strategies they deployed in these settings to prevent an overdose, and to survive an overdose. Almost half of participants reported using opioids in a "trap house" or other dealing locations, often to evade police after buying drugs, and reported that others present pressed them to use more than usual. If an overdose occurred in this setting, however, these same people might refuse to call EMS to protect themselves from arrest. Outdoor settings presented particular vulnerabilities to overdose and dying from an overdose. Most participants reported using opioids outdoors, where they skipped overdose prevention steps to reduce their risk of arrest; they worried that no one would find them if they overdosed, and that cell phone coverage would be too weak to summon EMS.

CONCLUSION

Findings suggest that initiatives to reduce overdoses in Eastern Kentucky would be strengthened by de-escalating the War on Drugs and engaging law enforcement in initiatives to protect the health of people who use opioids.

Using Web-Based Pin-Drop Maps to Capture Activity Spaces Among Young Adults Who Use Drugs in Rural Areas: Cross-Sectional Survey

Background

Epicenters of harmful drug use are expanding to US rural areas, with rural young adults bearing a disproportionate burden. A large body of work suggests that place characteristics (eg, spatial access to health services) shape vulnerability to drug-related harms among urban residents. Research on the role of place characteristics in shaping these harms among rural residents is nascent, as are methods of gathering place-based data.

Objective

We (1) analyzed whether young rural adults who used drugs answered self-administered Web-based mapping items about locations where they engaged in risk behaviors and (2) determined the precision of mapped locations.

Methods

Eligible individuals had to report recently using opioids to get high; be aged between 18 and 35 years; and live in the 5-county rural Appalachian Kentucky study area. We used targeted outreach and peer-referral methods to recruit participants. The survey asked participants to drop a pin in interactive maps to mark where they completed the survey, and where they had slept most; used drugs most; and had sex most in the past 6 months. Precision was assessed by (1) determining whether mapped locations were within 100 m of a structure and (2) calculating the Euclidean distance between the pin-drop home location and the street address where participants reported sleeping most often. Measures of central tendency and dispersion were calculated for all variables; distributions of missingness for mapping items and for the Euclidean distance variable were explored across participant characteristics.

Results

Of the 151 participants, 88.7% (134/151) completed all mapping items, and ≥92.1% (>139/151) dropped a pin at each of the 4 locations queried. Missingness did not vary across most participant characteristics, except that lower percentages of full-time workers and peer-recruited participants mapped some locations. Two-thirds of the pin-drop sex and drug use locations were less than 100 m from a structure, as were 92.1% (139/151) of pin-drop home locations. The median distance between the pin-drop and street-address home locations was 2.0 miles (25th percentile=0.8 miles; 75th percentile=5.5 miles); distances were shorter for high-school graduates, staff-recruited participants, and participants reporting no technical difficulties completing the survey.

Conclusions

Missingness for mapping items was low and unlikely to introduce bias, given that it varied across few participant characteristics. Precision results were mixed. In a rural study area of 1378 square miles, most pin-drop home addresses were near a structure; it is unsurprising that fewer drug and sex locations were near structures because most participants reported engaging in these activities outside at times. The error in pin-drop home locations, however, might be too large for some purposes. We offer several recommendations to strengthen future research, including gathering metadata on the extent to which participants zoom in on each map and recruiting participants via trusted staff.

Rural risk environments for hepatitis c among young adults in appalachian kentucky

BACKGROUND

Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context.

METHODS

Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods.

RESULTS

Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services.

CONCLUSION

This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.