American Society of Clinical Oncology Road to Recovery Report: Learning From the COVID-19 Experience to Improve Clinical Research and Cancer Care

This report presents the American Society of Clinical Oncology's (ASCO's) evaluation of the adaptations in care delivery, research operations, and regulatory oversight made in response to the coronavirus pandemic and presents recommendations for moving forward as the pandemic recedes. ASCO organized its recommendations for clinical research around five goals to ensure lessons learned from the COVID-19 experience are used to craft a more equitable, accessible, and efficient clinical research system that protects patient safety, ensures scientific integrity, and maintains data quality. The specific goals are: (1) ensure that clinical research is accessible, affordable, and equitable; (2) design more pragmatic and efficient clinical trials; (3) minimize administrative and regulatory burdens on research sites; (4) recruit, retain, and support a well-trained clinical research workforce; and (5) promote appropriate oversight and review of clinical trial conduct and results. Similarly, ASCO also organized its recommendations regarding cancer care delivery around five goals: (1) promote and protect equitable access to high-quality cancer care; (2) support safe delivery of high-quality cancer care; (3) advance policies to ensure oncology providers have sufficient resources to provide high-quality patient care; (4) recognize and address threats to clinician, provider, and patient well-being; and (5) improve patient access to high-quality cancer care via telemedicine. ASCO will work at all levels to advance the recommendations made in this report.

Abstract PO-022: Impact of COVID-19 pandemic on new patient and consult visits at 20 hematology/oncology practices in the ASCO PracticeNET learning network

Introduction: During March 2020, as the emergence of COVID-19 began to influence medical and social behaviors in the United States, oncology practices reported a disruption in normal referral and patient management patterns. Participants and staff of ASCO's PracticeNET learning network sought to explore and quantify the impact of this disruption through an analysis of patient activity at multiple hematology/oncology practices.

Methods: 20 practices submitted their billing data for analysis; practices were located in 14 states and ranged in size from 2 to 29 hematologists/oncologists. From this dataset we analyzed a total of 11,453 new patient and consult visits (Current Procedural Terminology codes 99201-99205, 99241-99245, 99251-99255, and 99341-99345) performed by hematologists/oncologists from February 9 to April 18, 2020. The number of visits performed from February 9 to March 14, 2020 was compared to visits performed from March 15 to April 18, 2020. A principal diagnosis was assigned to each visit following usual coding and billing practices.

Results: From February 9 to March 14, practices performed an average of 70.1 (median 55.5) new patient and consult visits per week. From March 15 to April 19, practices performed an average of 44.5 new patient and consult visits per week. The average decrease in visits among practices was 35% (95% confidence interval (CI): -42%, -29%). The decline in visits per practice ranged from -61% to -13%. New patient and consult visits for solid neoplasms decreased by an average of 22% (95% CI: -31%, -13%), visits for blood neoplasms decreased by an average of 36% (95% CI: -25%, -47%), and visits for benign hematology and circulatory disorders decreased by an average of 44% (95% CI: -53%, -34%).

Conclusions: Oncology practices experienced a decline in new patient and consult visits, first observed in the week of March 15. New patient and consult visits for blood neoplasms, benign hematology, and circulatory disorders experienced a greater decline than visits for solid neoplasms. The decrease in activity could be the result of prioritization of resources or changes in patient behavior in seeking care. Further study is necessary to quantify the impact of these findings on patient access and outcomes and to monitor recovery efforts.

Citation Format: Brian Bourbeau, Mou Guharoy, Elizabeth Garrett-Mayer, Stephen Grubbs, Paul Unger, Barbara McAneny, Richard L. Schilsky. Impact of COVID-19 pandemic on new patient and consult visits at 20 hematology/oncology practices in the ASCO PracticeNET learning network [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-022.

Abstract S06-01: Changes implemented by U.S. oncology practices in response to COVID-19 pandemic: Initial report from the ASCO Registry on COVID-19 and cancer

Background: In April 2020, ASCO initiated a registry to capture and analyze status and outcomes of patients with cancer and COVID-19, and to describe effects of the pandemic on U.S. cancer practices. Initial findings of changes to care delivery are included.

Methods: Practices provide data on changes to care delivery due to COVID-19 and longitudinal data on patients with cancer and confirmed COVID-19. At present, 26 cancer practices have enrolled in the Registry—5 academic, 15 hospital/health-system (H/HS) owned, and 6 physician-owned (P-O) located in 19 states. Enrollment of practices and data collection is ongoing.

Results: Twenty sites, from 17 practices (3 academic, 9 H/HS owned, and 5 P-O in 15 states) responded (April 20-June 4). All incorporated telemedicine visits; 90% reported use of telemedicine was new. 30% reported “declining some but not all” new patient requests. For patients with cancer not on active therapy, 15% of sites postponed some routine visits, 35% conducted virtually all routine visits by telemedicine, and 50% used telemedicine for some routine visits. Most sites (95%) reported following clinical guidelines for visit postponement; 90% reported following local health authorities on when to resume routine visits. 90% screened patients prior to in-office visits for COVID-19 symptoms by phone and at clinic entrance; 10% screened patients using only one method. 30% modified intravenous (IV) drug infusions, including halting some or all (10%), shortening some or all (20%), or switching from IV to oral drugs (15%). While no sites conducted home-based, anticancer drug infusions, 30% are considering this option if COVID19 conditions change. Most sites modified laboratory specimen collection, including allowing a collection site closer to home (60%) and collection in a patient’s home (1 site). Two sites only allowed patients on oral anticancer drugs to use alternate collection sites. Only 1 site reported specimen collection in patients’ homes. All reported making the following changes to clinic arrangements: requiring use of masks, eliminating accompaniment by a support person (with exceptions), and reducing the visit numbers or increasing time between visits. No sites reported shortages of anticancer or supportive care drugs. 45% experienced shortages of nasopharyngeal swabs, 45% of medical hand sanitizer, and 75% of personal protective equipment. 40% of sites have experienced staffing reductions or changes due to reduced patient visits (30%), transfer to other clinical areas (20%), availability (15%), and COVID-19 illness (15%).

Conclusions: The COVID-19 pandemic has had a substantial impact on most aspects of cancer care delivery in U.S. oncology practices. All practices incorporated telemedicine, which is new to most. Adjustments were made to patient visits and scheduled IV drug infusions. Sites reported shortages of equipment related to COVID-19, not cancer or supportive care drug shortages. At the time of the AACR meeting we expect to have data from more practices.

Citation Format: Suanna S. Bruinooge, Elizabeth Garrett-Mayer, Stephen Meersman, Patricia Hurley, Brian Bourbeau, Allyn Moushey, Sybil Green, Deborah Kamin, Stephen Grubbs, Richard L. Schilsky. Changes implemented by U.S. oncology practices in response to COVID-19 pandemic: Initial report from the ASCO Registry on COVID-19 and cancer [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S06-01.

Abstract PO-015: Differences in level-of-service for telehealth visits as compared to in-office visits for cancer and hematology patients seen in practices within the ASCO PracticeNET learning network

Introduction: In response to the need for social distancing and infection prevention during the COVID-19 pandemic, there has been increased use of telehealth services to manage cancer and hematology patients. Throughout March and April of 2020, the Medicare and Medicaid programs expanded coverage of telehealth services, allowing cancer and hematology patients to receive certain telehealth services from their home during the public health emergency. We analyzed data from ASCO’s PracticeNET learning network to examine the reported level-of-service for telehealth services compared to standard in-office visits.

Methods: 20 practices submitted their billing data for analysis; practices were located in 14 states and ranged in size from 2 to 29 hematologists/oncologists. We analyzed a total of 33,435 established patient evaluation and management visits performed by hematologists/oncologists from March 15 to April 18, 2020. 3,062 (9.1%) visits were performed via telehealth and 30,373 were performed in a physician office or outpatient hospital department. The level-of-service of each visit was identified through the reported Current Procedure Terminology (CPT) code, where levels 1-5 correspond to CPT codes 99211-99215, respectively, and level 5 represents the highest complexity visit. Telehealth visits were identified through use of the modifiers 95, GQ, and GT, as appended to the applicable CPT code.

Results: The level-of-service distribution for telehealth-based visits was level 1 (1%), level 2 (4%), level 3 (35%), level 4 (50%), and level 5 (11%). This contrasted with in-office visits: level 1 (3%), level 2 (2%), level 3 (27%), level 4 (51%), and level 5 (18%). Differences were greatest in level 3 visits (35% vs. 27%) and level 5 visits (11% vs. 18%). Differences in level-of-service persisted when exploring various disease cohorts, including patients with solid neoplasms, blood neoplasms, benign hematology disorders, and circulatory disorders.

Conclusions: Analysis of established patient visits showed that telehealth visits were reported at lower level-of-service as compared to in-office visits. This finding may be related to directing straightforward visits to be performed via telehealth or due to limitations in using telehealth by patients with complex medical problems.

Citation Format: Brian Bourbeau, Mou Guharoy, Stephen Grubbs, Elizabeth Garrett-Mayer, Kevin Olson, Richard L. Schilsky. Differences in level-of-service for telehealth visits as compared to in-office visits for cancer and hematology patients seen in practices within the ASCO PracticeNET learning network [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-015.

Determining If a Somatic Tumor Mutation Is Targetable and Options for Accessing Targeted Therapies

Targeted cancer therapies are drugs and biologics designed to affect cancer cell growth by blocking or interfering with specific molecular pathways in the cancer cell. Use of targeted agents usually requires verification through molecular testing that the patient's tumor harbors the molecular biomarker that is the target of the drug or is predictive of treatment benefit. Genomic mutations may be clinically actionable if they are associated with response or resistance to a potential therapy. If a genomic test reveals an actionable alteration, there are several options for accessing the targeted therapy. This article is intended to help clinicians determine if a tumor mutation is potentially treatable with a marketed or investigational drug or biologic product and to offer guidance on how to access the product of interest.

Phase II study of carboplatin, pemetrexed, and bevacizumab in advanced nonsquamous non-small-cell lung cancer

Lung cancer remains the leading cause of cancer death throughout the world. Despite new chemotherapeutic, immunomodulating and molecularly targeted agents, patients with locally advanced or metastatic disease still have a poor prognosis. This trial looked to combine antiangiogenic therapy with a first‐line cytotoxic chemotherapy doublet, hoping to extend median progression‐free survival (PFS) while minimizing toxicity in patients with advanced nonsquamous non–small‐cell lung cancer (NSCLC). In this single institution, single‐arm study, 51 patients (age >18 yo) were followed from 2007 to 2012. Patients with stage IV nonsquamous NSCLC and patients with recurrent unresectable disease (nonradiation candidates) were eligible. Treatment consisted of carboplatin AUC 5 IV 30‐60 minutes, pemetrexed 500/mg²IV 10 minutes, bevacizumab 15 mg/kg IV (90 minutes 1st dose, 60 minutes 2nd dose, 30 minutes subsequent doses). Treatment was administered every 21 days and planned for 6 cycles, in the absence of disease progression or unacceptable toxicities. Growth factor support was not permitted prophylactically but allowed for toxicities, as were dose reductions. Maintenance treatment for those with stable disease or better consisted of Bevacizumab 15 mg/kg every 3 weeks for up to 1 year. Between November 2007 and March 2012, 51 patients were followed in the phase II trial of carboplatin, pemetrexed, and bevacizumab. Patients were enrolled over a 24‐month period. After the end of treatment visits, subjects were followed at least every 3 months for survival data. The median follow‐up period was 49 weeks (6 weeks to 178), and the median number of treatment cycles was 6 (range, 1‐6). Among the 50 patients assessable for response, median overall survival was 49 weeks (95% CI, 0‐62.7) with median PFS of 28 weeks (95% CI, 0‐132.4). A complete or partial response was seen in 28 (59.5%) patients. Grade 3‐4 treatment‐related adverse events occurred in 9 (17.6%) of 51 patients; the most common were thrombocytopenia (4 [7.8%]) and neutropenia (3 [5.9%]). Three (5.8%) of 51 patients were discontinued because of treatment‐related adverse events (grade 3 diarrhea, thrombocytopenia, dehydration, fatigue, and grade 4 respiratory distress), and 1 patient (1.9%) was found to be ineligible due to anticoagulation use. A novel 3‐drug combination for advanced nonsquamous NSCLC shows promising efficacy with modest toxicity.

Abstract IA29: Eliminating racial disparities in colorectal cancer

The Delaware Cancer Advisory Council was convened in 2001 by Governor Ruth Ann Minner to develop a statewide cancer control program. Rather than reporting a comprehensive cancer control program, the Council in 2002 recommended a limited number of achievable deliverables to reduce Delaware's high rates of cancer incidence and mortality. The Delaware Legislature and the Governor Minner accepted the recommendations and fully funded the program. Three key elements of the program include a statewide coordinated colorectal screening program with coverage of the uninsured, a cancer treatment program providing for the uninsured, and an emphasis of African American cancer disparity reduction. The screening program featured statewide nurse navigation, colonoscopy promotion, statewide marketing, and coverage for both screening and up to two years of cancer treatment for the uninsured.

Over the next ten years, the program eliminated the Caucasian and African American colorectal cancer disparities between by raising screening rates, lowering the stage at diagnosis, reducing the incidence, and finally eliminating the mortality disparity. All Delaware populations achieved improved colorectal cancer outcomes with the greatest gain in the African American community that closed the disparity gaps.

Delaware can be viewed as a model for success, achieved when all parties including government, health care systems, providers, and the public are determined together to improve health and tackle health disparities.

Citation Format: Stephen Grubbs. Eliminating racial disparities in colorectal cancer. [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer: From Initiation to Outcomes; 2016 Sep 17-20; Tampa, FL. Philadelphia (PA): AACR; Cancer Res 2017;77(3 Suppl):Abstract nr IA29.

Ethical considerations for the clinical oncologist in an era of oncology drug shortages

Shortages of injectable drugs affect many cancer patients and providers in the U.S. today. Scholars and policymakers have recently begun to devote increased attention to these issues, but only a few tangible resources exist to guide clinical oncologists in developing strategies for dealing with drug shortages on a recurring basis. This article discusses existing information from the scholarly literature, policy analyses, and other relevant sources and seeks to provide practical ethical guidance to the broad audience of oncology professionals who are increasingly confronted with such cases in their practice. We begin by providing a brief overview of the history, causes, and regulatory context of oncology drug shortages in the U.S., followed by a discussion of ethical frameworks that have been proposed in this setting. We conclude with practical recommendations for ethical professional behavior in these increasingly common and challenging situations.

Health-related quality of life in long-term breast cancer survivors: differences by adjuvant chemotherapy dose in Cancer and Leukemia Group B study 8541

BACKGROUND

The Survivor's Health and Reaction (SHARE) study examined health-related quality of life (HRQL) in breast cancer patients who had participated in Cancer and Leukemia Group B Trial 8541 from 1985 to 1991.

METHODS

In total, 245 survivors (78% of eligible patients) who were 9.4 to 16.5 years postdiagnosis (mean, 12.5 years postdiagnosis) completed HRQL surveys relating to 5 domains. Analyses examined HRQL domains according to 3 different chemotherapy dose levels that were administered in the original treatment trial: low-dose cyclophosphamide, doxorubicin, and fluorouracil (CAF) at 300 mg/m(2), 30 mg/m(2), and 300 x 2 mg/m(2), respectively, over 4 cycles; standard-dose CAF at 400 mg/m(2), 40 mg/m(2), and 400 x 2 mg/m(2), respectively, over 6 cycles; and high-dose CAF at 600 mg/m(2), 60 mg/m(2) and 600 x 2 mg/m(2), respectively, over 4 cycles.

RESULTS

In univariate analyses, a statistically significant difference was observed on the Medical Outcomes Study 36-item short form Physical Role Functioning subscale by treatment group, with lower mean scores in the standard treatment arm (mean, 65.05) compared with mean scores in the low-dose arm (mean, 74.66) and the high-dose arm (mean, 84.94; P.0001). However, multivariate analysis revealed that treatment arm no longer was statistically significant, whereas the following factors were associated with decreased physical role functioning: age >or=60 years (odds ratio [OR], 3.55; P = .006), increased comorbidity interference total score (OR, 1.64; P = .005), lower vitality (OR, 1.05; P = .0002), and increased menopausal symptoms (OR, 1.04 P = .02).

CONCLUSIONS

At 9.4-16.5 years after their original diagnosis, differences in physical role functioning among breast cancer survivors who had received 3 different dose levels of chemotherapy were explained by clinical and demographic variables, such as age, fatigue, menopausal symptoms, and comorbidities. Prospective studies are needed to further assess the role of these factors in explaining HRQL and physical role functioning among long-term survivors.

A phase I study of pegylated doxorubicin (DOX) and weekly topotecan (TOP) in patients (pts) with advanced solid tumors

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Background: The primary endpoint of this prospective phase I study of DOX-TOP in pts with advanced solid tumors was to identify the maximum tolerated dose and dose-limiting toxicities (DLT) of this combination. Other objectives included a description of additional toxicities and efficacy in this patient population with refractory cancers. Pharmacokinetic sampling of TOP plasma levels will be reported separately. Methods: Eligible pts had advanced solid tumors and had either failed standard chemotherapy (chemo) or were pts for whom no standard therapy existed. They had ECOG PS = 0–2, adequate organ function, and gave written, informed consent. Initial doses included DOX 40 mg/m2 day 1 and TOP 2 mg/m2 days 1, 8 and 15 q 28 days. TOP was to be escalated in cohorts of pts. DLT was defined as febrile neutropenia, grade 4 thrombocytopenia, any grade 3 non-hematologic toxicity, or the inability to receive subsequent treatment due to ongoing toxicity. Treatment was held for ANC < 1000 or platelets < 75,000. Results: Fourteen pts have been enrolled on this phase I study, all of whom were evaluable for toxicity. There were 12 males and 2 females, and the median age was 57 years (range 25–86). Four had ECOG PS = 0, 9 had PS = 1, and 1 had PS = 2. Cancer types included head and neck (3), renal (2), and breast, pancreas, liver, esophagus, germ cell tumor, sarcoma, and others (one each). In the 6 pts treated at dose level 1, toxicities included grade 3 anemia (1) and neutropenia (2), and grade 4 neutropenia (1). DLT consisted of grade 4 thrombocytopenia (1) and inability to deliver day 15 TOP in 3/6 pts at this dose. Thus, TOP was reduced to 1.5 mg/m2 weekly for dose level -1, and 8 pts have been treated. Toxicities included grade 3 anemia (1)and neutropenia (2), and grade 4 neutropenia (1) and thrombocytopenia (1). Enrollment continues at this dose level to confirm tolerability. No patient achieved an objective response to therapy, but 2 pts have stable disease for up to 4 cycles. Conclusions: DOX-TOP can be safely combined in pts with advanced solid tumors, with hematologic toxicity as the DLT. The preliminary recommended phase II dose is DOX 40 mg/m2 and TOP 1.5 mg/m2. We plan to explore an additional dose level of DOX 30 mg/m2 and TOP 2 mg/m2. Phase II evaluation is contemplated in selected tumor types.

[Table: see text]

Preliminary report on reduction of esophagitis by amifostine in patients with non-small-cell lung cancer treated with chemoradiotherapy

Esophagitis is a major toxicity of chemoradiotherapy for lung cancer. Twenty-four patients with non-small-cell lung cancer received induction chemotherapy (paclitaxel/carboplatin) followed by concurrent thoracic irradiation (RT) and weekly paclitaxel. Acute esophagitis was scored weekly. Since a high rate of grade 3 esophagitis was noted in the initial group of 12 patients, amifostine (AMI) 500 mg intravenously twice weekly was added to the regimen in the subsequent 12 patients. Esophagitis Index (EI) was calculated as an area under the curve reflecting esophagitis grade over time. Median number of AMI doses was 12 per patient. AMI was well tolerated. Two patients were not evaluable for esophagitis. The incidence of grade 3 esophagitis was 18% in the initial 11 patients versus 9% in the AMI-treated patients (P = not significant). Mean EI was numerically lower in the AMI-treated patients than in the initial group (5.1 vs. 11.6, P = 0.14). The product of RT dose and length of esophagus in the RT field was larger in the AMI group (934 vs. 761, P = 0.035). Median survival time for all patients was 12.4 months. Esophagitis Index, a novel measure of the severity and duration of acute esophagitis, may be reduced in lung cancer patients receiving twice-weekly AMI with thoracic RT and paclitaxel. Twice weekly AMI did not eliminate grade 3 esophagitis; therefore, dose escalation of AMI is planned. The effect of AMI was not due to the shorter irradiated esophageal length. A phase III randomized trial is now open to assess AMI's effect on esophagitis.

Phase II: trial of twice weekly amifostine in patients with non-small cell lung cancer treated with chemoradiotherapy

Twenty-four patients with non-small cell lung cancer received induction chemotherapy (paclitaxel, carboplatin) followed by concurrent thoracic irradiation (RT) and weekly paclitaxel. Acute esophagitis was scored weekly. Amifostine (AMI), 500 mg intravenously twice weekly, was added to the regimen in the second cohort of 12 patients. AMI was well tolerated. The incidence of grade 3 esophagitis was 18% in the initial 11 patients versus 9% in the AMI-treated patients. Mean esophagitis index (EI) was numerically lower in the AMI-treated patients than in the initial group (5.1 v 11.6, P =.14). The length of esophagus in the RT field was similar in both groups. Median survival time for all patients was 12.4 months. The EI, a novel measure of the severity and duration of acute esophagitis, may be reduced in lung cancer patients receiving AMI twice weekly with thoracic RT and paclitaxel. The effect of AMI was not caused by the shorter irradiated esophageal length. A phase III randomized trial is now open to assess the effect of AMI on esophagitis.

Self-efficacy in normal adolescents

This descriptive study, one component of the Carolina Adolescent Health Project (CAHP), measured self-efficacy in a voluntary sample of 432 normal freshmen and sophomore urban high school students. Using Coppel's Self-Efficacy Scale (SES), which is based on Bandura's conceptualization of self-efficacy, the research also examined the effect of gender, race, socioeconomic status, and self-reported religiosity on self-efficacy. The teenagers in this sample had a moderately high degree of self-efficacy with a mean SES score of 45.37 (SES range = 13-65). A series of t tests and one-way and two-way analyses of variance indicated no significant difference in SES scores by race, gender, socioeconomic status, or religiosity. Findings did not support the investigators' original expectation that these demographic and psychosocial variables would affect self-efficacy. The study provides normative data for future comparative studies using the SES.

The prediction of the impedance of the thorax to defibrillating current

In this paper a technique for predicting thoracic impedance to defibrillator pulses is described. The impedance to low-current (1.0 mA) high-frequency (10-500kHz) sinusoidal current is used as an indicator of the impedance of the thorax to high-current, damped sinusoidal waveform pulses. Results from 71 dogs to which defibrillator shocks of 4 to 220 A peak current were applied show that thoracic impedance can be predicted by this method. This information indicates that it is possible to design a defibrillator that can automatically measure chest impedance prior to a defibrillation shock and deliver a predetermined peak current to the subject.