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issn:1935-469
1.  Access to Chemotherapy Services by Availability of Local and Visiting Oncologists 
Journal of Oncology Practice  2014;10(1):26-31.
Access to cancer care is dependent on the absolute number of providers, but it is also dependent on their geographic distribution.
Purpose:
Geographic disparities have raised important questions about factors related to treatment choice and travel time, which can affect access to cancer care.
Patients and Methods:
Iowa residents who received chemotherapy regardless of where they were diagnosed or treated were identified through the Iowa Cancer Registry (ICR), a member of the SEER program. Oncologists and their practice locations, including visiting consulting clinics (VCCs), were tracked through the Iowa Physician Information System. Oncologists, VCCs, and patients were mapped to hospital service areas (HSAs).
Results:
Between 2004 and 2010, 113,885 newly diagnosed invasive cancers were entered into ICR; among patients in whom these cancers were diagnosed, 31.6% received chemotherapy as a first course of treatment. During this period, 106 Iowa oncologists practiced in 14 cities, and 82 engaged in outreach to 85 VCCs in 77 rural communities. Of patients receiving chemotherapy, 63.0% resided in an HSA that had a local oncologist and traveled 21 minutes for treatment on average. In contrast, 29.3% of patients receiving chemotherapy resided in an HSA with a VCC, and 7.7% resided in an HSA with no oncology provider. These latter two groups of patients traveled 58 minutes on average to receive chemotherapy. Availability of oncologists and VCCs affected where patients received chemotherapy. The establishment of VCCs increased access to oncologists in rural communities and increased the rate that chemotherapy was administered in rural communities from 10% to 24%, a notable increase in local access.
Conclusion:
Access to cancer care is dependent on the absolute number of providers, but it is also dependent on their geographic distribution.
doi:10.1200/JOP.2013.001217
PMCID: PMC3889218  PMID: 24443731
3.  Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer 
Journal of Oncology Practice  2013;9(6 Suppl):60s-63s.
The authors found that cost-related medication nonadherence was prevalent among patients with cancer who sought financial assistance.
Purpose:
The relationship between prescription medication adherence and financial burden is understudied, particularly in patients seeking financial assistance.
Methods:
We conducted a cross-sectional survey to examine the association between patient-reported prescription medication nonadherence and financial distress. Eligible patients were adults receiving treatment for solid malignancies enrolled between June 2010 and May 2011 from the HealthWell Foundation, a national copay assistance program. Nonadherence was defined as taking less medication than prescribed because of cost, not filling or partially filling a prescription because of cost, or taking medications prescribed for others. Logistic regression assessed associations between medication nonadherence and patient-reported, subjective financial distress.
Results:
Among 164 participants, 45% reported cost-related medication nonadherence. Four percent took medications prescribed for another person, 22% took less medication than prescribed, 25% filled a partial prescription, and 27% did not fill a prescription, all as a result of cost. Nonadherent participants were more likely than adherent participants to reduce spending on basics like food and clothing to pay for medication (P = .01), and borrow and/or use credit to pay for medications (P < .01). In adjusted analyses, financial distress did not change odds of nonadherence (odds ratio [OR] = 1.60; 95% CI, 0.71 to 3.60). Having a prescription drug plan (OR = 0.27; 95% CI, 0.09 to 0.83) and older age (OR = 0.48; 95% CI, 0.27 to 0.85) decreased odds of nonadherence. Being unemployed increased odds of nonadherence (OR = 6.28; 95% CI, 1.60 to 24.64).
Conclusions:
Cost-related medication nonadherence was prevalent among cancer patients who sought financial assistance. Further investigation is needed to understand predictors of prescription medication adherence, a key component of quality care.
doi:10.1200/JOP.2013.000971
PMCID: PMC3825170
4.  The National Cancer Institute–American Society of Clinical Oncology Cancer Trial Accrual Symposium: Summary and Recommendations 
Journal of Oncology Practice  2013;9(6):267-276.
In 2010, the National Cancer Institute and the American Society of Clinical Oncology cosponsored a symposium to examine the state of clinical trial accrual science and identify opportunities to facilitate trial enrollment. The authors provide recommendations for best practices and for future research developed from the symposium.
Introduction:
Many challenges to clinical trial accrual exist, resulting in studies with inadequate enrollment and potentially delaying answers to important scientific and clinical questions.
Methods:
The National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) cosponsored the Cancer Trial Accrual Symposium: Science and Solutions on April 29-30, 2010 to examine the state of accrual science related to patient/community, physician/provider, and site/organizational influences, and identify new interventions to facilitate clinical trial enrollment. The symposium featured breakout sessions, plenary sessions, and a poster session including 100 abstracts. Among the 358 attendees were clinical investigators, researchers of accrual strategies, research administrators, nurses, research coordinators, patient advocates, and educators. A bibliography of the accrual literature in these three major areas was provided to participants in advance of the meeting. After the symposium, the literature in these areas was revisited to determine if the symposium recommendations remained relevant within the context of the current literature.
Results:
Few rigorously conducted studies have tested interventions to address challenges to clinical trials accrual. Attendees developed recommendations for improving accrual and identified priority areas for future accrual research at the patient/community, physician/provider, and site/organizational levels. Current literature continues to support the symposium recommendations.
Conclusions:
A combination of approaches addressing both the multifactorial nature of accrual challenges and the characteristics of the target population may be needed to improve accrual to cancer clinical trials. Recommendations for best practices and for future research developed from the symposium are provided.
doi:10.1200/JOP.2013.001119
PMCID: PMC3825288  PMID: 24130252
5.  Overcoming Recruitment Challenges in Palliative Care Clinical Trials 
Journal of Oncology Practice  2013;9(6):277-282.
Challenges to clinical trial recruitment in palliative care are significant but not insurmountable. Through their experience with designing and deploying a social-marketing based protocol, the authors show that a carefully crafted recruitment and retention protocol can be effective.
Purpose:
Palliative care is increasingly viewed as a necessary component of cancer care, especially for patients with advanced disease. Rigorous clinical trials are thus needed to build the palliative care evidence base, but clinical research—especially participant recruitment—is difficult. Major barriers include (1) patient factors, (2) “gatekeeping,” and (3) ethical concerns. Here we discuss an approach to overcoming these barriers, using the Palliative Care Trial (PCT) as a case study.
Patients and Methods:
The PCT was a 2 × 2 × 2 factorial randomized controlled trial (RCT) of different service delivery models to improve pain control in the palliative setting. It used a recruitment protocol that fused evidence-based strategies with principles of “social marketing,” an approach involving the systematic application of marketing techniques. Main components included (1) an inclusive triage algorithm, (2) information booklets targeting particular stakeholders, (3) a specialized recruitment nurse, and (4) standardization of wording across all study communications.
Results:
From an eligible pool of 607 patients, the PCT enrolled 461 patients over 26 months. Twenty percent of patients referred to the palliative care service were enrolled (76% of those eligible after screening). Several common barriers were minimized; among those who declined participation, family disinterest was uncommon (5%), as was the perception of burden imposed (4%).
Conclusion:
Challenges to clinical trial recruitment in palliative care are significant but not insurmountable. A carefully crafted recruitment and retention protocol can be effective. Our experience with designing and deploying a social-marketing–based protocol shows the benefits of such an approach.
doi:10.1200/JOP.2013.000996
PMCID: PMC3825289  PMID: 24130254
6.  Coaching Intervention As a Strategy for Minority Recruitment to Cancer Clinical Trials 
Journal of Oncology Practice  2013;9(6):294-299.
Among racial/ethnic minority study participants, quality of life and positive attitude toward trials predicted trial enrollment, regardless of assignment to a coaching intervention or usual care.
Purpose:
Lack of trust and rapport with health care providers has been identified in the under-representation of racial/ethnic minorities within clinical trials. Our study used a coach to promote trust among minority patients with advanced cancer.
Patients and Methods:
Minority patients with advanced breast, colorectal, lung, or prostate carcinoma were randomly assigned to receive a coach Intervention (CI) or usual care (UC). All patients completed baseline and 6-month telephone interviews to assess demographics, trust in health care providers, attitudes toward clinical trials, and quality of life. Patients randomly assigned to CI were assigned a coach, who made biweekly contacts for 6 months to address general issues, progress or development in cancer care, and available resources. Patients randomly assigned to UC received the standard of care, without this intervention. Clinical trial enrollment was assessed.
Results:
Over 21 months, we screened 268 patients and enrolled 73 African Americans and two Asian Americans. Patients were randomly assigned to CI (n = 38) or to UC (n = 37). Longitudinal analyses were conducted on 69 patients who completed the 6-month follow-up assessment. Trial enrollment was 16 and 13 patients for the CI and UC groups, respectively. This difference was not significant (P = .351). Higher quality of life (1-point odds ratio on Functional Assessment of Cancer Treatment–General = 1.033, P = .036) and positive attitudes toward trials predicted enrollment. There was no significant difference between these groups in quality of life, attitudes toward clinical trials, perceptions of racism, trust in doctors, or depression.
Conclusions:
Quality of life and positive attitude toward trials predicted trial enrollment, regardless of assignment to CI or UC.
doi:10.1200/JOP.2013.000982
PMCID: PMC3825290  PMID: 24130255
7.  Health Disparities Around the World: Perspectives From the 2012 Principles and Practice of Cancer Prevention and Control Course at the National Cancer Institute 
Journal of Oncology Practice  2013;9(6):e284-e289.
The collective discussion during the NCI course highlighted the pervasiveness of health disparities across all areas represented by course participants and suggested these issues are the largest impediment to achieving cancer prevention goals.
Introduction:
The National Cancer Institute Principles and Practice of Cancer Prevention and Control course is a 4-week course encompassing a variety of cancer prevention and control topics that is open to attendees from medical, academic, government, and related institutions around the world. Themes related to the challenges health disparities present to cancer prevention efforts and potential solutions to these issues emerged from facilitated group discussions among the 2012 course participants.
Materials and Methods:
Small-group discussion sessions with participants (n = 85 from 33 different countries) and facilitators (n = 9) were held once per week throughout the 4-week course. Facilitators prepared open-ended questions related to course topics. Participants provided responses reflecting their opinions of topics on the basis of experiences in their countries. A thematic analysis was conducted to explore themes emerging from the discussion groups.
Results:
The varied influences of health disparities on cancer prevention efforts among > 30 countries represented prominent themes across discussion groups. Participants discussed the interplay of individual characteristics, including knowledge and culture, interpersonal relationships such as family structure and gender roles, community and organizational factors such as unequal access to health care and access to treatment, and national-level factors including policy and government structure.
Conclusion:
The ideas and solutions presented here are from a geographically and professionally diverse group of individuals. The collective discussion highlighted the pervasiveness of health disparities across all areas represented by course participants and suggested that disparities are the largest impediment to achieving cancer prevention goals.
doi:10.1200/JOP.2013.001129
PMCID: PMC3825291  PMID: 24084887
8.  Prevalence of Pain and Analgesic Use in Men With Metastatic Prostate Cancer Using a Patient-Reported Outcome Measure 
Journal of Oncology Practice  2013;9(5):223-229.
The authors' results provide a method for estimating accruals along the disease continuum, and for enabling design of trials appropriately powered to assess pain.
Purpose:
Contemporary tumor-directed therapies for metastatic castration-resistant prostate cancer (mCRPC) are approved to prolong life, but their effects on symptoms such as pain are less well understood as a result of the lack of analytically valid assessments of pain prevalence and severity, clinically meaningful definitions of therapeutic benefit, and methodologic standards of trial conduct. This study establishes pain characteristics in the mCRPC population using a PRO measure.
Materials and Methods:
Patients with prostate cancer participated in an anonymous survey at five US comprehensive cancer centers in the Prostate Cancer Clinical Trials Consortium that incorporated the Brief Pain Inventory (BPI), analgesic use, and interference with daily activities. Prevalence and severity of cancer-related pain and analgesic use were tabulated according to castration-resistant status and exposure to docetaxel chemotherapy.
Results:
Four hundred sixty-one patients with prostate cancer participated, of whom 147 had mCRPC involving bone (61% [89 of 147] docetaxel exposed, 39% [58 of 147] docetaxel naive). Pain of any level was more common among docetaxel-exposed versus docetaxel-naive patients with mCRPC (70% [62 of 89] v 38% [22 of 58], respectively; P < .001). BPI score ≥ 4 was reported by 38% (34 of 89) of docetaxel-pretreated and 24% (14 of 58) of docetaxel-naive patients with mCRPC; 40% of these patients with pain intensity ≥ 4 reported no current narcotic analgesic.
Conclusion:
Pain prevalence and severity were higher in patients with prior docetaxel exposure. Analgesics were underutilized. These results provide a method for estimating accruals along the disease continuum, and for enabling design of trials appropriately powered to assess pain.
doi:10.1200/JOP.2013.000876
PMCID: PMC3994234  PMID: 23943897
9.  Childhood Cancer Survivors' Familiarity With and Opinions of the Patient Protection and Affordable Care Act 
Journal of Oncology Practice  2013;9(5):246-250.
Childhood cancer survivors have a low level of familiarity with the Patient Protection and Affordable Care Act (ACA) and are unaware of how it may affect them given their cancer history. These survivors require targeted education to increase knowledge about the ACA.
Purpose:
The Patient Protection and Affordable Care Act (ACA) offers avenues to increase insurance options and access to care; however, it is unknown whether populations with pre-existing conditions, such as cancer survivors, will benefit from the expanded coverage options. We explored childhood cancer survivors' familiarity with and opinion of the ACA to understand how survivors' insurance coverage may be affected.
Materials and Methods:
From April to July 2012 we conducted in-depth, semistructured telephone interviews with 53 adult survivors recruited from the Utah Cancer SEER Registry. Participants were randomly selected from sex, age, and rural/urban strata and were younger than 21 years at time of diagnosis. Interviews were recorded, transcribed, and analyzed with NVivo 9 by two coders (kappa = 0.94). We report on the 49 participants who had heard of the ACA.
Results:
Most survivors were unaware of ACA provisions beyond the insurance mandate. Few knew about coverage for children up to age 26 or pre-existing insurance options. Although one third believed the ACA could potentially benefit them via expanded insurance coverage, many were concerned that the ACA would lead to rising health care costs and decreasing quality of care. Survivors had concerns specific to their cancer history, including fears of future health care rationing if they developed subsequent health problems.
Conclusion:
Childhood cancer survivors have a low level of familiarity with the ACA and are unaware of how it may affect them given their cancer history. These survivors require targeted education to increase knowledge about the ACA.
doi:10.1200/JOP.2013.000919
PMCID: PMC3770506  PMID: 23943900
10.  Cost Concerns of Patients With Cancer 
Journal of Oncology Practice  2013;9(5):251-257.
Cost concerns are common among patients with cancer who have health insurance. Health care providers may alleviate concerns by discussing cost-related concerns with all patients, not only those of lower socioeconomic status or those without insurance.
Purpose:
Health care providers are accustomed to identifying populations for whom cost-related concerns may be a significant barrier, such as the poor, but few empiric data have been collected to substantiate such assumptions, particularly among insured patients.
Methods:
Patients with cancer from academic and community hospitals completed a questionnaire that included closed-ended items concerning demographic variables, optimism, numeracy, and concerns about present and future medical costs. In addition, they answered open-ended questions regarding cost concerns and medical expenses.
Results:
Nearly all (99%) participants were insured. In response to the closed-ended questions, 30.3% of patients reported concern about paying for their cancer treatment, 22.3% reported that their family had made sacrifices to pay for their care, and 8.3% stated that their insurance adequately covered their current health care costs, and 17.3% reported concerns about coverage for their costs in the future. On open-ended questions, 35.3% reported additional expenses, and 47.5% reported concerns about health care costs. None of the assessed patient characteristics proved to be a robust predictor across all cost-related concerns. There was a strong association between the identification of concerns or expenses on the open-ended questions and concerns on closed-ended questions.
Conclusion:
Cost concerns are common among patients with cancer who have health insurance. Health care providers may alleviate concerns by discussing cost-related concerns with all patients, not only those of lower socioeconomic status or those without insurance. A closed-ended screening question may help to initiate these conversations. This may identify potential resources, lower distress, and enable patients to make optimal treatment decisions.
doi:10.1200/JOP.2013.000929
PMCID: PMC3770507  PMID: 23943901
11.  Assessing Patient-Centered Communication in Cancer Care: Stakeholder Perspectives 
Journal of Oncology Practice  2013;9(5):e186-e193.
Patient reports of their communication experiences during cancer care could increase understanding of the communication process, stimulate improvements, inform interventions, and provide a basis for evaluating changes in communication practices.
Purpose:
Patient-centered communication is critical to quality cancer care. Effective communication can help patients and family members cope with cancer, make informed decisions, and effectively manage their care; suboptimal communication can contribute to care breakdowns and undermine clinician-patient relationships. The study purpose was to explore stakeholders' views on the feasibility and acceptability of collecting self-reported patient and family perceptions of communication experiences while receiving cancer care. The results were intended to inform the design, development, and implementation of a structured and generalizable patient-level reporting system.
Methods:
This was a formative, qualitative study that used semistructured interviews with cancer patients, family members, clinicians, and leaders of health care organizations. The constant comparative method was used to identify major themes in the interview transcripts.
Results:
A total of 106 stakeholders were interviewed. Thematic saturation was achieved. All stakeholders recognized the importance of communication and endorsed efforts to improve communication during cancer care. Patients, clinicians, and leaders expressed concerns about the potential consequences of reports of suboptimal communication experiences, such as damage to the clinician-patient relationship, and the need for effective improvement strategies. Patients and family members would report good communication experiences in order to encourage such practices. Practical and logistic issues were identified.
Conclusion:
Patient reports of their communication experiences during cancer care could increase understanding of the communication process, stimulate improvements, inform interventions, and provide a basis for evaluating changes in communication practices. This qualitative study provides a foundation for the design and pilot testing of such a patient reporting system.
doi:10.1200/JOP.2012.000772
PMCID: PMC3770509  PMID: 23943884
12.  Advanced Diagnostic Breast Cancer Imaging: Variation and Patterns of Care in Washington State 
Journal of Oncology Practice  2013;9(5):e194-e202.
Use of breast MRI and other advanced imaging is increasing among patients newly diagnosed with breast cancer; individual patient and insurance-related factors are associated with receipt of these imaging tests.
Introduction:
Because receipt of breast imaging likely occurs in nonrandom patterns, selection bias is an important issue in studies that attempt to elucidate associations between imaging and breast cancer outcomes. The purpose of this study was to analyze use of advanced diagnostic imaging in a cohort of patients with breast cancer insured by commercial, managed care, and public health plans by demographic, health insurance, and clinical variables from 2002 to 2009.
Methods:
We identified women with breast cancer diagnoses from a Surveillance Epidemiology and End Results (SEER) registry whose data could be linked to claims from participating health plans. We examined imaging that occurred between cancer diagnosis and initiation of treatment and classified patients according to receipt of (1) mammography or ultrasound only; (2) breast magnetic resonance imaging (MRI); and (3) other advanced imaging (computed tomography [CT] of the chest, abdoment, and pelvis; positron emission tomography [PET]; or PET-CT). We used logistic regression to identify factors associated with receipt of breast MRI as well as other advanced imaging.
Results:
Commercial health plan, younger age, and later year of diagnosis were strongly associated with receipt of breast MRI and other advanced imaging. Women with prescription drug plans and those who had less comorbidities were more likely to have received breast MRI.
Conclusion:
Use of breast MRI and other advanced imaging is increasing among patients newly diagnosed with breast cancer; individual patient and insurance-related factors are associated with receipt of these imaging tests. Whether use of diagnostic advanced imaging affects outcomes such as re-excision, cancer recurrence, mortality rates, and costs of breast cancer treatment remains to be determined.
doi:10.1200/JOP.2012.000796
PMCID: PMC3770510  PMID: 23943885
13.  An Automated System for Detecting Nonadherence in Laboratory Testing and Monitoring for Myelosuppression in Patients Receiving Self-Administered Oral Chemotherapy 
Journal of Oncology Practice  2013;9(5):e268-e271.
The authors sought to assess monitoring lapses and incidents of myelosuppression in patients undergoing self-administered chemotherapy for glioblastoma, as well as test software designed to detect and alert clinicians to lapses in monitoring.
Introduction:
Patient compliance with routine monitoring for self-administered chemotherapy is problematic. We sought to assess monitoring lapses and incidents of myelosuppression in patients undergoing self-administered chemotherapy for glioblastoma, as well as test software designed to detect and alert clinicians to lapses in monitoring.
Patients and Methods:
A retrospective analysis was conducted to identify patients (N = 117) who received standard oral temozolomide for glioblastoma at our institution from 2003 to 2010. Gaps in monitoring were classified as minor (10 to 12 days) or major (13 to 28 days), and adverse events were graded using standard criteria. During the prospective portion of the study, we tested a software-based system that alerted clinicians of monitoring lapses and adverse events among patients receiving self-administered temozolomide for glioblastoma (n = 37).
Results:
Our retrospective review found that 34 of 117 patients experienced monitoring gaps during treatment. No association between gaps and risk of myelosuppression were found. Patients with gaps were more likely to be male (P = .04). Patients monitored prospectively with the software experienced no major gaps in monitoring (P = .007 compared with retrospective patients).
Conclusion:
Our retrospective review demonstrated that monitoring nonadherence was occurring at a substantial rate. Our computerized system eliminated major gaps in monitoring in the prospective portion of our study. Although there is no association between monitoring gaps and the occurrence of adverse events, when they do coincide, continuing oral chemotherapy during an unrecognized adverse event may worsen the patient's condition. Automated systems are justified and serve a function not currently being addressed.
doi:10.1200/JOP.2012.000834
PMCID: PMC3814612  PMID: 23943891
14.  Addressing Tobacco Use in Patients With Cancer: A Survey of American Society of Clinical Oncology Members 
Journal of Oncology Practice  2013;9(5):258-262.
Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support.
Purpose:
Assessing tobacco use and providing cessation support is recommended by the American Society for Clinical Oncology (ASCO). The purpose of this study was to evaluate practice patterns and perceptions of tobacco use and barriers to providing cessation support for patients with cancer.
Methods:
In 2012, an online survey was sent to 18,502 full ASCO members asking about their practice patterns regarding tobacco assessment, cessation support, perceptions of tobacco use, and barriers to providing cessation support for patients with cancer. Responses from 1,197 ASCO members are reported.
Results:
At initial visit, most respondents routinely ask patients about tobacco use (90%), ask patients to quit (80%), and advise patients to stop using tobacco (84%). However, only 44% routinely discuss medication options with patients, and only 39% provide cessation support. Tobacco assessments decrease at follow-up assessments. Most respondents (87%) agree or strongly agree that smoking affects cancer outcomes, and 86% believe cessation should be a standard part of clinical cancer care. However, only 29% report adequate training in tobacco cessation interventions. Inability to get patients to quit (72%) and patient resistance to treatment (74%) are dominant barriers to cessation intervention, but only 8% describe cessation as a waste of time.
Conclusion:
Among ASCO members who responded to an online survey about their practice patterns regarding tobacco, most believe that tobacco cessation is important and frequently assess tobacco at initial visit, but few provide cessation support. Interventions are needed to increase access to tobacco cessation support for patients with cancer.
doi:10.1200/JOP.2013.001025
PMCID: PMC3770508  PMID: 23943904
15.  Journal Correction 
doi:10.1200/JOP.2013.001166
PMCID: PMC3710174
16.  Author Correction 
doi:10.1200/JOP.2013.00151
PMCID: PMC3710175
17.  Impact of Age Cutoffs on a Lynch Syndrome Screening Program 
Journal of Oncology Practice  2012;9(4):175-179.
Applying an age cutoff to a Lynch syndrome screening program has considerable potential for decreasing total screening costs and increasing efficiency, but at a loss of effectiveness.
Purpose:
To determine the impact of applying an age cutoff to tumor-based Lynch syndrome (LS) screening, specifically focusing on changes in relative effectiveness, efficiency, and cost. The project was undertaken to answer questions about implementation of the LS screening program in an integrated health care delivery system.
Patients and Methods:
Clinical data extracted from an internal cancer registry, previous modeling efforts, published literature, and gray data were used to populate decision models designed to answer questions about the impact of age cutoffs in LS screening. Patients with colorectal cancer (CRC) were stratified at 10-year intervals from ages 50 to 80 years and compared with no age cutoff. Outcomes are reported for a cohort of 325 patients screened and includes total cost to screen, LS cases present in the cutoff category, number of LS cases expected to be identified by screening, cost per LS case detected, and total number and percentage of LS cases missed.
Conclusion:
Applying an age cutoff to an LS screening program has considerable potential for decreasing total screening costs and increasing efficiency, but at a loss of effectiveness. Imposing an age cutoff of 50 years reduces the cost of the screening program to 16% of a program with no age cutoff, but at the expense of missing more than half of the cases. Failure to identify LS cases is magnified by a cascade effect in family members. The results of this analysis influenced the final policy in our system.
doi:10.1200/JOP.2012.000573
PMCID: PMC3710164  PMID: 23942916
19.  Evaluating Use Characteristics for the Oncotype Dx 21-Gene Recurrence Score and Concordance With Chemotherapy Use in Early-Stage Breast Cancer 
Journal of Oncology Practice  2013;9(4):182-187.
Patients who are younger, have better ECOG performance status, or have higher grade tumors are more likely to undergo recurrence score testing.
Purpose:
Oncotype Dx 21-gene assay recurrence score (RS) predicts recurrence of early-stage breast cancer (ESBC). We investigated whether patient, tumor, or practice characteristics drive its use and explored Oncotype DX RS and chemotherapy use in subgroups.
Methods:
Patients with ESBC with documented estrogen receptor–positive, lymph node–negative, human epidermal growth factor receptor 2–negative tumors registered within McKesson Specialty Health's iKnowMed electronic health record were included. Patient and practice characteristics by region and size were analyzed. The association between Oncotype DX RS value and use of chemotherapy were assessed.
Results:
The study included 6,229 patients. Of these, 1,822 (29%) had an Oncotype DX RS result. Test use was 36%, 38%, 34%, 25%, and 6%, respectively, in patients age ≤ 45, 46-55, 56-65, 66-75, and ≥ 76 years; 33%, 25%, and 9% in patients with Eastern Cooperative Oncology Group performance status of 0, 1, and ≥ 2; 7%, 9%, 25%, 38%, 27%, and 10% in T1mic, T1a, T1b, T1c, T2, and T3 tumors; and 26%, 32%, and 33% for grades 1, 2, and 3 tumors. Of the 1,822 patients with available Oncotype DX RS, adjuvant chemotherapy use was 6%, 42%, and 84% in the low-, intermediate-, and high-risk groups.
Conclusion:
Patients who were younger, had better ECOG performance status, or had higher grade tumors were more likely to undergo RS testing. It appears that the RS test may have influenced the decision about whether to administer adjuvant chemotherapy: a low RS score was associated with lower chemotherapy use and a high RS score was associated with higher chemotherapy use.
doi:10.1200/JOP.2012.000638
PMCID: PMC3710166  PMID: 23942918
20.  Overcoming Obstacles in Accessing Unfunded Oral Chemotherapy: Physician Experience and Challenges 
Journal of Oncology Practice  2013;9(4):188-193.
The authors claim Canadian physicians use numerous methods to obtain unfunded oral chemotherapies, including falsifying claims on access forms and submitting special requests to government agencies.
Purpose:
Previous studies have shown hematologists and medical oncologists may not accept the financial limits set by governing agencies on patient access to oral chemotherapy. The purpose of this study was to capture the methods physicians used to overcome barriers to accessing chemotherapeutic regimens for their patients.
Methods:
A total of 640 medical oncologists and hematologists across Canada were surveyed using a 13-item Web-based survey tool. The survey was delivered by e-mail with three follow-up reminders. After a response period of 3 months, results were collated and analyzed with descriptive statistics.
Results:
Of the 640 invitations, 568 were successfully delivered, and 183 responses were received (response rate, 32.0%). Among respondents, 101 treated solid malignancies (55.2%), 49 treated nonsolid malignancies (26.8%), and 33 treated both (18.0%). To overcome funding barriers, participating oncologists enrolled patients onto clinical trials (90.5%), used compassionate access programs (96.1%), and made special requests to government (91.8%). Other methods included writing false claims on forms to fit funding criteria for drugs (31.1%) and using leftover drug supplies (31.0%). Physicians felt their inability to obtain unfunded medications had a negative impact on their patients' clinical outcomes (56.0%) and psychosocial quality of life (73.0%). Only 28.5% of physicians contacted their governing body with concerns about oral chemotherapy funding.
Conclusion:
Canadian physicians use numerous methods to obtain unfunded oral chemotherapies, including falsifying claims on access forms and submitting special requests to government agencies. Further study is warranted to explore the disconnection between policymakers and physicians with regard to funding of oral chemotherapies.
doi:10.1200/JOP.2012.000680
PMCID: PMC3710167  PMID: 23942919
21.  Protecting Patient Access to Oral Cancer Drugs in the United States 
Journal of Oncology Practice  2013;9(4):194-196.
doi:10.1200/JOP.2012.000795
PMCID: PMC3710168  PMID: 23942920
22.  Physical, Psychosocial, Relationship, and Economic Burden of Caring for People With Cancer: A Review 
Journal of Oncology Practice  2012;9(4):197-202.
Having an understanding of the roles that caregivers play in the oncology setting may assist health care professionals in supporting caregivers with these tasks, and targeting services toward those most in need.
The aim of this article is to provide an overview of the issues faced by caregivers of people diagnosed with cancer, with a particular emphasis on the physical, psychosocial, and economic impact of caring.
A review of the literature identified cancer as one of the most common health conditions in receipt of informal caregiving, with the majority of caregivers reporting taking on the role of caring because of family responsibility and there being little choice or no one else to provide the care. For some, caregiving can extend for several years and become equivalent to a full-time job, with significant consequent health, psychosocial, and financial burdens.
Having a better understanding of the critical and broad roles that caregivers play in the oncology setting and the impact of these on their health and well-being may assist health care professionals in supporting caregivers with these tasks and targeting services and interventions toward those most in need.
doi:10.1200/JOP.2012.000690
PMCID: PMC3710169  PMID: 23942921
23.  Comparison of Pegfilgrastim Prescribing Practice to National Guidelines at a University Hospital Outpatient Oncology Clinic 
Journal of Oncology Practice  2012;9(4):203-206.
At one institution, approximately one half of primary prophylaxis pegfilgrastim was not indicated per published guidelines, highlighting a need to change prescribing practices, to reduce costs without harming patients.
Purpose:
Pegfilgrastim reduces the risk of febrile neutropenia (FN) and is indicated as primary prophylaxis when the risk of FN approaches 20% in each chemotherapy cycle. There have been few reports evaluating the appropriate use of pegfilgrastim in comparison with published guidelines. We sought to determine possible over-prescribing as a way to maintain quality and reduce cost.
Methods:
A retrospective medical record review was performed to determine whether pegfilgrastim was used appropriately in the primary prophylaxis of FN in chemotherapy regimens with less than 20% risk of FN. Patients were identified by means of administrative records, and data were collected from the electronic medical record at an academic cancer center outpatient clinic serving approximately 13,000 patients per year.
Results:
Two hundred ninety-two patients were identified, of whom 124 were initially evaluated and 88 were included. Thirty-three patients (37%) had no risk factors, and 20 (22%) had one risk factor that would justify pegfilgrastim use with low- or intermediate-risk regimens. The most common cancer diagnosis of patients with zero or one risk factor was lymphoma, and the most common regimens with overuse of pegfilgrastim were doxorubicin-bleomycin-vinblastine-dacarbazine (ABVD) and ritux-imab-cyclophosphamide-doxorubicin-vincristine-prednisone (R-CHOP). One hundred eighty-four pegfilgrastim doses (46%) were classified as avoidable. The cost to the health system for unnecessary drug use was $712,264 in 1 year.
Conclusion:
At one institution, approximately one half of all primary prophylaxis pegfilgrastim was not indicated per published guidelines. This represents an excellent opportunity to change prescribing practices to reduce costs without harming patients.
doi:10.1200/JOP.2012.000662
PMCID: PMC3710170  PMID: 23942922
24.  Communicating Safe Outpatient Management of Fever and Neutropenia 
Journal of Oncology Practice  2013;9(4):207-210.
doi:10.1200/JOP.2012.000815
PMCID: PMC3710171  PMID: 23942923
25.  Measuring Clinical Trial–Associated Workload in a Community Clinical Oncology Program 
Journal of Oncology Practice  2013;9(4):211-215.
Clinical trial workload has been successfully measured and used to guide staffing by the Wichita Community Clinical Oncology Program. Further research is needed regarding its applicability to other research programs.
Purpose:
The ability to quantify clinical trial–associated workload can have a significant impact on the efficiency and success of a research organization. However, methods to effectively estimate the number of research staff needed for clinical trial recruitment, maintenance, compliance, and follow-up are lacking. To address this need, the Wichita Community Clinical Oncology Program (WCCOP) developed and implemented an acuity-based workload assessment tool to facilitate assessment and balancing of workload among its research nursing staff.
Methods:
An acuity-based measurement tool was developed, assigning acuity scores for individual clinical trials using six trial-related determinants. Using trial acuity scores and numbers of patients per trial, acuity scores for individual research nursing staff were then calculated and compared on a monthly basis.
Results:
During the 11 years that data were collected, acuity scores increased from 65% to 181%. However, during this same period, WCCOP was able to decrease individual research nurse staff full-time equivalent (FTE) acuity scores and number of patients per FTE. These trends reflect the use of the acuity-based measurement tool to determine actual workload and use of the acuity data to direct hiring decisions.
Conclusion:
Clinical trial workload has been successfully measured and used to guide staffing by one community clinical oncology program. Further research is needed regarding its applicability to other research programs.
doi:10.1200/JOP.2012.000797
PMCID: PMC3710172  PMID: 23942924

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