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issn:1935-469
1.  Errata 
doi:10.1200/JOP.2016.013847
PMCID: PMC4957261  PMID: 27288473
2.  Complications Associated With Use of Long-Term Central Venous Catheters Among Commercially Insured Women With Breast Cancer 
Journal of Oncology Practice  2015;11(6):505-510.
Long-term central venous catheter (CVC) use is associated with increased morbidity. Evidence-based guidelines tools may help decrease discretionary use of long-term CVCs resulting from provider- or institution-driven variations in practice.
Purpose:
Despite some advantages to their use, long-term central venous catheters (CVCs) are associated with complications for patients who require chemotherapy. Understanding of these risks in commercially insured populations is limited. This information can inform medical policies that ensure the appropriate use of venous access devices. This study's objectives were to assess the extent of variation in use of long-term CVCs in a cohort of commercially insured women with breast cancer, and to assess risks of associated complications.
Methods:
Retrospective cohort analysis was conducted using health insurance claims between January 2006 and October 2013. The cohort included commercially insured women age ≥ 18 years diagnosed with breast cancer who received infusion chemotherapy (N = 31,047). We conducted matched and case-mix adjusted Cox proportional hazard modeling to assess differences in bloodstream infections and thrombovascular complications between patients using long-term CVCs and those using temporary intravenous catheters.
Results:
Approximately two thirds of the cohort had a long-term CVC, although rates varied across regions (57% to 75%), health plans (65% to 70%), and insurance coverage (63% to 68%). After propensity score matching, the adjusted hazard ratio for infection was 2.70 (95% CI, 2.31 to 3.16) and thrombovascular complications, 2.61 (95% CI, 2.33 to 2.93) in patients with long-term CVCs compared with those with temporary intravenous catheters.
Conclusion:
Although long-term CVCs may have benefits, they are associated with increased morbidity. Regional and health plan variation in long-term CVC insertion suggests that some of their use reflects provider- or institution-driven variation in practice. Evidence-based guidelines and tools may help decrease discretionary use of long-term CVCs.
doi:10.1200/JOP.2015.004796
PMCID: PMC4647067  PMID: 26265170
3.  Screening for Pain in the Ambulatory Cancer Setting: Is 0-10 Enough? 
Journal of Oncology Practice  2015;11(6):435-441.
Asking about pain frequency and intensity and reconsidering threshold values on pain intensity scales may be practical strategies to better identify patients with cancer who have relevant pain.
Purpose:
The purpose of this study was to explore concordance between patient self-reports of pain on validated questionnaires and discussions of pain in the ambulatory oncology setting.
Methods:
Adult, ambulatory patients (N = 452) with all stages of cancer were included. Three pain measures were evaluated: two items from the Symptom Distress Scale (frequency [SDSF] and intensity [SDSI]) and the Pain Intensity Numeric Scale (PINS). Relevant pain was defined as: (1) scores 3 of 5 on SDSF or SDSI or 5 of 10 on the (PINS); or (2) discussion of existing pain in an audio-recorded clinic visit. For each scale, McNemar's test assessed concordance of patient self-reports of relevant pain with discussions of relevant pain in the audio-recorded clinic visit. Sensitivity, specificity, and accuracy were calculated and a receiver operating characteristic analysis evaluated thresholds on self-report pain questionnaires to best identify relevant pain discussed in clinic.
Results:
Identification of relevant pain by self-report was discordant (P < .001) with discussed pain coded in audio-recorded visits for all three measures. Specificity was higher for intensity (SDSI, 0.94; PINS, 0.97) than frequency (SDSF, 0.87); sensitivity was higher for frequency (SDSF, 0.35) than intensity (SDSI, 0.24; PINS, 0.12). Accuracy was higher for the SDS pain items (SDSF, 0.57; SDSI, 0.54) than for PINS (0.48). Receiver operating characteristic analysis curves suggest that lower threshold scores may improve the identification of relevant pain.
Conclusion:
Self-report pain screening measures favored specificity over sensitivity. Asking about pain frequency (in addition to intensity) and reconsidering threshold scores on pain intensity scales may be practical strategies to more accurately identify patients with cancer who have relevant pain.
doi:10.1200/JOP.2015.004077
PMCID: PMC4647066  PMID: 26306620
4.  ReCAP: Oncologists’ Selection of Genetic and Molecular Testing in the Evolving Landscape of Stage II Colorectal Cancer 
Journal of Oncology Practice  2016;12(3):259-260.
CONTEXT AND QUESTION ASKED:
Genetic testing can be used in the diagnosis of Lynch syndrome, formerly known as hereditary nonpolyposis colorectal cancer (CRC), the most common inherited disorder that increases the risk for CRC; however, test results related to Lynch syndrome screening may also be used for predictive and prognostic purposes in patients with stage II CRC. Although national guidelines recommend the use of several genetic and molecular tests for patients with CRC, little is known about how guidelines, particularly the complex testing recommendations for Lynch syndrome, are translated into clinical practice. In this study, we asked: how does the family history of patients with stage II CRC influence medical oncologists’ selection of genetic and molecular testing, both related and unrelated to Lynch syndrome?
SUMMARY ANSWER:
We found that oncologists’ self-reported ordering of Lynch syndrome–related tests was strongly associated with the strength of CRC family history, but even so, not all oncologists would order germline testing for mismatch repair (MMR) genes, much less screen for Lynch syndrome by ordering microsatellite instability and/or immunohistochemistry for MMR proteins, in a patient scenario with the strongest family history of CRC (Table 2). We also found overtesting of KRAS and Oncotype DX for stage II CRC associated with certain practice and provider characteristics, with graduates of non-US or non-Canadian medical schools and physicians compensated under fee-for-service or by productivity-based salaries being more likely to choose KRAS testing. Fee-for-service and productivity-based salaries were also associated with increased Oncotype DX testing.
Percentages of Oncologists Who Reported They Would Order Genetic and Molecular Testing for a Patient Newly Diagnosed With Stage II CRC, Unadjusted
Abbreviations: IHC, immunohistochemistry; MMR, mismatch repair; MSI, microsatellite instability.
Maximum number of respondents for each scenario.
METHODS:
In 2012 and 2013, we surveyed medical oncologists in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) and evaluated their selection of microsatellite instability and/or immunohistorchemistry for MMR proteins, germline testing for MMR genes, BRAF and KRAS mutation analysis, and Oncotype DX in stage II CRC. Physicians were randomly assigned to receive one of three vignettes, varying by strength of CRC family history. We compared differences in testing by family history and provider and practice characteristics, and we used multivariate logistic regression to identify provider and practice characteristics associated with testing.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:
Although we surveyed a large cohort of oncologists from diverse geographic and practice settings, there were several limitations to this study. Whereas CanCORS patients are representative of the national patient population, participants were mostly oncologists who care for patients enrolled in CanCORS and who may be slightly older than US oncologists as a whole. Furthermore, our measures of testing relied on physician self-reporting rather than direct measures of use. In addition, we did not ask oncologists to report on the sequence in which they would order the various tests, and we were unable to determine whether such respondents would have ordered simultaneous or sequential testing. Finally, our study focused on patients with stage II CRC and may not be further generalizable.
REAL-LIFE IMPLICATIONS:
The high lifetime risk of CRC and other cancers among affected individuals and family members and low detection rates led the Centers for Disease Control and Prevention to recommend universal Lynch syndrome screening of all patients newly diagnosed with CRC. Previous efforts to increase the identification of patients and family members with Lynch syndrome have unfortunately achieved limited success. It remains to be seen whether the recapitulation by the National Comprehensive Cancer Network of the Centers for Disease Control and Prevention recommendation to screen all incident CRC specimens for Lynch syndrome can increase diagnoses. Undertesting related to Lynch syndrome screening and overtesting involving molecular tests among surveyed oncologists highlight the need for improved implementation, targeted education, and evaluation of organizational and financial arrangements to promote the appropriate use of genetic and molecular tests.
doi:10.1200/JOP.2015.007062
PMCID: PMC4960467  PMID: 26962170
5.  ReCAP: Association Between the Number of Suppliers for Critical Antineoplastics and Drug Shortages: Implications for Future Drug Shortages and Treatment 
Journal of Oncology Practice  2016;12(3):249-250.
QUESTION ASKED:
Cancer drug shortages remain common in the United States and may force oncologists to prioritize patients for treatment, improvise standard treatment regimens, and potentially choose unproven treatment options for patients with curable disease. Because increased competition may reduce drug shortages, the objective of our study was to investigate the association between the number of suppliers for first-line breast, colon, and lung antineoplastics and resulting drug shortages.
SUMMARY ANSWER:
Among 35 antineoplastic drugs approved for first-line treatment of breast, colon, and lung cancer, we saw an overall increase in drug shortages over time (12.5%, 33.3%, and 0% of breast, colon, and lung cancer drugs experienced shortages in 2003 v 40.0%, 37.5%, and 54.5% in 2014). Having a small number of drug suppliers more than doubled the odds of shortages compared with a large number of suppliers (five or more, Table 1), although the results were only statistically significant with three to four suppliers (odds ratio = 2.6; P = .049) but not with one to two suppliers (odds ratio = 3.49; P = .105); however, one of the strongest risk factors for drug shortages was the age of the drug, with older drugs significantly more likely to experience shortages (P < .001).
METHODS:
Using the 2003-2014 Redbook and national drug shortage data from the University of Utah’s Drug Information Service, we used exploratory analysis and generalized mixed models to (1) quantify time trends in first-line drug suppliers and shortages by cancer site and (2) examine the association between the number of suppliers for individual drugs and resulting drug shortages.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:
Although our study provides insights into the relationship between suppliers and drug shortages, we acknowledge the following drawbacks: (1) Information about the supply chain of raw materials, which may affect drug shortages, was not available. (2) As a result of sample size limitations, we were unable to conduct stratified analysis by cancer site. (3) As there is no regulatory requirement to disclose the manufacturer of a product, we could not distinguish drug suppliers from manufacturers as many suppliers participate in contract manufacturing. Despite these limitations, our analysis provides initial insights into the complicated relationship between drug shortages for first-line cancer treatment and the number of companies supplying these drugs.
REAL-LIFE IMPLICATIONS:
We found that having few drug suppliers (three to four) was associated with increased likelihood of shortages compared with having a large number (five or more) of suppliers, but the relationship was nonlinear. However, we saw that older drugs were the most likely to experience drug shortages. This suggests that policies focused predominately on promoting increases in distinct suppliers and competition may not alleviate shortages of critical cancer drugs. Given the continued significant impact of these shortages on patient care, future policies should promote targeted efforts to understand underlying causes of shortages in older drugs in order to evaluate contributors to and predictors of shortages in the oncology community. These finding are important for oncologists as they demonstrate that current strategies for preventing drug shortages have limited effect. Oncologists and patient advocates can help push for more effective policy initiatives and research aimed at understanding drug shortages.
Association Between the Number of Suppliers and Reported Shortages* for FDA-Approved Antineoplastics Drugs for First-Line Treatment of Breast, Colon, and Lung Cancer (2003-2014)
NOTE. Three hundred forty-two observations for 35 drugs over a 12-year period (model 1);191 observations for 21 drugs over a 12-year period (model 2). Model 1: Random slope model adjusting for the number of suppliers, year of observation, year of approval, cancer site and if a generic equivalent of the drug was on the market in a given year for all drugs. Model 2: Random slope model adjusting for the number of suppliers, year of observation, year of approval, and cancer site for drugs which had a generic equivalent was on the market during a given year.
Abbreviations: FDA, US Food and Drug Administration; OR, odds ratio.
Information about reported drug shortages obtained from the University of Utah’s Drug Information System.
Information about the number of suppliers obtained from the 2003-2009 Redbook: Pharmacy’s Fundamental Resource and the RED BOOK Online Database for subsequent years.
Year of FDA Approval for use of drug for specific cancer site based on drug information from the National Cancer Institute’s website http://www.cancer.gov/cancertopics/druginfo/alphalist; drugs approved before 1984 were assigned the value of 1984 as year of approval.
doi:10.1200/JOP.2015.007237
PMCID: PMC4960468  PMID: 26837565
6.  ReCAP: Physician Experience and Attitudes Toward Addressing the Cost of Cancer Care 
Journal of Oncology Practice  2016;12(3):247-248.
QUESTION ASKED:
Because the cost of oncologic care is perpetually rising, we wanted to know how often physicians who treat cancer discuss the cost of care (both out-of-pocket and societal) with their patients, what the nature of those discussions is, and whether such discussions affect treatment decisions.
SUMMARY ANSWER:
Sixty percent of responding physicians reported addressing costs frequently or always in clinic, 40% addressed costs rarely or never, and 36% did not believe it is the doctor’s responsibility to explain costs of care to patients. Additional responses are listed in Table 3. The majority of physicians feel their patients are not well informed about costs. “I don’t know enough/lack of resources” is the largest reported barrier to cost discussions, and those who reported frequent discussions were significantly more likely to explain costs and to prioritize treatments in terms of cost.
Physician Attitudes Toward Out-of-Pocket Costs Versus Societal Costs
METHODS:
A 15-question, study-specific, self-administered anonymous survey was sent electronically to a randomly selected sample of 2,290 ASCO physician members.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:
Our overall response rate was somewhat low at 15%, with an adjusted response rate of 25% after adjusting for nonpracticing physician ASCO members. This increased the potential for selection bias, by which the respondents to this survey may not represent the true beliefs and practices of medical, radiation, and surgical oncologists.
REAL-LIFE IMPLICATIONS:
Our study offers a current snapshot of the frequency, nature, and attitudes toward cost discussions among medical, radiation, and surgical oncologists and their patients. Although the majority of responding physicians seem to agree that such discussions are legitimate—and arguably necessary—components of quality cancer care, there remains a substantial proportion who do not discuss costs nor feel it is their duty. Few believe they have adequate resources to discuss costs, suggesting that greater cost transparency, education concerning costs of care, tools to facilitate discussions, and validated interventions are needed.
doi:10.1200/JOP.2015.007401
PMCID: PMC4960469  PMID: 26883407
7.  Implementing and Improving Automated Electronic Tumor Molecular Profiling 
Journal of Oncology Practice  2016;12(3):e332-e337.
Oncology practice increasingly requires the use of molecular profiling of tumors to inform the use of targeted therapeutics. However, many oncologists use third-party laboratories to perform tumor genomic testing, and these laboratories may not have electronic interfaces with the provider’s electronic medical record (EMR) system. The resultant reporting mechanisms, such as plain-paper faxing, can reduce report fidelity, slow down reporting procedures for a physician’s practice, and make reports less accessible. Vanderbilt University Medical Center and its genomic laboratory testing partner have collaborated to create an automated electronic reporting system that incorporates genetic testing results directly into the clinical EMR. This system was iteratively tested, and causes of failure were discovered and addressed. Most errors were attributable to data entry or typographical errors that made reports unable to be linked to the correct patient in the EMR. By providing direct feedback to providers, we were able to significantly decrease the rate of transmission errors (from 6.29% to 3.84%; P < .001). The results and lessons of 1 year of using the system and transmitting 832 tumor genomic testing reports are reported.
doi:10.1200/JOP.2015.008276
PMCID: PMC4960470  PMID: 26813927
8.  Implementation of a Breast/Reconstruction Surgery Coordinator to Reduce Preoperative Delays for Patients Undergoing Mastectomy With Immediate Reconstruction 
Journal of Oncology Practice  2016;12(3):e338-e343.
Purpose:
Mastectomy with immediate reconstruction (MIR) requires coordination between breast and reconstructive surgical teams, leading to increased preoperative delays that may adversely impact patient outcomes and satisfaction. Our cancer center established a target of 28 days from initial consultation with the breast surgeon to MIR. We sought to determine if a centralized breast/reconstructive surgical coordinator (BRC) could reduce care delays.
Methods:
A 60-day pilot to evaluate the impact of a BRC on timeliness of care was initiated at our cancer center. All reconstructive surgery candidates were referred to the BRC, who had access to surgical clinic and operating room schedules. The BRC worked with both surgical services to identify the earliest surgery dates and facilitated operative bookings. The median time to MIR and the proportion of MIR cases that met the time-to-treatment goal was determined. These results were compared with a baseline cohort of patients undergoing MIR during the same time period (January to March) in 2013 and 2014.
Results:
A total of 99 patients were referred to the BRC (62% cancer, 21% neoadjuvant, 17% prophylactic) during the pilot period. Focusing exclusively on patients with a cancer diagnosis, an 18.5% increase in the percentage of cases meeting the target (P = .04) and a 7-day reduction to MIR (P = .02) were observed.
Conclusion:
A significant reduction in time to MIR was achieved through the implementation of the BRC. Further research is warranted to validate these findings and assess the impact the BRC has on operational efficiency and workflows.
doi:10.1200/JOP.2015.008672
PMCID: PMC4960471  PMID: 26883406
9.  Double-Hit Lymphoma: Practicing in a Data-Limited Setting 
Journal of Oncology Practice  2016;12(3):239-240.
doi:10.1200/JOP.2015.010439
PMCID: PMC4960472  PMID: 26962167
10.  HIV Testing in Patients With Cancer at the Initiation of Therapy at a Large US Comprehensive Cancer Center 
Journal of Oncology Practice  2015;11(5):384-390.
Although HIV infection rates among patients with cancer were higher than the prevalence threshold above which national guidelines recommend routine opt-out testing, the overall HIV testing rate was low.
Purpose:
To determine the rates of HIV testing and infection among patients with cancer at initiation of systemic cancer therapy.
Methods:
We conducted a retrospective cohort study of adults with cancer who registered at a comprehensive cancer center from January 2004 through April 2011 and received systemic cancer therapy. We determined rates of HIV-1/2 and/or Western blot testing and HIV positivity at initiation of systemic cancer therapy. Multivariable logistic regression was used to determine predictors of HIV testing.
Results:
Of 18,874 patients with cancer who received systemic cancer therapy during the study period, 3,514 (18.6%) were tested for HIV at initiation of cancer therapy. The prevalence of positive HIV test results was 1.2% (41 of 3,514), and the prevalence of newly diagnosed HIV was 0.3% (12 of 3,514). The HIV testing rate was lower in black than in white patients (13.7% v 19.2%), but the prevalence of positive test results was higher in black patients (4.5%) than in any other racial/ethnic group. Among patients with AIDS-defining cancers (eg, non-Hodgkin lymphoma and cervical cancer), predictors of HIV testing were history of non-Hodgkin lymphoma, younger age, and registration after 2006. Among patients with non–AIDS-defining cancers, predictors of HIV testing were younger age, registration after 2006, male sex, history of illicit drug use or sexually transmitted disease, having a hematologic malignancy, and black race.
Conclusion:
The prevalence of HIV infection among patients with cancer was 1.2%, higher than the 0.1% prevalence threshold above which national guidelines recommend routine opt-out testing; however, the overall HIV testing rate was low.
doi:10.1200/JOP.2015.005116
PMCID: PMC4575402  PMID: 26243649
11.  Use of Bevacizumab in Community Settings: Toxicity Profile and Risk of Hospitalization in Patients With Advanced Non–Small-Cell Lung Cancer 
Journal of Oncology Practice  2015;11(5):356-362.
Findings here confirm the need for adherence to clinical recommendations for judicious use of carboplatin-paclitaxel-bevacizumab, but provide reassurance regarding the relative risk.
Purpose:
Little is known regarding toxicities and hospitalizations in community-based settings for patients with advanced non–small-cell lung cancer (NSCLC) who received commonly prescribed carboplatin-paclitaxel (CP) or carboplatin-paclitaxel-bevacizumab (CPB) chemotherapy.
Methods:
Patients with stages IIIB-IV NSCLC age ≥ 21 years diagnosed between 2005 and 2010 who received first-line CP or CPB were identified at four health maintenance organizations (N = 1,109). Using patient and tumor characteristics and hospital and ambulatory encounters from automated data in the 180 days after chemotherapy initiation, the association between CP and CPB and toxicities and hospitalizations were evaluated with χ2 tests and propensity score–adjusted regression models.
Results:
Patients who received CPB were significantly younger and had significantly more bleeding, proteinuria, and GI perforation events (all P < .05). For these patients, the unadjusted odds ratio associated with the likelihood of having a hospitalization was 0.46 (95% CI, 0.32 to 0.67). As shown by multivariable and propensity score–adjusted models, patients who received CPB were less likely to have been hospitalized (odds ratio, 0.48; 95% CI, 0.32 to 0.71) and had fewer total hospitalizations (rate ratio, 0.62; 95% CI, 0.47 to 0.82) and hospital days (rate ratio, 0.53; 95% CI, 0.47 to 0.60) than patients who received CP.
Conclusion:
Consistent with earlier randomized clinical trials, significantly more toxicity events were identified in patients treated with CPB. However, both unadjusted and adjusted models showed that patients who received CPB were less likely than patients who received CP to experience a hospital-related event after the initiation of chemotherapy. Findings here confirm the need for adherence to clinical recommendations for judicious use of CPB, but provide reassurance regarding the relative risk for hospitalizations.
doi:10.1200/JOP.2014.002980
PMCID: PMC4575400  PMID: 26060223
12.  Variation in Medicare Payments for Colorectal Cancer Surgery 
Journal of Oncology Practice  2015;11(5):391-395.
Medicare spending in the first year after colorectal cancer surgery varies across hospitals even after case-mix adjustment and price standardization.
Purpose:
Colorectal cancer (CRC) is the second most expensive cancer in the United States. Episode-based bundled payments may be a strategy to decrease costs. However, it is unknown how payments are distributed across hospitals and different perioperative services.
Methods:
We extracted actual Medicare payments for patients in the fee-for-service Medicare population who underwent CRC surgery between January 2004 and Decembe 2006 (N = 105,016 patients). Payments included all service types from the date of hospitalization up to 1 year later. Hospitals were ranked from least to most expensive and grouped into quintiles. Results were case-mix adjusted and price standardized using empirical Bayes methods. We assessed the contributions of index hospitalization, physician services, readmissions, and postacute care to the overall variation in payment.
Results:
There is wide variation in total payments for CRC care within the first year after CRC surgery. Actual Medicare payments were $51,345 per patient in the highest quintile and $26,441 per patient in the lowest quintile, representing a difference of Δ = $24,902. Differences were persistent after price standardization (Δ = $17,184 per patient) and case-mix adjustment (Δ = $4,790 per patient). Payments for the index surgical hospitalization accounted for the largest share (65%) of payments but only minimally varied (11.6%) across quintiles. However, readmissions and postacute care services accounted for substantial variations in total payments.
Conclusion:
Medicare spending in the first year after CRC surgery varies across hospitals even after case-mix adjustment and price standardization. Variation is largely driven by postacute care and not the index surgical hospitalization. This has significant implications for policy decisions on how to bundle payments and define episodes of surgical CRC care.
doi:10.1200/JOP.2015.004036
PMCID: PMC4575403  PMID: 26130817
13.  Health-Related Quality of Life of Food-Insecure Ethnic Minority Patients With Cancer 
Journal of Oncology Practice  2015;11(5):396-402.
Underserved racial/ethnic minority patients diagnosed with cancer are a vulnerable patient population, and at significant risk for inadequate food.
Purpose:
The association between food insecurity and health-related quality of life (QOL) of racial/ethnic minority patients with cancer has not been examined. The purpose of this study is to determine the relationship between food insecurity and health-related QOL reported by racial/ethnic minority patients with cancer.
Methods:
A consecutive sample of 1,390 underserved ethnic minority patients receiving cancer care in 10 cancer clinics and hospitals in New York City participated in this study. Health-related QOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and food security was assessed by the US Department of Agriculture Core Food Security Module.
Results:
Of the 1,390 patients, 581 (41.8%) were classified as food secure, 571 (41.1%) with low food security, and 238 (17.1%) with very low food security. Health-related QOL decreased with each lower food security level. Patient self-reported physical, functional, social, and emotional well-being subscale scores decrease significantly with increasing food insecurity. After controlling for demographic and medical-related factors, the decreases in QOL, physical, functional, social and emotional well-being scores with increasing food insecurity remained significant.
Conclusion:
Food insecurity was associated with lower QOL in this sample of underserved racial/ethnic minority patients with cancer. Underserved ethnic minority patients diagnosed with cancer are a vulnerable patient population, at significant risk for inadequate food access and the related lower QOL.
doi:10.1200/JOP.2015.003962
PMCID: PMC4575404  PMID: 26286100
14.  ReCAP: Impact of Multidisciplinary Care on Processes of Cancer Care: A Multi-Institutional Study 
Journal of Oncology Practice  2015;12(2):155-156.
QUESTION ASKED:
What is the relationship between the level of implementation of multidisciplinary care (MDC) and various processes of cancer care (eg, time to treatment receipt, evaluation for enrollment onto a clinical trial) among community cancer centers serving patients diagnosed with colon, rectal, or lung cancer? There is limited generalizable evidence on this topic. It is important to answer this question using data that can generalize across cancer patients, the majority of whom receive treatment in a community cancer center.
SUMMARY ANSWER:
Focusing on the time to receipt of cancer-directed treatment as one key process of cancer care in this patient population, we found that the answer to our question depended on the MDC assessment area and tumor site (Table 1). Among patients with colon cancer, higher MDC levels of physician engagement (ie, a higher level of physician engagement at the institutional level) were associated with a shorter time to treatment receipt, whereas higher MDC levels of case planning were associated with a longer time to treatment receipt. Among patients with rectal cancer, higher MDC levels of physician engagement were associated with a shorter time to cancer-directed treatment receipt, whereas higher MDC levels of evaluation for enrollment onto clinical trials were associated with a longer time to treatment receipt. Among patients with lung cancer, there was no association between the MDC areas of assessment and the time to cancer-directed treatment receipt.
Multivariable Analyses of the Associations Between MDC Implementation and Time to Cancer-Directed Treatment Receipt
NOTE. Hazard ratios were adjusted for patient clinical and demographic measures: age, race, ethnicity, diagnosis year, gender, and cancer center geographic classification (rural/urban). The final specification of each multivariate regression model varied with the disease site and outcome measure due to differences in sample sizes and in the performance of the statistical models (eg, model fit, convergence).
Abbreviations: HR, hazard ratio (covariate adjusted); MDC, multidisciplinary care.
Controlling for age, year of diagnosis, gender, cancer center location and race.
P < .05.
P< .001.
METHODS:
We collected data for patients receiving care at 14 National Cancer Institute (NCI) community cancer centers. We characterized the NCI community cancer centers according to their level of MDC implementation across seven MDC assessment areas and over time. Using statistical regression models, we investigated the relationship between the level of MDC implementation and various process measures, including time to treatment receipt, clinical trial evaluation, receipt of multimodality treatment, and adherence to treatment guidelines published by the National Comprehensive Cancer Network.
BIAS, CONFOUNDING FACTOR(S), DRAWBACKS:
In the absence of a validated MDC assessment tool, the NCI community cancer centers used a nonvalidated tool. Additional institutional-level data would have been useful for characterizing norms and practices that may have differed across cancer centers and potentially explained variation in care processes. Although we controlled for patient demographic characteristics, baseline data were not available to document patient comorbidity or performance status level. To the extent that cancer centers at higher levels of MDC implementation may have been more likely to treat clinically complex patients, the inability to control for potential confounding bias caused by patient case mix may have influenced the study results.
REAL-LIFE IMPLICATIONS:
MDC models are important decision-making forums in current oncology practice. They involve oncologists in generating a comprehensive and coordinated plan of care for patients. Although MDC is purported to offer benefits to patients, there is limited generalizable evidence regarding the benefit to individuals receiving care at community cancer centers in the United States. Across various care processes that are important for characterizing cancer care, this study’s results indicate that changes in the level of MDC implementation could differentially affect the process of care, depending on the MDC area of assessment and the cancer site. In addition, the study results can be used to generate hypotheses for future studies among individuals diagnosed with colon, rectal, or lung cancer.
doi:10.1200/JOP.2015.004200
PMCID: PMC4960465  PMID: 26464497
15.  Reducing the Time From Diagnosis to Treatment of Patients With Stage II/III Rectal Cancer at a Large Public Hospital 
Journal of Oncology Practice  2016;12(2):e257-e262.
Curative-intent therapy for stage II/III rectal cancer is necessarily complex. Current guidelines by the National Comprehensive Cancer Network recommend preoperative concurrent chemoradiation followed by resection and additional adjuvant chemotherapy. We used standard quality improvement methodology to implement a cost-effective intervention that reduced the time from diagnosis to treatment of patients with stage II/III rectal cancer by approximately 30% in a large public hospital in Houston, Texas. Implementation of the program resulted in a reduction in time from pathologic diagnosis to treatment of 29% overall, from 62 to 44 days. These gains were cost neutral and resulted from improvements in scheduling and coordination of care alone. Our results suggest that: (1) quality improvement methodology can be successfully applied to multidisciplinary cancer care, (2) effective interventions can be cost neutral, and (3) effective strategies can overcome complexities such as having multiple sites of care, high staff turnover, and resource limitations.
doi:10.1200/JOP.2015.007484
PMCID: PMC4960466  PMID: 26869658
16.  Are Patients With Cancer Less Willing to Share Their Health Information? Privacy, Sensitivity, and Social Purpose 
Journal of Oncology Practice  2015;11(5):378-383.
Although conventional thinking suggests patients with cancer might be less willing to share their health information, the authors found that participants with cancer were more willing to share their inherited genetic information.
Purpose:
Growing use of electronic health information increases opportunities to build population cancer databases for research and care delivery. Understanding patient views on reuse of health information is essential to shape privacy policies and build trust in these initiatives.
Methods:
We randomly assigned nationally representative participants (N = 3,336) with and without prior cancer to six of 18 scenarios describing different uses of electronic health information. The scenarios varied the user, use, and sensitivity of the information. Participants rated each scenario on a scale of 1 to 10 assessing their willingness to share their electronic health information. We used conjoint analysis to measure the relative importance of each attribute (ie, use, user, and sensitivity).
Results:
Participants with and without a prior diagnosis of cancer had a similar willingness to share health information (0.27; P = .42). Both cancer and noncancer participants rated the purpose of information use as the most important factor (importance weights, 67.1% and 45.6%, respectively). For cancer participants, the sensitivity of the information was more important (importance weights, 29.8% v 1.2%). However, cancer participants were more willing to share their health information when the information included more sensitive genetic information (0.48; P = .015). Cancer and noncancer respondents rated uses and users similarly.
Conclusion:
The information sharing preferences of participants with and without a prior diagnosis of cancer were driven mainly by the purpose of information reuse. Although conventional thinking suggests patients with cancer might be less willing to share their health information, we found participants with cancer were more willing to share their inherited genetic information.
doi:10.1200/JOP.2015.004820
PMCID: PMC4575401  PMID: 26265174
17.  Variation in the Cost of Radiation Therapy Among Medicare Patients With Cancer 
Journal of Oncology Practice  2015;11(5):403-409.
Factors unrelated to the individual patient accounted for the majority of variation in the cost of radiation therapy, suggesting potential inefficiency in health care expenditure.
Purpose:
Radiation therapy represents a major source of health care expenditure for patients with cancer. Understanding the sources of variability in the cost of radiation therapy is critical to evaluating the efficiency of the current reimbursement system and could shape future policy reform. This study defines the magnitude and sources of variation in the cost of radiation therapy for a large cohort of Medicare beneficiaries.
Patients and Methods:
We identified 55,288 patients within the SEER database diagnosed with breast, lung, or prostate cancer between 2004 and 2009. The cost of radiation therapy was estimated from Medicare reimbursements. Multivariable linear regression models were used to assess the influence of patient, tumor, and radiation therapy provider characteristics on variation in cost of radiation therapy.
Results:
For breast, lung, and prostate cancers, the median cost (interquartile range) of a course of radiation therapy was $8,600 ($7,300 to $10,300), $9,000 ($7,500 to $11,100), and $18,000 ($11,300 to $25,500), respectively. For all three cancer subtypes, patient- or tumor-related factors accounted for < 3% of the variation in cost. Factors unrelated to the patient, including practice type, geography, and individual radiation therapy provider, accounted for a substantial proportion of the variation in cost, ranging from 44% with breast, 43% with lung, and 61% with prostate cancer.
Conclusion:
In this study, factors unrelated to the individual patient accounted for the majority of variation in the cost of radiation therapy, suggesting potential inefficiency in health care expenditure. Future research should determine whether this variability translates into improved patient outcomes for further evaluation of current reimbursement practices.
doi:10.1200/JOP.2015.005694
PMCID: PMC4575405  PMID: 26265172
18.  Unplanned 30-Day Readmissions in a General Internal Medicine Hospitalist Service at a Comprehensive Cancer Center 
Journal of Oncology Practice  2015;11(5):410-415.
The authors observed a high unplanned readmission rate among their population of patients with cancer.
Purpose:
Hospital readmissions are considered by the Centers for Medicare and Medicaid as a metric for quality of health care delivery. Robust data on the readmission profile of patients with cancer are currently insufficient to determine whether this measure is applicable to cancer hospitals as well. To address this knowledge gap, we estimated the unplanned readmission rate and identified factors influencing unplanned readmissions in a hospitalist service at a comprehensive cancer center.
Methods:
We retrospectively analyzed unplanned 30-day readmission of patients discharged from the General Internal Medicine Hospitalist Service at a comprehensive cancer center between April 1, 2012, and September 30, 2012. Multiple independent variables were studied using univariable and multivariable logistic regression models, with generalized estimating equations to identify risk factors associated with readmissions.
Results:
We observed a readmission rate of 22.6% in our cohort. The median time to unplanned readmission was 10 days. Unplanned readmission was more likely in patients with metastatic cancer and those with three or more comorbidities. Patients discharged to hospice were less likely to be readmitted (all P values < .01).
Conclusion:
We observed a high unplanned readmission rate among our population of patients with cancer. The risk factors identified appear to be related to severity of illness and open up opportunities for improving coordination with primary care physicians, oncologists, and other specialists to manage comorbidities, or perhaps transition appropriate patients to palliative care. Our findings will be instrumental for developing targeted interventions to help reduce readmissions at our hospital. Our data also provide direction for appropriate application of readmission quality measures in cancer hospitals.
doi:10.1200/JOP.2014.003087
PMCID: PMC4575406  PMID: 26152375
19.  Acknowledgment of Reviewers 
Journal of Oncology Practice  2016;12(2):e268-e269.
doi:10.1200/JOP.2015.122e268
PMCID: PMC5015445
20.  Patients and Physicians Can Discuss Costs of Cancer Treatment in the Clinic 
Journal of Oncology Practice  2015;11(4):308-312.
In an era of rising co-pays, patients with cancer want cost-of-treatment discussions, and these conversations do not lead to negative feelings in the majority of patients.
Purpose:
As one solution to reducing costs and medical bankruptcies, experts have suggested that patients and physicians should discuss the cost of care up front. Whether these discussions are possible in an oncology setting and what their effects on the doctor-patient relationship are is not known.
Methods:
We used the National Comprehensive Cancer Network (NCCN) Guidelines and the eviti Advisor platform to show patients with metastatic breast, lung, or colorectal cancer the costs associated with their chemotherapy and/or targeted therapy options during an oncology consultation. We measured provider attitudes and assessed patient satisfaction when consultations included discussion of costs.
Results:
We approached 107 patients; 96 (90%) enrolled onto the study, three (3%) asked if they could be interviewed at a later date, and eight (7%) did not want to participate. Only five of 18 oncologists (28%) felt comfortable discussing costs, and only one of 18 (6%) regularly asked patients about financial difficulties. The majority of patients (80%) wanted cost information, and 84% reported that these conversations would be even more important if their co-pays were to increase. In total, 72% of patients responded that no health care professional has ever discussed costs with them. The majority of patients (80%) had no negative feelings about hearing cost information.
Conclusion:
In an era of rising co-pays, patients with cancer want cost-of-treatment discussions, and these conversations do not lead to negative feelings in the majority of patients. Additional training to prepare clinicians for how to discuss costs with their patients is needed.
doi:10.1200/JOP.2015.003780
PMCID: PMC4507390  PMID: 26015459
21.  How Do Payers Respond to Regulatory Actions? The Case of Bevacizumab 
Journal of Oncology Practice  2015;11(4):313-318.
Although insurers varied in terms of public statements regarding coverage intentions, bevacizumab use declined similarly among all payers, suggesting that provider decision making, rather than payer-specific coverage policies, drove reductions.
Purpose:
In February 2008, the US Food and Drug Administration (FDA) granted accelerated approval for bevacizumab for metastatic breast cancer. After public hearings in July 2010, and June 2011, the FDA revoked this approved indication in November 2011, on the basis of additional evidence regarding its risk/benefit profile. The Centers for Medicare and Medicaid Services, local Medicare contractors, and commercial payers varied in their stated intentions to cover bevacizumab after FDA's regulatory actions. We examined payer-specific trends in bevacizumab use after the FDA's regulatory actions.
Methods:
We used outpatient medical claims compiled by IMS Health to evaluate trends in bevacizumab use for breast cancer for Medicare-insured and commercially insured patients (N = 102,906) using segmented regression. Given that Medicare coverage policies may vary across regional contractors, we estimated trends in bevacizumab use across 10 local coverage areas. In a sensitivity analysis, we estimated trends in bevacizumab use for breast cancer compared with trends in use for lung cancer using difference-in-differences models.
Results:
Among chemotherapy infusions for breast cancer, bevacizumab use decreased from 31% in July 2010, to 4% in September 2012. Use decreased by 11% among commercially insured and 13% among Medicare-insured patients after July 2010 (interaction P = .68) and continued to decline by 9% per month (interaction P = .61). We observed no contractor-level variation in bevacizumab use among Medicare beneficiaries. During the same period, bevacizumab use for lung cancer was stable.
Conclusion:
Although insurers varied in public statements regarding coverage intentions, bevacizumab use declined similarly among all payers, suggesting that provider decision making, rather than payer-specific coverage policies, drove reductions.
doi:10.1200/JOP.2015.004218
PMCID: PMC4507391  PMID: 26060224
22.  Obtaining Helpful Information From the Internet About Prognosis in Advanced Cancer 
Journal of Oncology Practice  2015;11(4):327-331.
Oncologists should be aware that patients will not find estimates of survival or treatment effect on the Internet, which may contribute to overly optimistic estimates of survival.
Purpose:
Prognostic awareness, or knowing that one has a life-ending disease, is associated with a better end-of-life experience, including less depression and anxiety. We sought to determine whether reliable sources on the Internet contained helpful prognostic information about advanced cancer.
Methods:
We played the role of a 62-year-old person with stage IV incurable cancer and accessed four commonly used Web sites for the 10 most common causes of cancer death (American Cancer Society, ASCO, National Cancer Institute, Up To Date), as well as disease-specific Web sites.
Results:
Approximately half the Web sites (26 of 50; 52%) had some notation of 5-year survival. Only four of 50 (8%) gave any average or median survival. Only 13 of 50 (26%) noted that stage IV cancer was a serious and usually life-ending illness. Nearly all had some information about hospice and palliative care.
Conclusion:
Information that can help with patient prognostic awareness is not currently found on cancer-related Web sites. Oncologists should be aware that their patients will not find estimates of survival or treatment effect on the Internet. This may contribute to overoptimistic estimates of survival and subsequent aggressive end-of-life care.
doi:10.1200/JOP.2015.004739
PMCID: PMC4507392  PMID: 26188047
23.  Breast Cancer Risk Assessment Among Low-Income Women of Color in Primary Care: A Pilot Study 
Journal of Oncology Practice  2015;11(4):e460-e467.
Incorporation of US Preventive Services Task Force genetic counseling recommendations as part of primary care is feasible, and warrants further investigation as a strategy for addressing disparities in breast cancer mortality.
Purpose:
The US Preventive Services Task Force recommends identifying candidates for breast cancer (BC) chemoprevention and referring them for genetic counseling as part of routine care. Little is known about the feasibility of implementing these recommendations or how low-income women of color might respond to individualized risk assessment (IRA) performed by primary care providers (PCPs).
Methods:
Women recruited from a federally qualified health center were given the option to discuss BC risk status with their PCP. Comprehensive IRA was performed using a software tool designed for the primary care environment combining three assessment instruments and providing risk-adapted recommendations for screening, prevention, and genetic referral. Logistic regression models assessed factors associated with wanting to learn and discuss BC risk with PCP.
Results:
Of 237 participants, only 12.7% (n = 30) did not want to discuss IRA results with their PCP. Factors associated with lower odds of wanting to learn results included having private insurance and reporting ever having had a mammogram. Factors associated with higher odds of wanting to learn results included older age (50 to 69 years) and increased BC worry. For all women wishing to learn results, IRA was successfully completed and delivered to the PCP immediately before the encounter for incorporation into the well-visit evaluation.
Conclusion:
Incorporation of US Preventive Services Task Force recommendations as part of routine primary care is feasible. Interest in IRA seems high among underserved women. This approach warrants further investigation as a strategy for addressing disparities in BC mortality.
doi:10.1200/JOP.2014.003558
PMCID: PMC4507393  PMID: 26036266
24.  Statewide Longitudinal Hospital Use and Charges for Pediatric and Adolescent Patients With Cancer 
Journal of Oncology Practice  2015;11(4):e468-e475.
The authors found that children and adolescents diagnosed with cancer in 2014 in the United States will incur over $800 million more in hospital charges than individuals without cancer by 2024.
Purpose:
We investigated longitudinal hospitalization outcomes (total charges, hospital days and admissions) among pediatric and adolescent patients with cancer compared with individuals from the general population without cancer using a novel and efficient three-step regression procedure.
Methods:
The statewide Utah Population Database, with linkages to the Utah Cancer Registry, was used to identify 1,651 patients who were diagnosed with cancer from 1996 to 2009 at ages 0 to 21 years. A comparison group of 4,953 same-sex and -age individuals was generated from birth certificates. Claims-based hospitalization data from 1996 to 2012 were retrieved from the Utah Department of Health. Using the regression method, we estimated survival (differences due to survival) and intensity (differences due to resource accumulation) effects of the cancer diagnosis on hospitalization outcomes within 10 years after diagnosis.
Results:
At 10 years after diagnosis, on average, patients with cancer incurred $51,723 (95% CI, $48,100 to $58,284) more in charges, spent 30 additional days (95% CI, 27.7 to 36.1 days) in the hospital, and had 5.7 (95% CI, 5.4 to 6.4) more admissions than the comparison group. Our analyses showed that the highest hospitalization burden occurred during the first 4 years of diagnosis. Patients with leukemia incurred the greatest hospitalization burden throughout the 10 years from diagnosis. Intensity effects explained the majority of differences in hospital outcomes.
Conclusion:
Our results suggest that children and adolescents who were diagnosed with cancer in 2014 in the United States will incur over $800 million more in hospital charges than individuals without cancer by 2024. Interventions to reduce this burden should be explored in conjunction with improving health and survival outcomes.
doi:10.1200/JOP.2014.003590
PMCID: PMC4507394  PMID: 26105667
25.  Predictors of Long-Term Quality of Life for Survivors of Stage II/III Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium 
Journal of Oncology Practice  2015;11(4):e476-e486.
Neoadjuvant treatment may result in better quality of life and functional status 1 year after diagnosis.
Purpose:
Many patients do not receive guideline-recommended neoadjuvant chemoradiotherapy for resectable rectal cancer. Little is known regarding long-term quality of life (QOL) associated with various treatment approaches. Our objective was to determine patient characteristics and subsequent QOL associated with treatment approach.
Methods:
Our study was a geographically diverse population- and health system–based cohort study that included adults age 21 years or older with newly diagnosed stage II/III rectal cancer who were recruited from 2003 to 2005. Eligible patients were contacted 1 to 4 months after diagnosis and asked to participate in a telephone survey and to consent to medical record review, with separate follow-up QOL surveys conducted 1 and 7 years after diagnosis.
Results:
Two hundred thirty-nine patients with stage II/III rectal cancer were included in this analysis. Younger age (< 65 v ≥ 65 years: odds ratio, 2.49; 95% CI, 1.33 to 4.65) was significantly associated with increased odds of receiving neoadjuvant or adjuvant chemoradiotherapy. The adjuvant chemoradiotherapy group had significantly worse mean EuroQol-5D (range, 0 to 1) and Short Form-12 physical health component scores (standardized mean, 50) at 1-year follow-up than the neoadjuvant chemoradiotherapy group (0.75 v 0.85; P = .002; 37.2 v 43.3; P = .01, respectively) and the group that received only one or neither form of treatment (0.75 v 0.85; P = .02; 37.2 v 45.1; P = .008, respectively).
Conclusion:
Neoadjuvant treatment may result in better QOL and functional status 1 year after diagnosis. Further evaluation of patient and provider reasons for not pursuing neoadjuvant therapy is necessary to determine how and where to target process improvement and/or education efforts to ensure that patients have access to recommended treatment options.
doi:10.1200/JOP.2015.004564
PMCID: PMC4507395  PMID: 26080831

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