Cancer Care Delivery Research Articles

The Potential of Wearable Devices in Cancer Care Delivery

The Potential of Wearable Devices in Cancer Care Delivery

Decision-making and autonomy among participants in early-phase cancer immunotherapy trials: a qualitative study

BackgroundParticipants considering early-phase cancer clinical trials (CTs) need to understand the unique risks and benefits prior to providing informed consent. This qualitative study explored the factors that influence patients’ decisions about participating in early-phase cancer immunotherapy CTs through the ethical lens of relational autonomy.MethodsUsing an interpretive descriptive design, interviews were conducted with 21 adult patients with advanced cancer who had enrolled in an early-phase CT. Data was analyzed using relational autonomy ethical theory and constant comparative analysis.ResultsThe extent to which participants perceived themselves as having a choice to participate in early-phase cancer immunotherapy CTs was a central construct. Perceptions of choice varied according to whether participants characterized their experience as an act of desperation or as an opportunity to receive a novel treatment. Intersecting psychosocial and structural factors influenced participants’ decision making about participating in early-phase cancer immunotherapy trials. These relational factors included: (1) being provided with hope; (2) having trust; (3) having the ability to withdraw; and (4) timing constraints.ConclusionsFindings highlight the continuum of perceived choice that exists among patients with cancer when considering participation in early-phase cancer immunotherapy CTs. All participants were interpreted as exhibiting some degree of relational autonomy within the psychosocial and structural context of early-phase CT decision making. This study offers insights into the intersection of cancer care delivery, personal beliefs and values, and established CT processes and structures that can inform future practices and policies associated with early-phase cancer immunotherapy CTs to better support patients in making informed decisions.

Abstract 6377: UNC AYA Cancer Program: Reach and influence on cancer care delivery

Abstract Category: Cancer Disparities and Inequities Research Purpose of the study Adolescent and young adults (AYAs, aged 13-39) with cancer face barriers to care and stagnant outcomes. National groups have called for the development of AYA-specific programs, yet how these programs influence outcomes remains largely unexplored. With a dedicated AYA Cancer Program at the University of North Carolina (UNC) since 2015, we conducted a retrospective study to describe the AYA population and compare outcomes between those receiving program support and those who did not. Methods Linking electronic health records and NC Cancer Registry data, we defined a cohort of AYA patients who received cancer treatment at UNC from 2014-2022. We compared sociodemographic, clinical, utilization, and supportive care measures for those who received AYA Program contact and those who did not. Chi-square and two-group t-tests were used for comparison. Results Of 4044 AYAs receiving care at UNC, 670 engaged with our AYA Program (Table 1). Program-contacted patients were younger at diagnosis, more likely to be Black, have metastatic disease or hematologic malignancies, and more likely to receive systemic therapy. Program patients had increased clinical trial enrollment, more palliative care and fertility counseling. Conclusions Our findings suggest AYAs contacted by our program represent a distinct population with higher clinical and social needs. Despite higher rates of acute care events and no-shows, they were more likely to receive guideline-recommended care - clinical trial enrollment, fertility counseling, and palliative care. Future analyses will compare outcomes using adjusted modeling, and track trends over time. Results will inform next steps for the UNC AYA Cancer Program and other centers aiming to improve care delivery for AYAs. Table 1. Notable results for AYAs with and without program contact AYA Program Contact (n=670) No AYA Program Contact (n=3374) P value Age at diagnosis Mean years 27 31 <0.01 Sex Female 55% 61% 0.02 Male 45% 39% Race White 56% 61% <0.01 Black 26% 20% Other 18% 16% Ethnicity Hispanic 13% 12% 0.29 Non-Hispanic 86% 84% Marital Status Married/Partnered 34% 42% <0.01 Not Married 65% 51% Cancer Type Solid 54% 87% <0.01 Hematologic 46% 13% Stage Metastatic 52% 18% <0.01 Treatment Chemotherapy 85% 37% <0.01 Radiotherapy 6% 12% Immunotherapy 18% 9% Clinical Trial Enrollment 45% 26% <0.01 No-Shows Mean 7 4 <0.01 Supportive Care Palliative care visits 19% 3% <0.01 Advance Care Planning 14% 5% Fertility visit 18% 2% Hospice enrollment 3% 0.7% Complications ED visit 68% 48% <0.01 Unplanned hospitalization 63% 29% Citation Format: Jacob N. Stein, Dawn M. Ritzwoller, Alexis C. Wardell, Emily R. Haines, Bridgette Thom, Lauren Lux, Andrew B. Smitherman. UNC AYA Cancer Program: Reach and influence on cancer care delivery [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6377.

Abstract 1287: The ACCESS consortium: Advancing childhood cancer experience, science and survivorship in Canada

Abstract In Canada, >4,300 children, adolescents and young adults are diagnosed with cancer each year. 1/3 have refractory/metastatic disease or will relapse with an expected 5-year survival rate of <15%. The prognosis for most pediatric cancers has stagnated in the past 30 years and Canada trails the US and Europe in providing accessible clinical trials and improved outcomes. Advocacy for change by patients and families led to a federal government investment of $30M in pediatric cancer research. $23M was allocated to establishing a national pediatric cancer consortium. “ACCESS: advancing childhood cancer experience, science and survivorship” is the new multi-stakeholder network created with a vision that every Canadian child with cancer has access to the latest scientific advances, diagnostic tools, therapies and supportive care leading to better outcomes and quality of life. ACCESS will connect the Canadian pediatric cancer community, build partnerships, leverage research and clinical expertise across cancer types and ages, implement transformative change and create a unified national strategy. To date, >350 clinicians, researchers, policymakers, advocates, people with lived experience (PWLE; patients, families and survivors) and other stakeholders have been engaged, with a goal of representing Canada’s ethno-cultural, socioeconomic and geographic diversity. ACCESS is building partnerships between children, families, professionals, and existing programs to collaborate in coordinated research and knowledge mobilization. The goal is to implement transformative change in the delivery of fair, fast, effective and safe cancer care for all Canadian children. ACCESS has developed a statement of its values that includes patient/survivor and family centred; collaborative; anti-oppressive; innovation and excellence; accountable. Uniquely, ACCESS is an interdisciplinary and inclusive organization that directly engages and collaborates with PWLE at all levels of research and governance. ACCESS is organized into 7 themes that will address gaps, advance research and educate through all phases of the pediatric cancer journey: cancer biology; clinical trials; access to innovative therapies and optimal care; regulation, policy and economics; education and training; ethical, legal, societal implications and implementation science; and psychosocial and survivorship. In addition, there are two cross cutting groups focusing on Knowledge mobilization and Social justice, Indigenization and Inclusion. Collaborations with local, provincial, national and international initiatives are being established through the development of a partnership strategy. Cross-consortium priorities are being implemented, and a data management strategy is in development. The publication of a strategic and sustainability plan for ACCESS is anticipated in 2024. Citation Format: Christine J. Williams, Stephanie A. Grover, Adrienne Co-Dyre, David Malkin, James A. Whitlock, on behalf of the ACCESS consortium. The ACCESS consortium: Advancing childhood cancer experience, science and survivorship in Canada [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1287.

Abstract 6301: Mapping survivor-specific supportive care resources: A digital landscape analysis of NCI-designated cancer centers

Abstract Background: Optimal care for cancer survivors requires a comprehensive array of supportive care services to address the multitude of physical, psychological, social, financial, and health promotion needs of this population. To understand options to address their unique needs, survivors and their caregivers may seek information from online sources. Although National Cancer Institute-Designated Cancer Centers (NCIDCCs) serve as leaders in cancer treatment and care delivery, as well as credible sources for survivors to receive information on their recovery, no study has characterized the digital landscape of survivorship offerings on their website. This study aims to characterize the supportive care services offered to cancer survivors on NCIDCCs. Methods: Of the 72 NCIDCCs, 65 provide clinical care. We reviewed the webpage of each to identify supportive care offerings. Services were categorized based on the four domains of the quality-of-life model: (1) physical well-being, (2) psychological well-being, (3) social well-being, and (4) spiritual well-being. Supportive care services were classified as survivor-specific if the online description included information that specifically catered to cancer survivors. Results: Of the 65 clinical NCIDCC websites, 100% offer supportive care services and 54% offer supportive care services specific to survivors (Table). The most common supportive care service offered was nutrition (90.6%) and the least commonly offered was caregiver support (7.9%). Behavioral medicine was offered most frequently for survivors (28.3%) and caregiver support was offered the least (0%). Out of the four domains of the quality-of-life model, spiritual well-being services were offered the least at NCIDCCs. Conclusion: More than half of the NCIDCC websites provided survivor-specific supportive care services. Supportive care services on websites of NCI-Designated or Comprehensive Cancer Centers (N = 65) Supportive Care Service (n) % Supportive Care Service Specific to Cancer Survivors (n) % Physical Well Being Services Nutrition 58 90.6 14 24.1 Genetics 53 82.8 5 9.4 Pain and Palliative Care 52 81.3 8 15.4 Complementary and Alternative Medicine 49 75.4 6 12.2 Integrative Medicine 47 73.4 9 19.1 Occupational Therapy 45 70.3 6 13.3 Fertility Preservation 43 66.2 6 14 Tobacco Cessation 38 58.5 6 15.8 Speech 36 56.3 3 8.3 Exercise 29 45.3 5 17.2 Primary Care 6 9.2 3 50 Psychological Well-Being Services Behavioral Medicine 53 81.5 15 28.3 Recreational Therapy 36 58.1 5 13.9 Social Well-Being Services Oncology Social Work 56 87.5 5 8.9 Patient Navigation 33 51.6 3 9.1 Financial Counseling 32 50 4 12.5 Self-Image 27 41.5 3 11.1 Reproductive and Sexual Health 22 33.8 5 22.7 Caregiver Support 5 7.9 0 0 Spiritual Well-Being Services Pastoral Services 49 75.4 5 10.2 Citation Format: Alexis Taylor, Katherine Sterba, Evan Graboyes. Mapping survivor-specific supportive care resources: A digital landscape analysis of NCI-designated cancer centers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6301.

Abstract 819: Feasibility of patient-centered home care (PCHC) to reduce disparities in high-risk black men with advanced prostate cancer

Abstract The objective of our study is to evaluate the feasibility, acceptance, and impact of patient-centered home care (PCHC) on patient reported outcomes (PROs) and health-related quality of life (HQoL) of black men with advanced prostate cancer (CaP). Meeting patients where they are and offering treatment in or closer to their homes reduce psychological distress and increase treatment compliance, especially for disadvantaged patients in rural areas, those on low incomes, with poor access to transport, elderly and people with disabilities. In 2023, Mayo Clinic has developed the Cancer Care Beyond Walls (CCBW) program, a cancer care delivery model that integrates virtual with in facility treatment and provides a package of care to support administration of cancer-directed therapy (chemotherapy, immunotherapy, hormonal therapy) and/or supportive care in the patients’ homes. Our study will assess if patients and families are comfortable with cancer therapy at home, what factors influences their decision, and use this data to inform our understanding of the proportion of the black men with advanced CaP who would be willing to receive and would benefit from this level of care at home. Patients with advanced CaP from our practice requiring active anti-cancer therapy are administered a brief questionnaire regarding preference for location of therapy at the infusion center or in the home, with perceived difficulties and advantages of each approach. A focus group session with prostate cancer survivor advocates is also conducted to capture patients’ thoughts, feelings, attitudes, and questions towards cancer treatments being administered at home versus a hospital setting. In addition, we are conducting an observational study of 20 patients with advanced prostate cancer receiving supportive care/symptom management and/or anti-cancer therapy in the home as part of the Mayo Clinic CCBW Program to assess the safety of cancer directed therapy when administered at home by a home health provider with remote patient monitoring and command center support, and establish the impact of home cancer treatment administration on patient-reported function and global health/quality of life, patient-reported symptoms, clinical outcomes, and cost of care. Successful completion of the project will deliver data on patient understanding and acceptability of cancer care at home, strategies for overcoming barriers to care for underserved communities, and the foundation from which we discover, translate and apply new knowledge in administering personalized care to vulnerable populations. Citation Format: Roxana S. Dronca, Folakemi Odedina, Che Ngufor, Kimlin Ashing, Ernest Kaninjing, Solomon Rotimi. Feasibility of patient-centered home care (PCHC) to reduce disparities in high-risk black men with advanced prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 819.

How a Canadian federal organization integrated synoptic reporting and quality improvement tools to drive a national learning health system in cancer surgery.

Accurate and complete surgical and pathology reports are the cornerstone of treatment decisions and cancer care excellence. Synoptic reporting is a process for reporting specific data elements in a specific format in surgical and pathology reports. Since 2007, the Canadian Partnership Against Cancer has led the implementation of synoptic reporting mechanisms across multiple cancer disease sites and jurisdictions across Canada. While the implementation of synoptic reporting has been successful, its use to drive improvements in the quality of cancer care delivery has been lacking. Here we describe the 4-year, national multi-jurisdictional quality improvement initiative to catalyse the use synoptic data to drive cancer system improvements. Resources provided to the jurisdictions included operational funding, training in quality improvement methodology, national forums, expert coaches, and ad hoc monitoring and support. The program emphasized foundational concepts including data literacy, audit and feedback reports, communities of practice, and positive deviance methodology.

Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation.

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19

The COVID-19 pandemic had a profound impact on the delivery of cancer care, but less is known about its association with place of death and delivery of specialized palliative care (SPC) and potential disparities in these outcomes. To evaluate the association of the COVID-19 pandemic with death at home and SPC delivery at the end of life and to examine whether disparities in socioeconomic status exist for these outcomes. In this cohort study, an interrupted time series analysis was conducted using Ontario Cancer Registry data comprising adult patients aged 18 years or older who died with cancer between the pre-COVID-19 (March 16, 2015, to March 15, 2020) and COVID-19 (March 16, 2020, to March 15, 2021) periods. The data analysis was performed between March and November 2023. COVID-19-related hospital restrictions starting March 16, 2020. Outcomes were death at home and SPC delivery at the end of life (last 30 days before death). Socioeconomic status was measured using Ontario Marginalization Index area-based material deprivation quintiles, with quintile 1 (Q1) indicating the least deprivation; Q3, intermediate deprivation; and Q5, the most deprivation. Segmented linear regression was used to estimate monthly trends in outcomes before, at the start of, and in the first year of the COVID-19 pandemic. Of 173 915 patients in the study cohort (mean [SD] age, 72.1 [12.5] years; males, 54.1% [95% CI, 53.8%-54.3%]), 83.7% (95% CI, 83.6%-83.9%) died in the pre-COVID-19 period and 16.3% (95% CI, 16.1%-16.4%) died in the COVID-19 period, 54.5% (95% CI, 54.2%-54.7%) died at home during the entire study period, and 57.8% (95% CI, 57.5%-58.0%) received SPC at the end of life. In March 2020, home deaths increased by 8.3% (95% CI, 7.4%-9.1%); however, this increase was less marked in Q5 (6.1%; 95% CI, 4.4%-7.8%) than in Q1 (11.4%; 95% CI, 9.6%-13.2%) and Q3 (10.0%; 95% CI, 9.0%-11.1%). There was a simultaneous decrease of 5.3% (95% CI, -6.3% to -4.4%) in the rate of SPC at the end of life, with no significant difference among quintiles. Patients who received SPC at the end of life (vs no SPC) were more likely to die at home before and during the pandemic. However, there was a larger immediate increase in home deaths among those who received no SPC at the end of life vs those who received SPC (Q1, 17.5% [95% CI, 15.2%-19.8%] vs 7.6% [95% CI, 5.4%-9.7%]; Q3, 12.7% [95% CI, 10.8%-14.5%] vs 9.0% [95% CI, 7.2%-10.7%]). For Q5, the increase in home deaths was significant only for patients who did not receive SPC (13.9% [95% CI, 11.9%-15.8%] vs 1.2% [95% CI, -1.0% to 3.5%]). These findings suggest that the COVID-19 pandemic was associated with amplified socioeconomic disparities in death at home and SPC delivery at the end of life. Future research should focus on the mechanisms of these disparities and on developing interventions to ensure equitable and consistent SPC access.

Free flap reconstruction at a rural-based tertiary medical college hospital: Barriers and outcomes.

In a rural-based setting, providing optimal treatment is often difficult owing to the limited resources and financial constraints being rampant in cancer care delivery. Oncological resections often result in large, complex defects requiring free flap reconstruction to achieve cosmetic and/or functional goals. This article focuses on our experience of starting and promoting microvascular reconstruction in a rural tertiary medical college hospital. Retrospective observational study of patients undergoing free flap reconstruction for oncological indications was included. Standard oncological principles were followed for cancer extirpation. Free flap reconstruction was done using loupes of 4× magnification. Flap-related outcomes and barriers in doing free flap reconstruction were analysed. A total of 56 patients were included. The most common free flap undertaken was free anterolateral thighflap in 21 (37.5%) patients. The mean duration of reconstruction was 438 min. Re-exploration was undertaken in 17 patients (30.4%). Nonsalvageable flap loss was 19.64%. Adjuvant treatment was administered in all patients as per oncological indications, albeit with some delay in 12.5%. Barriers to reconstruction were noted in the pre-, intra- and postoperative periods. Reconstruction with free flaps is feasible in a resource-constrained setup with careful planning and a multidisciplinary team approach to overcome the barriers.

Practice Consolidation Among US Medical Oncologists, 2015-2022.

Health care consolidation has significantly affected cancer care delivery, with oncology practices undergoing substantial consolidation over the past two decades. This study investigates practice consolidation trends among medical oncologists (MOs), factors associated with consolidation, and changes in MO geographic distribution. Medicare data from 2015 to 2022 were used to assess MO practice consolidation in hospital referral regions (HRRs), linked with regional health care market data and physician demographics. The Herfindahl-Hirschman Index (HHI) was used to measure consolidation, and the Gini coefficient was used to measure MO distribution across counties. Multivariable linear regression explored factors associated with MO practice consolidation. Between 2015 and 2022, the number of MOs increased by 14.5% (11,727-13,433), whereas the number of MO practices decreased by 18.0% (2,774-2,276). The mean number of MOs per practice increased by 40% (4.26-5.95; P < .001). The percentage of MOs in small practices decreased, whereas larger practices saw an increase. MO consolidation, as indicated by the HHI, increased by 9% (median HHI, 0.3204-0.3480). HRRs with higher baseline hospital consolidation and more hospital beds per capita were more likely to have MO practice consolidation. Despite MO practice consolidation, the county-level distribution of MOs did not change substantially. On the basis of Federal Trade Commission classifications, MO practices were highly concentrated in 2015 and consolidated even further by 2022. While distribution of MOs at the county level remained stable, further research is needed to assess the effects of rapid consolidation on cancer care cost, quality, and access. These data have important implications for policymakers and payers as they design programs that ensure high-quality, affordable cancer care.

Defining Practice Capacity for Cancer Care Delivery to Adolescents and Young Adults in the Community Setting: 2022 Landscape Assessment Results.

Background: Adolescents and young adults (AYAs) commonly receive cancer care in the community setting, but the availability of treatment options, resources, and support services for this population is not well known. The National Cancer Institute Community Oncology Research Program (NCORP) funds a network of practices whose mission is to increase access to cancer care and clinical trials in the community setting. We describe our interdisciplinary methodological approach to identify and characterize NCORP practices where AYAs receive cancer care. Methods: NCORP practices completed a cross-sectional Landscape Assessment to describe resources and practice characteristics. We established an interdisciplinary team of stakeholders to analyze the Landscape Assessment data relating to AYAs. Through an iterative process, we assessed NCORP practice responses to questions assessing AYA cancer care capacity, determined a threshold to define practices treating AYAs, and characterized these practices. Results: We determined that practices provide cancer care to AYAs if the following criteria were met: (1) endorsed having an AYA program (n = 20), (2) AYAs comprised ≥5% of annual cancer cases (n = 55), or (3) the practice treated ≥50 AYA cancer cases annually (n = 70). Of 271 NCORP practices, 100 (37%) met any criteria, whereas 87 (32%) did not; 84 (31%) could not be classified due to missing or unknown data. Conclusion: Using an interdisciplinary process, we define practices that treat AYAs in the community. We posit a uniform approach to examine resources and practice capacity for AYAs receiving cancer care across the United States to guide future AYA-focused cancer care delivery research development.

Patient-reported symptom monitoring: using (big) data to improve supportive care at the macro-, meso-, and micro-levels.

This paper aims to provide a comprehensive understanding of the need for continued development of symptom monitoring (SM) implementation, utilization, and data usage at the macro-, meso-, and micro-levels. Discussions from a patient-reported SM workshop at the MASCC/ISSO 2022 annual meeting were analyzed using a macro-meso-micro analytical framework of cancer care delivery. The workshop categories "initiation and implementation, barriers to adoption and utilization, and data usage" were integrated for each level. At the macro-level, policy development could encourage data sharing and international collaboration, including the exchange of SM methods, supportive care models, and self-management modules. At the meso-level, institutions should adjust clinical workflow and service delivery and promote a thorough technical and clinical integration of SM. At the micro-level, SM should be individualized, with timely feedback for patients, and should foster trust and understanding of AI decision support tools amongst clinicians to improve supportive care. The workshop reached a consensus among international experts on providing guidance on SM implementation, utilization, and (big) data usage pathways in cancer survivors across the cancer continuum and on macro-meso-micro levels.

CaRE@ELLICSR: Effects of a clinically integrated, group-based, multidimensional cancer rehabilitation program.

Although oncology clinical practice guidelines recognize the need and benefits of exercise, the implementation of these services into cancer care delivery remains limited. We developed and evaluated the impact of a clinically integrated 8-week exercise and education program (CaRE@ELLICSR). We conducted a mixed methods, prospective cohort study to examine the effects of the program. Each week, participants attended a 1-h exercise class, followed by a 1.5-h education session. Questionnaires, 6-min walk tests (6MWT), and grip strength were completed at baseline (T0), 8 weeks (T1), and 20 weeks (T2). Semi-structured interviews were conducted with a sub-sample of participants about their experience with the program. Between September 2017 and February 2020, 277 patients enrolled in the program and 210 consented to participate in the research study. The mean age of participants was 55 years. Participants were mostly female (78%), white/Caucasian (55%) and half had breast cancer (50%). Participants experienced statistical and clinically meaninful improvements from T0 to T1 in disability, 6MWT, grip strength, physical activity, and several cancer-related symptoms. These outcomes were maintained 3 months after program completion (T2). Qualitative interviews supported these findings and three themes emerged from the interviews: (1) empowerment and control, (2) supervision and internal program support, and (3) external program support. This study demonstrates the impact of overcoming common organizational barriers to deliver exercise and rehabilitation as part of routine care. CaRE@ELLICSR demonstrated clinically meaningful improvements in patient-reported and functional outcomes and was considered beneficial and important by participants for their recovery and wellbeing.

The symbolic two-step method applied to cancer care delivery research: Safeguarding against designing an underpowered cluster randomized trial with a continuous outcome by accounting for the imprecision in the within- and between-center variation.

Knowing the predictive factors of the variation in a center-level continuous outcome of interest is valuable in the design and analysis of parallel-arm cluster randomized trials. The symbolic two-step method for sample size planning that we present incorporates this knowledge while simultaneously accounting for patient-level characteristics. Our approach is illustrated through application to cluster randomized trials in cancer care delivery research. The required number of centers (clusters) depends on the between- and within-center variance; the within-center variance is a function of estimates obtained by regressing the log within-center variance on predictive factors. Obtaining accurate estimates of the components needed to characterize the within-center variation is challenging. Using our previously derived sample size formula, our objective in the current research is to directly account for the imprecision in these estimates, using a Bayesian approach, to safeguard against designing an underpowered study when using the symbolic two-step method. Using estimates of the required components, including the number of centers that contribute to those estimates, we make formal allowance for the imprecision in these estimates on which a sample size will be based. The mean of the distribution for power is consistently smaller than the single point estimate that the sample size formula yields. The reduction in power is more pronounced in the presence of increased uncertainty about the estimates with the reduction becoming more attenuated with increased numbers of centers that contribute to the estimates. Accounting for imprecision in the estimates of the components required for sample size estimation using the symbolic two-step method in the design of a cluster randomized trial yields conservative estimates of power.

Randomized Trial of a Volunteer-Led Symptom Assessment Intervention on Documentation, Patient-Reported Outcomes, and Health Care Use Among Veterans With Lung Cancer.

Identification and documentation of Veterans' symptoms are crucial for optimal lung cancer care delivery. The objective of this study was to determine whether a volunteer-led proactive telephone symptom assessment intervention could improve comprehensive symptom documentation. Veterans with lung cancer were randomly assigned to usual care (control group) or usual care with proactive symptom assessment in which a peer volunteer made weekly phone calls to assess patient symptoms under nurse practitioner supervision. The primary outcome was oncologist documentation of symptoms in the electronic health record at all clinical visits within 6 months after enrollment. Secondary outcomes included patient satisfaction with decision, patient activation, health-related quality of life (HRQOL), and symptom burden, measured at baseline, and 3, 6, and 9 months after enrollment, and acute care use within 9 months after enrollment. Among 60 Veterans randomly assigned, median (range) age was 70.2 (50-86) years; 57 (95.0%) were male. More intervention participants had oncologist documentation of symptoms than control group participants (24 [77.4%] v seven [24.1%], respectively; odds ratio, 16.46 [95% CI, 4.58 to 59.16]). Intervention group participants had greater improvements over time in HRQOL (expected mean difference, 25.3 [95% CI, 15.00 to 35.70]) and patient activation (expected mean difference, 13.6 [95% CI, 3.79 to 23.39]), lower symptom burden (expected mean difference, -6.39 [95% CI, -15.21 to -2.46]), lower rates of emergency room visits (incidence rate ratio, 0.48 [95% CI, 0.30 to 0.75]), and hospitalizations (incidence rate ratio, 0.47 [95% CI, 0.28 to 0.77]) than control group participants. This symptom assessment intervention is an effective strategy for Veterans with lung cancer.

Novel Approach to Proficiency Testing Highlights Key Practice Variations in Cancer Biomarker Delivery

Biomarkers are fundamental to modern oncology practice, forming a close link to pathology practice. Pathology results must be accurate, timely, comprehensive, and comprehendible. External proficiency testing is a key tool in maintaining biomarker quality. Here, we demonstrate the feasibility and utility of a novel end-to-end proficiency testing exercise exploring accuracy, turnaround time, and communication. Challenge specimens were made using resected colon cancer tissue, each paired with a fictional clinical vignette, and distributed to participants who were asked to provide all molecular testing required and return a final report for each case upon completion. Reports were redistributed to an assessor team including medical oncologists, each of whom was asked to recommend a systemic therapy based on each lab’s biomarker report. Participants were graded based on their ability to guide oncologists to the correct treatment. Eight laboratories participated. Three laboratories were found to have suboptimal results, two leading oncologists to incorrect therapeutic prescriptions, and one withdrawn. Turnaround time ranged from 6 to 86 days (median 24). Substantial qualitative reporting differences were identified. This study demonstrates the feasibility of end-to-end proficiency testing. The approach provides considerable value beyond analytic accuracy, including specimen management, turnaround time, and communication of results. Results suggest that reporting differences may lead to treatment disparities. This style of quality assurance will help reinforce good practices critical to the delivery of precision cancer care.

Comparison of US Oncologist Rurality by Practice Setting and Patients Served

Studies of the oncology workforce most often classify physician rurality by their practice location, but this could miss the true extent of physicians involved in rural cancer care. To compare a method for identifying oncology physicians involved in rural cancer care that uses the proportion of rural patients served with the standard method based on practice location. This cross-sectional study used retrospective Centers for Medicare & Medicaid Services encounter data on medical oncologists, radiation oncologists, and surgeons treating Medicare beneficiaries diagnosed with breast, colorectal, or lung cancer from January 1 to December 31, 2019. Data were analyzed from May to September 2023. The standard method of classifying oncologist physician rurality based on practice location was compared with a novel method of classification based on proportion of rural patients served. The study included 27 870 oncology physicians (71.3% male), of whom 835 (3.0%) practiced in a rural location. Physicians practicing in a rural location treated a high proportion of rural patients (median, 50.0% [IQR, 16.7%-100%]). When considering the rurality of physicians' patient panels, 5123 physicians (18.4%) whose patient panel included at least 20% rural patients, 3199 (11.5%) with at least 33% rural patients, and 1996 (7.2%) with at least 50% rural patients were identified. Using a physician's patient panel to classify physician rurality revealed a higher number and greater spread of oncology physicians involved in rural cancer care in the US than the standard method, while maintaining high performance (area under the curve, 0.857) and fair concordance (κ, 0.346; 95% CI, 0.323-0.369) with the method based on practice setting. In this cross-sectional study, classifying oncologist rurality by the proportion of rural patients served identified more oncology physicians treating patients living in rural areas than the standard method of practice location and may more accurately capture the rural cancer physician workforce, as many hospitals have historically been located in more urban areas. This new method may be used to improve future studies of rural cancer care delivery.

Interventions addressing health-related social needs among patients with cancer.

Health-related social needs are prevalent among cancer patients; associated with substantial negative health consequences; and drive pervasive inequities in cancer incidence, severity, treatment choices and decisions, and outcomes. To address the lack of clinical trial evidence to guide health-related social needs interventions among cancer patients, the National Cancer Institute Cancer Care Delivery Research Steering Committee convened experts to participate in a clinical trials planning meeting with the goal of designing studies to screen for and address health-related social needs among cancer patients. In this commentary, we discuss the rationale for, and challenges of, designing and testing health-related social needs interventions in alignment with the National Academy of Sciences, Engineering, and Medicine 5As framework. Evidence for food, housing, utilities, interpersonal safety, and transportation health-related social needs interventions is analyzed. Evidence regarding health-related social needs and delivery of health-related social needs interventions differs in maturity and applicability to cancer context, with transportation problems having the most maturity and interpersonal safety the least. We offer practical recommendations for health-related social needs interventions among cancer patients and the caregivers, families, and friends who support their health-related social needs. Cross-cutting (ie, health-related social needs agnostic) recommendations include leveraging navigation (eg, people, technology) to identify, refer, and deliver health-related social needs interventions; addressing health-related social needs through multilevel interventions; and recognizing that health-related social needs are states, not traits, that fluctuate over time. Health-related social needs-specific interventions are recommended, and pros and cons of addressing more than one health-related social needs concurrently are characterized. Considerations for collaborating with community partners are highlighted. The need for careful planning, strong partners, and funding is stressed. Finally, we outline a future research agenda to address evidence gaps.

ЭКСПЕРТИЗА КАЧЕСТВА ОНКОЛОГИЧЕСКОЙ ПОМОЩИ КАК ИНСТРУМЕНТ ПРИНЯТИЯ УПРАВЛЕНЧЕСКИХ РЕШЕНИЙ

Significance. Objective data, including results of quality assessment and expertise carried out by health insurance organizations as part of monitoring over volumes, service periods, quality and conditions of medical care delivery within the compulsory health insurance system are needed to make management decisions on organizing appropriate quality care delivery at the regional and institutional levels. The subject of study: quality of medical care provided to patients with cancer. The purpose of the study: to evaluate results of medical and economic expertise and quality assessment of cancer care, carried out by health insurance organizations in the Arkhangelsk region in 2018 –first half of 2023 (25,012 expert opinions). Material and methods. The study used depersonalized results of medical-economic expertise and quality assessment of medical care (25,012 expert opinions). Methods: retrospective analysis, statistical (calculation of extensive and intensive coefficients and their comparison), analytical method. Results. In general, the frequency of cancer care defects during the period under study equaled to 29.1 per 100 assessed cases. The leading group of defects included a failure, untimely or improper implementation of diagnostic and (or) treatment activities necessary for the patient (49.3%). The study has identified significant differences in the frequency and structure of the identified defects of medical care under different conditions of its provision, in medical organizations of different levels and in different nosological groups. Conclusion. The study shows a decline in the total number of defects in cancer care delivery with the same frequency of medical-economic expertise and quality assessment in the Arkhangelsk region in 2018 - first half of 2023. To identify causes of the leading groups of defects in the provision of medical care according to code 3.2. (failure, untimely or improper implementation of diagnostic and (or) treatment activities necessary for the patient), it is necessary to conduct a sociological survey (questionnaire) of doctors involved in cancer care delivery. Scope of application: management decision-making aimed to improving access to and quality of cancer care at the regional and institutional levels.