Cancer-related Visits Research Articles

Patient reported symptoms after cancer diagnosis and the risk of short- and long-term severe mental health events among adolescents and young adults (AYA): A population-based study.

12019 Background: AYA with cancer are a vulnerable sub-population at risk of adverse mental health outcomes during and after cancer treatment. Tools to identify AYA at highest risk are required to guide screening and interventions. In a population-based cohort of AYA with cancer, we determined whether self-reported symptoms were associated with subsequent short- and long-term severe mental health events (SMHE). Methods: All Ontario, Canada AYA diagnosed with cancer aged 15-29 between 2010-2018 were identified and linked to healthcare databases, including one capturing self-reported Edmonton Symptom Assessment System (ESAS) scores at cancer-related visits. Scores for depression, anxiety, and poor well-being were categorized as not measured, mild (0-3), moderate (4-6), or severe (7-9). SMHE were defined as emergency room visits or hospitalizations for mental health reasons. First, we used Cox proportional hazard models to determine the association of ESAS scores (time-varying variable) with subsequent SMHE. Second, among 5-year survivors, we determined the association of maximum ESAS score within the first year of diagnosis with long-term SMHE (i.e. starting at 5 years from cancer diagnosis). All analyses were adjusted for patient and disease variables, including mental healthcare use prior to cancer diagnosis. Results: 5,435 AYA met inclusion criteria. Median age at cancer diagnosis was 25 years [interquartile range 22-27]. Hematologic cancers were most common (1,748; 32.2%). Symptom severity was associated with subsequent SMHE risk. For example, AYA reporting severe anxiety were at more than three-fold higher risk of SMHE compared to those reporting mild anxiety [adjusted hazard ratio (aHR) 3.6, 95th confidence interval (CI) 1.9-6.7; p < 0.001]. Similar risk was seen among AYA reporting severe vs. mild depression (aHR 3.5, 1.7-7.3; p < 0.001). Among 3,518 (64.7%) 5-year survivors, symptom severity also predicted long-term SMHE. For example, starting at 5 years post cancer diagnosis, the subsequent 3-year cumulative incidence of a SMHE among those who reported severe depression at any time during the first year post cancer diagnosis was 10.5% (95CI 6.9-15.9) compared to 2.4% (95CI 1.7-3.3) among those who only reported mild depression (aHR 3.0, 95CI 1.8-4.9; p < 0.0001). Similar results were seen pertaining to severe anxiety and severe impact on well-being. AYA endorsing severe anxiety represented 13.1% of the cohort but accounted for 25.8% of AYA experiencing SMHEs during the first three years of survivorship. Conclusions: Systematic symptom screening in the first year after cancer diagnosis identifies a proportion of AYA at high risk of both short and long-term SMHE who may benefit from targeted screening and interventions. Future work will determine whether interventions during cancer treatment mitigate this risk.

Organization of Cancer Specialists in US Physician Practices and Health Systems.

To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers. Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physicians providing cancer care. We stratified physicians by discipline (adult/pediatric medical oncologists, radiation oncologists, surgical/gynecologic oncologists, other surgeons performing cancer surgeries, or palliative care physicians), system type (National Cancer Institute [NCI] Cancer Center system, non-NCI academic system, nonacademic system, or nonsystem/independent practice), practice size, and composition (single disciplinary oncology, multidisciplinary oncology, or multispecialty). We computed the density of cancer specialists by county and calculated distances to the nearest NCI Cancer Center. More than half of all cancer specialists (57.8%) practiced in health systems, but 55.0% of cancer-related visits occurred in independent practices. Most system-based physicians were in large practices with more than 100 physicians, while those in independent practices were in smaller practices. Practices in NCI Cancer Center systems (95.2%), non-NCI academic systems (95.0%), and nonacademic systems (94.3%) were primarily multispecialty, while fewer independent practices (44.8%) were. Cancer specialist density was sparse in many rural areas, where the median travel distance to an NCI Cancer Center was 98.7 miles. Distances to NCI Cancer Centers were shorter for individuals living in high-income areas than in low-income areas, even for individuals in suburban and urban areas. Although many cancer specialists practiced in multispecialty health systems, many also worked in smaller-sized independent practices where most patients were treated. Access to cancer specialists and cancer centers was limited in many areas, particularly in rural and low-income areas.

Symptom severity, specialty palliative care, and subsequent symptom control among adolescents and young adults with cancer: A population-based study.

e24127 Background: Adolescents and young adults (AYA) with cancer can suffer from substantial symptom burdens. Specialty palliative care (SPC) is recommended but often uninvolved or involved late. In a population-based AYA cohort, we determined: 1) whether symptom severity measured by routine patient report was associated with subsequent SPC involvement; and 2) whether SPC involvement was associated with subsequent symptom improvement. Methods: All Ontario, Canada AYA diagnosed with cancer aged 15-29 between 2010-2018 were identified and linked to healthcare databases, including one capturing self-reported Edmonton Symptom Assessment System (ESAS) scores at cancer-related visits. SPC was identified through validated algorithms using PC fee codes billed by SPC physicians. ESAS scores were categorized as not measured, mild (0-3), moderate (4-6), or severe (7-9), and could vary over time. For each symptom, the association of ESAS score with subsequent SPC involvement was determined, adjusting for patient and disease characteristics. For objective #2, only AYA who died within 5 years of cancer diagnosis were included and a “difference-in-difference” approach was used. Cases (SPC involvement before death, index date was time of first SPC service) were matched 1:1 to controls (no SPC involvement at equivalent index date, defined by time prior to death) by sex and cancer type. By symptom type, linear regression determined whether the difference between the 90-day post-index and 90-day pre-index mean ESAS scores was itself different between cases and controls through examining interaction terms. Results: 5,435 AYA met inclusion criteria. 5-year cumulative incidence of SPC involvement was 19% [95th confidence interval (95CI) 18-20%]. For all symptoms, moderate and severe scores were associated with increasing likelihood of SPC involvement compared to mild scores; not being ESAS screened was associated with decreased likelihood. The greatest magnitude of association was seen for pain scores [adjusted hazard ratio of SPC involvement for severe vs. mild 7.7, 95CI 5.8-10.2, p < 0.001]. 721 (13.3%) AYA died within 5 years of diagnosis; 612 (84.9%) had at least one SPC visit prior to death. 202 case-control pairs were identified. SPC involvement was associated with improved pain score trajectories (mean pain scores improved from 3.4 to 3.1 in cases vs. worsened from 1.9 to 2.1 in controls; p = 0.003), but did not impact trajectories of other symptoms. Conclusions: AYA reporting moderate or severe symptoms through a provincial screening program were more likely to subsequently receive SPC; systematic screening may increase access. SPC was associated with a subsequent decrease in pain severity, but did not affect other symptoms. New interventions targeting these other symptoms during cancer treatment and particularly at the end-of-life are urgently needed.

Defining the psychiatric and financial burden of mental and substance use disorders in cancer patients.

To identify the proportion of Emergency Department (ED) visits in cancer patients associated with a mental and substance use disorder (MSUD) and the subsequent healthcare costs. Nationally representative data on ED visits from 2009 to 2018 was obtained from the Nationwide Emergency Department Sample (NEDS). We identified cancer-related visits with or without a MSUD using the Clinical Classifications Software diagnoses documented during the ED visit. Survey-adjusted frequencies and proportions of ED visits among adult cancer patients with or without a MSUD was evaluated. Survey-adjusted multivariable logistic regression models were used to examine demographic and clinical predictors of the presence of an MSUD and the likelihood of hospital admission for patients with a primary MSUD. Among 54,004,462 ED visits with a cancer diagnosis between 2009 and 2018, 11,803,966 (22%) were associated with a MSUD. Compared to a primary diagnosis of cancer, patients who presented to the ED with a chief complaint of MSUD were more likely to be female (54% vs. 49%), younger (median: 58 vs. 66), more likely to have Medicaid insurance, and more likely to be discharged home. The three most common MSUD diagnoses among cancer patients were alcohol-related disorders, anxiety disorders, and depressive disorders. The total costs associated with a primary MSUD from 2009 to 2018 was $3,133,432,103, of which alcohol-related disorders claimed the largest majority. Younger age (OR per 10-year increase: 0.86, 95% CI: 0.85, 0.86) and female sex (OR: 1.34, 95% CI: 1.33-1.35) were associated with higher odds of having an MSUD. Our findings demonstrate a high burden of psychiatric and substance use illness in the cancer population and provide the rationale for early psychosocial intervention to support these patients.

Emergency department utilization among skin cancer patients: a retrospective study of the national emergency department sample 2013-2015.

Skin cancer-related emergency department (ED) visits are among the most common cancer-related ED visits in the USA. However, ED utilization among skin cancer patients has not been evaluated. To assess overall utilization of EDs among skin cancer patients, reasons for skin cancer-related visits, and factors associated with inpatient admission. This was a retrospective, cross-sectional study of adults with skin cancer presenting to EDs using years 2013-2015 of the Nationwide Emergency Department Sample. In total, 693,835 of the 223,329,909 weighted ED visits were made by patients with skin cancer. Visits among this population were frequently due to age-related comorbidities and skin cancer treatment-specific adverse events. Melanoma accounted for the minority of skin cancer-related visits (27.58%), but over half of subsequent inpatient admissions (51.18%) and was associated with greater odds of inpatient admission compared to keratinocyte carcinoma (OR 1.278, 95% CI 1.264-1.293). Treatment and staging codes were not available, and thus, differences in ED utilization among skin cancer stages and treatment approaches could not be assessed. Ultimately, these findings are important in improving anticipatory outpatient care for patients with skin cancer and in guiding appropriate management of this unique population in the ED.

Impact of Breast Cancer Pathways on ER utilization and hospitalization.

423 Background:Optum’s Cancer Guidance Program promotes value-based care by ensuring that treatments follow evidence-based guidelines and encouraging the use of cancer therapy pathways. Criteria for selection of treatments for pathways include efficacy, toxicity and cost so Pathways could be expected to decrease emergency room utilization and hospitalizations that result from adverse events of therapy. We conducted this study to evaluate the impact of Pathways adherence (on vs. off Pathways) on hospital inpatient and emergency department utilization among commercially insured members with breast cancer. Methods: This cross-sectional matched case-control study used medical claims and prior authorization data to evaluate 12 months of program experience (11/1/2019 – 10/31/2020). Individuals were included if they were 19+ years old, enrolled in the health plan, had actively treated breast cancer (breast cancer diagnosis and 1+ cancer related treatment procedure), and had a cancer drug therapy prior authorization during the study period. On Pathway cases were matched to off Pathway controls with propensity score and outcomes were measured using generalized linear models. The propensity score was estimated using demographic characteristics, cost/utilization preceding the prior authorization request, and clinical indicators (HER2 status, advanced disease, adjuvant vs neoadjuvant therapy, multiple lines of therapy, ECOG /Karnofsky, regimen emetic risk). Outcomes were measured across the member’s treatment episode from first month of active cancer treatment to 3 months after last month of active cancer treatment. Results: Compared to those who were off Pathway (n = 1,001), patients treated with a Pathways regimen (n = 1,001) had 18% lower (p-value = 0.03) all-cause inpatient admissions, 14% lower (p-value = 0.10) cancer-related inpatient admissions, 18% lower (p-value = 0.11) all-cause emergency department visits, no difference in (p-value = 1.00) cancer-related inpatient bed days, 8% lower (p-value = 0.31) all-cause emergency department visits, and 1% lower (p-value = 0.92) cancer-related emergency department visits. Conclusions: Treatment with a Pathway regimen was associated with fewer all-cause and cancer-related visits to inpatient hospitalizations and fewer all-cause inpatient bed days.

An Analysis of Factors Related to Care Engagement along the Cancer Survivorship Care Continuum for Cancer Survivors in Florida.

This study identifies factors associated with care engagement along the cancer survivorship care continuum for Floridians. We identified patients from the OneFlorida Data Trust with a cancer diagnosis at any age and encounters from 2012-2020. Multivariable logistic regression models produced odds ratios (OR) predicting 1) any outpatient non-acute care visit, 2) cancer-related visit with any provider, 3) cancer-related visit with a cancer provider, and 4) survivorship visit with a cancer provider. Encounter-based independent variables were insurance, Social Deprivation Index quartile, and Rural Urban Continuum Area (adjusted for age, sex, race, ethnicity, and treatment). 662,489 survivors were included in the sample. Those with Medicaid and dual eligible status (Medicare and Medicaid) were more likely to have an outpatient visit (Medicaid OR 2.02, 95%CI 1.93-2.12; dual eligible 3.06, 2.91-3.22) or a cancer-related visit with a cancer provider (Medicaid 1.82, 1.77-1.86; dual eligible 1.32, 1.28-1.35), and less likely to have a survivorship visit (Medicaid 0.27, 0.26-0.28; dual eligible 0.20, 0.19-0.21). Uninsured survivors were less likely to have all visit types, while those with Medicare were more likely. Those from the most socially deprived areas were more likely to have an outpatient visit (1.09, 1.03-1.14) and less likely to have a cancer-related visit with any provider (0.90, 0.88-0.92) or a cancer provider (0.93, 0.91-0.95). Survivors from non-metropolitan areas were more likely to have an outpatient visit (1.38, 1.22-1.56), cancer-related visit (1.22, 1.16-1.28), cancer-related visit with a cancer provider (1.45, 1.39-1.52), and a survivorship visit (1.34, 1.22-1.48). Survivors who have public insurance are more likely to have outpatient visits, and those with Medicaid or dual eligible status are less likely to have survivorship visits. Uninsured status is consistently associated with lack of engagement across the care continuum. Those from areas with higher social deprivation are more likely to have outpatient visits, but less likely to have a cancer-related visit with or without a cancer provider. Survivors from non-metropolitan areas are more likely to engage in all visit types along the care continuum.

Main reasons and predictive factors of cancer-related emergency department visits in a Hungarian tertiary care center

BackgroundIdentifying the reasons for the Emergency Department (ED) visit of patients with cancer would be essential for possibly decreasing the burden of ED use. The aim of our study was to analyze the distribution of the demographic and clinical parameters of patients with cancer based on the reasons for the ED visits and to identify possible predictive factors for their visits.MethodsThis retrospective study, carried out at a large, public tertiary hospital in Hungary, involved all patients 18 years or over, who had received a cancer diagnosis latest within five years of their visit to the ED in 2018. Demographic and clinical characteristics were collected partly via automated data collection and partly through the manual chart review by a team of experts, including six emergency physicians and an oncologist. Five main reasons for the ED visit were hypothesized, pilot-tested, then identified, including those with cancer-related ED visits (whose visit was unambiguously related to their cancer illness) and those with non-cancer-related ED visits (whose visit to the ED was in no way associated with their cancer illness.) A descriptive approach was used for data analysis and binary logistic regression was used to determine predictive factors for patients with cancer visiting the ED.Results23.2% of the altogether 2383 ED visits were directly cancer-related, and these patients had a significantly worse overall survival than patients with non-cancer related ED visits. Age 65 or below (Odds Ratio: 1.51), presence of two more comorbidities (OR: 7.14), dyspnea as chief complaint (OR: 1.52), respiratory cancer (OR: 3.37), any prior chemotherapy (OR: 1.8), any prior immune/biological treatment (OR: 2.21), any prior Best Supportive Care/palliative care (OR: 19.06), or any prior hospice care (OR: 9.43), and hospitalization (OR:2.88) were independent risk factors for the ED visit to be cancer-related.ConclusionsOur study is the first to identify independent predictive factors of ED use by patients with cancer based on the chief cause of their visit in the Central and Eastern European region. These results may provide important information for the development of algorithms intended to identify the needs of care of patients with cancer at the ED.

Impact COVID-19 pandemic on lung cancer care from screening to postoperative follow-up.

e18509 Background: The COVID-19 pandemic has presented various challenges for the healthcare system. This study aims to estimate the impact of the COVID-19 pandemic on Lung Cancer Screening (LCS), Lung Resections (LR), and Outpatient Visits (OPV). Methods: This is a longitudinal quasi-experimental time-series analysis using data from the institutional electronic medical records (EMR) from January 2018 to December 2021, considering the first and second waves of COVID-19 cases in Massachusetts; March, and November 2020, respectively. The main outcomes were (A) Monthly LCS exams, (B) Monthly LR surgeries, (C) Monthly Overall-cancer-OPV. Results: 9,057 LSC exams, 333 LR surgeries, and 5,918 outpatient visits were analyzed. The average patient age that underwent LCS was 64; 48.9% were female and 91.4% White. LR was performed in patients 67 years old on average, 67.7% female and 93.6% White. The Overall-cancer-OPV was 58.1% for female patients, 89.4% for White patients, and the overall average patient age was 68 years. The monthly number of LCS (A) presented a statistically significant reduction in the first wave (p = 0.001) with a significant recovery in the following months with a monthly increase rate of 26 exams per month (p = 0.002). The second wave did not represent a sharp reduction in the LCS. Nevertheless, a significant monthly reduction of 44 exams was found. There was no statistical decline for the monthly LR surgeries (B). However, an increase in time from the first visit to the surgery was observed. The COVID-19 surges did not significantly impact the (C) Monthly Overall-cancer-OPV, and it was due to the implementation of telehealth services. The use of telehealth prevented a decline in OPV of 59% (p = 0.001) overall and 40% (p = 0.0190) for cancer. Telehealth visits accounted for 27.7% of cancer-related visits. Female patients were more likely to have a telehealth appointment. White, Black, and Asian patients presented with a similar percentage of telehealth use (26.3%, 25.0%, and 26.8%), while Latinos were less likely to have a telehealth appointment when compared with non-Latinos (18%, p < 0.02). Age was not significantly different between telehealth and non-telehealth appointments. However, for those who preferred a phone appointment, the average age was 67 years old, while for those who used video appointments, the age was 63 (p-value < 0.05). Conclusions: The COVID-19 pandemic affected significantly LCS while lung resections were stable over time; nonetheless, the time from the first visit to surgery increased. The use of telehealth technology allowed patients with cancer to safely receive care throughout the COVID-19 Pandemic. The adoption of telehealth can expand access to care in the pandemic context in low-resource areas. Still, future studies should assess the impact of the COVID-19 pandemic on staging at diagnosis, time to treatment initiation, and survival, especially for the underserved population.

Workforce Caring for Cancer Survivors in the United States: Estimates and Projections of Use.

This study aims to quantify the extent and diversity of the cancer care workforce, beyond medical oncologists, to inform future demand because the number of cancer survivors is expected to grow in the United States. Surveillance, Epidemiology, and End Results-Medicare data were used to evaluate health-care use of cancer survivors diagnosed between 2000 and 2014, enrolled in fee-for-service Medicare Parts A and B, and 65 years or older in 2008-2015. We calculated percentage of cancer survivors who saw each clinician specialty and their average annual number of visits in each phase of care. We projected the national number of individuals receiving care and number of annual visits by clinician specialty and phase of care through 2040. Cancer survivors had higher care use in the first year after diagnosis and last year of life phases. During the initial year after cancer diagnosis, most survivors were seen for cancer-related care by a medical oncologist (59.1%), primary care provider (55.9%), and/or other cancer-treating physicians (42.2%). The percentage of survivors with cancer-related visits to each specialty declined after the first year after diagnosis, plateauing after year 6-7. However, at 10 or more years after diagnosis, approximately 20% of cancer survivors had visits to medical oncologists and an average of 4 visits a year. Cancer survivors had higher care use in the first year after diagnosis and last year of life. High levels of care use across specialties in all phases of care have important implications for models of survivorship care coordination and workforce planning.

Study of the Veterans Affairs Health Care System highlights the impact of COVID-19 on cancer diagnoses in the USA

As health-care professionals and researchers worldwide continue to warn of the complications of COVID-19 on cancer, a new US-based study has now further highlighted the link between the pandemic and worsening cancer care. The time-frame study published on Dec 6, 2021, included the pre-pandemic phase and the primary surge of COVID-19 infections. The USA was hit hard by the pandemic: thousands of hospitals, medical institutions, and health-care services came to a halt in March, 2020, and organisations had to direct all their resources to care for patients with COVID-19. The consequences of this abrupt change in health-care priorities are reflected in the data collected: the study team found strong signals of cancer services being impacted by the pandemic. Co-author of the study, Brajesh K Lal (University of Maryland School of Medicine, Baltimore, MD, USA) told The Lancet Oncology: “[During] the primary surge, the curtailment of non-emergency services was intentional, and it was obvious that a lot of—in fact, all of—the non-emergency services that we delivered to our patients was essentially going to go away. What was unknown was how that curtailment, as short as it might be—2 weeks, 3 weeks, depending on the part of the country—and the subsequent outcome [was] going to affect patients with non-emergency disease, (…) and to what extent that curtailment was going to continue.” Data on the patient population for Lal's study, mostly consisting of male veterans, were gathered through the Veterans Affairs Health Administration—the largest integrated health-care system in the USA. Lal and colleagues selected the veteran database for its ease of access and uniqueness. As Lal explained, “you can actually measure how much the reduction in the screening and diagnostic activities are impacting the result [because] this is a closed system”. Lal and colleagues broke down the timeline into years of concern. Between 2018 and 2020, 4·1 million cancer-related visits and 3·9 million relevant procedures were reported, with around a quarter of a million new cancers diagnosed. Despite these large numbers, when this 2-year time period was compared with 2020, evidence of disruptions to services appeared. For example, colonoscopies decreased by 45% compared with pre-pandemic numbers. Other decreases included prostate biopsies (by 29%) and new cancer diagnoses (by 13–23%); findings that reflect those of a previous report in Medicare beneficiaries. Lal and his team also developed a visual diagram that can help health-care institutions and authorities to eliminate the backlog of missed procedures by increasing the average number of patients they are serving. Using the formula highlighted in the study could help to increase the monthly volume of patient traffic, looking at case deficit as a percentage of a monthly baseline, to calculate the time frame needed to clear the backlog. The study assessed four cancers: prostate, lung, bladder, and colorectal cancer. Prostate cancer is the leading cause of cancer death in men in the USA; lung and colorectal cancers are in the top ten. Although predominantly female cancers such as breast and ovarian cancers were not mentioned, Lal stressed that the same can be said about other cancers; regardless of cancer type, the number of new cancers diagnosed has gone down and that deficit continues to accumulate—translating to increasing numbers of patients with cancer being missed by the health-care system. Older people are a growing population reliant on government aid, such as Medicaid and Medicare. 18·2 million veterans in the USA are older than 65 years of age and are categorised as seniors. In November, 2021, the US Government launched the widely publicised Build Back Better Act, focused on US veterans and middle class. The Act is being negotiated in the US senate, but questions remain on how the bill and the increased medical costs attached to it will eventually help veterans with cancer in the post-COVID-19 scenario. Commenting on the study by Lal and colleagues, Umut Surpel (Mount Sinai Hospital, New York, NY, USA) told Lancet Oncology that, “I was actually looking forward to studies like this coming out and I heard some murmurings of people trying to capture [the decline of cancer care]. (…) We were all waiting for this wave… essentially of cancer cases to hit us. In New York, where we saw this big surge, everything shut down.” However, Matthew Rettig (VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA) had a different pandemic experience. He said, “I had no shutdown in delivery of care” and did not experience a reduction in patient treatment, but agrees that certain cancers have been greatly affected by COVID-19-related screening delays.

The effectiveness of a provincial symptom assessment program in reaching adolescents and young adults with cancer: A population‐based cohort study

BackgroundSymptom control is prioritized by cancer patients and may improve overall survival. Ontario, Canada thus offers all cancer patients screening using the Edmonton Symptom Assessment System (ESAS) at outpatient cancer‐related visits. We determined whether this initiative reached adolescents and young adults (AYA) and factors associated with screening in this population.MethodsWe linked all Ontario AYA diagnosed with cancer 2010–2018 aged 15–29 years to population‐based databases identifying outpatient visits and ESAS screening. For each 2‐week period in the year post‐diagnosis, AYA with cancer‐related visits were categorized as “unscreened” (no ESAS score) versus “screened” (≥1 ESAS score). Demographic and disease‐related covariates were examined.ResultsAmong 5435 AYA, 4204 (77.4%) had ≥1 ESAS screen. Within any 2‐week period, only 30%–44% of AYA attending cancer‐related visits were screened. Patients with hematologic malignancies were least likely to be screened [odds ratio (OR) vs. breast cancer 0.77, 95% confidence interval (95% CI) 0.67–0.88; p < 0.001]. AYA in remote Northern or rural areas had equivalent or higher rates of ESAS screening compared to those in high‐income urban areas. However, AYA living in the lowest income urban neighborhoods were less likely to be screened (OR 0.86, 95% CI 0.77–0.97; p = 0.01).ConclusionsWithin a population‐wide symptom assessment program, while AYA living in rural and remote areas had high rates of screening, than those in low‐income urban areas were substantially less likely to be screened. Though patients with hematologic cancers suffer from particularly high symptom burdens, they were also less likely to be screened. Interventions targeting AYA are required to increase uptake.

Project Forward: A Population-Based Cohort Among Young Adult Survivors of Childhood Cancers.

BackgroundChildhood cancer survivors (CCS) face increased risk of morbidity and are recommended to receive lifelong cancer-related follow-up care. Identifying factors associated with follow-up care can inform efforts to support the long-term health of CCS.MethodsEligible CCS (diagnosed between 1996 and 2010) identified through the Los Angeles County Cancer Surveillance Program responded to a self-report survey that assessed demographic, clinical, health-care engagement, and psychosocial risk and protective factors of recent (prior 2 years) cancer-related follow-up care. Weighted multivariable logistic regression was conducted to identify correlates of care. All statistical tests were 2-sided.ResultsThe overall response rate was 44.9%, with an analytical sample of n = 1106 (54.2% Hispanic; mean [SD] ages at survey, diagnosis, and years since diagnosis were 26.2 [4.9], 11.6 [5.4], and 14.5 [4.4] years, respectively). Fifty-seven percent reported a recent cancer-related visit, with lower rates reported among older survivors. Having insurance, more late effects, receipt of a written treatment summary, discussing long-term care needs with treating physician, knowledge of the need for long-term care, having a regular source of care, and higher health-care self-efficacy were statistically significantly associated with greater odds of recent follow-up care, whereas older age, Hispanic or Other ethnicity (vs non-Hispanic White), and years since diagnosis were associated with lower odds of recent care (all Ps < .05).ConclusionsAge and ethnic disparities are observed in receipt of follow-up care among young adult CCS. Potential intervention targets include comprehensive, ongoing patient education; provision of written treatment summaries; and culturally tailored support to ensure equitable access to and the utilization of care.

The effectiveness of a provincial symptom assessment program in reaching adolescents and young adults with cancer: A population-based cohort study.

12101 Background: Symptom control is prioritized by cancer patients and may improve overall survival. Several jurisdictions have thus launched population-wide initiatives to assess symptoms at regular intervals. In Ontario, Canada, for example, all cancer patients are screened using the Edmonton Symptom Assessment System (ESAS) at every outpatient visit. Few studies have examined symptom burdens in adolescents and young adults (AYA). Previous work suggests that AYA symptoms differ from those in older patients, and that general screening tools may not be appropriate. Despite this, whether current symptom screening initiatives reach AYA with cancer are unknown. We therefore determined 1) Whether AYA with cancer were participating in ESAS screening, and 2) Which AYA were at highest risk of not being screened. Methods: We identified all Ontario AYA diagnosed with cancer at age 15-29 years between 2010-2018 and treated in adult centers. Patients were linked to population-based databases to identify all cancer-related outpatient visits in the year following diagnosis and whether visits involved completion of an ESAS form. Each patient’s first year was divided into two-week periods. For each period, AYA were considered either “unscreened” if they had a cancer-related visit but no ESAS score, or “screened” if they had a cancer-related visit with at least one ESAS score. Periods without cancer-related visits were not considered, given no potential for ESAS screening during such periods. Covariates included age at diagnosis, sex, cancer type, neighbourhood income quintile, and institution type [regional cancer centre (RCC) vs. community]. Multivariable logistic regression models were implemented under a generalized estimating equations approach to account for individual-level correlation. Results: The final cohort included 5,435 AYA. Within any given two-week period, only 36-45% of AYA attending cancer-related outpatient visits were screened. In adjusted analyses, age and sex were not associated with being screened. However, AYA living in the lowest income quintile neighbourhood were less likely to be screened [odds ratio (OR) 0.86, 95th confidence interval (95CI) 0.77-0.97; p = 0.01] compared to those in the highest. Patients with hematologic malignancies were least likely to be screened (OR 0.77, 95CI 0.67-0.88; p &lt; 0.001), as were AYA attending community centers (OR 0.48, 95CI 0.42-0.55; p &lt; 0.001). Conclusions: Despite a population-wide symptom assessment program, only a minority of AYA are screened. Though patients with hematologic cancers suffer from particularly high symptom burdens, they were less likely to be screened. Interventions targeting AYA are required to increase uptake, particularly among those in disadvantaged neighborhoods or attending community hospitals. Studies of AYA-specific symptom assessment tools are also warranted.

Racial disparities in pediatric cancer care in the United States: An analysis of the Kids' Inpatient Database.

10016 Background: The impact of race and socioeconomic status (SES) on cancer mortality has been elucidated in adult patients, but is not well described in pediatric oncology. We hypothesize that racial and socioeconomic disparities exist in pediatric cancer patients, resulting in higher rates of hospitalization and mortality. Methods: We analyzed the Kids’ Inpatient Database (KID) which shows national estimates of inpatient stays for pediatric patients. Inclusion criteria included patients who were ≤20 with a cancer diagnosis identified through the Clinical Classifications Software (CCS). Variables analyzed were discharge status, patient demographics, hospital characteristics, expected payment source, total visit charge, and length of stay. Initial comparisons between cancer and non-cancer related discharges were performed using a chi-square test. To estimate disparities by race, clinical comparisons were performed across five racial groups: White, Black, Hispanic, Asian/Pacific Islander, and Native American/Other. A multivariable logistic regression model was used to examine predictors of hospitalization and mortality. Results: From 2006-2012, there were 9,488,477 non-cancer related pediatric inpatient stays and 242,489 cancer related stays. Patients with cancer related visits were more likely to be white, male (54.9% vs 46.1%, p &lt; 0.0001), older at admission, have private insurance (52.5% vs 41.7%), and were from a higher income quartile (76th-100th percentile, 25.2% vs 19.9%, p &lt; 0.001). These patients also had a higher rate of death during admission (1.2% vs 0.5%, p &lt; 0.0001), higher cost of visit charge ($25,097 vs $8,267, p &lt; 0.001), longer length of stay (4 vs 2 days), and were less likely to be discharged (85.5% vs 92.0%, p &lt; 0.0001).The four most frequent cancer diagnoses associated with hospital admission were leukemia (n = 75,807), Other and Unspecified Primary (n = 50,076), bone/connective tissue tumor (n = 42,477), and central nervous system tumor (n = 27,958). Patients who were non-white were more likely to die during their inpatient stay (1.5% Non-white versus 0.9% White, p &lt; 0.001). On multivariate logistic regression, Black (OR: 1.61, 95% CI: 1.57-1.66, p &lt; 0.0001) and Native American (OR: 1.39, 95% CI: 1.34-1.44, p &lt; 0.0001) race, as well as lower income quartile (OR: 1.24, 95% CI: 1.19-1.28, p &lt; 0.001) were associated with increased odds of death during admission. Conclusions: This is the largest observational study to date to identify the impact of race and SES on pediatric cancer hospitalization and mortality in the United States. Non-white race and lower SES was associated with significantly increased odds of death during admission. Given the significant difference in mortality by race, healthcare policy makers and insurance companies should investigate the specific drivers of increased admission and mortality and develop strategies to address inequity in cancer care.

Characteristics of patients hospitalized through the emergency department with an oncology drug-related side effect.

6557 Background: Recent advances in oncology treatment present an expanding spectrum of cancer-treatment-related emergencies.Many aspects of healthcare utilization, specifically emergency department (ED) visits, are not well studied in this population. The purpose of this study is to determine (1) what proportion of cancer patients visit the ED with an oncology drug-related side effect and are admitted and (2) what factors impact the probability of inpatient admission among these patients. Methods: This study evaluated ED visits by adult patients undergoing active drug treatment for cancer insured by a large commercial and Medicare health plan in the United States between January 1, 2018, and September 30, 2019. Among cancer-related ED visits, logistic regression was used to determine the marginal effect of demographic and clinical characteristics of patients on acute inpatient admission. Results: There were 39,921 total ED visits among patients undergoing drug treatment for cancer; of these, 76% presented with an oncology drug-related side-effect. 36% of all ED visits resulted in admission, 5% resulted in an observation stay. After adjusting, age was not a significant predictor of inpatient admission. Being male (p &lt; 0.01) and living in urban (p &lt; 0.01) or suburban (p &lt; 0.01) zip codes significantly increased the likelihood of admission. Patients with colorectal (p = 0.019), gastrointestinal (p &lt; 0.01), blood (p &lt; 0.01), lung (p &lt; 0.01), metastatic (p &lt; 0.01) cancers, or Hodgkin’s lymphoma (p &lt; 0.01) had significantly increased risk of admission. Patients with prostate (p &lt; 0.01) cancer had a significantly reduced risk of admission. The primary complaint upon presentation to the ED was the most important predictor of inpatient admission; sepsis, pneumonia, medical complications, white cell disorders, metastatic cancer, and fractures were all associated with a significantly higher (all p &lt; 0.001) risk of admission. Patients with comorbid heart failure (p &lt; 0.001), those taking ulcer medications (p &lt; 0.01), or inflammatory bowel disease (p = 0.03) had a significantly increased risk of admission. Results were consistent regardless of payer (Medicare or commercial health plan). Conclusions: This study identified cancer patients for whom acute inpatient admission from an ED presentation is more likely. Future studies identifying cancer patients who may be at risk of making an ED presentation based on demographic, clinical and disease-related characteristics are needed and may help inform targeted follow up of patients to mitigate potentially avoidable ED presentation and subsequent inpatient admission.

Health Care Utilization and Costs of Patients With Prostate Cancer in China Based on National Health Insurance Database From 2015 to 2017.

BackgroundIn terms of medical costs, prostate cancer is on the increase as one of the most costly cancers, posing a tremendous economic burden, but evidence on the health care utilization and medical expenditure of prostate cancer has been absent in China.ObjectiveThis study aimed to analyze health care utilization and direct medical costs of patients with prostate cancer in China.MethodsHealth care service data with a national representative sample of basic medical insurance beneficiaries between 2015 and 2017 were obtained from the China Health Insurance Association database. We conducted descriptive and statistical analyses of health care utilization, annual direct medical costs, and composition based on cancer-related medical records. Health care utilization was measured by the number of hospital visits and the length of stay.ResultsA total of 3,936 patients with prostate cancer and 24,686 cancer-related visits between 2015 and 2017 were identified in the database. The number of annual outpatient and inpatient visits per patient differed significantly from 2015 to 2017. There was no obvious change in length of stay and annual direct medical costs from 2015 to 2017. The number of annual visits per patient (outpatient: 3.0 vs. 4.0, P < 0.01; inpatient: 1.5 vs. 2.0, P < 0.001) and the annual medical direct costs per patient (US$2,300.1 vs. US$3,543.3, P < 0.001) of patients covered by the Urban Rural Resident Basic Medical Insurance (URRBMI) were both lower than those of patients covered by the Urban Employee Basic Medical Insurance (UEBMI), and the median out-of-pocket expense of URRBMI was higher than that of UEBMI (US$926.6 vs. US$594.0, P < 0.001). The annual direct medical costs of patients with prostate cancer in Western regions were significantly lower than those of patients in Eastern and Central regions (East: US$4011.9; Central: US$3458.6; West: US$2115.5) (P < 0.001).ConclusionsThere was an imbalanced distribution of health care utilization among regions in China. The direct medical costs of Chinese patients with prostate cancer remained stable, but the gap in health care utilization and medical costs between two different insurance schemes and among regions still needed to be further addressed.

P097: The emergency department experience for patients and caregivers referred from an outpatient oncology clinic

Introduction: Outpatient oncology clinics have become the mainstay of cancer treatment, but their limited services and hours of operation often lead to emergency department (ED) referrals. With Canada's aging population and cancer survival rates improving, cancer-related ED visits are becoming a significant aspect of emergency medicine. A cancer-related visit to the ED is associated with unique challenges for patients, their caregivers and clinicians. This study focuses on understanding the ED experience of patients and their caregivers sent from an outpatient oncology clinic to a separate affiliated large academic hospital. Methods: A descriptive, phenomenological study of interviews was conducted using the method of Giorgi. The sample included 12 participants (n = 9 patients, 3 caregivers) referred to the ED at a large academic hospital (i.e., Toronto General Hospital, TGH) following a same-day outpatient oncology appointment at an affiliated cancer centre (i.e., Princess Margaret Hospital, PMH). Interviews continued until thematic saturation. All transcripts were analyzed by 2 reviewers with bracketing to ensure accuracy. Results: Four themes were identified from analysis: (1) communication; (2) expectations; (3) care and symptom management and (4) potential improvements. Overall patients and caregivers felt communication between PMH and TGH, and from providers could have been better. Many felt there was a break-down in communication as they did not expect to go through the usual ED triage process, which caused additional anxiety and frustration with the wait times. The majority felt their symptoms were managed in a timely manner and reported the staff to be friendly, caring and professional; however, often felt forgotten and anxious due to a lack of “checking-in”. Their experience could have been improved by receiving more information on the process, a more welcoming environment and separate waiting area or private room for those who are immunocompromised. Conclusion: Although referral from an outpatient oncology clinic to the ED of an affiliated hospital is a common process within Canada, this is the first study to explore the patient and caregiver experience. Understanding the patient and caregiver experience is valuable for identifying quality improvement initiatives. Our analysis revealed the patient and caregiver experience could be improved with better communication and expectation setting regarding the ED process before and throughout the visit.

Barriers and facilitators of risk-based health care for adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

Optimal risk-based survivor health care includes surveillance for late effects and education targeted at reducing or preventing risky health behaviors. Understanding the reasons for a lack of risk-based follow-up care is essential. Adult participants from the Childhood Cancer Survivor Study were surveyed about having a cancer-related visit in the past 2years and the likelihood of having a cancer-related visit in the future. Additional factors thought to be related to the primary outcomes were also assessed. Nine hundred seventy-five survivors completed the survey. Twenty-seven percent (95% confidence interval [CI], 24%-30%) had a cancer-related medical visit in the previous 2years, and 41% (95% CI, 38%-44%) planned to have such a visit within the next 2years. The likelihood of having had a cancer-related visit within the last 2years was higher among survivors assigning greater importance to these visits (relative risk [RR], 1.2; 95% CI, 1.1-1.3), perceiving greater susceptibility to health problems (RR, 1.2; 95% CI, 1.1-1.3), having a moderate to life-threatening chronic health problem related to their cancer (RR, 2.1; 95% CI, 1.7-2.7), seeing a primary care provider for a cancer-related problem (RR, 1.3; 95% CI, 1.0-1.6), having a cancer treatment summary (RR, 1.3; 95% CI, 1.0-1.6), and endorsing greater confidence in physicians' abilities to address questions and concerns (RR, 1.2; 95% CI, 1.0-1.3). Educational interventions improving awareness of treatment history and susceptibility to cancer-related late effects and corresponding risk-based care are likely to be beneficial for survivors of childhood cancers.

Adherence to quality breast cancer survivorship care in four Canadian provinces: a CanIMPACT retrospective cohort study

BackgroundIn order to maximize later health, there are established components and guidelines for quality follow-up care of breast cancer survivors. However, adherence to quality follow-up in Canada may not be optimal, and may vary by province. We determined and compared the proportion of patients in each province who received adherent and non-adherent surveillance for recurrence, new cancers and late effects, recommended preventive care, and recommended physician visits for comorbidities.MethodsCohorts consisted of all adult women diagnosed with incident invasive breast cancer between 2007 and 2010/2012 in four Canadian provinces (British Columbia (BC) N = 9338; Manitoba N = 2688; Ontario N = 23,700; Nova Scotia (NS) N = 2735), identified from provincial cancer registries, alive and cancer-free at 30 months post-diagnosis. Their healthcare utilization was determined from one to 5 years post-treatment, using linked administrative databases. Adherence, underuse, and overuse of recommended services were evaluated yearly and compared using descriptive statistics.ResultsIn all provinces and follow-up years, the majority of survivors had more than the recommended number of visits to either an oncologist or primary care physician (range 53.8% NS Year 3; 85.8% Ontario Year 4). The proportion of patients with the guideline-recommended number of oncologist visits varied by province (range 29.8% BC Year 5; 74.8% Ontario Year 5), and the proportion of patients with less than the recommended number of specified breast cancer-related visits with either an oncologist or primary care physician ranged from 32.6% (Ontario Year 2) to 84.4% (NS Year 3). Underuse of surveillance breast imaging was identified in NS and BC. The proportion of patients receiving imaging for metastatic disease (not recommended in the guidelines) in BC, Manitoba, and Ontario (not reported in NS) ranged from 20.3% (BC Year 5) to 53.3% (Ontario Year 2). Compliance with recommended physician visits for patients with several chronic conditions was high in Ontario and NS. Preventive care was less than optimal in all provinces with available data.ConclusionsQuality of breast cancer survivor follow-up care varies among provinces. Results point to exploration of factors affecting differences, province-specific opportunities for care improvement, and the value of administrative datasets for health system assessment.