Cancer Treatment Care Research Articles

Excess Costs and Economic Burden of Obesity-Related Cancers in the United States

BackgroundObesity is a significant risk factor of several cancers that imposes a substantial economic burden on US healthcare that remains to be quantified. We estimated the excess costs and economic burden of obesity-related cancers in the United States. MethodsFrom the Medical Expenditure Panel Survey (2008-2015) data, we identified 19 405 cancer survivors and 175 498 non-cancer individuals. We estimated annual health expenditures using generalized linear regression with log link and gamma distribution by cancer types (stratified by 11 obesity-related cancers and other cancer types), controlling for sociodemographic and clinical characteristics. All cost estimates were adjusted to 2015 USD value. ResultsThe average annual total health expenditures were $21 503 (95% CI, $20 946-$22 061) for those with obesity-related cancer and $13 120 (95% CI, $12 920-$13 319) for those with other cancer types. There was a positive association between body mass index and health expenditures among cancer survivors: for each additional 5-unit increase in body mass index, the average predicted expenditures increase by $1503 among those with obesity-related cancer and by $722 among those with other cancers. With adjustments for sociodemographic and clinical characteristics, the mean incremental expenditures of treating obesity-related cancer were 2.1 times higher than those of other cancers ($4492 vs $2139) and more considerable among the non-elderly cancer population. Obesity-related cancers accounted for nearly 43.5% of total direct cancer care expenditures, estimated at $35.9 billion in 2015. ConclusionThe economic burden of obesity-related cancer in the United States is substantial. Our findings suggest a need for the inclusion of comprehensive obesity prevention and treatment in cancer care.

Effect of fragmentation of cancer care on treatment use and survival in hepatocellular carcinoma.

Fragmented cancer care (FC), or care received from multiple institutions, increases systemic health care costs and potentiates cancer care disparities. There is a paucity of data on mechanisms contributing to FC and the resulting effect on patient outcomes. This study characterized patient- and hospital-level factors associated with FC, time to treatment (TTT), and overall survival (OS) in patients with hepatocellular carcinoma (HCC). Patients newly diagnosed with HCC from 2004 to 2015 and receiving treatment were identified in the Texas Cancer Registry. Patient- and hospital-level factors were compared across 2 cohorts: an FC treatment group and a nonfragmented cancer care (NFC) treatment group. Covariate-adjusted treatment use and OS were compared between the 2 treatment groups. Among 4329 patients with HCC, 1185 (27.4%) received FC, and 3144 (72.6%) received NFC. Compared with NFC patients, FC patients had larger tumors (median size ≥4cm, 52.6% vs 35.2%; P<.001), and a higher proportion had a regional/metastatic stage (35.9% vs 26.7%; P<.001). Among patients with localized disease, FC was associated with decreased odds of curative therapy (odds ratio, 0.83; 95% confidence interval [CI], 0.7-0.9). FC was associated with worse OS (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24) and increased TTT (HR, 0.76; 95% CI, 0.7-0.8). In the subset of patients with localized-stage HCC who received curative therapy, FC was associated with worse OS (median survival, 67 vs 43months; HR, 1.2; 95% CI, 1.0-1.4) and increased TTT (HR, 0.74; 95% CI, 0.7-0.8). FC patients were less likely to undergo curative therapy when they were diagnosed at an early stage. After covariate adjustment, newly diagnosed patients with HCC receiving FC had worse OS and increased TTT.

Precision Medicine in Oncology Pharmacy Practice

The objective of this review is to provide an overview of the components, process and resources available to apply precision medicine strategies to drug therapy in cancer medicine, with an emphasis on oncology pharmacy practice. Precision medicine initiatives in oncology take into account individual variability in genes, environment and lifestyle factors. Genomic assays of patient tumors is now the standard of care in oncology and recommendations for targeted drug therapies are often formulated by interprofessional teams. Pharmacogenomics (PGx) is a component of precision medicine based on polymorphisms that impact medication selection and/or dosing. Several oncolytic agents used in the treatment of cancer and supportive care have pharmacogenomic- based dosing recommendations to minimize potential toxicities. Several resources are reviewed here to guide treatment options in oncology as they relate to somatic mutations and PGx. Examples include: OncoKB is a precision oncology knowledge base that offers evidence-based information for somatic mutations. The Clinical Pharmacogenetics Implementation Consortium provides PGx-based guidelines for several oncolytic therapies used to treat cancer and for supportive care. Pharmacists can be integral members of the interprofessional team in many practice settings in precision medicine. Involvement can include membership in molecular tumor boards, PGx dosing services and provide patient education. CONCLUSION: Precision medicine is a rapidly evolving field in oncology that requires an interprofessional approach of drug therapy experts.

Effects of the Values and Options in Cancer Care Communication Intervention on Personal Caregiver Experiences of Cancer Care and Bereavement Outcomes.

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (-0.19 to 0.63) to 0.39 (-0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.

Development of a psychoeducational intervention for people affected by pancreatic cancer

BackgroundPancreatic cancer has one of the highest mortality rates of any malignancy, placing a substantial burden on patients and families with high unmet informational and supportive care needs. Nevertheless, access to psychosocial and palliative care services for the individuals affected is limited. There is a need for standardized approaches to facilitate adjustment and to improve knowledge about the disease and its anticipated impact. In this intervention-development paper guided by implementation science principles, we report the rationale, methods, and processes employed in developing an interdisciplinary group psychoeducational intervention for people affected by pancreatic cancer. The acceptability and feasibility of implementation will be evaluated as a part of a subsequent feasibility study.MethodsThe Schofield and Chambers framework for designing sustainable self-management interventions in cancer care informed the development of the intervention content and format. The Consolidated Framework for Implementation Research served as an overarching guide of the implementation process, including the development phase and the formative evaluation plan of implementation.ResultsA representative team of stakeholders collaboratively developed and tailored the intervention content and format with attention to the principles of implementation science, including available resourcing. The final intervention prototype was designed as a single group-session led by an interdisciplinary clinical team with expertise in caring for patients with pancreatic cancer and their families and in addressing nutrition guidelines, disease and symptom management, communication with family and health care providers, family impact of cancer, preparing for the future, and palliative and supportive care services.ConclusionsThe present paper describes the development of a group psychoeducational intervention to address the informational and supportive care needs of people affected by pancreatic cancer. Consideration of implementation science during intervention development efforts can optimize uptake and sustainability in the clinical setting. Our approach may be utilized as a framework for the design and implementation of similar initiatives to support people affected by diseases with limited prognoses.

Impact of Natural Disasters on Health Outcomes and Cancer Among Older Adults.

There is growing evidence that older adults exposed to natural disasters are at disproportionate risk for adverse health events such as all-cause mortality, injury, hospital admissions, stroke, displacement, cardiopulmonary distress, stress-related mental health problems, and exacerbation of chronic illnesses. Typically, analyses of the health consequences of natural disasters focus only on the populations impacted for the duration and immediate aftermath of the disaster. With few exceptions, the long-term effects of natural disasters on older adult health have not been examined. This article describes the potential consequences of exposure to natural disasters that contribute to cancer and disruption of cancer care treatment systems for older adults. It is argued that exposures to floods and wildfires in particular present an underestimated threat to the onset and/or progression of cancer and cancer care management in older adults. We propose that these impacts should be examined not only from an emergency preparedness perspective during the event but also from a public health focus that prospectively assesses risks for cancer and other health disparities. Recommendations for comprehensive longitudinal risk assessment and emergency preparedness models that address the full impact of natural disasters on the health and well-being of vulnerable, at risk, older adults are offered.

Blanchard, A. and Strand, R. (eds) Cancer Biomarkers: Ethics, Economics and Society, Kokstad: Megaloceros Press2017. 149pp ISBN 978‐82‐91851‐04‐4

Blanchard, A. and Strand, R. (eds) Cancer Biomarkers: Ethics, Economics and Society, Kokstad: Megaloceros Press2017. 149pp ISBN 978‐82‐91851‐04‐4

Using clinical cancer registry data for estimation of quality indicators: Results from the Norwegian breast cancer registry

IntroductionIncreased focus on quality indicators and the use of clinical registries for breast cancer for real world studies have shown higher compliance to recommended therapy and better survival. In 2010, the European Society of Breast Cancer Specialist (EUSOMA) proposed quality indicators (QI) covering diagnosis, treatment and follow-up. To become a EUSOMA certified Breast Cancer Unit, 14 specified quality indicators, in addition to other requirements, need to be met. To evaluate the compliance and results of recommended treatment in breast cancer care in Norway and to improve the quality of epidemiological data, the Cancer Registry of Norway (CRN) in cooperation with the Norwegian Breast Cancer Group (NBCG) developed the Norwegian Breast Cancer Registry (NBCR).The objective of this study is to assess the feasibility of using the NBCR for estimating the EUSOMA QI individually for all hospitals diagnosing and treating breast cancer in Norway. MethodsTo provide researchers with high quality cancer data as well as for the purpose of national cancer statistics, the CRN employs a cancer registry system to 1) longitudinal capture data from all patients from all medical entities that diagnose and/or treat cancer patients (e.g., pathology, radiology and clinical departments) in Norway; 2) curate data, i.e. validate the correctness of collected data, and assemble the validated cancer data as cancer cases; 3) provide data for analytics and presentation. Estimates for 10 EUSOMA QI were calculated at national and hospital level. To compare hospitals, a summary score of QIs was defined for each hospital. ResultsAll hospitals currently treating breast cancer patients have the technical ability to submit data to the NBCR for estimation of QIs defined by EUSOMA. Data from pathology and surgery are of high quality. However, data from oncological and radiological departments are incomplete, but improving. This currently hinders three QIs from being calculated. QI on benign to malign diagnosis needs to be calculated at the individual Breast Centre. Over time the adherence to guidelines have improved and the hospital variation for the respective QI have decreased. Two hospitals met all minimum standard on ten QIs in year 2016 and one hospital did not meet one minimum standard, but met all other targets. ConclusionThe NBCR has since 2012 published annual reports on breast cancer care and for the year 2016 measured 10 of 14 QI defined by EUSOMA. Increased compliance of recommended treatment in Norway has been observed during the years the registry has been active.

A Community-Partnered, Evidence-Based Approach to Improving Cancer Care Delivery for Low-Income and Minority Patients with Cancer.

Community-engaged adaptations of evidence-based interventions are needed to improve cancer care delivery for low-income and minority populations with cancer. The objective of this study was to adapt an intervention to improve end-of-life cancer care delivery using a community-partnered approach. We used a two-step formative research process to adapt the evidence-based lay health workers educate engage andencourage patients to share (LEAPS) cancer care intervention. The first step involved obtaining a series of adaptations through focus groups with 15 patients, 12 caregivers, and 6 leaders and staff of the Unite Here Health (UHH) payer organization, and 12 primary care and oncology care providers. Focus group discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. The second step involved finalization of adaptations from a community advisory board comprised of 4 patients, 2 caregivers, 4 oncology providers, 2 lay health workers and 4 UHH healthcare payer staff and executive leaders. Using this community-engaged approach, stakeholders identified critical barriers and solutions to intervention delivery which included: (1) expanding the intervention to ensure patient recruitment; (2) including caregivers; (3) regular communication between UHH staff, primary care and oncology providers; and (4) selecting outcomes that reflect patient-reported quality of life. This systematic and community-partnered approach to adapt an end-of-life cancer care intervention strengthened this existing intervention to promote the needs and preferences of patients, caregivers, providers, and healthcare payer leaders. This approach can be used to address cancer care delivery for low-income and minority patients with cancer.

Patients Lost to Follow-Up for Cervical Cancer in the Limbe Regional Hospital.

PURPOSECervical cancer constitutes a public health problem in Cameroon where it represents 13.8% of cancers in women. We wanted to evaluate compliance with cervical cancer care with a focus on patients who are lost to follow-up from the time that symptoms suggestive of cervical cancer are clinically recognized to treatment.PATIENTS AND METHODSSociodemographic data, attitude toward diagnosis and treatment, and reason for discontinuing care were recorded and analyzed for a period of 5 years from January 2010 to December 2015.RESULTSOne hundred twenty-six patients had symptoms suggestive of cervical cancer, but only 110 (87.30%) could pay for biopsy, 29 (26.36%) of those did not collect their results, 17 (18.7%) denied their results, and 20 (19%) did not benefit from treatment. Only 44 of 110 patients were able to finish their cancer care treatment program. Reasons for discontinuing the cancer care included lack of financial means to pay for it, distance from the care center, and belief in alternative treatments.CONCLUSIONThis study highlights the magnitude of the difficulties of accessing and receiving cancer care in semiurban areas in Cameroon. Poverty, belief in alternative treatment options, and unequal distribution of care services determined which patients would be lost to follow-up. Redistribution of resources and cancer care providers is mandatory to improve this situation.

Contrasting evidence to reimbursement reality for off-label use (OLU) of drug treatments in cancer care: rationale and design of the CEIT-OLU project

BackgroundOff-label use (OLU) of a drug reflects a perceived unmet medical need, which is common in oncology. Cancer drugs are often highly expensive and their reimbursement is a challenge for many healthcare systems. OLU is frequently regulated by reimbursement restrictions. For evidence-based healthcare, treatment ought to be reimbursed if there is sufficient clinical evidence for treatment benefit independently of patient factors not related to the treatment indication. However, little is known about the reality of OLU reimbursement and its association with the underlying clinical evidence. Here, we aim to investigate the relationship of reimbursement decisions with the underlying clinical evidence.Methods/ designWe will extract patient characteristics and details on treatment and reimbursement of cancer drugs from over 3000 patients treated in three Swiss hospitals. We will systematically search for clinical trial evidence on benefits associated with OLU in the most common indications. We will describe the prevalence of OLU in Switzerland and its reimbursement in cancer care, and use multivariable logistic regression techniques to investigate the association of approval/rejection of a reimbursement requests to the evidence on treatment effects and to further factors, including type of drug, molecular predictive markers and the health insurer.DiscussionOur study will provide a systematic overview and assessment of OLU and its reimbursement reality in Switzerland. We may provide a better understanding of the access to cancer care that is regulated by health insurers and we hope to identify factors that determine the level of evidence-based cancer care in a highly diverse western healthcare system.

Effect of Aquatic Exercise on Fatigue, Fitness, Arm Edema, Levels of Distress, and Quality of Life among Breast Cancer Survivors

The purpose of this study was to evaluate the effect of a recreational therapy aquatic intervention on physical and psychosocial performance of breast cancer survivors. Eligible participants were assigned to either a water exercise group or a control group who received standard care treatment for breast cancer. The intervention group attended aquatic exercise sessions three times per week for eight weeks in a heated outdoor pool. Sessions lasted 50 minutes in duration. The aquatic exercise group significantly improved their endurance, body mass, level of distress, and total score for fatigue. No significant differences occurred in the control group. Social validity responses found that participants believed the exercise sessions improved physical fitness and that they desired to continue the program. Findings suggested that an aquatic exercise program may improve some physical and psychosocial measures among breast cancer survivors. The relatively small sample and quasi-experimental design limited capability of making greater generalizations.

Cancer Care Treatment Outcome Ontology: A Novel Computable Ontology for Profiling Treatment Outcomes in Patients With Solid Tumors.

There is as yet no computer-processable resource to describe treatment end points in cancer, hindering our ability to systematically capture and share outcomes data to inform better patient care. To address these unmet needs, we have built an ontology, the Cancer Care Treatment Outcome Ontology (CCTOO), to organize high-level concepts of treatment end points with structured knowledge representation to facilitate standardized sharing of real-world data. End points from oncology trials in ClinicalTrials.gov were extracted, queried using the keyword cancer, and followed by an expert appraisal. Synonyms and relevant terms were imported from the National Cancer Institute Thesaurus and Common Terminology Criteria for Adverse Events. Logical relationships among concepts were manually represented by production rules. The applicability of 1,847 rules was tested in an index case. After removing duplicated terms from 54,705 trial entries, an ontology holding 1,133 terms was built. CCTOO organized concepts into four domains (cancer treatment, health services, physical, and psychosocial health-related concepts), 13 subgroups (including efficacy, safety, and quality of life), and two (taxonomic and evaluative) concept hierarchies. This ontology has a comprehensive term coverage in the cancer trial literature: at least one term was mentioned in 98% of MEDLINE abstracts of phase I to III trials, whereas concepts about efficacy were mentioned in 7,208 (79%) phase I, 15,051 (92%) phase II, and 3,884 (86%) phase III trials. The event sequence of the index case was readily convertible to a comprehensive profile incorporating response, treatment toxicity, and survival by applying the set of production rules curated in the CCTOO. CCTOO categorizes high-level treatment end points used in oncology and provides a mechanism for profiling individual patient data by outcomes to facilitate translational analysis.

Using PARP Inhibitors in the Treatment of Patients With Ovarian Cancer.

Use of poly(ADP-ribose) polymerase (PARP) inhibitors has greatly increased over the past 5years. With several new Food and Drug Administration (FDA) approvals, three PARP inhibitors have entered into standard of care treatment for epithelial ovarian cancer (including ovarian, fallopian tube, and primary peritoneal cancer). Olaparib and rucaparib currently have indications for treatment of recurrent BRCA mutant ovarian cancer. Olaparib, rucaparib, and niraparib all have indications for maintenance therapy in recurrent platinum-sensitive ovarian cancer after response to platinum-based therapy. In our practice, we use both olaparib and rucaparib in the recurrent setting, and all three PARP inhibitors in the maintenance setting. Choice of which PARP inhibitor to use in either setting is largely based upon baseline laboratory values, number of prior therapies, and presence of a BRCA mutation and/or homologous recombination deficiency (HRD). As (HRD) and other biomarker assessments continue to improve, we anticipate being able to better identify which patients might most benefit from PARP inhibitor therapy in the future. The clinically available PARP inhibitors are currently undergoing extensive investigations in clinical trials. Other newer agents such as talazoparib, veliparib, 2X-121, and CEP-9722 are in earlier stages of development. As more FDA-approved indications for PARP inhibitor therapy in ovarian cancer become available, we anticipate the decision of which PARP inhibitor to use will become increasingly complex.

Evaluating the Demand for Integrative Medicine Practices in Breast and Gynecological Cancer Patients

Introduction: Integrative medicine is becoming increasingly relevant to modern oncology. The present study aims to assess the demand for integrative therapeutic approaches including complementary and alternative medicine (CAM), body and mind practices, nutritional counseling, and psychological assistance among breast and gynecological cancer patients. Methods: From April to July 2017, a pseudo-anonymous questionnaire was distributed to cancer patients at the Department of Gynecology and Obstetrics, Technical University of Munich. Patterns of CAM use and demand for integrative health approaches were investigated by generating descriptive statistics. Results: 182 (90%) of 203 patients participated in the survey. 59% indicated the use of CAM practices in general, and 41% specifically in relation to their oncological disease. Most frequently used modalities were herbal supplements (32%), homeopathy (29%), vitamins (28%), and selenium (21%). Integrative health approaches that patients would have desired alongside conventional oncological treatment were CAM (54%), relaxation therapies (44%), and dietary counseling (43%). Conclusion: There is a considerable demand for integrative medicine among breast and gynecological cancer patients. Our results underline the need for the implementation of evidence-based integrative treatments in cancer care in order to meet the standards of modern oncology.

Impact of age on receipt of curative treatment for cervical cancer: an analysis of patterns of care and survival in a large, national cohort.

Disparities in the receipt of standard of care based on age have been identified for several types of cancer including cervical cancer. The purpose of this study is to analyze patterns of care and survival for older patients receiving definitive treatment in a large, national cohort. The National Cancer Database was queried for patients with FIGO/AJCC IB2-IVA cervical cancer diagnosed from 2004 to 2014 who underwent definitive radiation or concurrent chemoradiation. Standard of care was defined as concurrent chemotherapy with external beam radiation and brachytherapy to a total dose ≥70 Gy. Multivariable logistic regression was used to determine factors associated with the receipt of standard of care. Multivariable Cox regression was used to determine covariables associated with differences in overall survival. 24,126 patients met inclusion criteria including 4052 women 61-70 years old, 2471 women 71-80 years old, and 1325 women over 80 years old. A smaller percentage of patients over age 60 received standard of care compared to younger aged patients. On multivariable analysis, older patients were less likely to be treated with standard of care. On multivariable Cox regression, ages 71-80 (HR 1.25, 95% CI-1.16-1.36, p < .001) and age > 80 (HR 1.90, 95% CI 1.73-2.07, P < .001) were associated with decreased overall survival. On subgroup analysis for patients with significant comorbidities, treatment with standard of care resulted in increased 5-year OS as compared to incomplete treatment. Age was found to be an independent predictor for the receipt of standard of care treatment for cervical cancer.

Radiation Therapy Dose in Anal Cancer: Patterns of Care and Survival

Definitive chemoradiotherapy represents standard of care treatment for localized squamous cell cancer of the anus. National Comprehensive Cancer Network (NCCN) guidelines recommend a minimum of 45 Gy and escalation to 54-59 Gy for advanced disease. Per the Phase II clinical trial RTOG 0529, 50.4 Gy was prescribed for T2N0 disease, and 54 Gy for T3-T4 and/or node-positive (N+) disease. We sought to compare utilization practice and survival based on radiotherapy (RT) dose. The hypothesis was that dose escalation above 54 Gy was not associated with improved survival. The National Cancer Database (NCDB) was queried to identify patients with non-metastatic squamous cell cancer of the anus from 2004-2013 treated with chemoradiotherapy. Patients were stratified into four groups based on the RT dose received: 40-<45 Gy, 45-<50 Gy, 50-54 Gy and >54-60 Gy. Subgroup analysis was conducted to evaluate survival based on RT dose, as recommended by RTOG 0529, for early (T1-2N0) and locally advanced (T3-T4 and/or N+) disease. The Kaplan-Meier method was used to estimate overall survival (OS) for each group. Hazard ratios (HR) were computed using Cox regression modeling. Of 8,005 patients identified, median age was 58 years and 29.7% were male. For both early and locally advanced disease, the most commonly prescribed RT dose was 54 Gy. After a median follow-up of 40.3 months, 1,949 deaths were reported with a 5-year OS of 73.4%. Five-year OS was 60.3% for the 40-<45 Gy group, compared to 73.1%, 74.9%, and 72.5% for the 45-<50, 50-54 and >54-60 Gy groups, respectively (p<0.0001). On multivariate analysis (MVA) adjusting for age, gender, race, insurance, income, education, Charlson-Deyo score, year of diagnosis, clinical T and N stage, facility characteristics, and tumor grade, RT dose of 40-<45 Gy had significantly worse survival compared to 50-54 Gy (HR 1.81 [95% confidence interval: 1.41-2.34], p<0.0001). Compared to 50-54 Gy, there was no significant difference in survival for patients who received 45-<50 Gy (HR 1.10 [0.93-1.29], p=0.27) or >54-60 Gy (HR 1.03 [0.91-1.15], p=0.67). For early disease, 5-year OS for patients was 81.4%, 81.3%, and 81.7% for patients receiving 45-<50, 50-51, and >51-60 Gy, respectively (p=0.85). MVA showed no significant difference in survival based on dose for these patients. For locally advanced disease, 5-year OS was 64.6%, 68.9%, 65.0% for <54, 54, and >54 Gy groups, respectively (p=0.19). On MVA, 54 Gy was associated with significantly higher survival compared to <54 Gy (HR 1.17 [1.01-1.37], p=0.038] but not >54 Gy (HR 1.12 [0.97-1.29], p=0.12). In this NCDB study, 54 Gy was the most utilized RT dose for anal cancer regardless of T or N stage. RT doses of ≥45 Gy were associated with improved OS overall. For locally advanced disease, 54 Gy but not >54 Gy was associated with improved OS. Thus, doses of 45 Gy and 54 Gy for early and locally advanced disease, respectively, may be adequate without dose-escalation to 59 Gy.

A focus on culturally sensitive communication to transform institutional awareness of health care disparities.

69 Background: Healthcare organizations can cultivate the strength of a diverse workforce in creating a culture of excellence. Enabling the team to understand how personal and cultural beliefs affect our decision making and how we interact with patients and colleagues is integral. Gaps in care exist in cancer diagnoses and treatment in many minority groups. A need for education in the nature of assumptions, unconscious biases, and awareness around the existence of healthcare disparities, was identified through culture transformation work within multiple healthcare institutions. Methods: An experiential course was designed for multi-disciplinary groups of providers. Designed to meet the evolving demographics in the country and help participants recognize how their own cultural beliefs and values affect their decision making. Topics include cultural awareness, assumptions and unconscious bias, effective use of interpreters, and skills to recognize when cultural differences may be playing a role and how to successfully navigate these situations. Raising awareness of healthcare disparities is highlighted, including disparities in cancer care diagnosis, treatment and outcomes for different ethnicities and socioeconomic groups. Examples include disparities in diagnosis, treatment and outcomes of lung cancer, colon cancer and breast cancer in minorities. Results: Participants engage in skills-based work. Participants develop a plan how they can take this information and education back to help create an awareness of disparities and skills to successfully navigate these situations. After this program, participants will be cognizant of the nature of assumptions and unconscious bias and understand the strength of diversity as an asset rather than a hindrance. Conclusions: Healthcare disparities can have a significant impact on patient experience, quality and outcomes. Specific inequities in cancer diagnosis and treatment in minorities is highlighted. Participants are provided with information and skills that can be introduced to their home institutions to have all caregivers recognize and successfully navigate culturally sensitive situations.

Machine learning to support social media empowered patients in cancer care and cancer treatment decisions

BackgroundA primary variant of social media, online support groups (OSG) extend beyond the standard definition to incorporate a dimension of advice, support and guidance for patients. OSG are complementary, yet significant adjunct to patient journeys. Machine learning and natural language processing techniques can be applied to these large volumes of unstructured text discussions accumulated in OSG for intelligent extraction of patient-reported demographics, behaviours, decisions, treatment, side effects and expressions of emotions. New insights from the fusion and synthesis of such diverse patient-reported information, as expressed throughout the patient journey from diagnosis to treatment and recovery, can contribute towards informed decision-making on personalized healthcare delivery and the development of healthcare policy guidelines.Methods and findingsWe have designed and developed an artificial intelligence based analytics framework using machine learning and natural language processing techniques for intelligent analysis and automated aggregation of patient information and interaction trajectories in online support groups. Alongside the social interactions aspect, patient behaviours, decisions, demographics, clinical factors, emotions, as subsequently expressed over time, are extracted and analysed. More specifically, we utilised this platform to investigate the impact of online social influences on the intimate decision scenario of selecting a treatment type, recovery after treatment, side effects and emotions expressed over time, using prostate cancer as a model. Results manifest the three major decision-making behaviours among patients, Paternalistic group, Autonomous group and Shared group. Furthermore, each group demonstrated diverse behaviours in post-decision discussions on clinical outcomes, advice and expressions of emotion during the twelve months following treatment. Over time, the transition of patients from information and emotional support seeking behaviours to providers of information and emotional support to other patients was also observed.ConclusionsFindings from this study are a rigorous indication of the expectations of social media empowered patients, their potential for individualised decision-making, clinical and emotional needs. The increasing popularity of OSG further confirms that it is timely for clinicians to consider patient voices as expressed in OSG. We have successfully demonstrated that the proposed platform can be utilised to investigate, analyse and derive actionable insights from patient-reported information on prostate cancer, in support of patient focused healthcare delivery. The platform can be extended and applied just as effectively to any other medical condition.

Increased Travel Distance Reduces Proportion of Patients Receiving Standard of Care Treatment for Breast Cancer

Increased Travel Distance Reduces Proportion of Patients Receiving Standard of Care Treatment for Breast Cancer