Clinical Oncology Research Articles

Examining the relationships between pain, activities of daily living, and perceptions of overall health in older adults with breast cancer: Results from a brief geriatric screening.

273 Background: Geriatric assessment has been identified as an essential component to caring for patients with cancer who are over 65 years old. Prior research suggests that physical pain and illness perceptions each impact important health behaviors. This retrospective study utilized a brief geriatric screen to examine the relationships between pain levels, activities of daily living (ADLs), and perceptions of overall health for older adults with breast cancer. Implications for methods to improve the patient experience for this population are considered. Methods: The Senior Adult Oncology Program (SAOP) screening tool was administered to 429 patients age 65 or older at a breast oncology clinic. A total ADL score was computed by summing patient-reported responses to 13 ADL items, such as ability to dress oneself, feed oneself, and remember to take medications. A higher ADL score indicates greater difficulty with these responsibilities. Pain was assessed using a 10-point scale; scores were dichotomized to form a low-pain group (scores 0-4) and high-pain group (scores 5-10). Overall Health was assessed on a 1-10 scale, with higher scores indicating perceptions of greater health. Demographic and medical information was abstracted from patients’ electronic health records. Independent samples t-tests examined differences between the high-pain and low-pain groups in total ADL score and self-assessed Overall Health. Results: The average age of the sample was 76 years old (range = 65-89 years). Approximately half of the sample identified as White (48%); 20% identified as Black. In comparing the high-pain and low-pain groups, the high-pain group reported significantly greater difficulty with ADLs (M score = 3.25, 1.41, respectively; p=.026). Additionally, patients endorsing high pain levels reported significantly worse Overall Health as compared to patients endorsing low levels of pain (M= 7.50, 6.11, respectively; p=.001). Conclusions: Older adults with breast cancer experiencing high levels of pain demonstrated greater difficulty with ADLs and worse perceptions of overall health. It is critical that pain is assessed early and often for older adults with breast cancer. Early identification of high pain levels in this population could allow those in need to receive pharmacological and/or behavioral treatments for pain, which may maintain stability or promote improvement in ADLs and perceptions of one’s health. Incorporating brief pain assessments into future geriatric screening tools could improve the process of aging during and after breast cancer.

Impact of a care delivery intervention for patients with socioeconomic disadvantages, in their preferred language of English or Spanish.

97 Background: Sinai Health System’s oncology program serves Chicago’s inner city patients with substantial needs for social and primary care, many of whom prefer communication in Spanish. Sinai has implemented a care delivery intervention to address these needs, using the 4R Oncology Model for patient-facing care planning and patient self-management. 4R (Right Info/Care/Patient/Time) has shown significant improvements in the timeliness of care cancer delivery and referrals to cancer care (1). Herein, we implemented the 4R intervention to improve the timeliness of care delivery and referrals to care, focusing on the social and primary care needs of Sinai patients. Methods: Evaluation was conducted by surveying historical control and intervention (4R) cohorts of patients in their preferred language of Spanish or English. The 4R cohort received care at a Sinai medical oncology clinic Apr 2023 - Jan 2024. Control cohort received care Jan 2023 – March 2023. Analyses were conducted using Fisher’s exact test. Results: Survey response rates: 76% (38/50) in control and 75% (33/44) in 4R cohorts. Participant characteristics were comparable between control and 4R cohorts, respectively: 55%, 58% Hispanic, 42%, 39% Black; 76%, 82% high school education or less; 87%, 97% < 30k income; 50%, 55% preferred language Spanish; 47%, 45% English. For the total cohorts, all 5 metrics improved between control and 4R, and 4 of the 5 metrics improved significantly (Table). Among Spanish-preferred patients, 3 of the 5 metrics improved significantly, while improvements among English-preferred patients were not statistically significant. Both language groups saw numerical, but not statistically significant improvement in receiving referrals to primary care and meeting all their practical and family needs. Conclusions: The 4R Oncology intervention resulted in significant improvement in time to treatment and referrals to social and primary care in our population of socioeconomically disadvantaged patients with high needs for these services. Patients preferring Spanish benefited at a higher rate than English-preferring patients, indicating that 4R may be an effective method to address the needs of this important patient group. Future efforts will further optimize 4R to address remaining gaps for this group, as well as to improve the delivery of this care for the English-preferred patients. 1. Trosman JCO OP 2021. Metric Control Total %N=38 4R Total %N=33 Control Spanish %n=19 4R Spanish %n=18 Control English %n=19 4R English %n=15 Started treatment within 6 weeks of diagnosis 61 88* 53 94* 68 80 Received referral to primary care 66 82* 74 83 58 80 Received referral to support for transportation, food, and other needs 68 85* 63 89* 74 80 Referred to help and resources to help pay for care 50 67* 47 78* 53 53 All of my practical and family needs were addressed 86 89 84 89 87 87 *p<0.1 comparing control and 4R cohorts.

Optimizing access to care for new patients with cancer discharged from an observation unit.

119 Background: Each year, approximately 33,000 new cancer patients seek treatment at our dedicated cancer hospital, with many placed in our observation unit, the Clinical Decision Unit (CDU). These patients often experience significant delays in receiving oncologic care after discharge resulting in distress for both patients and providers. Our goal is to reduce the two-week appointment time from CDU discharge to outpatient oncologic care by more 10% for those eligible to be seen at the hospital. Methods: In fiscal year 2023, we gathered data on patients admitted to and discharged from the CDU, focusing on new patients. A multidisciplinary team developed a fishbone diagram, process flowcharts, and an impact matrix. Interventions included automated referrals, discharge notifications, patient and provider education, discharge booklets, and oncology recommendations for urgent consults. A physician satisfaction survey was conducted pre- and post-intervention. Three months of post-intervention data (February-May 2024) were reviewed, measuring the baseline percentage of patients receiving an appointment within two weeks, one month or more after CDU discharge. Results: In 2023, 90 eligible patients new to the institution were discharged from the CDU. Of those, 3 (3%) had follow-up appointments within 2 weeks, and 39 (43%) had appointments after 30 days or no appointment at all. Post-intervention data showed that out of 15 new patients discharged between February and May 2024, 10 (66%) had follow up appointments within 2 weeks, 4 (27%) within 30 days, while 1 (7%) had not yet received an appointment. Conclusions: Streamlining the referral process through a central service, automating the requests, and educating both providers and patients can reduce the time to establish oncologic care through an observation unit. However, limitations remain for patients with out-of-network insurance or lack of insurance coverage. Further research is necessary to assess whether expediting follow up cancer care for new patients improves clinical outcomes and relieves associated stress as we suspect it does. Time interval for new patients to acquire oncology clinic appointments post discharge. Dates/Time Frame Eligible New Patients with Appointments Within 2 weeks Eligible New Patients with Appointments within 15 to 30 days Eligible New Patients with No Appointment or Appointment > 30 days* Baseline DataFY 2023 3%(3/90) 53%(48/90) 43%(39/90) Post-Intervention:2/6/24 – 5/6/24 66%%(10/15) 27%(4/15) 7%(1/15) *Includes patients without follow up.

Utilization of genomic tumor testing (GTT) among community oncologists participating in SWOG S2108CD.

320 Background: As targeted therapy options increase in oncology, GTT use is also increasing; however, the strategies and barriers to ordering GTT can vary across clinics. S2108CD is a cluster randomized trial comparing an educationally enhanced genomic tumor board intervention to usual practice to increase evidence-based genome-informed therapy based on GTT results. This analysis seeks to understand the utilization of GTT by physicians in rural and community oncology clinics. Methods: Physicians at sites enrolled on S2108CD completed baseline questionnaires collecting demographics, practice characteristics, and physicians’ experience with and use of GTT in practice. We also conducted semi-structured interviews at baseline and mid-study with select physicians in both arms to understand how and when physicians are ordering GTT and how it guides treatment decision making. Descriptive statistics were generated for survey data. Interviews were analyzed using conventional content analysis to identify recurring themes. Results: Surveys were completed by 117 physicians across 18 Recruitment Centers, with 57 from the usual practice and 60 from the intervention arm. Interviews were conducted with 10 physicians at baseline and 10 within 12-18 months of start of the study. Physicians reported feeling confident in determining whether GTT is clinically appropriate for a patient (42% moderately confident, 50% very confident). Some physicians utilize GTT from multiple vendors, with the following vendors used most frequently: Tempus (50% of physicians), Caris Life Sciences (61%), Foundation Medicine (62%) and Guardant Health (69%). Over two-thirds of physicians reported that professional guidelines were “very important” in the decision to utilize GTT. Reasons for not ordering GTT included “not relevant for the patient” (36%) and “difficulty in obtaining sufficient tissue” (20%) as “often” reasons. Notably, lack of access and cost/insurance coverage were “never” or “rarely” a reason for not ordering GTT in 80% physicians. Long waits to receive GTT results reportedly caused a delay in making patient care decisions (47% sometimes and 26% often). Physicians rely on the following sources to learn about new GTT panels: scientific meetings (91%), peer-reviewed literature (92%), and professional societies (90%). Interview data confirmed that physicians are generally confident ordering GTT but there is variability in the processes for ordering GTT and receipt of GTT results amongst clinics. Conclusions: Physicians enrolled on S2108CD self-reported high genomic confidence in ordering GTT. Access to GTT and coverage of GTT do not appear to be barriers to utilization. However, physicians did report delays in decision-making due to result turn-around times, which were sometimes attributed to length of time to tissue sendout and receipt of results into health record. Funding : NIH/NCI/NCORP grant UG1CA189974. Clinical trial information: NCT05455606 .

Association between food insecurity and healthcare utilization among patients at a breast oncology center.

143 Background: A breast cancer (BC) diagnosis often creates or exacerbates financial stress. As a result, many patients with BC struggle with a lack of consistent access to nutritious food due to limited resources, a condition termed “food insecurity” (FI). We investigated the association between FI and healthcare utilization among breast oncology patients at our urban academic medical center. Methods: Screening for health-related social needs (HRSN) was conducted primarily through the electronic patient portal, at appointment registration for a breast oncology clinic visit. The 8-item HRSN survey included 2 questions on access to food resources and 1 question quantifying emergency department (ED) visits over the past year. Any level of food hardship or concern constituted a positive FI screen. We conducted a retrospective analysis among patients evaluated between 11/2/22 and 4/20/24. Clinical and demographic data were obtained from the electronic health record (EHR). We evaluated the association between FI and health care utilization measures (ED visits, inpatient admissions) with a Pearson's Chi-squared test and univariate logistic regression. Results: A total of 2820 patients were screened for HRSN and provided responses to at least 1 FI question, of which 19.7% (555) reported some level of FI. Food-insecure patients self-reported significantly higher rates of ED visits in the past 12 months compared to food-secure patients: 43.2% vs 22.6% reported at least 1 ED visit, respectively (p<0.001), and 25.0% vs 8.45% reported multiple ED visits, respectively (p<0.001). Overall, FI was associated with 2.5 times the odds of self-reporting at least 1 ED visit (univariate OR 2.47, p<0.001). Similarly, on review of EHR data, 33.3% of food-insecure patients had at least 1 ED visit (vs 20.0% of food-secure patients, p<0.001), and 6.13% had 3 or more ED visits (vs 2.83%, p<0.001) during the study period. On univariate analysis, food-insecure patients had double the odds of having at least 1 ED visit documented in the EHR (univariate OR 2.00, p<0.001). We examined reasons for ED presentations among 186 food-insecure patients with ED visits during the study period, and found that 23.8% had at least 1 cancer-related complaint (oncological treatment-related (16.8%) and/or BC symptom-related (8.6%)). The incidence of inpatient admissions during the study period was similar among food-insecure vs food-secure patients (19.8% vs 18.4%, p=0.467). Conclusions: In this analysis of FI and health care delivery measures, ED utilization was significantly higher among food-insecure patients. A quarter of food-insecure patients who presented to the ED had oncological complaints. FI may be a marker of unmet healthcare needs in patient with cancer, and targeted interventions focused on symptom monitoring and management are warranted to optimize healthcare utilization.

Improving advance care planning outcomes through social work and provider collaboration.

55 Background: For many patients living with a life-limiting illness, the ability to have authority in their end-of-life (EOL) decision making is a foundational aspect in achieving a peaceful passing. Literature shows, however, that a low percentage of adults in the United States have completed advance directive documents or had discussions indicating their wishes for EOL care. With their unique communication and advocacy skills, licensed masters-prepared social workers (MSWs) are primed to play an active and effective role in Advance Care Planning (ACP) discussions with patients. The purpose of this study aimed to explore the extent to which MSWs in an oncology setting are harnessing these skills. Methods: An online survey was dispersed to social workers working in outpatient oncology clinics in The US Oncology Network. The survey reviewed the level of education, licensure status, involvement and comfort with ACP discussions, and factors that would aid increased engagement of these conversations. Results: 41 out of 75 social workers completed the survey. 95% of respondents were masters prepared (MSW) and licensed at the masters (27%) or clinical (73%) level. Of these MSWs, 95% are having ACP conversations with their patients and loved ones, and 87% are initiating these discussions independently. Although 64% report that they are getting referrals from physicians in their practice, almost half (49%) indicated they would like more support from physicians around ACP conversations with patients. Per respondent comments, a need was expressed for providers to help initiate and normalize ACP discussions. It was also indicated that MSWs do not believe providers fully understand MSWs ability to engage in these discussions. Interestingly, only 10% of MSWs are billing for ACP discussions, yet 46% indicated they would be interested in doing so. Conclusions: Our results indicate there is a gap between the work MSWs are doing in the ACP space and how providers are utilizing the MSW’s clinical expertise in this area. The use of MSWs in a cancer care setting can enhance patient self-determination and documentation of wishes for EOL, as well as support multidisciplinary care of the patient. Additional benefits could include improvement of ACP quality measures, increased revenue, and provider satisfaction in knowing these sensitive conversations are being addressed by a trusted member of the healthcare team.

Don’t drop the baton: A multidisciplinary and interprofessional approach to improving transfer of accountability and information transfer (TOAI).

3 Background: Cancer care involves complex transitions across facilities, services and providers. Optimal TOAI is critical to ensuring safe transitions in care. In 2018, the Princess Margaret (PM) Cancer Centre, Division of Medical Oncology and Hematology (DMOH), Quality Program conducted a multi-incident analysis to identify trends in patient transfer-related events (TRE). Priority areas for quality improvement included (1) use of standardized verbal communication, (2) timeliness of handover and (3) documentation. The PM TOAI Working Group (WG) was established to tailor, standardize, implement and evaluate optimal TOAI practices across PM, with the objective of eliminating TRE by 2024. Methods: The WG was established with multi-disciplinary and inter-professional representation across PM services, and met monthly. A needs assessment and environmental scan were completed. Change initiatives were prioritized, and WG focused on developing standards of work (SOW), educational approaches, and evaluation. This work coincided with University Health Network (UHN)’s adoption of I-PASS as the institution’s preferred handover tool, and I-PASS was embedded in all standards created. Change initiatives were: (1) An inter-/intra-facility TOAI SOW was developed (2) A nursing workflow mandating verbal/written handover with patient re-assessment within 1hr of transfer was created (3) Physician (MD) safety huddles with a focus on TOAI in acute oncology clinics and inpatient wards were established, and (4) Evening/weekend inpatient MD handovers were restructured and standardized. From Oct 2021 to Dec 2023, the TOAI WG completed eight cycles of PDSA change initiatives. Pre- and post-implementation surveys were conducted to identify and address barriers. Audits were used to evaluate consistency & quality of inpatient handover rounds. Results: PM reported a serious safety event rate per 10 000 adjusted patient days (SSER) of 1.24(2016); this has been reduced to 0.29 (2024). From 2013-2018, TRE occurred at PM with intervals ranging from 1 to 38 days. In the latter half of 2018, since establishing the TOAI WG, there was a gap of 123 days before the most recent event occurred. The current days between events is > 800 as of May 2024. Conclusions: Systematic implementation of TOAI initiatives at PM has improved the safety and effectiveness of patient care transitions through the adoption of tailored, standardized communication tools and targeted education, which has facilitated a sustained culture shift toward TOAI. These initiatives have reduced SSEs and fostered better communication and collaboration amongst healthcare providers. The sustained improvements highlight the significance of broad engagement of front-line staff and continuous evaluation in ensuring safe, high quality healthcare practices.

A multisite initiative to assess the immunization status of medical oncology patients.

289 Background: The Swedish Cancer Institute (SCI) is committed to holistic care and recognizes immunizations are an essential component to quality outcomes. In 2022 the SCI was selected to participate in the Specialty Societies Advancing Adult Immunization (SSAAI) project supported by the Centers for Disease Control and Prevention (CDC) with a goal of incorporating the CDC Standards for Adult Immunization Practice into medical oncology clinical care. The CDC Standards for Adult Immunization Practice are assess, recommend, administer or refer, and document. Recognizing immunization status is not routinely assessed, this quality initiative aimed to increase assessment of immunization status in medical oncology across 7 network clinics on 4 campuses to above 50 % by the end of 2023. Methods: All team members completed the ASCO Quality Training Program. The Plan Do Study Act (PDSA) framework was selected. Assessment was defined as having completed the Immunization Activity Record within the Epic Medical Record system, which includes reconciliation with the Washington state immunization registry. Data was initially abstracted manually to determine the baseline assessment rate until an automated method was developed. A Fishbone diagram determined the top barrier was the lack of awareness about this functionality and lack of training around the task. A workflow diagram and standard operating procedure were implemented. Clinic staff were trained on the new workflow when rooming patients. A small pilot with one clinic of solid tumor medical oncology clinics was completed. Patients included were on active treatment and seen face to face within the clinic. The standardized process and tools were refined, and problem areas addressed. The work was then expanded to all seven of the SCI network medical oncology clinics including hematology as the final PDSA cycle using the same training, process and tools. Results: The Epic Immunization Activity Record completion rate went from less than 1% of solid tumor patients with an active systemic treatment plan to 61% in the pilot project. After two additional PDSA cycles to refine the steps and target problem areas, the rate improved to 67% over a 3-month period. The PDSA cycle was expanded to bring the refined process to all 7 network clinics with a baseline assessment rate of 6% which increased to 45% after interventions within a 3-month period and concluding the 2023 year. Conclusions: Developing tools and implementing a new workflow for immunization assessment yielded a significant improvement in assessment rates thereby setting a foundation of assessment utilizing the CDC Standards for Immunization Practice. The use of concrete written tools improves the sustainability of the changes. Additional tools and refinement of existing tools will be studied to improve the current rate and sustain the gains. Reference: Standards for Adult Immunization Practices | CDC .

Enabling patients with health-related social needs.

183 Background: Addressing health-related social needs (HRSNs) is essential to help ensure patients surviving cancer achieve optimal outcomes. Socioeconomic and environmental insecurities can make it challenging for patients to successfully complete their treatments. The US Oncology Network (The Network), has partnered with Findhelp, a resource facilitation tool enabling anyone with internet access to connect with community-based organizations providing discounted or free social services to meet resource needs. This alliance enables an enhanced level of assistance for patients in need, supporting optimal outcomes for those disadvantaged by various circumstances, such as HRSNs impacted by social drivers of health (SDoH). Methods: Beginning April 25 th , 2024, patients utilizing Navigating Cancer’s patient portal, across 302 community-based oncology clinics serving nearly 500,000 patients annually, could access information through a Findhelp website unique to practices in The Network. The investigators are collecting engagement data based on click rates to the Findhelp website link via the patient portal, the number of unique visitors to The Network’s Findhelp application, and the county, city, and zip code of users accessing the application. Data from the Findhelp website will be assessed to determine which insecurity categories (i.e. food, housing, goods, transit, health, money, care, education, work, legal) and areas across the nationwide network of practices receive the highest engagement, and if there is variability based on subgroup analyses. The subgroup analyses will be performed based on patient demographics and include age, gender, race, and geographic location. Results: Initial retrospective results from this prospective study reveals the average number of searches by patients prior to go-live was 106/day. Post go-live averages have been 4,369/day, a 4,037% uplift in engagement. Top searched needs have been health (26.5%), food (22.3%), and housing (21.1%). Additional data elements are being derived from aggregated, de-identified patient engagement and search activity by geographic location categorized by resource insecurity. Conclusions: Conclusions are being drawn based on outcome measures and cross walking with search and referral activities. The goal of the collaboration is to increase awareness of technologies and local organizations within communities bridging the resource gap by way of facilitating services through the Findhelp platform; ultimately empowering patients to overcome health-related social needs and barriers to care leading to improved access.

Clinical utility and impact of a diagnostic oncology clinic.

74 Background: Oncologists have expertise in the work-up and management of patients with a suspected diagnosis of cancer. Patients diagnosed with cancer during acute care hospitalization often have poorer outcomes than those diagnosed as outpatients. For these patients, time to appropriate cancer diagnosis, management of cancer-related symptoms, and timely initiation of treatment are key to improved outcomes. Outpatient new diagnosis clinics may improve patient outcomes by improving access to subspecialty care. Methods: Patients seen by the inpatient oncology consult service over a two-month period (8/1/23-8/31/23 and 10/1/23-10/31/23) were included in this analysis. Inpatient management of disease was defined as an invasive procedure to treat the disease or a complication of the disease, initiation of systemic anti-neoplastic treatment, or radiation therapy. Surveys regarding perceived barriers to timely outpatient oncology care were distributed to oncology fellows and attendings. A Diagnostic Oncology Clinic (DOC) was started 2/1/2024 with the goal to decrease time to first outpatient oncology by a median of 12 days to less than 10 days, decrease hospital length of stay (LOS), improve outpatient management of cancer related symptoms, and improve time to treatment. Results: A total of 95 patients were evaluated. 74 (78%) of patients had a new diagnosis of cancer. Most patients had gastrointestinal cancer (n = 40, 42%) or thoracic cancer (n = 24, 25%). 51 patients (53.7%) had metastatic disease. 48 patients (50.5%) had an ECOG performance status of 0 or 1 at the time of consultation. The median hospital LOS was 11 days (IQR, 5-19). 13 patients (13.7%) had an inpatient PET scan and 43 patients (45.3%) required inpatient management of their disease or disease-related complication. 57 patients (60%) were discharged home, 21 (22%) to an extended care facility, and 17 (18%) expired or transitioned to hospice. 35 patients (37%) were seen as new outpatients with a median time to visit of 12 days (IQR 7-20). The median time to initiation of anti-neoplastic therapy as an outpatient was 24 days (IQR 18-33). There were 29 survey respondents corresponding to a response rate of 69%. 16 (55%) felt that about half the time or less patients will have timely follow-up with an oncologist after discharge, and 19 (65%) felt half the time or less patients will have appropriate cancer-related symptom management after discharge. Conclusions: Most patients seen by the inpatient oncology consult service with a new diagnosis of cancer have advanced and symptomatic disease. Historically, there has been significant time to outpatient care and cancer-specific management led by an oncologist. Creation of a diagnostic oncology clinic may shift some diagnostic testing and symptom management from the inpatient to outpatient setting, decrease time to first outpatient visit, and improve provider workflow for a vulnerable patient population. Analysis of this intervention is ongoing.

Implementation of Covid-19 assessment in 5 rural oncology clinics and resulting impact on immunization culture.

291 Background: Patients with cancer are at-risk for increased severity of infections due to compromised immunity, potentially leading to poorer patient outcomes. We aimed to increase documentation of Covid-19 assessment from 0% to 60% by implementing a quality improvement intervention impacting each patient encounter, beginning in a pilot rural oncology clinic. Methods: We engaged in a quality improvement initiative to implement, improve, and sustain a new process for COVID-19 assessment. A method to easily document Covid-19 status was needed in the EMR (OncoEMR). A Covid-19 verification, binary (yes-vaccinated/no-not vaccinated) checkbox tool was created and integrated into the patient assessment workflow and OncoEMR. This tool was piloted at one, then four additional rural clinics, but was available across the system. Spontaneous uptake in CARTI’s other nine clinics allowed us to identify early adopters who then became the champions to promote the application throughout the entire CARTI health system. Results: Beginning in May 2023, the pilot clinic assessment results reached 52% (n=25/48) after 4-weeks, and the tool was implemented into four additional rural clinics. An assessment rate of 57% (n=282/496) was achieved after 8 weeks at the other rural clinics and subsequently implemented throughout all CARTI clinics. In March 2024, Covid-19 assessment rates exceeded our initial aim of 60% reaching 88% (n=1692/1918) in the 5 rural clinics and 73% (n=8849/12195) throughout the entire health system. An initiation of immunization culture change was observed as a result of the initiative. Conclusions: Successful implementation of Covid-19 assessment tool was initiated by nursing and physician innovators and amplified by early adopters who propagated a cultural change emphasizing the importance of immunizations as part of cancer patient care. The resulting culture change resonates throughout the CARTI health system with dedication to increasing positive patient outcomes through completion of routine vaccinations for all who are eligible. With the continued support of innovators, CARTI has maintained Covid-19 assessment rates above 50% for the past nine months and plans to implement further immunization standards focusing on Covid-19 and other CDC recommended vaccines including the flu, shingles, pneumococcal and TdaP.

Trace elements and metal nanoparticles: mechanistic approaches to mitigating chemotherapy-induced toxicity-a review of literature evidence.

Anticancer chemotherapy (ACT) remains a cornerstone in cancer treatment, despite significant advances in pharmacology over recent decades. However, its associated side effect toxicity continues to pose a major concern for both oncology clinicians and patients, significantly impacting treatment protocols and patient quality of life. Current clinical strategies to mitigate ACT-induced toxicity have proven largely unsatisfactory, leaving a critical unmet need to block toxicity mechanisms without diminishing ACT's therapeutic efficacy. This review aims to document the molecular mechanisms underlying ACT toxicity and highlight research efforts exploring the protective effects of trace elements (TEs) and their nanoparticles (NPs) against these mechanisms. Our literature review reveals that the primary driver of ACT toxicity is redox imbalance, which triggers oxidative inflammation, apoptosis, endoplasmic reticulum stress, mitochondrial dysfunction, autophagy, and dysregulation of signaling pathways such as PI3K/mTOR/Akt. Studies suggest that TEs, including zinc, selenium, boron, manganese, and molybdenum, and their NPs, can potentially counteract ACT-induced toxicity by inhibiting oxidative stress-mediated pathways, including NF-κB/TLR4/MAPK/NLRP3, STAT-3/NLRP3, Bcl-2/Bid/p53/caspases, and LC3/Beclin-1/CHOP/ATG6, while also upregulating protective signaling pathways like Sirt1/PPAR-γ/PGC-1α/FOXO-3 and Nrf2/HO-1/ARE. However, evidence regarding the roles of lncRNA and the Wnt/β-catenin pathway in ACT toxicity remains inconsistent, and the impact of TEs and NPs on ACT efficacy is not fully understood. Further research is needed to confirm the protective effects of TEs and their NPs against ACT toxicity in cancer patients. In summary, TEs and their NPs present a promising avenue as adjuvant agents for preventing non-target organ toxicity induced by ACT.

Prognostic impact of body mass index on metastatic HER2-positive breast cancer survival

Background. The association between body mass index and prognosis in patients with HER2-positive metastatic breast cancer (mBC) is unclear. Purpose – the first purpose of our study was to determine whether BMI is an independent prognostic factor for progression-free survival (PFS) and overall survival (OS) in HER2-positive mBC patients. The second objective was to assess the mutual impact of baseline clinicopathological characteristics on survival outcomes. Materials and Methods. The study group included patients treated at the Sumy Regional Clinical Oncology Center. We considered the underweight patients if their BMI was <18.5 kg/m2, normal weight 18.5–24.9 kg/m2, overweight 25.0–29.9 kg/m2, and obese ≥ 30 kg/m2. The following formula was used for calculations: weight/height2 (kilograms/meter2). Information about the height, weight, and other clinicopathological characteristics of the patient at the time of the start of drug therapy was taken from the primary medical documentation. Pearson’s test and Chi2 test for categorical variables were used to compare baseline clinicopathological characteristics in groups with normal, overweight, and obesity. The Kaplan-Meier method was used to establish the medians of PFS and OS. Cox regression analysis assessed the mutual impact on the survival of various clinicopathological characteristics. The statistical significance threshold was considered P ≤0.05. Results. Seventy-eight patients with HER2-positive mBC were enrolled and categorized according to their BMI in normal weight, overweight, and obese groups. BMI had a different impact on PFS and OS. Median PFS was 14.9, 11.9, and 14.2 months for normal-weight, overweight, and obese patients, respectively. There is no statistically significant difference in PFS between groups (Р = 0.110). Multivariable regression analysis confirmed no impact of BMI on PFS. Nevertheless, metastases in bones and kidneys and the nuclear grade were statistically significant determinants of PFS. Median OS was 26.4, 28.8, and 37.9 months for normal-weight, overweight, and obese patients, respectively. BMI, kidney metastases, and nuclear grade were prognostically significant determinants of OS. Conclusions. BMI is an independent prognostic factor of OS in patients with HER2-positive mBC. Obesity is associated with better OS but does not impact PFS. Metastases in bones and kidneys and the nuclear grade can predict survival outcomes.

Effect of Smart Pill Box on Improving Adherence to 6-Mercaptopurine Maintenance Therapy in Pediatric ALL

Abstract Introduction 6-Mercaptopurine (6-MP) forms the backbone of maintenance chemotherapy for acute lymphoblastic leukemia (ALL). A Children's Oncology Group study found 3.9-fold increased risk of relapse in children with 6-MP adherence less than 90%. Objective This article estimates the impact of smart pill box in improving adherence to 6-MP during maintenance phase chemotherapy in children with ALL. Material and Methods It is a prospective interventional study done at pediatric oncology clinic of a tertiary care hospital. Participants being 40 newly diagnosed children with ALL. Baseline adherence was assessed and impact of smart pill box was estimated after using it for 60 days. Subjective and objective assessment of baseline adherence and adherence after intervention was done by subjecting the parents of the children to Morisky Medication Adherence Score 8 (MMAS-8) and measurement of patient's red blood cells (RBC) 6-MP metabolites (6-thioguanine [TGN] and 6-methylmercaptopurine [MMP]) levels, respectively, pre- and postintervention. Results The mean age was 7.39 ± 4.29 years. NUDT15*3 polymorphism was present in 10.26%, and none had TPMT polymorphism. Baseline assessment of adherence to 6-MP by MMAS-8 revealed low, medium, and high adherence in 7.5, 35, and 57.5%, respectively. Baseline 6-TGN and 6-MMP levels by cluster analysis revealed poor adherence in 10%. Following intervention, mean MMAS-8 improved from 7.34 ± 0.78 to 7.66 ± 0.55 (p-value < 0.015) and the median 6-TGN level improved from 150 to 253 pmol/8 × 108 RBCs (p-value < 0.001). Conclusion Nonadherence to 6-MP is widely prevalent in Indian children. Simple measures like smart pill box can improve adherence.

Development and Psychometric Evaluation of the Symptom Assessment Scale for Turkish Children with Cancer

Objective: The present study was conducted to developed the Symptom Assessment Scale for Children with Cancer (SAS-CC) and assessed its reliability and validity for Turkish children. Methods: This research was conducted among in 497 children with cancer who were between 7 and 18 years old. The data were collected with a demographic form and SAS-CC. Descriptive statistics, reliability and validity analysis were used to analyze the data. Results: The mean age of children with cancer was 12.02 +3.38 years. The scale consists of 16 items and 3 sub-dimensions. Total factor loads were more than 0.30 in factor analyses. The confirmatory factor analysis revealed all fit indexes as higher than 0.91, and the root mean square error of approximation (RMSEA) was less than 0.080. Cronbach’s alpha values of total was 0.96. According to the split-half analysis, α values of the first and second halves were 0.94 and 0.93, respectively. Conclusions: This study demonstrated that SAS-CC is the first study to develop and test and a valid scale to evaluate symptoms in children with cancer. Effective strategies of coping with symptoms in children with cancer are required to improve prognosis, increase survival, and improve the quality of life. Therefore, assessing symptoms and their frequency in children with cancer is an majority initiative of nurses working in the pediatric oncology clinic.

Leveraging State-of-the-Art AI Algorithms in Personalized Oncology: From Transcriptomics to Treatment

Background: Continuous breakthroughs in computational algorithms have positioned AI-based models as some of the most sophisticated technologies in the healthcare system. AI shows dynamic contributions in advancing various medical fields involving data interpretation and monitoring, imaging screening and diagnosis, and treatment response and survival prediction. Despite advances in clinical oncology, more effort must be employed to tailor therapeutic plans based on each patient’s unique transcriptomic profile within the precision/personalized oncology frame. Furthermore, the standard analysis method is not compatible with the comprehensive deciphering of significant data streams, thus precluding the prediction of accurate treatment options. Methodology: We proposed a novel approach that includes obtaining different tumour tissues and preparing RNA samples for comprehensive transcriptomic interpretation using specifically trained, programmed, and optimized AI-based models for extracting large data volumes, refining, and analyzing them. Next, the transcriptomic results will be scanned against an expansive drug library to predict the response of each target to the tested drugs. The obtained target-drug combination/s will be then validated using in vitro and in vivo experimental models. Finally, the best treatment combination option/s will be introduced to the patient. We also provided a comprehensive review discussing AI models’ recent innovations and implementations to aid in molecular diagnosis and treatment planning. Results: The expected transcriptomic analysis generated by the AI-based algorithms will provide an inclusive genomic profile for each patient, containing statistical and bioinformatics analyses, identification of the dysregulated pathways, detection of the targeted genes, and recognition of molecular biomarkers. Subjecting these results to the prediction and pairing AI-based processes will result in statistical graphs presenting each target’s likely response rate to various treatment options. Different in vitro and in vivo investigations will further validate the selection of the target drug/s pairs. Conclusions: Leveraging AI models will provide more rigorous manipulation of large-scale datasets on specific cancer care paths. Such a strategy would shape treatment according to each patient’s demand, thus fortifying the avenue of personalized/precision medicine. Undoubtedly, this will assist in improving the oncology domain and alleviate the burden of clinicians in the coming decade.

Systemic Therapy of Gastric Cancer—State of the Art and Future Perspectives

Background: The prognosis of patients diagnosed with locally advanced and metastatic gastric and esophago-gastric junction cancer is critical. The optimal choice of systemic therapy is essential to optimize survival outcomes. Methods: A comprehensive literature review via PubMed and analysis of major oncology congresses (European Society for Medical Oncology and American Society of Clinical Oncology websites) were conducted to ascertain the current status and latest developments in the systemic treatment of patients with localized or advanced gastric and esophago-gastric junction adenocarcinoma. Results: While neoadjuvant and perioperative chemotherapy for localized tumor stages is the preferred approach in the Western Hemisphere, adjuvant chemotherapy remains the preferred course of action in East Asia. The administration of chemotherapy, typically in the form of combinations comprising platinum and fluoropyrimidine compounds in combination with docetaxel, represents a standard of care. Investigations are underway into the potential of immunotherapy and other biologically targeted agents in the perioperative setting. To select the most appropriate therapy for advanced gastric cancer, including adenocarcinoma of the esophago-gastric junction, it is essential to determine biomarkers such as HER2 expression, PD-L1 combined positive score (CPS) (combined positive score), Claudin 18.2, and microsatellite instability (MSI). In the present clinical context, the standard first-line therapy is a combination of fluoropyrimidine and a platinum derivative. The selection of chemotherapy in combination with antibodies is contingent upon the specific biomarker under consideration. Conclusions: This article reviews the current state of the art based on recent clinical trial results and provides an outlook on the future of systemic therapy.

Implementing a Pilot Geriatric Oncology Service at a National Cancer Centre in Dublin

Abstract Background The American Society of Clinical Oncology and International Society of Geriatric Oncology recommend comprehensive geriatric assessment (CGA) for older adults commencing systemic anti-cancer treatments (SACTs) (1, 2). Routine CGA is lacking in cancer centres nationally. Methods A pilot, interdisciplinary geriatric-oncology (GO) clinic comprising a geriatric medicine consultant and specialist registrar, medical oncology fellow, physiotherapist and occupational therapist was established Dec 2023. New oncology patient referrals were screened applying the G8 tool; a score of ≤14 triggering referral. Polypharmacy was defined as ≥5 regular medications. Frailty was assessed using Clinical Frailty Scale (CFS) and cognition using Montreal Cognitive Assessment (MoCA). Results To date, 30 patients have attended the clinic; mean age 77.2 (SD5) years (range 68-85); 73% female, 50% with a CFS score of ≥4. Sixty-percent (n=18) were due to commence chemotherapy, the remainder hormonal or targeted treatment. Polypharmacy was identified in 66.6% (n=20), with 13.3% (n=4) having an anti-cholinergic burden score of ≥3, MoCAs were completed in 60% (n=18), of whom 77.8% (n=14) had an abnormal result (<26/30 MoCA or <18/22 MoCA blind). Twenty-six percent (n=8) reported ≥1 fall in the preceding six-months. Deprescribing interventions were completed in 40% (n=12); 58.3% (n=7) had ≥2 medications stopped. Medications most commonly deprescribed included opioids (n=2), antihypertensives (n=2), statins (n=2). Ambulatory blood pressure monitors were arranged for 33.3% (n=10) and DEXAs for 40% (n=12) and appropriately actioned. Follow up was arranged in the Falls and Syncope Unit for 7%, day hospital 10%, geriatric outpatients 10%, group psycho-oncology sessions 20%, specialist cancer rehabilitation physiotherapy service 17%. Parkinsons disease and dementia were diagnosed in 1 and 1 patients, respectively. Each patient had a detailed assessment and plan forwarded to their treating oncologist. Conclusion The development of a dedicated GO service is in line with international standards. By undergoing CGA, geriatric syndromes amenable to intervention were identified in patients.

Mindfulness to enhance quality of life and support advance care planning: a pilot randomized controlled trial for adults with advanced cancer and their family caregivers

BackgroundPatients with advanced cancer and family caregivers often use avoidant coping strategies, such as delaying advance care planning discussions, which contribute to deterioration in their quality of life. Mindfulness-based interventions have shown promise in improving quality of life in this population but have rarely been applied to advance care planning. This pilot trial examined the preliminary efficacy of a group-based Mindfulness to Enhance Quality of Life and Support Advance Care Planning (MEANING) intervention for patient-caregiver dyads coping with advanced cancer. Primary outcomes were patient and caregiver quality of life or well-being, and secondary outcomes included patient advanced care planning engagement (self-efficacy and readiness) and other psychological and symptom outcomes.MethodsIn this pilot trial, dyads coping with advanced cancer were recruited from five oncology clinics in the midwestern U.S. and randomized to six weekly group sessions of a mindfulness intervention (n = 33 dyads) or usual care (n = 22 dyads). Outcomes were assessed via surveys at baseline, post-intervention, and 1 month post-intervention. All available data were included in the multilevel models assessing intervention efficacy.ResultsPatients in the MEANING condition experienced significant increases in existential well-being and self-efficacy for advance care planning across follow-ups, whereas usual care patients did not. Other group differences in outcomes were not statistically significant. These outcomes included other facets of patient well-being, caregiver quality of life, patient readiness for advance care planning, caregiver burden, and patient and caregiver depressive symptoms, anxiety, sleep disturbance, cognitive avoidance, and peaceful acceptance of cancer. However, only MEANING patients showed moderate increases in psychological well-being across follow-ups, and MEANING caregivers showed moderate increases in quality of life at 1-month follow-up. Certain psychological outcomes, such as caregiver burden at 1-month follow-up, also showed moderate improvement in the MEANING condition. Patients in both conditions reported small to moderate increases in readiness to engage in advance care planning.ConclusionsA mindfulness-based intervention showed promise in improving quality-of-life and advance care planning outcomes in patients and caregivers coping with advanced cancer and warrants further testing.Trial RegistrationClinicalTrials.gov NCT03257007. Registered 22 August 2017, https://clinicaltrials.gov/ct2/show/NCT03257007.

Efficacy and safety of dexamethasone sparing for the prevention of nausea and vomiting associated with highly emetogenic risk antineoplastic agents: a systematic review and meta-analysis of the Clinical Practice Guidelines for Antiemesis 2023 from the Japan Society of Clinical Oncology.

Chemotherapy-induced nausea and vomiting (CINV) are common side effects, classified according to timing and severity. Conventional agents such as dexamethasone are effective but have various side effects. For moderately emetogenic chemotherapy, dexamethasone-sparing antiemetic therapies have been developed to minimize these side effects. This systematic review evaluated the efficacy and safety of dexamethasone-sparing antiemetic therapy for highly emetogenic chemotherapy (HEC). We performed a thorough literature search for studies related to dexamethasone-sparing antiemetic therapy with neurokinin-1 antagonists (NK1RA) for HEC using the PubMed, Cochrane Library, and Ichushi-Web databases. A qualitative analysis of the combined data was performed and risk differences with confidence intervals were calculated. Two reviewers independently assessed the 425 records and 12 full-text articles were evaluated for eligibility. Two studies were included in the qualitative and meta-analyses. These studies included anthracycline-cyclophosphamide (AC) regimens and cisplatin-based regimens, with palonosetron as the serotonin receptor antagonist. In the two studies, no difference was found in the prevention of vomiting (delayed complete response). However, non-inferiority was not demonstrated in the subgroup that received cisplatin-containing regimens. Delayed complete control showed different results for nausea prevention; however, there was no significant difference in the meta-analysis. Only one report has shown non-inferiority for delayed total control. Although the strength of evidence for individual outcomes varied, there was no difference in the duration of dexamethasone administration. This systematic review and meta-analysis revealed that dexamethasone-sparing antiemetic therapy with NK1RA and palonosetron can be used to prevent CINV in HEC, limited to AC combination therapy.