Cancer Institute Community Research Articles

Defining the Role of the Advanced Practice Provider Within the National Cancer Institute Community Oncology Research Program.

Oncology advanced practice providers (APPs), including nurse practitioners, clinical nurse specialists, physician assistants, and clinical pharmacists, contribute significantly to quality cancer care. Understanding the research-related roles of APPs in the National Cancer Institute's (NCI) Community Oncology Research Program (NCORP) could lead to enhanced protocol development, trial conduct, and accrual. The 2022 NCORP Landscape Assessment Survey asked two questions about the utilization and roles of APPs in the NCORP. A total of 271 practice groups completed the 2022 survey, with a response rate of 90%. Of the 259 nonpediatric exclusive practice groups analyzed in this study, 92% used APPs for clinical care activities and 73% used APPs for research activities. APPs most often provided clinical care for patients enrolled in trials (97%), followed by assistance with coordination (65%), presenting/explaining clinical trials (59%), screening patients (49%), ordering investigational drugs (37%), and consenting participants (24%). Some groups reported APPs as an enrolling investigator (18%) and/or participating in institutional oversight/selection of trials (15%). Only 5% of NCORP sites reported APPs as a site primary investigator for trials, and very few (3%) reported APPs participating in protocol development. Practice groups report involving APPs in clinical research within the NCORP network; however, opportunities for growth exists. As team-based care has enhanced clinical practice in oncology, this same approach can be used to enhance successful research. Suggested strategies include supporting APP research-related time, recognition, and education. The findings of this survey and subsequent recommendations may be applied to all adult oncology practices that participate in clinical research.

Research-practice partnership: supporting rural cancer survivors in Montana.

The objective of this Research-Practice Partnership was to disseminate and implement strategies to assist Community Health Centers in improving the care of rural cancer survivors in Montana. Funded by the National Cancer Institute's Community Outreach and Engagement mechanism, this project utilized the MAP-IT (Mobilize, Assess, Plan, Implement, Track) program planning framework from Healthy People 2020. Partners included Montana's Department of Public Health and Human Services' Cancer Control Program, Montana Primary Care Association, One Health Community Health Center, and Huntsman Cancer Institute at the University of Utah. Project activities focused on (1) Planning, creating, implementing, and evaluating provider/care team education sessions through the Project ECHO tele-mentoring platform and through short webinars and (2) Building processes for identifying, documenting, and connecting with survivors using electronic health records (EHRs) and other resources. Lessons learned from this project include the value of aligning partner goals from the outset to foster sustained commitment, the importance of adapting implementation plans to address challenges and leverage opportunities, and the need for accurate EHR data and formal processes for identifying and engaging with cancer survivors.

Promoting adherence to germline genetic testing for pancreatic cancer.

e18737 Background: Updated NCCN guidelines support universal germline genetic testing (GGT) for pancreatic ductal adenocarcinoma (PDAC), and literature recommends ordering GGT for PDAC at or near first oncology consult (Chittenden et al., 2021). However, recent studies demonstrate that adherence to updated GGT guidelines for PDAC is poor, and testing rates remain suboptimal (Klatte et al., 2023). A three-month pre-intervention audit (4/2022-6/2022) revealed that less than half of patients diagnosed with PDAC at our community cancer facility underwent GGT in alignment with NCCN guidelines, and only 33% had GGT ordered at the first oncology visit and before treatment. Automated workflows can increase GGT rates for PDAC, but community hospitals may lack infrastructure to support this type of model. Oncology Nurse Navigators (ONN) represent a practical tool for fostering guideline-concordant care for cancer patients treated in the community. The present study explored whether the use of a prompt (or alert message) facilitated by the ONN could change compliance with current recommendations for GGT at a community cancer institute. Methods: We conducted a series of four specific strategies, over a three-month period (7/2022-9/2022). 1. Targeted education was provided to oncologists about NCCN updates. 2. ONN identified newly diagnosed PDAC patients. 3. ONN implemented a prompting process (sending a message to patient’s oncologist within one week of identification of PDAC diagnosis) to review/remind about GGT. 4. Chart review was performed at designated intervals to monitor GGT ordering. The health system’s ONN tracking tool was used to gather, monitor data. Analysis was performed with SPSS software. Results: Nine PDAC patients were identified that met inclusion criteria. Following the ONN prompting intervention there was a 56% increase in PDAC patients who had testing ordered as recommended by NCCN guidelines, a 103% increase in PDAC patients who had GGT ordered at first consult and before treatment initiation. While differences between pre and post intervention were not statistically significant (Fishers Exact Test), the prompting process stimulated valuable discussion between Medical Oncologists (MO) and the ONN, possibly shaping ordering decisions. This included two MOs who switched to ordering GGT at first consult and one MO who had not been planning to order GGT and did so following the prompt. Conclusions: An ONN facilitated prompt offers a simple yet effective means for promoting adherence to GGT guidelines for PDAC in the community setting. ONNs can play a key role in identification of patients and communication and collaboration with MOs before the first oncology consult. The prompting process opens conversation and provides opportunities to clarify, educate about NCCN guidelines in the community setting.

Oncologists’ perceived confidence and attitudes toward managing pre-existing chronic comorbidities during patients’ active cancer treatment

PurposeTo examine practicing oncologists’ perceived confidence and attitudes toward management of pre-existing chronic conditions(PECC) during active cancer treatment(ACT). MethodsIn December 2018, oncologists in the National Cancer Institute's Community Oncology Research Program (NCORP) were invited to complete a was pilot-tested, IRB-approved online survey about their perceived confidence in managing PECC. Pearson chi-square test was used to identify oncologists’ differences in perceived confidence to manage PECC and attitudes toward co-management of patients’ PECC with non-oncologic care providers. Perceived confidence and attitudes were analyzed as a function of medical specialty while controlling demographic and medical practice variables. ResultsA total of 391 oncologists responded to the survey, 45.8% stated medical oncology as their primary specialty, 15.1% hematology oncology, 15.1% radiation oncology, 6.9% surgical oncology, and 17.1% other specialties such as gynecology oncology. Overall, 68.3% agreed (agree/strongly agree) that they were confident to manage PECC in the context of standard of care. However, only 46.6% and 19.7% remained confident when managing PECC previously managed by a primary care physician (PCP) and by a non-oncology subspecialist, respectively. Most oncologists (58.3%) agreed that patients’ overall care was well coordinated, and 63.7% agreed that patients had optimal cancer and non-cancer care when PECC was co-managed with a non-oncology care provider. ConclusionMost oncologists felt confident to manage all PECC during patients’ ACT, but their perceived confidence decreased for PECC previously managed by PCPs or by non-oncology subspecialists. Additionally, they had positive attitudes toward co-management of PECC with non-oncologic care providers. These results indicate opportunities for greater collaboration between oncologists and non-oncology care providers to ensure comprehensive and coordinated care for cancer patients with PECC.

Avoiding Daratumumab Interference with Blood Typing

Background Daratumumab is an IgG monoclonal antibody that binds CD38 on hematopoietic cells and induces apoptosis. It is FDA approved for upfront treatment of systemic light chain amyloidosis as well as treatment of frontline and relapsed/refractory multiple myeloma. Daratumumab, similar to other CD38 monoclonal antibodies, interferes with blood compatibility testing by causing panagglunination on the Indirect Antiglobulin Test (IAT) leading to false positive results and delays in blood availability for transfusion. This panagglutination can persist up to 6 months after the last Daratumumab infusion. Additionally, attempts to overcome this may mask the presence of a clinically significant antibody resulting in acute or delayed hemolytic transfusion reactions. Several laboratory techniques like RBC genotyping, phenotyping, and the use of Dithiothretol (DTT) treatment of serum are used to overcome this laboratory abnormality. These are either technically time consuming or not widely available in all healthcare institutions. DTT, though readily available, requires prior notification of the blood bank when a patient who is being treated with Daratumumab needs a transfusion. This labor intensive and time consuming process may result in delays in patient care adverse outcomes. By far, the most cost effective way is to obtain blood type and antibody screen (IAT) prior to the initial Daratumumab administration. However, this requires institutional strategy (policy, procedure and pathway) for all potential patients starting anti CD38 monoclonal antibodies in general and daratumumab in particular, to allow timely typing and screening of blood in preparation for future transfusion needs. This quality improvement project was instituted to obtain a type and screen (T&S) prior to patients starting Daratumumab in order to champion high value healthcare which balances clinical benefit with costs and harms with the ultimate goal of improving patient outcomes. Methods and Results We retrospectively identified 32 patients who received their first Daratumumab infusion or subcutaneous injection from 11/1/2017 to 5/31/2020 at Community Medical Centers and Community Cancer Institute in Clovis, California and Fresno, California. 13 patients did not have a T&S done within 30 days prior to initiation of Daratumumab, which translates to 40.6%. We conducted manual chart of all patients prior to the intervention and found 6 patients without prior T&S who required transfusions after starting Daratumumab. Each transfusion was regarded as an event regardless of the units of blood received. We calculated the time from T&S order to receipt of transfusion. In total, there were 15 events which amounts to 1,5990 cumulative minute, with the average time to transfusion (TTT) being 1066 minutes. There were also 6 patients with T&S performed prior to Daratumumab initiation who had a total of 22 transfusion events that took 20417 minutes. The average TTT for this group is 928 minutes. The difference in average TTT between patients who had T&S and those that did not have T&S is 138 minutes, which can be clinically significant. We implemented a T&S as part of "Day 0" in our chemotherapy orders in December 2020. 17 patients received their first Daratumumab from January 2021 to January 2022. 15 patients (88%) had T&S performed and 2 patients did not as they were patients from out of network providers. Conclusion We are continuing to gather additional data to see if this improvement results in a decrease in average TTT post implementation. This is quality improvement project represents a major step in reducing delays in blood compatibility testing due to Daratumumab. There are no significant changes in resource utilization since patients who need transfusions will require a T&S to be done regardless. Ensuring that a T&S is performed antecedent to the first Daratumumab treatment will reduce delays in obtaining matched blood products for our myeloma patients. This supports timely transfusions to lower adverse outcomes associated with anemia due to chemotherapy and multiple myeloma.

The Implementation of a Palliative Care Intervention During Induction Chemotherapy for Patients with Acute Myeloid Leukemia (AML) at a Community Cancer Institute

The Implementation of a Palliative Care Intervention During Induction Chemotherapy for Patients with Acute Myeloid Leukemia (AML) at a Community Cancer Institute

Facilitators and barriers to clinical practice guideline-consistent supportive care at pediatric oncology institutions: a Children\u2019s Oncology Group study

BackgroundClinical practice guideline (CPG)-consistent care improves patient outcomes, but CPG implementation is poor. Little is known about CPG implementation in pediatric oncology. This study aimed to understand supportive care CPG implementation facilitators and barriers at pediatric oncology National Cancer Institute (NCI) Community Oncology Research Program (NCORP) institutions.MethodsHealthcare professionals at 26 pediatric, Children's Oncology Group-member, NCORP institutions were invited to participate in face-to-face focus groups. Serial focus groups were held until saturation of ideas was reached. Supportive care CPG implementation facilitators and barriers were solicited using nominal group technique (NGT), and implementation of specific supportive care CPG recommendations was discussed. Notes from each focus group were analyzed using a directed content analysis. The top five themes arising from an analysis of NGT items were identified, first from each focus group and then across all focus groups.ResultsSaturation of ideas was reached after seven focus groups involving 35 participants from 18 institutions. The top five facilitators of CPG implementation identified across all focus groups were organizational factors including charging teams with CPG implementation, individual factors including willingness to standardize care, user needs and values including mentorship, system factors including implementation structure, and implementation strategies including a basis in science. The top five barriers of CPG implementation identified were organizational factors including tolerance for inconsistencies, individual factors including lack of trust, system factors including administrative hurdles, user needs and values including lack of inclusivity, and professional including knowledge gaps.ConclusionsHealthcare professionals at pediatric NCORP institutions believe that organizational factors are the most important determinants of supportive care CPG implementation. They believe that CPG-consistent supportive care is most likely to be delivered in organizations that prioritize evidence-based care, provide structure and resources to implement CPGs, and eliminate implementation barriers.Trial registrationClinicalTrials.gov Identifier: NCT02847130. Date of registration: July 28, 2016.

Selected Articles from This Issue

While many cancer risk prediction models have been developed, very few have been externally validated, and almost none are used routinely in clinical practice beyond identification of family risk. To address the gap in translation to practice, Rosner and colleagues simplified a summary of breast cancer risk factors, added mammographic breast density, and a 77 SNP polygenic risk score to predict 10-year risk of breast cancer. This simplified model performed well in external validation in the Mayo Mammography Health Study (AUC=0.687). Adding simplified questionnaire data and polygenic risk each improved performance over mammographic breast density and age. This approach can be easily implemented in routine mammography screening clinics.Identification and management of cancer patients' financial concerns is essential as cancer care costs rise. McLouth and colleagues aimed to describe the prevalence of financial screening, sources of financial navigation services, and availability of cancer-specific financial navigators within the National Cancer Institute's Community Oncology Research Program (NCORP). Most NCORP community oncology practice group. had a financial screening process. Practice groups reported multiple potential sources of financial navigation services, but cancer-specific financial navigators were available at only half of the practice groups. Critically, fewer NCORP practice groups serving a higher proportion of racial and ethnic minority patients screened for financial concerns and had a designated financial navigator for cancer patients. Results highlight several opportunities to improve identification of cancer patients who may be vulnerable to financial hardship and to increase services to address financial hardship in community cancer care.Observational studies suggest that men engaged in high levels of physical activity have lower risk of clinically significant prostate cancer. To investigate potential mechanisms, Pernar and colleagues evaluated molecular differences in prostate tissue in men with prostate cancer according to physical activity level. The authors identified several biological pathways that were altered between men with different levels of vigorous physical activity in adjacent normal prostate tissue, such as cancer- and immune-related pathways. These results help illuminate how physical activity may influence the prostate tissue in men with prostate cancer.Inflammation and insulin resistance/hyperinsulinemia are important pathways in hepatocarcinogenesis. Diet and lifestyle behaviors modulate inflammation and insulin response and may thus be crucial modifiable factors in primary prevention for hepatocellular carcinoma (HCC). In a cohort study that followed 119,316 US adults for 25.6 years, participants who consumed diet or had lifestyle behaviors with higher inflammatory and insulinemic potential had higher of developing HCC. These findings by Yang and colleagues suggest that inflammation and insulin resistance/hyperinsulinemia may partly underline the influence of diet and other lifestyle on HCC development, and interventions to reduce the adverse effect of pro-inflammatory and hyper-insulinemic lifestyle may reduce HCC risk.

Implementation of the Institute of Medicine treatment plan in oncology practice.

e19233 Background: Participation in the Center for Medicare and Medicaid Services (CMS) value-based payment reform, The Oncology Care Model, requires that every beneficiary has a documented 13-point Institute of Medicine (IOM) treatment plan (TP) when commencing antineoplastic therapy. The intent of this document is to enhance shared decision making between the patient and care team by providing transparent treatment recommendations and engaging patients and caregivers in meaningful discussion. There is limited discussion in the literature on how to adapt the CMS recommendations to diverse practice settings while maintaining fidelity to the intent of the TP. Methods: We compare how three clinically and geographically unique OCM participating institutions implemented the TP in their respective institutions within the domains of the Consolidated Framework for Implementation Research (CFIR). Settings include a community cancer institute in the northeast, an academic hospital setting in the southeast, and a large community cancer network in the southern United States. Results: We identified similar themes in implementation including engaging stakeholders, leveraging information technology, structuring the TP, development of clinic processes and considering scalability. We also describe adaptations unique to the culture and setting of each site. Conclusions: Although studies have shown patients do not feel informed of their diagnosis, there are currently many approaches to improving shared decision making including utilizing the 13 points of the IOM TP as mandated by the OCM. We provide practical strategies for incorporation of the TP into clinical care with lessons from diverse settings. As shown by the wide variability in implementing shared decision making, further research is needed to optimize illness understanding. Additionally, optimal implementation of CMS’s IOM TP would ideally include concrete metrics measuring impact on shared decision making, illness understanding, or patient satisfaction.

Anticancer Therapy at the End of Life: Lessons From a Community Cancer Institute.

Studies have shown aggressive cancer care at the end of life is associated with decreased quality of life, decreased median survival, and increased cost of care. This study describes the patients most likely to receive systemic anticancer therapy at the end of life in a community cancer institute. We performed a retrospective cohort study of 201 patients who received systemic anticancer therapy in our institution and died between July 2016 and April 2017. Data collected included primary malignancy, hospice enrollment, healthcare utilization, Oncology Care Model (OCM) enrollment, and clinical assessments at last office visit prior to a treatment decision before death. We defined our outcome variable as the receipt of anticancer treatment in the last 14 days of a patient's life. We evaluated 20 clinical exposure variables with respect to the outcome classes. Risk ratios along with their associated confidence intervals and P values were calculated. Significance was determined using the Benjamini-Hochberg procedure to account for multiple testing. Of the 201 patients who died of cancer, 36 (17%) received anticancer therapy within the last 14 days of life. Several risk factors were significantly positively associated with receiving anticancer therapy at the end of life including hospitalization within 30 days of end of life, number of hospitalizations per patient (≥2), death in hospital, enrollment in OCM, and a diagnosis of hematologic malignancy. Our findings demonstrate those enrolled in the OCM and those with hematologic malignancies have a higher risk of receiving anticancer therapy in the last 14 days of life. These observations highlight the need for better identifying the needs of high-risk patients and providing good quality care throughout the disease trajectory to better align end-of-life care with patients' wishes.

Patterns of Anti-Cancer Therapy Use in the Last 14 Days of Life in a Community Cancer Institute (S852)

1.Define the costs of providing aggressive end of life care.2.Describe population most likely to receive anti-cancer therapy at end of life in a community cancer center.3.Discuss implications and potential application of these findings. Studies have shown that aggressive cancer care at end of life is associated with decreased quality of life, decreased median survival, and increased cost of care. This study describes the patients most likely to receive aggressive anti-cancer therapy at the end of life in a community cancer institute. We performed a retrospective review of 213 patients who received anti-cancer therapy in our institution and died between July 2016 and April 2017. Data collected included primary malignancy, death date, date of last anti-cancer treatment, hospice enrollment, healthcare utilization, Oncology Care Model (OCM) enrollment, and clinical assessments at last office visit prior to a treatment decision before death. Data were analyzed using univariate logistic regression to determine feature importance. Of the 201 patients who died of cancer, 36(17%) received anti-cancer therapy within the last 14 days of life. Several factors were significantly positively correlated with receiving anti-cancer therapy at end of life, including enrollment in OCM (p < 0.001), frequency of hospital utilization (p < 0.001), death in hospital (p<0.001), referral to hospice (p<0.001), and hematologic malignancy (p = 0.014). In our community cancer institute, enrollment in OCM, frequency of hospitalizations, death in a hospital, referral to hospice, and hematologic malignancy diagnosis were predictive of receiving aggressive anticancer therapy at the end of life, suggesting that these factors should have greater importance in our clinic.

The Implementation of a Palliative Care Intervention During Induction Chemotherapy for Patients with Acute Myeloid Leukemia (AML) at a Community Cancer Institute (QI721)

The Implementation of a Palliative Care Intervention During Induction Chemotherapy for Patients with Acute Myeloid Leukemia (AML) at a Community Cancer Institute (QI721)

Patterns of anti-cancer therapy use in the last 14 days of life in a community cancer institute.

66 Background: Studies have shown that aggressive cancer care at end of life is associated with decreased quality of life, decreased median survival, and increased cost of care. This study describes the patients most likely to receive aggressive anti-cancer therapy at the end of life in a community cancer institute. Methods: We performed a retrospective review of 213 patients who received anti-cancer therapy in our institution and died between July 2016-April 2017. Data collected included primary malignancy, death date, date of last anti-cancer treatment, hospice enrollment, healthcare utilization, Oncology Care Model (OCM) enrollment, and clinical assessments at last office visit prior to a treatment decision before death. Data were analyzed using univariate logistic regression to determine feature importance. Results: Of the 201 patients who died of cancer, 36 (17%) received anti-cancer therapy within the last 14 days of life. Several factors were significantly positively correlated with receiving anti-cancer therapy at end of life, including enrollment in OCM (p &lt; 0.001), frequency of hospital utilization (p &lt; 0.001), death in hospital (p&lt;0.001), referral to hospice (p&lt;0.001), and hematologic malignancy (p = 0.014). Conclusions: In our community cancer institute, enrollment in OCM, frequency of hospitalizations, death in a hospital, referral to hospice, and hematologic malignancy diagnosis were predictive of receiving aggressive anticancer therapy at the end of life, suggesting that these factors should have greater importance in our clinic. Taken as a whole, these data will help inform clinicians and patients in choices regarding care near the end of life.

The implementation of a palliative care intervention during induction chemotherapy for patients with acute myeloid leukemia (AML) at a community cancer institute.

113 Background: Patients with hematologic malignancies are referred to palliative care less than patients with solid tumor malignancies. Clinical trials are underway at academic centers exploring early inpatient palliative care for patients newly diagnosed with AML receiving induction chemotherapy. Feasibility of such interventions have not been studied in a community setting. We structured a multi-faceted intervention for our community hematology and palliative team on the benefits of early palliative care in hematologic malignancies with the aim to increase utilization. Methods: In 2017, 24% of patients with AML admitted to Lancaster General Hospital for induction chemotherapy received an inpatient palliative consultation. Needs assessment performed on the hematology and palliative teams demonstrated a need for integration of palliative care into clinical pathways, automatic triggers for consultation, a need for increased education on AML, and creation of standard elements in inpatient consultations. Results: In the spring of 2018, we integrated palliative care into institutional AML clinical pathways such that all patients receive inpatient palliative consultation within 72 hours of admission. A consultation trigger was placed within the admission order set and is currently being incorporated into the chemotherapy treatment protocol. An educational program on AML was created and presented by the hematology team to the inpatient palliative team. This intervention included creation of minimum standards for inpatient palliative consultation including provider assessment within 72 hours of referral, two visits per week by a provider and a minimum of one visit by the interdisciplinary team during admission with a focus on symptom management, psychosocial assessments, and advanced care planning. Conclusions: We have demonstrated feasibility of creating standards for early palliative care intervention in AML patients with collaboration from the hematology and palliative teams. Next steps will include assessing whether these interventions increase uptake of palliative care utilization and specific patient outcomes.

Utilization of Support Services, Emergency Department and Hospitalization in Advanced Cancer Patients with Severe Disease in a Community Cancer Institute (QI809)

•Define advanced cancer population and severity of disease.•Describe a model of support service delivery in a community cancer institute.•State the correlation of as-needed support service referral on ED utilization and unplanned hospitalizations in one community cancer center. Patients with advanced cancer are at high risk for emergency department (ED) and hospital utilization, which is distressing and costly. Palliative care consultation and symptom management clinics have been shown to decrease ED and hospital utilization, but the frequency and composition of these interventions is still being delineated. To describe healthcare utilization in patients with advanced cancer with respect to support services provided and severity of disease in a community setting. 157 patients with advanced cancer of pulmonary, gastrointestinal, genitourinary or gynecologic origin diagnosed January-December 2015 were reviewed retrospectively. Descriptive data including demographics, disease characteristics, palliative care consultation, support services utilized, and ED visits/hospitalizations were collected for 12 months, or to date of death. Support services included physician assistant–led symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor. Support service referrals were made based on identified needs. Severe disease was defined as death within 6 months of diagnosis. Patients with severe disease had a mean of 6 ED visits per year, significantly greater than patients with non-severe disease (p < 0.001). Patients with severe disease also had more contacts with support services per year (30.3 vs 9.1, p < 0.001). A palliative care consult was placed in 50% of patients with severe disease, and 23% in patients with non-severe disease (p < 0.001). Patients with advanced cancer have high healthcare utilization in the last 6 months of life. As-needed involvement of support services correlated with severity of disease but did not result in decreased ED utilization or hospitalization. These data suggest that availability of as-needed support services alone is not a reliable strategy to impact unplanned hospitalizations and ED visits. Further research is needed to determine if preemptive or mandatory utilization of support services is sufficient to reduce healthcare utilization.

Utilization of support services, emergency department, and hospital in advanced cancer patients with severe disease in a community cancer institute.

112 Background: Patients with advanced cancer are at high risk for emergency department (ED) and hospital utilization, which is distressing and costly. Palliative care consultation and symptom management clinics have been shown to decrease ED and hospital utilization, but the frequency and composition of these interventions is still being delineated. More evaluation is needed to determine practical approaches to implementing interdisciplinary management of distress for patients with advanced cancer in the community setting. This retrospective review evaluates healthcare utilization with respect to support services provided in our community based cancer institute. Methods: 157 patients with advanced cancer of lung, gastrointestinal, genitourinary or gynecologic origin diagnosed January 2015-December 2015 were reviewed retrospectively. Descriptive data including demographics, disease characteristics, palliative care consultation, support services utilized and ED visits/hospitalizations were collected for 12 months, or to date of death. Support services included physician assistant–led symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor. Support service referrals were made based on identified needs. Severe disease was defined as death within 6 months of diagnosis. Results: Patients with severe disease had a mean of 6 ED visits per year, significantly greater than patients with non-severe disease (p &lt; 0.001). Patients with severe disease also had more contacts with support services per year (30.3 vs 9.1, p &lt; 0.001). A palliative care consult was placed in 50% of patients with severe disease, and 23% in patients with non-severe disease (p &lt; 0.001). Conclusions: Patients with advanced cancer have evidence of significant needs as reflected by high healthcare utilization in the last 6 months of life. As needed involvement of support services correlated with severity of disease but did not result in decreased ED utilization or hospitalization. This suggests that availability of support services alone is not a feasible strategy to impact unplanned hospitalizations and ED visits.

A description of cancer directed therapy within 14 days of death in a community cancer institute.

73 Background: It is recommend that no more than 10% of patients receive chemotherapy within 14 days of death. Aggressive end of life interventions like chemotherapy and hospitalization are used as measures of quality. However, cancer care now includes immunotherapy and targeted therapies. It is therefore important to understand how all cancer directed treatments are utilized at end of life, to better define the group of patients for whom they are indicated. Therefore, we sought to describe the people in our institution who received cancer directed therapy in the last two weeks of life. Methods: Adult patients who received cancer directed therapy for any malignancy in a single community cancer institute and died from July 2016-April 2017 were included. Retrospective data collection included clinical cancer stage and type, ECOG performance status (ECOG), last cancer therapy, date of death, dates of treatment, type of treatment, treatment goal, demographics and utilization of ED, hospital, palliative care and hospice. Results: A total of 218 patients were included. 13.7% (30/218) received cancer directed therapy within 14 days of death. Of those patients, only four had ECOG of 3, while 26 had ECOG 0-2. The average duration from treatment to death in this group was eight days, with one patient dying on the day of treatment. The average duration from treatment to death for all patients was 166 days (median 59). 20 patients receiving cancer directed therapy at end of life received chemotherapy, while the remaining 10 received targeted therapy (8) or immunotherapy (2). 40% (8/20) of patients in the chemotherapy group died in hospital as did 50% (5/10) of the remaining patients. Most patients in the overall sample (83%) were being treated with palliative intent. 20% (6/30) of the patients who died within 14 days of treatment were being treated with curative intent. Conclusions: Recommendations regarding cancer directed treatment near end of life need to include non-chemotherapy treatments such as immunotherapy and targeted treatments. Although a small sample size, our data suggest that patients on these treatments receive aggressive end of life care at a similar frequency as those who receive chemotherapy.

Standardized Tobacco Assessment for Retail Settings (STARS): dissemination and implementation research

ObjectiveThe Standardized Tobacco Assessment for Retail Settings (STARS) was designed to characterise the availability, placement, promotion and price of tobacco products, with items chosen for relevance to regulating the retail...

Abstract A28: Closing the disparity gap: Attributes of patients referred to a community cancer program

Abstract Background: Evidence suggests that the experience of cancer differs across racial and ethnic underserved populations. We describe the referral patterns and clinical characteristics of patients receiving care at Dana-Farber Cancer Institute's clinical outreach community cancer program, an initiative established to improve access to quality cancer care across the spectrum of the disease for medically underserved patients. Methods: Two hundred and twenty five patients, receiving care at our community cancer care site, based within a Federally Qualified Health Center in Boston, were consented to research and enrolled between January 2012 and June 2015. The program accommodates all oncology and hematology referrals from primary care providers (PCP) at the health center. Variables of interest were collected through medical chart review and a patient intake survey that was developed for the program, and included age, gender, ethnicity, health insurance coverage, reasons for referral, presence of co-morbidity (defined by the International Classification of Disease-9th edition codes) and type of resolution attained. Due to the wide range of services provided by the program, resolution was defined as the number of days from the patient's initial appointment with an oncologist at the center until one of the following events occurred: an initial appointment with a medical specialist at the Dana-Farber Cancer Institute/Brigham and Women's Hospital (DFCI/BWH) to establish a treatment plan; establishment of a surveillance plan; or direction back to his or her PCP. Descriptive statistical analysis was performed using JMP Pro (version 11, SAS Institute Inc., Cary, NC) Results: The mean age of the study population was 52 (SD±13.9) years and 44% were men. The majority of participants (70%) were Blacks/African Americans, 15% were Hispanic Whites, 11% were non-Hispanic Whites and 1% were two or more races. Forty eight percent had Medicaid insurance, 24% had Medicare while 13% and 15% had other public and private insurance, respectively. The reasons for referral include hematologic consultation (22%), evaluation for cancer (20%), cancer genetics counseling and testing (20%), lung cancer screening/smoking cessation counseling (19%), follow up care for cancer (15%), cancer treatment (1%) and others (2%). Of the 54 participants with a cancer diagnosis, 76% were previously diagnosed elsewhere and the most common cancer sites were prostate (35%) breast (13%) and colon/rectum (11%). Hypertension (52%), diabetes (31%) and psychological disorders (22%) were the most frequent co-morbidities in participants with cancer. Surveillance plans were established for 44% of genetic counseling/ testing referrals and 86% of lung cancer screening referrals. Those requiring treatment (33%) and active surveillance (43%) plans for cancer had a median time to resolution of 17 (SD±91.1) days and 12(SD±34.5) days, respectively. Overall, treatment plans were required for 9% of participants, 55% had surveillance plans established while 34% were directed back to their PCP for continued care and only 2% of referrals were unresolved. Conclusion: Our findings highlight the wide spectrum of cancer care concerns and needs in underserved populations receiving care within the community. Interventions targeted at eliminating cancer disparities should take into account services that span the continuum of care from prevention to survivorship. Citation Format: Ruth N. Akindele, Ludmila A. Svoboda, Yolanda Martins, Rachel A. Freedman, Aymen Elfiky, Suzanne T. Berlin, Christopher S. Lathan. Closing the disparity gap: Attributes of patients referred to a community cancer program. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A28.

Starving for attention: Malnutrition screening in a community cancer center.

96 Background: It is estimated that 50% of cancer patients are at risk for malnutrition, causing physical and emotional distress that interferes with cancer treatment. Early detection and intervention may prevent severe malnutrition. Assessment and management of malnutrition are included in National Comprehensive Cancer Network (NCCN) guidelines but no specific recommendation regarding screening tool selection is provided. The Malnutrition Screening Tool (MST) is a short, easily administered screening tool, validated for identification of malnutrition in cancer patients. In this study, we describe the results of MST administration in a large community cancer institute. Methods: The MST was administered during all patient visits to our cancer institute in 2015. Patients scoring 2 or higher were identified as ‘at risk’ for malnutrition, resulting in electronic dietitian referral prompts. We retrospectively reviewed MST results from April through June 2015 and compared to dietitian referrals during the same period in 2014. At that time, dietitian consults were prompted by physician referral, patient request, or triggered by NCCN distress thermometer screen. Results: The MST identified 84% more patients in need of dietitian referral in 2015 compared to usual care in 2014. From April through June 2015, the MST was administered during 4082 discrete patient encounters. 6.7% of these visits resulted in MST score of 2 or greater for a total of 193 ‘at risk’ patients in need of referral to dietitian. Weight loss of 2 pounds or greater was reported by patients in 16% of encounters. Eating poorly because of a decreased appetite was reported by patients in 13% of the encounters. From April through June 2014, 105 patients were referred for dietitian consult, indicating the MST identified 88 more ‘at risk’ patients. Conclusions: The MST is a simple, valid tool for malnutrition screening in cancer patients that resulted in an 84% increase in identification of ‘at risk’ patients. This tool should be considered for standard malnutrition screening of cancer patients, to prompt referral for dietitian intervention.