Medical Oncology Practice Research Articles

Trends in Private Equity Involvement in Oncology Practices in the United States

<h3>Purpose/Objective(s)</h3> Private equity (PE) firms have become increasingly involved in healthcare practices. Generally, PE firms pool financial capital and acquire clinics and physician practices. Then, by implementing operational changes that increase revenues or cut costs, they seek to increase the "value" of the practice before selling it—generally in 5 to 10 years. To date, PE-backed acquisitions among oncology practices have not been well studied. Thus, we sought to characterize the extent of PE involvement among medical and radiation oncology practices over time. <h3>Materials/Methods</h3> We performed a comprehensive analysis of PE-backed transactions involving oncology practices in the United States. Transaction data was compiled from 5 financial databases (CB Insights, Thomson ONE, Capital IQ, PitchBook, and Irving Levin) supplemented by publicly available press releases, clinic websites, and 10-K financial reports. Transactions included financial partnerships, recapitalizations, and direct acquisitions of clinics or physician practices, but did not include new clinics established by PE-backed companies through organic growth. We confirmed that all transactions involved practices providing clinical services in medical and/or radiation oncology and excluded acquisitions of hospitals, biotechnology, and pharmaceutical companies. The transaction date, geographic location, and number of affiliated clinics and physicians involved in each PE transactions were recorded when available. <h3>Results</h3> Between January 1, 2003 and June 20, 2022, we observed 1,074 PE-backed transactions among medical oncology and radiation oncology practices. Transactions were executed by 23 PE-backed healthcare companies and involved 723 individual clinics—including 232 (32.1%) medical oncology clinics and 381 (52.7%) radiation oncology clinics, and 110 (15.2%) clinics providing both medical and radiation oncology. Location data was available for 714 clinics and showed PE involvement spanning 45 states, with the most activity observed in California and Florida, accounting for 248 (34.3%) acquired clinics. Currently, at least 1,033 medical oncologists (55.6%) and radiation oncologists (44.4%) are affiliated with oncology practices involved in PE-backed transactions. The rate of PE-backed transactions increased rapidly over the past two decades, with 149 clinics acquired from 2003-2007, 218 clinics acquired from 2008-2012, 192 clinics acquired from 2013-2017, and 515 clinics acquired from 2018-2022. <h3>Conclusion</h3> PE firms have substantial financial stakes among medical and radiation oncology practices. The frequency of PE-backed transactions among oncology practices has rapidly expanded over the past two decades and is likely contributing to increasing practice consolidation. Further investigation is needed to determine the implications of PE involvement on health care costs, access, and patient outcomes.

The Use of Phytochemicals to Improve the Efficacy of Immune Checkpoint Inhibitors: Opportunities and Challenges

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy and reshaped medical oncology practice over the past decade. However, despite unprecedented and durable clinical responses, most patients eventually fail to respond to ICI therapy due to primary or acquired resistance. There is a great need for complementary alternative medicine, such as botanicals and nutritional supplements, because of their capability to modulate a myriad of molecular mechanisms to prevent immunotherapy resistance and reduce its adverse effects. Mounting evidence suggests that phytochemicals, biologically active compounds derived from plants, can favorably regulate key signaling pathways involved in tumor development and progression. In addition, phytochemicals have been found to exert anticancer effects by altering the expression of checkpoint inhibitors of the immune response. The immunomodulatory activity of phytochemicals in the tumor microenvironment has recently received immense interest. Based on these immunomodulatory activities, phytochemicals could be candidates for combination with ICIs in future clinical studies. The current review focuses on the available evidence for combining phytochemicals with a discussion on the promising opportunities to enhance the efficacy of immune checkpoint inhibitors and potential challenges resulting from these combinations.

I-DO GOC: Improving documentation in oncology with goals of care.

314 Background: Goals of Care (GOC) discussions are part of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early GOC discussions are associated with better quality of life, reduced use of futile medical care, and enhanced goal-concordant care. In order to increase GOC documentation within the electronic medical record (EMR), the Kaiser Permanente San Francisco medical oncology practice began an ASCO Quality Training Program initiative in January 2022 to increase oncologist discussion and documentation of GOC in advanced cancer patients. Methods: Baseline data on the frequency of GOC discussions was obtained through a structured chart review with a historical cohort of stage IV or recurrent cancer patients &gt; 18 years old between 1/1/2020-6/1/2020. The project aimed to improve accessible GOC documentation from a baseline of 0% to a goal of 25% among stage IV or recurrent cancer patients seen by an oncologist between 1/2022 and 5/14/2022. Patients with hematologic malignancies were excluded. Oncologists were instructed to use a templated GOC automated phrase (Smartphrase) that consolidated content into a visible, centralized EMR location. The frequency of GOC Smartphrase usage among oncologists was tracked monthly through a customized dashboard. Plan-Do-Study-Act cycles included education on GOC documentation and monthly feedback for oncologists on performance. Results: Review of the 2020 historical cohort revealed no structured or accessible GOC documentation by oncologists. During the intervention period, 300 Stage IV and recurrent cancer patients were eligible for GOC documentation. The median age of the intervention group was 70 years, with the most common types of cancers represented: Prostate (21%), Breast (19%), and Lung (17%). Our study cohort included a diverse population: White (45%), Asian (36%), Black/African American (11%), and Hispanic (7%). Between 1/1/2022 to 5/14/22, 142 (47%) patients had at least one documented GOC conversation, exceeding the target of 25%. 100% of these structured conversations were viewable in the designated area in the EMR. Conclusions: Our ASCO Quality Training Program initiative successfully increased oncologists' overall number of GOC conversations and made those conversations more easily accessible to the entire care team. Our process for standardizing the documentation of GOC conversations was based on the use of a Smartphrase that helped organize the collected information within the EMR. During the study period, we increased the documented GOC rate from 0% to 47%. This can improve patient and physician satisfaction, as well as improve goal concordant care for patients with advanced cancer. Further efforts will be focused on sustaining these initial gains in GOC documentation and on promoting their broader use across our organization.

Post-traumatic stress disorder symptoms and associated factors in breast cancer patients during the first COVID-19 lockdown in France.

IntroductionWe aimed to study post-traumatic stress disorder (PTSD) symptoms in breast cancer (BC) patients during the coronavirus disease (COVID-19) pandemic.Materials and methodsWe included BC patients receiving medical treatment during the first COVID-19 lockdown in France. PTSD symptoms were evaluated using the Impact of Event Scale-Revised (IES-R) questionnaire. Quality of life [Functional Assessment of Cancer Therapy-General (FACT-G)], cognitive complaints [Functional Assessment of Cancer Therapy–Cognitive Function (FACT-Cog)], insomnia [Insomnia Severity Index (ISI)], and psychosocial experiences during lockdown were also evaluated. Multivariable logistic regression was used to identify clinical factors (from medical records) and psychosocial factors (from questionnaires) associated with PTSD symptoms.ResultsAmong the 253 included BC patients (mean age: 58), 46% had metastatic cancer and 52% were treated by chemotherapy alone. COVID-19-induced adjustments in medical oncology practices were experienced by 27% of patients (mainly teleconsultations). No case of COVID-19 was reported; 23% of BC patients had PTSD symptoms. Compared to other patients, patients with PTSD symptoms had more fears relative to COVID-19 infection (83 vs. 60%, p = 0.009), had more feeling of isolation (69 vs. 41%, p = 0.003), and had more prescription or increased use of psychotropic drugs (49 vs. 20%, p = 0.001). In the multivariable model adjusted for clinical factors, fears relative to COVID-19 and increased use of psychotropic drugs were independently associated with PTSD symptoms (OR [95% CI] = 3.01 [1.20–8.44] and 3.45 [1.48–8.17], respectively). Besides, patients with PTSD symptoms had poor quality of life (QoL), and more cognitive complaints and insomnia.ConclusionPost-traumatic stress disorder symptoms were observed in 23% of BC patients during the first COVID-19 lockdown in France. Psychological supports are needed for patients treated during the COVID-19 pandemic.

Cutting-Edge: Preclinical and Clinical Development of the First Approved Lag-3 Inhibitor.

Immune checkpoint inhibitors (ICIs) have revolutionized medical practice in oncology since the FDA approval of the first ICI 11 years ago. In light of this, Lymphocyte-Activation Gene 3 (LAG-3) is one of the most important next-generation immune checkpoint molecules, playing a similar role as Programmed cell Death protein 1 (PD-1) and Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4). 19 LAG-3 targeting molecules are being evaluated at 108 clinical trials which are demonstrating positive results, including promising bispecific molecules targeting LAG-3 simultaneously with other ICIs. Recently, a new dual anti-PD-1 (Nivolumab) and anti-LAG-3 (Relatimab) treatment developed by Bristol Myers Squibb (Opdualag), was approved by the Food and Drug Administration (FDA) as the first LAG-3 blocking antibody combination for unresectable or metastatic melanoma. This novel immunotherapy combination more than doubled median progression-free survival (PFS) when compared to nivolumab monotherapy (10.1 months versus 4.6 months). Here, we analyze the large clinical trial responsible for this historical approval (RELATIVITY-047), and discuss the preclinical and clinical developments that led to its jump into clinical practice. We will also summarize results achieved by other LAG-3 targeting molecules with promising anti-tumor activities currently under clinical development in phases I, I/II, II, and III. Opdualag will boost the entry of more LAG-3 targeting molecules into clinical practice, supporting the accumulating evidence highlighting the pivotal role of LAG-3 in cancer.

A Prospective Audit of Inpatient Medical Oncology Consultation Patterns in a Tertiary Teaching Hospital in South Australia

Objectives: Given the expanding role of medical oncology practice, with increasing therapeutic options for those with advanced malignancy, we sought to document the population of patients receiving inpatient medical oncology consultation. The aim of the study was to document patterns of inpatient referral to medical oncology in order to better understand service needs. We looked to define the relative frequency of cancer types, stage and treatment recommendations.&#x0D; Design: A large prospective clinical audit was undertaken between January 2005 and January 2007.&#x0D; Settings: The audit was conducted at the Royal Adelaide Hospital, a major tertiary referral hospital.&#x0D; Participants: During the two year study period 1,173 consecutive inpatient referrals for medical oncology consultations were included in this analysis.&#x0D; Main Outcome Measures: Information was collected regarding patient demographics, referral unit, cancer diagnosis and stage, treatment recommendations and follow-up plans.&#x0D; Results: The most common referral units were General Medicine (19.8%) and Thoracic medicine (15%). The most common primary sites of cancer were lung (22.6%), colorectal (14.9%), primary brain tumours (9.6%) and head and neck (9.3%). The clear majority of patients had Stage 4 disease (80%) and were thus incurable in most cases. Chemotherapy was recommended in 43.7% of patients, chemo-radiation in 12.6% of patients, radiotherapy alone in 16.9% of patients and best supportive care in 24.1% of patients.&#x0D; Conclusions: This large prospective clinical audit defines the population of patients referred for inpatient medical oncology consultation at our tertiary hospital. Cancer patients are being cared for by a wide variety of non-cancer specialists. The majority of patients have advanced, non-curable disease but anticancer therapy is provided to most with the intention of prolonging survival and maintaining quality of life.

Practice consolidation among U.S. medical oncologists over time.

e13627 Background: Physician practices across the U.S. are increasingly merging with hospitals and other practices. The extent of such “practice consolidation” varies by specialty and across geography but has not been well characterized within medical oncology. Methods: Utilizing Medicare data, we identified all medical oncologists (MO) who billed for Medicare services each year between 2015 and January 2022. We associated each physician to one or more unique practices via organizational Taxpayer Identification Numbers (TIN), and classified practices by the number of medical oncologists—including solo (1 MO), small (2-10 MOs), medium (11-24 MOs), and large (25+ MOs) practices. We defined the extent of regional healthcare markets according to Hospital Referral Regions (HRRs), and calculated levels of practice consolidation using the Herfindahl-Hirschman Index (HHI). The HHI is a commonly used measure of consolidation, calculated by summing the square of each practice’s market share. HHI values range from 0 to 1 with higher numbers indicating greater consolidation and less competition among practices. Finally, we generated a multivariable linear regression model to determine which regional market factors were associated with changes in levels of medical oncology practice consolidation over time. Results: Between 2015 and 2022, the number of practices with MOs in the U.S. declined 18.0% from 2,774 to 2,276, while the number of practicing MOs increased 14.5% from 11,727 to 13,433. The median medical oncology practice HHI increased from 0.3204 to 0.3480. Over time the proportion of solo practices fell (48.4% in 2015, 43.9% in 2022) while the proportion of medium and large practices increased (medium: 5.7% to 8.4%; large: 2.7% to 4.5%). By 2022, large practices had grown to employ a significantly larger proportion of all medical oncologists (33.6% to 43.7%, p &lt; 0.001). Between 2015 and 2022, the proportion of practices solely comprised of MOs (as opposed to multispecialty practices) decreased from 40.0% to 28.2%. On multivariable analysis, HRRs with higher levels of hospital consolidation (p &lt; 0.001), greater numbers of hospital beds per 1,000 persons (p = 0.02), and a lesser degree of baseline medical oncology practice consolidation in 2015 (p &lt; 0.001) experienced more consolidation during the study period. Conclusions: Medical oncologists across the U.S. are increasingly working in larger practices. By 2022, more than 40% of all practicing MOs were employed at the largest 5% of practices. Consolidation of medical oncology practices occurred more readily in regions with higher levels of hospital consolidation and a greater supply of hospital beds, suggesting that integration into hospital systems may be a leading source of consolidation. Further study is required to determine the impact of practice consolidation on the cost, quality, and accessibility of cancer care.

Racial and ethnic disparities in adherence and reported symptoms during routine collection of patient-reported outcomes (PROs).

6510 Background: Routine collection of PROs for patients with cancer is an evidence-based practice and critical component of high-quality cancer care, but real-world adherence and reporting patterns are poorly understood. We examined differences in PRO adherence and reported symptoms by race and ethnicity. Methods: We conducted a retrospective cross-sectional study using de-identified electronic health record data from a National Cancer Institute Comprehensive Cancer Center. Participants included adults seen in follow-up at one of two medical oncology practices (1 academic, 1 community) from June 2019 to February 2020, during which two validated PRO instruments (NCI PRO-CTCAE and PROMIS Global v1.2) were routinely administered electronically via portal or tablet at return visits. Adherence was defined for each participant as the proportion of visits in which a PRO questionnaire was completed within 30 days. Using ordinary least squares regression, we modeled patient adherence as a function of race/ethnicity and adjusted for age, sex, insurance, median area income, ECOG performance status, cancer type, cancer stage, visit site, and number of visits during the study. Among study participants completing at least one PRO questionnaire, we modeled reported symptoms from the first questionnaire using a similar approach. Results: From June 2019 to February 2020, there were 29,726 patients (mean [SD] age 60.8 [15.1] years; 18,045 [60.7%] female) seen across 111,262 medical oncology visits. Of these patients, 19,971 (67.2%) completed at least one PRO questionnaire. Adjusted mean PRO adherence and reported symptoms varied by race/ethnicity, with Black and Hispanic patients reporting significantly higher symptom burden than White patients (Table). Conclusions: In this large cohort reflecting real-world PRO collection patterns, Black and Hispanic patients were less likely than White patients to complete PRO questionnaires, but more likely to report more severe symptoms. There is urgent need to ensure equitable PRO access and implementation and to address greater reported symptom burden among minority patients. [Table: see text]

The adoption of relugolix for treatment of prostate cancer (PCa) in a large community medical oncology practice.

e13541 Background: Relugolix was approved by the FDA in late 2020 as an oral gonadotropin-releasing hormone (GnRH) receptor antagonist for the treatment of adults with advanced PCa. The approval was based on a large randomized trial (Shore et al NEJM) of patients with evidence of biochemical or clinical relapse after local primary intervention with curative intent (50%), newly diagnosed mCSPCa (23%), and advanced localized disease not suitable for primary surgical intervention with curative intent (28%). Our study aims to observe the adoption of relugolix in a large community-based medical oncology practice with affiliated urologists. Methods: A retrospective study using our EMR identified 39 males with PCa for whom relugolix was initiated between January 2021 and December 2021. The charts were analyzed for demographics, indications for treatment, barriers encountered to initiation of treatment, duration of therapy, previous therapies, specialty, primary insurance, and cardiovascular history. Results: Thirty-nine (39) patients with either localized PCa (40%) or with metastases to lymph nodes or distant sites (51%) were recommended initiation of relugolix by either urology (26%) or oncology (74%). Of these, 77% actually started the medication. 9 patients did not start therapy, of which 3 were due to insurance denial, 1 due to death, 2 changed their mind, and 3 did not start for unclear reasons. Medicare covered 56% of the patients. Cardiovascular disease was notable in 87%. 28% switched from another ADT due to intolerance, 10% started relugolix due to progressive disease, and 33% started as initial ADT. 13% discontinued within 6 months. Of these, 1 completed planned therapy, 3 were intolerant, 1 was switched to alternate therapy due to progression, and 1 had complications due to COVID. In comparison, 689 patients initiated ADT with leuprolide over the same time. Conclusions: ADT using GnRH agonists or antagonists form the backbone of PCa treatment, typically given as injections. The HERO trial showed that relugolix, a newer oral therapy, is associated with lower rates of cardiovascular events compared to leuprolide. While having at least one cardiovascular risk factor is a consideration for patients to either start with or switch to relugolix, the large majority of our patients still received first-line therapy with leuprolide. This study demonstrates limitations to initiating relugolix including financial constraints (e.g., insurance coverage), patient preference, and medication intolerance.[Table: see text]

COVID-19 vaccine uptake in patients with cancer and Sars-Cov-2 infection in 2020: Results from the ASCO registry.

e18713 Background: The availability of safe and effective COVID-19 vaccines has enabled protections against serious outcomes from SARS-CoV-2 infection. The ASCO Registry provides an opportunity to study the rate of vaccine uptake among patients (pts) with cancer who had SARS-CoV-2 infection prior to availability of vaccines. Methods: Participating US medical oncology practices identify pts eligible for inclusion: pts with a positive SARS-CoV-2 test and, at the same time, either (a) or (b) cancer-free less than 12 months (i.e., in complete remission or post-resection) and receiving adjuvant treatment. Registry data were extracted on 2/4/22. Pts in this analysis had a SARS-CoV-2 positive test between 3/1/2020 and 12/31/2020 and at least one clinical encounter on or after 1/1/21, documenting receipt or not of 1st and 2nd vaccine shots. Pts lacking data on vaccination status in their medical records were excluded from analysis. When the exact date of 1st vaccine shot was known, the primary endpoint was number of days from 1/1/21 to 1st shot date. If the exact date of 1st shot was unknown, date was categorized as within 7 days from the clinical encounter, 2-4 weeks, or more than 1 month prior. Summary statistics and 95% confidence intervals (CIs) were calculated using Kaplan-Meier methods. Results: The Registry included 1260 pts with SARS-CoV-2 infection in 2020. Time to vaccination (described using cumulative incidence) across age categories is shown in Table, with 1/1/21 as the baseline. Median time to vaccination ranged from 63 days in the oldest pts (&gt; 80 years of age) to 220 days in the youngest pts (&lt; 45 years of age). Differences in rates of vaccination uptake were most pronounced in the early months (Jan – Mar) and diminished in April and beyond. Conclusions: Older pts with cancer who were infected with SARS-CoV-2 in 2020 received COVID-19 vaccinations in 2021 at higher rates than those of younger ages. Delayed uptake by younger aged pts at outset could be related to lack of clarity on pts with cancer qualifying for early vaccine access and state policies on availability.[Table: see text]

MP28-12 PROLIFERATION OF PHYSICIAN DISPENSING AMONG LARGE SINGLE-SPECIALTY MEDICAL ONCOLOGY AND UROLOGY PRACTICES

You have accessJournal of UrologyCME1 May 2022MP28-12 PROLIFERATION OF PHYSICIAN DISPENSING AMONG LARGE SINGLE-SPECIALTY MEDICAL ONCOLOGY AND UROLOGY PRACTICES Lillian Lai, Samuel Kaufman, Mary Oerline, Megan Caram, Avinash Maganty, Chad Ellimoottil, Vahakn Shahinian, and Brent Hollenbeck Lillian LaiLillian Lai More articles by this author , Samuel KaufmanSamuel Kaufman More articles by this author , Mary OerlineMary Oerline More articles by this author , Megan CaramMegan Caram More articles by this author , Avinash MagantyAvinash Maganty More articles by this author , Chad EllimoottilChad Ellimoottil More articles by this author , Vahakn ShahinianVahakn Shahinian More articles by this author , and Brent HollenbeckBrent Hollenbeck More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002571.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: With the availability of oral targeted therapies, such as abiraterone since 2011 and enzalutamide since 2012, men with advanced prostate cancer can receive cancer treatment at home. By 2015, these oral therapies replaced docetaxel, an intravenous chemotherapy, as the most common first-line treatment for advanced prostate cancer. Prescriptions for oral therapies can be dispensed on-site or through a pharmacy owned by the practice of the physician (collectively referred to as physician dispensing). As a first step towards understanding physician dispensing in the context of increasing use of oral targeted therapies, we described the proliferation of physician dispensing among large single-specialty medical oncology and urology practices from 2011 to 2018. METHODS: Men with advanced prostate cancer were identified in a 20% sample of national Medicare claims. The predominate managing physician was identified and associated with a practice using the Medicare Data on Provider Practice and Specialty file. Physician dispensing was identified using data from the National Council for Prescription Drug Program, which included the inception date of the pharmacy or the non-pharmacy dispensing site. Large single-specialty medical oncology and urology practices were defined as practices with ≥10 medical oncologists (or urologists, respectively) in which ≥50% of the physicians were medical oncologists (or urologists, respectively). This analysis focused on practices present throughout all 8 years of the study. RESULTS: From 2011 to 2018, the percentage of large single-specialty medical oncology practices with physician dispensing grew from 40% to 79%. Over the same eight-year period, the percentage of large single-specialty urology practices with physician dispensing grew from 3% to 62%. The largest increase occurred from 2014 to 2015, with an additional 20% of large single-specialty urology practices offering physician dispensing, which coincided with when enzalutamide was approved for use in the pre-chemotherapy setting. CONCLUSIONS: Physician dispensing is increasingly common. The streamlined model, coupled with the longstanding patient-physician relationship, has the potential to reduce care fragmentation and improve access. Source of Funding: AHRQ R01 HS025707 for VBS/BKH; NCI T32 CA180984 for LYL/AM © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e465 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lillian Lai More articles by this author Samuel Kaufman More articles by this author Mary Oerline More articles by this author Megan Caram More articles by this author Avinash Maganty More articles by this author Chad Ellimoottil More articles by this author Vahakn Shahinian More articles by this author Brent Hollenbeck More articles by this author Expand All Advertisement PDF DownloadLoading ...

Shared barriers and facilitators to enrollment of adolescents and young adults on cancer clinical trials

Adolescent and young adult (AYA) enrollment in cancer clinical trials (CCT) is suboptimal. Few studies have explored site level barriers and facilitators to AYA enrollment on CCTs and the efficacy of interventions to enhance enrollment. A cross sectional survey was developed by the COG AYA Oncology Discipline Committee Responsible Investigator (RI) Network to identify perceived barriers and facilitators to enrollment, as well as opportunities to improve enrollment. Associations of barriers and facilitators to enrollment with program demographics were assessed. The survey was sent to all AYA RI Network members (n = 143) and quantitative and thematic analyses were conducted. The overall response rate was 42% (n = 60/143). Participants represented diverse institutions based on size, presence or absence of dedicated AYA programs, and proximity and relationship between pediatric and medical oncology practices within the institution. The most frequently cited barriers to enrolling AYAs in CCTs were administrative logistical issues (45%), disparate enrollment practices (42%) and communication issues (27%) between pediatric and medical oncology and perceived limited trial availability (27%). The most frequently reported facilitators to enrollment included having strong communication between pediatric and medical oncology (48%), having a supportive research infrastructure (35%) and the presence of AYA champions (33%). Many barriers and facilitators were similar across institutions and AYA program types. Shared barriers and facilitators to AYA CCT enrollment exist across the landscape of cancer care settings. Interventions aimed at increasing coordination between pediatric and medical oncology clinical trials offices and providers have high potential to improve site-level AYA enrollment.

Integrating Medical Genetics Into Precision Oncology Practice in the Veterans Health Administration: The Time Is Now.

Increased access and utilization of tumor profiling of cancers in our veteran population uncovered a modest number of potentially pathogenic germline variants (PPGVs) that require genetics referral for follow-up evaluation and germline sequencing. Challenges identified specific to the veteran population include paucity of genetics providers, either at a veteran's VA facility or nearby non-VA facilities. We sought to investigate the number of veterans who would benefit from having such resources at both local and national levels. Annotated clinical reports of mutations identified by tumor-only profiling and medical records of veterans with solid tumors at the Veterans Administration Ann Arbor Healthcare System (VA AAHS) between 2015 and 2020 were reviewed. PPGVs were identified according to society recommendations (such as ESMO and American Board of Medical Genetics and Genomics), expert review, and/or previously published criteria. After the analysis of our local VA population, these same criteria were then applied to veterans in the National Precision Oncology Program (NPOP). Two hundred eight veterans underwent tumor profiling at the VA AAHS over the defined time period. This included 20 different primary tumor sites with over half (n = 130) being advanced cancer at diagnosis. Of these, 18 veterans (8.5%) had mutations suggestive of a PPGV. Applying these criteria to the larger NPOP database (n = 20,014), a similar percentage (6%) of PPGVs were identified. These results indicate a PPGV frequency (6%-9% of veterans) consistent with the prevalence of inherited cancer predisposition syndromes in the general population, underscoring the need for medical genetics as part of standard oncologic care for veterans. We explore current and future care delivery models to optimize incorporation of medical genetics and genetic counseling to best serve veterans needing such services.

Early Findings on the Use of Clinical Pathways for Management of Unwarranted Variation in Cancer Care.

Clinical pathways have the potential to improve complex clinical decision-making in cancer care. The authors implemented pathways with customized content to assist oncologists to select treatments, aiming for an on-pathway rate of 70%-85%. Treatment decisions were captured as on or off pathway, and metrics were shared monthly with users. Oncologists were categorized into quintiles based on on-pathway performance during the first 90 days of use. On-pathway rates were then calculated for days 91-360 (N = 121). Median on-pathway quintile rates varied from 50% to 100% in the initial 90-day period. During follow-up, median on-pathway rates shifted into the prespecified goal range for all groups. Clinical pathways resulted in greater uniformity in medical oncology practice. Monthly feedback about usage, familiarity with the electronic platform, and regular content updates are some factors that may influence on-pathway rates. Clinical pathways hold promise to manage unwarranted variation in cancer care.

Difficult removal of totally implantable venous access devices in adult patients: Incidence, risk factors, and management.

Totally implantable venous access devices (TIVADs) have played an important role of medical oncology practice. However, operators sometimes encounter considerable difficulty when removing TIVADs. This study aimed to investigate the incidence of difficult TIVAD removal, determine associated risk factors, and investigate interventional radiology (IR) approaches to difficult removal. A total of 514 TIVAD removal procedures performed in a single-center between January 2014 and May 2021 were retrospectively analyzed to determine incidence of difficult removal and associated risk factors. IR approaches applied in difficult removal cases were also reviewed. The incidence of difficult removal was 7.4% (38/514). In univariable analysis, indwelling duration, silicone catheter, and subcutaneous leakage of fluid were identified as significant risk factors for difficult removal. Multivariable analysis showed that indwelling duration per year (odds ratio (OR), 1.46; 95% confidence interval (CI), 1.28-1.67; p < 0.01) and subcutaneous leakage of fluid (OR, 6.04; 95% CI, 2.45-14.91; p < 0.01) were significantly associated with difficult removal. In the 38 difficult removal cases, 32 TIVADs could be removed using more dissection and traction than the standard removal method. In the other 6, TIVADs were successfully removed by using several IR techniques, including insertion of a guide wire (n = 1), dissection using an introducer sheath (n = 2), pushing with a dilator (n = 1), and pulling with a snare (n = 2). Difficult TIVAD removal is uncommon. However, operators should expect it when removing long indwelling TIVADs and those with subcutaneous leakage. IR approaches to difficult removal are minimally invasive and can be useful.

Changes in medical oncology practice due to the COVID-19 pandemic in Turkey, and the risk of neglect of cancer patients

Cancer patients are among patient groups most affected by the COVID-19 outbreak. During the COVID-19 pandemic, rearrangement of oncological services and adaptation to the pandemic process has become mandatory. In this review, we mentioned the changes in medical oncology practice and adaptive treatment modifications. COVID-19 infection will continue to affect and change the practice of oncology unless the COVID-19 outbreak ends.

Implementation of a medical oncology fellow-initiated financial toxicity screening program in outpatient medical oncology clinics

Introduction The National Cancer Institute defines financial toxicity as “problems a patient has related to costs of cancer care.” Financial toxicity is a critical problem in cancer treatment and one that remains conventionally outside of clinical discussion and treatment decision-making. Methods This is a feasibility pilot study of the implementation of a medical oncology fellow-led financial toxicity screening intervention program at the Helen Diller Family Comprehensive Cancer Center (HDFCCC) at the University of California San Francisco. Fellows were asked to conduct and document financial toxicity screening of patients seen in medical oncology outpatient clinics from August 2017 to March 2018 in the electronic medical record. Results At baseline, no fellows documented financial toxicity screening. Screening rates peaked at 49%, however at the end of the intervention the screening rate decreased to 11% among participants. Conclusions The results of the pilot feasibility study revealed that a fellow-led financial toxicity screening program in medical oncology clinics rendered low adherence to patient screening. Future research will need to develop mechanisms for identifying patients who may experience high levels of financial distress in medical oncology practice.

Post-traumatic stress symptomatology and adjustment of medical oncology practice during the COVID-19 pandemic among adult patients with cancer in a day care hospital.

BackgroundThe COVID‐19 pandemic may induce post‐traumatic stress disorder (PTSD) symptoms among patients with cancer, who also face adaptations to their treatment. The authors assessed the occurrence of PTSD symptoms, investigated pandemic‐induced adjustments in medical oncology practice in patients with cancer, and explored risk factors for PTSD and the association between PTSD symptoms, insomnia, and quality of life (QoL).MethodsThis prospective French study was conducted in patients with solid/hematologic tumors who were receiving medical treatment in the day care departments of 2 cancer centers during the lockdown. Adjustments to medical oncology practice were collected from medical records. PTSD (measured using the Impact of Event Scale‐Revised), insomnia (measured using the Insomnia Severity Index), QoL (measured using the Functional Assessment of Cancer Therapy‐General instrument), and cognitive complaints (measured using the Functional Assessment of Cancer Therapy–Cognitive Function instrument) were collected through validated questionnaires.ResultsClinical data and questionnaires were available for 734 and 576 patients, respectively. The median patient age was 64 years, and 69% of patients were women. Twenty‐one percent of patients had PTSD. Twenty‐seven percent (95% CI, 23%‐30%) had an adjustment in their medical oncology program, including adjournments (29%), treatment interruptions (16%), modified treatment plans (27%), or adapted monitoring (27%). Women and patients experiencing an adjustment in oncology practice had a higher odds of PTSD (odds ratio= 2.10 [95% CI, 1.07‐4.14] and 1.65 [95% CI, 1.03‐2.63]; P < .05). PTSD symptoms were correlated with worse scores for QoL, cognition, and insomnia.ConclusionsTwenty‐one percent of patients with cancer experienced PTSD symptoms associated with poor QoL during the first COVID‐19–induced lockdown. Medical oncology practice was adjusted in approximately one‐quarter of patients and was associated with the occurrence of PTSD symptoms. Psychosocial support should be offered in cancer centers to promote emotional resilience and avoid PTSD symptoms in patients.

Improving the delivery of team-based survivorship care after primary breast cancer treatment through a multi-level intervention: a pilot randomized controlled trial.

We developed and tested a multi-level intervention, ConnectedCancerCare (CCC), which includes a tailored website and appointment reminder system for women with early-stage breast cancer and a provider summary letter sent to their medical oncologist and primary care provider to improve the delivery of team-based survivorship care. We conducted a pilot randomized controlled trial to establish the feasibility and acceptability of CCC. Women diagnosed with stages 0-II breast cancer within one year of completing primary treatment were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed baseline and 3-month follow-up surveys online. Post-trial interviews with 5 PCPs, 6 oncology providers, and 8 intervention patients were conducted. Of the 160 eligible women invited to participate, 66 completed the baseline survey and were randomized (41%) and 54 completed a follow-up survey (83%). Participants in the intervention arm found the CCC content to be acceptable, with 82% reporting it was easy to use and 86% reporting they would recommend it to other patients. Women randomized to CCC (vs. control) more often reported scheduling a PCP follow-up visit (64% vs. 42%), communicating with their PCP about provider roles (67% vs. 18%), and higher mean team-based cancer care knowledge scores (3.7 vs. 3.4). Deploying CCC in medical oncology practices was feasible, and the intervention content was acceptable. CCC shows promise for improving patient knowledge and patient-provider communication about provider roles in team-based cancer care and encouraging patients to engage with their PCP early in the survivorship period.

Impact of Covid-19 on Cancer Care – A Single Institution Experience – GoVernment Arignar Anna Memorial Cancer Hospital &amp; Research Institute (RCC), Kanchipuram

Background: COVID-19 has impacted health care all over the world. In this article, we will discuss how the pandemic has influenced daily practice and treatment protocols in cancer care in our institution, during the course of its two waves, i.e., from March to September 2020 and March to June 2021. Materials and Methods: Several measures were taken to ensure safety and treatment of cancer patients. Setting up of isolation wards, admission of all patients for treatment, increasing radiotherapy machine ‘on time’, periodic sanitation, treatment area hygiene, personal protection equipments for medical personnel were some of them. Changes were made in radiotherapy, medical oncology, surgical oncology and anaesthesia practices. Patients who became COVID positive were managed in a Covid Care Centre, outside the premises of our institution. Results: The number of patients treated and procedures done in our institution during the first wave of the pandemic in 2020 was much lower compared to the same time period in 2019. But that was not the case with the second wave in 2021. Among the health care workers who tested positive for the virus during the two waves, none required hospitalization and no deaths occurred. Conclusion: Covid-19 has definitely influenced our cancer care for a transient period during the first wave. Modifications in treatment procedures were done only for a short period before we switched back to standard department protocols. With the onset of the second wave, taking previous wave’s experiences into consideration, measures were taken to ensure safe and continuous cancer treatment delivery.