National Cancer Institute Designated Cancer Center Research Articles

Clinician-to-clinician connectedness and access to gastric cancer surgery at National Cancer Institute-designated cancer centers

BackgroundFor patients with gastric cancer, the pathway from primary care (PC) clinician to gastroenterologist to cancer specialist (medical oncologist or surgeons) is referral dependent. The impact of clinician connectedness on disparities in quality gastric cancer care, such as at National Cancer Institute–designated cancer centers (NCI-CC), remains underexplored. This study evaluated how clinician connectedness influences access to gastrectomy at NCI-CC. MethodsMaryland’s All-Payer Claims Database was used to evaluate 667 patients who underwent gastrectomy for cancer from 2013 to 2018. Two separate referral linkages, defined as ≥9 shared patients, were examined: (1) PC clinicians to gastroenterologists at NCI-CC and (2) gastroenterologists to cancer specialists at NCI-CC. Multiple logistic regression models determined associations between referral linkages and odds of undergoing gastrectomy at NCI-CC. ResultsOnly 15% of gastrectomies were performed at NCI-CC. Patients of gastroenterologists with referral links to cancer specialists at NCI-CC were more likely to be <65 years, male, White, and privately insured. Every additional referral link between PC clinician and gastroenterologist at NCI-CC and between gastroenterologist and cancer specialist at NCI-CC increased the odds of gastrectomy at NCI-CC by 71% and 26%, respectively. Black patients had half the odds as White patients in receiving gastrectomy at NCI-CC; however, adjusting for covariates including clinician-to-clinician connectedness attenuated this observation. ConclusionPatients of clinicians with low connectedness and Black patients are less likely to receive gastrectomy at NCI-CC. Enhancing clinician connectedness is necessary to address disparities in cancer care. These results are relevant to policy makers, clinicians, and patient advocates striving for health equity.

Representativeness of Patients With Lung Cancer in an Integrated Health Care Delivery System.

Observational research is important for understanding the real-world benefits of advancements in lung cancer care. Integrated health care systems, such as Kaiser Permanente Northern California, have extensive electronic health records suitable for such research, but the generalizability of their populations is often questioned. Leveraging data from the California Cancer Registry, the authors compared distributions of demographic and clinical characteristics, in addition to neighborhood and environmental conditions, between patients diagnosed with lung cancer from 2015 through 2019 at Kaiser Permanente Northern California, National Cancer Institute-designated cancer centers (NCICCs), and all other non-NCICC hospitals within the same catchment area. Of 20,178 included patients, 30% were from Kaiser Permanente Northern California, 8% from NCICCs, and 62% from other non-NCICC hospitals. Compared to NCICC patients, Kaiser Permanente Northern California patients were more similar to other non-NCICC patients on most characteristics. Compared to other non-NCICC patients, Kaiser Permanente Northern California patients were slightly older, more likely to be female, and less likely to be Hispanic or Asian/Pacific Islander and to reside in lower socioeconomic status (SES) neighborhoods. In contrast, NCICC patients were younger, less likely to be female or from non-Asian/Pacific Islander minoritized racial groups, and more likely to present with early-stage disease and adenocarcinoma and to reside in neighborhoods with higher SES and lower air pollution than Kaiser Permanente Northern California or other non-NCICC patients. Patients from Kaiser Permanente Northern California, compared to NCICCs, are more broadly representative of the underlying patient population with lung cancer. Research using electronic health record data from integrated health care systems can contribute generalizable real-world evidence to benchmark and improve lung cancer care.

Access to cancer center information for patients with limited English proficiency from NCI Cancer Center websites.

e23124 Background: Patients with Limited English Proficiency (LEP) can experience health disparities in cancer care and clinical trial participation. This study sought to assess the availability of information on interpreter services, clinical trials, and second opinions from National Cancer Institute – Designated Cancer Center (NCI-DCC) websites for patients with LEP. Methods: The public facing websites of all 65 adult NCI-DCCs were reviewed from January 1, 2023 to May 15, 2023 to assess availability of English and translated, non-English information on interpreter services, second opinion programs, and clinical trials. Data abstraction was conducted through predefined criteria for website inspection and search bars. Three authors independently abstracted websites for content, with constant comparison until consensus was achieved. Chi-square tests were used to ascertain any significant association between the proportion of LEP populations served by the centers ( &gt; 5%) and their likelihood to provide translated information. Results: 92.3% of NCI-DCCs and their affiliated flagships hospitals provide information on interpreter services for patients with LEP. This information was translated into a non-English language approximately half of the time. All NCI-DCC center webpages provide information on clinical trials and 38.5% provide information regarding second opinions. There was no difference in the availability of translated information on interpreter services or second opinion programs based on percentage of LEP population. However, there was an association between higher LEP population and the provision of translated clinical trial pages. Conclusions: The majority of NCI-DCCs provide information on their webpages related to interpreter services and clinical trials. Half of these centers provide this information in a non-English language and there was an association between higher percentage of LEP populations in the NCI-DCC state and translated clinical trial pages. Future work should identify optimal methods to provide cancer related information to patients with LEP with the goal of improving clinical trial participation for LEP populations. [Table: see text]

Evolution of community outreach and engagement at National Cancer Institute-Designated Cancer Centers, an evolving journey.

Cancer mortality rates have declined during the last 28 years, but that process is not equitably shared. Disparities in cancer outcomes by race, ethnicity, socioeconomic status, sexual orientation and gender identity, and geographic location persist across the cancer care continuum. Consequently, community outreach and engagement (COE) efforts within National Cancer Institute-Designated Cancer Center (NCI-DCC) catchment areas have intensified during the last 10 years as has the emphasis on COE and catchment areas in NCI's Cancer Center Support Grant applications. This review article attempts to provide a historic perspective of COE within NCI-DCCs. Improving COE has long been an important initiative for the NCI, but it was not until 2012 and 2016 that NCI-DCCs were required to define their catchment areas rigorously and to provide specific descriptions of COE interventions, respectively. NCI-DCCs had previously lacked adequate focus on the inclusion of historically marginalized patients in cancer innovation efforts. Integrating COE efforts throughout the research and operational aspects of the cancer centers, at both the patient and community levels, will expand the footprint of COE efforts within NCI-DCCs. Achieving this change requires sustained commitment by the centers to adjust their activities and improve access and outcomes for historically marginalized communities.

Abstract 6301: Mapping survivor-specific supportive care resources: A digital landscape analysis of NCI-designated cancer centers

Abstract Background: Optimal care for cancer survivors requires a comprehensive array of supportive care services to address the multitude of physical, psychological, social, financial, and health promotion needs of this population. To understand options to address their unique needs, survivors and their caregivers may seek information from online sources. Although National Cancer Institute-Designated Cancer Centers (NCIDCCs) serve as leaders in cancer treatment and care delivery, as well as credible sources for survivors to receive information on their recovery, no study has characterized the digital landscape of survivorship offerings on their website. This study aims to characterize the supportive care services offered to cancer survivors on NCIDCCs. Methods: Of the 72 NCIDCCs, 65 provide clinical care. We reviewed the webpage of each to identify supportive care offerings. Services were categorized based on the four domains of the quality-of-life model: (1) physical well-being, (2) psychological well-being, (3) social well-being, and (4) spiritual well-being. Supportive care services were classified as survivor-specific if the online description included information that specifically catered to cancer survivors. Results: Of the 65 clinical NCIDCC websites, 100% offer supportive care services and 54% offer supportive care services specific to survivors (Table). The most common supportive care service offered was nutrition (90.6%) and the least commonly offered was caregiver support (7.9%). Behavioral medicine was offered most frequently for survivors (28.3%) and caregiver support was offered the least (0%). Out of the four domains of the quality-of-life model, spiritual well-being services were offered the least at NCIDCCs. Conclusion: More than half of the NCIDCC websites provided survivor-specific supportive care services. Supportive care services on websites of NCI-Designated or Comprehensive Cancer Centers (N = 65) Supportive Care Service (n) % Supportive Care Service Specific to Cancer Survivors (n) % Physical Well Being Services Nutrition 58 90.6 14 24.1 Genetics 53 82.8 5 9.4 Pain and Palliative Care 52 81.3 8 15.4 Complementary and Alternative Medicine 49 75.4 6 12.2 Integrative Medicine 47 73.4 9 19.1 Occupational Therapy 45 70.3 6 13.3 Fertility Preservation 43 66.2 6 14 Tobacco Cessation 38 58.5 6 15.8 Speech 36 56.3 3 8.3 Exercise 29 45.3 5 17.2 Primary Care 6 9.2 3 50 Psychological Well-Being Services Behavioral Medicine 53 81.5 15 28.3 Recreational Therapy 36 58.1 5 13.9 Social Well-Being Services Oncology Social Work 56 87.5 5 8.9 Patient Navigation 33 51.6 3 9.1 Financial Counseling 32 50 4 12.5 Self-Image 27 41.5 3 11.1 Reproductive and Sexual Health 22 33.8 5 22.7 Caregiver Support 5 7.9 0 0 Spiritual Well-Being Services Pastoral Services 49 75.4 5 10.2 Citation Format: Alexis Taylor, Katherine Sterba, Evan Graboyes. Mapping survivor-specific supportive care resources: A digital landscape analysis of NCI-designated cancer centers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6301.

Variability in expenses related to spine oncology care: comparison of payer-negotiated rates at National Cancer Institute-Designated Cancer Centers

BACKGROUNDAs of 2021, the Centers for Medicare and Medicaid Services (CMS) requires all hospitals to publish their commercially negotiated prices. To our knowledge, price variation of spine oncology diagnosis and treatments has not been previously investigated. PURPOSEThe aim of this study is to characterize the availability and variation of prices for spinal oncology services among National Cancer Institute-Designated Cancer Centers (NCI-DCC). STUDY DESIGNCross-sectional analysis. METHODSCancer centers were identified; those that did not provide patient care or participate in Medicare's Inpatient Prospective System were excluded. A cross-sectional analysis was conducted to gather commercially negotiated prices by searching online for “[center name] price transparency OR machine-readable file OR chargemaster.” Data obtained was queried using 44 current procedural terminology (CPT) codes for imaging, procedures, and surgeries relevant to spine oncology. Comparison of prices was achieved by normalizing the median price for each service at each center to the estimated 2022 Medicare reimbursement for the center's Medicare Administrator Contractor. The ratios between the lowest and highest median commercial negotiated price within a center and across all centers were defined as “within-center ratio” and “across-center ratio” respectively. RESULTSIn total, 49 centers disclosed commercial payer-negotiated rates. Mean rate (±SD) for cervical corpectomy was $9,134 (±$10,034), thoracic laminectomy for neoplasm excision was $5,382 (±$5502), superficial bone biopsy was $1,853 (±$1,717), and single-photon emission computerized tomography (SPECT) was $813 (±$232). Within-center ratios ranged from 5.0 (SPECT scan) to 17.8 (radiofrequency bone ablation). Across-center ratios (for codes with > 10 centers reporting) ranged from 9.0 (corpectomy, thoracic, lateral extra-cavitary) to 418.7 (anterior approach cervical corpectomy). CONCLUSIONSPrice transparency for spinal oncology remains elusive despite recent CMS regulatory oversight, with marked heterogeneity in the quality of published rates complicating patients' ability to “shop” for care. Additionally, there continues to be significant variation in commercial rates for spine oncology diagnosis and treatment. CLINICAL SIGNIFICANCEDespite regulation by CMS, prices for spinal oncology services are not uniformly available to patients and vary between NCI-DCC. The findings of this manuscript present potential barriers for patients to compare and obtain affordable care.

Readability Analysis of Online Breast Cancer Surgery Patient Education Materials from National Cancer Institute-Designated Cancer Centers Compared with Top Internet Search Results.

The National Institutes of Health (NIH) recommends patient education materials reflect the average reading grade level of the US population. Due to the importance of shared decision-making in breast cancer surgery, this study evaluates the reading level of patient education materials from National Cancer Institute-designated cancer centers (NCI-DCC) compared with top Internet search results. Online materials from NCI-DCC and top Internet search results on breast cancer, staging, surgical options, and pre- and postoperative expectations were analyzed using three validated readability algorithms: Simplified Measure of Gobbledygook Readability Formula, Coleman-Liau index, and Flesch-Kincaid grade level. Mean readability was compared across source groups and information subcategories using an unpaired t-test with statistical significance set at p < 0.05. Mean readability was compared using a one-way analysis of variance. Mean readability scores from NCI-DCC and Internet groups ranged from a 9th-12th grade level, significantly above the NIH recommended reading level of 6th-7th grade. There was no significant difference between reading levels from the two sources. The discrepancy between actual and recommended reading level was most pronounced for "surgical options" at a 10th-12th grade level from both sources. Patient education materials on breast cancer from both NCI-DCC and top Internet search results were written several reading grade levels higher than the NIH recommendation. Materials should be revised to enhance patient comprehension of breast cancer surgical treatment and guide patients in this important decision-making process to ultimately improve health outcomes.

Geographic Disparity of Outcome in Patients With Cancer Over Decades: The Surveillance, Epidemiology, and End Results

BackgroundImprovements in prevention, early detection, and effective cancer therapy have decreased cancer-related mortality; however, significant health disparities exist. Therefore, we investigated the impact of these disparities on survival. MethodsIn the Surveillance, Epidemiology, and End Results, we identified 784,341 patients with cancer between 1990 and 2016 in Georgia, 68,493 between 1990 and 1999; 371,353 between 2000 and 2009; and 322,932 between 2010 and 2016. We assessed the overall survival (OS) of patients with all cancers, chronic myeloid leukemia (CML), and lung cancer, given the dramatic improvement in outcomes in patients with CML since 2000 compared to the generally considerably worse outcomes in lung cancer. In addition, we assessed the distance from each county to the Georgia Cancer Center (GCC) or the National Cancer Institute-designated Cancer Center (NCI-CC). ResultsThe 5-year OS of patients with any cancer was 55%, and the 5-year OS of each county ranged from 33% to 82% (interquartile range, 51%-65%) (P < .001). In patients with lung cancer and CML, the 5-year OS rates were 15% and 52%, respectively. The geographic differences between counties were relatively small and constant over time for patients with lung cancer. However, geographic differences were more prominent in patients with CML and widened after the introduction of modern therapies. Multivariate Cox regression showed that age, median county income, race, and distance to GCC or NCI-CC were predictive factors. ConclusionsSignificant disparities in cancer care exist among geographic locations. Geographic differences in survival appear more prominent when highly effective therapies are available.

Assessing the translation capabilities of NCI-designated cancer websites with a focus on lung, breast, prostate and ovarian cancers.

e18514 Background: The world is becoming more and more dependent on the internet for garnering information. Medicine is no exception, with studies suggesting that 70% of patients will consult the internet to learn more about their health. Considering the diverse population served by the United States healthcare system, it is crucial that information can be accessed by Americans of Limited English Proficiency (LEP). This is especially true when it comes to cancer, a disease affecting hundreds of thousands of LEP Americans each year. National Cancer Institute (NCI)-designated cancer treatment centers represent the cutting-edge treatment facilities in oncology. Americans diagnosed with cancer often turn to the website of the nearest NCI-designated cancer center. Our study provides a snapshot of which NCI-designated cancer center websites provide translation capabilities for patient navigations including appointment scheduling, disease information and treatment for four of the most common types of cancer. Methods: Over the course of 2022, we performed a cross-sectional review of the language and translation services available to patients on each of the 71 NCI-designated cancer center websites with a focus on lung, breast, prostate and ovarian cancers. The primary outcomes included availability of translation services, method of translation (google translator vs. written text vs. telephonic) and number of languages offered. Results: Of the 71 NCI-designated cancer center websites, 15 (21.1%) provide information on prostate, lung, ovarian and breast cancer in languages other than English. Among these, 9 (60%) provide direct translation, 1 redirects the user to the NCI website for cancer information, and 5 offer only language lines. Furthermore, of the 9 cancer centers offering direct translation on their websites, only 6 had 2 or more languages. The most common translation language was Spanish (15/15) followed by Arabic and Chinese (11/15). The availability of translated cancer information on these websites did not correlate with the prevalence of LEP in each state. Analyzing previous NCI website interrogations shows that there has been no increase in the translation capabilities of NCI websites since 2019. Conclusions: One way to improve the quality of care in patients with Limited English Proficiency by improving access to care is to increase language concordant resources. NCI designated cancer center websites are sources of cancer related health knowledge. Our research exemplified that there are areas of opportunity to improve the reachability of these recourses to the LEP population. Increasing language concordant resources acknowledges and addresses one of the barriers to care that interferes with the quality of cancer care for LEP patients, promoting shared health care decision making for better health outcomes in a vulnerable population.

Geographic disparities in Medicare telehealth utilization and access to specialized cancer care in the United States.

e13683 Background: Access to specialized cancer care varies by place of residence, partly due to differences in geographic proximity to designated cancer centers. Telehealth services can help alleviate some of these geographic disparities. In response to the COVID-19 pandemic, Medicare telehealth services were expanded rapidly. In this study, we sought to describe the geographic variations in Medicare telehealth utilization and their relationship with locations of designated cancer centers in the United States. We hypothesized that differences in telehealth utilization might be reflective of barriers to telehealth access for Medicare beneficiaries in these regions. Methods: We used the Medicare Telehealth Trends data file and calculated the proportion of Medicare users who used a telehealth service (% Telehealth Users) across all quarters of 2021. To obtain % Telehealth Users in a state, the number of telehealth users were divided by the total number of telehealth-eligible users. Then, using % Telehealth Users as a metric of telehealth utilization, we ranked all US states by overall % Telehealth Users, and % Telehealth Users in rural and urban locations. Finally, we correlated these ranks with the presence of an NCI (National Cancer Institute) Designated Cancer Center within the states. Results: The % Telehealth Users ranged from 15%-53% overall, 16%-54% for rural locations, and 14%-54% for urban locations, across lowest ranked to highest ranked states. The 5 lowest ranking states and their respective % Telehealth Users overall were- Wyoming (20%), Montana (20%), Iowa (20%), South Dakota (18%), Nebraska (17%), and North Dakota (15%). The lowest ranking states in terms of rural % Telehealth Users were Montana, Kansas, Iowa, Tennessee, Wyoming (19% each), and South Dakota and Nebraska (16% each). The lowest ranking states in terms of urban % Telehealth Users were Montana (20%), Wyoming (20%), Nebraska (19%), South Dakota (16%), and North Dakota (14%). 4 out of 6 states overall, 3 out of 7 in the rural category, and 4 out of 5 states in the urban category that were ranked the lowest in telehealth utilization did not have an in-state NCI designated cancer center. Conclusions: Telehealth services can bridge gaps in access to specialty cancer care for patients that do not live in geographic proximity of cancer centers. However, regions lacking geographic proximity to cancer centers were also regions with poorest telehealth utilization. Advocacy and policy efforts directed towards increasing access to telehealth can ensure equitable and timely access to specialized cancer care in these regions of need.

Geographical Barriers to Accessing Specialty Cancer Care Among Adolescents and Young Adults with Acute Lymphoblastic Leukemia

Background Prior studies demonstrated that a minority of adolescents and young adults (AYA, age 15-39 years) with acute lymphoblastic leukemia (ALL) receive care at specialty cancer centers (SCC), defined as National Cancer Institute Designated Cancer Centers (NCIDCC) and/or Children's Oncology Group (COG) sites. Receipt of front-line ALL treatment at an SCC appears particularly important, as a significant survival benefit has been observed for AYA ALL patients treated at these sites. In this population-based analysis, we describe the geographical distribution of U.S. AYA ALL patients relative to SCCs and identify patients at risk of severe geographical barriers to SCC-level care. Although an association between NCI Community Oncology Research Program (NCORP) sites and AYA ALL outcomes have not, to our knowledge, been assessed, we also evaluated NCORP sites, as the NCORP program may offer an opportunity for clinical trial participation. Methods We used data obtained from the North American Association of Central Cancer Registries (NAACCR) to identify the county at diagnosis of AYA ALL patients diagnosed between 2004-2016 across 43 U.S. states; 7 states did not release data (light gray in Figures). Addresses of NCIDCC, COG and NCORP sites were obtained from publicly available websites. Driving distance and travel time from counties where participants lived to the closest NCI, COG and NCORP sites were calculated for each individual. For Hawaii and Alaska only, straight line distances were calculated because distances between patients and facilities are separated by water, separated by another country or the counties are so large that counties centroids had to be moved long distances to attach to the road network. Geographic access to an SCC or NCORP site was mapped by county. Based on a combination of driving distance and the number of patients diagnosed within a county during our study period, we grouped each county as having excellent, mild, moderate or severe access issues (see Figure for definitions). Results Among 11,813 AYA ALL patients, 43% were 25-39 years old, 66% were male, 33% were Hispanic, and 37% had public insurance. More patients lived in the West (30%), followed by the Northeast (22%), Southwest (17%), Midwest (16%), and Southeast (15%). A total of 1,537 U.S. counties were found to have at least one newly diagnosed AYA ALL patient; the largest patient population was present in Los Angeles County, CA (n=749). The distribution of U.S. AYA ALL patients relative to NCIDCC (Fig 1A), COG (Fig 1B), and NCORP centers (not shown) demonstrates that moderate/severe issues in geographical access to NCIDCC affects 43% of AYA ALL patients, relative to COG (19%) and NCORP (28%). Strikingly, 31%, 21% and 13% of patients would need to drive ≥ 1.5 hours one way to access the nearest NCIDCC, NCORP or COG center, respectively. In contrast, 43% of AYA ALL patients experience excellent geographical access to an NCIDCC, while 61% and 58% have excellent access to a COG or NCORP site, respectively. Conclusions Although AYA ALL patients have experienced superior survival following treatment at an SCC, substantial geographical barriers exist to accessing this care across the U.S., particularly at NCIDCC. Broader geographical access to COG sites suggests some younger AYAs may benefit from consideration of referral to these pediatric centers. While NCORP centers appear more geographically accessible than NCIDCC, work is needed in order to understand whether these sites consistently provide comprehensive ALL care and clinical trial options across the U.S. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

MSPP06 Presentation Time: 4:50 PM: Price Availability for Prostate Brachytherapy, External Beam Radiation Therapy, and Radical Prostatectomy

<h3>Purpose</h3> For patients with low to favorable-intermediate risk prostate cancer (PC), management with active surveillance, radical prostatectomy (RP), external beam radiation therapy (EBRT), and brachytherapy (BT) are all National Cancer Center Network-supported monotherapy options. Because therapy is non-urgent and choosing between these options can be complex, patients routinely seek second opinions. Expectedly, the cost of therapy can be an important consideration. Recent federal price transparency (PT) guidance requires hospitals to provide payer-negotiated prices for at least 300 common services in a "shoppable," user-friendly, online format. Seventy services, including RP, are specified, while the remainder are left to the discretion of each institution. Even though there is equipoise between radiation therapy (RT, inclusive of EBRT and BT) and RP in definitive treatment for PC, inclusion of prices for RT is optional. National Cancer Institute (NCI)-designated cancer centers (NCI-CC) are referral centers catering to high volumes of patients with cancer. Although NCI-CC have the option to volunteer prices for RT, the rate at which these institutions choose to report payer-negotiated price estimates for prostate-directed RT is unknown. We hypothesize that reporting rates for BT and EBRT may substantially trail rates of mandatory price reporting for RP. <h3>Materials and Methods</h3> Through online query, we identified "shoppable" price tools for NCI-CC in December 2021. Using Current Procedural Terminology billing codes and keyword searches, we queried these price tools for cost estimates for RP, EBRT (delivered using intensity modulated radiation therapy), and BT. Both high dose rate (HDR) and low dose rate (LDR) BT were considered. NCI-CC were stratified by Medicare Prospective Payment System(PPS)-exempt status; these 11 NCI-CC are exempt from standard Medicare fee for service reimbursement caps. Descriptive statistics, include frequency counts and proportions, were performed. The rate of reporting of "shoppable," negotiated prices for each therapy was assessed. These rates were compared using the chi-squared test at a significance level of α=0.05. <h3>Results</h3> Of the 63 NCI-CC offering clinical care, 58 (92%) published "shoppable" tools. Seven (11%), 6 (10%), and 51 (81%) published "shoppable" prices for BT, EBRT, and RP, respectively (Figure 1), translating to a significantly higher rate of publication of prices for RP than for EBRT or BT (<i>P</i> < 0.001). All of the published prices for BT were for HDR-BT and none were for LDR-BT. PPS-exempt cancer hospitals had the highest rates of reporting "shoppable" prices at 91%, with 64%, 27%, and 36% including prices for RP, EBRT, and BT, respectively. <h3>Conclusions</h3> Under current federal guidance, patients with PC can obtain online payer-negotiated price estimates for BT and EBRT from just roughly 10% of NCI-CC, while price estimates for RP are offered by more than 80% of these institutions. For patients with PC, this represents a potential obstacle to informed decision making, undermines the stated goals of US PT health policy, and the impact of this unintended effect of PT laws on BT utilization rates (or patient choice of therapy) is unknown. Moving forward, mandating the inclusion of common radiotherapy services (EBRT and BT) in "shoppable" price tools is a straightforward intervention that may be highly beneficial to this patient population.

Price variability of pembrolizumab across U.S. National Cancer Institute–designated Cancer Centers (NCICCs) from 2016-2021.

48 Background: NCICCs are poorly compliant to price transparency rules set forth by the CMS. Competitive price shopping is prevented due to a lack of uniform rate setting, and service charges are often higher than what a hospital reasonably expects to be reimbursed. We investigated variability in the charged and reimbursed payments for pembrolizumab utilizing Medicare claims across all NCICCs. Methods: Medicare claims data from 2016-2021 for pembrolizumab (HCPCS J9271) infusions in a hospital outpatient department were selected from the Definitive Healthcare claims database for all hematology-oncology and medical oncology providers at NCICCs. Average charges, reimbursements, and total claims were obtained. Annual percentage changes (APC) were calculated to evaluate trends during study period. Prices are presented as inflation adjusted numbers (charged and reimbursed; 2021 dollars). Analyses were performed in Excel (Microsoft Corp). Results: Our analysis included 53 NCICCs of which 47 were part of the 340B Drug Pricing Program (NCI-340B), 11 were Prospective Payment System-exempt (NCI-PPS), and 6 NCICCs were both (PPS/340B). From 2016 to 2021, total Medicare claims increased from 9461 to 46291 across NCICCs, with NCI-PPS centers comprising 30% of claims. Total payments to NCICCs increased from $55.9M to $388.1M annually. Average charge for pembrolizumab in 2021 were: $45,227 (NCI-PPS), $46,000 (all NCICCs), $49,057 (NCI-340B), $59,392 (dual-eligible PPS/340B). During study period, APC were: 9.2% (NCICCs), 9.6% (NCI-340B), 12.8% (NCI-PPS), and 17.5% (dual-eligible PPS/340B). Despite high charged prices, reimbursement was much lower, about 18.4% (or $7364) of charged price at NCICCs over study period. Highest reimbursement was noted at NCI-PPS (22%, or $8551), and lowest at NCI-340B (16.4% or $7086) over study period. When considering a smaller cohort of PPS-only or 340B-only, PPS-only status was associated with lowest charged price but highest reimbursement (33.5%, or $8568). Conclusions: NCICCs charged &gt; 4 times the average reimbursed price for pembrolizumab, with charges increasing faster than inflation. While lower charges were noted at NCI-PPS, they received higher reimbursement. Dual PPS/340B status commanded the highest charged prices and quickest price increases. Our study informs greater price transparency regulation at NCICCs and raises questions regarding utility of special status benefits from the federal government.[Table: see text]

Impact of proposed 2022 changes to the Merit-Based Incentive Payment System (MIPS) on oncologist performance and reimbursement.

6 Background: In 2017, the Centers for Medicare &amp; Medicaid Services (CMS) executed a landmark bipartisan legislation aimed at gradually shifting American healthcare from a fee-for-service model to a value-based system. The resulting payment model, MIPS, uses cost and quality metrics to assign clinicians an overall MIPS score, where higher scores correspond to greater payments for practices. In 2018, cost metrics contributed only 10% of this composite score, while quality metrics contributed 50%. Beginning with 2022, the cost and quality categories will be equally weighted (30% each) to encourage clinicians to reduce healthcare costs. As the cost of cancer care is disproportionately high, we investigated the implications of the updated scoring on reimbursements for oncologists and other providers participating in MIPS. Methods: We included physicians participating in the 2018 MIPS Performance Year files. We categorized hematological-, medical, radiation, gynecological, and surgical oncologists as oncologists and delineated those with National Cancer Institute-designated Cancer Center (NCICC)-affiliation. We excluded individuals who were exempt from reporting cost scores due to their MIPS-filing method. We calculated the projected 2022 MIPS composite scores (range, 0-100) by multiplying the 2022 weights by the 2018 component scores. We compared the change in composite MIPS score and the corresponding negative payment adjustments due to reweighing across specialties. Clopper–Pearson 95% confidence intervals were reported. Results: The cohort included 168,659 physicians, of which 163,150 (97%) were non-oncologists and 5,509 (3%) were oncologists. Of oncologists, 1,757 (32%) were at a NCICC. Cost scores (higher is better) for each group were as follows: non-oncologists, 75.2; all oncologists, 65.5; NCICC oncologists, 57.1. Reweighing the 2018 MIPS composite scores with the updated 2022 cost/quality weights resulted in a mean 1.7-point decrease (88.7 to 87) for non-oncologists, a 3.8-point decrease (89.7 to 85.9) for all oncologists, and a 5.2-point decrease (89.2 to 84) for NCICC oncologists. Following the reweighing, the proportion of non-oncologists incurring penalties will increase by 12.8% (95% CI, 12.7%–12.9%); all oncologists by 14.3% (95% CI, 13.2%–15.4%); and NCICC oncologists by 20% (95% CI, 18.1%–21.9%). Conclusions: Beginning with 2022 performance year, federally mandated reweighing of MIPS cost metrics will result in a disproportionate increase in oncologists receiving negative payment adjustments. With a majority Medicare population with new cancer diagnoses, higher patient complexity, and declining operating margins at many oncologic practices, we highlight striking upcoming changes that may inform further optimization of MIPS cost metrics by CMS to ensure oncologists providing high quality care are not penalized.

Improved survival in cervical cancer patients receiving care at National Cancer Institute–designated cancer centers

BackgroundLocally advanced cervical cancer (CC) remains lethal in the United States. We investigate the effect of receiving care at an National Cancer Institute–designated cancer center (NCICC) on survival.MethodsData for women diagnosed with CC from 2004 to 2016 who received radiation treatment were extracted from the California Cancer Registry (n = 4250). Cox proportional hazards regression models assessed whether (1) receiving care at NCICCs was associated with risk of CC‐specific death, (2) this association remained after multivariable adjustment for age, race/ethnicity, and insurance status, and (3) this association was explained by receipt of guideline‐concordant treatment.ResultsMedian age was 50 years (interquartile range [IQR] 41–61 years), with median follow‐up of 2.7 years (IQR 1.3–6.0 years). One‐third of patients were seen at an NCICC, and 29% died of CC. The hazard of CC‐specific death was reduced by 20% for those receiving care at NCICCs compared with patients receiving care elsewhere (HR = .80; 95% CI, 0.70–0.90). Adjustment for guideline‐concordant treatment and other covariates minimally attenuated the association to 0.83 (95% CI, 0.74–0.95), suggesting that the survival advantage associated with care at NCICCs may not be due to receipt of guideline‐concordant treatment.ConclusionsThis study demonstrates survival benefit for patients receiving care at NCICCs compared with those receiving care elsewhere that is not explained by differences in guideline‐concordant care. Structural, organizational, or provider characteristics and differences in patients receiving care at centers with and without NCI designation could explain observed associations. Further understanding of these factors will promote equality across oncology care facilities and survival equity for patients with CC.

Lack of price transparency for prostate-directed radiation therapy relative to radical prostatectomy.

1579 Background: For patients with low to favorable-intermediate risk prostate cancer (PC), management with active surveillance, radical prostatectomy (RP), external beam radiation therapy (EBRT), and brachytherapy (BT) are all National Cancer Center Network-supported definitive monotherapy options. Because therapy is non-urgent and choosing therapy can be complex, patients routinely seek second opinions and cost can be an important consideration. Recent federal price transparency (PT) guidance requires hospitals to provide payer-negotiated prices for ≥300 common services in a “shoppable,” user-friendly, online format. 70 services, including RP, are specified, while the remainder are left to institutional discretion. Despite equipoise between radiation therapy (RT, inclusive of EBRT and BT) and RP in definitive treatment for PC, inclusion of prices for RT is optional. National Cancer Institute (NCI)-designated cancer centers (NCI-CC) are high volume referral centers who have the option to volunteer prices for RT; the rate at which NCI-CC choose to report payer-negotiated price estimates for prostate-directed RT is unknown. We hypothesize that reporting rates for BT and EBRT are significantly lower than for RP. Methods: Through online query, we identified “shoppable” price tools for NCI-CC in December 2021. Using billing codes and keyword searches, we queried these price tools for cost estimates for RP, EBRT (delivered using intensity modulated radiation therapy), and BT. Descriptive statistics, include frequency counts and proportions, were performed. The rate of reporting of “shoppable,” negotiated prices for each therapy was assessed. These rates were compared using the chi-squared test (significance level of α = 0.05). Results: Of the 63 NCI-CC offering clinical care, 58 (92%) published “shoppable” tools. 6 (10%), 7 (11%), and 51 (81%) published “shoppable” prices for EBRT, BT, and RP, respectively, demonstrating a significantly higher rate of publication of prices for RP than for EBRT or BT ( P &lt; 0.001). All of the published prices for BT were for high dose rate BT. The 11 Medicare Prospective Payment System–exempt NCI-CC had the highest rates of reporting “shoppable” prices at 91%, with 64%, 27%, and 36% including prices for RP, EBRT, and BT, respectively. Conclusions: Under existing regulations, patients with PC can obtain payer-negotiated price estimates for EBRT and BT from just roughly 10% of NCI-CC, while price estimates for RP are offered by &gt; 80% of these institutions. This represents a potential obstacle to informed decision making, undermines the stated goals of US PT health policy, and the impact on utilization rates (or patient choice of therapy) is unknown. Moving forward, mandating the inclusion of common RT services (EBRT and BT) in “shoppable” price tools is a straightforward intervention that may be highly beneficial in this common cancer population.

National cancer centers addressing climate change: An overview and analysis of organizations' sustainability plans.

e13623 Background: Climate change is one of the largest threats to human health and greenhouse gas (GHG) emissions are a substantial component of climate change. In the U.S., the healthcare industry accounts for an estimated 8.5% of GHG emissions, equating to the loss of 470,000 disability-adjusted life-years annually. Cancer care encapsulates a significant portion of hospital resources and climate change has disproportionate effects on cancer patients. Therefore, it is imperative and urgent that cancer centers actively engage in reducing healthcare related GHG emissions. In this systematic analysis and comprehensive review, we reviewed publicly accessible sustainability plans of National Cancer Institute (NCI)-designated Cancer Centers and their affiliated organizations to understand the involvement Cancer Centers have in their organization's sustainability efforts. Methods: We reviewed 64 NCI designated Cancer Centers, using the first 20 results of a Google search with terms: “Hospital X AND (climate action plan OR climate change OR sustainability plan OR carbon neutral)” and hospital homepages to identify publicly accessible sustainability plans for each organization. We reviewed the plans, performed a Google search/Cancer Center homepage search and messaged sustainability plan developers to identify involvement of the hospital and Cancer Center. We identified which hospitals assigned sustainability personnel. We performed a student’s t-test to assess for a correlation between incidence of lung cancer in a state and presence of a sustainability plan for that state’s Cancer Center. Data was collected by one reviewer, independently validated by a separate reviewer and differences were resolved by a joint data review. Results: Amongst the 65 Cancer Centers and organizations reviewed, 55 (36 university, 12 hospital, 7 joint) had publicly available sustainability plans. Of which, 31% (11/36) of university plans explicitly mentioned an affiliated hospital as part of the sustainability plan. Two Cancer Centers (3%) had independent sustainability plans and 7 (11%) centers mentioned sustainability on their homepage. 77% (23/30) of hospitals with sustainability plans identified sustainability personnel. We did not find an association between the existence of Cancer Center sustainability plan and that state’s lung cancer incidence rates (p = 0.932). Conclusions: In this review and analysis of NCI-designated Cancer Center sustainability plans, we found that while most centers’ affiliated organizations have publicly accessible sustainability plans, the majority (86%) of centers do not independently report on their sustainability efforts. These findings highlight a pressing need to increase engagement between Cancer Centers and their organizations regarding sustainability plans, and a need for greater transparency in publicizing sustainability plans.

Survival of Patients With Primary Osseous Malignancies of the Mobile Spine Is Associated With Access to "Standard Treatment" Protocols.

Malignancies of the mobile spine carry high morbidity and mortality. This study sought to examine factors associated with receipt of "standard" treatment and survival for patients with primary mobile spine tumors in the California Cancer Registry (CCR). The CCR (1988 to 2016) data were obtained for patients with primary tumors of the mobile spine and at least 1-year follow-up. Sacrum/pelvis tumors were excluded. Age at diagnosis, sex, race, neighborhood socioeconomic status, insurance, Charlson Comorbidity Index, histologic diagnosis, stage at diagnosis, and treatment at a National Cancer Institute-designated Cancer Center (NCICC) were collected. Multivariate analyses were done to identify factors associated with all-cause mortality and receipt of "standard" treatment. Four hundred eighty-four patients (64% White, 56% low neighborhood socioeconomic status, and 36% privately insured) were included. Chordoma (37%) was the most common diagnosis. Only 16% had metastatic disease at presentation. Only 29% received treatment at an NCICC. Lower age, Charlson Comorbidity Index, less extensive stage of disease, and private insurance were associated with lower all-cause mortality (all P < 0.05). Medicaid/public insurance (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.13 to 2.41) and Medicare (HR, 1.80; 95% CI, 1.25 to 2.59) were associated with higher mortality compared with private insurance. Patients who received no known treatment (HR, 2.41; CI, 1.51 to 3.84) or treatment other than the "standard" (HR, 1.45; CI, 1.11 to 1.91) had higher mortality compared with those who received the standard protocols. A critical predictor of receiving the standard treatment protocol was being treated at an NCICC. If patients did not receive care at such institutions, they received optimal treatment only 40% of the time (HR, 0.5; P = 0.004). Receipt of defined "standard treatment" protocols was associated with care received at an NCICC and lower all-cause mortality in patients with primary osseous malignancies of the mobile spine. Patients with public insurance are vulnerable to worse outcomes, regardless of age, disease burden, or receipt of standard treatment. III.

Inequity in Telemedicine Use Among Patients with Cancer in the Deep South During the COVID-19 Pandemic.

BackgroundTelemedicine use has increased significantly during the COVID-19 pandemic. It remains unclear if its rapid growth exacerbates disparities in healthcare access. We aimed to characterize telemedicine use among a large oncology population in the Deep South during the COVID-19 pandemic.Materials and MethodsA retrospective cohort study was performed at the only National Cancer Institute designated-cancer center in Alabama March 2020 to December 2020. With a diverse (26.5% Black, 61% rural) population, this southeastern demographic uniquely reflects historically vulnerable populations. All non-procedural visits at the cancer center from March to December 2020 were included in this study excluding those with a department that had fewer than 100 visits during this time period. Patient and clinic level characteristics were analyzed using t-test and Chi-square to compare characteristics between visit types (in-person versus telemedicine, and video versus audio within telemedicine). Generalized estimating equations were used to identify independent factors associated with telemedicine use and type of telemedicine use.ResultsThere were 50 519 visits and most were in-person (81.3%). Among telemedicine visits, most were phone based (58.3%). Black race and male sex predicted in-person visits. Telemedicine visits were less likely to have video among patients who were Black, older, male, publicly insured, and from lower income areas.ConclusionsTelemedicine use, specifically with video, is significantly lower among historically vulnerable populations. Understanding barriers to telemedicine use and preferred modalities of communication among different populations will help inform insurance reimbursement and interventions at different socioecological levels to ensure the continued evolution of telemedicine is equitable.

Frontline treatment patterns and outcomes among older adults with acute myeloid leukemia: A population-based analysis in the modern era.

Traditionally, conventional induction chemotherapy has been the primary frontline treatment for acute myeloid leukemia (AML); however, older adults are often poor chemotherapy candidates. Recently, several nonconventional frontline AML regimens, including hypomethylating agents, the BCL-2 inhibitor venetoclax, and targeted therapies, have emerged, and they may offer new options for older adults. This study was aimed at describing treatment patterns and outcomes of older adult AML in a modern population-based cohort. This study evaluated patients aged ≥60 years with a first primary diagnosis of AML (2014-2017) in the California Cancer Registry linked to inpatient hospitalizations. Multivariable regression examined factors associated with the frontline treatment regimen and survival. In all, 3068 patients were included; 36% received frontline therapy with a conventional chemotherapy backbone, 42% received nonconventional therapy, and 22% received no treatment. The use of nonconventional therapy increased over time from 38% of patients in 2014 to 47% in 2017 (P < .001). In multivariable analyses, receipt of treatment was associated with an age younger than 80 years, fewer than 2 comorbidities, and care at a National Cancer Institute-designated cancer center (NCI-CC). Compared with conventional chemotherapy, nonconventional therapy was associated with Black race/ethnicity, public health insurance, fewer hospital admissions, and fewer inpatient days. Receiving frontline therapy at an NCI-CC was independently associated with superior overall survival. Using a population-based approach, this study has demonstrated that patterns of care for frontline AML treatment in older adults are changing, with increasing use of nonconventional therapies. A significant proportion of older adults remain untreated. At the population level, there remain opportunities to increase therapy access for older adults with AML.