New Diagnosis Of Cancer Research Articles

Metformin is associated with lower risks of incident cancers compared to sulphonylurea use: a population-based study with competing risk analyses

Abstract Objective To investigate the effects of sulphonylurea compared to metformin on the risks new-onset cancers and mortality in patients with type 2 diabetes mellitus. Methods This is a retrospective population-based cohort study of patients with type 2 diabetes mellitus between 1st January and 31st December 2009 with follow-up until 31st December 2019. Propensity score matching (1:2 ratio) between metformin and sulphonylurea users was performed. The primary outcome is new diagnosis of any cancer. The secondary outcomes are cancer, cardiovascular, or all-cause mortality. Cox regression was used to identify significant predictors. Competing risks were considered using cause-specific or subdistribution hazard models. Propensity score stratification, inverse probability weighting, and high-dimensional propensity score adjustment were also used. Results In the matched cohort, 36487 sulphonylurea and 71306 metformin users were included. Univariable Cox regression showed that compared to metformin users, sulphonylurea users had a higher risks of any new cancer diagnosis (hazard ratio [HR]: 2.26, 95% confidence interval [CI]: 2.18-2.34, P<0.0001), including pancreatic (HR: 4.03 [3.37, 4.82], P<0.0001), colorectal (HR: 2.12 [1.97, 2.27], P <0.0001), genitourinary (HR: 1.73 [1.57, 1.90], P<0.0001), breast (HR: 1.36 [1.22, 1.51], P<0.0001) and lung cancer (HR: 3.37 [3.11, 3.65], P<0.0001) cancers. Sulphonylurea users also had higher risks of cancer-related (HR: 2.38, 95% CI: 1.87-3.03; P<0.0001) and all-cause mortality (HR: 1.92, 95% CI: 1.78 -2.08; P<0.0001). Conclusion Metformin use was associated with lower risks of new diagnosis of any cancer, cancer-related and all-cause mortality in patients with type 2 diabetes mellitus.Figure 1.Study flow diagram.FIgure 2.New diagnosis of cancer.

Clinical utility and impact of a diagnostic oncology clinic.

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

The Edmonton Frail Scale as a screening score for frailty in oncogeriatrics.

The comprehensive geriatric assessment (CGA) is recommended for assessing frailty in older cancer patients but is time-consuming. The G8 screening tool was developed to select frail patients requiring CGA to optimize resources. The Edmonton Frail Scale (EFS) is another frailty scale validated for preoperative frailty screening, but scarcely studied in the field of oncogeriatrics. In this study, we examined the added value of the EFS in older cancer patients already considered as frail by the G8, by analyzing the association of EFS with CGA adjusted for age, gender, metastatic stage and comorbidity. We also analyzed the association of EFS with the one-year mortality rate after adjusting for cancer type and metastatic stage. This retrospective study included patients aged over 70 years old with a new diagnosis of cancer, considered as potentially frail according to the G8 and who had had a CGA (N = 380). The EFS identified 329 (86.58%) patients as frail and having a statistically significant predicted number of pathological components on the CGA (r = 0.64, p < 0.001). When adjusted for age, sex, comorbidity, and metastatic stage, the EFS was independently associated with the CGA (p < 0001), as well as with comorbidity (p = 0.004). The patients who died in the first year (43%) had a significantly higher mean EFS score (8/17) than living patients (6/17) (p < 0.0001). After adjustment for cancer type and stage, EFS independently predicted one-year mortality (OR 1.17; 95% CI 1.08-1.28; pseudo R 2 = 0.228, p < 0.001). The EFS is a reliable tool for predicting frailty identified by the CGA in an older cancer population pre-selected as frail by the G8. EFS is an independent predictor of one-year mortality after adjustment for confounding factors. Validation of the EFS as a screening tool for frailty in cancer requires further studies to assess its performance in patients with normal G8 scores.

1190 Clinical Features and Outcomes from the Acute PresentatiOn of coLorectaL Cancer – an internatiOnal Snapshot (APOLLO) – an International Prospective Audit

Abstract Aim The APOLLO study aimed to describe the international variation in the presentation, management and outcomes of patients presenting acutely with colorectal cancer. Method APOLLO was an international prospective, multicentre cohort study delivered through the EuroSurg student and trainee-led collaborative network. Adult patients presenting acutely with colorectal cancers were included. The primary outcome was 90-day mortality. Country-level variation was analysed using funnel plots. Results 1414 patients (216 centres, 39 countries) were enrolled (median age 70 years; 645 females [45.6%]; ASA Grade I-II: 689 [48.7%]). Common presentations were bowel obstruction (n=774, 54.7%), gastrointestinal haemorrhage (n=297, 21.0%),bowel perforation (n=161, 11.4%). Overall, 56.9% of patients presented with a new diagnosis of cancer (n=804), 13.9% presented while awaiting elective surgery (n=196), and 9.3% while undergoing neoadjuvant therapy (n=132). Most cases were managed with curative intent (n=805, 56.9%). Of the 1022 patients undergoing surgery, 813 underwent surgical resection (79.5%), 582 underwent stoma formation (56.9%), and 498 (48.7%) underwent primary anastomosis. Only 57 patients underwent colonic metallic stenting (4.0%). Overall, 90-day mortality was 19.4%; 90-day surgical mortality was 13.9% and 90-day non-operative mortality was 33.7%. There was significant variation in overall mortality, but not surgical mortality, between countries after case-mix adjustment. Conclusions Emergency colorectal cancer presentations carry significant mortality with and without surgery. Many acute presentations are in patients with known colorectal cancer awaiting treatment. Operative mortality is similar globally, but overall mortality varies between countries. Further work is needed to guide individualised decision making on who benefits from acute surgery with curative-intent.

Quality of Life in Patients and Their Spouses and Cohabitating Partners in the Year Following a Cancer Biopsy (the Couples Cope Study): Protocol for a Prospective Observational Study.

Receiving a diagnosis of cancer is a profound and often very stressful experience. Few studies have prospectively recruited patients prior to receiving a new diagnosis of cancer and included spouses or partners. The aim of the Couples Cope Study is to understand the impact of undergoing a diagnostic biopsy and receiving a new cancer diagnosis on quality of life (QoL) in both patients and their spouses or partners, as well as on the quality of their relationship. This protocol paper describes the study design and assesses the feasibility of recruitment and retention. Study staff reviewed the schedules of collaborating physicians using specific encounter codes to identify patients scheduled for breast or prostate biopsies. Potential participants were prescreened via the electronic health record and sent a recruitment letter at least 2 to 3 weeks prior to their biopsy procedure. Patients subsequently underwent a phone screening to determine eligibility. Patients who enrolled provided study staff with contact information for their spouses or partners. All consent forms were completed online. Surveys were completed online prior to receiving the biopsy results (baseline), and at 1, 3, 6, and 9 months after the biopsy. Study staff engaged in ongoing, personalized contact with participants and sent assessment completion reminders via phone and email. A total of 2294 patients undergoing a breast or prostate biopsy were identified and 69% (n=1582) were eligible for phone screening following electronic health record prescreening. Of the 431 patients who underwent phone screening, 75% (n=321) were eligible to participate. Of the eligible patients, 72% (n=231) enrolled and 82% (n=190) of enrolled patients had an accompanying partner or spouse who also enrolled. A total of 77% (34/44) of patients who received a cancer diagnosis and 72% (26/36) of their spouses or partners were retained through 9 months, while 80% (53/66) of patients who received a benign diagnosis and 68% (42/62) of their partners were retained. Prospective recruitment of patients undergoing diagnostic biopsy and their partners is feasible and requires both strategic collaboration with providers and concerted prescreening and recruitment efforts by study staff. Importantly, this study was able to conduct all study activities online without disrupting clinical workflow and without requiring patients and their spouses or partners to come into the laboratory. Consideration should be given to the ratio of biopsies to cancer diagnoses, which can vary significantly by cancer type. Prospective studies are needed and can inform our ability to provide effective support earlier to couples facing a possible cancer diagnosis. Future studies should examine other tumor types that have received less attention in QoL studies, include behavioral and neurobiological assessments beyond self-report measures, and follow couples beyond 9 months in order to examine long-term effects on QoL. DERR1-10.2196/52361.

Beyond the “teachable moment”: Smoking cessation during cancer treatment remains challenging despite high motivation to quit.

e24141 Background: Continued smoking throughout cancer treatment, including surgery, is associated with treatment-related complications and a higher total symptom burden during treatment. This can lead to interruptions and delays in therapy that can compromise treatment efficacy and survival. Approximately 1 in 3 patients smoke at or around time of cancer diagnosis. Despite this “teachable moment” for smoking cessation, at least half of patients with cancer are unsuccessful in their attempts, and relapse rates for post-surgical cancer patients are high. Better understanding of quit motivation among these patients can help guide tobacco treatment interventions in the post-operative and adjuvant treatment time periods. Methods: This is an analysis of a longitudinal nationwide multicenter study of 1003 patients through the University of Rochester Cancer Center NCI Community Oncology Research Program (URCC NCORP) that assessed treatment type, treatment-related symptoms, smoking status, and motivation to quit smoking for patients with a new diagnosis of cancer. Patients supplied demographic and clinical information at enrollment with assessments at two weeks pre- adjuvant treatment, post adjuvant treatment, and 6 months. Chi-square, multinomial logistic regression, and ANOVA were used to analyze the difference between smokers and nonsmokers, and those with previous surgical treatment. Results: The majority of patients had surgery as part of their cancer treatment (n = 718, 71.6%). Of these (n = 222, 30.9%) had a diagnosis of a tobacco-associated cancer, which was associated with smoking status at pre-treatment (p &lt; 0.05). For those with previous surgery, n = 90 (68.7%, p &lt; 0.001) were current smokers before starting adjuvant treatment. Post-surgical patients who smoke had both higher total symptom burden ( M= 23.7 vs M= 17.0; p &lt; 0.05) and higher symptom severity ( M =1.97 vs M= 1.42; p &lt; 0.001) pre-adjuvant treatment and at 6 month follow up [( M =31.3 vs M= 22.2; p &lt; 0.05);( M= 2.6 vs M= 1.8; p &lt; 0.05)] compared to post-surgical patients who were not smokers. Motivation to quit was sustained among current smokers between the pre- and post- adjuvant treatment periods (p &lt; 0.001), as well as for those that had previous surgery (p &lt; 0.05). Despite motivation to quit among 64.4% of current smokers with previous surgery, 15.4% reported being able to quit by post-adjuvant treatment with 50% relapsing to smoking at 6-month follow up. Conclusions: For patients that continue to smoke after surgical treatment, cessation rates are much lower than motivation to quit with high rates of relapse. Early intervention around the time of surgery presents an ideal opportunity to optimize the “teachable moment” by providing longitudinal tobacco treatment as part of cancer care to improve treatment-related symptoms, as well as overall survival.

Does metformin reduce the risk of cancer in obesity and diabetes? A systematic review and meta-analysis.

To evaluate the effect of metformin on cancer incidence in subjects with overweight/obesity and/or prediabetes/diabetes. We searched MEDLINE, Embase and CENTRAL for randomized controlled trials (RCTs) in adults with overweight/obesity and/or prediabetes/diabetes that compared metformin to other interventions for ≥24 weeks. Independent reviewers selected and extracted data including population and intervention characteristics and new diagnoses of cancer. We used the RoB 2.0 risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework to assess risk of bias and certainty of evidence. From 14 895 records after removal of duplicates, 27 trials were included, providing a total of 10 717 subjects in the metformin group and 10 003 in the control group, with 170 and 208 new cases of cancer, respectively. Using a random-effects model, the relative risk was 1.07 (95% confidence interval 0.87-1.31), with similar results in subgroup analyses by study duration or effect of control intervention on weight. Risk of bias in most studies was low, and no evidence of publication bias was found. Trial sequential analysis provided evidence that the cumulative sample size was large enough to exclude a significant effect of metformin on cancer incidence. Metformin did not reduce cancer incidence in RCTs involving subjects with overweight/obesity and/or prediabetes/diabetes.

Abstract TMP105: Development and Validation of a Risk Prediction Model for Ischemic Stroke Among Individuals Newly Diagnosed With Cancer

Introduction: Cancer is an emerging risk factor for ischemic stroke. The risk of stroke is highest during the first year after a new diagnosis of cancer, but no tools exist to identify which patients are at the highest risk.. Methods: Using linked clinical and administrative health databases, we conducted a population-based retrospective cohort study of adults in Ontario, Canada with newly diagnosed cancer from 2010 - 2021 (excluding non-melanoma skin cancer &amp; central nervous system malignancies). Patients were randomly selected for model derivation (60%) or validation (40%). The final model predicting stroke within 1 year following cancer diagnosis was derived using multivariable Fine-Gray regression with candidate predictors selected via backward elimination. Sub-distribution adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated, where all-cause mortality was treated as a competing event. Model performance of the validation cohort was assessed using the C-statistic &amp; calibration plots for discrimination and calibration, respectively. Results: Of the 698,566 eligible patients, 418,911 were randomly allocated to derivation, and 279,576 to validation. The overall rate of stroke per 1000 person-years was 6.7 (6.4 - 6.9) for the derivation cohort. The final model included 22 predictors: age, sex, long-term care residency, history of heart failure, hypertension, dementia, asthma, atrial fibrillation, dyslipidemia, liver disease, ischemic stroke, transient ischemic attack, valvular disease, venous thromboembolism, hospitalization within the last 3 months, cancer type, cancer stage, cancer surgery or chemotherapy 3 months following diagnosis, and several 2-way interactions with age &amp; cancer type. Discrimination was good, with a c-statistic of 0.73 in the validation cohort. The model was well calibrated, with points following the 45-degree line (Fig 1). Conclusion: We derived and validated a risk prediction model for ischemic stroke in patients with a new cancer diagnosis with good discrimination. Although our results require external validation, it has potential to identify individuals at highest risk for future randomized trials.

An audit of the maternal medicine clinic: Cancer and pregnancy.

To explore the incidence and complexity of women presenting for maternity care who require concurrent cancer care, and to report the birth outcomes of these women. A retrospective audit of women attending a 'high risk' maternal medicine clinic at an Australian tertiary maternity hospital between 1 October 2021 and 30 April 2023 was conducted. The inclusion criteria were a diagnosis of cancer and a concurrent pregnancy, or a diagnosis of cancer prior to the current pregnancy. Clinic lists and coding data were screened via the electronic medical record to identify potential subjects. Data were collected from the individual maternity and neonatal records. Forty of 705 (5.7%) women attending the maternal medicine clinic met the inclusion criteria, of which ten had a new diagnosis of cancer in pregnancy and 30 presented for maternity care after a previous diagnosis of cancer. Cancer therapy during pregnancy included surgery and chemotherapy. Most pregnancies (92.5%) resulted in term deliveries (≥37 weeks gestation). Four neonates were preterm, and one was small-for-gestational-age. Caesarean section delivery and post-partum haemorrhage were more common than expected, but the rate of other adverse pregnancy outcomes was consistent with the background population. Over half of neonates required neonatal intensive care unit / special care nursery admission but the indications for admission were common, self-limiting conditions, and the length of stay was short (mean <5.0 days). Approximately 6% of women attending the maternal medicine clinic had a current or previous diagnosis of cancer. Most pregnancies resulted in term deliveries and neonatal outcomes were excellent.

1689 Establishing an oncogeriatric multi-disciplinary team (MDT) and accompanying clinic at a DGH in Somerset

Abstract Introduction Recent studies show the use of comprehensive geriatric assessment (CGA) in older patients with cancer can result in better quality of life, improved treatment tolerance and reduced hospital admissions, leading to international consensus that CGA should be routinely included in care. We have piloted an onco-geriatric MDT, consisting of oncologists, geriatricians and therapy input, alongside a rapid-access geriatrician-led onco-geriatric clinic Method Referrals were invited from oncologists for older patients (&amp;gt;70) with a new diagnosis of cancer, with expected prognosis of more than 1 year, about whom they had concerns regarding their ability to undergo radical treatment due to co-morbidities, falls, cognitive impairment or social isolation. A CGA was completed prior to starting radical treatment in most cases. Performance status, Rockwood frailty score (RFS) and G8 score were calculated for all patients. Results During the 24-week trial period, an MDT and clinic has run every week. A total of 32 patients have been discussed at MDT, with 22 seen in clinic, from cancer sites including colorectal, breast, urological and ovarian. Patient seen in clinic had an average RFS of 4.5 and G8 score of 13. All patients have seen a geriatrician, with most also seeing our physiotherapist. Interventions included medication review and rationalisation, anaemia review and treatment, referral to specialist memory and continence services, blood pressure optimisation and completion of a treatment escalation plan. Conclusions Feedback from patients attending the clinic has been resoundingly positive, with 100% of patients rating their service experience as “good” or “very good” and praising the time to talk about their health as a whole. Follow up of clinic patients is in progress, identifying emergency admissions alongside treatment toxicities and complications within this group, as well as whether G8 is an appropriate screening tool for clinic review, to secure the long-term future of the service.

OP22 Benchmarking Of Population-Based Childhood Cancer Survival By Toronto Stage: Know The Differences To Propose Effective Interventions

IntroductionPediatric cancers are rare tumors, heterogeneous in location and biologically very different from adult cancers. Documented survival variation across European countries and Italian regions shows that there is still room for further improvement by reducing inequalities. We aim to understand why there are differences in survival. The BENCHISTA-ITA project (National Benchmarking of Childhood Cancer Survival by Stage at diagnosis), that is the Italian twin project of the International BENCHISTA, collects stage at diagnosis of solid pediatric tumors, according to the Toronto Guidelines. We will compare how far the cancer has spread at diagnosis and test if differences in tumor stage explain any survival differences between Italian regions.MethodsThe project study involved the stage distribution and the survival of 9 pediatric solid tumors diagnosed between 2013 and 2017 in Italy. All patients therefore had at least 3 years of follow-up in 2021 for life-stage definition. The study involves the identification of all new diagnoses of cancer, evaluation of the clinical documentation of cases eligible for research, and international classification and coding. Analyses of stage distribution and survival rates for each tumor type will be described.ResultsData from 35 population-based cancer registries from 18 out of 20 Italian regions were collected covering about 84 percent of the Italian child population. In particular, data on: imaging/examination performed before any treatment; source used for staging; primary treatment defined as given within one year from diagnosis; relapse/ recurrence/ progression; follow up and status of life. The study tested the applicability of the Toronto Guidelines as a tool to obtain population-level comparable stage information for childhood cancers. There were 1,343 cases collected (242 Neuroblastoma, 124 Wilms Tumour, 145 Medulloblastoma, 148 Osteosarcoma, 135 Ewing sarcoma, 115 Rhabdomyososarcoma, 54 Ependymoma, 47 Retinoblastoma, 333 Astrocytoma). Toronto stage could be assigned in more than 90 percent in the majority of tumors. Tumors in which it was more difficult to assign the stage using the Toronto staging guidelines were ependymoma, astrocytoma, and retinoblastoma. It was easier to retrieve data for patients in the 0-14 years of age range than adolescents (14-18 years). Differences in stage distribution and survival differences between regional grouping were presented.ConclusionsThe Italian BENCHISTA project, improving the connection between pediatric cancer registries, aims to improve care of children with cancer across the nation, reducing possible disparities.The wide adoption of the Toronto Guidelines will facilitate international comparative incidence studies, strengthen the interpretation of survival data, and contribute to more appropriate solutions to improve childhood cancer outcomes.

Impact of Cancer Diagnosis on Appropriate Use of Antithrombotic Medications in Individuals with Cardiovascular Diseases

Introduction: Cancer and Cardiovascular disease (CVD) often coexist and CVD is the leading cause of non-cancer mortality in people with cancer. Antithrombotic medications used to manage CVD are associated with increased bleeding risk, particularly in people with cancer. Appropriate management of CVD is therefore essential in individuals with cancer, both to decrease recurrent CVD as well as to prevent bleeding. In this study, we assessed utilization patterns of antithrombotic medications for CVD following a new diagnosis of cancer. Methods: Among people receiving primary care at the University of Vermont Medical Center from 2010 to 2019, we identified a cohort of 4,010 subjects with baseline CVD, identified from problem lists or billing codes within the first year of follow-up. Exclusion criteria included baseline cancer diagnosis (cancer known at the time of inclusion in the cohort or within the first year of follow-up) or a known history of venous thrombosis. Incident cancer was defined as new diagnosis of cancer after the first year of follow-up and did not include people with non-melanomatous skin cancers. We used the National Cancer Institute list of ICD-9 and ICD-10 codes for different cancer diagnoses. Patient's use of antithrombotics, prescribed or non-prescribed, were captured using computable phenotypes developed from the electronic outpatient medication reconciliation record and validated using chart review. People with baseline CVD who were diagnosed with cancer after the first year of follow up were matched 1:1 by sex and age with people with CVD and no cancer. We used logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (95% CI) of persistent guideline-directed use of antithrombotic medications for 6 months after a new cancer diagnosis versus a matched time-period in those without incident cancer (use of antiplatelets in those with a history of atherosclerotic CVD and use of anticoagulation in those with a history of atrial fibrillation). Results: We identified 4,010 individuals with baseline CVD, 841 of whom (20%) developed incident cancer during follow-up. Distribution of CVD and antithrombotic use in the age- and sex-matched population are presented in Table 1. 2/3 of the population had coronary artery disease and about 30% had atrial fibrillation or flutter. About 65% of individuals were on any antiplatelet therapy and 18% were on anticoagulation for CVD. 41% of people with baseline CVD, and incident cancer diagnosis were still on antiplatelet therapy 6 months after their cancer diagnosis as opposed to 38 % in the matched population without a cancer diagnosis. 33% of individuals with incident cancer were still on anticoagulation for atrial fibrillation or flutter as opposed to 28% of the matched population without cancer. Both of these differences were statistically significant with OR=1.55 (95% CI, 1.15-2.1) for antiplatelets, and OR=1.56 (95% CI, 1.05,2.31) for anticoagulants, compared to those with no cancer diagnosis (Table 2). Conclusion: Surprisingly, our study found that incident cancer in individuals with baseline CVD was associated with increased adherence to antithrombotic therapy. We had hypothesized that incident cancer would be associated with lower use of antithrombotic therapy. This result could be related to increased interaction with medical specialists following a cancer diagnosis. The impact of increased adherence to antithrombotics on bleeding however, will need to be further investigated.

“A double-edged sword”: Influence of the 21st Century Cures Act on the childhood cancer care experience.

360 Background: The 21st Century Cures Act allows patients to immediately access their electronic health record (EHR) via an online portal. For pediatric patients with cancer and their families, this federal mandate has profound implications. We sought to explore perspectives of key stakeholders on how the Cures Act influences the childhood cancer care experience, receipt of results, and communication with the oncology team. Methods: In a multi-center qualitative study at three National Cancer Institute-designated comprehensive cancer centers, we conducted semi-structured interviews with adolescent and young adult patients with cancer (n=26), parents of children with cancer (n=32), and interdisciplinary clinicians in pediatric oncology (n=23). Interviews were audio-recorded, transcribed verbatim, coded, and thematically analyzed. Results: Across 81 participants, 73% self-identified as women, 69% as White race, and 17% as Hispanic/Latinx ethnicity. Most patients and parents perceived the EHR portal to be a convenient, centralized record-keeping tool that enables them to prepare for appointments, track treatment progress, and assume greater agency in their cancer care. Many patients and parents preferred the immediacy of the portal to bypass wait times and facilitate real-time decision-making. Access to notes and results on the portal was widely perceived to enhance communication and appeared to engender greater trust in the oncology team. Simultaneously, patients and parents acknowledged that instant access to results laden with medical jargon can heighten confusion, worry, and anger, particularly upon receipt of concerning results (i.e., pathology or radiology results revealing a new diagnosis of cancer or relapse) before meeting with a clinician. Clinicians generally favored the EHR portal and reported adapting their practices to provide greater anticipatory guidance, occasionally altering language in clinical notes to avoid upsetting patients or families. However, several clinicians expressed concern about situations in which high-stakes results are instantly available to patients and the responsible clinician has not yet had an opportunity to interpret and discuss. Clinicians spoke of shifting expectations regarding prompt communication of results. Many clinicians would prefer a system in which a time delay is built into the release of particularly sensitive results. Overall, clinicians reported that the EHR portal may increase administrative burden and interfere with clinical workflow. Conclusions: While key stakeholders recognize that the Cures Act offers important patient-centered innovations, many participants identified challenges that impede on optimal implementation. This study underscores the need to establish best practices for integrating use of the EHR portal into routine childhood cancer care.

High sensitivity flow cytometry immunophenotyping increases the diagnostic yield of malignant pleural effusions.

Diagnosing malignant pleural effusions (MPE) is challenging when patients lack a history of cancer and cytopathology does not detect malignant cells in pleural effusions (PE). We investigated whether a systematic analysis of PE by flow cytometry immunophenotyping (FCI) had any impact on the diagnostic yield of MPE. Over 7 years, 570 samples from patients with clinical suspicion of MPE were submitted for the FCI study. To screen for epithelial malignancies, a 3-color FCI high sensitivity assay was used. The FCI results, qualified as "malignant" (FCI+) or "non-malignant" (FCI-), were compared to integrated definitive diagnosis established by clinicians based on all available information. MPE was finally diagnosed in 182 samples and FCI detected 141/182 (77.5%). Morphology further confirmed FCI findings by cytopathology detection of malignant cells in PE (n = 91) or histopathology (n = 29). Imaging tests and clinical history supported the diagnosis in the remaining samples. The median percentage of malignant cells was 6.5% for lymphoma and 0.23% for MPE secondary to epithelial cell malignancies. FCI identified a significantly lower percentage of EpCAM+ cells in cytopathology-negative MPE than in cytopathology-positive cases (0.02% vs. 1%; p < 0.0001). Interestingly, 29/52 MPE (55.8%) where FCI alerted of the presence of malignant cells were new diagnosis of cancer. Overall, FCI correctly diagnosed 456/522 samples (87.4%) suitable for comparison with cytopathology. These findings show that high sensitivity FCI significantly increases the diagnostic yield of MPE. Early detection of FCI + cases accelerates the diagnostic pathway of unsuspected MPE, thus supporting its implementation in clinical diagnostic work-up as a diagnostic tool.

Characteristics of self-triaged emergency department visits by adults with cancer.

Adults with a new diagnosis of cancer frequently visit emergency departments (EDs) for disease- and treatment-related issues, although not exclusively. Many cancer care providers have 24/7 clinician phone triage available, but initial recorded phone messages tend to advise patients to go to the nearest ED if they are "experiencing a medical emergency." It is unclear how well patients triage themselves to the optimal site of care. Cross-sectional study of tumor registry records (university patients diagnosed 2008-2018 and safety-net patients diagnosed 2012-2018) identifiably linked to electronic health records and a regional health information exchange. We geoprocessed addresses to calculate driving time distance from the patient's home to the ED. We used mixed-effects regression to predict the diagnosis code-based severity for ED visits within 6 months of diagnosis, clustering visits within patients and hospitals. A total of 39,498 adults made 38,944 ED visits to 67 different hospitals. Patients self-referred for 85.5% of visits and bypassed a median (IQR) of 13 (4-33) closer EDs. Visits closer to home were not significantly more clinically severe; visits were significantly less severe if the patient self-referred (adjusted odds ratio [AOR], 0.89; 95% CI, 0.81-0.97) or they were on weekends (AOR, 0.93; 95% CI, 0.87-0.99). Reanalyzing within each individual health system also showed similar findings. Adults with cancer infrequently use available clinician advice before visiting the ED and may use factors other than clinical severity to determine their need for emergency care. Future work should explore the challenges that patients face navigating unplanned acute care, including reasons for underusing existing resources.

Multicentric, observational, longitudinal study for the evaluation of nutritional management implications in newly diagnosed Italian cancer patients: the Italian Registry of Malnutrition in Oncology (IRMO)

BackgroundMalnutrition is a frequent problem in oncology and is associated with reduced response to cancer treatments, increased drug-related toxicity, higher rates of clinical complications, reduced quality of life (QoL) and...

HYPERTENSION IN CANCER PATIENTS TREATED WITH ANTI-ANGIOGENIC BASED THERAPY: A POPULATION-BASED COHORT STUDY

Objective: Data from randomized clinical trials showed that new-onset hypertension is a common side effect of anti-angiogenic drugs. We compared the cumulative incidence of new-onset hypertension in cancer patients treated with either anti-angiogenic based therapy (AAG) or other chemotherapy only, and in patients who did not received antineoplastic agents (untreated). Design and method: Retrospective population-based cohort study based on the healthcare utilization databases of Lombardy Region (Italy). We identified the cohort of patients aged 40 years or older with a new diagnosis of cancer between 2009 and 2017. We excluded patients with antihypertensive treatment in the five years before cancer diagnosis. We 1:1:1 matched each patient who started a therapy with AAG (index case) with one patient treated with other chemotherapy only and with one untreated patient by date of cancer diagnosis, tumoral site and date of start of antineoplastic therapy. We followed-up each of the three matched patients from the date of start of AAG of the index case until the first date between onset of antihypertensive treatment with at least 3 prescriptions (the outcome of interest), death, migration or 2 years after the start of follow-up. We estimated the incidence cumulative function by considering death as competing event and we fitted a Fine and Grey regression model, adjusted for age, sex and Cancer Multimorbidity Score, in order to estimate the association between treatment and new-onset hypertension. Results: The final cohort included 3,333 1:1:1 matched patients (median age 62 years; 43.6% males). The cumulative incidence of new-onset hypertension was higher among patients treated with AAG, as compared to others. The cumulative incidence rapidly increased 1 year (26.3%) after starting therapy with AAG. The adjusted hazard ratios were 3.73 (95% CI 3.34 to 4.15) and 4.00 (3.56 to 4.48), when compared to patients treated with other chemotherapy and with those untreated, respectively. Moreover, patients treated with AAG also showed a significant increased risk of major cardiovascular events compared to others. Conclusions: Cancer patients treated with AAG showed a markedly higher risk of new-onset hypertension. The risk rapidly increased 1 year after the start of therapy.

Multi-cancer early detection screening tools: A dream come true or a nightmare in the offing.

e18926 Background: US cancer deaths were at 610,000 in 2022 with 1.9 million new diagnoses of cancer, 86% of which were patients over age fifty. Roughly 150,000 advanced cancers were diagnosed with five current screening techniques. That leaves 1.75 million cancers to be diagnosed symptomatically, largely in advanced stages. The dream is to screen in a minimally invasive fashion for multiple types of cancer at earlier, treatable, life-saving stages. The Galleri test claims to fulfill that dream by identifying more than fifty different cancers, and their location, using a blood test that captures ctDNA linked to aberrant methylation. As their dream approaches reality, with a dozen US hospital systems already offering Galleri, a fiscal and ethical nightmare is likely to ensue. We will demonstrate to providers that Galleri’s analytical validity and clinical utility is marginal at best – largely due to uncertainty surrounding the nature of those fifty malignancies. Methods: Systematic review of literature was performed across multiple databases using the key terms "Cancer Early Detection" AND OR "MCED" AND OR "GALLERI." Grail’s optimistic portrayal of the test’s current efficacy is largely derived from Hubbell and colleagues’ recent work modelling a Galleri-like test that claimed an achievable 24% reduction in cancer mortality (~150,000 lives). Critics contend that their assumptions are too optimistic. The natural histories of most of those fifty cancers are poorly understood, such as tumor latency periods, which means the cancer shift detection to an earlier stage is unknowable. Moreover, we cannot know whether these cancers would have been caught earlier, symptomatically, and successfully treated - which is true of 68% of diagnosed cancers. Etzioni and colleagues concluded that 6% of cancer deaths might be reduced by Galleri, despite that number is still uncertain and optimistic. Galleri cannot take credit for those saved lives. Results: GRAIL proposes population-based screening for 110 million Americans over age fifty annually at a cost of $950 per test. That would add over $100 billion per year to the health costs to discover no cancer in 99% of the persons tested. Roughly $50 billion would be added to Medicare program costs, now at $1 trillion. To save 18,000 Medicare lives would cost $2.8 million per life saved, a significant misallocation of Medicare resources, given many less costly opportunities to save more lives. Finally, individuals with marginal or no health insurance would be informed by Galleri they had an early-stage cancer unaffordable to treat. They represent statistically salvageable lives not actually salvaged, which is a presumptive injustice. This argument holds, despite the company’s pledge to reduce cost by over 40% over four years. Conclusions: In sum, Galleri, as a population-based cancer screening test, is not economically affordable, not ethically equitable, and only marginally medically beneficial.

Incidence of Intrauterine Adhesions After Hysteroscopic Myomectomy in Patients Seeking Fertility

To study the incidence of intrauterine adhesions (IUAs) after hysteroscopic myomectomy. Previous studies report a range of incidence for IUAs after hysteroscopic myomectomy. A retrospective review study. An academic community hospital in the Boston metropolitan area. Patients undergoing hysteroscopic myomectomy at our institution from January 2019 to February 2022. Patients were excluded if they did not have plans for future fertility or had a new diagnosis of cancer. All patients underwent hysteroscopic myomectomy using bipolar resectoscope without postoperative medical or barrier treatment. All procedures were performed by 1 of 4 fellowship-trained high-volume gynecologic surgeons with resident and fellow assistance. Incidence of postoperative IUAs was assessed and treated using second-look office hysteroscopy. A total of 44 patients without preoperative IUAs underwent hysteroscopic myomectomy during our study period, and 4 patients (9.1%) developed new IUAs. Among 9 patients who were found to have preoperative IUAs and underwent concurrent hysteroscopic myomectomy and lysis of adhesions, we found a recurrence of IUAs in 5 patients (55.6%). We found the number, size, and deepest type of myoma removed were not correlated to an increased risk of new IUA formation. In addition, removing myomas on opposing walls during the same operation did not increase the incidence of new IUAs. Formation of IUAs after hysteroscopic myomectomy is a well-documented consequence. Our reported incidence of 9.1% of new IUAs that are not affected by the number, size, deepest type of myoma resected, and resection of myomas on opposing uterine walls contributes to the current literature. In addition, our finding of 55.6% of recurrent IUAs in patients undergoing both hysteroscopic myomectomy and lysis of adhesions highlights a high-risk population requiring additional study.

Clinical and Demographic Characteristics, Mechanisms, and Outcomes in Patients With Acute Ischemic Stroke and Newly Diagnosed or Known Active Cancer.

Patients with a new diagnosis of cancer carry an increased risk of acute ischemic stroke (AIS), and this risk varies depending on age, cancer type, stage, and time from diagnosis. Whether patients with AIS with a new diagnosis of neoplasm represent a distinct subset from those with a previously known active malignancy remains unclear. We aimed to estimate the rate of stroke in patients with newly diagnosed cancer (NC) and previously known active cancer (KC) and to compare the demographic and clinical features, stroke mechanisms, and long-term outcomes between groups. Using 2003-2021 data from the Acute STroke Registry and Analysis of Lausanne registry, we compared patients with KC with patients with NC (cancer identified during AIS hospitalization or within the following 12 months). Patients with inactive and no history of cancer were excluded. Outcomes were the modified Rankin scale (mRS) score at 3 months and mortality and recurrent stroke at 12 months. We used multivariable regression analyses to compare outcomes between groups while adjusting for important prognostic variables. Among 6,686 patients with AIS, 362 (5.4%) had active cancer (AC), including 102 (1.5%) with NC. Gastrointestinal and genitourinary cancers were the most frequent cancer types. Among all patients with AC, 152 (42.5%) AISs were classified as cancer related, with nearly half of these cases attributed to hypercoagulability. In multivariable analysis, patients with NC had less prestroke disability (adjusted odds ratio [aOR] 0.62, 95% CI 0.44-0.86) and fewer prior stroke/transient ischemic attack events (aOR 0.43, 95% CI 0.21-0.88) than patients with KC. Three-month mRS scores were similar between cancer groups (aOR 1.27, 95% CI 0.65-2.49) and were predominantly driven by the presence of newly diagnosed brain metastases (aOR 7.22, 95% CI 1.49-43.17) and metastatic cancer (aOR 2.19, 95% CI 1.22-3.97). At 12 months, mortality risk was higher in patients with NC vs patients with KC (hazard ratio [HR] 2.11, 95% CI 1.38-3.21), while recurrent stroke risk was similar between groups (adjusted HR 1.27, 95% CI 0.67-2.43). In a comprehensive institutional registry spanning nearly 2 decades, 5.4% of patients with AIS had AC, a quarter of which were diagnosed during or within 12 months after the index stroke hospitalization. Patients with NC had less disability and prior cerebrovascular disease, but a higher 1-year risk of subsequent death than patients with KC.