Oncology Visits Research Articles

Implementing Screening for Eating Disorders in Adolescents and Young Adults with a History of Cancer.

Eating disorders are prevalent in the adolescent and young adult (AYA) population, with 2.7% of adolescents effected. AYAs with cancer possess several risk factors for eating disorders that may place them at an even higher risk. Since these patients see their oncology team frequently, oncology clinics are opportune settings for eating disorder screening. Here, we describe a study to implement screening for eating disorders in AYA patients in an oncology clinic. During regularly scheduled oncology visits, eligible patients were given the SCOFF questionnaire. A total of 163 eligible patients filled out the SCOFF questionnaire with 11 positive results (6.75%). Eating disorder screening was successfully implemented in our pediatric oncology clinic. With a rate more than double than the general population, we observed that AYA patients with a history of cancer are at a higher risk for eating disorders and should undergo routine screening in oncology clinics.

Time from Final Oncologist Visit to Death and Palliative Systemic Treatment Use Near the End of Life in Heavily Pretreated Patients with Luminal Breast Cancer.

Background: Palliative care must be tailored for patients with extended disease trajectories, such as those with hormone receptor-positive, Human Epidermal Growth Factor Receptor 2 (HER2)-negative advanced breast cancer (ABC), including the appropriate timing of discontinuing treatment. This study aimed to assess the interval between the last oncologist visit and death and the application of systemic treatment near the end of life in this patient population. Methods: This retrospective study included patients with luminal ABC who received at least two lines of palliative systemic treatment at the National Research Institute of Oncology in Poland, and died between November 2020 and March 2024. Results: Seventy-six women, with a median age 62.8 years (range: 35.3-91.5), were included. The median number of prior palliative systemic treatment lines was three (range: 2-6). At their last recorded oncologist visit, 75% of the patients were receiving active treatment (53% with hormonal therapy and 22% with chemotherapy). Only 25% were under continuous palliative care at this visit. Treatment was administered within the last month of life to 53% of the patients. The median duration from the last oncologist visit to death was 23 days (range: 0-408). The duration of this time interval was only associated with the performance status at the last visit (p < 0.05). Conclusions: Oncologists frequently delay the recognition of the need to discontinue systemic therapy. Patients with luminal HER2-negative ABC may be offered numerous effective lines of systemic treatment, complicating this decision further. Implementing clearer guidelines for end-of-life care for this group and providing proper training for healthcare providers is essential.

Telephone Survey-Reported Perceptions of Telehealth Visits Among Black and Non-Black Patients Diagnosed With Cancer.

Empirical evidence underscores both benefits of telehealth visits and persistent disparities in use for Black adults. Guided by the Technology Acceptance Model, we evaluated perceptions regarding telehealth visits among Black and Non-Black adults receiving cancer care from two academic health systems. Between April 2022 and October 2023, a survey was conducted among adult patients treated for cancer in the past 3 years. Survey recruitment was stratified by visit type (telehealth or in-person) and race. Before a scheduled oncology visit, respondents completed a telephone survey to assess their perceptions of usefulness, ease of use, and attitudes toward telehealth visits. Frequency differences were estimated using chi-square tests, and prevalence differences using logistic regression. The survey was completed by 773 respondents (42% Black) with a 15% response rate. Black respondents were younger and less likely to report male sex, being married, having a college education, comfortable income, or confidence in medical and e-literacy. Compared with Non-Black respondents, Black respondents perceived telehealth visits as less useful for determining health needs (37% v 48%) and asking questions (9% v 15%). They thought that telehealth visits were less easy with regard to understanding their health care provider (14% v 21%) and the ability to connect (23% v 30%). Black respondents expressed more concern about internet access (26% v 15%), access to electronic devices (17% v 9%), and finding assistance for connecting (24% v 12%). They also found telehealth visits to be less private (19% v 34%). Racial differences in telehealth ease of use and usefulness perceptions highlight the need for oncology practices to couple connectivity support with effective communication strategies to avoid disparities in oncology telehealth services.

Vaccine hesitancy in patients with solid tumors: a cross-sectional single-center survey

BackgroundVaccination rates are still suboptimal in cancer patients. Oncologists play a central role in recommending vaccines to their patients. Our goal was to investigate vaccine acceptance among cancer patients and understand the factors shaping their choices, thereby aiding physicians in better supporting their patients’ vaccination decisions.MethodsWe designed a prospective cross-sectional survey exploring vaccination status, attitudes, and reasons for hesitancy towards vaccinations against the main vaccine preventable diseases (VPDs) among patients undergoing active cancer treatment. The primary endpoint was to evaluate the proportion of vaccinated subjects in our cohort of cancer patients. The secondary endpoints were to assess the proportion of vaccinated subjects against different types of VPDs: flu, COVID-19, pneumococcal disease, Herpes Zoster (HZ).ResultsBetween 12 February and 01 March 2024, a total of three hundred and seventeen patients with cancer were invited to respond to the survey, 309 of whom (97%) agreed to do it. Two hundred seventy-three patients (0.88, 95% confidence interval [CI] 0.84–0.91) had received at least one vaccination. Two hundred thirty-one patients (74.76%) reported that at their first oncology visit their oncologist recommended vaccinations, primarily anti-flu (92.21%) and anti-SARS-CoV-2 (83.55%) vaccinations, while less frequently the anti-pneumococcal (42.42%) and anti-HZ (37%) vaccines were recommended. On the univariate analysis, age over 75 years (p = 0.041), marital status (p = 0.003) and the oncologist’s vaccine recommendation during the first visit (p < 0.001) were significantly associated to vaccine acceptance. At the multivariable analysis, these variables were independently associated with vaccine willingness. Overall in our cancer population, the two main reasons for vaccine hesitancy were the lack of recommendation by the oncologist (55.41%, n = 128) and the lack of awareness of the importance of vaccination in the context of oncological care (49.35%, n = 114).ConclusionsThis survey emphasizes the importance of vaccine counseling by the oncologist to their patients. Oncologists can motivate patients to receive the correct vaccine schedule by addressing doubts and concerns about the potential negative impact of the vaccine on cancer and cancer therapies.

Association between telehealth use in oncology and downstream utilization at a large academic health system.

While telemedicine has been beneficial in oncology by reducing infectious exposure and improving access for patients with poor functional status, it also has intrinsic limitations, including the inability to perform a physical exam, which could lead to increased downstream utilization in this population at high risk of medical decompensation. We conducted a retrospective cohort study investigating the relationship between telemedicine use in oncology and subsequent outpatient oncology encounters, emergency department (ED) visits, and hospitalizations. We included outpatient oncology encounters, including telemedicine and in-person visits, occurring between 1 January 2018 and 31 December 2022 at a large academic health system. Unadjusted descriptive statistics and multiple linear regressions were used to estimate subsequent outpatient oncology visits, ED visits, and hospitalizations within 30 days of an index visit based on modality (telemedicine versus in-person). The multiple regressions were adjusted for various demographic and clinical characteristics, including palliative care visits, baseline utilization, recent chemotherapy, and comorbidities. Our cohort included 63,722 patients with 689,356 outpatient encounters, of which 639,217 (92.7%) were in-person and 50,139 (7.3%) were telemedicine visits. Patients on average had 0.91 outpatient oncology visits, 0.04 ED visits, and 0.05 hospitalizations within 30 days following an index encounter. In our adjusted analyses, telemedicine was associated with 13.7 fewer downstream outpatient oncology visits (95% CI 12.5-14.9; p < 0.001) per 100 index encounters, 0.7 fewer ED visits (95% CI 0.4-1.0; p < 0.001) per 100 index encounters and 0.9 fewer hospitalizations (95% CI 0.6-1.3; p < 0.001) per 100 index encounters compared to in-person visits. Contrary to our hypothesis, oncology patients who had a telemedicine visit had fewer follow-up outpatient oncology encounters, ED visits and hospitalizations after 30 days than those with in-person visits. Future studies should further investigate the efficacy of telemedicine in oncology and outline specific scenarios for appropriate use in this and other populations.

7839 Assess Management of Adrenal Insufficiency in Melanoma Patients Treated with Cancer Immunotherapy

Abstract Disclosure: W. Lin: None. L. Min: None. Despite high prevalent of adrenal insufficiency in melanoma patients treated with cancer immunotherapy, no study has examined the management of adrenal insufficiency in these patients. We performed this retrospective, longitudinal cohort study at Mass General Brigham, Boston, aims to characterize the management of adrenal insufficiency in melanoma patients. Patients were identified through our RPDR search tool, and medical record reviews were conducted. Three patient groups were analyzed: Melanoma with secondary adrenal insufficiency group (Mel_SAI, n=74), Melanoma matched control group (Mel_Con, n=69), and Pituitary macroadenoma-related adrenal insufficiency matched control group (Pit_Con, n=37). We compared self-perceived quality of life, glucocorticoid replacement dose, and clinic visit. Mel_SAI patients exhibited significantly higher incidences of anxiety (43.1%, 95%CI: 32.3-54.6), fatigue (73.6%, 95%CI: 62.4-82.4), pain (58.3%, 95%CI: 46.8-69.0), and insomnia (36.1%, 95%CI: 26.0-47.6), as compared to Pit_Con group (21.6%, 11.4-37.2; 24.3, 13.4-40.1; 29.7%, 17.5-45.8; 5.4%, 1.5-17.7, respectively). The initial hydrocortisone dose was higher for Mel_SAI (30mg qd, 95%CI: 20.5-25.1) compared to Pit_Con (15mg qd, 95%CI: 12.8-18.3). Additionally, the Mel_SAI group had fewer endocrinology clinic visits (3, 95%CI: 3.40-5.04) than the Pit_Con group (9, 95%CI: 7.35-10.9). Subgroup analysis indicated a higher mortality risk (HR 2.61, 95% CI 1.11-6.13) in Mel_SAI patients with fewer than three endocrinology visits over five years. Compared to the Mel_Con group, Mel_SAI patients also showed higher incidences of fatigue (71.6%, 95%CI: 60.5-80.6; Mel_Con: 55.1%, 95%CI: 43.4%-66.2%), but lower rates of depression (25.7%, 95%CI: 17.1-36.7; Mel_Con: 43.5%, 95%CI: 32.4-55.2) and appetite loss (24.3%, 95%CI: 16.0-35.2; Mel_Con: 47.8%, 95%CI: 36.4-59.4). No significant difference in other self-perspective symptoms. Furthermore, Mel-SAI patients had more oncological clinic visits (71, 95%CI: 74.0-109.2) than those in the Mel_Con group (41, 95%CI: 42.1-64.1). Our study suggests that most self-perceived quality of life in the Mel_SAI group is related to melanoma rather than adrenal insufficiency. Therefore, a higher initiating dose of hydrocortisone in melanoma patients with adrenal insufficiency may not be necessary. However, increasing endocrine clinic visits in cancer patients with cancer immunotherapy-related adrenal insufficiency may improve their survival outcomes. Presentation: 6/3/2024

Integrating diabetes care into an oncology practice: A patient-centric model of care delivery at a safety-net health system.

2 Background: Oncologic treatments can disrupt glycemic control in people with diabetes and induce dysglycemia in individuals without diabetes through the use of steroids and/or targeted therapies. Severe hyperglycemia can result in delay/interruption of oncologic care and emergency department (ED) utilization. Here we report on an integrated model of diabetes care at a safety-net system, where patients commonly use the ED for their care. Methods: Parkland Health is an academic-affiliated safety-net system, primarily providing care for the un-/under-insured patients in Dallas County. An advanced nurse practitioner specializing in diabetes care (DM-ANP), supervised by an endocrinologist, was embedded in oncology clinics. Patients were referred to the DM-ANP by their oncology provider, or through an automated process if they had a recent hemoglobin A1c &gt;8.0% or a random blood sugar &gt; 250mg/dL. Patient education was provided by a trained nurse educator. Nutrition consult was available through an oncology dietitian. An acute hyperglycemia management protocol was developed to manage patients in the infusion center and prevent unnecessary ED visits. Results: Between March 2021 and March of 2024, the DM-ANP provided 4,276 visits to 797 distinct patients (average, 1425 visits per year). Breast cancer was the most common malignancy among patients seen in the integrated clinic. DM-ANP visits were coupled with oncology visits (clinic or infusion) or via telehealth, thereby increasing access and decreasing number of days patients had to come to clinic to receive care. Telehealth visit rate was highest in 2021 (27.5%) reflecting the impact of the pandemic, and subsequently dropped to 10.1% in 2023. Patients who were seen by the DM-ANP had an overall lower number of ED visits. Comparing prior vs post establishing care with the DM-ANP, the total number of ED visits by patients with diabetes significantly reduced in 2021-2022 (2021: 970 vs. 241, p &lt;0.01; 2022: 796 vs. 501, p&lt;0.01) before equilibrating in 2023-2024; (2023: 426 vs. 468, p=0.24). On average, patients had 1.2 less ED visits after receiving care from the DM-ANP. Since in-person visits were coupled with other oncology visits, the no-show rate for DM-ANP mirrored the rates for oncology clinics/infusion visits. Conclusions: Integrating diabetes/glycemic management into our oncology practice provided a patient-centric model of care delivery, improved visit adherence compared to an off-site model, reduced the time-toxicity by having fewer clinic visit days. Future directions include comparing oncologic outcomes in patients who had DM-ANP management to those who were managed by primary care.

The association of oncology telehealth visits with acute care events and follow-up appointments.

384 Background: Use of telehealth visits in cancer care expanded with the pandemic, yet few studies have assessed its impact on subsequent care outcomes. We evaluated differences in acute care events (ACEs) and follow-up visits among patients with telehealth compared to in-person oncology visits. Methods: We identified a cohort of adults with an upcoming oncology visit related to their cancer treatment at two academic medical centers (in central NC and southeast MI) and their community affiliates. Black adults and those with a scheduled telehealth visit were oversampled. Pre-visit surveys administered by telephone collected information on sociodemographic characteristics, prior telehealth use, health status/symptoms and travel distance. We joined survey and electronic health record (EHR) data and used geocoding to assign census-tract-level community characteristics to participants. ACE and follow-up visit use were ascertained via the EHR. Unadjusted and adjusted prevalence differences in ACEs within 30 and 180 days as well as follow-up visits within 7 and 30 days were assessed by visit type. Results: 502 patients were study eligible, 90 telehealth and 412 in-person visits. In unadjusted and adjusted models, the proportion of patients incurring an ACE within 7 and 30 days was not significantly different (6 vs. 3% and 17 vs. 10%, telehealth vs. in-person, respectively). Nor did the proportion of patients having a follow-up visit within 7 or 30 days differ significantly (26 vs. 20% and 65 vs. 54%, telehealth vs. in-person, respectively). Some patient characteristics were similar regardless of visit format. For example, most patients were older (63 mean age SD 13), not currently employed (66%), and reported getting by/living comfortably with current income (88%), having some college education (80%), no transportation troubles (85%), and activated patient portal accounts (89%). Symptom presentation per the PRO-CTCAE was similar between groups as was broadband connectivity. Telehealth patients were significantly less likely to be Black (14 vs. 44%), female (48 vs. 72%), have breast cancer (22 vs. 48%), received chemotherapy (72 vs. 83%), or to live within 60 minutes of care (49 vs. 68%), and more likely to have advanced disease (24 vs. 14%), report LGBTQ sexual orientation (10 vs. 4%), and be married (70 vs. 57%). Conclusions: Similar ACE and follow-up visit use among those with telehealth and in-person visits supports the idea that telehealth could be a viable substitute for some in-person care within oncology. Differences between those using telehealth and in-person visits highlight equity concerns and missed opportunities to enhance patient convenience and other aspects of care access. To better understand telehealth’s impact, not only on care use, but other indicators of quality (including patient outcomes), matching via propensity score analyses are needed and underway.

Improving the detection and documentation of patients’ symptoms in an integrated gastrointestinal oncology and palliative care clinic.

336 Background: Patients with gastrointestinal (GI) malignancies experience a high burden of disease-related symptoms and treatment side effects. We established an integrated GI oncology and palliative care (PC) clinic in which a PC physician is co-located with the oncology team and can provide timely response to patient distress and facilitate communication with the interdisciplinary palliative care team. Yet, even in the integrated clinic, patient symptoms were unreliably assessed, leading to missed opportunities to address patient suffering. Between October 2023 and January 2024 for patients seen in-person in the integrated clinic for oncology or PC visits, the median rate of symptom documentation was 45%. Emotional, financial, and spiritual distress documentation rates were lowest. We hypothesized that by implementing a systematic, comprehensive patient-reported symptom assessment tool, we could increase the detection and documentation of symptoms, and in turn, improve communication around patient distress and timely response to symptoms. Methods: We measured the rate of symptom documentation (primary outcome) and the use of a patient-reported symptom assessment tool for adults with GI cancers seen in-person in the integrated clinic in Spring 2024. Based on the Edmonton Symptom Assessment Scale (ESAS) and expert consensus, we determined which symptoms were most important to identify. Documentation rates were assessed via manual chart review of visit notes and flowsheet data. Prospective post-intervention data (March to May 2024) were compared to retrospective pre-intervention baseline data (October 2023 to January 2024). Interventions included modification of the ESAS to include GI oncology-specific symptoms, implementation of the tool in paper format to encourage patient-clinician communication, frequent staff education and feedback sessions, creation and dissemination of a resource guide for clinicians to respond to identified distress, and patient satisfaction surveys. Results: 126 patients were included in the study (31 pre-intervention and 95 post-intervention). During the post-intervention period, the median rate of symptom documentation increased from 45% to 83% and the median rate of ESAS survey completion increased from 9% to 68%. Documentation of financial and spiritual distress increased from 13% to 71%, for both, and documentation of emotional distress increased from 35% to 72%. On satisfaction surveys (N=20), most patients reported the tool was helpful in sharing their symptoms (70%), was easy to read and understand (100%), and that their clinician was engaged in addressing their symptoms (67%). Conclusions: The implementation of a patient-reported symptom assessment tool in an integrated GI oncology/PC clinic increased documentation of important symptoms, potentially increasing clinician awareness of patient distress.

Early integration of outpatient palliative care among adults with advanced cancer in a safety-net health system.

195 Background: Medically underserved adults with cancer present at later disease stages. The American Society of Clinical Oncology recommends all advanced cancer patients receive early intervention by a palliative care (PC) team soon after diagnosis (within 8 weeks) and during active treatment. Few studies have examined early integration of PC in the outpatient setting among advanced cancer patients within a safety-net system. This study examined patterns of outpatient PC service delivery (referrals and visits) for advanced cancer patients seen in the primary safety-net provider of cancer care for under- and uninsured adults in Dallas, TX. Methods: Patients diagnosed with advanced-stage solid tumor and who had at least one outpatient oncology visit January 1, 2018 to July 31, 2023 at the safety-net system were identified via electronic health record. The primary outcome was timeliness of outpatient PC referral (categorical outcome). Among patients with an outpatient PC referral, we used Kruskal-Wallis to test univariate associations across key characteristics, including age, race/ethnicity, cancer site, preferred language, insurance, and diagnosis year. Further, we used multivariate logistic regression to evaluate associations between key characteristics and completed PC visits among those with any outpatient PC referral. Results: Among 1,572 eligible patients (mean age 59, range: 21-94), 44% were female and 76% were non-White. Diagnoses included lung (20%), gastrointestinal (17%), colorectal (14%), breast (9%), prostate (9%), head/neck (9%), pancreatic (8%), and gynecologic (6%) cancers. Over half (n=870, 55%) of patients received an outpatient PC referral during the study period. Of those with a referral, 486 (56%) patients were referred ≤ 8 weeks of diagnosis, 157 (18%) between 9 and 24 weeks, 105 (12%) between 25 and 52 weeks, and 122 (14%) &gt; 52 weeks. Timeliness of referral varied according to race/ethnicity and cancer type (p&lt;.05; Table). Two-thirds of referred patients (n=576) completed a PC visit during the study period. In the adjusted regression model, compared to males, females had higher odds of completing a PC visit – (aOR, 1.40; 95% CI, 1.01-1.94). Conclusions: Just over half of advanced cancer patients received a referral to the outpatient PC team. Nearly half of referred patients had the referral ordered after 8 weeks of diagnosis. Except for gender, there were no other factors associated with PC visit completion. These findings demonstrate a need and potential for interventions targeting PC service delivery to improve care for underserved cancer patients. Time from diagnosis to PC referral.* ≤8 Weeks 9 - 24 Weeks 25 - 52 Weeks &gt; 52 Weeks Cancer type (%) Colorectal 50 16 17 17 Lung 64 17 11 8 Pancreatic 64 19 8 9 Prostate 30 17 12 40 Race/ethnicity, (%) White 66 14 10 9 Black 54 22 12 12 Hispanic 52 17 13 18 Select cancer types shown where significant differences were found. *p&lt;.05.

Using patient-reported performance status to guide management of advanced cancer: A quality improvement initiative.

379 Background: Performance status is a key prognostic factor among patients with advanced cancer and can inform the need for supportive care services. However, assessment and documentation of performance status is inconsistently integrated into standard oncology care. Patient-reported performance status (PRPS) is a surrogate for clinician-assessed performance status and has the potential to address this challenge. We piloted a decision support tool in our electronic health record (EHR) that uses PRPS to prompt clinician assessment of performance status and suggest referrals to supportive care services. Methods: We identified patients with advanced cancer using a pre-built and validated registry driven by ICD codes in our EHR (EPIC). For patients with advanced cancer seen at one of our clinics, a multiple-choice question with options derived from the Eastern Cooperative Oncology Group (ECOG) scale in patient-friendly language was added to the pre-visit questionnaire sent electronically prior to oncology visits. For patients with a poor PRPS (2 or greater), a clinical decision support tool alerted providers of the patient’s self-reported performance status, encouraged input of the clinician’s ECOG assessment, and suggested referral orders to supportive care services such as palliative care, nutrition, and social work. We are currently evaluating how our PRPS-driven decision support tool impacts the rate of clinician-assessed ECOG documentation, referral rates, and clinical outcomes. Results: Between 3/13/24 and 5/13/24, of 336 patients identified by the advanced cancer registry, 70% (235) of patients completed the PRPS questionnaire. Among patients with an available PRPS score, 18% (42) of patients reported a poor performance status (2 or greater) at least once, triggering the decision support tool. Providers entered ECOG assessments for 93% (39) of patients and sent referrals to supportive care services for 10% (4) of the patients. Three patients died during this time period, and all three of them reported a poor performance status of 3 or 4. Oncologists at the clinic reported no significant disruption to routine workflow. Conclusions: Preliminary results suggest feasibility of a PRPS-driven decision support tool to flag patients with advanced cancer and declining function and improve discrete documentation of clinician-assessed performance status. Notably, the rate of referrals to supportive care services remains low. Next steps include obtaining longitudinal data from this pilot, assessing the impact of the pilot on goals of care documentation, and validating the concordance of PRPS and ECOG and their effect on clinical outcomes. Ultimately, we aim to use the resulting data and harness our dashboard of patients with advanced cancer and poor performance status to develop innovative, automated, and targeted quality improvement interventions.

Learning about and living with toxicity: a qualitative study of patients receiving immune checkpoint inhibitors for melanoma or lung cancer and their caregivers.

Immune checkpoint inhibitors (ICIs) have revolutionized treatment for melanoma and lung cancer and are in widespread use. This study aims to describe how patients and caregivers learn about ICI toxicities and their perceptions and experiences of toxicity. We conducted a qualitative study of 42 patients with advanced non-small cell lung cancer (NSCLC; n = 16) or melanoma (n = 26) who were initiating or discontinuing an ICI and their caregivers (n = 9). We conducted in-depth interviews to explore patients' and caregivers' experiences learning about and living with ICI side effects. We audio-recorded the first oncology visit after enrollment. We used a framework approach to code interview and visit transcripts and synthesized codes into themes. The median age of patients was 67; 68% were male. Themes of participant interviews and clinician-patient dialogue included: (i) Patients initiating an ICI received extensive information about side effects, which some patients found overwhelming or scary and difficult to absorb; (ii) patients who were deterred by fear of toxicity ultimately proceeded with treatment because of oncologist encouragement or the sense of no alternative; (iii) participants found hope in the association between toxicity and ICI efficacy; (iv) caregivers helped patients navigate the deluge of information and uncertainty related to ICIs. Participants suggested ways to improve ICI side effect education, such as incorporating patient stories. Patients perceived that ICI toxicity counseling was overwhelming yet were encouraged by oncologists' reassurance that serious side effects were manageable and by the framing of toxicity as a sign of efficacy. We identified opportunities to improve communication of ICI risks and benefits.

Facilitating patient-oncologist communication in advanced treatment-resistant cancer: development and feasibility testing of a question prompt list

BackgroundPatients’ expectations regarding medical information in advanced stages of cancer are still poorly understood. Tailoring information to advanced cancer patients is a subtle task. We developed a question prompt list (QPL) that serves as a patient-oncologist communication aid in France.MethodsA four-step sequential mixed method involving patients with luminal B/triple-negative metastatic breast cancer or metastatic uveal melanoma (N = 110) and patients’ partners, oncologists, and researchers (N = 18) was used. In-depth interviews and questionnaires focused on the information needed at the disclosure of metastasis or resistance to treatment (step 1), the formulation of questions and procedures for use in oncology visits (steps 2 and 3), and the acceptability of the final tool (stage 4).ResultsThe initial version of the QPL consists of 17 questions covering 5 themes (disease, current treatment, other options, living with cancer, prognosis). In step 2, 13 questions were added, 2 were merged, and 5 were deleted; a short form (4 questions) and recommendations for clinical use were proposed. In step 3, 2 questions were merged, and 6 were deleted. Four oncologists (27% of the target population) took part in step 4, and the QPL was discussed with 20 patients, revealing a positive appraisal.ConclusionWe provide a rigorously developed, relevant, concise, and acceptable question prompt list for clinical application in the advanced cancer care setting in France. Further research needs to assess whether this tool actually facilitates oncologist–patient communication and improves satisfaction with care and health outcomes.Trial registrationThe study is listed on ClinicalTrials.gov (NCT04118062) and registered under identification n° IRRID “International Registered Report Identifier”: DERR1-10.2196/26414.

Tailored approach to participant recruitment and retention to maximize health equity in pediatric cancer research

BackgroundLack of diversity in participants throughout the research process limits the generalizability of findings and may contribute to health disparities. There are unique challenges to recruitment of families to pediatric cancer research studies, especially for those from disadvantaged backgrounds. Thus, there is a need to evaluate the most effective recruitment and retention strategies to optimize equitable recruitment of diverse participants.MethodsThe present study adapted and implemented methods outlined previously in the literature. These previous efforts were developed to address barriers to pediatric research, behavioral health intervention research and research with Black adolescents. Recruitment and retention strategies are described across four different time points: pre-approach, initial connection, building connection and follow-up. Eligible families of children with a pediatric cancer diagnosis were approached during a routine oncology visit. Once consented, enrollment and retention rates over three timepoints of data collection were recorded and evaluated.ResultsResults indicated high rates of enrollment (86%) and retention (95%) for eligible participants. There were no trends in heightened attrition for any specific subgroup.ConclusionsThe findings of this study are promising and suggest these recruitment and retention strategies may be useful in recruiting individuals from disadvantaged backgrounds.

Learning About and Living With Toxicity: A Qualitative Study of Patients Receiving Immune Checkpoint Inhibitors For Melanoma or Lung Cancer and Their Caregivers.

Immune checkpoint inhibitors (ICIs) have revolutionized treatment for melanoma and lung cancer and are in widespread use. This study aims to describe how patients and caregivers learn about ICI toxicities and their perceptions and experiences of toxicity. We conducted a qualitative study of 42 patients with advanced non-small cell lung cancer (NSCLC; n = 16) or melanoma (n = 26) who were initiating or discontinuing an ICI and their caregivers (n = 9). We conducted in-depth interviews to explore patients' and caregivers' experiences learning about and living with ICI side effects. We audio-recorded the first oncology visit after enrollment. We used a framework approach to code interview and visit transcripts and synthesized codes into themes. The median age of patients was 67; 68% were male. Themes of participant interviews and clinician-patient dialogue included: i) Patients initiating an ICI received extensive information about side effects, which some patients found overwhelming or scary and difficult to absorb; ii) Patients who were deterred by fear of toxicity ultimately proceeded with treatment because of oncologist encouragement or the sense of no alternative; iii) participants found hope in the association between toxicity and ICI efficacy; iv) caregivers helped patients navigate the deluge of information and uncertainty related to ICIs. Participants suggested ways to improve ICI side effect education, such as incorporating patient stories. Patients perceived that ICI toxicity counseling was overwhelming yet were encouraged by oncologists' reassurance that serious side effects were manageable and by the framing of toxicity as a sign of efficacy. We identified opportunities to improve communication of ICI risks and benefits.

“The oncologist told me”: Reported speech as a patients’ resource to volunteer concerns in oncological visits

Based on the “patient centered approach”, growing emphasis within policies has been put on patients' active participation in medical encounters. Consistently, research has investigated patients' initiatives during medical visits in a wide array of settings and specialties. Among these, oncological care constitutes a setting where patient participation is particularly crucial as well as challenging. However, previous studies in this setting have focused mainly on doctors' interactional work, with few works exploring patients' expressions of fears, uncertainties, and hopes. The present study contributes to this underexplored line of inquiry by showing how oncological patients take the initiative and make relevant their concerns through reported speech (RS). Based on a corpus of 106 video-recorded oncological visits collected in Italy and adopting conversation analysis, the article shows how patients use RS to volunteer some information they have previously been told by other, non-present physicians. Through RS, patients cautiously make relevant specific aspects of their case that have not been addressed in the ongoing interaction and appear to constitute a concern for them (e.g., presence of metastases, treatment side effects, hospitalization length). In response, the physician addresses the patient's concern, either by confirming the reported information or by distancing themselves from it, thus providing their opinion on the matter.

Assessing the association between quantity and quality of family caregiver participation in decision-making clinical encounters on patient activation in the metastatic breast cancer setting

ObjectiveCaregivers support individuals undergoing cancer treatment by assisting with activities, managing care, navigating healthcare systems, and communicating with care teams. We explored the quality and quantity of caregiver participation during recorded decision-making clinical appointments in women with metastatic breast cancer.MethodsThis was a convergent parallel mixed methods study that utilized qualitative and quantitative data collection and analysis. Caregiver participation quality was operationalized using a summative thematic content analysis to identify and sum caregiver actions performed during appointments. Performance of a greater number of actions was considered greater quality of participation. Caregiver participation quantity was measured by calculating the proportion of speaking time. Participation quality and quantity were compared to patient activation, assessed using the Patient Activation Measure 1-month post decision-making appointment.ResultsFifty-three clinical encounters between patients with MBC, their caregivers, and oncologists were recorded. Identified caregiver actions included: General Support; Management of Treatment or Medication; Treatment History; Decision-Making; Insurance or Money; Pharmacy; Scheduling; Travel Concerns; General Cancer Understanding; Patient Specific Cancer Understanding; Caregiver-Initiated or Emphasis on Symptom Severity; and Caregiver Back-Up of Patient Symptom Description. Caregivers averaged 5 actions (SD 3): 48% of patient’s caregivers had low quality (< 5 actions) and 52% had high quality (> 6 actions) participation. Regarding quantity, caregivers spoke on average for 4% of the encounter, with 60% of caregivers speaking less than 4% of the encounter (low quantity) and 40% of caregivers speaking more than 4% (high quantity). Greater quality and quantity of caregiver participation was associated with greater patient activation.ConclusionsCaregivers perform a variety of actions during oncological decision-making visits aiding both patient and provider. Greater participation in terms of quantity and quality by the caregiver was associated with greater patient activism, indicating a need for better integration of the caregiver in clinical decision-making environments.

The journey of patients with lung cancer: The gap between symptom onset and treatment.

e23119 Background: Prompt access to health care services is a priority in public health policies. The aim of this study was to map the journey of patients (pts) diagnosed with lung cancer (LC) and determine the time interval (TI) from symptom onset (SO) to treatment initiation and assess the impact on survival. Methods: A retrospective cohort study was conducted at the University Hospital of Larissa. Pts’ demographic and disease-related data were captured from medical records. The TI from SO to first doctor visit (StD), SO to first oncologist visit (StO), diagnosis to treatment initiation (DtT) and SO to treatment initiation (StT) were estimated. Overall survival (OS) was defined as the TI between treatment initiation and the date of death or the date of last follow-up. OS were estimated using the Kaplan–Meier analysis and the comparisons were computed with the log-rank test. Results: Overall, 251 sequential pts with metastatic LC were included in the study. Pts’ mean age was 71 years (range 35-88). The majority were men (82%) and 24%, 32%, 28% and 16% were diagnosed with small cell lung cancer (SCLC), squamous cell (SCC), adenocarcinoma (ADC) and large cell (LCC) LC, respectively. The median StD and StO was 32 (0-212) days and 102 (11-608) days, respectively. No difference was detected across genders, age ( &gt; or &lt; 70), family history of cancer or not, and area of residence (rural, urban). The median StT and DtT was 123 (30-851) days and 26 (1-105) days, respectively, with this time intervals being shorter among pts with SCLC compared to pts with non-small cell LC (NSCLC) ( p: 0.006 and p&lt; 0.001, respectively). Pts with sort StT intervals had significantly improved OS, compared to pts with longer StT intervals (SCLC p:0.044, NSCLC p:0.004). Conclusions: To the best of our knowledge, this is the first study aiming to determine specific TI from SO to treatment initiation for pts with LC in Greece and assess the potential impact on OS. Our data revealed a substantially prolonged StT (~4months) that is associated with worse survival rates. This indicates a need to improve public awareness of LC symptoms, enable pts’ access to specialized health care services and facilitate earlier diagnosis and treatment.

Correlation of significant delays and ethnic disparities in the receipt of treatment, palliative care, and supportive care interventions in pancreatic adenocarcinoma.

e16355 Background: In patients with pancreatic adenocarcinoma (PDAC), immediate treatment initiation is preferred. Early palliative care initiation has also improved quality of life and symptom burden. However, the timing of real-world treatment and palliative care initiation and possible ethnic disparities are not well understood. The objective of this study was to evaluate the timing of care initiation in a mainly Hispanic population of PDAC patients. Methods: We conducted a retrospective cohort study that included patients diagnosed with PDAC from 2014 to 2023 at Loma Linda University Health (the only tertiary care center for two large Hispanic-majority counties with large rural populations). Data were obtained on the presence and timing of appropriate provider referrals, care establishment, treatment, advanced care planning, and hospital admissions. We used a Wilcoxon rank-sum test to compare Hispanic and non-Hispanic patients regarding the time to treatment initiation and palliative care initiation. Results: 263 PDAC patients were identified (mean age 66, 57% female, 47% Hispanic, 67% head tumor, 78% stage III/IV). After diagnosis, 93% of patients were referred to medical oncology, 82% to surgical oncology, 61% to palliative care, and 30% to genetic testing. An advanced directive or physician orders for life-sustaining treatment was completed for 24% of patients. The time to care initiation is as follows: a median of 23 days (IQR 14, 54) from diagnosis to the first medical oncology visit, 13 days (IQR 6, 37) to the first surgical oncology visit, 73 days (IQR 24, 132) to the first palliative care visit and 133 days (IQR 47, 329) to hospice referral. 64% of hospice referrals were placed within the last two weeks of life. Hispanic patients had a significantly longer time to treatment initiation (68 days vs. 48 days, p= 0.008) but similar times to palliative care initiation (73 vs 74 days, p= 0.64). Hispanics also had a lower rate of completing genetic testing (45% to 66%, p= 0.07). Conclusions: In our retrospective cohort study, significant delays in establishing care with oncology, palliative care, and hospice initiation in patients with PDAC were noted. Low rates of advanced care planning were also noted despite guideline recommendations for early-focused symptomatic interventions and advanced care planning. Hispanic patients had significantly longer time to treatment initiation and lower rates of genetic testing. These results indicate a need for improved targeted patient care navigation for multidisciplinary PDAC management, particularly in Hispanic patients.

An AI-assisted navigation approach for patients with radiographic suspicion of new pancreas cancer.

11002 Background: The traditional cancer care paradigm relies on passive referral streams, resulting in suboptimal care delivery. Here, we assessed the results of an AI-assisted navigation approach to proactively coordinate specialty cancer care services for patients with radiographically suspected pancreas cancer. Methods: A natural language processing (NLP) classifier was trained to identify radiology reports suspicious for pancreas cancer from imaging reports generated within Northwell Health. The daily workflow consists of the following: the NLP flags reports with suspicion of pancreas cancer, a coordinator validates the finding, a GI oncologist and navigator coordinates specialty oncology and tumor board referral, and a clinical research coordinator pre-screens for research studies. Patients determined to be hospice-bound or with non-PDAC malignancy are excluded. Care delivery metrics were compared by Mann-Whitney U tests. Results: Prior to implementation, patients with new suspicion of pancreas cancer at our institution experienced a mean of 22 days to biopsy, 32 days to oncology visit, and 56 days to treatment initiation from radiology report with 17% referred to pancreatic multidisciplinary clinic (PMDC). Per monthly average, 1.8 patients were approached for biospecimen studies, 1.5 were consented, and 0.9 were enrolled. In the month following implementation of the AI-assisted navigation pilot, reports from 1666 patients were flagged, resulting in 38 patients with new suspicion of pancreas cancer identified (Table). Of these, 53% underwent biopsy, 50% were seen by an outpatient oncologist, 29% were referred to PMDC, and 42% received treatment at our institution. From date of radiology report, these patients underwent biopsy at a mean of 7 days (p&lt;0.01), outpatient oncology visit at 15 days (p=0.285), and treatment initiation at 34 days (p=0.3479). A monthly average of 4 patients were approached for biospecimen studies, 4 were consented, and 3.2 were enrolled. Conclusions: An AI-guided navigation workflow identified patients earlier in the diagnostic timeline; reduced time to biopsy, follow-up, and treatment initiation; increased patient referrals to PMDC; and tripled participation in biospecimen studies at our institution. [Table: see text]