Thoracic Oncology Clinic Research Articles

OA17.03 Missed Opportunities for Early Lung Cancer Detection in a Multi-Disciplinary Thoracic Oncology Clinic Cohort

OA17.03 Missed Opportunities for Early Lung Cancer Detection in a Multi-Disciplinary Thoracic Oncology Clinic Cohort

The more you test, the more you find: Expansion of routine urine drug screening facilitated through an embedded palliative care clinic in thoracic oncology.

194 Background: Consensus guidelines strongly recommend urine drug screening (UDS) for all patients receiving opioids for cancer pain management. However, implementation of UDS in oncology clinics is underreported. The primary aim of this study was to evaluate incidence of unexpected UDS results among patients with lung cancer after implementation of confirmatory UDS in a thoracic oncology clinic. Methods: This is a single-institution retrospective study of UDS results among patients diagnosed with any stage thoracic malignancy before and after expansion of chromatography-based UDS facilitated by a palliative care provider embedded in a thoracic medical oncology clinic. Patients were included if their first UDS was collected during the year prior to (pre-intervention) or during the 12 months after (post-intervention) opening of the embedded Thoracic Onco-Palliative Clinic on September 5, 2018. In the pre-intervention period, UDS was routinely ordered for only patients referred to a standalone palliative care clinic. This 2-step UDS includes immunoassay and chromatography-based testing followed by interpretation of results by a specialty-trained palliative care clinical pharmacist. In the post-intervention period, UDS was expanded to include any patient seen by Thoracic Medical Oncology regardless of palliative care referral status. A Kaplan-Meier curve and log-rank test were used to compare time to first unexpected UDS between cohorts. Results: More patients had UDS testing in the post-intervention (n = 182) versus pre-intervention (n = 61) period. A higher volume and proportion of patients had unexpected UDS results in the post-cohort (25/182; 13.7%) compared to pre-cohort (6/61; 9.8%), although this difference was not statistically significant (p = 0.43). The number of UDS tests per patient was significantly higher (p < 0.01) in the post-cohort (mean (SD): 2.4 (2.7)) vs. pre-cohort (1.5 (1.3)). A larger proportion of pre-cohort patients completed only one UDS during the study period (pre: 73.8% (45/61); post: 53.3% (97/182); p < 0.01). In the post-cohort, 58 (31.9%) patients completed UDS ordered by oncology team prior to palliative care referral compared to 0 patients in the pre-cohort; 29 (21.4%) patients completed UDS without receiving outpatient palliative care compared to 0 patients in the pre-cohort. Kaplan-Meier curves for the pre- and post-cohorts were similar during the first 6 months of drug screening (p = 0.7) and diverged after 6 months, with a higher probability of detecting an unexplained UDS in the post cohort at 24 months (Pre: 15.0%; Post: 40.0%). Conclusions: Implementation of confirmatory UDS in a thoracic oncology clinic facilitates closer monitoring for nonprescribed substance use during opioid management and continued detection of unexpected UDS results up to 24 months.

Abstract B136: Health related social needs of people with cancer underrepresented in clinical trials: Early experience of the Cancer Research Equity and Advocacy through Engagement Initiative (CREATE) clinical trial patient navigation program

Abstract Background: Black and African Americans (AA) remain severely underrepresented in therapeutic oncology clinical trials (TOCTs) and have the highest cancer mortality rates compared to all other groups. Racially biased clinical trial offers, poor physician-patient communication, and social determinants of health largely contribute to these racial inequities. The UNC Lineberger CREATE Clinical Trial Patient Navigation (CTPN) program was established to advance racial equity in TOCT participation. The CTPN program entails clinical trial education, facilitating communication between patients and their medical/research team, identifying barriers to clinical trial participation and connecting patients to resources to address those barriers. Here we describe the health-related social needs and referrals made to address those needs. Methods: The CTPN program employed a targeted proactive approach to reach patients with a new cancer diagnosis who self-identified as Black/African American (AA) or were insured by Medicaid. The patient navigator used the electronic medical record (EMR) to review the oncologist's schedule to identify patients meeting the above criteria. Identified patients received a letter in the mail describing the CTPN program and were offered an in-person clinic visit and/or telephone call with the patient navigator. During these encounters, the patient navigator assessed clinical trial barriers including health-related social needs and made referrals to resources to help address these needs. The CTPN program was initially launched in the thoracic oncology clinic but later became available for direct referrals from all oncology groups. Results: In the first 18 months of the CTPN program, there were 292 patient encounters among183 unique patients who received navigation services. Most patients (83%) were identified through the EMR, 79% identify as Black or AA, 64% have Medicaid. Patients had a diagnosis of lung (62%), head and neck (18%), gynecological (9%), and breast (2%) cancers. Clinical trial related barriers and health-related social needs included lack of clinical trial knowledge (68%), housing (9%), transportation (26%), financial support (18%), and family/caregiver support (14%). CTPN program materials were provided to address clinical trial informational needs (78%), and referrals were made to assist with emotional (13%), logistical (20%), and financial (21%) needs. On average, 2 referrals were made per patient encounter. Conclusion: CTPN can engage Black/AA patients with cancer using a proactive EMR approach to identify patients and may help address health-related social needs to facilitate cancer care and potential clinical trial participation. Future work will evaluate the impact of CTPN on enrollment of Black/AAs in therapeutic cancer clinical trials. Citation Format: Ashley Rankin Collins, Hayley N. Morris, Lauren N. Matthews, Omar N. Buenaventura Gomez, Marjory Charlot. Health related social needs of people with cancer underrepresented in clinical trials: Early experience of the Cancer Research Equity and Advocacy through Engagement Initiative (CREATE) clinical trial patient navigation program [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B136.

Barriers to and enablers of physical activity participation in lung cancer survivors.

Although physical activity physical activity has been shown to have significant benefits for individuals living with cancer, engaging lung cancer survivors (LCS) in increasing routine physical activity participation has been particularly challenging. To describe enablers of, barriers to, and patterns of physical activity among LCS and to characterize interest in a physical activity program as a first step to improving physical activity engagement. The study consisted of a cross-sectional survey (n = 100) of adult LCS recruited from a thoracic oncology clinic assessing multiple domains of physical activity (engagement, perceived barriers, benefits, physical function, psychosocial factors, self-efficacy, and programmatic preferences). Only 12% of LCS in our cohort (average age 67 years, 54% male, 81% with stage III or IV disease) met American College of Sports Medicine (ACSM) physical activity guidelines. Participants engaged in moderate-to-vigorous physical activity, with an average (SD) of 48.4 (91.8) minutes per week. The most commonly reported barriers to physical activity were fatigue (49%), dyspnea (39%), and difficulty with daily activities (34%). Regression analysis demonstrated a positive association between moderate-to-vigorous physical activity and higher income (r = 0.241, p = .016), physical function (r = 0.281, p = .005), and physical activity self-efficacy (r = 0.270, p = .007). Qualitative results demonstrated a strong interest in physical activity programming that is lung-cancer specific with a high level of support and guidance. This study identified that LCS had low levels of physical activity with fatigue, dyspnea, socioeconomic, and functional limitations contributing. The majority of LCS are interested in an exercise program and believe that exercise engagement will produce functional benefits. The present study presents a framework to guide development of community-based interventions to increase LCS physical activity participation among LCS.

Unmet Needs, Quality of Life, and Financial Toxicity Among Survivors of Lung Cancer

Despite a growing population of survivors of lung cancer, there is limited understanding of the survivorship journey. Survivors of lung cancer experience unmet physical, social, emotional, and medical needs regardless of stage at diagnosis or treatment modalities. To investigate the association of unmet needs with quality of life (QOL) and financial toxicity (FT) among survivors of lung cancer. This survey study was conducted at Johns Hopkins Sidney Kimmel Comprehensive Cancer Center thoracic oncology clinics between December 1, 2020, and September 30, 2021, to assess needs (physical, social, emotional, and medical), QOL, and FT among survivors of lung cancer. Patients had non-small cell lung cancer of any stage and were alive longer than 1 year from diagnosis. A cross-sectional survey was administered, which consisted of an adapted needs survey developed by the Mayo Survey Research Center, the Comprehensive Score for Financial Toxicity measure, and the European Organization for Research and Treatment of Cancer QLQ-C30 QOL scale. Demographic and clinical information was obtained through retrospective medical record review. Data analysis was performed between May 9 and December 8, 2022. Separate multiple linear regression models, treating QOL and FT as dependent variables, were performed to assess the adjusted association of total number of unmet needs and type of unmet need (physical, emotional, social, or medical) with QOL and FT. Of the 360 survivors of lung cancer approached, 232 completed the survey and were included in this study. These 232 respondents had a median age of 69 (IQR, 60.5-75.0) years. Most respondents were women (144 [62.1%]), were married (165 [71.1%]), and had stage III or IV lung cancer (140 [60.3%]). Race and ethnicity was reported as Black (33 [14.2%]), White (172 [74.1%]), or other race or ethnicity (27 [11.6%]). A higher number of total unmet needs was associated with lower QOL (β [SE], -1.37 [0.18]; P < .001) and higher FT (β [SE], -0.33 [0.45]; P < .001). In the context of needs domains, greater unmet physical needs (β [SE], -1.24 [0.54]; P = .02), social needs (β [SE], -3.60 [1.34]; P = .01), and medical needs (β [SE], -2.66 [0.98]; P = .01) were associated with lower QOL, whereas only greater social needs was associated with higher FT (β [SE], -3.40 [0.53]; P < .001). The findings of this survey study suggest that among survivors of lung cancer, unmet needs were associated with lower QOL and higher FT. Future studies evaluating targeted interventions to address these unmet needs may improve QOL and FT among survivors of lung cancer.

Outpatient Embedded Palliative Care for Patients with Advanced Thoracic Malignancy: A Retrospective Cohort Study.

Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.

Three-Year Overall Survival of Advanced Stage ALK-Positive NSCLC at a Single Clinical Setting in Indonesia

Background: ALK-positive Non-Small Cell Lung Cancer (NSCLC) is a rare condition predominantly observed in much younger non-smokers with adenocarcinoma histology, often accompanied by brain metastases. Despite its unique features, there is a lack of data concerning the treatment of ALK-positive NSCLC in Indonesia. Therefore, this study represented the first attempt to document the treatment landscape for ALK-positive NSCLC in the country. The available ALK inhibitors included crizotinib, alectinib, brigatinib, and lorlatinib, and none of these were listed under the Indonesian Universal Health Coverage as of September 2022. This study aimed to characterize survival outcomes of ALK-positive NSCLC patients treated within a specialized thoracic oncology practice in Indonesia.Methods: The retrospective observational cohort study drew secondary data from medical records of ALK-positive NSCLC patients treated at a private thoracic oncology clinic. Data were collected retrospectively, spanning from December 2019 to December 31, 2022. Exclusion criteria included incomplete data, untreated ALK-positive NSCLC, cases at stage I-III, or diagnoses made after August 2021. The observation period extended up to 36 months, although several patients exceeded 48 months, with one individual currently boasting a 96-month survival.Results: A total of 15 patients with ALK-positive NSCLC were selected as the respondents in this study. The median age stood at 50.8 years, predominantly female, and diagnosed with adenocarcinoma. Predominant sites of metastasis included pleural effusion and brain metastases, and preliminary 36-month survival rates reached 73.3%. The 1-year survival rate was recorded at 100%, while the 2-year overall survival (OS) stood at 80%, aligning closely with global ALK inhibitors clinical trial data.Conclusions: This study provided the first-ever dataset indicating an ALK-positive profile within a singular thoracic oncology clinic in Indonesia. Despite the accessibility constraints of treatments, ALK-positive patients showed comparable total survival to pivotal clinical trial data. This preliminary dataset shed light on the profile and treatment of ALK-positive NSCLC in the country.

Improving Access to Early Palliative Care Delivery for Patients With an Advanced Thoracic Malignancy Through an Embedded Oncopalliative Clinic Model.

Early integration of palliative care (PC) with standard oncology care is driving the development of innovative PC delivery models. This was a single-institution retrospective study of outpatient PC before and after the opening of an embedded thoracic oncology-palliative clinic at The Ohio State University. Patients included in the preintervention (October 2017-July 2018) and postintervention (October 2018-July 2019) cohorts had a diagnosis of any non-small-cell lung cancer (stages I-IV) or small-cell lung cancer (limited or extensive stage) and were newly established in the thoracic medical oncology clinic during the study time periods. All patients in the preintervention cohort had access to outpatient PC through a freestanding clinic, while the postintervention cohort had access to both freestanding and embedded clinics. Using time-to-event analyses, we evaluated differences in time intervals from first medical oncology visit to PC referral and first PC visit between cohorts. The majority of patients in both cohorts had metastatic disease at diagnosis. In the postintervention cohort, 20.9% of patients were referred to outpatient PC compared with 9.2% in the preintervention cohort (P < .01). PC referrals for patients outside of Franklin and adjacent counties increased from 4.0% to 14.2% after opening the embedded clinic (P < .01). Completion percentages of PC referrals increased from 57.6% to 76.0% in the preintervention versus postintervention cohorts (P = .048). Median time from palliative referral order to first PC visit decreased from 29 to 20 days (P = .047). Similarly, median time from the first oncology visit to PC referral completion decreased from 103 to 41 days (P = .08). Implementation of an embedded PC model was associated with increased access to early PC among patients with thoracic malignancies.

Feasibility of an embedded palliative care clinic model for patients with an advanced thoracic malignancy

PurposeEarly palliative care (PC) with standard oncology care has demonstrated improved patient outcomes, but multiple care delivery models are utilized. This study prospectively evaluated the feasibility of an embedded PC clinic model and collected patient-reported outcomes (PROs) and caregiver needs.MethodsIn this observational study of embedded outpatient PC for patients with advanced thoracic malignancies treated at The Ohio State University Thoracic Oncology clinic, patients received same-day coordinated oncology and palliative care visits at one clinic location. PC encounters included comprehensive symptom assessment and management, advanced care planning, and goals of care discussion. Multiple study assessments were utilized. We describe the feasibility of evaluating PROs and caregiver needs in an embedded PC model.ResultsForty patients and 28 caregivers were enrolled. PROs were collected at baseline and follow-up visits. Over a 12-month follow-up, 36 patients discontinued study participation due to hospice enrollment, death, study withdrawal, or COVID restrictions. At baseline, 32 patients (80%) rated distress as moderate-severe with clinically significant depression (44%) and anxiety (36%). Survey completion rates significantly decreased over time: 3 months (24 eligible, 66% completed), 6 months (17 eligible; 41% completed), 9 months (9 eligible; 44% completed), and 12 months (4 eligible; 50% completed).ConclusionWe found that an embedded PC clinic was feasible, although there were challenges encountered in longitudinal collection of PROs due to high study attrition. Ongoing assessment and expansion of this embedded PC model will continue to identify strengths and challenges to improve patient and caregiver outcomes.

EP06.01-015 Will Virtual Care Stand the Test of Time; One Site’s Perspective on the Continuity of Virtual Care Post-Pandemic

EP06.01-015 Will Virtual Care Stand the Test of Time; One Site’s Perspective on the Continuity of Virtual Care Post-Pandemic

Clinical outcomes and immune phenotypes associated with STK11 co-occurring mutations in non-small cell lung cancer.

BackgroundSTK11 mutation in non-small cell lung cancer (NSCLC) is associated with worse survival as well as primary resistance to PD-1/PD-L1 targeting immunotherapy. We hypothesize that co-occurring mutations and tumor mutation burden (TMB) may impact response to therapy and prognosis.MethodsForty-one patients with STK11-mutated NSCLC seen in our Thoracic oncology clinic with available next-generation sequencing tumor data were included in the analysis. Data from the Cancer Genome Atlas (TCGA) was used for survival and immune gene expression analysis. Overall and progression-free survival (PFS) was estimated by the Kaplan-Meier method and compared using a log-rank test.ResultsIn the 41 patients included, common co-occurring alterations with STK11 were KRAS (54%), TP53 (44%), CDKN2A (37%) and KEAP1 (27%). Overall 17 patients received locoregional therapy with surgery or radiation with median OS of 8.6 years and there was no significant difference in clinical outcomes with KRAS and TP53 co-occurring mutations. Response to both chemotherapy and immunotherapy was poor across all co-occurring mutations. However, TP53 co-mutation was associated with improved clinical benefit with immunotherapy. Patients with higher TMB had longer PFS with immunotherapy. In TCGA survival analysis, tumors with STK11 mutation with or without KRAS co-mutation were associated with worse survival (P<0.05) but tumors with STK11/TP53 co-mutation did not have worst survival compared to STK11 wild type tumors. Moreover, co-occurring mutations had significant effect on intratumoral immune status with both STK11 alone and STK11/KRAS co-mutated tumors showing more enrichment for wound healing immune subtype while STK11/TP53 co-mutated tumors showed more enrichment for IFN-g immune subtype.ConclusionsOur retrospective analysis in patients with STK11-mutated NSCLC found that both TMB and co-occurring mutations may be predictors for response to immunotherapy with worse outcomes in patients with low TMB or KRAS co-mutation and improved outcomes with TP53 co-mutation. Patients with STK11-mutated NSCLC also demonstrate chemotherapy resistance but have similar outcomes with localized treatment compared to STK11 wild type tumors. Moreover, co-mutations with KRAS or TP53 significantly alter tumor immune landscape of STK11-mutated tumors and therefore response to immunotherapy.

Acceptability of a machine learning-powered clinical decision support system aiding serious illness conversation and its impact on clinical outcomes: A pilot study.

6562 Background: Patients with advanced cancer that utilize end of life planning see benefits including better quality of life and medical care that is more consistent with their values. We developed a 30-day mortality predictive model using a machine learning algorithm and integrated it into a clinical decision support system (CDSS) that encourages clinicians to use the serious illness conversation (SIC) guide—a standardized questionnaire and conversational tool that facilitates end-of-life planning. The CDSS was piloted in the thoracic oncology clinic. We evaluated clinicians’ use of this system and its impact on patient outcomes. Methods: Between 4/14/21-1/15/22, information about patients identified by the model was sent to clinical teams via the electronic health record (EHR) to assess eligibility for a SIC. We reviewed the EHR for patients identified, SIC completion, and level of agreement by oncologists with the model. We evaluated the SIC guide responses using descriptive statistics and assessed differences in rates of hospice referral, hospital visits, and 30-day mortality by SIC completion status. Chi-squared test was used for testing association. Results: 94 patients were evaluated for SIC eligibility. Of these, oncologists agreed with 48 (51%) model predictions and SIC was completed for 28 (58%) of those patients. A median of 2.5 SIC eligibility assessments per week were completed, with a median time of 4 days from prediction to assessment. Likewise, a median of 1 SIC per week was completed, with a median time of 20 days from SIC eligibility assessment to conversation. Regarding the responses to the SIC guide, out of 28 patients, 75% have an appropriate understanding of their illness; 64% want to be fully informed of their medical information while 21% prefer information to be limited. Common patient goals were “being comfortable” (54%), “being at home” (29%) and “being independent” (25%). The most prevalent patient fears were “family concerns” (29%) or “physical suffering” (25%). The clinician who performs the SIC most often recommended an “additional conversation with physician” (39%), “conversation with family” (36%), or “referral to palliative care” (18%). SIC completion was associated with an increased rate of enrollment in hospice (33% vs 14%, P= 0.03) on univariate analysis. SIC was not associated with a difference in 30-day mortality or hospital visits. Multivariable analysis is ongoing. Conclusions: The machine-learning powered CDSS was adopted by the oncology care team within a reasonable timeframe. However, even if an oncologist used and agreed with the CDSS, the rate of eventual completion of SIC was not 100%. Additional barriers to SIC will be studied to optimize the CDSS. SIC completion may lead to increased enrollment in hospice and should continue to be studied as a standard component of comprehensive cancer care.

Features of surgical treatment of the apical right lung cancer

The tumor of the upper sulcus of the lung is an atypical form of cancer, which is characterized by invasion into the aperture of the chest and mediastinum, which in turn determines the manifestation of the disease of neurological symptoms.Tactical approaches in the treatment of this disease are well known. To date, complex treatment is used, which includes neoadjuvant chemoradiotherapy followed by surgical treatment. This approach gives the best result in terms of prognosis and survival of patients.Considering the local invasion, planning the surgical stage in the treatment of this group of patients is a difficult task and requires a multidisciplinary approach to determine the optimal surgical tactics.This paper presents our own clinical observation of the successful surgical treatment of a 54‑year‑old patient with a tumor of the upper sulcus of the right lung. In order to adequately visualize the pathological process, safety and convenience of surgical intervention, Hemi‑Clamshell access was used, which combined the advantages of sternotomy and thoracotomy. Taking into account the topical location of the tumor, the greatest technical difficulties during the operation arose when performing mobilization of the upper lobe of the right lung, adequate lymph dissection near large arterial and venous vessels, removal of part of the chest wall of the pleural cavity dome.Also, one of the important issues when planning surgical treatment of this group of patients is to determine the indications for restoring the skeletal function of the chest after rib resection. In our case, despite the resection of the posterior segments of the I–III ribs, all the muscles of the anterior chest wall were preserved, which took over part of the skeletal function of the chest. There was no development of paradoxical breathing in the postoperative period.Surgical interventions of this amount should be performed in specialized thoracic oncology clinics and multidisciplinary medical institutions. At the same time, a multidisciplinary approach of doctors of various specialties, the experience of the operating team in performing such operations and the appropriate anesthesiological and resuscitation service is needed.

OA05.01 Impact of an Embedded Palliative Care Clinic on Healthcare Utilization for Patients With an Advanced Thoracic Malignancy

While early palliative care is beneficial for patients with advanced cancer, the best method of palliative care delivery is unknown. We investigated healthcare utilization before and after embedding a palliative care clinic within a thoracic medical oncology clinic.

Cancer patient satisfaction with telehealth: Survey results from a large NCI-designated cancer institute.

1579 Background: Telehealth (TH) utilization for patients at our cancer institute increased in 2020 in response to the COVID-19 pandemic, however oncology-specific TH patient satisfaction is unknown. Methods: Monthly TH utilization at a single large NCI-designated institute from 3/1/2020-11/30/2020 was reviewed. Utilization was calculated as chargeable TH visits (new video, established video, phone) as a proportion of all consult/follow up visits. Patient satisfaction surveys for oncology TH visits for MD/PA/NP providers were reviewed from 4/1/2020-11/30/2020. Surveys were sent after every TH visit, unless the patient had a prior visit in the past 3 months. Percent (%) top box score (TBS) was defined as proportion of responses in the highest possible response category (i.e. very good). % TBS was reported for 14 survey items in 4 domains: technology, access, care provider (CP), and overall assessment. Satisfaction was assessed over time and according to patient factors: generation, gender, insurance type, employment status, and clinic site. The Cochrane-Armitage trend test was used to compare proportions of TBS responses across monthly time points. Results: TH comprised 21% (22,055/103,461) of all encounters in the study period. TH use increased from 9% in 3/2020 to a peak of 47% in 4/2020. In 11/2020, TH use was 18%. 28.0% (2,286/8,173) of TH patient surveys were returned. Multiple patient satisfaction metrics were improved over time (Table). Patients had higher satisfaction with phone compared to video visits with regards to technology (86% vs 76%) and access (80% vs 72%). Millennials (born 1981-1995) had higher satisfaction with access to TH (87%) compared to Gen X (1965-1980) (77%), Baby Boomer (1946-1964) (74%), and Silent Generation (1928-1945) (72%), however all generations had similar levels of satisfaction with technology (range 77-80%). Disabled patients had higher overall satisfaction of TH (82%) versus those working full time or retired (71%). Patients with commercial insurance had worse overall satisfaction of TH compared to other insurance types (65% vs 72%). Patients with encounters in genitourinary, thoracic, and endocrine oncology clinics had the highest levels of overall satisfaction (75%) compared to other clinics (69%). There were no observed differences in TH satisfaction according to gender. Conclusions: TH cancer patient satisfaction is high and has improved over time, however satisfaction differs by patient demographics. Further data are needed to best select patients appropriate for TH.[Table: see text]

Implementation of an Early Palliative Care Referral Program in Lung Cancer: A Quality Improvement Project at the Tata Memorial Hospital, Mumbai, India.

Objectives:Access to early palliative care (EPC) for all patients with metastatic lung cancer is yet to be achieved in spite of recommendations. This quality improvement (QI) project was initialized to improve the rates of such referrals from the thoracic oncology clinic for all new outpatients in a premier cancer center in India.Materials and Methods:Change in the proportion of patients receiving referrals for EPC during and after intervention (April–May 2018), compared to baseline (January–March 2018) were explored. Interventions included understanding of the process flow, identification of key drivers, and root cause analysis which identified the gaps as lack of documentation for EPC. Teaching and encouraging staff at the clinic to incorporate referrals into all initial visits for patients with metastatic lung cancer were incorporated.Results:The bundle of QI interventions increased referrals from an average of 50% to 75%, mean difference = 12.64 (standard deviation = 10.13) (95% confidence interval = 22.01–3.29), P = 0.016 (two-tailed) on paired sample test.Conclusion:Improved referral rates for EPC in a multidisciplinary cancer clinic is possible with a QI project. This project also identifies the importance of data documentation and patient information processes that can be targeted for improvement.

Abstract PO-010: Changes in lung cancer treatment as a result of the COVID19 pandemic: A prospective observational study

Abstract Background: Patients with lung cancer are at high risk from COVID19. Efforts are ongoing to limit exposure of patients with lung cancer to the health care system. As a result, the COVID19 pandemic has drastically changed cancer care, but the extent and type of these changes are unknown. The goal of this study was to evaluate the changes in lung cancer treatment during the peak of the COVID19 pandemic. Methods: We prospectively assessed the cancer management plan of all patients seen in the thoracic oncology clinic at our center between March 2 and April 30, 2020. Inclusion criteria for this study were a diagnosis of either non-small cell lung cancer or small-cell lung cancer. Those who had a diagnosis of COVID19 were excluded from the study. Primary endpoints were to describe the extent of changes in the cancer treatment plan and qualify the types of changes observed. Results: A total of N=289 patients were evaluated between March 2 and April 30, 2020. N=14 patients were excluded due to presence of other tumor histology, and 2 patients were COVID19-positive. Among the 275 patients included, median age was 68 and 47% were male. Among the 238 patients (86.5%) with non-small cell lung cancer, 172 (62.5%) had advanced disease. Among the 37 patients (13.5%) with small-cell lung cancer, 11 (4%) had extensive disease. 211 were receiving active treatment (76.5%), with 35.1% on chemotherapy, 21.8% on oral agents, 31.8% on immune checkpoint inhibitors, and 11.4% on combination therapy. 121 (57%) of patients experienced at least one change in their lung cancer treatment plan as a direct result of the COVID19 pandemic, with 19 (9.0%) patients experiencing more than one change. The majority of changes encompassed delay or cessation of palliative treatment, N=48 (39.7%), N=18 (14.9%), respectively. Mean time to resumption of palliative treatment was 36 days, and 3% of patients stopped palliative treatment permanently as a direct result of the pandemic. Changes in dosing and schedule occurred in N=32 (26.4%), which included changing pembrolizumab to q 6 weeks or durvalumab to q 4 weeks. A minority of patients experienced delays in adjuvant chemotherapy administration (N=3 (2.5%)) with a mean delay of 42 days. Lastly, 6.6% of patients experienced deferrals or cancellations of surveillance scans or visits due to COVID19. Other changes included the decision not to pursue palliative chemotherapy. Conclusion: Our study demonstrated that a significant proportion (57%) of patients experienced changes in their lung cancer management plan as a direct result of the COVID19 pandemic. Given the preliminary findings that active cancer treatment is not associated with increased complications from COVID19, lung cancer treatments and surveillance visits should continue to proceed with caution, and oncology care providers should continue to carefully proceed with evidence-based care in lung cancer. Citation Format: Suzanne Kazandjian, Nathaniel Bouganim, Arielle Elkrief. Changes in lung cancer treatment as a result of the COVID19 pandemic: A prospective observational study [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-010.

Thoracic Oncology Multidisciplinary Clinic Reduces Unnecessary Health Care Expenditure Used in the Workup of Patients With Non–small-cell Lung Cancer

BackgroundNational costs of lung cancer care exceed $12 billion. We investigate the resource-savings benefit of a single-day thoracic oncology multidisciplinary clinic (MDC) in the diagnostic period prior to non–small-cell lung cancer (NSCLC) treatment. Materials and MethodsFrom July 2007 to January 2015, patients with NSCLC treated with multimodality therapy at a tertiary hospital-based cancer center in Maryland were identified. Patient and treatment details were collected. Health care resources utilized in the 90 days prior to receipt of first oncologic treatment were identified using billed activity codes. Associated total charges, including professional fees and hospital-based technical fees, were identified and inflated to 2014 dollars using the Consumer Price Index. Codes were categorized into provider visits, procedures, pathology/laboratory, radiology, and other tests. χ2, Student t, and Wilcoxon rank-sum tests compared charges of patients seen in and out of the MDC. ResultsTwo-hundred ninety-seven (non-MDC = 161, 54%; MDC = 136, 46%) of 308 patients identified had total charges available. Patients seen through MDC had on average a 23% decrease in total charges per patient incurred ($5839 savings; range, $5213-$6464) compared with patients seen through non-MDC settings. Evaluation through MDC reduced the average number of provider visits per patient (non-MDC, 6.8 vs. MDC, 4.8; P < .01) prior to treatment start, which led to a 50% (average $3092; range, $2451-$3732) reduction in provider charges per patient (P < .01). ConclusionsEvaluation of patients with NSCLC through a coordinated single-day MDC reduced hospital charges per patient by 23% during the diagnostic period prior to treatment when compared with evaluation through traditional referral-based thoracic oncology clinics.

Optimization of immune-related adverse event management in a thoracic oncology clinic.

261 Background: Improved awareness and management of immune checkpoint inhibitor (ICI) related adverse events (IRAEs) is a mandate for best practice given widespread use of ICIs in clinic. IRAE grading is standardized by the Common Terminology Criteria for Adverse Events (CTCAE); management has been standardized in recently published consensus guidelines. In the thoracic oncology clinic at the Beth Israel Deaconess Medical Center grading and management of IRAEs has been inconsistent. Methods: A retrospective review of 98 patients receiving ICIs in the thoracic oncology clinic from March 2015-April 2018 was conducted with a focus on IRAE grading and management. Oncologists were surveyed regarding barriers to grading, management, and subspecialty referral for IRAEs. We aimed to improve documentation of IRAE grading to 75% as well as the rate of specialist referral for grade 3-4 IRAEs. As an intervention we implemented a macro to document IRAE CTCAE grade and management. Additionally, our team created a pathway for specialist referral for patients with grade 3-4 IRAEs. Results: Upon review of 98 patient charts, 38 patients developed 58 IRAEs of which 36% were grade 1-2, 17% were grade 3, 0% were grade 4 and 47% were ungraded. The most commonly affected organs were skin (25%), thyroid (25%) and lung (11%). 53% of active IRAEs were formally graded in the oncologist’s assessment, only 6% of resolved IRAEs were documented in the subsequent oncologic history. A total of 11 patients were hospitalized for IRAEs, 7 of which had undocumented severity; 40% of grade 3 IRAEs were hospitalized. 14 specialist referrals were made, most with undocumented severity; 30% of patients with grade 3 IRAEs were referred. Overall, 18 patients required steroids, of these 40% were ungraded, and 19 had immunotherapy stopped or held, of these 45% were ungraded. Conclusions: While the presence of IRAEs is consistently documented, documentation of severity and subsequent management are inconsistent- including amongst those patients requiring hospitalization, specialty referral and/or treatment modification. Further data will be reported regarding utilization of the macro, documentation of IRAE grading and management as well as specialist referral rate.

Improving the assessment and documentation of constipation at UF Health Cancer Center through mandatory prompts.

263 Background: Opioids are commonly prescribed to patients for management of pain and the most common and persistent side effect from opioid use is constipation. Opioid-induced constipation (OIC) affects 52% of patients with advanced cancer and 87% of terminally ill patients. In the Spring 2017 Quality Oncology Practice Initiative (QOPI) chart abstraction round, UF Health Cancer Center’s Medical Oncology clinic notes documented the assessment of constipation in only 45.45% of charts. This is below the academic hospital aggregate documentation rate of 55.61%. Methods: Our objective was to improve the rate of documentation of assessment of constipation in the Thoracic Oncology Clinic at UF Health Cancer Center by 33% to a goal rate of at least 60% by 3 months. We used a Plan-Do-Study-Act model in order to design our project. We worked with the EPIC developers to include a mandatory prompt at the end of the assessment/plan section of the clinic template notes for the Thoracic Oncology practice. Our prompt was “Constipation was addressed and @HE@ {DOES/DOES NOT} have symptoms” where the author chooses from a drop down list to select whether the patient “does” or "does not” have symptoms. We planned to assess a total of 60 random charts in the 3 month post intervention period. Results: At the end of our study, a total of 48 out of 60 charts (80%) documented constipation thus surpassing our goal of 60%. Of the 12 charts assessed that did not address constipation, 11 did not use our revised templates and were notes that were “copied forwarded” from previous encounters. Conclusions: Given that our intervention was a success, we plan to expand these revised templates to the other medical oncology subspecialties in order to better document assessment of constipation for all cancer patients. While our mandatory prompt was shown to lead to increased documentation of constipation, further studies to show whether or not this leads to decreased complaints of abdominal pain, decreased incidences of bowel obstructions, and/or decreased hospital admissions, would be interesting to pursue.