Thoracic Oncology Research Articles

Changes in Behavior After Vaccination and Opinions Toward Mask Wearing: Thoracic Oncology Patient-Reported Experiences During the COVID-19 Pandemic.

Background:The COVID-19 vaccines, face masks, and social distancing are effective interventions to prevent SARS-CoV-2 infections. In this study, we aimed to determine lung cancer patients’ attitudes toward vaccination, changes in behavior after vaccination, and willingness to continue mask wearing after the pandemic.Methods:We sent out questionnaires to 220 thoracic oncology patients treated at our lung cancer center in May 2021. The questionnaire focused on patients’ vaccination status, self-reported experiences surrounding vaccination, and assessed changes in behaviors before and after vaccination as well as opinions toward mask wearing after the pandemic. Results are presented as absolute and relative frequencies and means with standard deviation and compared using t test, paired t test, and analysis of variance test as well as chi2 test, and Fisher exact text.Results:About 91.0% of patients reported having received at least 1 vaccination. About 73.3% of patients reported having at least 1 reaction to the vaccination. The most common reactions were pain at the injection site, fatigue, and headache. After vaccination, patients increased contact with family and friends, use of public transport, and grocery shopping. Overall, the level of willingness to wear masks beyond the end of the pandemic differed according to vaccination status.Conclusions:Acceptance of the COVID-19 vaccination among thoracic oncology patients in Germany was high. Overall, patients with thoracic malignancies tolerated the COVID-19 vaccination well. Rate of adverse reaction was not higher compared with the general population. After the vaccination, patients increased social contacts and usage of public transport. These changes suggest positive psychological effects on quality of life. While reducing social distancing can increase the risk of infection, our results indicate that an extension of mask mandates after the pandemic would likely be accepted by a majority of thoracic oncology patients, suggesting that our cohort was still aware and in support of other measure of protection.

Correlation research between fear of disease progression and quality of life in patients with lung cancer.

Lung cancer has the highest incidence rate and mortality rate of all malignancies. In recent years, the therapeutic effect of lung cancer has been greatly improved, but the fear of disease progression still directly affects the quality of life (QOL) of patients. The aim of this study was to evaluate the factors affecting the progression of fear of disease and its impact on the quality of life in patients with lung cancer. From December 2019 to February 2020, 102 patients with lung cancer in the Department of Thoracic Oncology of a top three hospital were investigated by using the simplified fear of disease progression scale (FoP-Q-SF) and the quality-of-life scale for cancer patients (FACT-G). Data were collected and statistically analyzed by SPSS25.0 software. A total of 110 questionnaires were distributed and 102 valid questionnaires were recovered, indicating a recovery rate of 92.7%. The results of multiple stepwise regression analyses showed that blood group, monthly income, and mood state were the influencing factors for the progression of phobic diseases in cancer patients (P<0.05), and the score of progression of phobic disease was negatively correlated with the quality-of-life score (r=-0.382). The progress of phobic diseases in patients with lung cancer seriously affects their QOL, and further attention by medical staff in providing health education, psychological counseling, social support, and other measures is required.

Survival of clinical stage III NSCLC according to therapeutic strategy: Relevance of the tumor board decision in the era of immunotherapy

IntroductionStage III NSCLC comprises a heterogeneous population. Different treatment strategies are available, including surgery, radiotherapy, and chemotherapy. The PACIFIC trial results represented a significant change and improvement in the therapeutic strategy for these patients. We aimed to compare the different treatment strategies employed in Stage III NSCLC patients within our institution. MethodsAll Stage III NSCLC patients discussed during the weekly thoracic oncology multidisciplinary team meetings at the University hospital Grenoble Alpes (France) between January 2010 and January 2017 were included. Patients’ overall survival (OS) according to treatment strategies along with their respective changes were compared. ResultsOverall, 476 patients were identified. Among patients initially scheduled to receive neoadjuvant chemotherapy followed by surgery (n = 60), only 37 (62%) actually underwent surgery. Median OS of the cohort was 21.3 months [IQR 25%–75%: 9.6–48.3]. Patients who received neoadjuvant chemotherapy followed by surgery displayed better survival than those treated by CT-RT: 53.2 months [IQR 25%–75%: 16.1–87.3] versus 23.9 [IQR 25%–75%, 13.3–48.1]. Survival was slightly superior for patients treated by upfront CT-RT than for those planned for neoadjuvant chemotherapy followed by surgery who eventually converted to CT-RT (concurrent or sequential): 23.9 months [IQR 25%–75%: 13.3–48.1] versus 20.4 [IQR 25%–75%:10.8–36], respectively. ConclusionWhile patients who underwent neoadjuvant chemotherapy followed by surgery displayed a better survival than those treated using CT-RT, switch from surgery to CT-RT actually shortened survival. These results stress the relevance of the tumor board in deciding which is the best therapeutic strategy for Stage III disease patients.

Letter to Editor: Interpretation and Application of the Likelihood Ratio to Clinical Practice in Thoracic Oncology.

To the Editor: A recent opinion piece entitled Interpretation and application of the likelihood ratio to clinical practice in thoracic oncology presents an incorrect description of the statistical approach used in the Nodify XL2 Proteomic Test and an erroneous view of the way the Nodify XL2 test results are used by clinicians. Current clinical management of lung nodule patients is challenging for physicians because the available tools are insufficient. This insufficiency can lead to a misclassification of risk of malignancy and subsequently to delayed diagnosis or unnecessary procedures,1 including invasive and painful biopsies, increased risk of complications for patients, and higher patient expenses. Because of this, we designed the Nodify XL2 test to help physicians make more informed decisions about the risk of malignancy of a lung nodule based on a simple blood draw. The Nodify XL2 test, when used as intended, has been widely validated using multiple clinical studies. The test has been reviewed and approved by third-party statisticians and the New York State Department of Health Clinical Laboratory Evaluation Program/Wadsworth Center. Clinical studies evaluating the test have been reviewed by a centralized Institutional Review Board and local Institutional Review Boards at 30 different academic and community centers.2 The concept of likelihood ratios, as applied in the Nodify XL2 test, is widely used and understood. There are >300,000 publications3 discussing the application of likelihood ratios and >80004 published papers that reference this same standard approach for determining likelihood ratio in conjunction with diagnostic tests. In fact, the Centre for Evidence-Based Medicine at Oxford, the industry global standards developer, advocates the use of this approach. By using a well-established likelihood ratio application and aggregate data modeling, not only does the Nodify XL2 test align more closely to the empirical data,5 it reduces variance across the thresholds and thereby reduces patient risk as compared to the author’s method. In contrast, the author’s approach of a multilevel likelihood ratio increases variance, overestimates risk, and may lead physicians to recommend a more invasive procedure, all of which can lead to further complications and higher patient costs. We continue to generate and incorporate emerging data and identify opportunities to further enhance the way physicians utilize this Nodify XL2 test. For example, a team of biostatisticians and clinical statisticians are currently analyzing results from over 1500 patients and samples from the prospective ORACLE Study and 2 major US cancer centers for continued assessment of the clinical utility and performance of the Nodify XL2 test. As the author states, we have also initiated a first-in-class,6 prospective randomized, blinded, controlled clinical trial7 (ALTITUDE). Interim results are anticipated in 2022. Biodesix will continually assess and apply the data’s learnings to our methodology and if necessary, make any changes needed to ensure the best possible performance of the test for patients with indeterminate pulmonary nodules. It is important to note that Nodify XL2 results provide supplementary information to the standard of care patient risk assessment and are intended to assist physicians with decisions related to patient management. Physician recommendations, patient choice, other clinical information, and guideline recommendations are all used in combination with these test results to determine the best course of action for each patient. Biodesix is committed to patient safety and improving health outcomes. The Nodify XL2 test, when used as intended, is a safe8 and valuable tool, in combination with other important clinical factors, to provide supplemental information to aid physicians in treatment decision-making. Steven Springmeyer, MD James Jett, MDBiodesix Inc., Boulder, CO

Defining comprehensive biomarker-related testing and treatment practices for advanced non-small-cell lung cancer: Results of a survey of U.S. oncologists.

BackgroundAn ASCO taskforce comprised of representatives of oncology clinicians, the American Cancer Society National Lung Cancer Roundtable (NLCRT), LUNGevity, the GO2 Foundation for Lung Cancer, and the ROS1ders sought to: characterize U.S. oncologists’ biomarker ordering and treatment practices for advanced non‐small‐cell lung cancer (NSCLC); ascertain barriers to biomarker testing; and understand the impact of delays on treatment decisions.MethodsWe deployed a survey to 2374 ASCO members, targeting U.S. thoracic and general oncologists.ResultsWe analyzed 170 eligible responses. For non‐squamous NSCLC, 97% of respondents reported ordering tests for EGFR, ALK, ROS1, and BRAF. Testing for MET, RET, and NTRK was reported to be higher among academic versus community providers and higher among thoracic oncologists than generalists. Most respondents considered 1 (46%) or 2 weeks (52%) an acceptable turnaround time, yet 37% usually waited three or more weeks to receive results. Respondents who waited ≥3 weeks were more likely to defer treatment until results were reviewed (63%). Community and generalist respondents who waited ≥3 weeks were more likely to initiate non‐targeted treatment while awaiting results. Respondents <5 years out of training were more likely to cite their concerns about waiting for results as a reason for not ordering biomarker testing (42%, vs. 19% with ≥6 years of experience).ConclusionsRespondents reported high biomarker testing rates in patients with NSCLC. Treatment decisions were impacted by test turnaround time and associated with practice setting and physician specialization and experience.

Novel Program Offering Remote, Asynchronous Subspecialist Input in Thoracic Oncology: Early Experience and Insights Gained During the COVID-19 Pandemic.

PURPOSE:AccessHope is a program developed initially by City of Hope to provide remote subspecialist input on cancer care for patients as a supplemental benefit for specific payers or employers. The leading platform for this work has been an asynchronous model of review of medical records followed by a detailed assessment of past and current management along with discussion of potential future options in a report sent to the local oncologist. This summary describes an early period of development and growth of this service, focusing on cases of lung cancer, particularly during the COVID-19 pandemic.METHODS:Cases were primarily identified by a trigger list of cancer diagnoses that included non–small-cell lung cancer and small-cell lung cancer. After medical records were obtained, a summary narrative was provided to a thoracic oncology specialist who wrote a case review sent to the local physician, followed by a direct discussion with the recipient. We focused on feasibility as measured by case volumes, the rates of concordance between the subspecialist reviewer with the local team, and cost savings from recommended changes, using descriptive statistics.RESULTS:From April 2019 to November 2020, 110 cases were reviewed: 55% male, median age 62.5 years (range, 33-92 years); 82% non–small-cell lung cancer (12% stage I or II, 16% stage III, and 57% stage IV), and 17% small-cell lung cancer (4% limited and 14% extensive). Median turnaround time for report send-out was 5.0 days. The review agreed with local management in 79 (72%) cases and disagreed in 31 (28%) cases; notably, specific additional recommendations were associated with evidence-based anticipated improvements in efficacy in 76 cases (69%) and improvement in potential for cure in 14 cases (13%). Recommendations leading to cost savings were identified in 14 cases (13%), translating to a projected cost savings of $19,062 (USD) per patient for the entire cohort of patient cases reviewed.CONCLUSION:We demonstrate the feasibility of completing a rapid turnaround of cases of lung cancer either patient-initiated for review or prospectively triggered by diagnosis and stage. This program of asynchronous second opinions identified evidence-based management changes affecting current treatment in 28% and potential improvements to improve care in 92% of patients, along with cost savings realized by eliminating low-value interventions.

P033 Moving the Needle on Speaker Diversity at AIBD.

Diversity of invited speakers at academic conferences is a topic of increased focus in recent years. While there have been efforts to improve speaker diversity, an evaluation of this in the IBD field has not been undertaken to date. We aimed to address gaps in knowledge of speaker gender, race, and experience at a major annual IBD conference over time. AIBD program brochures from 2014 to 2020 were reviewed by two providers to evaluate speaker demographic information including gender, race, topic of discussion, institutional affiliation, and, for those trained in gastroenterology, years post-fellowship. In addition, the proportion of all-male panels was calculated. As a comparator, the proportion of female speakers and all-male panels was then compared to a control conference run by the same CME organization (Personalized Therapies in Thoracic Oncology). The percentage of female speakers of any specialty at AIBD increased from 25% in 2016 to 39% in 2020. Female adult gastroenterologist speakers increased from 12% in 2015 to 27% in 2020. The percentage of all gastroenterologists that are female in the US is 19%. All-male panels also decreased from an average of 47% in 2014-2017, to 11% in 2018-2020. As a comparator, 47% of speakers at the control conference were female and there were no all-male panels in 2020. For race, in any given year an average of 13% of speakers were Asian, 5% Hispanic/Latinx, and 1% Black. This remained static over time. The percentage of Asian, Hispanic/Latinx, and Black gastroenterologists in the US is 29%, 5%, and 6%, respectively. Average years of experience of speakers at AIBD appeared relatively static, with a mean of 15 years since fellowship training per speaker. From 2014-2020, the proportion of female speakers at AIBD has increased to over one third in main programming. There remains room for improvement, particularly in increasing the racial and ethnic diversity of speakers and inviting more gastroenterologists in the early stages of their careers.

What Oncologists Want: Identifying Challenges and Preferences on Diagnosis Data Entry to Reduce EHR-Induced Burden and Improve Clinical Data Quality.

Accurate recording of diagnosis (DX) data in electronic health records (EHRs) is important for clinical practice and learning health care. Previous studies show statistically stable patterns of data entry in EHRs that contribute to inaccurate DX, likely because of a lack of data entry support. We conducted qualitative research to characterize the preferences of oncological care providers on cancer DX data entry in EHRs during clinical practice. We conducted semistructured interviews and focus groups to uncover common themes on DX data entry preferences and barriers to accurate DX recording. Then, we developed a survey questionnaire sent to a cohort of oncologists to verify the generalizability of our initial findings. We constrained our participants to a single specialty and institution to ensure similar clinical backgrounds and clinical experience with a single EHR system. A total of 12 neuro-oncologists and thoracic oncologists were involved in the interviews and focus groups. The survey developed from these two initial thrusts was distributed to 19 participants yielding a 94.7% survey response rate. Clinicians reported similar user interface experiences, barriers, and dissatisfaction with current DX entry systems including repetitive entry operations, difficulty in finding specific DX options, time-consuming interactions, and the need for workarounds to maintain efficiency. The survey revealed inefficient DX search interfaces and challenging entry processes as core barriers. Oncologists seem to be divided between specific DX data entry and time efficiency because of current interfaces and feel hindered by the burdensome and repetitive nature of EHR data entry. Oncologists' top concern for adopting data entry support interventions is ensuring that it provides significant time-saving benefits and increasing workflow efficiency. Future interventions should account for time efficiency, beyond ensuring data entry effectiveness.

Development and Evaluation of a Real-World Outcomes-Based Tool to Support Informed Clinical Decision Making in the Palliative Treatment of Patients With Metastatic NSCLC.

To develop and evaluate a tool for patients with stage IV non-small-cell lung cancer and their thoracic oncologists (TOs) that provides insight into real-world effectiveness of systemic treatments to support informed clinical decision making in the palliative setting. A participatory design approach was used to acquire insights from patients and TOs into preferences regarding the content and design of the web-based tool. Implementation was investigated by means of an adoption and usage rate. The appreciation of the tool was evaluated through a telephone survey with patients and a questionnaire for TOs. From clinical data of 2,989 patients with stage IV non-small-cell lung cancer diagnosed in one of the Santeon hospitals, an interface was developed to show treatments plus both real-world outcomes and clinical trial results after selecting patient characteristics (patients like me). This prototype of the tool was finalized after discussion in a focus group with four TOs and semi-structured interviews with six patients. The tool was implemented and used by TOs in three of six Santeon hospitals (50% adoption rate). The tool was used in 48 patients (29% usage rate), of which 17 participated in the telephone survey. Ten TOs responded to the questionnaire. The responses varied from positive reactions on the clear overview of treatment outcomes to statements that the tool rarely changed treatment decisions. Overall, the majority of patients and TOs scored the tool as of added value (71% and 83%, respectively). Our real-world data tool in metastatic lung cancer was appreciated in clinical practice by both patients and TOs. However, the efficacy of the implementation can be improved.

A randomised phase II study of osimertinib and bevacizumab versus osimertinib alone as second-line targeted treatment in advanced NSCLC with confirmed EGFR and acquired T790M mutations: the European Thoracic Oncology Platform (ETOP 10-16) BOOSTER trial

While osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is the standard treatment in patients with advanced non-small-cell lung cancer (NSCLC) with sensitising EGFR and acquired T790M mutations, progression inevitably occurs. The angiogenic pathway is implicated in EGFR TKI resistance. BOOSTER is an open-label randomised phase II trial investigating the efficacy and safety of combined osimertinib 80 mg daily and bevacizumab 15 mg/kg every 3 weeks, versus osimertinib alone, in patients with EGFR-mutant advanced NSCLC and acquired T790M mutations after failure on previous EGFR TKI therapy. Primary endpoint was investigator-assessed progression-free survival (PFS). Secondary endpoints were overall survival (OS), objective response rate (ORR) and adverse events (AEs). Between May 2017 and February 2019, 155 patients were randomised (combination: 78; osimertinib: 77). At data cut-off of 22 February 2021, median follow-up was 33.8 months [interquartile range (IQR): 26.5-37.6 months] and 129 (83.2%) PFS events were reported in the intention-to-treat population. There was no difference in median PFS between the combination [15.4 months; 95% confidence interval (CI) 9.2-18.0 months] and osimertinib arm (12.3 months; 95% CI 6.2-17.2 months; stratified log-rank P= 0.83), [hazard ratio (HR)= 0.96; 95% CI 0.68-1.37]. Median OS was 24.0 months (95% CI 17.8-32.1 months) in the combination arm and 24.3 months (95% CI 16.9-37.0 months) in the osimertinib arm (stratified log-rank P= 0.91), (HR= 1.03; 95% CI 0.67-1.56). Exploratory analysis revealed a significant interaction of smoking history with treatment for PFS (adjusted P= 0.0052) with a HR of 0.52 (95% CI 0.30-0.90) for smokers, and 1.47 (95% CI 0.92-2.33) for never smokers. ORR was 55% in both arms and the median time to treatment failure was significantly shorter in the combination than in the osimertinib arm, 8.2 months versus 10.8 months, respectively (P= 0.0074). Safety of osimertinib and bevacizumab was consistent with previous reports with grade ≥3 treatment-related AEs (TRAEs) reported in 47% and 18% of patients on combination and osimertinib alone, respectively. No difference in PFS was observed between osimertinib plus bevacizumab and osimertinib alone. Grade ≥3 TRAEs were more common in patients on combination.

Radiomics for Predicting Lung Cancer Outcomes Following Radiotherapy: A Systematic Review

Lung cancer's radiomic phenotype may potentially inform clinical decision-making with respect to radical radiotherapy. At present there are no validated biomarkers available for the individualisation of radical radiotherapy in lung cancer and the mortality rate of this disease remains the highest of all other solid tumours. MEDLINE was searched using the terms ‘radiomics’ and ‘lung cancer’ according to the Preferred Reporting Items for Systematic Reviews and Met-Analyses (PRISMA) guidance. Radiomics studies were defined as those manuscripts describing the extraction and analysis of at least 10 quantifiable imaging features. Only those studies assessing disease control, survival or toxicity outcomes for patients with lung cancer following radical radiotherapy ± chemotherapy were included. Study titles and abstracts were reviewed by two independent reviewers. The Radiomics Quality Score was applied to the full text of included papers. Of 244 returned results, 44 studies met the eligibility criteria for inclusion. End points frequently reported were local (17%), regional (17%) and distant control (31%), overall survival (79%) and pulmonary toxicity (4%). Imaging features strongly associated with clinical outcomes include texture features belonging to the subclasses Gray level run length matrix, Gray level co-occurrence matrix and kurtosis. The median cohort size for model development was 100 (15–645); in the 11 studies with external validation in a separate independent population, the median cohort size was 84 (21–295). The median number of imaging features extracted was 184 (10–6538). The median Radiomics Quality Score was 11% (0–47). Patient-reported outcomes were not incorporated within any studies identified. No studies externally validated a radiomics signature in a registered prospective study. Imaging-derived indices attained through radiomic analyses could equip thoracic oncologists with biomarkers for treatment response, patterns of failure, normal tissue toxicity and survival in lung cancer. Based on routine scans, their non-invasive nature and cost-effectiveness are major advantages over conventional pathological assessment. Improved tools are required for the appraisal of radiomics studies, as significant barriers to clinical implementation remain, such as standardisation of input scan data, quality of reporting and external validation of signatures in randomised, interventional clinical trials.

Imaging of therapeutic airway interventions in thoracic oncology

Tracheobronchial obstruction, haemoptysis, and airway fistulas caused by airway involvement by primary or metastatic malignancies may result in dyspnoea, wheezing, stridor, hypoxaemia, and obstructive atelectasis or pneumonia, and can lead to life-threatening respiratory failure if untreated. Complex minimally invasive endobronchial interventions are being used increasingly to treat cancer patients with tracheobronchial conditions with curative or, most often, palliative intent, to improve symptoms and quality of life. The selection of the appropriate treatment strategy depends on multiple factors, including tumour characteristics, whether the lesion is predominately endobronchial, shows extrinsic compression, or a combination of both, the patient's clinical status, the urgency of the clinical scenario, physician expertise, and availability of tools. Pre-procedure multidetector computed tomography (MDCT) imaging can aid in the most appropriate selection of bronchoscopic treatment. Follow-up imaging is invaluable for the early recognition and management of any potential complication. This article reviews the most commonly used endobronchial procedures in the oncological setting and illustrates the role of MDCT in planning, assisting, and follow-up of endobronchial therapeutic procedures.

Optimal Management of Radiation Pneumonitis: Preliminary Findings of an International Delphi Consensus Study

Radiation pneumonitis (RP) is a dose-limiting toxicity for lung cancer patients undergoing radiotherapy (RT) and systemic therapy. As the optimal practice for diagnosis, management and follow-up for RP is variable, we sought to establish expert consensus recommendations.International leaders in multidisciplinary thoracic oncology were invited to participate (n = 31) in this delphi consensus-building process. Following literature review on RP, open-ended questions related to knowledge, risk-reduction, diagnosis and treatment were generated for Round 1. Responses were used to generate 37 statements regarding RP diagnosis and management for Round 2. In this round, participants rated their agreement/disagreement with statements using a 5-point Likert scale, with oncologists receiving a survey with 2 additional items focused on planning technicalities. Consensus was achieved once ≥75% of respondents agreed with a statement. A final round to establish consensus in unresolved areas is planned.Round 1 had a 74% response rate (n = 23; 12 radiation oncologists, 5 clinical oncologists, 6 respirologists), and Round 2, a 61% response rate (n = 19; 15 oncologists, 4 respirologists). Of the 37 Round 2 statements, 36 received ≥75% agreement. By the end of Round 2, there was consensus opinion with agreement on the following: (1) risk stratification and mitigation should include patient factors (exposures, ILD, autoimmune and genetic conditions, COPD, emphysema, previous RT, and demographics); (2) minimizing RP risk through treatment planning (tight PTV margins, limiting dose to normal lung, dose/fractionation, IV contrast, motion management, IMRT/VMAT, daily imaging, and meeting constraints for V20 and MLD) should be utilized when possible; (3) diagnosis should be based on symptoms, exam, temporal relationship to treatment, imaging, and common toxicity grading scales; (4) Treatment of RP should be multidisciplinary, with oncologists and respiratory physicians, and should involve administration of oral steroids with gastroprotection, starting with 60 mg PO prednisolone or equivalent, for a duration of 2 weeks, with a taper of 10 mg in the daily dose per week, or for severe pneumonitis, IV methylprednisolone for 3 days before PO. Treatment adjuncts may include oxygen, inhalers, and antibiotics; (5) in differentiating drug-related pneumonitis vs. RP, standard review of patients receiving immunotherapy, per ASCO/ESMO guidelines, is insufficient to identify early pneumonitis, and thus it would be helpful to develop guidelines which recognize the additive nature of toxicities.Responses from international thoracic oncology experts highlight areas lacking consensus in the diagnosis and management of RP. These data will inform the development of final consensus statements to provide practical guidance on diagnosis and management of RP.

Clinician perspectives on communication and implementation challenges in precision oncology.

Aim: To describe patientcommunication challenges encountered by oncology clinicians, whichrepresent a fundamental barrier to implementing precision oncology. Materials & methods: We conducted three focus groups including breast, melanomaand thoracic oncology clinicians regarding their precision oncology communication experiences. Transcripts were reviewed and coded using inductive thematic text analysis. Results: We identified four themes: varied definitions of precision oncology exist, clinicians and patients face unique challenges to precision oncology implementation, patient communication challenges engendered or heightened by precision oncology implementation and clinician communication solutions and training needs. Conclusion: This study elucidated clinicians' perspectives on implementing precision oncology and related communication challenges. Understanding these challenges and developing strategies to help clinicians navigate these discussions are critical for ensuring that patients reap the full benefits of precision oncology.

Thoracic Oncologists Adopt Telehealth During COVID-19 Pandemic

Thoracic Oncologists Adopt Telehealth During COVID-19 Pandemic

Impact of telemedicine adoption on accessibility and time to treatment in patients with thoracic malignancies during the COVID-19 pandemic

BackgroundTo ensure safe delivery of oncologic care during the COVID-19 pandemic, telemedicine has been rapidly adopted. However, little data exist on the impact of telemedicine on quality and accessibility of oncologic care. This study assessed whether conducting an office visit for thoracic oncology patients via telemedicine affected time to treatment initiation and accessibility.MethodsThis was a retrospective cohort study of patients with thoracic malignancies seen by a multidisciplinary team during the first surge of COVID-19 cases in Philadelphia (March 1 to June 30, 2020). Patients with an index visit for a new phase of care, defined as a new diagnosis, local recurrence, or newly discovered metastatic disease, were included.Results240 distinct patients with thoracic malignancies were seen: 132 patients (55.0%) were seen initially in-person vs 108 (45.0%) via telemedicine. The majority of visits were for a diagnosis of a new thoracic cancer (87.5%). Among newly diagnosed patients referred to the thoracic oncology team, the median time from referral to initial visit was significantly shorter amongst the patients seen via telemedicine vs. in-person (median 5.0 vs. 6.5 days, p < 0.001). Patients received surgery (32.5%), radiation (24.2%), or systemic therapy (30.4%). Time from initial visit to treatment initiation by modality did not differ by telemedicine vs in-person: surgery (22 vs 16 days, p = 0.47), radiation (27.5 vs 27.5 days, p = 0.86, systemic therapy (15 vs 13 days, p = 0.45).ConclusionsRapid adoption of telemedicine allowed timely delivery of oncologic care during the initial surge of the COVID19 pandemic by a thoracic oncology multi-disciplinary clinic.

Implementing clinical decision support for oncology advanced care planning: A systems engineering framework to optimize the usability and utility of a machine learning predictive model in clinical practice.

330 Background: Machine learning models are well-positioned to transform cancer care delivery by providing oncologists with more accurate or accessible information to augment clinical decisions. Many machine learning projects, however, focus on model accuracy without considering the impact of using the model in real-world settings and rarely carry forward to clinical implementation. We present a human-centered systems engineering approach to address clinical problems with workflow interventions utilizing machine learning algorithms. Methods: We aimed to develop a mortality predictive tool, using a Random Forest algorithm, to identify oncology patients at high risk of death within 30 days to move advance care planning (ACP) discussions earlier in the illness trajectory. First, a project sponsor defined the clinical need and requirements of an intervention. The data scientists developed the predictive algorithm using data available in the electronic health record (EHR). A multidisciplinary workgroup was assembled including oncology physicians, advanced practice providers, nurses, social workers, chaplain, clinical informaticists, and data scientists. Meeting bi-monthly, the group utilized human-centered design (HCD) methods to understand clinical workflows and identify points of intervention. The workgroup completed a workflow redesign workshop, a 90-minute facilitated group discussion, to integrate the model in a future state workflow. An EHR (Epic) analyst built the user interface to support the intervention per the group’s requirements. The workflow was piloted in thoracic oncology and bone marrow transplant with plans to scale to other cancer clinics. Results: Our predictive model performance on test data was acceptable (sensitivity 75%, specificity 75%, F-1 score 0.71, AUC 0.82). The workgroup identified a “quality of life coordinator” who: reviews an EHR report of patients scheduled in the upcoming 7 days who have a high risk of 30-day mortality; works with the oncology team to determine ACP clinical appropriateness; documents the need for ACP; identifies potential referrals to supportive oncology, social work, or chaplain; and coordinates the oncology appointment. The oncologist receives a reminder on the day of the patient’s scheduled visit. Conclusions: This workgroup is a viable approach that can be replicated at institutions to address clinical needs and realize the full potential of machine learning models in healthcare. The next steps for this project are to address end-user feedback from the pilot, expand the intervention to other cancer disease groups, and track clinical metrics.

MA12.01 A Novel Program Offering Remote, Asynchronous Subspecialist Input in Thoracic Oncology: Early Experience During a Pandemic

AccessHope (AH) is a program developed initially by City of Hope to provide remote subspecialist input on cancer care for patients as a supplemental benefit for specific payers and employers. While offering several platforms, the leading one has been an asynchronous model of review of medical records followed by a detailed assessment of past and current management along with discussion of potential future options in a report sent to the local oncologist. The intent of this program is that the patient can continue to have most or all management in their home environment, with the input and support of a subspecialist in that tumor type available “on demand”.

Racial diversity and reporting in FDA registration trials for thoracic malignancies from 2006 to 2020.

135 Background: Black patients have a disproportionately high incidence and mortality from lung cancer. Despite the importance of clinical trials, there continue to be significant racial disparities in recruitment for pivotal registration studies. In 2016, the FDA recommended reporting racial enrollment with a minimum of 5 categories (White, Black, Asian, American Indian or Alaskan Native [AIAN] and Native Hawaiian or Pacific Islander [NHPI]). The International Committee of Medical Journal Editors also recommend reporting race and ethnicity. We evaluated race reporting and representation in registration trials for thoracic cancers. Methods: We reviewed the FDA website and identified all new drug licensing indications in thoracic malignancies (small cell lung cancer (SCLC), non-small cell lung cancer (NSCLC) and mesothelioma) from 2006 to 2020. NSCLC was further classified as EGFR+, ALK+, other mutation and NOS (no driver mutation). Clinical trials cited on the licensing label for market authorization were recorded and the corresponding registration trial publication was identified. If race was unreported or underreported (defined as ≤3 groups) in the licensing study, then additional information was obtained from clinicaltrials.gov. We calculated the proportion of registration trials meeting FDA criteria and the proportion of each racial group in trials. Results: From 2006-2020, we identified 55 new licensing indications, involving 26 unique drugs; 5 approvals in SCLC, 49 approvals in NSCLC and 1 in mesothelioma. Prior to the FDA race reporting guidelines, 33% (6/18) of registration studies did not meet FDA requirements. This improved to 27% (10/37) after the guideline introduction. Overall 29,545 patients participated in thoracic registration trials; 66% White, 22% Asian, 2% Black, &lt;1% AIAN, &lt;1% NHPI, 1% other or multiple races and 9% unknown. Table shows race distribution by cancer subtype. Conclusions: Although improving, a substantial number of registrational clinical trials in thoracic oncology still do not report race per FDA guidance. In addition, Black individuals are disproportionately under-represented in registration trials. Greater efforts are needed for the inclusion of Black patients and other minorities in clinical trials.[Table: see text]

Surgery versus SABR for early-stage lung cancer-time to call it a draw?

Randomised controlled trials comparing surgery with non-surgical treatment for cancer have been notoriously difficult to complete, owing to challenges in both equipoise and preference in patients and providers alike. 1 Nguyen TK Nguyen EK Warner A Louie AV Palma DA Failed randomized clinical trials in radiation oncology: what can we learn?. Int J Radiat Oncol Biol Phys. 2018; 101: 1018-1024 Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Debate on the relative merit of stereotactic ablative radiotherapy (SABR) versus surgery for early-stage non-small-cell lung cancer (NSCLC) is no exception. Prospective randomised controlled trials designed to identify a so-called winner between surgery and SABR have not been able to accrue, and the pooled analysis from the prematurely closed original STARS and ROSEL studies has been a lightning rod for discussion among thoracic oncologists. 2 Jones DR Do we know bad science when we see it?. J Thorac Cardiovasc Surg. 2015; 150: 472-473 Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Even with other comparative effectiveness studies attempting to adjust for confounding, inherent limitations engender polarising opinions. 3 Chen H Laba JM Boldt RG et al. Stereotactic ablative radiation therapy versus surgery in early lung cancer: a meta-analysis of propensity score studies. Int J Radiat Oncol Biol Phys. 2018; 101: 186-194 Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar Stereotactic ablative radiotherapy for operable stage I non-small-cell lung cancer (revised STARS): long-term results of a single-arm, prospective trial with prespecified comparison to surgeryLong-term survival after SABR is non-inferior to VATS L-MLND for operable stage IA NSCLC. SABR remains promising for such cases but multidisciplinary management is strongly recommended. Full-Text PDF