Publications by authors named "Angel M Cronin"

122 Publications

Variation in Use of High-Cost Technologies for Palliative Radiation Therapy by Radiation Oncologists.

J Natl Compr Canc Netw 2021 04 12;19(4):421-431. Epub 2021 Feb 12.

2Division of Population Sciences and the Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts.

Background: Understanding the sources of variation in the use of high-cost technologies is important for developing effective strategies to control costs of care. Palliative radiation therapy (RT) is a discretionary treatment and its use may vary based on patient and clinician factors.

Methods: Using data from the SEER-Medicare linked database, we identified patients diagnosed with metastatic lung, prostate, breast, and colorectal cancers in 2010 through 2015 who received RT, and the radiation oncologists who treated them. The costs of radiation services for each patient over a 90-day episode were calculated, and radiation oncologists were assigned to cost quintiles. The use of advanced technologies (eg, intensity-modulated radiation, stereotactic RT) and the number of RT treatments (eg, any site, bone only) were identified. Multivariable random-effects models were constructed to estimate the proportion of variation in the use of advanced technologies and extended fractionation (>10 fractions) that could be explained by patient fixed effects versus physician random effects.

Results: We identified 37,361 patients with metastatic lung cancer, 3,684 with metastatic breast cancer, 5,323 with metastatic prostate cancer, and 8,726 with metastatic colorectal cancer, with 34%, 27%, 22%, and 9% receiving RT within the first year, respectively. The use of advanced technologies and extended fractionation was associated with higher costs of care. Compared with the patient case-mix, physician variation accounted for a larger proportion of the variation in the use of advanced technologies for palliative RT and the use of extended fractionation.

Conclusions: Differences in radiation oncologists' practice and choices, rather than differences in patient case-mix, accounted for a greater proportion of the variation in the use of advanced technologies and high-cost radiation services.
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http://dx.doi.org/10.6004/jnccn.2020.7633DOI Listing
April 2021

Association between the 21-gene recurrence score and isolated locoregional recurrence in stage I-II, hormone receptor-positive breast cancer.

Radiat Oncol 2020 Aug 17;15(1):198. Epub 2020 Aug 17.

Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.

Background: Although the 21-gene recurrence score (RS) assay is widely used to predict distant recurrence risk and benefit from adjuvant chemotherapy among women with hormone receptor-positive (HR+) breast cancer, the relationship between the RS and isolated locoregional recurrence (iLRR) remains poorly understood. Therefore, we examined the association between the RS and risk of iLRR for women with stage I-II, HR+ breast cancer.

Methods: We identified 1758 women captured in the national prospective Breast Cancer-Collaborative Outcomes Research Database who were diagnosed with stage I-II, HR+ breast cancer from 2006 to 2012, treated with mastectomy or breast-conserving surgery, and received RS testing. Women who received neoadjuvant therapy were excluded. The association between the RS and risk of iLRR was examined using competing risks regression.

Results: Overall, 19% of the cohort (n = 329) had a RS ≥25. At median follow-up of 29 months, only 22 iLRR events were observed. Having a RS ≥25 was not associated with a significantly higher risk of iLRR compared to a RS < 25 (hazard ratio 1.14, 95% confidence interval 0.39-3.36, P = 0.81). When limited to women who received adjuvant endocrine therapy without chemotherapy (n = 1199; 68% of the cohort), having a RS ≥25 (n = 74) was significantly associated with a higher risk of iLRR compared to a RS < 25 (hazard ratio 3.66, 95% confidence interval 1.07-12.5, P = 0.04). In this group, increasing RS was associated with greater risk of iLRR (compared to RS < 18, hazard ratio of 1.66, 3.59, and 7.06, respectively, for RS 18-24, 25-30, and ≥ 31; P = 0.02).

Conclusions: The RS was significantly associated with risk of iLRR in patients who did not receive adjuvant chemotherapy. The utility of the RS in identifying patients who have a low risk of iLRR should be further studied.
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http://dx.doi.org/10.1186/s13014-020-01640-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429461PMC
August 2020

Overuse of Diagnostic Brain Imaging Among Patients With Stage IA Non-Small Cell Lung Cancer.

J Natl Compr Canc Netw 2020 05;18(5):547-554

The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Among patients diagnosed with stage IA non-small cell lung cancer (NSCLC), the incidence of occult brain metastasis is low, and several professional societies recommend against brain imaging for staging purposes. The goal of this study was to characterize the use of brain imaging among Medicare patients diagnosed with stage IA NSCLC.

Methods: Using data from linked SEER-Medicare claims, we identified patients diagnosed with AJCC 8th edition stage IA NSCLC in 2004 through 2013. Patients were classified as having received brain imaging if they underwent head CT or brain MRI from 1 month before to 3 months after diagnosis. We identified factors associated with receipt of brain imaging using multivariable logistic regression.

Results: Among 13,809 patients with stage IA NSCLC, 3,417 (25%) underwent brain imaging at time of diagnosis. The rate of brain imaging increased over time, from 23.5% in 2004 to 28.7% in 2013 (P=.0006). There was significant variation in the use of brain imaging across hospital service areas, with rates ranging from 0% to 64.0%. Factors associated with a greater likelihood of brain imaging included older age (odds ratios [ORs] of 1.16 for 70-74 years, 1.13 for 75-79 years, 1.31 for 80-84 years, and 1.46 for ≥85 years compared with 65-69 years; all P<.05), female sex (OR, 1.09; P<.05), black race (OR 1.23; P<.05), larger tumor size (ORs of 1.23 for 11-20 mm and 1.28 for 21-30 mm tumors vs 1-10 mm tumors; all P<.05), and higher modified Charlson-Deyo comorbidity score (OR, 1.28 for score >1 vs score of 0; P<.05).

Conclusions: Roughly 1 in 4 patients with stage IA NSCLC received brain imaging at the time of diagnosis despite national recommendations against the practice. Although several patient factors are associated with receipt of brain imaging, there is significant geographic variation across the United States. Closer adherence to clinical guidelines is likely to result in more cost-effective care.
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http://dx.doi.org/10.6004/jnccn.2019.7384DOI Listing
May 2020

Mortality After Invasive Second Breast Cancers Following Prior Radiotherapy for DCIS.

J Natl Compr Canc Netw 2019 11;17(11):1367-1371

Brigham and Women's Hospital.

Background: Women with a history of ductal carcinoma in situ (DCIS) are at increased risk for developing a second breast cancer (SBC). A prior meta-analysis of randomized studies of radiotherapy (RT) for DCIS has shown a trend toward increased breast cancer-specific mortality after SBC, but it did not have the power needed to detect a significant difference, due to a limited number of recurrences. This study sought to evaluate the impact of RT for DCIS on mortality after SBC in a larger cohort.

Patients And Methods: Using the SEER database, 3,407 patients were identified who received breast-conserving therapy with or without RT for primary DCIS in 2000 through 2013 and subsequently developed a stage I-III invasive SBC within the same time period. Fine-Gray competing risk models were used to study the association between receipt of RT and mortality after SBC.

Results: Prior RT was found to be associated with higher rates of breast cancer-specific mortality (hazard ratio [HR], 1.70; 95% CI, 1.18-2.45; P=.005), even after controlling for cancer stage. Interaction analysis suggested that this risk trended higher in patients with ipsilateral versus contralateral SBC (HR, 2.07 vs 1.26; P=.16). Furthermore, compared with patients who developed contralateral SBC, those with ipsilateral SBC were younger (P<.001) and more often lacked estrogen receptor expression (P<.001).

Conclusions: Patients who previously received RT for DCIS had higher mortality after developing an invasive SBC than those who did not receive RT. This finding may have implications for initial treatment decisions in the management of DCIS.
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http://dx.doi.org/10.6004/jnccn.2019.7323DOI Listing
November 2019

Unrealistic parental expectations for cure in poor-prognosis childhood cancer.

Cancer 2020 01 4;126(2):416-424. Epub 2019 Oct 4.

Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.

Background: Many parents of children with advanced cancer pursue curative goals when cure is no longer possible. To the authors' knowledge, no pediatric studies to date have prospectively evaluated prognosis communication or influences on decision making in poor-prognosis childhood cancer.

Methods: The authors conducted a prospective cohort study at 9 pediatric cancer centers that enrolled 95 parents of children with recurrent or refractory, high-risk neuroblastoma (63% of those who were approached), a condition for which cure rarely is achieved. Parents were surveyed regarding the child's likelihood of cure; their primary goal of care; the child's symptoms, suffering, and quality of life; and regret concerning the last treatment decision. Medical records identified care and treatment decisions.

Results: Only 26% of parents recognized that the chance of cure was <25%. When asked to choose a single most important goal of care, approximately 72% chose cure, 10% chose longer life, and 18% chose quality of life. Parents were more likely to prioritize quality of life when they recognized the child's poor prognosis (P = .002). Approximately 41% of parents expressed regret about the most recent treatment decision. Parents were more likely to experience regret if the child had received higher intensity medical care (odds ratio [OR], 3.14; 95% CI, 1.31-7.51), experienced suffering with limited benefit from the most recent treatment (OR, 4.78; 95% CI, 1.16-19.72), or experienced suffering from symptoms (OR, 2.91; 95% CI, 1.18-7.16).

Conclusions: Parents of children with poor-prognosis cancer frequently make decisions based on unrealistic expectations. New strategies for effective prognosis communication are needed.
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http://dx.doi.org/10.1002/cncr.32553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523918PMC
January 2020

Patient-preferred outcomes measurement after post-mastectomy radiation therapy and immediate reconstruction.

Breast J 2020 02 8;26(2):319-321. Epub 2019 Sep 8.

Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute (DFCI), Boston, Massachusetts.

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http://dx.doi.org/10.1111/tbj.13592DOI Listing
February 2020

Duality of purpose: Participant and parent understanding of the purpose of genomic tumor profiling research among children and young adults with solid tumors.

JCO Precis Oncol 2019 22;3. Epub 2019 Jan 22.

Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.

Purpose: Increasing use of genomic tumor profiling may blur the line between research and clinical care. We aimed to describe research participants' perspectives on the purpose of genomic tumor profiling research in pediatric oncology.

Methods: We surveyed 45 participants (response rate 85%) in a pilot study of genomic profiling in pediatric solid tumors at four academic cancer centers following return of sequencing results. We defined understanding according to a one-item ("basic") definition (recognizing that the primary purpose was not to improve the patient's treatment) and a four-item ("comprehensive") definition (primary purpose was not to improve patient's treatment; primary purpose was to improve treatment of future patients; there may not be direct medical benefit; most likely result of participation was not increased likelihood of cure).

Results: Sixty-eight percent of respondents (30/44) demonstrated basic understanding of the study purpose; 55% (24/44) demonstrated comprehensive understanding. Understanding was more frequently seen in those with higher education and greater genetic knowledge according to basic (81% vs 50%, p=0.05; and 82% vs 46%, p=0.03, respectively) and comprehensive definitions (73% vs 28%, p=0.01; 71% vs 23%, p=0.01). Ninety-three percent of respondents who believed the primary purpose was to improve the patient's care simultaneously stated that the research also aimed to benefit future patients.

Conclusions: Most participants in pediatric tumor profiling research understand that the primary goal of this research is to improve care for future patients, but many express dual goals when participating in sequencing research. Some populations demonstrate increased rates of misunderstanding. Nuanced participant views suggest further work is needed to assess and improve participant understanding, particularly as tumor sequencing moves beyond research into clinical practice.
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http://dx.doi.org/10.1200/po.18.00176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6592430PMC
January 2019

Psychological outcomes related to exome and genome sequencing result disclosure: a meta-analysis of seven Clinical Sequencing Exploratory Research (CSER) Consortium studies.

Genet Med 2019 12 13;21(12):2781-2790. Epub 2019 Jun 13.

Department of Population Science, City of Hope, Duarte, CA, USA.

Purpose: As exome and genome sequencing (ES/GS) enters the clinic, there is an urgent need to understand the psychological effects of test result disclosure. Through a Clinical Sequencing Exploratory Research (CSER), phase 1 (CSER1) Consortium collaboration, we evaluated participants' psychological outcomes across multiple clinical settings.

Methods: We conducted a random effects meta-analysis of state anxiety (Hospital Anxiety and Depression Scale [HADS]/Generalized Anxiety Disorder 7-item), depressive symptoms (HADS/Personal Health Questionnaire 9-item), and multidimensional impact (i.e., test-related distress, uncertainty and positive impact: modified Multidimensional Impact of Cancer Risk Assessment/Feelings About Genomic Testing Results scale).

Results: Anxiety and depression did not increase significantly following test result disclosure. Meta-analyses examining mean differences from pre- to postdisclosure revealed an overall trend for a decrease in participants' anxiety. We observed low levels of test-related distress and perceptions of uncertainty in some populations (e.g., pediatric patients) and a wide range of positive responses.

Conclusion: Our findings across multiple clinical settings suggest no clinically significant psychological harms from the return of ES/GS results. Some populations may experience low levels of test-related distress or greater positive psychological effects. Future research should further investigate the reasons for test-related psychological response variation.
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http://dx.doi.org/10.1038/s41436-019-0565-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260995PMC
December 2019

Spending for Advanced Cancer Diagnoses: Comparing Recurrent Versus De Novo Stage IV Disease.

J Oncol Pract 2019 07 20;15(7):e616-e627. Epub 2019 May 20.

5 Kaiser Permanente Colorado, Denver, CO.

Purpose: Spending for patients with advanced cancer is substantial. Past efforts to characterize this spending usually have not included patients with recurrence (who may differ from those with de novo stage IV disease) or described which services drive spending.

Methods: Using SEER-Medicare data from 2008 to 2013, we identified patients with breast, colorectal, and lung cancer with either de novo stage IV or recurrent advanced cancer. Mean spending/patient/month (2012 US dollars) was estimated from 12 months before to 11 months after diagnosis for all services and by the type of service. We describe the absolute difference in mean monthly spending for de novo versus recurrent patients, and we estimate differences after controlling for type of advanced cancer, year of diagnosis, age, sex, comorbidity, and other factors.

Results: We identified 54,982 patients with advanced cancer. Before diagnosis, mean monthly spending was higher for recurrent patients (absolute difference: breast, $1,412; colorectal, $3,002; lung, $2,805; all < .001), whereas after the diagnosis, it was higher for de novo patients (absolute difference: breast, $2,443; colorectal, $4,844; lung, $2,356; all < .001). Spending differences were driven by inpatient, physician, and hospice services. Across the 2-year period around the advanced cancer diagnosis, adjusted mean monthly spending was higher for de novo versus recurrent patients (spending ratio: breast, 2.39 [95% CI, 2.05 to 2.77]; colorectal, 2.64 [95% CI, 2.31 to 3.01]; lung, 1.46 [95% CI, 1.30 to 1.65]).

Conclusion: Spending for de novo cancer was greater than spending for recurrent advanced cancer. Understanding the patterns and drivers of spending is necessary to design alternative payment models and to improve value.
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http://dx.doi.org/10.1200/JOP.19.00004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6804885PMC
July 2019

How Do Blood Cancer Doctors Discuss Prognosis? Findings from a National Survey of Hematologic Oncologists.

J Palliat Med 2019 06 23;22(6):677-684. Epub 2019 Mar 23.

1 Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.

Although blood cancers are accompanied by a high level of prognostic uncertainty, little is known about when and how hematologic oncologists discuss prognosis. Characterize reported practices and predictors of prognostic discussions for a cohort of hematologic oncologists. Cross-sectional mailed survey in 2015. U.S.-based hematologic oncologists providing clinical care for adult patients with blood cancers. We conducted univariable and multivariable analyses assessing the association of clinician characteristics with reported frequency of initiation of prognostic discussions, type of terminology used, and whether prognosis is readdressed. We received 349 surveys (response rate = 57.3%). The majority of respondents (60.3%) reported conducting prognostic discussions with "most" (>95%) of their patients. More than half (56.8%) preferred general/qualitative rather than specific/numeric terms when discussing prognosis. Although 91.3% reported that they typically first initiate prognostic discussions at diagnosis, 17.7% reported routinely never readdressing prognosis or waiting until death is imminent to revisit the topic. Hematologic oncologists with ≤15 years since medical school graduation (odds ratio [OR] 0.51; confidence interval (95% CI) 0.30-0.88) and those who considered prognostic uncertainty a barrier to quality end-of-life care (OR 0.57; 95% CI 0.35-0.90) had significantly lower odds of discussing prognosis with "most" patients. Although the majority of hematologic oncologists reported discussing prognosis with their patients, most prefer general/qualitative terms. Moreover, even though prognosis evolves during the disease course, nearly one in five reported never readdressing prognosis or only doing so near death. These findings suggest the need for structured interventions to improve prognostic communication for patients with blood cancers.
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http://dx.doi.org/10.1089/jpm.2018.0441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533786PMC
June 2019

Performance of Cancer Recurrence Algorithms After Coding Scheme Switch From International Classification of Diseases 9th Revision to International Classification of Diseases 10th Revision.

JCO Clin Cancer Inform 2019 03;3:1-9

Dana-Farber Cancer Institute, Boston, MA.

Purpose: We previously developed and validated informatic algorithms that used International Classification of Diseases 9th revision (ICD9)-based diagnostic and procedure codes to detect the presence and timing of cancer recurrence (the RECUR Algorithms). In 2015, ICD10 replaced ICD9 as the worldwide coding standard. To understand the impact of this transition, we evaluated the performance of the RECUR Algorithms after incorporating ICD10 codes.

Methods: Using publicly available translation tables along with clinician and other expertise, we updated the algorithms to include ICD10 codes as additional input variables. We evaluated the performance of the algorithms using gold standard recurrence measures associated with a contemporary cohort of patients with stage I to III breast, colorectal, and lung (excluding IIIB) cancer and derived performance measures, including the area under the receiver operating curve, average absolute prediction error, and correct classification rate. These values were compared with the performance measures derived from the validation of the original algorithms.

Results: A total of 659 colorectal, 280 lung, and 2,053 breast cancer cases were identified. Area under the receiver operating curve derived from the updated algorithms was 89.0% (95% CI, 82.3% to 95.7%), 88.9% (95% CI, 79.3% to 98.2%), and 80.5% (95% CI, 72.8% to 88.2%) for the colorectal, lung, and breast cancer algorithms, respectively. Average absolute prediction errors for recurrence timing were 2.7 (SE, 11.3%), 2.4 (SE, 10.4%), and 5.6 months (SE, 21.8%), respectively, and timing estimates were within 6 months of actual recurrence for more than 80% of colorectal, more than 90% of lung, and more than 50% of breast cancer cases using the updated algorithm.

Conclusion: Performance measures derived from the updated and original algorithms had overlapping confidence intervals, suggesting that the ICD9 to ICD10 transition did not affect the RECUR Algorithm performance.
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http://dx.doi.org/10.1200/CCI.18.00113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706070PMC
March 2019

Determining the Time of Cancer Recurrence Using Claims or Electronic Medical Record Data.

JCO Clin Cancer Inform 2018 12;2:1-10

Hajime Uno, Angel M. Cronin, and Michael J. Hassett, Dana-Farber Cancer Institute, Boston, MA; Debra P. Ritzwoller and Nikki M. Carroll, Kaiser Permanente Colorado, Denver, CO; and Mark C. Hornbrook, Kaiser Permanente Center for Health Research, Portland, OR.

Purpose: Data from claims and electronic medical records (EMRs) are frequently used to identify clinical events (eg, cancer diagnosis, stroke). However, accurately determining the time of clinical events can be challenging, and the methods used to generate time estimates are underdeveloped. We sought to develop an approach to determine the time of a clinical event-cancer recurrence-using high-dimensional longitudinal structured data.

Methods: Manual chart abstraction provided information regarding the actual time of cancer recurrence. These data were linked to claims from Medicare or structured EMR data from the Cancer Research Network, which were used to determine time of recurrence for patients with lung or colorectal cancer. We analyzed the longitudinal profile of codes that could help determine the time of recurrence, adjusted for systematic differences between code dates and recurrence dates, and integrated time estimates from different codes to empirically derive an optimal algorithm.

Results: We identified twelve code groups that could help determine the time of recurrence. Using claims data for patients with lung cancer, the optimal algorithm consisted of three code groups and provided an average prediction error of 4.8 months. Using EMR data or applying this approach to patients with colorectal cancer yielded similar results.

Conclusion: Time estimates were improved by selecting codes not necessarily the same as those used to identify recurrence, combining time estimates from multiple code groups, and adjusting for systematic bias between code dates and recurrence dates. Improving the accuracy of time estimates for clinical events can facilitate research, quality measurement, and process improvement.
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http://dx.doi.org/10.1200/CCI.17.00163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338474PMC
December 2018

Performance of the International Myeloma Working Group myeloma frailty score among patients 75 and older.

J Geriatr Oncol 2019 05 22;10(3):486-489. Epub 2018 Nov 22.

Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, USA; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, USA; Center for Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, USA. Electronic address:

Objectives: We compared the performance of two frailty scoring systems in predicting survival among older patients with multiple myeloma: the International Myeloma Working Group (IMWG) frailty score (which includes age), and the Fried model for frailty (which does not).

Methods: From 2015 to 2018, all patients aged 75 years and older presenting at our institution with a diagnosis of multiple myeloma were approached for a frailty screening assessment. We first categorized patients' frailty using the Fried model. Then, using available deficit measures, we reclassified frailty using the IMWG approach. We compared the performance of the IMWG strategy to the Fried model in terms of association with overall survival.

Results: Of the 98 (92%) patients who consented to a baseline frailty assessment, we found 57% discordance among frailty classification between the two scoring systems. Using the IMWG strategy, 9% of the cohort was "fit," 29% "intermediate-fit," and 62% "frail." Using the Fried model, 29% of the cohort was "robust," 52% "pre-frail," and 19% "frail." Frailty category in the Fried model was predictive of overall survival among our cohort, while frailty category in the IMWG strategy was not (log-rank p = 0.04 vs. 0.34).

Conclusion: Among our cohort of older patients with myeloma (aged 75 and higher), the Fried model appears to be a better predictor of survival compared to the IMWG strategy. These results suggest that using age as a criterion to identify frailty in older patients with multiple myeloma may limit treatment options for the functionally vigorous.
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http://dx.doi.org/10.1016/j.jgo.2018.10.010DOI Listing
May 2019

Impact of pre-diagnosis depressive symptoms and health-related quality of life on treatment choice for ductal carcinoma in situ and stage I breast cancer in older women.

Breast Cancer Res Treat 2019 Feb 8;173(3):709-717. Epub 2018 Nov 8.

Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.

Purpose: To examine whether pre-diagnosis patient-reported health-related quality of life (HRQOL) and depressive symptoms are associated with local treatment for older women with ductal carcinoma in situ (DCIS) and stage I breast cancer (BC).

Methods: Using the SEER-MHOS dataset, we identified women ≥ 65 years old with DCIS or stage I BC diagnosed 1998-2011 who completed surveys ≤ 24 months before diagnosis. Depressive symptoms were measured by major depressive disorder (MDD) risk and HRQOL was measured by Physical and Mental Component Summary scores (PCS and MCS, respectively) of the SF-36/VR-12. Associations with treatment choice (breast-conserving surgery [BCS] and radiation therapy [RT], BCS alone, mastectomy) were assessed with multivariable multinomial logistic regression, controlling for patient characteristics.

Results: We identified 425 women with DCIS and 982 with stage I BC. Overall, 20.4% endorsed depressive symptoms placing them at risk for MDD pre-diagnosis; mean MCS and PCS scores were 52.3 (SD = 10.1) and 40.5 (SD = 11.5), respectively. Among women with DCIS, those at risk for MDD were more likely to receive BCS (adjusted odds ratio [AOR] 2.04, 95% CI 1.04-4.00, p = 0.04) or mastectomy (AOR 1.88, 95% CI 0.91-3.86, p = 0.09) compared to BCS + RT. For DCIS, MCS score was not associated with treatment; higher PCS score was associated with decreased likelihood of receiving mastectomy versus BCS + RT (AOR 0.71 per 10-point increase, 95% CI 0.54-0.95, p = 0.02). For BC, none of the measures were significantly associated with treatment.

Conclusion: Older women at risk for MDD before DCIS diagnosis were less likely to receive RT after BCS, compared to BCS alone or mastectomy.
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http://dx.doi.org/10.1007/s10549-018-5006-5DOI Listing
February 2019

Parental distress and desire for information regarding long-term implications of pediatric cancer treatment.

Cancer 2018 12 1;124(23):4529-4537. Epub 2018 Oct 1.

Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.

Background: Parents of children with cancer have unmet information needs regarding future limitations resulting from cancer or its treatment. Prior research has demonstrated that, in early care discussions, clinicians focus on the acute effects of therapy rather than long-term limitations, partly due to worries of causing distress. The validity of concerns regarding distress is unknown. In the current study, the authors evaluated parental distress associated with information regarding future limitations, and the extent to which distress is associated with information preferences.

Methods: The authors surveyed 355 parents of children with cancer within 3 months of diagnosis, and the children's physicians at Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and the Children's Hospital of Philadelphia. The primary outcome was parental distress associated with information regarding long-term limitations.

Results: Approximately 46% of parents found information regarding future limitations to be extremely or very upsetting. In multivariate analysis, parents were more likely to consider information regarding future limitations distressing if they also found prognostic information upsetting (odds ratio [OR], 5.36; P<.001), struggled to accept their child's illness (OR, 2.57; P<.001), or had depression (OR, 1.79; P=.01). However, approximately 92% of parents considered information regarding potential future limitations to be extremely/very important. Those who found information regarding future limitations distressing were more likely to consider it important (96% vs 89%; P=.03) and to desire a precise understanding of their child's risks (92% vs 80%; P=.001).

Conclusions: Although information regarding future limitations caused by cancer treatment is upsetting to many parents, the majority of them desire this information, and those who are distressed are more likely to value this information.
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http://dx.doi.org/10.1002/cncr.31772DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289673PMC
December 2018

Medical Care Costs for Recurrent versus De Novo Stage IV Cancer by Age at Diagnosis.

Health Serv Res 2018 12 24;53(6):5106-5128. Epub 2018 Jul 24.

Dana-Farber Cancer Institute, Boston, MA.

Objective: To address the knowledge gap regarding medical care costs for advanced cancer patients, we compared costs for recurrent versus de novo stage IV breast, colorectal, and lung cancer patients.

Data Sources/study Setting: Virtual Data Warehouse (VDW) information from three Kaiser Permanente regions: Colorado, Northwest, and Washington.

Study Design: We identified patients aged ≥21 with de novo or recurrent breast (n  = 352; n  = 765), colorectal (n  = 1,072; n  = 542), and lung (n  = 4,041; n  = 340) cancers diagnosed 2000-2012. We estimated average total monthly and annual costs in the 12 months preceding, month of, and 12 months following the index de novo/recurrence date, stratified by age at diagnosis (<65, ≥65). Generalized linear repeated-measures models controlled for demographics and comorbidity.

Principal Findings: In the pre-index period, monthly costs were higher for recurrent than for de novo breast (<65: +$2,431; ≥65: +$1,360), colorectal (<65: +$3,219; ≥65: +$2,247), and lung cancer (<65: +$3,086; ≥65: +$2,260) patients. Conversely, during the index and post-index periods, costs were higher for de novo patients. Average total annual pre-index costs were five- to ninefold higher for recurrent versus de novo patients <65.

Conclusions: Cost differences by type of advanced cancer and by age suggest heterogeneous patterns of care that merit further investigation.
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http://dx.doi.org/10.1111/1475-6773.13014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232408PMC
December 2018

Comparing Survival After Recurrent vs De Novo Stage IV Advanced Breast, Lung, and Colorectal Cancer.

JNCI Cancer Spectr 2018 Apr 28;2(2):pky024. Epub 2018 Jun 28.

Kaiser Permanente Colorado, Institute for Health Research, Denver, CO.

The treatments provided to and survival of patients with recurrent vs de novo stage IV advanced breast, lung, and colorectal cancer may differ but have not been well studied. Using population-based data from the Cancer Research Network for 4510 patients with advanced breast, lung, or colorectal cancer, we matched recurrent/de novo patients on demographic factors. We found longer survival for recurrent vs de novo lung cancer (182 matched pairs); no significant difference for colorectal cancer (332 matched pairs); and shorter survival for recurrent vs de novo breast cancer (219 matched pairs). Compared with recurrent cases, chemotherapy use and radiation therapy use were more common among de novo cases. Differences in treatment and survival between recurrent and de novo advanced cancer patients could inform prognostic estimates and clinical trial design.
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http://dx.doi.org/10.1093/jncics/pky024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024888PMC
April 2018

Estrogen-receptor status and risk of contralateral breast cancer following DCIS.

Breast Cancer Res Treat 2018 Oct 26;171(3):777-781. Epub 2018 Jun 26.

Department of Radiation Therapy, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA.

Purpose: As local therapies improve, contralateral breast cancer (CBC) risk for women with ductal carcinoma in situ (DCIS) may exceed the risk of a second ipsilateral breast cancer. We sought to determine whether estrogen-receptor (ER) status influenced CBC risk.

Methods: We identified women aged 40-79 with DCIS diagnosed between 1990 and 2002 using the Surveillance, Epidemiology, and End Results database. We used multivariable competing risk regression to examine predictors of time from index DCIS to CBC (invasive or in situ).

Results: Multivariable competing risk regression found ER status to be a highly significant predictor of CBC. The 10-year cumulative incidence was estimated to be 5.3% (95% CI 4.8-5.8%) among ER positive (ER+) cases and 3.3% (95% CI 2.6-4.0%) among ER negative (ER-).

Conclusions: This finding suggests that ER+ DCIS may represent a field effect that confers increased propensity for developing cancer across breast tissue, regardless of laterality. In contrast, ER- DCIS may represent an isolated local event. Given that the majority of DCIS is ER+, and only a minority of DCIS patients receive hormonal therapy, consideration of ER status may influence treatment and surveillance approaches.
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http://dx.doi.org/10.1007/s10549-018-4860-5DOI Listing
October 2018

Development, Validation, and Dissemination of a Breast Cancer Recurrence Detection and Timing Informatics Algorithm.

J Natl Cancer Inst 2018 03;110(3):273-281

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Background: This study developed, validated, and disseminated a generalizable informatics algorithm for detecting breast cancer recurrence and timing using a gold standard measure of recurrence coupled with data derived from a readily available common data model that pools health insurance claims and electronic health records data.

Methods: The algorithm has two parts: to detect the presence of recurrence and to estimate the timing of recurrence. The primary data source was the Cancer Research Network Virtual Data Warehouse (VDW). Sixteen potential indicators of recurrence were considered for model development. The final recurrence detection and timing models were determined, respectively, by maximizing the area under the ROC curve (AUROC) and minimizing average absolute error. Detection and timing algorithms were validated using VDW data in comparison with a gold standard recurrence capture from a third site in which recurrences were validated through chart review. Performance of this algorithm, stratified by stage at diagnosis, was compared with other published algorithms. All statistical tests were two-sided.

Results: Detection model AUROCs were 0.939 (95% confidence interval [CI] = 0.917 to 0.955) in the training data set (n = 3370) and 0.956 (95% CI = 0.944 to 0.971) and 0.900 (95% CI = 0.872 to 0.928), respectively, in the two validation data sets (n = 3370 and 3961, respectively). Timing models yielded average absolute prediction errors of 12.6% (95% CI = 10.5% to 14.5%) in the training data and 11.7% (95% CI = 9.9% to 13.5%) and 10.8% (95% CI = 9.6% to 12.2%) in the validation data sets, respectively, and were statistically significantly lower by 12.6% (95% CI = 8.8% to 16.5%, P < .001) than those estimated using previously reported timing algorithms. Similar covariates were included in both detection and timing algorithms but differed substantially from previous studies.

Conclusions: Valid and reliable detection of recurrence using data derived from electronic medical records and insurance claims is feasible. These tools will enable extensive, novel research on quality, effectiveness, and outcomes for breast cancer patients and those who develop recurrence.
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http://dx.doi.org/10.1093/jnci/djx200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5972574PMC
March 2018

Meaningful changes in end-of-life care among patients with myeloma.

Haematologica 2018 08 10;103(8):1380-1389. Epub 2018 May 10.

Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.

Patients with advanced myeloma experience a high symptom burden particularly near the end of life, making timely hospice use crucial. Little is known about the quality and determinants of end-of-life care for this population, including whether potential increases in hospice use are also accompanied by "late" enrollment (≤ 3 days before death). Using the Surveillance, Epidemiology, and End-Results-Medicare database, we identified patients ≥ 65 years diagnosed with myeloma between 2000 and 2013 who died by December 31, 2013. We assessed prevalence and trends in hospice use, including late enrollment. We also examined six established measures of potentially aggressive medical care at the end of life. Independent predictors of late hospice enrollment and aggressive end-of-life care were assessed using multivariable logistic regression analyses. Of 12,686 myeloma decedents, 48.2% enrolled in hospice. Among the 6111 who enrolled, 17.2% spent ≤ 3 days there. There was a significant trend in increasing hospice use, from 28.5% in 2000 to 56.5% by 2013 ( <0.001), no significant rise in late enrollment (12.2% in 2000 to 16.3% in 2013, =0.19), and a slight decrease in aggressive end-of-life care (59.2% in 2000 to 56.7% in 2013, =0.01). Patients who were transfusion-dependent, on dialysis, or survived for less than one year were more likely to enroll late in hospice and experience aggressive medical care at the end of life. Gains in hospice use for myeloma decedents were not accompanied by increases in late enrollment or aggressive medical care. These findings suggest meaningful improvements in end-of-life care for this population.
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http://dx.doi.org/10.3324/haematol.2018.187609DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6068022PMC
August 2018

A flexible and coherent test/estimation procedure based on restricted mean survival times for censored time-to-event data in randomized clinical trials.

Stat Med 2018 07 22;37(15):2307-2320. Epub 2018 Apr 22.

Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA.

In randomized clinical trials where time-to-event is the primary outcome, almost routinely, the logrank test is prespecified as the primary test and the hazard ratio is used to quantify treatment effect. If the ratio of 2 hazard functions is not constant, the logrank test is not optimal and the interpretation of hazard ratio is not obvious. When such a nonproportional hazards case is expected at the design stage, the conventional practice is to prespecify another member of weighted logrank tests, eg, Peto-Prentice-Wilcoxon test. Alternatively, one may specify a robust test as the primary test, which can capture various patterns of difference between 2 event time distributions. However, most of those tests do not have companion procedures to quantify the treatment difference, and investigators have fallen back on reporting treatment effect estimates not associated with the primary test. Such incoherence in the "test/estimation" procedure may potentially mislead clinicians/patients who have to balance risk-benefit for treatment decision. To address this, we propose a flexible and coherent test/estimation procedure based on restricted mean survival time, where the truncation time τ is selected data dependently. The proposed procedure is composed of a prespecified test and an estimation of corresponding robust and interpretable quantitative treatment effect. The utility of the new procedure is demonstrated by numerical studies based on 2 randomized cancer clinical trials; the test is dramatically more powerful than the logrank, Wilcoxon tests, and the restricted mean survival time-based test with a fixed τ, for the patterns of difference seen in these cancer clinical trials.
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http://dx.doi.org/10.1002/sim.7661DOI Listing
July 2018

Cancer drug shortages: Awareness and perspectives from a representative sample of the US population.

Cancer 2018 05 8;124(10):2205-2211. Epub 2018 Apr 8.

Dana-Farber Cancer Institute, Boston, Massachusetts.

Background: Although cancer drug shortages are a persistent problem in oncology, little is known about the awareness and perspectives of the US population with respect to shortages.

Methods: In 2016, we administered a 13-item cross-sectional survey to 420 respondents who were randomly selected from an online, probability-based sample demographically representative of the adult US population with respect to sex, age, race/ethnicity, education, geography, and income. Analyses applied poststratification sampling weights to draw national inferences.

Results: Overall, 16% of respondents reported being aware of drug shortages. Those with a personal history of cancer were more likely to be aware (31% vs 14% [P = .03]). In the overall cohort, most reported wanting to be informed about a substitution due to shortage: 87% and 82% for major or minor differences in efficacy, and 87% and 83% for major or minor differences in side effects. Most also reported they would transfer care to avoid a substitution: 72% for major differences in efficacy, and 61% for major differences in side effects. Black respondents, the uninsured, the unemployed, those with lower income, and the less well-educated were all less likely to report that they would transfer care to avoid major differences in efficacy (all P < .05).

Conclusion: These data suggest that the US population is largely unaware of cancer drug shortages. Moreover, if being treated for cancer, most people would want to know about drug substitutions, even if it were to result in only minor differences in efficacy or side effects. With more significant differences, many would transfer care. Cancer 2018;124:2205-11. © 2018 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.31246DOI Listing
May 2018

Parent understanding of the risk of future limitations secondary to pediatric cancer treatment.

Pediatr Blood Cancer 2018 07 30;65(7):e27020. Epub 2018 Mar 30.

Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.

Background: Parents and physicians may have different understandings of a child's risk of future limitations due to cancer or cancer treatment. We evaluated alignment between parent- and physician-estimated risk of late effects.

Methods: We surveyed 352 parents of children with cancer within 12 weeks of diagnosis, and the children's oncologists, at Dana-Farber/Boston Children's Cancer and Blood Disorders Center and Children's Hospital of Philadelphia. We assessed parent and physician estimations of the child's risk of future limitations in physical abilities, intelligence, or quality of life (QOL) due to cancer treatment. Physician-estimated risk of limitations ≥50% was considered high risk.

Results: Physicians considered 22% of children at high risk of physical impairments, 9% at high risk for impaired intelligence, and 6% at high risk for impaired QOL. Among high-risk children, 38% of parents recognized this risk in physical abilities, 21% in intelligence, and 5% in QOL. In multivariable analysis, parental understanding of risk, defined as concordant parent and physician estimates, was greater among parents of children at lower risk of future limitations (odds ratio 2.59; 95% confidence interval 1.35-4.96). Regardless of risk, 92% of parents considered it very/extremely important to receive information about potential health implications of cancer treatment.

Conclusions: Although most parents want information about life after cancer, most parents of children at high risk of future impairment do not recognize this risk. Strategies to improve communication about late effects throughout pediatric cancer treatment should prioritize meeting information needs and improving parent understanding of the risk of impairment.
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http://dx.doi.org/10.1002/pbc.27020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980702PMC
July 2018

Insurance status and cancer treatment mediate the association between race/ethnicity and cervical cancer survival.

PLoS One 2018 15;13(2):e0193047. Epub 2018 Feb 15.

Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America.

Cervical cancer outcomes remain poor among disadvantaged populations, including ethnic minorities, low-income, and underinsured women. The aim of this study was to evaluate the mechanisms that underlie the observed association between race/ethnicity and cervical cancer survival. We identified 13,698 women, ages 21 to 64 years, diagnosed with stages I-III primary cervical cancer between 2007-2013 in Surveillance, Epidemiology, and End Results (SEER). Multivariable Cox proportional hazards regression models evaluated associations between race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other) and cervical cancer-specific mortality. We conducted mediation analysis to calculate the mediation proportion and its 95% confidence interval. Non-Hispanic black women had an increased risk of cervical cancer-specific mortality (HR: 1.23, 95% CI: 1.08-1.39), and Hispanic women a decreased risk of dying from their disease (HR: 0.82, 95% CI: 0.72-0.93), compared with non-Hispanic white. The estimated proportion of excess cervical cancer mortality for non-Hispanic black women relative to non-Hispanic white women that was mediated by insurance was 18.6% and by treatment was 47.2%. Furthermore, non-Hispanic black women were more likely to receive radiation and less likely to receive surgery for early-stage disease. In this population-based study we found that some of the excess cervical cancer-specific mortality for non-Hispanic black women is mediated by factors such as insurance status and treatment. These findings suggest that enhancing existing insurance coverage and ensuring equal and adequate treatment in all women may be a key strategy for improving cervical cancer outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0193047PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814056PMC
May 2018

Interactive or static reports to guide clinical interpretation of cancer genomics.

J Am Med Inform Assoc 2018 05;25(5):458-464

Harvard Medical School, Boston, MA, USA.

Objective: Misinterpretation of complex genomic data presents a major challenge in the implementation of precision oncology. We sought to determine whether interactive genomic reports with embedded clinician education and optimized data visualization improved genomic data interpretation.

Materials And Methods: We conducted a randomized, vignette-based survey study to determine whether exposure to interactive reports for a somatic gene panel, as compared to static reports, improves physicians' genomic comprehension and report-related satisfaction (overall scores calculated across 3 vignettes, range 0-18 and 1-4, respectively, higher score corresponding with improved endpoints).

Results: One hundred and five physicians at a tertiary cancer center participated (29% participation rate): 67% medical, 20% pediatric, 7% radiation, and 7% surgical oncology; 37% female. Prior to viewing the case-based vignettes, 34% of the physicians reported difficulty making treatment recommendations based on the standard static report. After vignette/report exposure, physicians' overall comprehension scores did not differ by report type (mean score: interactive 11.6 vs static 10.5, difference = 1.1, 95% CI, -0.3, 2.5, P = .13). However, physicians exposed to the interactive report were more likely to correctly assess sequencing quality (P < .001) and understand when reports needed to be interpreted with caution (eg, low tumor purity; P = .02). Overall satisfaction scores were higher in the interactive group (mean score 2.5 vs 2.1, difference = 0.4, 95% CI, 0.2-0.7, P = .001).

Discussion And Conclusion: Interactive genomic reports may improve physicians' ability to accurately assess genomic data and increase report-related satisfaction. Additional research in users' genomic needs and efforts to integrate interactive reports into electronic health records may facilitate the implementation of precision oncology.
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http://dx.doi.org/10.1093/jamia/ocx150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018970PMC
May 2018

Intended and unintended consequences: Ethics, communication, and prognostic disclosure in pediatric oncology.

Cancer 2018 03 26;124(6):1232-1241. Epub 2017 Dec 26.

Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.

Background: The majority of patients desire all available prognostic information, but some physicians hesitate to discuss prognosis. The objective of the current study was to examine outcomes of prognostic disclosure among the parents of children with cancer.

Methods: The authors surveyed 353 parents of children with newly diagnosed cancer at 2 tertiary cancer centers, and each child's oncologist. Using multivariable logistic regression, the authors assessed associations between parental report of elements of prognosis discussions with the oncologist (quality of information/communication and prognostic disclosure) and potential consequences of these discussions (trust, hope, peace of mind, prognostic understanding, depression, and anxiety). Analyses were stratified by oncologist-reported prognosis.

Results: Prognostic disclosure was not found to be associated with increased parental anxiety, depression, or decreased hope. Among the parents of children with less favorable prognoses (<75% chance of cure), the receipt of high-quality information from the oncologist was associated with greater peace of mind (odds ratio [OR], 5.23; 95% confidence interval [95% CI], 1.81-15.16) and communication-related hope (OR, 2.54; 95% CI, 1.00-6.40). High-quality oncologist communication style was associated with greater trust in the physician (OR, 2.45; 95% CI, 1.09-5.48) and hope (OR, 3.01; 95% CI, 1.26-7.19). Accurate prognostic understanding was less common among the parents of children with less favorable prognoses (OR, 0.39; 95% CI, 0.17-0.88). Receipt of high-quality information, high-quality communication, and prognostic disclosure were not found to be significantly associated with more accurate prognostic understanding.

Conclusions: The results of the current study demonstrate no evidence that disclosure is associated with anxiety, depression, or decreased hope. Communication processes may increase peace of mind, trust, and hope. It remains unclear how best to enhance prognostic understanding. Cancer 2018;124:1232-41. © 2017 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.31194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5839950PMC
March 2018

A comparison of cancer risk assessment and testing outcomes in patients from underserved vs. tertiary care settings.

J Community Genet 2018 Jul 18;9(3):233-241. Epub 2017 Nov 18.

Center for Cancer Genetics and Prevention, Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave DA 1122, Boston, MA, USA.

In cancer genetics, technological advances (next generation sequencing) and the expansion of genetic test options have resulted in lowered costs and increased access to genetic testing. Despite this, the majority of patients utilizing cancer genetics services lack diversity of gender, ethnicity, and socioeconomic status. Through retrospective chart review, we compared outcomes of cancer genetics consultations at a tertiary cancer center and a Federally Qualified Health Center (FQHC) (58 tertiary and 23 FQHC patients) from 2013 to 2015. The two groups differed in race, ethnicity, use of translator services, and type of insurance coverage. There were also significant differences in completeness of family history information, with more missing information about relatives in the FQHC group. In spite of these differences, genetic testing rates among those offered testing were comparable across the two groups with 74% of tertiary patients and 60% of FQHC patients completing testing. Implementation of community-based cancer genetics outreach clinics represents an opportunity to improve access to genetic counseling services, but more research is needed to develop effective counseling models for diverse patient populations.
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http://dx.doi.org/10.1007/s12687-017-0347-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6002308PMC
July 2018

Detecting Lung and Colorectal Cancer Recurrence Using Structured Clinical/Administrative Data to Enable Outcomes Research and Population Health Management.

Med Care 2017 12;55(12):e88-e98

*Dana-Farber Cancer Institute †Harvard Medical School, Boston, MA ‡Institute for Health Research, Kaiser Permanente Colorado, Denver, CO §The Center for Health Research, Kaiser Permanente Northwest, Portland, OR.

Introduction: Recurrent cancer is common, costly, and lethal, yet we know little about it in community-based populations. Electronic health records and tumor registries contain vast amounts of data regarding community-based patients, but usually lack recurrence status. Existing algorithms that use structured data to detect recurrence have limitations.

Methods: We developed algorithms to detect the presence and timing of recurrence after definitive therapy for stages I-III lung and colorectal cancer using 2 data sources that contain a widely available type of structured data (claims or electronic health record encounters) linked to gold-standard recurrence status: Medicare claims linked to the Cancer Care Outcomes Research and Surveillance study, and the Cancer Research Network Virtual Data Warehouse linked to registry data. Twelve potential indicators of recurrence were used to develop separate models for each cancer in each data source. Detection models maximized area under the ROC curve (AUC); timing models minimized average absolute error. Algorithms were compared by cancer type/data source, and contrasted with an existing binary detection rule.

Results: Detection model AUCs (>0.92) exceeded existing prediction rules. Timing models yielded absolute prediction errors that were small relative to follow-up time (<15%). Similar covariates were included in all detection and timing algorithms, though differences by cancer type and dataset challenged efforts to create 1 common algorithm for all scenarios.

Conclusions: Valid and reliable detection of recurrence using big data is feasible. These tools will enable extensive, novel research on quality, effectiveness, and outcomes for lung and colorectal cancer patients and those who develop recurrence.
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http://dx.doi.org/10.1097/MLR.0000000000000404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4732933PMC
December 2017

Evaluation of Patient and Family Outpatient Complaints as a Strategy to Prioritize Efforts to Improve Cancer Care Delivery.

Jt Comm J Qual Patient Saf 2017 Oct 1;43(10):498-507. Epub 2017 Sep 1.

Background: Limited systematic data about complaints related to cancer care are available. Patient complaints related to ambulatory care at a large academic cancer center were examined to better understand patient experiences of care and prioritize opportunities for quality improvement.

Methods: Content analysis of outpatient complaints made to the Patient/Family Relations Office at Dana-Farber Cancer Institute, Boston, in a two-year period (January 2013-December 2014) were conducted. Narrative complaint records were reviewed independently by two to four reviewers to categorize primary and secondary reasons underlying complaints and to assess complaint severity.

Results: Among 78,668 outpatients seen during the two-year period, 266 complaints (0.3%) were made to the Patient/Family Relations Office. Some 48% of the complaints involved management issues, including finance and billing (10%), service issues (15%), delays (13%), and access and admission (6%); 11% of complaints related to quality and safety, whereas 41% of complaints related to relationships, including communication breakdowns (15%), patient-staff dialogue (5%), and humanness and caring (18%). Twenty percent of the complaints were classified as high severity, including 57% of quality- and safety-related complaints. Eleven percent of the patients involved in complaints ultimately transferred care to another provider or institution; 43% of high-severity complaints resulted in a transfer of care.

Conclusion: Most of the concerns represented in the complaints related to humanistic rather than technical aspects of care. A systematic review of complaints would offer the opportunity to improve patient-centeredness of care by identifying areas where care fails to meet patient and family needs.
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http://dx.doi.org/10.1016/j.jcjq.2017.04.008DOI Listing
October 2017

Disparities in prognosis communication among parents of children with cancer: The impact of race and ethnicity.

Cancer 2017 Oct 5;123(20):3995-4003. Epub 2017 Sep 5.

Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.

Background: Most parents of children with cancer say they want detailed information about their child's prognosis. However, prior work has been conducted in populations of limited diversity. The authors sought to evaluate the impact of parental race/ethnicity on prognosis communication experiences among parents of children with cancer.

Methods: In total, 357 parents of children with cancer and the children's physicians were surveyed at Dana-Farber Cancer Institute/Boston Children's Hospital and Children's Hospital of Philadelphia. Outcome measures were parental preferences for prognostic information, physician beliefs about parental preferences, prognosis communication processes, and communication outcomes. Associations were assessed by logistic regression with generalized estimating equations to correct for physician clustering.

Results: Two hundred eighty-one parents (79%) were white, 23 (6%) were black, 29 (8%) were Hispanic, and 24 (7%) were Asian/other. Eighty-seven percent of parents wanted as much detail as possible about their child's prognosis, with no significant differences by race/ethnicity (P = .75). However, physician beliefs about parental preferences for prognosis communication varied based on parent race/ethnicity, with physicians considering black and Hispanic parents less interested in details about prognosis than whites (P = .003). Accurate understanding of a less favorable prognosis was greater among white (49%) versus nonwhite parents (range, 20%-29%), although this difference was not statistically significant (P = .14).

Conclusions: Most parents, regardless of racial and ethnic background, want detailed prognostic information about their child's cancer. However, physicians underestimate the information needs of black and Hispanic parents. To meet parents' information needs, physicians should ask about parents' information preferences before prognosis discussions. Cancer 2017;123:3995-4003. © 2017 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30960DOI Listing
October 2017
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