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PURPOSE: Decision aids have been found to improve patients’ knowledge of treatments and decrease decisional regrets. Despite these benefits, there is not widespread use of decision aids for newly diagnosed prostate cancer (PCa). This analysis investigates factors that impact men’s choice to use a decision aid for newly diagnosed prostate cancer. MATERIALS AND METHODS: This is a retrospective analysis of a PCa registry from the Michigan Urological Surgery Improvement Collaborative (MUSIC). We included data from men with newly diagnosed, clinically localized PCa seen from 2018-21 at practices offering a PCa decision aid (Personal Patient Profile-Prostate; P3P). The primary outcome was men’s registration to use P3P. We fit a multilevel logistic regression model with patient-level factors and included urologist specific random intercepts. We estimated the intra-class correlation (ICC) and predicted the probability of P3P registration among urologists. RESULTS: A total of 2629 men were seen at practices that participated in P3P and 1174 (45%) registered to use P3P. Forty-one percent of the total variance of P3P registration was attributed to clustering of men under a specific urologist’s care. In contrast, only 1.5% of the variance of P3P registration was explained by patient factors. Our model did not include data on socioeconomic, literacy or psychosocial factors, which limits the interpretation of the results. CONCLUSIONS: These results suggest that urologists’ effect far outweighs patient factors in a man’s decision to enroll in P3P. Strategies that encourage providers to increase decision aid adoption in their practices are warranted.

PURPOSE: We developed and tested a multi-level intervention, ConnectedCancerCare (CCC), which includes a tailored website and appointment reminder system for women with early-stage breast cancer and a provider summary letter sent to their medical oncologist and primary care provider to improve the delivery of team-based survivorship care. METHODS: We conducted a pilot randomized controlled trial to establish the feasibility and acceptability of CCC. Women diagnosed with stages 0-II breast cancer within one year of completing primary treatment were randomized to CCC (intervention), or a static online survivorship care plan (control). Participants completed baseline and 3 month follow-up surveys online. Post-trial interviews with 5 PCPs, 6 oncology providers, and 8 intervention patients were conducted. RESULTS: Of the 160 eligible women invited to participate, 66 completed the baseline survey and were randomized (41%), and 54 completed a follow-up survey (83%). Participants in the intervention arm found the CCC content to be acceptable, with 82% reporting it was easy to use, and 86% reporting they would recommend it to other patients. Women randomized to CCC (vs. control) more often reported scheduling a PCP follow-up visit (64% vs. 42%), communicating with their PCP about provider roles (67% vs. 18%), and higher mean team-based cancer care knowledge scores (3.7 vs. 3.4). CONCLUSIONS: Deploying CCC in medical oncology practices was feasible, and the intervention content was acceptable. CCC shows promise for improving patient knowledge and patient-provider communication about provider roles in team-based cancer care, and encouraging patients to engage with their PCP early in the survivorship period.

Objective To evaluate the association between post-diagnosis continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer. Methods This retrospective claims analysis included 6680 Medicare beneficiaries over age 66 with ovarian cancer who survived at least one year after diagnosis, had at least 4 outpatient evaluation and management visits and died between 2000 and 2016. We calculated the Bice-Boxerman Continuity of Care Index (COC) for each woman, and split COC into tertiles (high, medium, low). We compared late or no hospice use, >1 emergency department (ED) visit, intensive care unit (ICU) admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life extending procedures among women with high or medium vs. low COC using multivariable adjusted logistic regression. Results In this sample, 49.8% of women received aggressive care in the last month of life. Compared to women with low COC, women with high COC had 66% higher odds of chemotherapy (adjusted OR 1.66 CI 1.23–2.24) in the last two weeks of life. Women with high COC also had 16% greater odds of not enrolling in hospice compared to women with low COC (adjusted OR 1.16 CI 1.01–1.33). COC was not associated with late enrollment in hospice, hospital utilization, or aggressive procedures. Conclusions COC at the end of life is complicated and may pose unique challenges in providing quality end of life care. Future work exploring the specific facets of continuity associated with quality end of life care is needed.

Introduction:Shared decision making balances the best available evidence with patients’ preferences and values in order to make a medical decision. The use of shared decision making and its...

OBJECTIVES: This study examined the association of ED use in the first year of diagnosis and patient experiences in care among older adults with hematologic malignancies. MATERIALS AND METHODS: Cross-sectional design using SEER-CAHPS® data from 2002-2015 to study Medicare fee-for-service enrollees with a primary diagnosis of leukemia or lymphoma. We linked the CAHPS survey data (patient-reported experiences with health services) to patients’ cancer registry information and Medicare outpatient claims from the SEER-CAHPS resource. We estimated associations of ED use and clinical characteristics with two CAHPS outcomes – “getting care quickly” (timeliness) and “getting needed care” (access) – with bivariate and multivariate analyses. RESULTS: The analytic sample included 751 patients, 125 of whom had an ED claim in the first year of cancer diagnosis. The most frequent ED diagnosis clusters were fever and infection (n=17, 13.6%), orthopedic and injury (16, 12.8%) and pain (16, 12.8%). Significantly more enrollees with an ED claim were diagnosed with lymphoma (p < 0.01), lived in rural areas (p < 0.01), and lived in areas with many families living in poverty (p < 0.01). In adjusted models, enrollees with an ED claim reported significantly worse access to care (β −4.83; 95%CI −9.29,−.38; p = 0.03). CONCLUSION: The management of urgent care concerns for adults with hematologic malignancies remains an important clinical and quality improvement imperative. Further study is warranted to enhance the management of emergent complications in older adults receiving care for hematologic malignancies, with efforts that enhance coordination of ambulatory oncology care.

Objective To establish the rates of self-reported shared decision-making (SDM) and decision aid use among practicing urologists. Additionally, we aim to determine the practice factors that influence SDM use. Materials and Methods This study uses data from the 2019 American Urological Association Annual Census SDM module. Urologists were presented with a rubric of 7 preference sensitive clinical situations and asked to choose the elements of SDM that they regularly use for the diagnosis. Multivariable logistic regression models were fit to evaluate factors contributing to the use of SDM. Results Two thousand two hundred and nineteen urologists responded. Of these, 77% reported that they regularly use SDM in at least 1 preference sensitive clinical scenario. Between 40% and 58% regularly gave patients decision aids. Urologists who reported barriers to SDM had a decreased odds of reporting SDM (adjusted odds ratio OR [aOR] 0.80 [95% confidence interval [CI] 0.71-0.91]). Those practicing in academic settings (aOR 0.78 [95% CI 0.69-0.88]) were less likely than those in private practice to report SDM use. The number of patient visits per week was inversely associated with SDM use, with greater than 76 visits per week having decreased odds (aOR 0.65 [95% CI 0.57-0.74]). Conclusion In this sample of practicing urologists in the United States, the majority report regularly using SDM. However, rates of SDM varied by training, practice setting and clinical volume. Our findings highlight specific opportunities to improve in SDM in urology.

BACKGROUND: Primary care provider’s (PCP) role in cancer care is expanding and may include supporting patients in their treatment decisions. However, the degree to which PCPs engage in this role for low-risk prostate cancer is unknown. OBJECTIVE: Characterize PCP perceptions regarding their role in low-risk prostate cancer treatment decision-making. DESIGN: Cross-sectional, national survey. MAIN MEASURES: For men with low-risk prostate cancer, PCP reports of (1) confidence in treatment decision-making (high vs. low); (2) intended participation in key aspects of active surveillance treatment decision-making (more vs. less). KEY RESULTS: A total of 347 from 741 eligible PCPs responded (adjusted response rate 56%). Half of respondent PCPs (50.3%) reported high confidence about engaging in low-risk prostate cancer treatment decision-making. The odds of PCPs reporting high confidence were greater among those in solo practice (vs working with > 1 PCP) (OR 2.18; 95% CI 1.14–4.17) and with higher volume of prostate cancer patients (> 15 vs. 6–10 in past year) (OR 2.16; 95% CI 1.02–4.61). PCP report of their intended participation in key aspects of active surveillance treatment decision-making varied: discussing worry (62.4%), reviewing benefits (48.5%) and risks (41.8%), and reviewing all treatment options (34.2%). PCPs who reported high confidence had increased odds of more participation in all aspects of active surveillance decision-making: reviewing all treatment options (OR 3.11; 95% CI 1.82–5.32), discussing worry (OR 2.12; 95% CI 1.28–3.51), and reviewing benefits (OR 3.13; 95% CI 1.89–5.16) and risks (OR 3.20; 95% CI 1.91–5.36). CONCLUSIONS: The majority of PCPs were confident about engaging with patients in low-risk prostate cancer treatment decision-making, though their intended participation varied widely across four key aspects of active surveillance care. With active surveillance being considered for other low-risk cancers (such as breast and thyroid), understanding factors influencing PCP involvement will be instrumental to supporting team-based cancer care.

Importance Surveillance imaging and visits are costly and have not been shown to improve oncologic outcomes for patients with head and neck cancer (HNC). However, the benefit of surveillance visits may extend beyond recurrence detection. To better understand surveillance and potentially develop protocols to tailor current surveillance paradigms, it is important to elicit the perspectives of the clinicians who care for patients with HNC. Objective To characterize current surveillance practices and explore clinician attitudes and beliefs on deintensifying surveillance for patients with HNC. Design, Setting, and Participants This qualitative study was performed from January to March 2021. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from March to April 2021. Otolaryngologists and radiation oncologists were recruited using purposive and snowball sampling strategies. Main Outcomes and Measures The main outcomes were current practice, attitudes, and beliefs about deintensifying surveillance and survivorship as well as patients’ values and perspectives collected from interviews of participating physicians. Results Twenty-one physicians (17 [81%] men) were interviewed, including 13 otolaryngologists and 8 radiation oncologists with a median of 8 years (IQR, 5-20 years) in practice. Twelve participants (57%) stated their practice comprised more than 75% of patients with HNC. Participants expressed that there was substantial variation in the interpretation of the surveillance guidelines. Participants were open to the potential for deintensification of surveillance or incorporating symptom-based surveillance protocols but had concerns that deintensification may increase patient anxiety and shift some of the burden of recurrence monitoring to patients. Patient and physician peace of mind, the importance of maintaining the patient-physician relationship, and the need for adequate survivorship and management of treatment-associated toxic effects were reported to be important barriers to deintensifying surveillance. Conclusions and Relevance In this qualitative study, clinicians revealed a willingness to consider altering cancer surveillance but expressed a need to maintain patient and clinician peace of mind, maintain the patient-clinician relationship, and ensure adequate monitoring of treatment-associated toxic effects and other survivorship concerns. These findings may be useful in future research on the management of posttreatment surveillance.

PURPOSE: End-of-life care for women with ovarian cancer is persistently aggressive, but factors associated with overuse are not well understood. We evaluated physician-level variation in receipt of aggressive end-of-life care and examined physician-level factors contributing to this variation in the SEER-Medicare data set. METHODS: Medicare beneficiaries with ovarian cancer who died between 2000 and 2016 were included if they were diagnosed after age 66 years, had complete Medicare coverage between diagnosis and death, and had outpatient physician evaluation and management for their ovarian cancer. Using multilevel logistic regression, we examined physician variation in no hospice enrollment, late hospice enrollment (≤ 3 days), > 1 emergency department visit, an intensive care unit stay, terminal hospitalization, > 1 hospitalization, receiving a life-extending or invasive procedure, and chemotherapy (in the last 2 weeks). RESULTS: In this sample of 6,288 women, 51% of women received at least one form of aggressive end-of-life care. Most common were no hospice enrollment (28.9%), an intensive care unit stay (18.6%), and receipt of an invasive procedure (20.7%). For not enrolling in hospice, 9.9% of variation was accounted for by physician clustering ( P < .01). Chemotherapy had the highest physician variation (12.4%), with no meaningful portion of the variation explained by physician specialty, volume, region, or patient characteristics. CONCLUSION: In this study, a meaningful amount of variation in aggressive end-of-life care among women dying of ovarian cancer was at the physician level, suggesting that efforts to improve the quality of this care should include interventions aimed at physician practices and decision making in end-of-life care.

INTRODUCTION AND OBJECTIVE:Decision aids (DA) have been found to improve patients’ knowledge of treatment and decrease decisional regrets. Despite their many benefits, there is not widespread use o...

INTRODUCTION AND OBJECTIVE:The association between decision aids (DA) use and clinically-meaningful patient reported outcomes is not well established. We evaluated whether completing a DA, Personal...

Context Little is known about provider specialties involved in thyroid cancer diagnosis and management. Objective Characterize providers involved in diagnosing and treating thyroid cancer. Design/Setting/Participants We surveyed patients with differentiated thyroid cancer from the Georgia and Los Angeles County Surveillance, Epidemiology and End Results registries (N = 2632, 63% response rate). Patients identified their primary care physicians (PCPs), who were also surveyed (N = 162, 56% response rate). Main outcome measures (1) Patient-reported provider involvement (endocrinologist, surgeon, PCP) at diagnosis and treatment; (2) PCP-reported involvement (more vs less) and comfort (more vs less) with discussing diagnosis and treatment. Results Among thyroid cancer patients, 40.6% reported being informed of their diagnosis by their surgeon, 37.9% by their endocrinologist, and 13.5% by their PCP. Patients reported discussing their treatment with their surgeon (71.7%), endocrinologist (69.6%), and PCP (33.3%). Physician specialty involvement in diagnosis and treatment varied by patient race/ethnicity and age. For example, Hispanic patients (vs non-Hispanic White) were more likely to report their PCP informed them of their diagnosis (odds ratio [OR]: 1.68; 95% CI, 1.24-2.27). Patients ≥65 years (vs Conclusions PCPs were involved in thyroid cancer diagnosis and treatment, and their involvement was greater among older patients and patients of minority race/ethnicity. This suggests an opportunity to leverage PCP involvement in thyroid cancer management to improve health and quality of care outcomes for vulnerable patients.

Summary Background Little is known about how patients with eosinophilic esophagitis (EoE) experience their symptoms, receive care, and cope with their disease. Patients commonly seek peer support from online communities, which provide insights on unmet needs and barriers to care. We performed a qualitative analysis of electronic health forums to characterize patient-to-patient conversations about EoE symptoms and the experience of disease. Methods We identified three publicly accessible electronic health forums hosting EoE communities. Conversation threads posted between July 2018 and June 2020 were coded using emergent and a priori codes based on the THRIVE conceptual framework of coping with chronic illness. Results Of 659 threads (4,933 posts) collected over two years, a random sample of 240 threads (30 per 3-month quarter) were selected for analysis. Thematic saturation was reached after 172 threads. Patient experience of EoE was driven by their perspectives in four key domains: (i) perception of EoE as episodic rather than chronic, (ii) treatment choices, (iii) personal definitions of success in the disease, and (iv) views of providers. Conclusion Online health communities are a valuable and unfiltered source of patient perspectives that can be used to understand patient needs and goals. EoE patients interpret their disease as sporadic events and lack reliable sources of knowledge, which may influence how patients prioritize treatment. If providers are to succeed in providing high-quality EoE care, they need to equip themselves with evidence-based knowledge, engage in shared decision making, and look outside of clinical settings to recognize barriers to disease management.

Background: The US Health Retirement Study (HRS) is an ongoing population-representative cohort of US adults ages >50 with rich data on health during aging. Self-reported cancer diagnoses have been collected since 1998, but they have not been validated. We compared self-reported cancer diagnoses in HRS interviews against diagnostic claims from linked Medicare records. Methods: Using HRS–Medicare linked data, we examined the validity of first incident cancer diagnoses self-reported in biennial interviews from 2000 to 2016 against ICD-9 and ICD-10 diagnostic claim records as the gold standard. Data were from 8,242 HRS participants ages ≥65 with 90% continuous enrollment in fee-for-service Medicare. We calculated the sensitivity, specificity, and κ for first incident invasive cancer diagnoses (all cancers combined, and each of bladder, breast, colorectal/anal, uterine, kidney, lung, and prostate cancers) cumulatively over the follow-up and at each biennial study interview. Results: Overall, self-reports of first incident cancer diagnoses from 2000 to 2016 had 73.2% sensitivity and 96.2% specificity against Medicare claims (κ = 0.73). For specific cancer types, sensitivities ranged from 44.7% (kidney) to 75.0% (breast), and specificities ranged from 99.2% (prostate) and 99.9% (bladder, uterine, and kidney). Results were similar in sensitivity analyses restricted to individuals with 100% continuous fee-for-service Medicare enrollment and when restricted to individuals with at least 24 months of Medicare enrollment. Conclusions: Self-reported cancer diagnoses in the HRS have reasonable validity for use in population-based research that is maximized with linkage to Medicare. Impact: These findings inform the use of the HRS for population-based cancer and aging research.

BACKGROUND To the authors' knowledge, studies regarding risk perception among survivors of thyroid cancer are scarce. METHODS The authors surveyed patients who were diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County (2632 patients; 63% response rate). The analytic cohort was defined by a ≤5% risk of disease recurrence and mortality (1597 patients). Patients estimated their recurrence and mortality risks separately (increments of 10% and endpoints of ≤5% and ≥95%). Both outcomes were dichotomized between reasonably accurate estimates (risk perception of ≤5% or 10%) versus overestimation (risk perception of ≥20%). Multivariable logistic regression was used to identify factors associated with risk overestimation, and the relationships between overestimation and both worry and quality of life were evaluated. RESULTS In the current study sample, 24.7% of patients overestimated their recurrence risk and 12.5% overestimated their mortality risk. A lower educational level was associated with overestimating disease recurrence (≤high school diploma: odds ratio [OR], 1.64 [95% CI, 1.16-2.31]; and some college: OR, 1.36 [95% CI, 1.02-1.81]) and mortality (≤high school diploma: OR, 1.86 [95% CI, 1.18-2.93]) risk compared with those attaining at least a college degree. Hispanic ethnicity was found to be associated with overestimating recurrence risk (OR, 1.44, 95% CI 1.02-2.03) compared with their white counterparts. Worry about recurrence and death was found to be greater among patients who overestimated versus those who had a reasonably accurate estimate of their risk of disease recurrence and mortality, respectively (P

BACKGROUND: Gabapentinoid use for cancer-pain control may be problematic, given unclear mechanisms of action and increased concerns for physical dependence. The purpose of this report is to examine trends of gabapentinoid use among US adults with cancer from 2005–2015. METHODS: We conducted a serial, cross-sectional study using data from the Medical Expenditure Panel Survey (MEPS). We performed multiple logistic regression to examine the annual percentages of gabapentinoid users, which were adjusted for age, sex, and US region of residence. RESULTS: The amount of gabapentinoid prescriptions filled in 2015 was also estimated. The adjusted percentage of gabapentinoid users in 2015 was 5.60% (3.79%, 7.41%), 2.39 times greater than the percentage in 2005 (p < .001). By 2015, the number of gabapentinoid prescriptions had grown to approximately 3.52 million (2.40 million, 4.65 million). CONCLUSION: We observed greater than a two-fold increase in the trend of gabapentinoid medication use among US adults with cancer. Investigations on the long-term efficacy of gabapentinoids for complex pain syndromes, and mitigation of risks, is essential to guide informed clinical management and keep patients safe.

PURPOSE For many patients with differentiated thyroid cancer, use of radioactive iodine (RAI) does not improve survival or reduce recurrence risk. Yet there is wide variation in RAI use, emphasizing the importance of understanding patient perspectives regarding RAI decision making. PATIENTS AND METHODS All eligible patients diagnosed with thyroid cancer from 2014 to 2015 from the Georgia and Los Angeles SEER registries were surveyed (N = 2,632; response rate, 63%). Patients in whom selective RAI use is recommended were included in this analysis (n = 1,319). Patients were asked whether they felt like they had a choice to receive RAI (yes or no), how strongly their physician recommended RAI (5-point Likert-type scale), whether they received RAI (yes or no), and how satisfied they were with their RAI decision (more [score of 4 or greater] v less). Multivariable, weighted logistic regression with multiple imputation was used to assess the associations between patient characteristics and perception of no RAI choice and between perception of no RAI choice with receipt of RAI and decision satisfaction. RESULTS More than half of respondents (55.8%) perceived they did not have an RAI choice, and the majority of patients (75.9%) received RAI. The odds of perceiving no RAI choice was greater among those whose physician strongly recommended RAI (adjusted odds ratio [OR], 1.56; 95% CI, 1.13 to 2.17). Patients who perceived they did not have an RAI choice were more likely to receive RAI (adjusted OR, 2.50; 95% CI, 1.64 to 3.82) and report lower decision satisfaction (adjusted OR, 2.31; 95% CI, 1.67 to 3.20). CONCLUSION Many patients did not feel they had a choice about whether to receive RAI. Patients who perceived they did not have a choice were more likely to receive RAI and report lower decision satisfaction, suggesting a need for more shared decision making to reduce overtreatment.

PURPOSE: Patients report strong preferences regarding which provider—oncologist or primary care provider (PCP)—handles their primary care after initial cancer treatment (eg, other cancer screenings, preventive care, comorbidity management). Little is known about associations between provider involvement during initial cancer treatment and patient preferences for provider roles after initial treatment. METHODS: Women who received a diagnosis of early-stage breast cancer in 2014 to 2015 were identified from the Georgia and Los Angeles County SEER registries and surveyed (N = 2,502; 68% response rate). Women reported the level of their providers’ involvement in their care during initial cancer treatment. Associations between level of medical oncologist’s participation and PCP’s engagement during initial cancer treatment and patient preferences for oncologist led ( v PCP led) other cancer screenings after initial treatment were examined using multivariable logistic regression models. Results: During their initial cancer treatment, 20% of women reported medical oncologists participated substantially in delivering primary care and 66% reported PCPs were highly engaged in their cancer care. Two-thirds (66%) of women preferred medical oncologists to handle other cancer screenings after initial treatment. Women who reported substantial medical oncologist participation in primary care were more likely (adjusted odds ratio, 1.42; 95% CI, 1.05 to 1.91) and those who reported high PCP engagement in cancer care were less likely (adjusted odds ratio, 0.41; 95% CI, 0.31 to 0.53) to prefer oncologist-led other cancer screenings after initial treatment. Conclusions: Providers’ involvement during initial cancer treatment may affect patient preferences regarding provision of follow-up primary care. Clarifying provider roles as early as during cancer treatment may help to better delineate their roles throughout survivorship.

INTRODUCTION: Primary care providers can collaborate with urologists to ensure men with low risk prostate cancer on active surveillance receive followup testing and adhere to the management strategy, yet primary care provider attitudes about active surveillance and their roles remain unknown. METHODS: We surveyed 1,000 primary care providers (347/741 eligible primary care providers responded). We assessed primary care provider support for and beliefs about active surveillance, and attitudes about and preferences for their role in various aspects of low risk prostate cancer management. We then examined associations between 1) primary care provider support for and primary care provider beliefs about active surveillance; and 2) primary care provider attitudes and preferences for their role. RESULTS: Nearly 50% of primary care providers strongly supported active surveillance for all low risk men, and 81% strongly agreed that active surveillance allows men to avoid side effects, while 57% strongly agreed it caused worry. Primary care providers who strongly supported active surveillance were less likely to strongly agree that active surveillance contributes to worry (50.3% vs 63.7% respectively, p=0.01). Half of the primary care providers strongly agreed that primary care providers can provide cancer-related care (50.5%), and the majority preferred a shared care model to ordering prostate specific antigen tests (60.1%). Primary care providers who strongly agreed that primary care providers can provide cancer-related care were more likely to prefer a primary care provider-led (79.3% vs 20.7%) or shared care (53.9% vs 46.1%) model vs urologist-led for ordering prostate specific antigen tests (p

BACKGROUND: Older patients (65+) with mild cognitive impairment (MCI) receive less guideline-concordant care for cardiovascular disease (CVD) and other conditions than patients with normal cognition (NC). One potential explanation is that patients with MCI want less treatment than patients with NC; however, the treatment preferences of patients with MCI have not been studied. OBJECTIVE: To determine whether patients with MCI have different treatment preferences than patients with NC. DESIGN: Cross-sectional survey conducted at two academic medical centers from February to December 2019 PARTICIPANTS: Dyads of older outpatients with MCI and NC and patient-designated surrogates. MAIN MEASURES: The modified Life-Support Preferences-Predictions Questionnaire score measured patients’ preferences for life-sustaining treatment decisions in six health scenarios including stroke and acute myocardial infarction (range, 0–24 treatments rejected with greater scores indicating lower desire for treatment). KEY RESULTS: The survey response rate was 73.4%. Of 136 recruited dyads, 127 (93.4%) completed the survey (66 MCI and 61 NC). The median number of life-sustaining treatments rejected across health scenarios did not differ significantly between patients with MCI and patients with NC (4.5 vs 6.0; P=0.55). Most patients with MCI (80%) and NC (80%) desired life-sustaining treatments in their current health (P=0.99). After adjusting for patient and surrogate factors, the difference in mean counts of rejected treatments between patients with MCI and patients with NC was not statistically significant (adjusted ratio, 1.08, 95% CI, 0.80–1.44; P=0.63). CONCLUSION: We did not find evidence that patients with MCI want less treatment than patients with NC. These findings suggest that other provider and system factors might contribute to patients with MCI getting less guideline-concordant care. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06839-w.

The clinical landscape has moved toward less aggressive end-of-life care for women with ovarian cancer. However, whether there has been a decline in the use of aggressive end-of-life services is unknown. The authors evaluated current national trends and racial disparities in end-of-life care among women with ovarian cancer using the Surveillance, Epidemiology, and End Results-Medicare-linked data set.In total, 7756 Medicare beneficiaries aged66 years with ovarian cancer who died between 2007 and 2016 were identified. The authors examined trends and racial disparities in late hospice or no hospice use,1 emergency department (ED) visit, intensive care unit admission,1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life-extending procedures using multivariable logistic regression.The median hospice length of stay did not change over time; however, women were increasingly admitted to the intensive care unit and had multiple ED visits in the last month of life (P.001). Not enrolling in hospice at the end of life and terminal hospitalizations decreased over time (P.001). Non-White women were more likely to receive aggressive end-of-life care, particularly for hospital-related utilization and life-extending procedures, whereas non-Hispanic Black women were more likely to have1 ED visit (odds ratio, 2.04; 95% CI, 1.57-2.64) or life-extending procedures (odds ratio, 1.89; 95% CI, 1.45-2.48) compared with non-Hispanic White women.Despite clinical guidelines and increasing emphasis on reducing aggressive end-of-life care, the use of aggressive end-of-life care for women with ovarian cancer persists, and care is most aggressive for non-White women.

Context The use of radioactive iodine (RAI) for low-risk thyroid cancer is common, and variation in its use exists, despite the lack of benefit for low-risk disease and potential harms and costs. Objective To simultaneously assess patient- and physician-level factors associated with patient-reported receipt of RAI for low-risk thyroid cancer. Methods This population-based survey study of patients with newly diagnosed differentiated thyroid cancer identified via the Surveillance Epidemiology and End Results (SEER) registries of Georgia and Los Angeles County included 989 patients with low-risk thyroid cancer, linked to 345 of their treating general surgeons, otolaryngologists, and endocrinologists. We assessed the association of physician- and patient-level factors with patient-reported receipt of RAI for low-risk thyroid cancer. Results Among this sample, 48% of patients reported receiving RAI, and 23% of their physicians reported they would use RAI for low-risk thyroid cancer. Patients were more likely to report receiving RAI if they were treated by a physician who reported they would use RAI for low-risk thyroid cancer compared with those whose physician reported they would not use RAI (adjusted OR: 1.84; 95% CI, 1.29-2.61). The odds of patients reporting they received RAI was 55% lower among patients whose physicians reported they saw a higher volume of patients with thyroid cancer (40+ vs 0-20) (adjusted OR: 0.45; 0.30-0.67). Conclusions Physician perspectives and attitudes about using RAI, as well as patient volume, influence RAI use for low-risk thyroid cancer. Efforts to reduce overuse of RAI in low-risk thyroid cancer should include interventions targeted toward physicians, in addition to patients.

BACKGROUND: Oncology settings increasingly use patient experience data to evaluate clinical performance. Given that older patients with hematologic malignancies are a high-need and high-risk population, this study examined factors associated with patient-reported health care experiences during the first year of their cancer diagnosis. METHODS: Cross-sectional study using the 2000–2015 SEER-CAHPS® data to examine patient experiences of Medicare enrollees with a primary diagnosis of leukemia or lymphoma. The primary outcomes were three CAHPS assessments: overall care, personal doctor and health plan overall. We estimated case-mix adjusted and fully adjusted associations between factors (i.e., clinical and sociodemographic) and the CAHPS outcomes using bivariate statistical tests and multiple linear regression. RESULTS: The final sample included 1,151 patients, with 431 diagnosed with leukemia and 720 diagnosed with lymphoma (median time from diagnosis to survey 6 months). Patients who completed the survey further apart from the diagnosis date reported significantly higher adjusted ratings of care overall (p=.008) than those closer to diagnosis. American Indian/Alaska Native, Asian, and Pacific Islander patients had lower adjusted ratings of care overall (p= .003) than Non-Hispanic White patients. Multimorbidity was significantly associated with higher adjusted personal doctor ratings (p=.003). CONCLUSIONS: Unfavorable patient experience ratings among vulnerable and under-represented older adults diagnosed with hematologic malignancies warrant targeted efforts to measure and improve care quality. Future measurement of experiences of cancer care soon after diagnosis, coupled with careful sampling of high-priority populations, will inform oncology leaders and clinicians on strategies to improve care for high-risk, high-cost populations.

Objective To compare the risk of mortality among men treated for benign prostatic hyperplasia (BPH) with 5 alpha-reductase inhibitors (5ARI) to those treated with alpha-blockers (AB) in community practice settings. Methods We employed a retrospective matched cohort study in 4 regions of an integrated healthcare system. Men aged 50 years and older who initiated pharmaceutical treatment for BPH and/or lower urinary tract symptoms between 1992 and 2008 and had at least 3 consecutive prescriptions that were eligible and followed through 2010 (N = 174,895). Adjusted hazard ratios were used to estimate the risk of mortality due to all-causes associated with 5ARI use (with or without concomitant ABs) as compared to AB use. Results In this large and diverse sample with 543,523 person-years of follow-up, 35,266 men died during the study period, 18.9% of the 5ARI users and 20.4% of the AB users. After adjustment for age, medication initiation year, race, region, prior AB history, Charlson score, and comorbidities, 5ARI use was not associated with an increased risk of mortality when compared to AB use (Adjusted hazard ratios: 0.64, 95% confidence interval: 0.62, 0.66). Conclusion Among men receiving medications for BPH in community practice settings, 5ARI use was not associated with an increased risk of mortality when compared to AB use. These data provide reassurance about the safety of using 5ARIs in general practice to manage BPH and/or lower urinary tract symptoms.

Background Little is known regarding whether growing awareness of the financial toxicity of a cancer diagnosis and its treatment has increased clinician engagement or changed the needs of current patients. Methods The authors surveyed patients with early-stage breast cancer who were identified through population-based sampling from 2 Surveillance, Epidemiology, and End Results (SEER) regions and their physicians. The authors described responses from approximately 73% of surgeons (370 surgeons), 61% of medical oncologists (306 medical oncologists), 67% of radiation oncologists (169 radiation oncologists), and 68% of patients (2502 patients). Results Approximately one-half (50.9%) of responding medical oncologists reported that someone in their practice often or always discusses financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists. Patients indicated that financial toxicity remains common: 21.5% of white patients and 22.5% of Asian patients had to cut down spending on food, as did 45.2% of black and 35.8% of Latina patients. Many patients desired to talk to providers about the financial impact of cancer (15.2% of whites, 31.1% of blacks, 30.3% of Latinas, and 25.4% of Asians). Unmet patient needs for engagement with physicians about financial concerns were common. Of 945 women who worried about finances, 679 (72.8%) indicated that physicians and their staff did not help. Of 523 women who desired to talk to providers regarding the impact of breast cancer on employment or finances, 283 (55.4%) reported no relevant discussion. Conclusions Many patients report inadequate clinician engagement in the management of financial toxicity, even though many providers believe that they make services available. Clinician assessment and communication regarding financial toxicity must improve; cure at the cost of financial ruin is unacceptable. Cancer 2018;000:000-000. © 2018 American Cancer Society.

Purpose Little is known about the extent to which genetic counseling is integrated into community practices for patients newly diagnosed with breast cancer. We examined the receipt of clinically indicated genetic counseling in these patients. Patients and Methods We surveyed 5,080 patients between the ages of 20 and 79 years, diagnosed from July 2013 to August 2015 with early-stage breast cancer and reported to the SEER registries of Georgia and Los Angeles County. Surveys were linked to SEER clinical data and genetic test results. The study sample (N = 1,711) comprised patients with indications for formal genetic risk evaluation. Results Overall, 47.4% did not get tested, 40.7% tested negative, 7.4% had a variant of uncertain significance only, and 4.5% had a pathogenic mutation. Three quarters (74.6%) received some form of genetic counseling (43.5%, formal counseling and 31.1%, physician-directed discussion). Virtually all tested patients (96.1%) reported some form of genetic discussion (62.2%, formal counseling and 33.9%, physician-directed discussion). However, only one half (50.6%) of those not tested received any discussion about genetics. Younger women were more likely to report some type of counseling, controlling for other factors: odds ratio, 4.5 (95% CI, 2.6 to 8.0); 1.9 (95% CI, 1.1 to 3.3); and 1.5 (95% CI, 1.0 to 2.3) for women younger than 50 years of age, 50 to 59 years of age, and 60 to 69 years of age versus those 70 years of age and older. Patients’ assessments of the amount of information they received about whether to get tested were similarly high whether they were counseled by a genetics expert or by a physician only (80.8% v 79.4% stated information was just right, P = .59). Conclusion Less than one half (43.5%) of patients with clinical indications received formal genetic counseling. There is a large gap between mandates for timely pretest formal genetic counseling in higher-risk patients and the reality of practice today.

BACKGROUND The omission of radiotherapy (RT) after lumpectomy is a reasonable option for many older women with favorable-prognosis breast cancer. In the current study, we sought to evaluate patient perspectives regarding decision making about RT. METHODS Women aged 65 to 79 years with AJCC 7th edition stage I and II breast cancer who were reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results registries were surveyed (response rate, 70%) regarding RT decisions, the rationale for omitting RT, decision-making values, and understanding of disease recurrence risk. We also surveyed their corresponding surgeons (response rate, 77%). Patient characteristics associated with the omission of RT were evaluated using multilevel, multivariable logistic regression, accounting for patient clustering within surgeons. RESULTS Of 999 patients, 135 omitted RT (14%). Older age, lower tumor grade, and having estrogen receptor-positive disease each were found to be strongly associated with omission of RT in multivariable analyses, whereas the number of comorbidities was not. Non-English speakers were more likely to omit RT (adjusted odds ratio, 5.9; 95% confidence interval, 1.4-24.5). The most commonly reported reasons for RT omission were that a physician advised the patient that it was not needed (54% of patients who omitted RT) and patient choice (41%). Risk of local disease recurrence was overestimated by all patients: by approximately 2-fold among those who omitted RT and by approximately 8-fold among those who received RT. The risk of distant disease recurrence was overestimated by approximately 3-fold on average. CONCLUSIONS To some extent, decisions regarding RT omission are appropriately influenced by patient age, tumor grade, and estrogen receptor status, but do not appear to be optimally tailored according to competing comorbidities. Many women who are candidates for RT omission overestimate their risk of disease recurrence. Cancer 2018;124:2714-2723. © 2018 American Cancer Society.

Background: Despite thyroid cancer being the second most common cancer in Hispanic women, little is known about access to and utilization of medical information resources by Hispanic women with thyroid cancer. Methods: Hispanic women who had diagnoses of thyroid cancer reported to the Los Angeles Surveillance Epidemiology and End Results (SEER) registry in 2014-2015, and who had previously completed our thyroid cancer survey in 2017-2018, were offered follow-up surveys in both English and Spanish (N=273; 80% response rate). Acculturation, which is the process by which individuals adopt the language, values, attitudes, and behaviors of a different culture, was assessed with the Short Acculturation Scale for Hispanics (SASH). Health literacy was assessed with the validated single-item question of “How confident are you filling out medical forms by yourself?” with response categories based on a five-point Likert scale from “extremely” to “not at all”. Patients were also asked about their internet access, information resources used, and ability to access medical information about thyroid cancer in their preferred language. We generated descriptive statistics for all categorical variables and used Rao-Scott adjusted chi-square tests to test for a relationship between level of acculturation and the following variables: health literacy, internet access, information resources used, and ability to access information. Results: Participants’ median age at diagnosis was 47 years (range 20-79); 49% were low-acculturated, 25% had low health literacy, and 14% reported no internet access at home. Low-acculturated Hispanic women reported using information resources in both English and Spanish whereas high-acculturated women used resources in English only. Hispanic women were more likely to report the ability to access medical information about thyroid cancer all of the time if they preferred information in English compared to if they preferred it in Spanish (89% vs 37%, P

142 Background: Goals of care conversations are associated with less aggressive end of life care and may be most effective in an outpatient setting. Yet, the relationship between initial utilization of care and subsequent hospice enrollment is unknown. We evaluated whether inpatient, outpatient and emergency department (ED) evaluation and management (E/M) visits differed by patient race/ethnicity, and whether less outpatient management was associated with failure to enroll in hospice in a sample of women dying of ovarian cancer. Methods: Women diagnosed with first and only ovarian cancer who died between 2000 and 2016 and had ≥ one inpatient and outpatient ovarian cancer E/M encounter between diagnosis and the last two months of life in SEER-Medicare were included (N = 8,806). Women whose proportion of outpatient E/M encounters fell below the median were classified as having low outpatient management (vs. high). Multivariable-adjusted logistic regression was used to estimate the association of: (1) race/ethnicity with outpatient management, and (2) outpatient management with hospice enrollment, stratified by race/ethnicity. Models were adjusted for stage at diagnosis, histology, survival time, age, Charlson score, geographic region, and year. Results: In this sample, 29.2% of ovarian cancer E/M took place in an inpatient setting, 66.4% outpatient, and 4.4% in the ED. Non-Hispanic Black women had 53.9% of their E/M occur in an outpatient setting, compared to 67.6% in non-Hispanic White women, 60.7% in Hispanic women, and 64.2% in women of other races (p

312 Background: Population aging and improving cancer survival rates are resulting in a growing population of older cancer survivors in the United States (US). As a result, there is an increasing need for longitudinal, population-representative data for interdisciplinary cancer research among older adults. The US Health Retirement Study (HRS) is an ongoing population-representative cohort of US adults over age 50 that contains rich interview and biomarker data on health during aging. Interviews have collected self-reported cancer diagnoses since 1998, but these self-reports have not been validated. We compared first incident cancer diagnoses self-reported in HRS interviews against diagnostic claims from linked Medicare records. Methods: We examined the validity of first incident cancer diagnoses self-reported in biennial HRS interviews from 2000 through 2016 against ICD-9 and ICD-10 diagnostic claim records among 8,242 HRS participants aged ≥65 with 90% continuous enrollment in fee-for-service Medicare, using the claim records as the gold standard. We calculated the sensitivity, specificity, and k for first incident cancer diagnoses (all cancers combined, excluding non-melanoma skin cancer, and each of bladder, breast, colorectal/anal, uterine, kidney/renal, lung/bronchus, and prostate cancers) cumulatively over the follow-up, and at each biennial study interview. Results: Self-reports of first incident cancer diagnosis (agnostic of site) between 2000 and 2016 had 73.2% sensitivity and 96.2% specificity against Medicare claims (k = 0.73). For site-specific self-reports, sensitivities ranged from 44.7% (kidney) to 75.0% (breast), and specificities ranged from 99.2% (prostate) to 99.9% (bladder, uterine, and kidney). Results were similar in sensitivity analyses restricting to individuals with 100% continuous fee-for-service Medicare enrollment and when restricting to individuals with at least 24 months of Medicare enrollment. Conclusions: Self-reported cancer diagnoses in the HRS have reasonable validity for population-based research on cancer and aging across cancer types. Apart from breast cancer, cancer site specific analyses will greatly benefit from the improved validity of self-report with Medicare claim linkage.

BACKGROUND Many patients with breast cancer work for pay at the time of their diagnosis, and the treatment plan may threaten their livelihood. Understanding work experiences in a contemporary population-based sample is necessary to inform initiatives to reduce the burden of cancer care. METHODS Women who were 20 to 79 years old and had been diagnosed with stage 0 to II breast cancer, as reported to the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries in 2014-2015, were surveyed. Of the 3672 eligible women, 2502 responded (68%); 1006 who reported working before their diagnosis were analyzed. Multivariate models evaluated correlates of missing work for >1 month and stopping work altogether versus missing work for ≤1 month. RESULTS In this diverse sample, most patients (62%) underwent lumpectomy; 16% underwent unilateral mastectomy (8% with reconstruction); and 23% underwent bilateral mastectomy (19% with reconstruction). One-third (33%) received chemotherapy. Most (84%) worked full-time before their diagnosis; however, only 50% had paid sick leave, 39% had disability benefits, and 38% had flexible work schedules. Surgical treatment was strongly correlated with missing >1 month of work (odds ratio [OR] for bilateral mastectomy with reconstruction vs lumpectomy, 7.8) and with stopping work altogether (OR for bilateral mastectomy with reconstruction vs lumpectomy, 3.1). Chemotherapy receipt (OR for missing >1 month, 1.3; OR for stopping work altogether, 3.9) and race (OR for missing >1 month for blacks vs whites, 2.0; OR for stopping work altogether for blacks vs whites, 1.7) also correlated. Those with paid sick leave were less likely to stop working (OR, 0.5), as were those with flexible schedules (OR, 0.3). CONCLUSIONS Working patients who received more aggressive treatments were more likely to experience substantial employment disruptions. Cancer 2017. © 2017 American Cancer Society.

BACKGROUND The authors examined racial/ethnic differences in patient perspectives regarding their breast cancer treatment experiences. METHODS A weighted random sample of women newly diagnosed with breast cancer between 2013 and 2015 in Los Angeles County and Georgia were sent surveys 2 months after undergoing surgery (5080 women; 70% response rate). The analytic sample was limited to patients residing in Los Angeles County (2397 women). RESULTS The pattern of visits with different specialists before surgery was found to be similar across racial/ethnic groups. Low acculturated Latinas (Latinas-LA) were less likely to report high clinician communication quality for both surgeons and medical oncologists ( 72% for all other groups; P

PURPOSE To understand the effect of patient preferences on thyroid cancer surveillance intensity. PATIENTS AND METHODS Eligible patients diagnosed with thyroid cancer between January 1, 2014, and December 31, 2015, from the Georgia and Los Angeles County SEER registries were surveyed between February 2017 and October 2018 (N = 2,632; response rate, 63%). Patient reports on health care utilization in the past year and responses to the validated Medical Maximizer-Minimizer Scale were linked to SEER data in the 2,183 disease-free patients. Ordered logistic regression was performed using a cumulative logit with nonproportional odds. RESULTS Of disease-free patients, 31.6% were classified as minimizers, 42.5% as moderate maximizers, and 25.9% as strong maximizers. In the past year, 25.2%, 27.3%, and 38.5% of minimizers, moderate maximizers, and strong maximizers, respectively, had ≥ 4 doctor visits, and 18.3%, 24.9%, and 29.5%, respectively, had ≥ 2 neck ultrasounds. When controlling for age, sex, race and ethnicity, comorbidity, stage, and SEER site, strong maximizers (compared with minimizers) were significantly more likely to report ≥ 4 doctor visits (odds ratio [OR], 1.45; 95% CI, 1.10-1.92), ≥ 2 neck ultrasounds (OR, 1.58; 95% CI, 1.17-2.14), ≥ 1 radioactive iodine scan (OR, 1.73; 95% CI, 1.19-2.50), and ≥ 1 additional imaging study (OR, 2.06; 95% CI, 1.56-2.72). CONCLUSION Among patients with thyroid cancer who have been declared disease free, preference for a more maximal versus minimal approach to medical care is associated with increased number of physician visits and imaging tests. Because increased surveillance does not clearly correlate with improved outcomes, poses potential risks to patients, and contributes to increased healthcare costs, stronger consideration of the role of patient preferences is necessary when framing discussions on surveillance.

Context Cancer-related fatigue (CRF) is one of the most common symptoms experienced by cancer patients after hematopoietic cell transplantation (HCT). Yoga is an approach with supportive evidence to improve CRF in different cancer populations, but to our knowledge, it has not been tested in an adult HCT population. Objectives The aim of this study was to evaluate the feasibility of a yoga intervention offered to adult HCT survivors with moderate-to-severe CRF. Methods This feasibility study used a single-arm, pretest-posttest design. Adult HCT survivors were enrolled in a six-week restorative yoga intervention that consisted of a one-hour once-weekly class with twice-weekly home practice using a DVD. Results Twenty participants (13 women and seven men) enrolled in this study with a mean age of 51 years (SD = 12.5). The sample consisted of 19 allogeneic HCT survivors, seven of whom had a history of acute graft-vs.-host disease (GVHD), six with active, extensive chronic GVHD, and one autologous HCT survivor. The accrual acceptance rate was 23.2% (20/86 HCT survivors) and retention rate was 60% (12/20). Overall adherence was 45.4%. No adverse events were reported. Conclusion The results of this study suggest that a restorative yoga intervention in adult HCT survivors is safe and feasible. The incidence of GVHD may have impacted adherence. Strategies to improve accrual acceptance, retention, and adherence are needed.

Introduction: Prior studies have shown an overall increase in surveillance intensity after initial treatment of differentiated thyroid cancer without a clear impact on survival. However, little is known about the role that patient care preferences play in this trend. Methods: Using the Georgia and Los Angeles Surveillance, Epidemiology, and End Results (SEER) cancer registries, we identified eligible patients diagnosed with differentiated thyroid cancer (DTC) between 2014-2015. Patients were surveyed by mail and queried on current disease status and healthcare utilization within the last year including physician visits and imaging studies. Patients also completed the validated Medical Maximizer-Minimizer Scale (MMS), which measures stable generalized preferences for seeking more versus less medical care. Patients with recurrent or persistent disease were excluded from the analysis. Ordered logistic regression was performed using a cumulative logit with non-proportional odds. Results: Of the 2,190 patients, 1,707 (77.9%) were female, 1,296 (59.6%) were white, and the median age was 51 years. Using the MMS, 703 respondents (32.8%) were classified as minimizers, 910 (42.4%) were classified as moderate maximizers, and 532 (24.8%) were classified as strong maximizers. In the last year, 173 (24.6%), 244 (27.0%), and 202 (38.4%), respectively, had four or more doctor visits, and 125 (17.8%), 219 (24.2%), and 155 (29.5%) had two or more neck ultrasounds. When controlling for age, sex, race/ethnicity, comorbidity, and AJCC stage, strong medical maximizers as compared with medical minimizers, were significantly more likely to report four or more doctor visits (Odds Ratio (OR) 1.56 (95% Confidence Interval (CI) 1.19-2.04)), two or more neck ultrasounds (OR 1.65 (CI 1.23-2.21)), one or more RAI scans (OR 1.56 (CI 1.08-2.25)), and one or more additional imaging studies (OR 2.09 (CI 1.60-2.74)). Conclusions: Among disease-free differentiated thyroid cancer patients, patient preference for a more maximal versus minimal approach to medical care is associated with increased numbers of physician visits and imaging tests. Given that these additional visits and tests do not clearly correlate with improved outcomes, pose potential risks to patients, and contribute to increased healthcare costs, stronger consideration of patient preferences may be needed when framing discussions on the risks and benefits of surveillance care.

Provider communication that supports patient autonomy has been associated with numerous positive patient outcomes. However, to date, no research has examined the relationship between perceived provider communication style and patient-assessed decision quality in breast cancer.Using a population-based sample of women with localized breast cancer, we assessed patient perceptions of autonomy-supportive communication from their surgeons and medical oncologists, as well as patient-reported decision quality. We used multivariable linear regression to examine the association between autonomy-supportive communication and subjective decision quality for surgery and chemotherapy decisions, controlling for sociodemographic and clinical factors, as well as patient-reported communication preference (non-directive or directive).Among the 1690 women included in the overall sample, patient-reported decision quality scores were positively associated with higher levels of perceived autonomy-supportive communication from surgeons (β=0.30; p0.001) and medical oncologists (β=0.26; p0.001). Patient communication style preference moderated the association between physician communication style received and perceived decision quality.Autonomy-supportive communication by physicians was associated with higher subjective decision quality among women with localized breast cancer. These results support future efforts to design interventions that enhance autonomy-supportive communication.Autonomy-supportive communication by cancer doctors can improve patients' perceived decision quality.

Objective To examine the racial and ethnic variation in time to prostate biopsy after an elevated screening level of serum prostate-specific antigen (PSA). Methods Male members of the Kaiser Permanente of Southern California health plan, 45 years of age or older, with no history of prostate cancer or a prostate biopsy, and at least 1 elevated screening level of serum PSA between January 1, 1998 and December 31, 2007 were retrospectively identified (n = 59,506). All participants were passively followed via electronic health records until their time of prostate biopsy, death, membership disenrollment, or study conclusion (December 31, 2014), whichever was the initial event. Proportional hazard regression analyses were used to estimate the association between time from an elevated screening level of serum PSA to prostate biopsy, adjusting for age, benign prostatic hyperplasia, prostatitis, type 2 diabetes mellitus, hypertension, and Charlson Comorbidity Index score. Results Median time until biopsy was 0.6 years (214 days), with approximately 41% of participants receiving a prostate biopsy within the study period. Results from the fully adjusted analysis indicated that the non-Hispanic Asian or Pacific Islanders (hazard ratio: 1.10, 95% confidence interval: [1.04, 1.15]) and the non-Hispanic blacks (hazard ratio: 1.04, 95% confidence interval: [1.00, 1.08]) had a slightly shorter time to prostate biopsy after an elevated screening level of serum PSA compared to the non-Hispanic whites. Conclusion These data suggest that, within an integrated healthcare organization, minimal differences exist between racial and ethnic subgroups in their time to prostate biopsy after an elevated screening level of serum PSA.

The objectives of this study are to describe racial/ethnic differences and clinical/treatment correlates of worry about recurrence and examine modifiable factors in the health care experience to reduce worry among breast cancer survivors, partners, and pairs. Women with non-metastatic breast cancer identified by the Detroit and Los Angeles SEER registries between 6/05 and 2/07 were surveyed at 9 months and 4 years. Latina and Black women were oversampled. Partners were surveyed at time 2. Worry about recurrence was regressed on sociodemographics, clinical/treatment, and modifiable factors (e.g., emotional support received by providers) among survivors, partners, and pairs. The final sample included 510 pairs. Partners reported more worry about recurrence than survivors. Compared to Whites, Latinas(os) were more likely to report worry and Blacks were less likely to report worry (all p

7056 Background: The delivery of team-based survivorship care after primary cancer treatment remains challenging, in part due to a lack of effective interventions. We developed a multi-level intervention for breast cancer patients and their primary care and medical oncology providers to improve the delivery of team-based survivorship care called ConnectedCancerCare (CCC). CCC includes a patient-facing, personalized mobile website, and tailored feedback letters to providers. Methods: We conducted a pilot randomized controlled trial in a breast oncology clinic to establish the feasibility and acceptability of CCC. Women within one year of completing primary treatment for stages 0-II breast cancer were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed online surveys at baseline and 3 months, ascertaining their knowledge about PCP roles in their survivorship care, their communication with their PCP about team-based care, and whether they scheduled a follow-up visit with their PCP. Multiple measures of acceptability were collected among women in the intervention arm (n = 28). Qualitative interviews were conducted at the completion of the study with 5 PCPs, 6 oncology providers, and 10 intervention patients to identify barriers and facilitators to implementing CCC. Results: Among 160 eligible women invited to participate, 66 women completed the baseline survey and were randomized (41% participation rate), and 54 completed the 3-month follow-up survey (83% response rate). Women in the intervention arm found the content of the CCC website to be highly acceptable, with 82% reporting it was easy to use, and 86% reporting they would recommend it to other patients. A greater proportion of women randomized to CCC (vs. control) reported scheduling a PCP follow-up visit (64% vs. 42%) and communicating with their PCP about provider roles (67% vs. 18%). Women in the CCC arm also reported higher mean knowledge scores regarding team-based cancer care (3.7 vs. 3.4). Providers noted challenges to implementing CCC, including integration into electronic medical records, and supporting sustained engagement with CCC over time. Conclusions: Our findings suggest deploying CCC in medical oncology practices is feasible, and the intervention content is acceptable among breast cancer patients. CCC shows promise for improving understanding and communication about provider roles in survivorship care, and facilitating patients to follow up with their PCP early in the survivorship period. Clinical trial information: NCT03618017 .

e14028 Background: While prior research has examined how primary care providers (PCPs) can help care for breast and colon cancer survivors, little is known about the role of PCPs in thyroid cancer survivorship. We surveyed PCPs to understand their involvement and confidence in providing several aspects of thyroid cancer survivorship care. Methods: Thyroid cancer patients (N = 2632) diagnosed in 2014-2015 and identified from the Georgia and LA SEER registries, were surveyed, and identified their PCPs, who then were also surveyed (N = 162, 56% response rate). PCPs were asked to report their: 1) involvement in thyroid cancer long-term surveillance (not involved: never/rarely vs. involved: sometimes/often/almost always involved); and 2) confidence in handling four aspects of thyroid cancer survivorship care (low: not at all/a little/somewhat vs. high: quite/very confident). We examined PCP factors (individual, practice, attitudes and beliefs) associated with PCP involvement in long-term surveillance using multivariable logistic regression. We then examined associations between PCP involvement in long-term surveillance and PCP confidence in handling the four aspects of thyroid cancer survivorship care using Chi-squared tests. Results: The majority of PCPs (76%) reported involvement in long-term surveillance. Adjusted odds of PCPs reporting involvement was greater among PCPs who somewhat/strongly believed that PCPs have the skills necessary to provide survivorship care (OR 4.33; 95% CI 1.38-15.37), and PCPs who noted clinical guidelines as being the most influential in guiding treatment (OR 4.48; 95% CI 1.67-13.07). PCP reports of high confidence in handling the four aspects of survivorship care were consistently less than 50%: when to refer patient to specialist (40%), role of neck ultrasound (36%), role of random thyroglobulin levels (27%), and when to end long-term surveillance (14%). PCPs who reported involvement in long-term surveillance were more likely to report high confidence in discussing the role of random thyroglobulin levels (33.3% vs. 7.9% for those not involved, p < 0.01) but not the other aspects of survivorship care. Conclusions: Though many PCPs reported they were involved in thyroid cancer long-term surveillance, gaps remain in their confidence in handling several aspects of thyroid cancer survivorship care. Guidelines were noted as important in influencing management; therefore, developing guidelines that specifically delineate PCP roles in thyroid cancer survivorship may present one opportunity to increase PCPs’ confidence about their participation.

Background Treatment decisions for patients with early-stage breast cancer often involve discussions with multiple oncology providers. However, the extent to which primary care providers (PCPs) are involved in initial treatment decisions remains unknown. Methods A stratified random sample of PCPs identified by newly diagnosed patients with early-stage breast cancer from the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries were surveyed (n = 517; a 61% response rate). PCPs were asked how frequently they discussed surgery, radiation, and chemotherapy options with patients; how comfortable they were with these discussions; whether they had the necessary knowledge to participate in decision making; and what their confidence was in their ability to help (on 5-item Likert-type scales). Multivariate logistic regression was used to identify PCP-reported attitudes associated with more PCP participation in each treatment decision. Results In this sample, 34% of PCPs reported that they discussed surgery, 23% discussed radiation, and 22% discussed chemotherapy options with their patients. Of those who reported more involvement in surgical decisions, 22% reported that they were not comfortable having a discussion, and 17% did not feel that they had the necessary knowledge to participate in treatment decision making. PCPs who positively appraised their ability to participate were more likely to participate in all 3 decisions (odds ratio [OR] for surgery, 6.01; 95% confidence interval [CI], 4.16-8.68; OR for radiation, 8.37; 95% CI, 5.16-13.58; OR for chemotherapy, 6.56; 95% CI, 4.23-10.17). Conclusions A third of PCPs reported participating in breast cancer treatment decisions, yet gaps in their knowledge about decision making and in their confidence in their ability to help exist. Efforts to increase PCPs' knowledge about breast cancer treatment options may be warranted.

Author(s): Wallner, Lauren P; Slezak, Jeffrey M; Loo, Ronald K; Bastani, Roshan; Jacobsen, Steven J | Abstract: CONTEXT:Few studies have assessed the longer-term quality of preventive care in prostate cancer (PCa) survivors. OBJECTIVE:To compare the rates of preventive services among PCa survivors five years before and after diagnosis, to men without PCa. DESIGN:Men enrolled in Kaiser Permanente Southern California with newly diagnosed PCa (2002-2008) were matched 1:1 to men without a PCa diagnosis on age, race, and timing of prostate-specific antigen test (N = 31,180). The use of preventive services, including colorectal cancer screening, diabetes tests, lipid panels, and influenza and pneumococcal vaccinations was assessed 5 years before and after diagnosis (or index date for controls). MAIN OUTCOME MEASURES:Relative rates (RRs) of use were calculated for cases and controls separately and compared using Poisson regression, adjusting for comorbidities and outpatient utilization in 2014. RESULTS:Overall, the rates of preventive services were lower among men with PCa vs men without PCa. However, in the 5 years after diagnosis, rates of preventive service use for all services were greater among PCa survivors vs men without PCa (colorectal cancer: RR = 1.05, 95% confidence interval [CI] = 1.01-1.10; lipids: RR = 1.10, 95% CI = 1.08-1.11; hemoglobin A1C: RR = 1.17, 95% CI = 1.14-1.19; glucose: RR = 1.24, 95% CI = 1.23-1.26; influenza vaccine: RR = 1.05, 95% CI = 1.03-1.07; pneumococcal vaccine: RR = 1.03, 95% CI = 0.97-1.09). CONCLUSION:Delivery of preventive care improved after PCa diagnosis, with survivors receiving comparable preventive care to men without PCa during the five years following diagnosis.

Purpose: Work loss is one of many personal costs for patients with cancer and their families. Many women with breast cancer face long-term job loss that stems from their diagnoses. However, little is known about the economic and employment outcomes of partners of women with breast cancer. Methods: Women with nonmetastatic breast cancer identified by the Detroit and Los Angeles SEER registries between June 2005 and February 2007 were surveyed at both 9 months and 4 years after diagnosis. Partners were surveyed 4 years after patients’ diagnoses. Nonretired partners were asked about employment and financial consequences that stemmed from the patients’ breast cancer diagnoses and treatments. Results: A total of 517 (67%) of 774 eligible partners completed the survey; 32% reported worsened financial status attributed to patients’ breast cancers. Two hundred forty nonretired partners worked during the year after the patients’ diagnoses; 90% were still working 4 years postdiagnosis. A total of 32% of partners decreased their work hours as a result of patients’ breast cancer diagnoses and treatments; 64% of partners reported that, as a result of patients’ breast cancer diagnoses and treatments, it was very/extremely important to keep working to keep health insurance. Overall, 51% of partners reported that it was very/extremely important to avoid changing jobs, because they were worried about loss of health insurance. Conclusion: Nearly one third of partners reported that their financial status was worse because of the patient’s breast cancer, although most remained working 4 years after a diagnosis. Partners may continue to work longer than desired to compensate for a loss of financial resources in the family.

Background. Breast cancer patients’ misunderstanding of their systemic cancer recurrence risk has consequences on decision-making and quality of life. Little is known about how women derive their risk estimates. Methods. Using Los Angeles and Georgia’s SEER registries (2014–2015), a random sample of early-stage breast cancer patients was sent surveys about 2 to 3 months after surgery ( N = 3930; RR, 68%). We conducted an inductive thematic analysis of open-ended responses about why women chose their risk estimates in a uniquely large sub-sample ( N = 1,754). Clinician estimates of systemic recurrence risk were provided for patient sub-groups with DCIS and with low-, intermediate-, and high-risk invasive disease. Women’s perceived risk of systemic recurrence (0% to 100%) was categorized as overestimation, reasonably accurate estimation, or underestimation (0% for invasive disease) and was compared across identified factors and by clinical presentation. Results. Women identified 9 main factors related to their clinical experience (e.g., diagnosis and testing; treatment) and non-clinical beliefs (e.g., uncertainty; spirituality). Women who mentioned at least one clinical experience factor were significantly less likely to overestimate their risk (12% v. 43%, P < 0.001). Most women who were influenced by “communication with a clinician” had reasonably accurate recurrence estimates (68%). “Uncertainty” and “family and personal history” were associated with overestimation, particularly for women with DCIS (75%; 84%). “Spirituality, religion, and faith” was associated with an underestimation of risk (63% v. 20%, P < 0.001). Limitations. The quantification of our qualitative results is subject to any biases that may have occurred during the coding process despite rigorous methodology. Conclusions. Patient-clinician communication is important for breast cancer patients’ understanding of their numeric risk of systemic recurrence. Clinician discussions about recurrence risk should address uncertainty and relevance of family and personal history.

Purpose Prior studies have suggested a need for greater clarity about provider roles in team-based cancer care; however, little is known about patients’ preferences regarding which providers handle their care needs after primary cancer treatment. Methods We surveyed women with newly diagnosed stages 0 to II breast cancer who were treated in 2014 and 2015 as reported to the Georgia and Los Angeles SEER registries (N = 2,372; 68% response rate). Patient preferences regarding which provider handles the following care needs after treatment were ascertained: follow-up mammograms, screening for other cancers, general preventive care, and comorbidity management. Associations between patient demographic factors with preferences for provider roles—oncology-directed care versus primary care provider (PCP)–directed care—were assessed by using multivariable logistic regression. Results The majority of women preferred that their PCPs handle general preventive care (79%) and comorbidity care (84%), but a notable minority of women preferred that their oncologists direct this care (21% and 16%, respectively). Minority women—black and Asian versus white—and women with a high school education or less—versus undergraduate college education or more—displayed greater odds of preferring oncology-directed care—versus PCP-directed care—for their general preventive care (black odds ratio [OR], 2.01; 95% CI, 1.43 to 2.82; Asian OR, 1.74; 95% CI, 1.13 to 2.69; high school education or less OR, 1.51; 95% CI, 1.10 to 2.08). Similar variations existed for comorbidity care. Conclusion In this sample, minority women and those with less education more often preferred that oncologists direct certain aspects of their care after breast cancer treatment that are normally delivered by a PCP. Efforts to clarify provider roles in survivorship care to patients may be effective in improving team-based cancer care.