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Background Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

PURPOSE: To examine associations between preoperative magnetic resonance imaging (MRI) use and clinical outcomes among women undergoing breast-conserving surgery (BCS) with or without radiotherapy for early-stage breast cancer. METHODS: We identified women from the Surveillance, Epidemiology, and End Results-Medicare dataset aged 67–94 diagnosed during 2004–2010 with stage I/II breast cancer who received BCS. We compared subsequent mastectomy and breast cancer mortality with vs. without preoperative MRI, using Cox regression and competing risks models. We further stratified by receipt of radiotherapy for subgroup analyses. RESULTS: Our sample consisted of 24,379 beneficiaries, 4,691 (19.2%) of whom received preoperative MRI. Adjusted rates of subsequent mastectomy and breast cancer mortality were not significantly different with and without MRI: 3.2 vs. 4.1 per 1,000 person-years (adjusted hazard ratio [AHR], 0.92; 95% confidence interval [CI]: 0.70–1.19) and 5.3 vs. 8.7 per 1,000 person-years (AHR, 0.89; 95% CI: 0.73–1.08), respectively. In subgroup analyses, women receiving BCS plus radiotherapy had similar rates of subsequent mastectomy (AHR, 1.17; 95% CI: 0.84–1.61) and breast cancer mortality (AHR 1.00; 95% CI: 0.80–1.24) with vs. without MRI. However, among women receiving BCS alone, MRI use was associated with lower risks of subsequent mastectomy (AHR, 0.60; 95% CI: 0.37–0.98) and breast cancer mortality (AHR, 0.57; 95% CI: 0.36–0.92). CONCLUSIONS: Preoperative MRI was associated with improved outcomes among older women with breast cancer receiving BCS alone, but not among those receiving BCS plus radiotherapy. Further research is needed to identify appropriate settings for which MRI may be helpful.

BackgroundTreatment-related toxicity can vary substantially between chemotherapy regimens. In this study we evaluated the frequency of outpatient office visits among a cohort of early stage breast cancer survivors after completion of 4 different adjuvant chemotherapy regimens to better understand how differences in toxicities between regimens might affect health care use.Materials and methodsWe analyzed administrative claims data from a US commercial insurance database (OptumLabs) to identify women who received adjuvant doxorubicin/cyclophosphamide (AC), AC followed or preceded by docetaxel or paclitaxel (AC-T), AC concurrent with docetaxel or paclitaxel (TAC), or docetaxel/cyclophosphamide (TC) between 2008 and 2014. We compared mean numbers of visits per patient (adjusted for age, race/ethnicity, region, year, surgery type, radiation, chronic conditions, and previous hospitalizations) across the different regimens (TC= reference) for 12 months, starting 4 months after the end of chemotherapy.ResultsIn 6247 eligible patients, the mean adjusted number of outpatient visits per patient was significantly higher in patients who received AC-T (8.1) or TAC (7.3) than TC (6.5) or AC (6.0; P< .001 for comparisons of AC-T and TAC with TC), primarily because of differences in Medical Oncology visits. Approximately 40% did not see a primary care provider at all during this time frame.ConclusionsAC-T and TAC are associated with more subsequent outpatient visits than TC. Visits to primary care providers are infrequent during the year after completion of chemotherapy.

Objective To examine whether regional practice patterns impact racial/ethnic differences in intensity of end-of-life care for cancer decedents. Data sources The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Study design We classified hospital referral regions (HRRs) based on mean 6-month end-of-life care expenditures, which represented regional practice patterns. Using hierarchical generalized linear models, we examined racial/ethnic differences in the intensity of end-of-life care across levels of HRR expenditures. Principal findings There was greater variation in intensity of end-of-life care among Hispanics, Asians, and whites in high-expenditure HRRs than in low-expenditure HRRs. Conclusions Local practice patterns may influence racial/ethnic differences in end-of-life care.

Physicians “purchase” many health care services on behalf of patients yet remain largely unaware of the costs of these services. Electronic health record (EHR) cost displays may facilitate cost-conscious ordering of health services. To determine whether displaying hospital lab and imaging order costs is associated with changes in the number and costs of orders placed. Quasi-experimental study. All patients with inpatient or observation encounters across a multi-site health system from April 2013 to October 2015. Display of order costs, based on Medicare fee schedules, in the EHR for 1032 lab tests and 1329 imaging tests. Outcomes for both lab and imaging orders were (1) whether an order was placed during a hospital encounter, (2) whether an order was placed on a given patient-day, (3) number of orders placed per patient-day, and (4) cost of orders placed per patient-day. During the lab and imaging study periods, there were 248,214 and 258,267 encounters, respectively. Cost display implementation was associated with a decreased odds of any lab or imaging being ordered during the encounter (lab adjusted odds ratio [AOR] = 0.97, p = .01; imaging AOR = 0.97, p

BACKGROUND Hearing and visual impairments are common among community-dwelling older adults, and are associated with psychological, functional, and cognitive deficits. However, to the authors' knowledge, little is known regarding their prevalence among older patients with cancer. METHODS The current study was a secondary analysis combining 2 prospective cohorts of adults aged ≥65 years with solid tumors who were receiving chemotherapy. The authors assessed the association between patient-reported hearing and/or visual impairment (defined as fair/poor grading by self-report) and physical function, instrumental activities of daily living (IADLs), anxiety, depression, and cognition. Descriptive analyses were conducted to summarize patient and treatment characteristics. One-way analysis of variance and chi-square tests were conducted as appropriate to examine differences between patients with and without sensory impairments. Logistic regression was used to analyze associations between sensory impairments and outcomes. RESULTS Among 750 patients with a median age of 72 years who had solid tumors (29% with breast/gynecological tumors, 28% with lung tumors, and 27% with gastrointestinal tumors), approximately 18% reported hearing impairment alone, 11% reported visual impairment alone, and 7% reported dual sensory impairment. Hearing impairment was associated with IADL dependence (odds ratio [OR], 1.9), depression (OR, 1.6), and anxiety (OR, 1.6). Visual impairment was associated with IADL dependence (OR, 1.9), poor physical function (OR, 1.9), and depression (OR, 2.5). Dual impairment was associated with IADL dependence (OR, 2.8), anxiety (OR, 2.3), depression (OR, 2.5), and cognitive impairment (OR, 3.2). CONCLUSIONS Sensory impairment is common among older adults with cancer. Patients with sensory impairment are more likely to have functional, psychological, and cognitive deficits. Interventions aimed at improving the vision and hearing of older adults with cancer should be studied. Cancer 2018. © 2018 American Cancer Society.

Background A survivorship care plan (SCP), that is, individualized treatment summary and schedule of off-therapy surveillance, will be mandated by January 2019. It is unclear whether SCPs improve adherence to recommended follow-up care in the community. In this trial, we evaluated the impact of randomly assigning childhood cancer survivors to 1) SCPs to be taken to their primary care physician (PCP) to implement or 2) survivorship clinic (SC) on health care quality measures. Methods Eligibility included cancer diagnosis younger than age 18 years (2000-2012), cancer free, one or more years off therapy, and no prior survivorship clinic attendance. At 12 months, the random assignment groups were compared (SCP+PCP vs SC) by intent-to-treat analysis with two-sided statistical tests in terms of patient adherence to guideline-recommended surveillance tests (eg, echocardiogram) and number of newly identified late complications of therapy. Results From 2011 to 2013, 96 participants (46.9% female, mean age = 15.9 ± 6.1 years) were randomly assigned. Adherence to 14 evaluated guideline-recommended surveillance tests ranged from 0% to 46.9% in the SCP+PCP group (n = 47) and from 50.0% to 86.4% in the SC group (n = 47). Adherence to 10 tests was statistically significantly different between the groups (all P < .05). One mild new late complication was identified in the SCP+PCP group compared with 21 late complications, ranging from mild to severe, identified in 11 patients in the SC group (2.1% vs 23.4% of patients, respectively, P = .003). Conclusions Our randomized trial suggests that empowering childhood cancer survivors with SCPs to be implemented by their PCPs is not sufficient to meet consensus follow-up recommendations.

PURPOSE: Little is known about how the structure of interdisciplinary groups of physicians affects the timeliness of breast cancer surgery their patients receive. We used social network methods to examine variation in surgical delay across physician peer groups and the association of this delay with group characteristics. METHODS: We used linked Surveillance, Epidemiology, and End Results-Medicare data to construct physician peer groups based on shared breast cancer patients. We used hierarchical generalized linear models to examine the association of three group characteristics, patient racial composition, provider density (the ratio of potential vs. actual connections between physicians), and provider transitivity (clustering of providers within groups), with delayed surgery. RESULTS: The study sample included 8338 women with breast cancer in 157 physician peer groups. Surgical delay varied widely across physician peer groups (interquartile range 28.2–50.0%). For every 10% increase in the percentage of black patients in a peer group, there was a 41% increase in the odds of delayed surgery for women in that peer group regardless of a patient’s own race [odds ratio (OR) 1.41, 95% confidence interval (CI) 1.15–1.73]. Women in physician peer groups with the highest provider density were less likely to receive delayed surgery than those in physician peer groups with the lowest provider density (OR 0.65, 95% CI 0.44–0.98). We did not find an association between provider transitivity and delayed surgery. CONCLUSIONS: The likelihood of surgical delay varied substantially across physician peer groups and was associated with provider density and patient racial composition.

OBJECTIVE:To estimate the prevalence of corpus uteri, cervix uteri, and ovarian malignancy in women undergoing hysterectomy or myomectomy for presumed benign indications.METHODS:We conducted a secondary analysis of data from the 2014–2015 American College of Surgeons National Surgical Quality Improv

Purpose To examine the associations between sentinel lymph node biopsy (SLNB) and complications among older patients who underwent breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Methods We identified women from the Surveillance, Epidemiology, and End Results–Medicare dataset aged 67–94 years diagnosed during 1998–2011 with DCIS who underwent BCS as initial treatment. We assessed incidence of complications, including lymphedema, wound infection, seroma, or pain, within 9 months of diagnosis. We used Mahalanobis matching and generalized linear models to estimate the associations between SLNB and complications. Results Our sample consisted of 15,515 beneficiaries, 2409 (15.5%) of whom received SLNB. Overall, 16.8% of women who received SLNB had complications, compared with 11.3% of women who did not receive SLNB (p

Because immune checkpoint inhibitor therapies (CPI) lack the toxicities of chemotherapy, oncologists may prescribe CPI to patients at the end of life. This article describes real‐world patterns of CPI initiation near the end of life among individuals with metastatic urothelial cell carcinoma., Several immune checkpoint inhibitor therapies (CPIs) have been approved to treat metastatic urothelial cell carcinoma (mUC). Because of the favorable toxicity profile of CPI compared with chemotherapy, oncologists may have a low threshold to prescribe CPI to patients near the end of life. We evaluated trends in initiation of end‐of‐life systemic therapy in 1,637 individuals in the Flatiron Health Database who were diagnosed with mUC between 2015 and 2017 and who died. Rates of systemic therapy initiation in the last 30 and 60 days of life were 17.0% and 29.8%, respectively. The quarterly proportion of patients who initiated CPI within 60 days of death increased from 1.0% to 23% during the study period (ptrend < .001). After CPI approval, end‐of‐life CPI initiation significantly increased among patients with poor performance status (ptrend = .020) and did not significantly change among individuals with good performance status. The quarterly proportion of patients who initiated any systemic therapy at the end of life doubled (17.4% to 34.8%) during the study period, largely explained by increased CPI use. These findings suggest a dramatic rise in CPI use at the end of life in patients with mUC, a finding that may have important guideline and policy implications.

This cohort study characterizes changes in breast cancer screening costs as digital breast tomosynthesis has been adopted at both the patient and population levels.

137 Background: Prior studies indicate that Black patients with cancer are more likely to receive aggressive EOL care, including chemotherapy within 14 days (d) prior to death. However, most studies are limited to specific subgroups, and it is unclear if disparities remain in the immunotherapy era. In this study, we evaluated racial differences in systemic oncologic EOL treatment among a national all-payer cohort of patients treated in routine practice. Methods: We conducted a retrospective cohort study utilizing data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database. Patients with confirmed cancer diagnosis, with documented treatment on or after 1/1/2011 and who died between 2015 and 2019, were included. Patients with documented race of White or Black or African American were included. We defined our outcome measures as receipt of any systemic oncologic treatment within 30d or 14d prior to death, and also stratified by mono-chemotherapy (Chemo) and immunotherapy ± targeted therapy (ICI). We used mixed-level logistic regression models to assess the likelihood of receiving each treatment, compared to patients without any EOL treatment, between Black and White patients, adjusted for patient- and practice-level characteristics as fixed effects and a practice-specific random intercept. Race-specific adjusted rates were estimated using stratified analysis. Results: A total of 40,675 White and 5,150 Black patients were included in the analysis. Compared to White patients, Black patients were younger at diagnosis, were more likely to be female and have Medicaid coverage. Black patients were more likely to be treated at practices with higher patient-to-physician ratio (25.8% in highest quintile vs. 18.7%) and with a high proportion (> 10%) of patients with Medicaid (38.1% vs. 31.6%). Compared to White patients within the same practice, Black patients were less likely to receive any EOL treatment within 30d (adjusted odds ratio [aOR]: 0.87; 95% CI: 0.81-0.93) or 14d (aOR: 0.87; 95% CI: 0.80-0.96). Adjusted rates of any EOL treatment within 30d prior to death were 33.8% and 37.6% among Black and White patients, respectively. When stratified by treatment types, Black patients were less likely to receive ICI within 30d prior to death, compared to White patients (aOR: 0.87; 95% CI: 0.76-1.00). Conclusions: Our findings differ from prior studies of oncologic EOL care and suggest that in contemporary practice Black patients are less likely to receive anti-cancer therapy near EOL, largely driven by lower rates of ICI use. Future research should investigate the complex causal pathway underlying observed racial differences among patient and practice-level factors.

253 Background: Among patients with cancer, receipt of systemic oncolytic therapy near the end-of-life (EOL) does not improve outcomes and worsens patient and caregiver experience. Accordingly, the ASCO/NQF measure, Proportion Receiving Chemotherapy in the Last 14 Days of Life, was published in 2012. Over the last decade there has been exponential growth in high cost targeted and immune therapies which may be perceived as less toxic than traditional chemotherapy. In this study, we identified rates and types of EOL systemic therapy in today’s real-world practice; these can serve as benchmarks for cancer care organizations to drive improvement efforts. Methods: Using data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database we included patients who died during 2015 through 2019, were diagnosed after 2011, and who had documented cancer treatment. We identified the use of aggressive EOL systemic treatment (including, chemotherapy, immunotherapy, and combinations thereof) at both 30 days and 14 days prior to death. We estimated standardized EOL rates using mixed-level logistic regression models adjusting for patient and practice-level factors. Year-specific adjusted rates were estimated in annualized stratified analysis. Results: We included 57,127 patients, 38% of whom had documentation of having received any type of systemic cancer treatment within 30 days of death (SD: 5%; range: 25% - 56%), and 17% within 14 days of death (SD: 3%; range: 10% - 30%). Chemotherapy alone was the most common EOL treatment received (18% at 30 days, 8% at 14 days), followed by immunotherapy (± other treatment) (11% at 30 days, 4% at 14 days). Overall rates of EOL treatment did not change over the study period: treatment within 30 days (39% in 2015 to 37% in 2019) and within 14 days (17% in 2015 to 17% in 2019) of death. However, the rates of chemotherapy alone within 30 days of death decreased from 24% to 14%, and within 14 days, from 10% to 6% during the study period. In comparison, rates for immunotherapy with chemotherapy (0%-6% for 30 days, 0% -2% for 14 days), and immunotherapy alone or with other treatment types (4%-13% for 30 days, 1%-4% for 14 days) increased over time for both 30 and 14 days. Conclusions: End of life systemic cancer treatment rates have not substantively changed over time despite national efforts and expert guidance. While rates of traditional chemotherapy have decreased, rates of costly immunotherapy and targeted therapy have increased, which has been associated with higher total cost of care and overall healthcare utilization. Future work should examine the drivers of end-of-life care in the era of immune-oncology.

Background Improving oral anticancer agent (OAA) initiation and adherence is the important quality‐of‐care issues, particularly since one fourth of anticancer agents being developed will be administered orally. Our objective was to identify provider‐ and patient‐level characteristics associated with OAA initiation and adherence among individuals with metastatic renal cell carcinoma (mRCC). Methods We used state cancer registry data linked to multi‐payer claims data to identify patients with mRCC diagnosed in 2004–2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. We estimated risk ratios (RRs) and corresponding 95% confidence limits (CLs) using modified Poisson regression to evaluate factors associated with OAA initiation and adherence. Results Among the 207 (out of 687) patients who initiated an OAA following mRCC diagnosis and survived 90 days, median proportion of days covered was 0.91. Patients with a modal provider specializing in hematology/medical oncology were much more likely to initiate OAAs than those seen by other specialties. Additionally, patients with a female provider were more likely to initiate OAAs than those with a male provider. Compared to patients treated by providers practicing in both urban and rural areas, patients with providers practicing solely in urban areas were more likely to initiate OAAs, after controlling for patient‐level factors (RR = 1.37; 95% CL: 1.09–1.73). Medicare patients were less likely to be adherent than those with private insurance (RR = 0.61; 95% CL: 0.42–0.87). Conclusions Our results suggest that provider‐ and patient‐level factors influence OAA initiation in patients with mRCC but only insurance type was associated with adherence., While several patient‐level factors have been associated with oral anticancer agent (OAA) initiation and adherence for metastatic renal cell carcinoma (mRCC) and other cancers, few provider‐level factors have been examined, despite providers being a key component driving OAA access. We examined provider and patient characteristics associated with OAA initiation and adherence among individuals with mRCC. Our results suggest that provider‐ and patient‐level factors are associated with OAA initiation but only patient‐level factors are associated with adherence.

116 Background: It is important to understand how emerging new therapies, such as oral anti-cancer agents (OAAs), diffuse across and can improve outcomes within real-world populations, which include age groups and racial groups not well-represented in clinical trials, such as people older than age 65 and Black patients. Our objectives were to examine whether disparities in mortality persist among patients with metastatic renal cell carcinoma (mRCC) receiving OAAs and whether these disparities may be partially explained by patient’s clinical characteristics or provider-level factors. Methods: We used linked state cancer registry data and multi-payer claims data to identify patients with mRCC who were diagnosed in 2004 through 2015 and had initiated an OAA and survived ≥ 90 days after initiating. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. A patient’s modal provider was the provider most frequently on claims with a diagnosis code of RCC or metastatic cancer between 2 months prior to and 3 months following the index date. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox proportional hazard models to evaluate which patient demographics, patient clinical characteristics, and provider-level factors were associated with 2-year all-cause mortality. Results: The cohort included 207 patients with mRCC. In unadjusted analyses, public insurance (Medicaid or Medicare), de novo metastatic diagnosis, frailty, polypharmacy, and a visit to a skilled nursing facility were associated with increased all-cause mortality. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, Medicare-insured patients continued to have higher all-cause mortality compared to privately insured patients (HR: 2.35, 95% CL: 1.32-4.18). None of the provider-level covariates (i.e., specialization, experience, volume, or practice location) investigated were associated with all-cause mortality. Conclusions: Even when adjusting for age, frailty, and comorbidities, Medicare-insured patient had lower overall survival than privately-insured patients. Patient survival did not differ based on modal provider’s characteristics.

This cross-sectional study examines social connectedness among Medicare beneficiaries during the COVID-19 pandemic.

Hazard Ratios (95% CI) of Overall Mortality by Comparing Early-onset and Later-onset CRCAgeUnadjustedAdjusted for Stage OnlyFully Adjusted except StageFully Adjusted Despite significantly reduced colorectal cancer (CRC) incidence in Americans aged 50 and older since 2000, the incidence of CRC among those Citation Format: En Cheng, Holly N. Blackburn, Kimmie Ng, Donna Spiegelman, Melinda L. Irwin, Xiaomei Ma, Cary P. Gross, Fred K. Tabung, Edward L. Giovannucci, Pamela L. Kunz, Xavier Llor, Kevin Billingsley, Jeffrey A. Meyerhardt, Nita Ahuja, Charles S. Fuchs. Survival for patients with early-onset colorectal cancer - An overall survival analysis from the National Cancer Database, 2004-2015 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 898.

Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes.To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival.A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients' HRR quintile and survival.In total, 12,610 Medicare beneficiaries diagnosed with stage II-III breast cancer during 2005-2008 who underwent surgery.Outcome measures for our analysis were 3- and 5-year overall survival.Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients' 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results.For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer-related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.

Introduction Up to 40% of patients with breast cancer may not adhere to adjuvant endocrine therapy. Therapy-related adverse effects (AEs) are important contributors to nonadherence. We developed a bidirectional text-message application, BETA-Text, that simultaneously tracks adherence, records symptoms, and alerts the clinical team. Patients and Methods We piloted our intervention in 100 patients. The intervention consisted of text messages to which patients responded for 3 months: daily, evaluating adherence; weekly, evaluating medication-related AEs; and monthly, regarding barriers to adherence. Concerning responses prompted a telephone call from a clinic nurse. The primary objective was to assess patient acceptance of this intervention using self-reported surveys. To compare participants with the general population at our institution, we assessed 100 consecutively treated patients as historical controls using medical record review. Results We approached 141 consecutive patients, 100 (71%) of whom agreed to participate and 89 of whom completed the intervention. A majority of patients reported that the intervention was easy to use (98%) and helpful in taking their medication (96%). Four patients discontinued therapy before 3 months, and 93% of patients who continued therapy took ≥ 80% of their medication. The frequency of AEs reported by participants via text was higher than that reported in clinical trials: hot flashes (72%), arthralgias (53%), and vaginal symptoms (35%). Approximately 39% of patients reported one or more severe AE that prompted an alert to the provider team to call the patient. Conclusion A daily bidirectional text-messaging system can monitor adherence and identify AEs and other barriers to adherence in real time without inconveniencing patients. AEs of endocrine therapy, as detected using this texting approach, are more prevalent than reported in clinical trials.

e18175 Background: There is limited available information on the patterns of utilization and efficacy of alternative medicine (AM) for patients with cancer. The primary objective was to compare survival between patients with cancer receiving AM and conventional cancer treatment. The secondary objective was to determine cancer patient characteristics associated with selection of AM. Methods: Patients diagnosed with non-metastatic breast, prostate, lung, or colorectal cancer were identified between 2004-2013 using the National Cancer Database (NCDB). Alternative medicine use was defined as ‘Other-Unproven: Cancer treatments administered by nonmedical personnel’ administered as sole anti-cancer treatment among patients who did not receive chemotherapy, radiotherapy, surgery, and/or hormone therapy. Treatment selection was evaluated by the chi-square test, t-test, and logistic regression. Patients were 2:1 matched on age, clinical group stage, Charlson-Deyo comorbidity score, insurance type, race, year of diagnosis, and cancer type. Overall survival was analyzed using the Kaplan-Meier method, log-rank test, and Cox proportional hazards regression. Results: We identified 281 patients who chose AM in lieu of conventional cancer treatment. Approximately 44% of these patients had breast cancer, followed by prostate (25.5%), lung (18.4%) and colorectal cancer (12.1% of patients). Independent covariates associated with increased likelihood of AM use included breast or lung primary site (vs. prostate), higher socioeconomic status, Intermountain West or Pacific location (vs. Northeast), stages II or III (vs. I) and Charlson-Deyo comorbidity score of 0 (vs. 1). Alternative medicine was independently associated with greater risk of death compared to conventional cancer treatment overall (HR: 2.50, 95% confidence interval 1.88-3.27) and in subgroups of patients with breast, lung, and colorectal cancer. Conclusions: Alternative medicine utilization in patients with cancer is rare and varied by geographic, socioeconomic, and disease-related factors. Patients who chose alternative medicine for primary treatment of their curable cancer had greater risk of death compared to those who chose conventional cancer treatment.

Purpose: In postmenopausal women with breast cancer treated with aromatase inhibitors (AIs), most expert panels advise baseline bone mineral density testing with a dual-energy x-ray absorptiometry (DXA) scan repeated every 1 to 2 years. How often this recommendation is followed is unclear. Methods: We performed a retrospective analysis of women with stage I to III breast cancer who started AI therapy from January 1, 2008, to December 31, 2010, with follow-up through December 31, 2012, by using the SEER-Medicare database. Selection criteria included AI use for ≥ 6 months and no recent osteoporosis diagnosis or bisphosphonate use. We used multivariable logistic regression to investigate associations between patient characteristics and receipt of a baseline DXA scan. In patients who continued AI treatment, we assessed rates of follow-up scans. Results: In the sample of 2,409 patients (median age, 74 years), 51.0% received a baseline DXA scan. Demographic characteristics associated with the absence of a baseline DXA scan were older age (85 to 94 years v 67 to 69 years; odds ratio [OR], 0.62; 95% CI, 0.42 to 0.92) and black v white race (OR, 0.68; 95% CI, 0.47 to 0.97). Among patients who underwent a baseline DXA scan and continued AI for 3 years, 28.0% had a repeat DXA scan within 2 years and 65.9% within 3 years. In aggregate, of the 1,164 patients who continued with AI treatment for 3 years, only 34.5% had both a baseline and at least one DXA scan during the 3-year follow-up period. Conclusion: The majority of older Medicare beneficiaries with breast cancer treated with AIs do not undergo appropriate bone mineral density evaluation.

More than eight million children risk having their health insurance coverage disrupted if federal funding for the Children's Health Insurance Program (CHIP) is not extended beyond 2017. In this study we explored two current policy alternatives: extending federal funding for CHIP or enrolling children in the existing health insurance Marketplace plans. We simulated annual out-of-pocket expenses using detailed health plan data from CHIP and federally facilitated Marketplace plans for a nationally representative cohort of children with chronic conditions, conducting comparisons at four different percentage categories of the federal poverty level. If CHIP funding is not renewed and children with chronic conditions shift to coverage under Marketplace plans, their families face increased annual out-of-pocket expenses ranging from $233 at the lowest income levels to $2,472 at the highest income level of 251-400 percent of poverty. Families with children who have epilepsy, diabetes, or mood disorders may face the highest costs. Cost sharing for prescription drugs (25 percent) and hospitalizations (23 percent) account for much of the difference. Absent enhancements to Marketplace cost-sharing protections, and given recent efforts to repeal the Affordable Care Act, renewing funding for CHIP will provide the greatest financial protections to families of income-eligible children with chronic conditions.

Background: Racial disparities have been reported in breast cancer care, yet little is known about disparities in access to gene expression profiling (GEP) tests. Given the impact of GEP test results, such as those of Oncotype DX (ODx), on treatment decision-making for hormone receptor-positive (HR+) breast cancer, it is particularly important to assess disparities in its use. Methods: We conducted a retrospective population-based study of 8,784 patients diagnosed with breast cancer in Connecticut during 2011 through 2013. We assessed the association between race, ethnicity, and ODx receipt among women with HR+ breast cancer for whom NCCN does and does not recommend ODx testing, using bivariate and multivariate logistic analyses. Results: We identified 5,294 women who met study inclusion criteria: 83.8% were white, 6.3% black, and 7.4% Hispanic. Overall, 50.9% (n=4,131) of women in the guideline-recommended group received ODx testing compared with 18.5% (n=1,163) in the nonrecommended group. More white women received the ODx test compared with black and Hispanic women in the recommended and nonrecommended groups (51.4% vs 44.6% and 47.7%; and 21.2% vs 9.0% and 9.7%, respectively). After adjusting for tumor and clinical characteristics, we observed significantly lower ODx use among black (odds ratio [OR], 0.64; 95% CI, 0.47-0.88) and Hispanic women (OR, 0.59; 95% CI, 0.45-0.77) compared with white women in the recommended group and in the guideline-discordant group (blacks: OR, 0.39; 95% CI, 0.20-0.78, and Hispanics: OR, 0.44; 95% CI, 0.23-0.85). Conclusions: In this population-based study, we identified racial disparities in ODx testing. Disparities in access to innovative cancer care technologies may further exacerbate existing disparities in breast cancer outcomes.

Introduction Although needle biopsy (NB) is recommended prior to breast cancer surgery, the use of NB has been shown to vary according to patient socioeconomic status (SES), operating surgeon, and geographic region. We hypothesized that surgeons who work in the same peer referral network (defined by patient sharing) might have similar practice patterns with regard to NB, and that the magnitude of SES disparities might vary across networks. We therefore examined: 1) SES disparities in the receipt of NB, 2) variation in NB across networks, and 3) whether the association between SES and NB varied across networks. Methods We used the SEER database and 5% Medicare sample to examine all patients with a new diagnosis of breast cancer from 2004 through 2006. We used Medicare claims to construct peer groups of physicians based on patient-sharing ties. Patients were assigned to peer groups based on the surgeon who performed their definitive surgery. We defined a patient as having low SES if she was in the lowest quintile of area-level income. We used hierarchical generalized linear models (HGLM) to assess the association between low SES and receipt of NB, including random effects for the surgeon, peer group, and Hospital Referral Region (HRR). We then allowed the low SES effect to vary across peer groups in order to determine whether the association between SES and NB varied across groups. Results In the full sample of 14,552 patients, 9,498 (65%) received needle biopsy. In bivariable analysis, patients in the lowest income quintile were less likely to receive NB compared to all other patients (59% vs 67%, p Conclusions Patients with low SES are significantly less likely to receive NB prior to breast cancer surgery, and moreover the magnitude of this SES-related disparity varies significantly according to which referral networks are providing care. Future policies to increase NB rates and standardize care for all breast cancer patients may consider the implications of how care for patients with low SES varies across surgical provider networks.Introduction Although needle biopsy (NB) is recommended prior to breast cancer surgery, the use of NB has been shown to vary according to patient socioeconomic status (SES), operating surgeon, and geographic region. We hypothesized that surgeons who work in the same peer referral network (defined by patient sharing) might have similar practice patterns with regard to NB, and that the magnitude of SES disparities might vary across networks. We therefore examined: 1) SES disparities in the receipt of NB, 2) variation in NB across networks, and 3) whether the association between SES and NB varied across networks. Methods We used the SEER database and 5% Medicare sample to examine all patients with a new diagnosis of breast cancer from 2004 through 2006. We used Medicare claims to construct peer groups of physicians based on patient-sharing ties. Patients were assigned to peer groups based on the surgeon who performed their definitive surgery. We defined a patient as having low SES if she was in the lowest quintile of area-level income. We used hierarchical generalized linear models (HGLM) to assess the association between low SES and receipt of NB, including random effects for the surgeon, peer group, and Hospital Referral Region (HRR). We then allowed the low SES effect to vary across peer groups in order to determine whether the association between SES and NB varied across groups. Results In the full sample of 14,552 patients, 9,498 (65%) received needle biopsy. In bivariable analysis, patients in the lowest income quintile were less likely to receive NB compared to all other patients (59% vs 67%, p Conclusions Patients with low SES are significantly less likely to receive NB prior to breast cancer surgery, and moreover the magnitude of this SES-related disparity varies significantly according to which referral networks are providing care. Future policies to increase NB rates and standardize care for all breast cancer patients may consider the implications of how care for patients with low SES varies across surgical provider networks. Citation Format: Killelea BK, Herrin J, Soulos PR, Pollack CE, Forman HP, Yu J, Xu X, Tannenbaum S, Wang S, Gross CP. Socioeconomic disparities in needle biopsy prior to breast cancer surgery across physician referral networks [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-03.

Hospice use is expected to decrease end-of-life expenditures, yet evidence for its financial impact remains inconclusive. One potential explanation is that the use of hospice may produce differenti...

Purpose: To quantify the burden and complexity associated with treatment of Medicare beneficiaries with stage I non–small-cell lung cancer (NSCLC). Methods: Using the SEER-Medicare database, we conducted a retrospective cohort study of Medicare beneficiaries who were diagnosed with stage I NSCLC from 2007 to 2011 and who were treated with surgery, stereotactic body radiation therapy, or external beam radiation therapy. Main outcome measures were the number of days a patient was in contact with the health care system (encounter days), the number of physicians involved in a patient’s care, and the number of medications prescribed. Logistic regression modeled the association between patient characteristics, treatment type, and high treatment burden (defined as ≥ 66 encounter days). Results: On average, 7,955 patients spent 1 in 3 days interacting with the health care system during the initial 60 days of treatment. Patients experienced a median of 44 encounter days with high variability (interquartile range [IQR], 29 to 66) in the 12 months after treatment initiation. The median number of physicians involved was 20 (IQR, 14 to 28), and the median number of medications prescribed was 12 (IQR, 8 to 17). Patients who were treated with surgery had high treatment burden (predicted probability, 21.6%; 95% CI, 20.2 to 23.1) compared with patients who were treated with stereotactic body radiation therapy (predicted probability, 16.1%; 95% CI, 12.9 to 19.3), whereas patients who were treated with external beam radiation therapy had the highest burden (predicted probability, 46.8%; 95% CI, 43.3 to 50.2). Conclusion: The treatment burden imposed on patients with early-stage NSCLC was substantial in terms of the number of encounters, physicians involved, and medications prescribed. Because treatment burden varied markedly across patients and treatment types, future work should identify opportunities to understand and ameliorate this burden.

Chromosome 1 abnormalities (C1As) are common genetic aberrations among patients with multiple myeloma (MM). We aimed to evaluate the significance of C1As among a contemporary cohort of patients with MM in the United States. We used electronic health records from the Flatiron Health database to select patients newly diagnosed with MM from January 2011 to March 2018 who were tested using fluorescence in situ hybridization within 90 days of diagnosis. We characterized patients as having documented C1As or other high-risk chromosomal abnormalities (HRCAs) as defined by the Revised-International Staging System (R-ISS) such as del(17p), t(14;16), and t(4;14). We used Kaplan-Meier methods to compare overall survival (OS) of patients with or without C1As and stratified log-rank tests (with the presence of HRCAs as a stratifying variable). We used Cox proportional hazards regression models to compare OS, adjusting for age, sex, stage, HRCAs, and type of first-line therapy. Of 3578 eligible patients, 844 (24%) had documented C1As. Compared with patients without C1As, patients with C1As were more likely to have higher stage (R-ISS stage III; 18% vs 12%), to have HRCAs (27% vs 14%), and to receive combinations of proteasome inhibitors and immunomodulatory agents (41% vs 34%). Median OS was lower for patients with C1As (46.6 vs 70.1 months; log-rank P < .001). C1As were independently associated with worse OS (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-2.69; P < .001), as were older age, higher R-ISS stage, HRCAs, and immunoglobulin A isotype. C1As were associated with inferior OS, independent of other HRCAs, despite greater use of novel therapies. Clinical trials testing newer therapies for high-risk MM should incorporate patients with C1As.

PURPOSE Despite concerns that power morcellation may adversely affect prognosis of patients with occult uterine cancer, empirical evidence has been limited and inconclusive. In this study, we aimed to determine whether uncontained power morcellation at the time of hysterectomy or myomectomy is associated with increased mortality risk in women with occult uterine cancer. METHODS By linking statewide hospital discharge records with cancer registry data in New York, we identified 843 women with occult endometrial carcinoma and 334 women with occult uterine sarcoma who underwent a hysterectomy or myomectomy for presumed benign indications during the period October 1, 2003, through December 31, 2013. Within this cohort, we compared disease-specific and all-cause mortality of women who underwent laparoscopic supracervical hysterectomy/laparoscopic myomectomy (LSH/LM), a surrogate indicator for uncontained power morcellation, with women who underwent supracervical abdominal hysterectomy and total abdominal hysterectomy (TAH), which did not involve power morcellation. Multivariable Cox regressions and propensity score method were used to adjust for patient characteristics. RESULTS Among women with occult uterine sarcoma, LSH/LM was associated with a higher risk for disease-specific mortality than TAH (adjusted hazard ratio [aHR], 2.66, 95% CI, 1.11 to 6.37; adjusted difference in 5-year disease-specific survival, −19.4%, 95% CI, −35.8% to −3.1%). In the subset of women with leiomyosarcoma, LSH/LM was associated with an increased risk for disease-specific mortality compared with supracervical abdominal hysterectomy (aHR, 3.64, 95% CI, 1.50 to 8.86; adjusted difference in 5-year disease-specific survival, −31.2%, 95% CI, −50.0% to −12.3%) and TAH (aHR, 4.66, 95% CI, 1.97 to 11.00; adjusted difference in 5-year disease-specific survival, −37.3%, 95% CI, −54.2% to −20.3%). Among women with occult endometrial carcinoma, there was no significant association between surgical approach and disease-specific mortality. CONCLUSION Uncontained power morcellation was associated with higher mortality risk in women with occult uterine sarcoma, especially in those with occult leiomyosarcoma.

OBJECTIVE To examine changes in utilization of different types of laparoscopic hysterectomy, as well as their associated resource use and surgical outcomes, after the U.S. Food and Drug Administration (FDA) safety statement in April 2014 regarding power morcellation. METHODS We retrospectively analyzed data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement Program and identified 145,746 women undergoing hysterectomy for benign indications. We measured use of laparoscopic supracervical hysterectomy compared to total laparoscopic hysterectomy (including laparoscopic-assisted vaginal hysterectomy) in these patients, as well as operative time, surgical setting (inpatient vs outpatient), length of stay, and 30-day surgical outcomes (wound complication, medical complication, reoperation, and readmission). We used an interrupted time series analysis to examine the association between FDA warning and changes in utilization and outcomes of laparoscopic hysterectomy. RESULTS After adjusting for patient characteristics and background trends in practice, use of laparoscopic supracervical hysterectomy was significantly lower in the postwarning than prewarning period (odds ratio [OR]=0.49, 95% CI 0.45-0.53), whereas use of total laparoscopic hysterectomy was not affected (OR 1.01, 95% CI 0.96-1.06). Overall, after an initial reduction, use of laparoscopic hysterectomy (laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy combined) increased over time in the postwarning period (adjusted OR of utilization for each calendar quarter elapsed=1.03, 95% CI 1.02-1.03). After the FDA warning, operative time for laparoscopic supracervical hysterectomy increased by 11.45 minutes (95% CI 6.22-16.69), whereas the decreasing trend in the likelihood of inpatient stay for total laparoscopic hysterectomy was attenuated (OR for each calendar quarter elapsed=0.92 in prewarning period, 95% CI 0.91-0.93; and 0.97 in postwarning period, 95% CI 0.97-0.98). There was no significant change in 30-day surgical outcomes after the FDA warning. CONCLUSION Rates of laparoscopic supracervical hysterectomy fell in association with power morcellation safety warnings, whereas rates of other laparoscopic hysterectomies continued to rise. There was no change in patient outcomes among laparoscopic hysterectomies.

Background Nutritional status can directly affect morbidity and mortality in older adults with cancer. This study evaluated the association between pretreatment body mass index (BMI), albumin level, and unintentional weight loss (UWL) in the prior 6 months and chemotherapy toxicity among older adults with solid tumors. Methods This was a secondary analysis of a prospective, multicenter study involving chemotherapy-treated patients 65 years old or older. Geriatric assessment, BMI, albumin level, and UWL data were collected before treatment. Multivariable logistic regression models evaluated the associations between nutritional factors and the risk of grade 3 or higher (grade 3+) chemotherapy toxicity. Results Seven hundred fifty patients with a median age of 72 years (range, 65-94 years) and mostly stage IV disease were enrolled. The median pretreatment BMI and albumin values were 26 kg/m2 (range, 15.1-52.1 kg/m2 ) and 3.9 mg/dL (range, 1.0-5.0 mg/dL), respectively. Nearly 50% of the patients reported UWL, with 17.6% reporting >10% UWL. Multivariable analysis revealed no association between >10% UWL and a risk for grade 3+ chemotherapy toxicity (adjusted odds ratio [AOR], 0.87; P = .58). Multivariable analysis showed a trend toward an association between a BMI ≥ 30 kg/m2 and a decreased risk of grade 3+ chemotherapy toxicity (AOR, 0.65; P = .06), whereas a low albumin level (≤3.6 mg/dL) was associated with a higher risk of grade 3+ chemotherapy toxicity (AOR, 1.50; P = .03). An analysis of the joint effect of BMI and albumin demonstrated the lowest risk of grade 3+ chemotherapy toxicity among patients with high BMIs (≥30 kg/m2 ) and normal albumin levels (AOR, 0.41; P = .008). Conclusions Among older adults with solid tumors, higher BMIs and normal albumin levels are associated with a lower risk of grade 3+ chemotherapy toxicity. Additional research is warranted to define the clinical significance of nutritional markers and to inform future interventions.

This study uses administrative claims from an insurance database to examine adoption of digital breast tomosynthesis for cancer screening and describe regional patterns and sociodemographic characteristics associated with its use.

To evaluate if real-world utilization of neoadjuvant endocrine therapy (NET) is associated with similar rates of response and breast conservation surgery (BCS) compared to neoadjuvant chemotherapy (NAC). Our population-based assessment used the National Cancer Data Base to identify women diagnosed with stage II–III, hormone receptor (HR)-positive BC who underwent surgery and received endocrine therapy from 2004 to 2014. Women were categorized by receipt of NET, NAC or no neoadjuvant therapy. We used logistic regression to assess differences in outcomes between therapies using inverse propensity score weighting to adjust for potential selection bias. In our sample of 211,986 women, 6584 received NET, 52,310 received NAC, and 153,092 did not receive any neoadjuvant therapy. After adjusting for multiple relevant covariates and cofounders, there was no significant difference between NET and NAC with regard to BCS [odds ratio (OR) 0.91; 95% confidence interval (CI) (0.82–1.01)]; however, women who received NET were significantly less likely to achieve pCR [OR 0.34; 95% CI (0.23–0.51)] or a decrease in T stage [OR 0.39; CI (0.34–0.44)] compared to women treated with NAC. Patients who received NET for ≥ 3 months had higher odds of BCS (OR 1.59; 95% CI 1.46–1.73) and downstaging (OR 1.79; 95% CI 1.63–1.97) compared to patients who did not receive neoadjuvant therapy. Women who received NET had similar rates of BCS compared to women who received NAC. Those who received NET for longer treatment durations had increased odds of BCS and downstaging compared to women who did not receive neoadjuvant therapy.

Physician ownership of imaging equipment has been shown to be associated with greater use of low-value imaging. However, it is unclear whether ownership also influences utilization of appropriate imaging. We conducted a cohort study of older adults diagnosed with three non-Hodgkin lymphomas with distinct guideline recommendations concerning the use of positron emission tomography (PET) during staging (recommended, not recommended, or equivocal). We found patients who were treated by oncologists with PET ownership were more likely to receive a staging PET regardless of lymphoma subtype. However, the difference in utilization by ownership status was smallest (6%, 95% confidence interval = 2% to 11%, P = .01) in the setting of diffuse large B cell lymphoma, where consensus guidelines recommend routine use of PET. Overall, removing financial incentives related to imaging self-referral may reduce utilization during cancer care, with the potential for greatest impact on imaging of equivocal or low clinical utility.

Objectives. To evaluate the association of state dense breast notification (DBN) laws with use of supplemental tests and cancer diagnosis after screening mammography. Methods. We examined screening mammograms (n = 1 441 544) performed in 2014 and 2015 among privately insured women aged 40 to 59 years living in 9 US states that enacted DBN laws in 2014 to 2015 and 25 US states with no DBN law in effect. DBN status at screening mammography was categorized as no DBN, generic DBN, and DBN that mandates notification of possible benefits of supplemental screening (DBN+SS). We used logistic regression to examine the change in rate of supplemental ultrasound, magnetic resonance imaging, breast biopsy, and breast cancer detection. Results. DBN+SS laws were associated with 10.5 more ultrasounds per 1000 mammograms (95% CI = 3.0, 17.6 per 1000; P = .006) and 0.37 more breast cancers detected per 1000 mammograms (95% CI = 0.05, 0.69 per 1000; P = .02) compared with no DBN law. No significant differences were found for generic DBN laws in either ultrasound or cancer detection. Conclusions. DBN legislation is associated with increased use of ultrasound and cancer detection after implementation only when notification of the possible benefits of supplemental screening is required.

Importance Systemic therapy and radiotherapy can be associated with acute complications that may require emergent care. However, there are limited data characterizing complications and the financial burden of cancer therapy that are treated in emergency departments (EDs) in the United States. Objectives To estimate the incidence of treatment-related complications of systemic therapy or radiotherapy, examine factors associated with inpatient admission, and investigate the overall financial burden. Design, Setting, and Participants A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was performed. Between January 2006 and December 2015, there was a weighted total of 1.3 billion ED visits; of these, 1.5 million were related to a complication of systemic therapy or radiotherapy for cancer. Data analysis was conducted from February 22 to December 23, 2018. External cause of injury codes, Clinical Classifications Software,International Classification of Diseases, Ninth Revision, Clinical Modification, andInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), Clinical Modificationcodes were used to identify patients with complications of systemic therapy or radiotherapy. Main Outcomes and Measures Patterns in treatment-related complications, patient- and hospital-related factors associated with inpatient admission, and median and total charges for treatment-related complications were the main outcomes. Results Of the 1.5 million ED visits included in the analysis, 53.2% of patients were female and mean age was 63.3 years. Treatment-related ED visits increased by a rate of 10.8% per year compared with 2.0% for overall ED visits. Among ED visits, 90.9% resulted in inpatient admission to the hospital and 4.9% resulted in death during hospitalization. Neutropenia (136 167 [8.9%]), sepsis (128 171 [8.4%]), and anemia (117 557 [7.7%]) were both the most common and costliest (neutropenia: $5.52 billion; sepsis: $11.21 billion; and anemia: $6.78 billion) complications diagnosed on presentation to EDs; sepsis (odds ratio [OR], 21.00; 95% CI, 14.61-30.20), pneumonia (OR, 9.73; 95% CI, 8.08-11.73), and acute kidney injury (OR, 9.60; 95% CI, 7.77-11.85) were associated with inpatient admission. Costs related to the top 10 most common complications totaled $38 billion and comprised 48% of the total financial burden of the study cohort. Conclusions and Relevance Emergency department visits for complications of systemic therapy or radiotherapy increased at a 5.5-fold higher rate over 10 years compared with overall ED visits. Neutropenia, sepsis, and anemia appear to be the most common complications; sepsis, pneumonia, and acute kidney injury appear to be associated with the highest rates of inpatient admission. These complications suggest that significant charges are incurred on ED visits.

Background With improving survival for patients with multiple myeloma (MM), supportive care that is focused on optimizing quality of life and minimizing treatment-related toxicities is increasingly important. The extent to which patients with MM are receiving recommended supportive care is unknown. Methods This study used the Surveillance, Epidemiology, and End Results-Medicare database to identify older adults (age ≥66 years) diagnosed with MM in 2008-2013 who had received active treatment and survived 1 year or longer after their diagnosis. Outcomes of interest included guideline-recommended supportive care, which was defined as 1) bone-modifying drugs (BMDs) within the 12 months after the diagnosis, 2) influenza vaccination in the first season after the diagnosis, and 3) concomitant use of prophylactic antivirals with proteasome inhibitors. Multivariable logistic regression models were used to evaluate associations between patient/facility-level characteristics and supportive care use. Results Among 1996 patients receiving MM-directed therapy, 64%, 52%, and 49% received BMDs, an influenza vaccination, and antiviral prophylaxis, respectively. Non-Hispanic black patients (odds ratio [OR] vs white patients, 0.63; 95% confidence interval [CI], 0.46-0.88) and patients with baseline renal impairment (OR, 0.43; 95% CI, 0.34-0.54) had lower odds of BMDs. Non-Hispanic blacks (OR, 0.52; 95% CI, 0.37-0.73) and those with dual Medicaid enrollment (OR, 0.76; 95% CI, 0.58-0.99) had lower odds of influenza vaccination. Treatment in a community-based setting was associated with reduced odds of antiviral prophylaxis (OR, 0.58; 95% CI, 0.46-0.72). Conclusions Substantial underutilization of guideline-recommended supportive care was observed among older adults with MM in the United States, and this was associated with both patient and facility characteristics. Targeted interventions are needed to improve supportive care for patients with MM.

INTRODUCTION AND OBJECTIVES:Young adults are historically the least likely to have health insurance in the United States. We aimed to investigate whether implementation of key provisions of the Aff...

Background Social media is an increasingly popular means to disseminate medical research. However, it is unknown whether the extent to which content is shared mirrors conventional measures of scientific merit or impact. Objective To examine whether Twitter activity (as measured by the number of “likes” and “retweets” [RTs]) relating to original research presented at a national urology meeting was associated with subsequent publication status and journal impact factor (IF). Design, setting, and participants We retrospectively reviewed Twitter data obtained through the Keyhole archiving platform using the hashtag “#aua15” from May 1 through June 1, 2015 reflecting the hashtag of the American Urological Association (AUA) meeting. Outcome measurements and statistical analysis We analyzed all posts containing keywords related to research studies. Among posts reporting on newly presented studies with discernable attribution, we evaluated subsequent publication status within 45 mo, including journal IF. We compared social media reception (number of likes/RTs) by publication status, and assessed the relationship between social media reception and subsequent journal IF using Pearson’s correlation. Results and limitations A total of 15 303 posts were associated with #aua15 between May 1 and June 1, 2015, which reached 2 263 438 users. The median number of likes/RTs was 2 (interquartile range 1–3). We analyzed all posts receiving at least one like/RT (n = 2964) for text content related to research and identified 496 associated with new scientific studies presented at the meeting. Forty-five months following the AUA meeting, 96 studies were identifiable on PubMed (19.4%). Research with more likes/RTs at the AUA meeting were more likely to be subsequently published (p = 0.001). Among published studies, there was a modest, positive correlation between the number of likes/RTs and publication journal IF (r2 = 0.36). Conclusions Measures of social media engagement with data presented at a national medical meeting were positively correlated with subsequent publication and journal IF after presentation. Patient summary New urological research that was shared more often at a national meeting was more likely to be published in journals that are more highly cited.

There is a lack of consensus to guide which breast cancer patients require left ventricular function assessment (LVEF) prior to anthracycline therapy; the cost-effectiveness of screening this patient population has not been previously evaluated. We performed a retrospective analysis of the Yale Nuclear Cardiology Database, including 702 patients with baseline equilibrium radionuclide angiography (ERNA) scan prior to anthracycline and/or trastuzumab therapy. We sought to examine associations between abnormal baseline LVEF and potential cardiac risk factors. Additionally, we designed a Markov model to determine the incremental cost-effectiveness ratio (ICER) of ERNA screening for women aged 55 with stage I–III breast cancer from a payer perspective over a lifetime horizon. An abnormal LVEF was observed in 2% (n = 14) of patients. There were no significant associations on multivariate analysis performed on self-reported risk factors. Our analysis showed LVEF screening is cost-effective with ICER of $45,473 per QALY gained. For a willingness-to-pay threshold of $100,000/ QALY, LVEF screening had an 81.9% probability of being cost-effective. Under the same threshold, screening was cost-effective for non-anthracycline cardiotoxicity risk of RR ≤ 0.58, as compared to anthracycline regimens. Age, preexisting cardiac risk factors and coronary artery disease did not predict a baseline abnormal LVEF. While the prevalence of an abnormal baseline LVEF is low in patients with breast cancer, our results suggest that cardiac screening prior to anthracycline is cost-effective.

While increased adherence to colorectal cancer (CRC) screening guidelines in the US has been associated with significant reductions in cancer incidence in US individuals aged 50 years and older, the incidence of CRC among those aged younger than 50 years has been steadily increasing. Understanding the survival among individuals with early-onset CRC compared with those aged 50 years and older is fundamental to informing treatment approaches and understanding the unique biological distinctiveness within early-onset CRC.To characterize the overall survival for individuals with early-onset CRC.This cohort study used data from the National Cancer Database. Included individuals were ages 0 to 90 years and diagnosed with primary CRC from January 1, 2004, through December 31, 2015. Individuals diagnosed at ages 51 through 55 years were selected as the reference group and defined as later-onset CRC for this study. Individuals diagnosed at age 50 years were excluded to minimize an apparent screening detection bias at that age in our population, given that these individuals disproportionately presented with earlier stage. All statistical analyses were conducted from January 4, 2020, through December 26, 2020.Early-onset CRC was defined as age younger than 50 years at diagnosis.Overall survival was assessed by Kaplan-Meier analysis and Cox proportional hazards regression.Among 769 871 individuals with CRC (377 890 [49.1%] women; 636 791 White individuals [82.7%]), 353 989 individuals (46.0%) died (median [range] follow-up: 2.9 [0-14.0] years), 102 168 individuals (13.3%) had early-onset CRC, and 78 812 individuals (10.2%) had later-onset CRC. Individuals with early-onset CRC, compared with those diagnosed with CRC at ages 51 through 55 years, had a lower 10-year survival rate (53.6% [95% CI, 53.2%-54.0%] vs 54.3% [95% CI, 53.8%-54.8%]; P .001) in unadjusted analysis. However, after adjustment for other factors associated with mortality, most notably stage, individuals with early-onset CRC had a lower risk of death compared with individuals diagnosed from ages 51 through 55 years (adjusted hazard ratio [HR], 0.95 [95% CI, 0.93-0.96]; P .001). In the model adjusted for stage, the HR for individuals with early-onset CRC was 0.89 (95% CI, 0.88-0.90; P .001). The survival advantage was greatest for individuals diagnosed at ages 35 through 39 years (adjusted HR, 0.88 [95% CI, 0.84-0.92]; P .001) and stages I (adjusted HR, 0.87 [95% CI, 0.81-0.93]; P .001) and II (adjusted HR, 0.86 [95% CI, 0.82-0.90]; P .001) and was absent among those diagnosed at ages 25 years or younger and stages III through IV.These findings suggest that there is a survival benefit for individuals with early-onset CRC compared with those diagnosed with CRC at later ages. Further study is needed to understand the underlying heterogeneity of survival among individuals with early-onset CRC by age and stage.