Tevaarwerk, Amyé

Electronic patient‐reported outcome (ePRO) programs may offer advantages for patients with cancer, clinicians, health care systems, payors, and society in general; but developing and maintaining an ePRO program will require cancer centers to navigate defining meaningful problems, collecting ePROs, implementing action when those ePROs require intervention without over‐burdening clinicians, and monitoring the successes and failures of their ePRO programs. Physician informaticists from the National Comprehensive Cancer Network Electronic Health Record Advisory Group offer 10 guiding principles to consider when contemplating, building, or refining an ePRO program for patients with cancer.

Abstract Background: Two poly (adenosine diphosphate-ribose) polymerase inhibitors (PARPi) are currently FDA-approved for the treatment of HER2-negative metastatic breast cancer (MBC) in carriers of germline pathogenic variants (PVs) in BRCA1 or BRCA2 (BRCA1/2). This study explores the clinical outcomes of MBC patients treated with a PARPi. Methods: In this retrospective study, we included MBC patients treated with a PARPi between January 2017 and February 2022 at Mayo Clinic (Minnesota, Arizona, Florida, and Mayo Clinic Health Systems). We used the Kaplan Meier method to estimate the time-to-treatment-failure (TTF) and the log-rank test to compare different subsets. In addition, predictors of TTF were identified in a multivariate cox-proportional hazard regression model, including age at PARPi initiation, race, ethnicity, histology, estrogen receptor (ER), progesterone receptor (PR), and HER2 expression of the tumor, the number of prior therapies, type of PARPi, and PV carrier status (germline BRCA1/2 or PALB2 vs. somatic BRCA1/2 vs. other). Results: Sixty-five patients treated with PARPi (olaparib: 51; talazoparib: 14) were included in the final analysis. Fifty-five patients were carriers of germline PVs in BRCA1 (n=24, 37%), BRCA2 (n=27, 42%) or PALB2 (n=4, 6%), whereas ten patients (15%) had no germline PVs but the tumor had a somatic mutation in the homologous recombination-related (HRR) genes (7 in BRCA1/2, 2 in ATM, and 1 in CDKN2A and CDH1). At the data cutoff, 48 (74%) patients had discontinued PARPi due to progression or death. Fifteen (23%) patients required a dose reduction due to side effects. Occurrence of grade ≥ 3 side effects: anemia in 8, fatigue in 4, neutropenia in 2, and thrombocytopenia in 2 patients. Eight (15.7%) patients in the olaparib group and seven (50%) patients in the talazoparib group required a dose reduction for side effects. No patient on olaparib required drug discontinuation due to side effects, whereas two patients on talazoparib were switched to olaparib due to cytopenias and could tolerate olaparib. Median TTF in the overall population was 8 months (95% confidence interval [CI]: 6.4 – 9.6), and there was no difference (p=0.64) in TTF between the olaparib and talazoparib groups. Median TTF in the germline BRCA1, BRCA2, and PALB2 PV carriers were 7, 8, and 11 months, respectively (p=0.57). Among patients with somatic BRCA1/2 mutations, the median TTF was 4 months. Numerically, patients with HER2-positive tumors (n=8) had a shorter TTF compared to HER2-negative tumors (Median TTF: 4 vs. 8 months, p=0.098). No significant difference in TTF was observed by ER or PR status of the tumor, age at initiation of PARPi, the number of prior therapies, and prior use of platinum-based chemotherapy or CDK4/6 inhibitors. In multivariate analysis, HER2 positivity (hazard ratio [HR]: 8.0, 95% CI: 2.2 – 29.4, p=0.002), somatic BRCA1/2 mutations (HR: 7.6, 95% CI: 1.2 – 50.0, p=0.03) and somatic mutations in other HRR genes (HR: 19.1, 95% CI: 3.1 – 118.6, p=0.002) were associated with worse TTF. Conclusions: In the real world, PARPi were well-tolerated with promising time-to-treatment-failure (TTF) benefits comparable to data from clinical trials. Notably, relatively shorter TTF was observed in patients with somatic BRCA1/2 and other HRR gene mutations and HER2-positive MBC. These findings improve our understanding of the role of PARPi in MBC and will help to guide treatment decisions with PARPi in the clinical setting. Citation Format: Nusrat Jahan, Jodi Taraba, Karthik V. Giridhar, Roberto A. Leon-Ferre, Amye J. Tevaarwerk, Elizabeth Cathcart-Rake, Ciara C. O’Sullivan, Prema Peethambaram, Timothy J. Hobday, Kathryn Ruddy, Lida A. Mina, Pooja Advani, Felipe Batalini, Matthew P. Goetz, Tufia C. Haddad, Fergus J. Couch, Siddhartha Yadav. Clinical outcomes of metastatic breast cancer patients treated with poly (adenosine diphosphate-ribose) polymerase inhibitors (PARPi): the Mayo Clinic experience [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-01-22.

Abstract Background The COVID-19 (coronavirus disease 2019) pandemic rapidly expanded telemedicine scale and scope. As telemedicine becomes routine, understanding how specialty and diagnosis combine with demographics to impact telemedicine use will aid in addressing its current limitations. Objectives To analyze the relationship between medical specialty, diagnosis, and telemedicine use, and their interplay with patient demographics in determining telemedicine usage patterns. Methods We extracted encounter and patient data of all adults who scheduled outpatient visits from June 1, 2020 to June 30, 2021 from the electronic health record of an integrated academic health system encompassing a broad range of subspecialties. Extracted variables included medical specialty, primary visit diagnosis, visit modality (video, audio, or in-person), and patient age, sex, self-reported race/ethnicity and 2013 rural–urban continuum code. Six specialties (General Surgery, Family Medicine, Gastroenterology, Oncology, General Internal Medicine, and Psychiatry) ranging from the lowest to the highest quartile of telemedicine use (video and audio) were chosen for analysis. Relative proportions of video, audio, and in-person modalities were compared. We examined diagnoses associated with the most and least frequent telemedicine use within each specialty. Finally, we analyzed associations between patient characteristics and telemedicine modality (video vs. audio/in-person, and video/audio vs. in-person) using a mixed-effects logistic regression model. Results A total of 2,494,296 encounters occurred during the study period, representing 420,876 unique patients (mean age: 44 years, standard deviation: 24 years, 54% female). Medical diagnoses requiring physical examination or minor procedures were more likely to be conducted in-person. Rural patients were more likely than urban patients to use video telemedicine in General Surgery and Gastroenterology and less likely to use video for all other specialties. Within most specialties, male patients and patients of nonwhite race were overall less likely to use video modality and video/audio telemedicine. In Psychiatry, members of several demographic groups used video telemedicine more commonly than expected, while in other specialties, members of these groups tended to use less telemedicine overall. Conclusion Medical diagnoses requiring physical examination or minor procedures are more likely to be conducted in-person. Patient characteristics (age, sex, rural vs. urban, race/ethnicity) affect video and video/audio telemedicine use differently depending on medical specialty. These factors contribute to a unique clinical scenario which impacts perceived usefulness and accessibility of telemedicine to providers and patients, and are likely to impact rates of telemedicine adoption.

PURPOSE We sought to evaluate the patterns of portal usage among patients with cancer who regularly log in to the portal. These data will inform approaches to facilitate portal use among patients with cancer. PATIENTS AND METHODS We conducted a retrospective analysis of patient portal usage by patients with cancer at the University of Wisconsin Carbone Cancer Center. Our analysis focuses on patterns of portal use by regular users (≥ 2 portal logins/year, > 3 months) receiving ongoing oncology care between January 1, 2017, and December 31, 2019. Demographics, cancer characteristics, number of oncology visits per month, and portal usage data were extracted. Regular portal users were grouped and compared on the basis of their frequency of use. A linear mixed-effects model was used to determine if the frequency of oncology visits influenced the number of logins. RESULTS We identified 2076 regular portal users. The median number of portal logins/year was 72 for the entire cohort. Age and race were associated with frequency of portal logins. There was no difference in frequency of portal login on the basis of cancer type or stage. Each additional oncology office visit in a month increased the frequency of portal logins by 3.05 ± 0.11 (SE) within the same month. Messages and test result functionalities were used by 98.7% and 98.9% of the regular users, respectively. Regular users who logged in to portal more frequently used all five studied portal functionalities. CONCLUSION Patients with cancer who use portals regularly use it more in proximity to an oncology office visit and use multiple available portal functionalities. These findings can direct strategic planning to facilitate portal utilization among those not engaged with this tool.

The NCCN Guidelines for Survivorship are intended to help healthcare professionals who work with survivors to ensure that the survivors’ complex and varied needs are addressed. The NCCN Guidelines provide screening, evaluation, and treatment recommendations for the consequences of adult-onset cancer and its treatment; recommendations to help promote physical activity, weight management, and immunizations in survivors; and a framework for care coordination. This article summarizes updates to the NCCN Guidelines pertaining to preventive health for cancer survivors, including recommendations about alcohol consumption and vaccinations.

46 Background: Tumor boards (TBs) are considered a key component for ensuring high quality cancer care. However, little is known about TB operational aspects that impact effectiveness. We aimed to understand how TBs leverage Electronic Health Record (EHR) functionalities and how pandemic-driven transitions from in-person TBs to virtual TBs impacted TB quality and effectiveness. Methods: The National Comprehensive Cancer Network (NCCN) Oncology EHR Advisory Group formed a Workgroup to assess the current state of TBs, obtain providers’ views on ideal TB state, and develop recommendations for improving TB quality and effectiveness. The Workgroup surveyed providers in various specialties at 31 NCCN Member Institutions in March 2022. Results: 846 providers from 27 institutions responded to the survey (n = 76 respondents were excluded from analysis because they reported not participating in TBs). Almost all (n = 764/767, 99%) indicated that one or more participants always or frequently attended TB meetings virtually. When comparing (newly established) virtual to (pre-pandemic) in-person TBs, 69% indicated increased attendance at virtual TBs. 65% reported no change in case volume, and 56% reported unchanged discussion quality while 19% reported increased discussion quality when comparing virtual to in-person TB meetings. In regards to EHR integration, several gaps between current and ideal state were noted. For instance, 40% always or frequently added patients to the TB roster via the EHR, but 57% reported this functionality to be very important or important for TBs. Additionally, 53% always or frequently document TB recommendations within the EHR, while 87% indicated EHR documentation of recommendations as very important or important. Respondents reported that barriers to documentation include resource constraints, concerns with patient access to documentation, legal and liability concerns, and poor EHR functionality. Conclusions: Overall, the majority of responding providers reported virtual TBs to be at least similar in quality to in-person TB meetings. A major gap identified by this study is the lack of documentation of TB recommendations in the EHR. Workflows and EHR functionalities could be improved to fully optimize the EHR for TB management and documentation.[Table: see text]

Purpose: Anthracyclines can cause long-term cardiovascular (CV) morbidity, especially in long-term Adolescent and Young Adult (AYA) lymphoma survivors. Pre-treatment left ventricular ejection fraction (LVEF) evaluation is recommended, although its utility in AYA is not established. We sought to determine the pre-treatment LVEF assessment practices in AYA lymphoma survivors treated with anthracyclines and factors associated with long-term cardiotoxicity. Methods: Through an electronic health records review, we retrospectively identified AYA lymphoma survivors with ≥5 years of follow-up postanthracycline treatment. Pre-treatment and follow-up data were abstracted. CV health conditions were defined as risk factors for CV disease and confirmed CV diagnoses. Survivors who had new CV health conditions at follow-up were compared to those who were not using descriptive statistics and logistic regression. Results: One hundred fifteen AYA lymphoma survivors met the study criteria. Pre-treatment LVEF assessment did not affect chemotherapy decisions. Survivors with pre-treatment CV evaluation had mean follow-up since diagnosis of 8 ± 3.3 years, while survivors without it had 10.3 ± 4.2 years, p < 0.05. Survivors with pre-treatment LVEF assessment received lower cumulative anthracycline dose (240.4 mg/m 2 vs. 280.1 mg/m 2 , p < 0.05) and fewer cycles of chemotherapy (4.8 ± 1.5 vs. 5.6 ± 1.2, p < 0.05). Body mass index (BMI) category at diagnosis and follow-up, in addition to age were associated with development of new CV health conditions, pre-treatment LVEF evaluation was not. Conclusion: Pre-treatment LVEF assessment for AYA lymphoma survivors does not impact oncologic treatment decisions or development of CV health conditions. It may be more valuable to assess and modify CV risk factors such as BMI for CV disease prevention.

PURPOSE Structured data elements within electronic health records are health-related information that can be entered, stored, and extracted in an organized manner at later time points. Tracking outcomes for cancer survivors is also enabled by structured data. We sought to increase structured data capture within oncology practices at multiple sites sharing the same electronic health records. METHODS Applying engineering approaches and the Plan-Do-Study-Act cycle, we launched dual quality improvement initiatives to ensure that a malignant diagnosis and stage were captured as structured data. Intervention: Close Visit Validation (CVV) requires providers to satisfy certain criteria before closing ambulatory encounters. CVV may be used to track open clinical encounters and chart delinquencies to encourage optimal clinical workflows. We added two cancer-specific required criteria at the time of closing encounters in oncology clinics: (1) the presence of at least one malignant diagnosis on the Problem List and (2) staging all the malignant diagnoses on the Problem List when appropriate. RESULTS Six months before the CVV implementation, the percentage of encounters with a malignant diagnosis on the Problem List at the time of the encounter was 65%, whereas the percentage of encounters with a staged diagnosis was 32%. Three months after cancer-specific CVV implementation, the percentages were 85% and 75%, respectively. Rates had increased to 90% and 88% more than 2 years after implementation. CONCLUSION Oncologist performance improved after the implementation of cancer-specific CVV criteria, with persistently high percentages of relevant malignant diagnoses and cancer stage structured data capture 2 years after the intervention.

Sella and colleagues provide insight into the mechanisms potentially underlying weight changes for young survivors after a breast cancer diagnosis. However, policy and regulatory changes that target modifiable determinants of health with practical, sustainable interventions are needed to translate this information into meaningful action.

The NCCN Guidelines for Survivorship are intended to help healthcare professionals working with cancer survivors to ensure that each survivor’s complex and varied needs are addressed. The Guidelines provide screening, evaluation, and treatment recommendations for consequences of adult-onset cancer and its treatment; recommendations to help promote healthful lifestyle behaviors, weight management, and immunizations in survivors; and a framework for care coordination. This article summarizes the recommendations regarding employment and return to work for cancer survivors that were added in the 2021 version of the NCCN Guidelines.