Tilburt, Jon C.

6126 Background: Little is known about the actual constraints of doing so in the distinctive geographic context of Alaska. We performed a survey of primary care providers (PCPs) within the Alaska Tribal Health System (ATHS) to learn more about their attitudes and practices surrounding prostate cancer (PC) survivorship care. Methods: We surveyed primary care physicians, nurse practitioners, and physician assistants practicing in the ATHS. We administered surveys to assess attitudes about PSA monitoring, responsibility for long-term surveillance, supporting emotional health and medical needs, their degree of confidence in managing patients on androgen deprivation therapy (ADT), as well as their comfort level in managing common side effects of treatment. Results: Of the 221 providers surveyed, 114 responded (52%). Most PCPs indicated a preference for annual PSA monitoring (69%), but several (27%) indicated monitoring every 6 months, and a few (4%) indicated monitoring every 24 months. Most (60%) thought PCPs should manage cancer surveillance, but many (40%) thought a specialist (urologist or medical oncologist) should perform that function. When asked about supporting patients’ emotional needs, PCPs indicated that support groups (63%) followed by survivorship clinics (16%) or on-site specialist visits (14%) were the most appropriate venues to address these concerns. Most respondents thought that medical needs of PC survivors could be addressed locally with appropriate specialty input (71%) or potentially through dedicated survivorship clinics (14%). Only 46% indicated being "moderately" or "very" confident managing ADT. Most PCPs indicated being moderately or very comfortable monitoring for recurrence (59%), managing erectile dysfunction (66%), addressing urinary incontinence (63%), and addressing emotional needs (61%). Conclusions: PCPs practicing in the ATHS express comfort with monitoring for PC recurrence, but express some concerns about the full range of issues in PC survivorship. Constructing cancer survivor care models in geographically dispersed and resource-limited contexts for Alaska Natives is an ongoing clinical and policy challenge.

4657 Background: While active surveillance (AS) is well recognized as an acceptable treatment strategy for low-risk prostate cancer (PC), the extent to which radiation oncologists and urologists perceive AS as effective and routinely recommend it to patients is unknown. Therefore, we sought to assess the attitudes and treatment recommendations for low-risk PC from a national survey of PC specialists. Methods: A mail survey was sent to a population-based sample of 1,439 physicians in the U.S. from late 2011 and early 2012. Physicians were queried about their attitudes regarding AS and treatment recommendations for patients diagnosed with low-risk PC (PSA<10 ng/dl; T1c; Gleason 6 in one of twelve cores). Pearson Chi-square and multivariate logistic regression were used to test for differences in attitudes and treatment recommendations by physician demographics, compensation structure, primary place of employment, and specialty. Results: Overall, 321 radiation oncologists and 322 urologists completed the survey for a 45% response rate. Most physicians reported that AS is effective for low-risk PC (71%) and stated that they were comfortable routinely recommending AS (67%). Urologists were more likely to agree that AS is effective (77% vs. 67%; p=0.005) and were comfortable recommending AS (74% vs. 61%; p=0.001) compared with radiation oncologists. Most physicians recommended radical prostatectomy (47%) or radiation therapy (32%), but fewer endorsed AS (21%) for low-risk disease. After adjusting for physician covariates, radiation oncologists were more likely to recommend radiation therapy (OR: 10.97; p<0.001), while urologists were more likely to recommend surgery (OR: 4.69; p<0.001) and AS (OR: 2.18; p=0.001) for low-risk PC. Conclusions: Although AS is widely viewed as effective by both radiation oncologists and urologists, most urologists continue to recommend surgery, while most radiation oncologists recommend radiation therapy. Our results may explain in part the relatively low contemporary use of AS in the U.S.

With ever-growing emphasis on high-stakes testing in medical education, such as the Medical College Admission Test and the United States Medical Licensing Examination Step 1, there has been a recent surge of concerns on the rise of a “Step 1 climate” within U.S. medical schools. The authors propose an alternative source of the “climate problem” in current institutions of medical education. Drawing on the intertwined concepts of trust and professionalism as organizational constructs, the authors propose that the core problem is not hijacking-by-exam but rather a hijackable learning environment weakened by a pernicious and under-recognized tide of commodification within the U.S. medical education system. The authors discuss several factors contributing to this weakening of medicine’s control over its learning environments, including erosion of trust in medical school curricula as adequate preparation for entry into the profession, increasing reliance on external profit-driven sources of medical education, and the emergence of an internal medical education marketplace. They call attention to breaches in the core tenets of a profession—namely a logic that differentiates its work from market and managerial forces, along with related slippages in discretionary decision making. The authors suggest reducing reliance on external performance metrics (high-stakes exams and corporate rankings), identifying and investing in alternative metrics that matter, abandoning the marketization of medical education “products,” and attending to the language of educational praxis and its potential corruption by market and managerial lexicons. These steps might salvage some self-governing independence implied in the term “profession” and make possible (if not probable) a recovery of a public trust becoming of the term and its training institutions.

Abstract Introduction Although allogeneic hematopoietic cell transplantation (HCT) is an expensive modality of treatment for hematological disorders, very little is known about the financial burden for the patients themselves. We analyzed factors associated with financial burden and its impact on health behaviors of allogeneic HCT recipients. Patients and Methods A questionnaire was mailed to adult patients who were alive after allogeneic HCT performed between 1/06 to 6/12 at Mayo Clinic to collect information regarding financial concerns, household income, employment status, insurance, out-of-pocket expenses and health and functional status. A multivariable logistic regression analysis was performed to determine socio-demographic and clinical factors associated with financial hardship. Results Of 482 patients, 268 responded (response rate 56%). Respondents were more likely to be older and Non-Hispanic Whites. No significant differences were seen in disease or transplant characteristics between the two groups except that respondents were more likely to have received reduced intensity conditioning. Median follow-up after HCT was 2.3 years (range 0.7-6.7 years). All the patients for whom the insurance information was available (missing n=13) were insured. Median physical and mental component score, as derived from the SF-12, were 36.8 [Interquartile range (IQR) 29.3-49.0] and 53.1 (IQR 42.1-57.1) respectively, where the general population score is 50, and lower scores indicate worse functioning. The proportion of patients that reported being on medical disability increased from 8% prior to HCT to 29% after HCT. 73% of the respondents reported that being sick had hurt them financially. 54% experienced adverse financial consequences such as decrease in household income by &gt;50% due to the HCT, need to sell/mortgage home, withdraw money from retirement accounts or having to pay more for medical care than they could afford. 3% declared bankruptcy. 12% had out-of pocket costs for the past 3 months that were&gt; $5000. Median monthly medication copayments were $100 (range $ 0-3000). 36% patients felt that their insurance coverage was poor which was strongly correlated with adverse financial consequences (p=0.0013). Other risk factors for financial burden were poor physical functioning reflected by the physical component score &lt;40 (OR 3.2; p=0.005), lower household income (OR 3.08; p=0.006) and lack of commercial/private insurance (OR 4.2; p&lt;0.001) while adjusting for patient and transplant related characteristics. Time from transplant was a significant predictor (OR 1.2; p=0.03) in the univariate analysis, but lost its significance in the multivariate analysis. 18 to 27% patients reported deleterious health behaviors due to financial constraints such as not taking prescribed medications, not using a recommended medical service or not making physician appointments. Conclusions A significant proportion of allogeneic HCT survivors experience adverse financial consequences with a few reporting severe outcomes like bankruptcy, despite having health insurance coverage. Future research should investigate potential interventions such as early financial counseling and connecting with sources of financial support to help at-risk patients and prevent long-term adverse financial outcomes after this life-saving procedure. Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 2059 Introduction: Two randomized trials have demonstrated a benefit in progression free survival (PFS) of 18–20 mofor maintenance treatment with lenalidomide after auto-PBSCT for multiple myeloma (MM). Although results on survival benefit are conflicting and quality of life (QOL) data is lacking, some have begun to recommend maintenance. No study has evaluated patient perceptions of maintenance. We conducted a systematic survey of MM patients (pts) regarding what constitutes a meaningful benefit that would make burdens of maintenance (toxicity and cost) acceptable. Methods: We mailed a brief self-administered survey in 3 waves to 1159 consecutive living pts evaluated at Mayo Clinic. The survey provided background on the standard of care for MM in transplant eligible pts and data on maintenance. Pts were asked to estimate the magnitude of OS benefit that would be acceptable for varying degrees of toxicity and cost. Results: Of the 1159 surveys sent, 886 pts (83.2%) responded, including 150 notifying us of a decision not to participate. 736 pts returned a completed survey (66% raw response rate). (56%) male, 407 (55%) had undergone auto-PBSCT, 467 (63%) had discussed maintenance with a physician, and 9 (1%) pts had received no treatment. 10% of pts had MM for 3–12 mo, 14% for 1–2 yr, 13% for 2–3 yr, 20% for 3–5 yr, 44% for 5 yr or more. Pt age: 4% 18–49 yr, 24% 50–59 yr, 40% 60–69 yr, 27% 70–79 yr, and 6% >80 yrs. The most worrisome potential toxicity was identified as peripheral neuropathy by 27% of pts, cytopenias by 24%, LE DVT 20%, fatigue 15%, nausea 8%, diarrhea/constipation 7%. In response to a question about whether they would choose maintenance if there was a PFS benefit but no improvement in OS, 92% would opt for maintenance if it were known to cause mild toxicity, while 77% would opt for maintenance despite moderate toxicity. Subsequent questions included cost and toxicity considerations and required pts to identify minimum acceptable duration of OS benefit to estimate more precisely a meaningful clinical benefit. If treatment was free, had no toxicity, and the OS benefit was 1 yr or less, 49% would choose maintenance (see Figure). In the same scenario, if toxicities were mild, the proportion of pts who choose maintenance was similar (46%). If pts experienced moderate toxicity, 42% choose maintenance. With rising financial burden (out-of-pocket) and toxicity, the proportion of pts who choose maintenance declined (see Table). For example, if the cost was $25/mo, mild toxicity experienced, and the OS benefit was one year or less, 46% would choose maintenance, while 39% of pts would choose maintenance if it cost $250/month and there was moderate toxicity. If maintenance cost $10,000/mo and was associated with mild or moderate toxicity, 18% and 17% of pts would choose treatment, respectively. Conclusions: For the first time, we have described the broad range of patient perspectives regarding trade-offs in the treatment of MM with maintenance therapy. We found that willingness to be treated with maintenance declined when actual benefits were provided in concrete numeric terms compared with a general statement of PFS benefit. The discrepancy between the 92% of pts choosing to undergo maintenance if free and mild toxicity when there is a PFS benefit but no OS benefit, compared to 49% of pts choosing maintenance if free, mild toxicity, and associated with an OS benefit of 1 yror less; suggests pts have difficulty understanding the concept of PFS. We also found that the magnitude of benefit required to consider maintenance was affected by cost and toxicity. In our experience, pts typically incur a cost of approximately $25/mo and experience mild toxicity. In this study, nearly half (46%) of such pts would opt for maintenance if the OS benefit was 1 year or less while only 33% of pts would opt for maintenance if the OS benefit was 6 months or less. Our data implies that good care in MM requires detailed conversations about each and every patient's priorities and expectations prior to making recommendations for or against such treatments. Disclosures: No relevant conflicts of interest to declare.

Abstract Context Myth busting engages scholars in the critical examination of commonly accepted but poorly evidenced claims with the goal of instilling quality and trust in knowledge making. The debunking of such knowledge “myths” and associated misguided practices purportedly serves to avert resources and attention from wasteful and dangerous scholarship. We address the myth that “all myths in medical education deserve to be busted”. Methods Using a critical narrative approach, we searched the medical education literature for orientations to myths and myth busting, and reviewed this literature analytically drawing from the sociology of science and Merton's concepts of manifest and latent functions. The results of this analysis are presented in the form of a narrative that deploys the articles reviewed to explore the utility of myth busting for medical education reform and begins with a brief exploration of the etymology of “myth” and how meaning making is related to symbols, practices and storytelling. Results Our analysis revealed the important function of myths in the social practice of medical education and practice. A deconstruction of five salient examples of the contemporary myth in medical education (the myth of the “ideal candidate”, the myth of “cut‐throats”, the myth of “cadaver stories”, the myth of “learning styles”, and the myth of “patient information leaflets”) demonstrates that myths continue to have material effects even after they have been busted. Conclusions Our analysis makes evident that myth busting disrupts, renegotiates and reconstitutes socio‐epistemic relationships rather than simply correcting falsehoods. We also argue that myths play important and inescapable roles in the social practice of medical education and the negotiation of values, and in constructing the conditions for group change and transformation. Imperatives related to humanism , compassion and patient engagement offer a healthy humanising counter‐mythologising that we suggest must survive any contemporary myth‐busting endeavour aimed at improving medical education practice.