JCO oncology practice最新文献

Purpose: Employment is a core component of development in young adulthood and may be drastically affected by cancer. As part of a multi-institution financial navigation trial (ClinicalTrials.gov identifier: NCT05620979), we sought to explore employment-related experiences of long-term young adult (YA) survivors of cancer.

Methods: We conducted a secondary qualitative analysis of YA (age 18-39 years) survivors of hematologic malignancies. Participants completed baseline questionnaires pertaining to education and work. A subset of participants completed an optional semistructured interview after trial completion, focused on financial experiences. To contextualize the cohort and supplement qualitative findings, survey data were analyzed using descriptive statistics. We analyzed interview transcripts using directed content analysis and inductive reasoning to examine employment-related themes.

Results: One hundred thirty YA participants (median 31 years; Q1-Q3, 27-35) were enrolled with median time from cancer diagnosis of 10 years (Q1-Q3, 6-16). Most (82%) were currently employed, 77% of whom worked full time; 21% were students. Almost half (46%) reported that cancer continued to affect their education and/or employment; 29% had taken extended work leave in the previous year for cancer-related reasons. Challenges expressed in interviews with 45 participants included difficulties maintaining work because of treatment and side effects, interruptions affecting employment trajectory, and choosing work primarily for insurance/health-related reasons. Recommendations from YAs included building personal financial literacy, seeking financial resources, and suggesting clinicians incorporate screening and training for vocational and financial challenges.

Conclusion: Many long-term YA survivors of cancer reported substantial, ongoing impacts on their work-related achievement and trajectory. These findings underscore the need for universal screening and support throughout the cancer care continuum.

Purpose: To develop and evaluate real-world interventions to move guidelines on timely palliative care utilization into practice.

Methods: A knowledge-to-action cycle theory-informed, process improvement project facilitated implementation of a clinical practice guideline by (1) systematically screening clinic patients for unmet palliative care needs and alerting the oncologist, (2) using a dedicated community-based palliative care nurse for each referral, and (3) using Shared-care letters (structured communication between oncologist, family physician, and patient) to enhance information exchange and awareness of patients' needs. Implementation occurred for advanced colorectal cancer (CRC) within the GI clinics of the Tom Baker Cancer Center, Calgary, AB, Canada, and the neighboring city's Cross Cancer Institute, Edmonton, AB, Canada acted as control. The primary outcome was the proportion of adult decedents with CRC who received early specialist palliative care (SPC; defined as >90 days before death), evaluated using a pragmatic, controlled, before-and-after study. Eligible decedents in each city were identified using provincial cancer registry data and linked with administrative data identifying palliative care consultation, homecare, hospice, or inpatient unit usage.

Results: The cohort included 695 decedents: 341 baseline period (153 control, 188 intervention, April 2017-December 2018) and 354 implementation period (145 control, 209 intervention, April 2019-December 2020); the mean age was 66.5 years, 60% was male, and 95.2% was urban-dwelling. In the intervention arm, the proportion of decedents who received palliative care >90 days before death increased from 44.7% at baseline to 57.4% after implementation; in the control arm, the proportion decreased from 47.7% to 44.1% (17.7% difference in differences [95% CI, 3.1-32.4]; P = .018).

Conclusion: This intervention effectively increased early SPC utilization and provides a pragmatic approach to achieve and measure system-level change.

Purpose: We examined clinician- and facility-level factors associated with selection of nonguideline chemotherapy at treatment initiation in women with stage I-IIIA breast cancer (BC).

Methods: The Optimal Breast Cancer Chemotherapy Dosing Study collected information on chemotherapy delivery in an integrated health care delivery system. This analysis included 9,758 women treated with chemotherapy for stage I-IIIA BC between 2006 and 2019 at Kaiser Permanente Northern California (KPNC). Prevalence ratios (PRs) and corresponding 95% CIs were estimated for the clinician and facility factors in relation to nonguideline regimen (NGR) use. Analyses were stratified by time (pre- and post-2015) to reflect the period before and after KPNC's transition to a subspecialized care model. Secondary outcomes focused on nonguideline drug combinations (NGDCs) and nonguideline administration schedules (NGASs).

Results: Women treated by clinicians with substantially greater time since medical school (30+ years v <10 years since medical school) were more likely to receive NGR (PR, 1.38; 95% CI, 1.01 to 1.88; P trend = .01) with significant associations observed for both NGDC and NGAS. While not associated in the primary analysis, larger practice size (10+ oncologists) was associated with a lower likelihood of NGDC use compared with smaller practices (<5 oncologists; PR, 0.43; 95% CI, 0.26 to 0.70; P trend = .01). Time stratification revealed that, in the study's early years, clinician sex and years since medical school were associated with NGR use, but neither association remained post-2015.

Conclusion: Clinician and facility characteristics significantly influenced the use of NGR in stage I-IIIA BC treatment. Notably, associations diminished over time, suggesting that health system changes in care delivery may enhance guideline adherence and reduce the impact of nonclinical factors on treatment decisions.

Purpose: Consolidation durvalumab after concurrent chemoradiation (CCRT) for locally advanced non-small cell lung cancer (NSCLC) extends survival. In the PACIFIC trial, the timing to initiate durvalumab was 1-42 days after CCRT. However, in practice, many patients are treated outside this time frame. This study examined the impact of treatment timing.

Methods: We performed an analysis of a nationwide electronic health record-derived deidentified database. Patients with stage III NSCLC diagnosed in 2019-2023 and treated with CCRT were identified. Outcomes were overall survival and time to durvalumab discontinuation (TDD). Sequential landmark and propensity score analyses were performed to investigate timing of durvalumab initiation from week 1 to 13 after CCRT.

Results: Among 854 patients analyzed, durvalumab was initiated at a median of 5.6 weeks after CCRT (IQR, 4.0-8.3 weeks). When not considering the timing of durvalumab, patients who received durvalumab had better survival than those who did not: adjusted HR, 0.44 (95% CI, 0.34 to 0.56, P < .001). When considering the timing of durvalumab, no significant survival difference was found when durvalumab was initiated on or before week 4: adjusted HR, 0.81 (95% CI, 0.62 to 1.05, P = .07). The survival benefit increased over time and became significant on or after week 5. We found no deterioration in survival benefit when durvalumab was started after week 6. No significant difference in TDD by durvalumab timing was found.

Conclusion: This analysis demonstrated the survival benefit of durvalumab consolidation in the real-world setting. However, the benefit was not significant when durvalumab was initiated on or before week 4 after CCRT.

Purpose: Over 10 million jail admissions occur each year in the United States. Whether county-level incarceration shapes population-level cancer mortality remains unclear. We assessed county jail incarceration rates in relation to lung, liver, and colorectal cancer deaths.

Methods: This ecological study linked county incarceration rates (1995-2018, Vera Institute) with age-adjusted cancer mortality from the National Vital Statistics System (2000-2019). Incarceration was grouped into lagged quartiles (Q1 lowest; Q4 highest). Pooled Poisson regression with county-clustered robust errors estimated adjusted incidence rate ratios (aIRRs) while controlling for sociodemographic, behavioral, health care, and structural factors. Sex- and race-stratified analyses and longer exposure lags tested robustness.

Results: Relative to Q1, Q4 counties had higher mortality from lung (aIRR, 1.08 [95% CI, 1.04 to 1.12]), liver (aIRR, 1.10 [95% CI, 1.00 to 1.22]), and colorectal (aIRR, 1.09 [95% CI, 1.04 to 1.15]) cancers. Among men, liver cancer deaths rose 13% in Q4 (aIRR, 1.13 [95% CI, 1.03 to 1.24]). Black residents experienced elevated lung and colorectal mortality across all incarceration quartiles and a 29% increase in liver cancer deaths in Q4 (aIRR, 1.29 [95% CI, 1.04 to 1.61]); excess mortality among White residents emerged only in Q4 counties (all P < .05). Findings persisted in sensitivity analyses.

Conclusion: Counties with the highest jail incarceration rates had 7%-10% more lung, liver, and colorectal cancer deaths with disproportionate impacts on men and Black residents. Incarceration operates as a structural driver of cancer disparities; targeted prevention, screening, and treatment efforts are urgently needed in high-incarceration communities.

Purpose: Although clinical trials support osimertinib's efficacy over standard epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in metastatic EGFR-mutant non-small cell lung cancer (NSCLC), large real-world comparisons against first-generation TKIs are limited. We compared the real-world effectiveness and safety of first-line osimertinib versus first-generation TKIs (erlotinib, gefitinib) using a target trial emulation approach.

Methods: This retrospective cohort study used the TriNetX Research Network global database. We identified adults with newly diagnosed metastatic EGFR-mutant NSCLC initiating first-line EGFR-TKI therapy (January 2014-March 2025). After 1:1 propensity score matching (PSM), overall survival (OS; primary outcome) and safety were compared between treatment arms.

Results: Following PSM, a total of 3,168 patients (1,584 per arm) were analyzed. The median OS was significantly longer with osimertinib compared with first-generation TKIs (1,505 v 901 days; hazard ratio [HR], 0.612 [95% CI, 0.549 to 0.683]; P < .001). Survival benefits were consistent across subgroups, particularly pronounced in Asian patients (HR, 0.439). First-generation TKIs had higher rates of dermatologic toxicities, severe infections, and hospitalizations. Osimertinib showed higher rates of abnormal ECG findings and thrombocytopenia. Sensitivity analyses confirmed the robustness of the primary findings.

Conclusion: In this large real-world comparative effectiveness study using target trial emulation, first-line osimertinib was associated with substantially prolonged OS and a favorable safety profile, including lower rates of severe infections and hospitalizations, compared with first-generation EGFR-TKIs in patients with metastatic EGFR-mutant NSCLC.

Purpose: To evaluate utilization trends and survival outcomes of single-fraction stereotactic body radiation therapy (SF-SBRT) for early-stage non-small cell lung cancer (NSCLC).

Methods: The National Cancer Database (2006-2021) was queried to identify patients with stage I NSCLC treated with either SF-SBRT or multifraction (MF) SBRT delivered in 3-5 fractions. Patients receiving chemotherapy or surgery were excluded. Utilization trends were assessed using the Cochran-Armitage test. Predictors of SF-SBRT use were evaluated via multivariable logistic regression. Overall survival (OS) was compared using the log-rank test.

Results: A total of 83,377 patients were identified, of whom 937 (1.1%) received SF-SBRT. The proportion of SF-SBRT rose from 0% in 2006 to 1.6% in 2021 (P < .0001). The most frequent SF-SBRT prescriptions were 34 Gy (39%), 27 Gy (28%), and 30 Gy (28%); the most frequent MF-SBRT prescriptions were 10 Gy × 5 (42%), 18 Gy × 3 (14%), and 12 Gy × 4 (14%). The proportion of facilities delivering SF-SBRT increased from 0% in 2006 to 11% in 2021 (P < .0001) and, as of 2021, varied significantly by annual lung SBRT case volume: 6% for centers treating <10 patients, 25% for centers treating 10-19 patients, 41% for centers treating 20-29 patients, and 69% for centers treating ≥30 patients per year. Factors associated with SF-SBRT utilization included smaller tumor size (≤2 cm), treatment at a high-volume center or academic facility, and later year of treatment (all P < .0001). There was no difference in OS between patients treated with SF-SBRT and MF-SBRT (P = .89).

Conclusion: Utilization of SF-SBRT for stage I NSCLC is increasing, particularly at high-volume and/or academic centers. Yet, its overall utilization remains low despite evidence supporting its safety and efficacy.