JCO oncology practice最新文献

Purpose: As the complexity and need for cancer care services continue to grow, time to treatment initiation (TTI) has been increasing across cancer types. Presently there are no comprehensive analyses identifying the recent changes in TTI and the important variables causing variation in TTI for all the most prevalent cancer types.

Methods: This is a retrospective, observational study using data from the National Cancer Database from 2004 to 2015. The database was queried for newly diagnosed patients with cancer stages I-IV who had TTI within 0-180 days. Stepwise linear regression models were used as a variable selection technique to identify the most significant independent variables to evaluate as predictor variables.

Results: The study sample included 5,615,193 patients (median age, 65; 51.5% female; 86.1% White) across 30 different cancer types (most prevalent: breast [22.1%], lung [18.8%], prostate [16.6%]). The median [IQR] TTI across all 30 cancer types was 26 [6-47] days, with an increase of 7 days from 2004 (21 [4-44]) to 2015 (28 [9-49]; P < .001). No individual cancer type decreased in TTI from 2004 to 2015. The proportion of patients diagnosed with new stage I disease increased by 52.2% from 2004 (28.4%, n = 78,732) to 2015 (43.2%, n = 256,150). All other stages decreased in percent incidence. There was a 100.0% increase in median TTI for stage I patients from 2004 to 2015 (14-28 days). Cancer stage was the most important predictor of change in TTI for 16 cancer types (P < .001 for all 16).

Conclusion: TTI is increasing for patients with cancer, and the recent increase in stage I diagnoses is highly associated with this change.

Purpose: Cancer survivors often experience financial hardship, negatively affecting quality of life, health care use, and survival. Health-related social needs (HRSNs)-such as food/housing insecurity and transportation barriers-are prevalent among survivors and may correlate with financial hardship. Research exploring associations between financial hardship and HRSNs is limited. This study quantifies these associations in a nationally representative US sample.

Methods: We identified adult cancer survivors from the 2013 to 2018 National Health Interview Survey. Medical financial hardship was defined as (1) problems paying medical bills, (2) worry about medical bills, or (3) delaying/forgoing care because of cost. HRSNs were defined as (1) food insecurity, (2) housing insecurity, and (3) transportation barriers to care. Multivariable logistic regression models were used to assess associations between financial hardship and each HRSN, controlling for socioeconomic characteristics.

Results: Among 13,626 cancer survivors, 4,623 (34.2%) reported medical financial hardship. Survivors with financial hardship were significantly more likely to report any HRSN compared with those without hardship (53.1% v 8.7%, adjusted odds ratio [aOR], 6.99 [95% CI, 6.06 to 8.07]). This association persisted across household income levels (interaction P = .58). Specifically, survivors with financial hardship were more likely to experience food insecurity (21.9% v 2.2%, aOR, 5.49 [95% CI, 4.38 to 6.87]), housing insecurity (44.6% v 6.4%, aOR, 7.14 [95% CI, 6.1 to 8.35]), and transportation barriers to care (6.6% v 1.1%, aOR, 3.1 [95% CI, 2.27 to 4.22]), than survivors without hardship.

Conclusion: Medical financial hardship among cancer survivors is strongly associated with HRSNs, such as food, housing, and transportation insecurity, across income levels. These findings highlight the importance of systematic screening of financial hardship and HRSNs, along with providing comprehensive socioeconomic support to address the needs of all cancer survivors, regardless of their household income.

Purpose: To develop a clinical practice guideline and recommendations for symptom management of patients with well-differentiated grade 1 to grade 3 metastatic gastroenteropancreatic neuroendocrine tumors.

Methods: ASCO convened an Expert Panel to develop a clinical practice guideline by reviewing the literature for relevant guidelines, systematic reviews, randomized controlled trials (RCTs), and observational studies to develop recommendations for clinical practice.

Results: The literature review identified eight guidelines, 19 systematic reviews, and three RCTs that informed the development of guideline recommendations.

Recommendations: Recommendations are included for carcinoid syndrome, carcinoid heart disease and carcinoid crisis, and functional pancreatic neuroendocrine tumor syndromes. Recommendations are provided for surgical management, liver-directed therapy, and systemic therapy options, as well as palliative care. Limited guidance is provided for sequencing of interventions.Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines.

Purpose: To understand oncology physician perceptions of and experiences with specialist scarcity in their referral networks, strategies for delivering care after the departure of a colleague who they view as critical to their cancer care networks (ie, a linchpin colleague), and impacts of shortages on patient care.

Methods: We conducted semistructured interviews with oncologists who practice in health systems that serve a predominantly rural patient catchment area. We used deductive and inductive approaches to predetermine codes and then performed a thematic analysis.

Results: We interviewed 20 oncology physicians from five sites. We identified three major themes related to specialist scarcity. The first theme described the effects of physician shortages on care team expertise, collaborative relationships, and patient volume. The second theme uncovered strategies oncologists use when facing physician shortages, including referrals to outside health systems or generalists, practicing outside their subspecialization, and reallocating time from other responsibilities. The third theme identified unintended consequences of adaptive strategies, including greater patient travel burden, less optimal or delayed treatment, reduced access to clinical trials, and increased physician burnout and lower job satisfaction.

Conclusion: Oncology physician shortages lead to myriad adaptive strategies and downstream consequences to patient and physicians. Mapping these cascades can help guide resources to mitigate the negative effects of departures and shortages.

Purpose: This study aimed to determine if high-deductible health plan (HDHP) enrollment contributes to financial burden and hinders access to care for patients with multiple myeloma (MM).

Materials and methods: Patients diagnosed with MM from 2010 to 2020 were identified in Merative MarketScan, an employer-based health insurance database. Primary outcomes were total health care and out-of-pocket (OOP) costs in the year after diagnosis. Secondary outcomes included time to treatment initiation and stem-cell transplant receipt. Multivariable analyses using linear, logistic, and Cox regression were performed, as appropriate. Covariates included age, sex, year diagnosed, comorbidities, data provider, and stem-cell transplant receipt.

Results: The cohort included 4,029 patients; 17.6% were enrolled on HDHPs. HDHP enrollees were younger (mean age, 54.9 v 55.5 years; P = .036). Over the first year, mean total and OOP costs were $406,401 in US dollars (USD) and $9,220 USD for HDHP enrollees, respectively, versus $386,802 USD (P = .027) and $7,021 USD (P < .001) for the standard plan enrollees. There was no statistically significant difference in total cost (β = 11; P = .999) but mean OOP costs were $2,544 USD (β = 2,544; P < .001) higher for HDHP enrollees after adjusting for covariates. The additional OOP costs incurred in the first 2 months, presumably because of deductibles, and after the deductible reset. Contrary to our hypothesis, HDHPs enrollees had shorter time to treatment initiation (median, 20 v 22 days; hazard ratio, 1.18; P < .001) and were more likely to receive a stem-cell transplant (55.1% v 47.6%; odds ratio, 1.25; P = .010), after adjusting for covariates.

Conclusion: Compared with standard plan enrollees, OOP costs were higher for HDHP enrollees in the year after diagnosis, but HDHP enrollment was not associated with delays in treatment initiation or reduced access to stem-cell transplant.

The advent of next-generation antibody-drug conjugates (ADCs), particularly trastuzumab deruxtecan (T-DXd), has transformed our understanding of human epidermal growth factor receptor 2 (HER2) targetability for breast cancer (BC) treatment. Historically categorized as HER2-positive or HER2-negative on the basis of trastuzumab eligibility, this classification has evolved significantly over the past 5 years. The DESTINY-Breast04 trial marked the entry of anti-HER2 therapies for patients with HER2-low BC, while DESTINY-Breast06 demonstrated the potential for earlier and broader use of T-DXd. The latter trial revealed that even minimal HER2 expression in tumors previously classified as HER2-0 might be clinically relevant and targetable with T-DXd. This has led to further refinement of HER2 classification, introducing the concepts of HER2-ultralow (HER2-0 with staining) and HER2-null BC (HER2-0 without staining). With these findings, most patients with metastatic BC are currently considered eligible for T-DXd. Accurately identifying candidates for these therapies has highlighted the limitations of current HER2 diagnostic practices, on the basis of immunohistochemistry (IHC)/in situ hybridization assessment. IHC assay, optimized to detect high levels of HER2 protein, faces limitations in discriminating finer variations at the lower end of the HER2 expression spectrum. This is further complicated by the heterogeneity of HER2 expression. To overcome these barriers, new approaches may be required. Quantitative methods for HER2 membrane assessment, genomic and transcriptomic evaluations of HER2, and the integration of artificial intelligence into tissue analysis hold promise and are currently under investigation. Additionally, noninvasive strategies, such as analysis of circulating tumor DNA or circulating tumor cells, may enable real-time HER2 status assessment and better patient selection for ADC. However, these techniques require rigorous validation to ensure their clinical utility. This evolving landscape underscores the need for improvement of diagnostic approaches to support the expanding role of ADCs in BC treatment.