JCO oncology practice最新文献

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.

Purpose: Cytokine release syndrome (CRS) of any grade occurs in 56%-80% of bispecific antibodies (BsAbs) used in multiple myeloma (MM). Risk mitigation strategies are required to expedite escalation of care if toxicities develop. The rarity of grade 3 or 4 CRS compels protocolized outpatient management of BsAbs as outpatient practice may avoid hospital admissions and costly resource utilization without compromising safety.

Materials and methods: Patients with MM who received BsAb step-up dosing (SUD) from August 23, 2023, to March 29, 2024, were enrolled. Baseline demographics, patient outcomes, and CRS management were reviewed to assess the safety of outpatient practice. Resource utilization was also analyzed.

Results: In this study, 34 patients received outpatient SUD of BsAbs (teclistamab n = 17, talequetamab n = 17) with 16 remaining outpatient throughout the entire SUD period. CRS occurred in seven patients who did not require hospitalization, demonstrating the safety of outpatient management of BsAb toxicity, regardless of low-grade CRS. CRS was observed in 24 patients (maximum grade 2) and immune effector cell-associated neurotoxicity syndrome in four patients (maximum grade 3). All patients with CRS received steroids, including 12 patients at home when instructed. Tocilizumab was given to 13 patients, accounting for 18 doses. If all doses of BsAbs and tocilizumab were given outpatient, the medication margin would be $115,004 in US dollars (USD).

Conclusion: An outpatient-based practice for BsAb administration demonstrated safety and cost savings. The description of our practice and results of this study provide valuable insights into the safety, feasibility, and resource stewardship of outpatient management of BsAbs. Future research should attempt to predict and stratify CRS risk to deliver a tailored supportive strategy and continued increase of outpatient management.

Purpose: Identifying patients with hereditary cancer syndromes through genetics referral enhances early detection and reduces healthcare costs. Despite potential benefits, genetics referral rates globally, including Singapore, remain low. This study investigates the real-world rates of genetics referrals in eligible cancer patients at Singapore's largest healthcare cluster using Electronic Health Records.

Methods: Referral criteria for genetics referrals were based on international guidelines. The institution's data repository was queried for eligible patients with relevant diagnosis codes from 2017 to 2021. We assessed genetics clinic attendance among eligible patients to evaluate referral rates. Variations in referral rates over time were analysed using linear regression and two-tailed t-test.

Results: Of the 10,080 patients eligible for a genetics referral, 17.1% (1719) were referred to a cancer genetics clinic. Breast, ovarian, colorectal, and endometrial cancers accounted for 42.9%, 33.5%, 11.3%, and 8.6% of referrals, respectively. Other tumour types accounted for 3.7% of referrals. Referral rates for suspected Hereditary Breast and Ovarian Cancer syndrome (HBOC)-related cancers were higher (19.4%) than referrals for suspected Lynch syndrome (11.9%). Among HBOC referrals, women (20.7%) were more likely to be referred than males (7.8%). From 2017 to 2021, we found an increase in referral rates for HBOC (12.8%-28.6%, P = .005) but not for Lynch syndrome-related indications (7.7%-13.5%, P = NS). The increase in referral rates for suspected HBOC in women was more significant than in men (P = .03).

Conclusion: This study found lower referral rates for Lynch syndrome than HBOC, and identified a gender discrepancy, with men with HBOC being less likely to be referred. Efforts to increase referral rates should include raising clinician awareness and electronically identifying suspected cases, especially for male breast cancer and Lynch Syndrome.

Purpose: Cure of metastatic gastric or gastroesophageal junction cancer (mGC/GEJC) with systemic chemotherapy alone is extremely rare. Although long-term follow-up from previous phase III studies suggest that durable complete response (CR) may occur in a limited number of patients with first-line treatment, clinical characteristics of such cases remain poorly characterized.

Materials and methods: We retrospectively reviewed medical records of patients with mGC/GEJC who received systemic chemotherapy at our institute between April 2013 and March 2022. Patients were defined as having a potential cure if they demonstrated a clinical or pathologic CR, maintained progression-free survival for more than 3 years from the treatment initiation, and remained free from disease progression for at least 1 year after treatment discontinuation. Clinicopathologic features, treatment regimens, and biomarker profiles, including human epidermal growth factor receptor 2 (HER2), mismatch repair (MMR), programmed death ligand-1 (PD-L1), and claudin 18.2 (CLDN18.2), were analyzed.

Results: Fifty-one patients met the criteria for potential cure. The median age was 67 years and 72.5% of the patients were male and had single-organ metastasis. Among patients with assessable biomarker status, the proportions of positive cases were 23.5% for HER2 (n = 51), 23.3% for deficient MMR (dMMR; n = 43), 16.0% for CLDN18.2 (n = 25), and 30.0% for PD-L1 Combined Positive Score (CPS) ≥10 (n = 30). First-line therapy led to potential cure in 52.9% of patients. Ten patients were potentially cured with cytotoxic chemotherapy alone, while 23 and 26 patients received molecular targeted agents or immunotherapy, respectively.

Conclusion: The introduction of molecular targeted agents and immunotherapy has expanded the chance of potential cure. The enrichment of dMMR, HER2-positive, and CPS-high tumors among potentially cured cases highlights the urgent need to develop effective therapies for those lacking actionable biomarkers.

Purpose: The OVHIPEC-1 trial demonstrated that adding hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) for patients with stage III epithelial ovarian cancer results in a significant increase in recurrence-free survival and overall survival. To inform policymakers about the macroeconomic budget, we conducted a budget impact analysis.

Methods: The expenditure of the Dutch health care system between 2017 and 2025 associated with the introduction of HIPEC for patients with stage III ovarian cancer eligible for interval CRS (target population) was assessed during their entire treatment course (surgical and subsequent treatment). Cost estimates are based on national registry data, national benchmark costs for hospital-related activities, list prices for drugs, therapeutic guidelines, and expert opinion. Sensitivity and scenario analyses were performed to test robustness of the analysis.

Results: The Dutch target population is expected to increase from 200 patients in 2017 to 233 patients in 2025, with 80% receiving HIPEC in 2025. Between 2017 and 2025, the impact on the annual surgical budget is €3.5 million, of which €1.8 million is directly attributable to HIPEC and its associated costs. When considering the cost of all ovarian cancer-related treatments, an additional €30,898 per HIPEC patient is spent in 2025, mainly driven by prolonged recurrence-free survival resulting in extended maintenance therapy and treatment for more platinum-sensitive recurrences. This leads to an annual total treatment budget impact of €26 million in 8 years, with €5.7 million directly associated with HIPEC use.

Conclusion: Within the Dutch health care system, the surgical budget impact of HIPEC is acceptable and falls within the boundaries for reimbursement of the responsible decision-making bodies. The total budget impact is mostly affected by the high costs of systemic treatment after prolonged recurrence-free survival due to HIPEC.

Purpose: The use of immunotherapy for cancer treatment is becoming increasingly prevalent, resulting in a growing number of patients experiencing immune-related adverse events (irAEs). Given the frequency of immunotherapy-related thyroid dysfunction (irTD), there is a growing demand for endocrine consultations, which has led to scheduling delays. This quality improvement project aimed to decrease the time to consultation and normalization of thyroid function tests (TFTs) in patients with irTD.

Methods: Using the Plan-Do-Study-Act framework, a clinic dedicated to the evaluation and treatment of irTD was created. The immuno-oncology toxicity (IOTOX) clinic is staffed by advanced practice providers (APPs) using standardized algorithms and physician support.

Results: After implementation, a prospective analysis of 46 patients from the IOTOX clinic was compared with 67 historical control patients seen before implementation. The median consultation wait time improved from 21 to 9 days (P = .01), and the median time to follow-up decreased from 180 to 58 days (P < .001). Notably, the median time to thyroid-stimulating hormone normalization was reduced from 102 to 38 days (P < .001).

Conclusion: These findings suggest that an IOTOX clinic staffed by APPs using standardized algorithms with physician support effectively improved patient access to consultation and expedited the time to normalization of TFTs. This approach can serve as a framework for addressing other irAEs at our institution and has the potential to be implemented or adapted by other institutions to improve the care of patients with irAEs.