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PURPOSE To improve skin cancer screening among survivors of childhood cancer treated with radiotherapy where skin cancers make up 58% of all subsequent neoplasms. Less than 30% of survivors currently complete recommended skin cancer screening. PATIENTS AND METHODS This randomized controlled comparative effectiveness trial evaluated patient and provider activation (PAE + MD) and patient and provider activation with teledermoscopy (PAE + MD + TD) compared with patient activation alone (PAE), which included print materials, text messaging, and a website on skin cancer risk factors and screening behaviors. Seven hundred twenty-eight participants from the Childhood Cancer Survivor Study (median age at baseline 44 years), age > 18 years, treated with radiotherapy as children, and without previous history of skin cancer were randomly assigned (1:1:1). Primary outcomes included receiving a physician skin examination at 12 months and conducting a skin self-examination at 18 months after intervention. RESULTS Rates of physician skin examinations increased significantly from baseline to 12 months in all three intervention groups: PAE, 24%-39%, relative risk [RR], 1.65, 95% CI, 1.32 to 2.08; PAE + MD, 24% to 39%, RR, 1.56, 95% CI, 1.25 to 1.97; PAE + MD + TD, 24% to 46%, RR, 1.89, 95% CI, 1.51 to 2.37. The increase in rates did not differ between groups ( P = .49). Similarly, rates of skin self-examinations increased significantly from baseline to 18 months in all three groups: PAE, 29% to 50%, RR, 1.75, 95% CI, 1.42 to 2.16; PAE + MD, 31% to 58%, RR, 1.85, 95% CI, 1.52 to 2.26; PAE + MD + TD, 29% to 58%, RR, 1.95, 95% CI, 1.59 to 2.40, but the increase in rates did not differ between groups ( P = .43). CONCLUSION Although skin cancer screening rates increased more than 1.5-fold in each of the intervention groups, there were no differences between groups. Any of these interventions, if implemented, could improve skin cancer prevention behaviors among childhood cancer survivors.

PURPOSE: Oral anticancer drug (OACD) prescriptions require extensive coordination between providers and payers, which can delay drug receipt. Specialty pharmacies facilitate communication between multiple entities. In 2018, our cancer center partnered with a freestanding organization to implement a hospital-based specialty pharmacy (HB-SP). We evaluated the time to drug receipt (TTR) before and after HB-SP implementation. METHODS: Data were prospectively collected on all new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019. In fall 2018, a HB-SP was initiated. We collected patient sociodemographic, clinical, and prescription data. TTR was the number of days from OACD prescription to drug receipt. We used multivariable logistic regression to examine factors associated with TTR ≤ 7 days before and after HB-SP implementation. RESULTS: In total, 954 patients were included, representing 1,102 new OACDs. The majority of prescribed drugs were targeted OACDs (56%, n = 617), and 71% (n = 779) required prior authorization. Of all prescriptions, 84% (n = 960) were successfully received with an overall median TTR of 7 days. In unadjusted analysis, HB-SP implementation, drug class, race and ethnicity, and prior authorization requirement were significantly associated with TTR. Adjusted analyses found that patients were more likely to receive their drugs ≤ 7 days after HB-SP implementation (53% v 47%; adjusted odds ratio [aOR], 1.29; 95% CI, 1.00 to 1.68; P = .05). CONCLUSION: The implementation of a HB-SP in partnership with a collaborative care model contributed to a decrease in TTR for OACDs. This difference is in part attributable to improved care coordination and communication. A centralized approach may improve overall efficiency due to fewer practice disruptions.

Background Sedative-hypnotic medications are used to treat chemotherapy-related nausea, anxiety, and insomnia. However, prolonged sedative-hypnotic use can lead to dependence, misuse, and increased health-care use. We aimed to estimate the rates at which patients who receive adjuvant chemotherapy for breast cancer become new persistent users of sedative-hypnotic medications, specifically benzodiazepines and nonbenzodiazepine sedative-hypnotics (Z-drugs). Methods Using the MarketScan health-care claims database, we identified sedative-hypnotic–naïve patients who received adjuvant chemotherapy for breast cancer. Patients who filled 1 and more prescriptions during chemotherapy and 2 and more prescriptions up to 1 year after chemotherapy were classified as new persistent users. Univariate and multivariable logistic regression analyses were used to estimate odds of new persistent use and associated characteristics. Results We identified 22 039 benzodiazepine-naïve patients and 23 816 Z-drug–naïve patients who received adjuvant chemotherapy from 2008 to 2017. Among benzodiazepine-naïve patients, 6159 (27.9%) filled 1 and more benzodiazepine prescriptions during chemotherapy, and 963 of those (15.6%) went on to become new persistent users. Among Z-drug–naïve patients, 1769 (7.4%) filled 1 and more prescriptions during chemotherapy, and 483 (27.3%) became new persistent users. In both groups, shorter durations of chemotherapy and receipt of opioid prescriptions were associated with new persistent use. Medicaid insurance was associated with new persistent benzodiazepine use (odds ratio = 1.88, 95% confidence interval = 1.43 to 2.47) compared with commercial or Medicare insurance. Conclusions Patients who receive sedative-hypnotic medications during adjuvant chemotherapy for breast cancer are at risk of becoming new persistent users of these medications after chemotherapy. Providers should ensure appropriate sedative-hypnotic use through tapering dosages and encouraging nonpharmacologic strategies when appropriate.

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Background: Poorer survival from endometrial cancer in blacks than in whites is well documented. The aims of this study were to determine whether diabetes, hypertension, or other conditions influence survival and whether accounting for these conditions reduces this racial disparity.Methods: Using the SEER-Medicare database, we investigated the influence of diabetes, hypertension, and other comorbid conditions on survival in black and white women age ≥66 with endometrial cancer. We used Cox proportional hazards regression to evaluate the influence of comorbidities on survival for blacks and whites separately and to study survival differences between blacks and whites after adjustment for diabetes, hypertension, and other medical conditions, as well as for demographics, tumor characteristics, and treatment.Results: In both racial subgroups, women with diabetes or other conditions had poorer overall survival, whereas hypertensive black women experienced better survival [HR, 0.74; 95% confidence interval (CI), 0.60–0.92]. For disease-specific survival, diabetes was associated with poorer survival in white women (HR, 1.19; 95% CI, 1.06–1.35) but not in blacks (HR, 0.97; 95% CI, 0.73–1.30); hypertension and other conditions were not significantly related to survival. After adjustment, black women had poorer survival than white women, with HRs of 1.16 (95% CI, 1.05–1.28) for overall and 1.27 (95% CI, 1.08–1.49) for disease-specific survival.Conclusions: Diabetes influences disease-specific survival in white women but not in blacks. The racial disparity in survival is not explained by the presence of other health conditions.Impact: Further research should focus on the unknown factors that lead to poorer survival in black women compared with whites. Cancer Epidemiol Biomarkers Prev; 21(5); 753–60. ©2012 AACR.

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PURPOSEImplementation of routine financial screening is a critical step toward mitigating financial toxicity. We evaluated the feasibility, sustainability, and acceptability of systematic financial screening in the outpatient breast oncology clinic at a large, urban cancer center.METHODSWe developed and implemented a stakeholder-informed process to systematically screen for financial hardship and worry. A 2-item assessment in English or Spanish was administered to patients through the electronic medical record portal or using paper forms. We evaluated completion rates and mode of completion. Through feedback from patients, clinicians, and staff, we identified strategies to improve completion rates and acceptability.RESULTSFrom March, 2021, to February, 2022, 3,500 patients were seen in the breast oncology clinic. Of them, 39% (n = 1,349) responded to the screening items, either by paper or portal, 12% (n = 437) preferred not to answer, and the remaining 49% (n = 1,714) did not have data in their electronic health record, meaning they were not offered screening or did not complete the paper forms. Young adults (18-39 years) were more likely to respond compared with patients 70 years or older (61% v 30%, P < .01). English-preferring patients were more likely to complete the screening compared with those who preferred Spanish (46% v 28%, P < .01). Non-Hispanic White patients were more likely to respond compared with Non-Hispanic Black patients and with Hispanic patients (46% v 39% v 32%, P < .01). Strategies to improve completion rates included partnering with staff to facilitate paper form administration, optimizing patient engagement with the portal, and clearly communicating the purpose of the screening.CONCLUSIONSystematic financial screening is feasible, and electronic data capture facilitates successful implementation. However, inclusive procedures that address language and technology preferences are needed to optimize screening.

Introduction: Sedative-hypnotic medications, such as benzodiazepines (BZDs) and non-benzodiazepine sedative-hypnotics (Z-drugs), are used to treat chemotherapy-related nausea, anxiety and insomnia. While effective for these indications, prolonged use can lead to dependence, misuse and increased healthcare utilization. We aimed to estimate rates of new and persistent BZD and Z-drug use after adjuvant chemotherapy for breast cancer. Methods: We used the MarketScan health care claims database to identify patients who received adjuvant chemotherapy for breast cancer from 2008 to 2017. We categorized prescriptions for BZDs or Z-drugs into three periods: 365 days prior to chemotherapy to the start of chemotherapy (period 1); start of chemotherapy to 90 days after the end of chemotherapy (period 2); and 90 days to 365 days after chemotherapy (period 3). Patients who filled no BZD prescriptions in period 1 were considered BZD-naïve. Those who then filled at least one BZD prescription in period 2, and at least two BZD prescriptions in period 3, were classified as new persistent BZD users. The same definitions were used for Z-drugs. We used multivariable logistic regression to estimate associations between patient characteristics and new persistent use of BZDs and Z-drugs. Results: We identified 17,532 BZD-naïve patients and 21,863 Z-drug-naïve patients who received adjuvant chemotherapy for breast cancer. The median age was 57 for BZD-naïve patients (IQR = 13) and 56 for Z-drug-naïve patients (IQR = 13). The majority of patients had commercial or Medicare insurance (92.6% BZD-naïve, 92.7% Z-drug-naïve) versus Medicaid. A slight majority received lumpectomy (56.6% BZD-naïve, 55.1% Z-drug-naïve) versus mastectomy. Roughly half of patients received less than 4 months of chemotherapy (48.0% BZD-naïve, 48.6% Z-drug-naïve). Among BZD-naïve patients, 4,447 (25%) filled at least one BZD prescription during chemotherapy, and 1,192 (7% of all BZD-naïve patients, 27% of those filling at least one BZD prescription during chemotherapy) became new persistent BZD users after chemotherapy. Among Z-drug naïve patients, 2,160 (10%) filled at least one Z-drug prescription during chemotherapy, and 730 (3% of all Z-drug-naïve patients, 34% of those filling at least one prescription during chemotherapy) became new persistent Z-drug users afterwards. There were 115 patients who became new persistent users of both types of sedative-hypnotics. Several characteristics were associated with new persistent BZD use: age 50-65 (Table 1; OR = 1.23, p = 0.01) and age > 65 (OR = 1.38, p = 0.005) relative to age ≤ 49; as well as Medicaid insurance, relative to commercial and Medicare insurance (OR = 1.68, p < 0.0001). Chemotherapy duration of less than 4 months was associated with both new persistent BZD and Z-drug use relative to 4 or more months of chemotherapy (OR = 1.17, p = 0.03 for BZDs; OR = 1.58, p < 0.0001 for Z-drugs). Conclusion: Women who receive sedative-hypnotic medications during adjuvant chemotherapy for breast cancer are at risk of becoming persistent users of these medications after chemotherapy. With an awareness of this observation, providers can take steps to ensure appropriate use of these medications, through tapering dosages and encouraging non-pharmacologic strategies when appropriate. Associations between Patient Characteristics and New Persistent Sedative-Hypnotic UseNew Persistent BZD UseNew Persistent Z-Drug UseVariableOdds Ratio95% CIp valueOdds Ratio95% CIp valueAge (years)≤ 49ReferentReferent50-651.231.05 - 1.430.011.210.99 - 1.480.07> 651.381.10 - 1.720.0050.950.68 - 1.310.7InsuranceMedicaid1.681.31 - 2.16 Citation Format: Jacob C. Cogan, Rohit R. Raghunathan, Melissa P. Beauchemin, Melissa K. Accordino, Elena B. Elkin, Alexander Melamed, Jason D. Wright, Dawn L. Hershman. New and persistent sedative hypnotic use after adjuvant chemotherapy for breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD5-08.

OBJECTIVE While there are a number of benefits to minimally invasive surgery (MIS) for women with ovarian cysts, there is an increased risk of ovarian capsule rupture during the procedure, which could potentially seed the abdominal cavity with malignant cells. We developed a decision model to compare the risks, benefits, effectiveness and cost of MIS versus laparotomy in women with ovarian masses. DESIGN Cost-effectiveness study POPULATION: Hypothetical cohort of 10 000 women with ovarian masses who were undergoing surgical management. METHODS The initial decision point in the model was performance of surgery via laparotomy or a MIS approach. Model probabilities, costs and utility values were derived from published literature and administrative data sources. Extensive sensitivity analyses were conducted to assess the robustness of the findings. MAIN OUTCOME MEASURES The primary outcome was the cost-effectiveness of MIS versus laparotomy for women with a pelvic mass measured by incremental cost-effectiveness ratios (ICERs). RESULTS MIS was the least costly strategy at $7,732 per women on average, compared with $17,899 for laparotomy. In our hypothetical cohort of 10 000 women, there were 64 cases of ovarian rupture in the MIS group and 53 in the laparotomy group, while there were 26 cancer-related deaths in the MIS group and 25 in the laparotomy group. MIS was more effective than laparotomy (188 462 QALYs for MIS versus 187 631 quality adjusted life years [QALYs] for laparotomy). Thus, MIS was a dominant strategy, being both less costly and more effective than laparotomy. These results were robust in a variety of sensitivity analyses. CONCLUSION MIS constitutes a cost-effective management strategy for women with suspicious ovarian masses. TWEETABLE ABSTRACT MIS is a cost-effective management strategy for women with suspicious ovarian masses.

Background: Due to therapeutic advancements, people diagnosed with metastatic breast cancer (MBC) are living longer. This is particularly true for elderly patients who are often diagnosed with more indolent disease. However, elderly patients have higher rates of comorbidity and are vulnerable to other adverse health outcomes, but the primary care management of patients with advanced cancer may be sub-optimal. Every year influenza results in hundreds of thousands of hospitalizations and tens of thousands of deaths. Guidelines recommend the influenza vaccine annually for those over the age of 65 as well as those with cancer based on studies showing a 40-60% reduction in hospitalizations and death. Patterns of use in patients with MBC is unknown. Methods: A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Patients were included if they were diagnosed with stage IV MBC from 1/1/2008 – 12/31/2017, were ≥65 years of age, and had continuous Medicare enrollment for 12 months prior to diagnosis and at least three months after. Our primary outcome of interest was influenza vaccine use identified via CPT codes and defined as any use, use among patients surviving > 3-years, use among patients surviving >5-years, and repeated vaccine use. We then conducted bivariate analyses using demographic variables, including race, ethnicity, SES, age, and marital status, and clinical factors, including chemotherapy use, ER/PR positivity, and HER2 positivity. A multivariable logistic model was used to identify factors associated with influenza vaccine use in each cohort. Results: We identified 5182 patients with stage IV MBC during the study period that met our inclusion criteria. Overall, the median survival was 21 months and only 44% received at least one vaccination at any time after diagnosis. Within the cohort with the > 3-year survival (n=1864), only 1222 (66%) received an influenza vaccination at least one time and only 54% received the vaccine at least two times during 3 years of follow-up. Among patients with at least five-years of survival (n=763), 73% received at least one vaccination and only 65% received the vaccine at least two times during 5 years of follow-up. In a bivariate analysis in the 3-year survival cohort, we found that black race (47% vs 67%, p< 0.001) and Hispanic ethnicity (53% vs 66%, p=0.026), compared to white race and non-Hispanic ethnicity, respectively, were significantly associated with decreased vaccine use. The only factor associated with increased use was chemotherapy exposure. A multivariable model found lower odds of influenza vaccine receipt for black patients (OR=0.44, 95% CI 0.30-0.65, p< 0.001) and Hispanic patients (OR=0.58, 95% CI 0.36-.94, p=0.026). Similar findings were found in the 5-year survival cohort. Ongoing landmark analyses will be presented evaluating the impact of vaccination on survival. Conclusions: Over 50% of survivors with MBC do not receive the influenza vaccine after diagnosis. Importantly black and Hispanic patients with MBC are about half as likely to receive the influenza vaccine as white patients. Given the known impact of influenza vaccination in the elderly, improving access to vaccination could be an important strategy to reduce disparities in health outcomes. Our findings demonstrate primary care access disparities amongst the MBC population and indicate a need for educational and policy-based interventions. Citation Format: Sahil D. Doshi, David DeStephano, Melissa K. Accordino, Elena B. Elkin, Jason D. Wright, Dawn Hershman. PD6-06 Racial and ethnic disparities with influenza vaccine use in long-term survivors of metastatic breast cancer [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 PD6-06.

Background Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches. Methods We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios. Results Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence. Conclusion All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

OBJECTIVE To compare surgical characteristics and complications between well drilling (WD) and subperiosteal pocket techniques (SPT) for receiver/stimulator (R/S) fixation of cochlear implant (CI), and conduct cost-effectiveness analysis. STUDY DESIGN Retrospective clinical study, decision-analysis model. SETTING Tertiary referral center. PATIENTS Three-hundred and eighty-eight CI recipients with a minimum of 6-months follow-up. INTERVENTIONS CI surgery using either WD or SPT for R/S fixation. A decision-analysis model was designed using data from a systematic literature review. MAIN OUTCOME MEASURES Surgical operation time, rates of major and minor long-term complications were compared. Incremental cost-effectiveness was also estimated, comparing the two methods of fixation. RESULTS We compared 179 WD with 209 SPT. Surgery time was significantly shorter in SPT (148 versus 169 min, p = 0.001) and remained significant after adjustment for possible confounders. Higher rates of major complications requiring surgical intervention were found with SPT (10.5% versus 4.5%, p = 0.042), however, the difference was not significant after adjusting for follow-up time (47.8 versus 32.5 months for SPT, WD respectively; p

Opioid misuse is a public health crisis, and unused postoperative opioids are an important source. Although 70% of pills prescribed go unused, only 9% are discarded. This study evaluated whether an inexpensive pill-dispensing device with mail return capacity could enhance disposal of unused opioids after cancer surgery.A prospective pilot study was conducted among adult patients who underwent major cancer-related surgery. Patients received opioid prescriptions in a mechanical device (Addinex) linked to a smartphone application (app). The app provided passwords on a prescriber-defined schedule. Patients could enter a password into the device and receive a pill if the prescribed time had elapsed. Patients were instructed to return the device and any unused pills in a disposal mailer. The primary end point was feasibility of device return, defined as ≥50% of patients returning the device within 6 weeks of surgery. Also explored was total pill use and return as well as patient satisfaction.Among 30 patients enrolled, the majority (n = 24, 80%) returned the device, and 17 (57%) returned it within 6 weeks of surgery. In total, 567 opioid pills were prescribed and 170 (30%) were used. Of 397 excess pills, 332 (84% of unused pills, 59% of all pills prescribed) were disposed of by mail. Among 19 patients who obtained opioids from the device, most (n = 14, 74%) felt the benefits of the device justified the added steps involved.Use of an inexpensive pill-dispensing device with mail return capacity is a feasible strategy to enhance disposal of unused postoperative opioids.

With anecdotal observations of atypical recurrences following minimally invasive surgery and alongside new concerns following cervical cancer surgery, there is a need to evaluate cancer specific outcomes for minimally invasive kidney cancer surgery using national data. We evaluated cancer specific outcomes following minimally invasive surgery vs open surgery for early stage kidney cancer.We performed a retrospective population based cohort study using data from the SEER (Surveillance, Epidemiology, and End Results) program linked with Medicare claims that included beneficiaries at least 66 years old diagnosed between 2004 and 2013 with early stage, nonurothelial kidney cancer who underwent surgical resection within a year of diagnosis. We compared overall survival, disease specific survival, rate of second kidney cancer surgery and rate of postoperative systemic cancer therapy based on whether surgery was minimally invasive surgery or an open resection. Multivariable regression was used to account for confounders.A total of 5,150 patients were included in analysis and 3,062 (59.5%) underwent minimally invasive surgery. On multivariable analysis minimally invasive surgery was not associated with differences in overall survival (HR 0.94, 95% CI 0.84-1.06) or disease specific survival (HR 0.96, 95% CI 0.83-1.11). Patients treated with minimally invasive surgery were more likely to receive systemic cancer therapy (HR 1.31, 95% CI 1.09-1.59). No difference in the rate of second surgery associated with surgical approach was observed.Use of minimally invasive surgery for early stage kidney cancer was not associated with differences in overall or disease specific survival, or the rate of second kidney cancer surgery. Patients treated with minimally invasive surgery received more postoperative systemic therapy, which could represent a disparate cancer specific outcome associated with minimally invasive surgery.

ImportanceOral anticancer drugs (OACDs) are increasingly prescribed for cancer treatment and require significant coordination of care. Retrospective studies suggest that 10% to 20% of OACD prescriptions are never received by the patients, but the reasons behind this are poorly understood.ObjectivesTo estimate the rate of failure to receive OACD prescriptions among patients with cancer and to examine the underlying reasons for this failure.Design, Setting, and ParticipantsA prospective cohort study was conducted among patients with cancer who were prescribed a new OACD from January 1, 2018, to December 31, 2019, at an urban academic medical center. Data analysis was conducted between 2021 and 2022.Main Outcomes and MeasuresPatient demographic, clinical, and insurance data and OACD delivery dates were collected. The reasons for a failure to receive a prescribed OACD within 3 months were confirmed by manual review of medical records and were classified into 7 categories: clinical deterioration, financial access, clinician-directed change in decision-making, patient-directed change in decision-making, transfer of care, loss to follow-up, and unknown or other. A multivariable random-effects model was developed to identify factors associated with failure to receive a prescribed OACD.ResultsThe cohort included 1024 patients (538 men [53%]; mean [SD] age, 66.2 [13.9] years; 463 non-Hispanic White patients [45%], 140 non-Hispanic Black patients [14%], and 300 Hispanic patients [29%]), representing 1197 new OACD prescriptions. Of the 1197 prescriptions, 158 (13%) were categorized as having not been received by the patient. The most common reason for the failure to receive a prescribed OACD was due to patient and clinician decision-making (73 of 158 [46%]), and 20 cases (13%) in which prescriptions were not received were associated with financial access issues. In multivariable analysis, patients with a nonmetastatic solid malignant neoplasm were significantly less likely to not receive their OACDs than those with a hematologic malignant neoplasm (odds ratio, 0.57 [95% CI, 0.33-1.00]; P = .048).Conclusions and RelevanceThis cohort study of patients prescribed a new OACD found that 13% of prescriptions were not received. The failure to receive a prescribed OACD was most frequently due to a change in clinical decision-making or patient choice. Ultimately, the reasons for the failure to receive a prescribed OACD were multifactorial and may have been appropriate in some cases.

Prolonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M + R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications. Using the MarketScan health-care claims database, we identified opioid- and sedative-hypnotic-naive women who had M + R from 2008 to 2017. Women who filled ≥ 1 peri-operative prescription and ≥ 2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors. We evaluated 23,025 opioid-naive women and 25,046 sedative-hypnotic-naive women. We found that 17,174 opioid-naive women filled a peri-operative opioid prescription, and of those, 2962 (17.2%) became opioid NPUs post-operatively. Additionally, 9426 sedative-hypnotic-naive women filled a peri-operative sedative-hypnotic prescription, and of those, 1612 (17.1%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤ 49 [OR 1.77 (95% CI 1.40–2.24)] and age 50–64 [1.60 (1.27–2.03)] compared to age ≥ 65; Medicaid insurance [2.34 (1.40–3.90)]; southern residence [1.42 (1.22–1.64)]; breast cancer diagnosis [2.24 (1.28–3.91)]; and chemotherapy [2.17 (1.94–2.42)]. Risk of NPU increased with higher risk score. Women with ≥ 3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors [2.94 (2.51–3.43)]. Comparable findings were seen regarding new persistent opioid use. Women who have M + R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient’s risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.

PURPOSE The aim of the current study was to increase the uptake of screening mammography among high-risk women who were treated for a childhood cancer with chest radiotherapy. PATIENTS AND METHODS Two hundred four female survivors in the Childhood Cancer Survivor Study who were treated with chest radiotherapy with 20 Gy or greater, age 25 to 50 years, and without breast imaging in the past 24 months were randomly assigned 2:1 to receive a mailed informational packet followed by a tailored telephone-delivered brief motivational interview (intervention) versus an attention control. Primary outcome was the difference in the proportion of participants who completed a screening mammogram by 12 months as evaluated in an intent-to-treat analysis. Stratum-adjusted relative risk (RR) and 95% CI were estimated using the Cochran-Mantel-Haenszel method. Secondary outcomes included the completion of screening breast magnetic resonance imaging (MRI) and barriers to screening and moderating factors. RESULTS Women in the intervention group were significantly more likely than those in the control group to report a mammogram (45 [33.1%] of 136 v 12 [17.6%] of 68; RR, 1.9; 95% CI, 1.1 to 3.3). The intervention was more successful among women age 25 to 39 years (RR, 2.2; 95% CI, 1.1 to 4.7) than among those age 40 to 50 years (RR, 1.4; 95% CI, 0.6 to 3.2). The proportion of women who reported a breast MRI at 12 months was similar between the two groups: 16.2% (intervention) compared with 13.2% (control; RR, 1.2; 95% CI, 0.6 to 2.5). Primary barriers to completing a screening mammogram and/or breast MRI included lack of physician recommendation, deferred action by survivor, cost, and absence of symptoms. CONCLUSION Use of mailed materials followed by telephone-delivered counseling increased mammography screening rates in survivors at high risk for breast cancer; however, this approach did not increase the rate of breast MRI. Cost of imaging and physician recommendation were important barriers that should be addressed in future studies.

1592 Background: The past decade has seen a dramatic increase in the number of oral anti-cancer drug (OACD) approvals in the United States. Though polypharmacy and drug-drug interactions (DDIs) likely contribute to OACD toxicity, the prevalence of these features in patients on OACDs remains largely unknown. We aimed to evaluate a one-time 30-minute pharmacist-led video consultation among metastatic cancer patients initiating OACDs to identify medication list inaccuracies as well as the prevalence, characteristics, and severity of OACD-related potential DDIs. Methods: We conducted a single-arm, prospective telehealth intervention study among 29 patients initiating OACDs to evaluate a one-time 30-minute pharmacist-led video consultation. The video visits focused on identifying and discussing polypharmacy and potential DDIs, and pharmacists then communicated recommendations to each patient's oncologist. We estimated the prevalence, characteristics (QTc prolongation, absorption interactions, etc.), and severity of OACD-related potential DDIs. Lexicomp and Micromedex were used to assess potential DDIs and measure severity on a standardized scale (A – D, X). In addition, we assessed the prevalence of medication list inaccuracies, polypharmacy, and patient satisfaction. Results: Twenty-five patients completed the intervention (86% completion rate) of whom 40% were 75 years of age or older and 60% were men. The majority were white (68%) and non-Hispanic (76%). Sixteen patients (68%) had a solid tumor diagnosis. Nearly half (48%) were insured by Medicare. The median number of medications per patient was 9 with a range of 4 – 21, and 96% of patients had at least 5 prescriptions listed. The median number of medication list errors was 2 with a range of 0 – 16, with at least 1 error for 76% and more than 1 error for 52% of patients. Pharmacists identified potential OACD-related interactions in 9 cases (40%). These included change in drug absorption or metabolism (7), QTc prolongation (1), hypotension (1), and bleeding (1). Interactions were classified as either category C (8) or D (2), requiring close monitoring or a change in treatment, respectively. All patients expressed a high level of satisfaction with the video visit. Conclusions: Polypharmacy, medication list errors, and potential DDIs are prevalent among patients initiating OACDs despite use of an electronic medical record requiring medication reconciliation. Our study suggests that a one-time remote 30-minute pharmacist-led video consultation can effectively identify and address OACD-related potential DDIs, which may decrease medication complexity and improve adherence in this population.

6593 Background: An interim analysis of the OlympiA trial found that olaparib given in the adjuvant setting can improve distant disease-free and overall survival for patients with early-stage, BRCA-mutated breast cancer; however, the cost-effectiveness of adjuvant olaparib is unknown. This study aimed to evaluate the cost-effectiveness of adjuvant olaparib in patients with early-stage, BRCA-mutated breast cancer. Methods: We used a decision-analytic model to compare outcomes of treatment with and without one year of oral olaparib after completion of systemic therapy in 42-year-old women with BRCA-mutated, early-stage breast cancer. Olaparib’s effectiveness was based on the OlympiA trial, and other model parameters were identified from the literature. We calibrated the model to reflect the 1-, 2-, and 3-year distant disease-free survival (DDFS) and overall survival (OS) observed in the OlympiA trial, and we assumed that olaparib reduced the risk of distant recurrence only in the first 3 years. Olaparib was estimated to cost $14,523 per month. Average lifetime costs were estimated from a health care system perspective in 2021 $ US, and incremental cost-effectiveness ratios (ICER) were estimated as $ per quality-adjusted life-year (QALY) gained. Costs, life-years, and QALYs were discounted by 3% annually. Results: Simulating the OlympiA trial, DDFS for the olaparib arm was 94.3% at 12 months, 90.0% at 24 months, and 87.5% at 36 months, compared to placebo with DDFS of 90.2%, 83.9%, and 80.4% respectively. Similarly, OS for the olaparib arm was 98.1%, 94.8%, and 92.0% compared to 96.9%, 92.3%, and 88.3% with placebo at 12, 24, and 36 months respectively. In the base case, adjuvant olaparib was associated with a 1.21-year increase in life expectancy and a 1.15-QALY increase at an incremental cost of $131,167 compared to placebo. The resulting ICER was about $114,500/QALY gained. At a willingness-to-pay threshold of USD$150,000/QALY, olaparib was cost effective at its current price. Results were sensitive to assumptions about the effectiveness of olaparib and its impact on quality of life. Conclusions: Adjuvant olaparib is cost-effective for women with early-stage, BRCA-mutated breast cancer at the current price of olaparib in the U.S. and at a willingness-to-pay threshold of $150,000. As such, clinicians and payers should consider adjuvant olaparib as a cost-effective option for this patient population. [Table: see text]

PurposeProlonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M+R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications.MethodsUsing the MarketScan health care claims database, we identified opioid- and sedative-hypnotic-naïve women who had M+R from 2008-2017. Women who filled ≥1 peri-operative prescription and ≥2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors.ResultsWe evaluated 25,270 opioid-naïve women and 27,651 sedative-hypnotic-naïve women.We found that 18,931 opioid-naïve women filled a peri-operative opioid prescription, and of those, 3,315 (17.5%) became opioid NPUs post-operatively. Additionally, 10,781 sedative-hypnotic-naïve women filled a peri-operative sedative-hypnotic prescription, and of those, 1,837 (17.0%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤49 (OR 1.79 [95% CI 1.43–2.25]) and age 50-64 (1.65 [1.31-2.07]) compared to age ≥65; Medicaid insurance (1.92 [1.23–2.98]); southern residence (1.38 [1.20–1.59]); breast cancer diagnosis (1.78 [1.09–2.91]); and chemotherapy (2.24 [2.02–2.49]). Risk of NPU increased with higher risk score. Women with ≥3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors (3.03 [2.60–3.53]). Comparable findings were seen regarding new persistent opioid use.ConclusionWomen who have M+R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient’s risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.

Prolonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M + R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications.Using the MarketScan health-care claims database, we identified opioid- and sedative-hypnotic-naïve women who had M + R from 2008 to 2017. Women who filled ≥ 1 peri-operative prescription and ≥ 2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors.We evaluated 23,025 opioid-naïve women and 25,046 sedative-hypnotic-naïve women. We found that 17,174 opioid-naïve women filled a peri-operative opioid prescription, and of those, 2962 (17.2%) became opioid NPUs post-operatively. Additionally, 9426 sedative-hypnotic-naïve women filled a peri-operative sedative-hypnotic prescription, and of those, 1612 (17.1%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤ 49 [OR 1.77 (95% CI 1.40-2.24)] and age 50-64 [1.60 (1.27-2.03)] compared to age ≥ 65; Medicaid insurance [2.34 (1.40-3.90)]; southern residence [1.42 (1.22-1.64)]; breast cancer diagnosis [2.24 (1.28-3.91)]; and chemotherapy [2.17 (1.94-2.42)]. Risk of NPU increased with higher risk score. Women with ≥ 3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors [2.94 (2.51-3.43)]. Comparable findings were seen regarding new persistent opioid use.Women who have M + R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient's risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.

43 Background: Most oral anti-cancer drugs (OACD) prescriptions require extensive coordination between providers and payers, which can delay drug receipt. Specialty pharmacies are intended to facilitate communication between multiple entities to deliver OACDs with increased efficiency. In 2018, our cancer center partnered with Shields Health Solutions (SHS), a freestanding organization providing care coordination to implement a hospital-based specialty pharmacy. We evaluated the rate of failed drug receipt (FR) and time to drug receipt (TTR) before and after specialty pharmacy implementation. Methods: We prospectively collected data on all new OACD prescriptions for adult oncology patients at a large, urban cancer center from 1/1/2018 to 12/31/2019. In fall 2018, a specialty pharmacy was opened to facilitate drug procurement for patients. We collected patient demographic, clinical, and insurance data, OACD name, date prescribed, delivery date, and interactions with payers and financial assistance groups. For prescriptions received, TTR was the number of days from OACD prescription to patient receipt of the drug. FR was defined as failure to receive a prescribed OACD. We excluded OACD prescriptions for a washout period of two months during pharmacy initiation. We used multivariable logistic regression to examine factors associated with TTR > 7 days and FR before and after specialty pharmacy implementation. Results: In total, 883 patients were prescribed 1145 new OACDs. The majority of prescribed drugs were targeted treatment (56%, N = 646) and 72% (N = 819) required prior authorization (PA). Of all prescriptions, 86% (N = 999) were successfully received with an overall median TTR of 7 days. Adjusted analyses showed that patients were more likely to receive their drugs in less than 7 days after specialty pharmacy implementation (OR: 1.4 95% CI 1.04 – 1.81), p = 0.03). In an unadjusted analysis, patients were more likely to receive their initial medications after specialty pharmacy implementation, compared to before specialty pharmacy implementation (89% vs. 84%, p = 0.04). Multivariable analysis showed a trend toward more patients receiving drugs after specialty pharmacy implementation (OR: 1.42, 95% CI 0.98 – 2.03, p = 0.06). Conclusions: The implementation of a hospital-based specialty pharmacy in partnership with SHS decreased TTR. This difference is in part attributable to improved care coordination and communication. A centralized approach may improve overall efficiency due to fewer clinical practice disruptions.

6 Background: The past decade has seen a dramatic increase in the number of Food and Drug Administration approvals of oral anti-cancer drugs (OACDs). Most OACD prescriptions require coordination between payers and providers, which can delay drug receipt. In May 2021, two bills were introduced in the US House of Representatives (HR 3173 and HR 3258) to streamline the prior authorization (PA) process. In this study, we examined clinical and process-related factors associated with PA and time to drug receipt (TTR) for patients who received a new OACD prescription. Methods: We prospectively collected data on all new OACD prescriptions for adult oncology patients from 1/1/2018 to 12/31/2019. We collected patient demographic, medical, and insurance data, drug type (hormonal, chemotherapy, targeted), and specialty pharmacy interactions with payers and financial assistance groups, including PA information. TTR was defined as the number of days from OACD prescription to patient receipt of the drug. We used multivariable logistic regression to separately assess factors associated with TTR and factors associated with PA for patients who received a new OACD prescription. Results: The cohort for both models included 883 patients who were prescribed 1014 new OACDs. Of these prescriptions, 72.3% (N=733) required PA. The median age was 66 and 44% identified as White. The median TTR was 7 days (IQR 0 – 142; 25% ≥ 14 days; and 5% ≥ 30 days). In unadjusted analyses, PA was associated with insurance and drug type and delayed TTR was associated with PA and insurance type. In a multivariable analysis, patients with Medicaid insurance were more likely to require PA compared to patients with Medicare (OR 1.93 (1.14 – 3.32), p=0.03). In addition, patients prescribed targeted and hormone therapies were more likely to require PA than those prescribed oral chemotherapy (targeted: OR 3.33 [2.38 – 4.68], p

41 Background: Oral anti-cancer drugs (OACDs) have become increasingly prescribed over the last 10 years and require a significant amount of care coordination. Preliminary administrative database studies have shown that 10-15% of prescriptions are never received by the patient, but the reasons behind this are poorly understood. In this study, we prospectively identified failure to receive (FR) cases in which OACD prescriptions were never received by patients, examined underlying reasons for FR, and assessed clinical and process-related factors associated with FR. Methods: We prospectively collected data on new OACD prescriptions for adult oncology patients at a large, urban academic cancer center from 1/1/2018 to 12/31/2019. We collected patient demographic, clinical, and insurance data, OACD delivery date, and interactions with payers and financial assistance groups. FR was defined as failure to receive a prescribed OACD. Reasons for FR were confirmed by manual chart review and classified into seven categories: clinical deterioration, financial access, provider-driven clinical decision making, patient-directed change, transfer of care, lost to follow up, and other. We calculated the relative proportion of each FR category and used multivariable logistic regression to identify factors associated with FR, including initiation of a prior authorization and drug class. Results: The cohort included 1,080 patients who were prescribed 1,269 new OACDs. Of these prescriptions, 13% (N=163) were categorized as FR. Among the 158 patients with FR, average patient age was 66 years, 55% identified as non-Hispanic white, 61% had any Medicare plan, 11% had Medicaid only, and 25% had commercial insurance. Overall, 18% of FR cases were attributed to clinical deterioration, 13% to financial access, 29% to provider-driven clinical decision making, 17% to patient-directed change, 13% to transfer of care, and 5% were lost to follow up. Univariate analysis showed that FR was less likely in cases where prior authorization was initiated (p < 0.001) and multivariate analysis confirmed this result (OR 0.47 [CI 0.33-0.66], p < 0.001). Conclusions: Though the majority of oncology patients prescribed OACDs received the drug, 13% of patients in our study experienced FR. FR is associated with a lack of prior authorization initiation, which may reflect barriers to access, a change in clinical decision-making, or patient choice. Ultimately, FR is multifactorial and may be appropriate in some cases. More work is needed to determine whether improved access would increase uptake in some patients. [Table: see text]

184 Background: Routine screening for financial hardship may identify patients at risk of financial crisis (bankruptcy or inability to afford food or medication). Identifying financial hardship risk is a critical step toward mitigating financial toxicity, associated with earlier mortality and poorer quality of life. We are studying the implementation of systematic financial hardship screening using the electronic health record (EHR) in a large, urban, outpatient cancer center. Methods: Guided by the Consolidated Framework for Implementation Research, we met with key stakeholders, including providers, medical assistants (MA’s), administrative staff, and patient advocates to develop a process to systematically screen all cancer patients for financial hardship risk using 2 items (Q1 and Q3) from the Comprehensive Score for Financial Toxicity (COST). We initiated the process in the breast oncology clinic and partnered with EPIC to integrate the items in the EHR and patient portal. In March 2021, we implemented systematic screening, with automatic prompts to reassess monthly. Results: The workflow includes two mechanisms for patients to complete the 2 items: through the online patient portal during appointment check-in; or through a paper form in English or Spanish, distributed to patients during check-in. An EHR flag was created to notify staff if the patient is due to complete the questions during check-in. During vital signs assessment, the MA collects the form and enters the responses into the EHR. Two important factors were identified to improve the implementation: 1) Patient support to facilitate EHR portal use to reduce clinic workflow congestion; and 2) printed resources for patients who express financial concern. Ongoing discussions reveal that certain clinic days are busier, during which staff find it difficult to review EHR flag, provide and collect paper forms. To date, of 1,358 patients seen in the breast oncology clinic, 526 (39%) have responded to the question, “I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment,” and of those, 278 (53%) responded “not at all” or “a little bit.” Of the 532 patients (39%) who responded to the question, “I worry about the financial problems I will have in the future as a result of my illness or treatment,” 215 (40%) responded “quite a bit” or “very much.” Conclusions: Preliminary analysis highlights the complexities of initiating systematic financial screening in oncology clinics. However, interim results suggest financial hardship is prevalent. Next steps include: expanding to pediatric and gynecologic oncology; building a dashboard to inform financial referrals; comparison of the 2-item screener to the COST survey in a subset of patients; qualitative interviews and focus groups with patients and staff to improve current procedures and optimize the use of dashboards and alerts to focus interventions and referrals on patients most in need.

264 Background: Opioid misuse is a public health crisis. Initial opioid exposures often occur post-operatively, and 10% of opioid-naïve patients who undergo cancer surgery subsequently become long-term opioid users. It has been shown that 70% of opioids prescribed post-operatively go unused, but only 9% of unused pills are disposed appropriately, which increases the risk of unintended use. We evaluated the impact of an inexpensive, password-protected dispensing device with mail return capacity on retrieval of unused pills after cancer surgery. Methods: Adult patients scheduled for major cancer-related surgery were eligible. Enrolled patients received opioid prescriptions in a password-protected, pill-dispensing device (Addinex) from a specialty pharmacy. The mechanical device links to a smartphone app, which provides passwords on a prescriber-defined schedule. Patients request a password when they are in pain, enter the password into the device and receive a pill if the prescribed time has elapsed. The smartphone app provides clinical guidance based on patient-reported pain levels, and suggests tapering strategies. Patients are instructed to return the device in a DEA-approved mailer when opioid use is no longer required for pain control. Unused pills are destroyed upon receipt. The primary objective was to determine the feasibility of device return, defined as > 50% of patients with device return. We also explored patterns of device use, patient reported outcomes, and device satisfaction via surveys and semi-structured interviews. Results: Between October, 2020 and April, 2021, 13 patients completed the study; 4 patients are currently enrolled. Among the initial 13 patients, 7 underwent abdominal hysterectomy, 4 underwent mastectomy and 2 underwent cutaneous tumor resections. The majority of these patients (n = 10, 77%) returned the device, and more than half (n = 7, 54%) returned the device within 6 weeks of surgery. Only a minority of patients (n = 5, 38%) used the device to obtain opioids; most (n = 8, 62%) used no opioids at home, and all of these patients returned the device and the unused pills. Of 11 patients who participated in semi-structured interviews, most (n = 7, 64%) said they felt safer having opioids in the device instead of a regular pill bottle. Among device users, the majority (n = 4, 80%) reported an overall positive experience. All non-users reported having no opioid requirement for pain control. Conclusions: Our early findings suggest that use of an inexpensive, password-protected, pill-dispensing device to assist with opioid dispensing and return is feasible, with a high rate of device and unused opioid return to the pharmacy. This strategy may be effective for reducing opioid diversion. Analyses and recruitment are ongoing to evaluate the benefits of reducing post-operative opioid consumption.

Several organizations have developed frameworks to systematically assess the value of new drugs.To evaluate the convergent validity and interrater reliability of 4 value frameworks to understand the extent to which these tools can facilitate value-based treatment decisions in oncology.Eight panelists used the American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), Institute for Clinical and Economic Review (ICER), and National Comprehensive Cancer Network (NCCN) frameworks to conduct value assessments of 15 drugs for advanced lung and breast cancers and castration-refractory prostate cancer. Panelists received instructions and published clinical data required to complete the assessments, assigning each drug a numeric or letter score. Kendall's Coefficient of Concordance for Ranks (Kendall's W) was used to measure convergent validity by cancer type among the 4 frameworks. Intraclass correlation coefficients (ICCs) were used to measure interrater reliability for each framework across cancers. Panelists were surveyed on their experiences.Kendall's W across all 4 frameworks for breast, lung, and prostate cancer drugs was 0.560 (P= 0.010), 0.562 (P = 0.010), and 0.920 (P0.001), respectively. Pairwise, Kendall's W for breast cancer drugs was highest for ESMO-ICER and ICER-NCCN (W = 0.950, P = 0.019 for both pairs) and lowest for ASCO-NCCN (W = 0.300, P = 0.748). For lung cancer drugs, W was highest pairwise for ESMO-ICER (W = 0.974, P = 0.007) and lowest for ASCO-NCCN (W = 0.218, P = 0.839); for prostate cancer drugs, pairwise W was highest for ICER-NCCN (W = 1.000, P0.001) and lowest for ESMO-ICER and ESMO-NCCN (W = 0.900, P = 0.052 for both pairs). When ranking drugs on distinct framework subdomains, Kendall's W among breast cancer drugs was highest for certainty (ICER, NCCN: W = 0.908, P = 0.046) and lowest for clinical benefit (ASCO, ESMO, NCCN: W = 0.345, P = 0.436). Among lung cancer drugs, W was highest for toxicity (ASCO, ESMO, NCCN: W = 0. 944, P0.001) and lowest for certainty (ICER, NCCN: W = 0.230, P = 0.827); and among prostate cancer drugs, it was highest for quality of life (ASCO, ESMO: W = 0.986, P = 0.003) and lowest for toxicity (ASCO, ESMO, NCCN: W = 0.200, P = 0.711). ICC (95% CI) for ASCO, ESMO, ICER, and NCCN were 0.800 (0.660-0.913), 0.818 (0.686-0.921), 0.652 (0.466-0.834), and 0.153 (0.045-0.371), respectively. When scores were rescaled to 0-100, NCCN provided the narrowest band of scores. When asked about their experiences using the ASCO, ESMO, ICER, and NCCN frameworks, panelists generally agreed that the frameworks were logically organized and reasonably easy to use, with NCCN rated somewhat easier.Convergent validity among the ASCO, ESMO, ICER, and NCCN frameworks was fair to excellent, increasing with clinical benefit subdomain concordance and simplicity of drug trial data. Interrater reliability, highest for ASCO and ESMO, improved with clarity of instructions and specificity of score definitions. Continued use, analyses, and refinements of these frameworks will bring us closer to the ultimate goal of using value-based treatment decisions to improve patient care and outcomes.This work was funded by Eisai Inc. Copher and Knoth are employees of Eisai Inc. Bentley, Lee, Zambrano, and Broder are employees of Partnership for Health Analytic Research, a health services research company paid by Eisai Inc. to conduct this research. For this study, Cohen, Huynh, and Neville report fees from Partnership for Health Analytic Research. Outside of this study, Cohen receives grants and direct consulting fees from various companies that manufacture and market pharmaceuticals. Mei reports a grant from Eisai Inc. during this study. The other authors have no disclosures to report. Study concept and design were contributed by Bentley and Broder, with assistance from Elkin and Cohen. Bentley took the lead in data collection, along with Elkin, Huynh, Mukherjea, Neville, Mei, Popescu, Lee, and Zambrano. Data interpretation was performed by Bentley and Broder, along with Elkin, Cohen, Copher, and Knoth. The manuscript was written primarily by Bentley, along with Elkin and Broder, and revised by Bentley, Broder, Elkin, Cohen, Copher, and Knoth. Select components of this work's methods were presented at ISPOR 19th Annual European Congress held in Vienna, Austria, October 29-November 2, 2016, and Society for Medical Decision Making 38th Annual North American Meeting held in Vancouver, Canada, October 23-26, 2016.

Background Several organizations have developed frameworks to systematically assess the value of new drugs. These organizations include the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO), the Institute for Clinical and Economic Review (ICER), and the National Comprehensive Cancer Network (NCCN). Objectives To understand the extent to which these four tools can facilitate value-based treatment decisions in oncology. Methods In this pilot study, eight panelists conducted value assessments of five advanced lung cancer drugs using the ASCO, ESMO, and ICER frameworks. The panelists received instructions and published clinical data required to complete the assessments. Published NCCN framework scores were abstracted. The Kendall's W coefficient was used to measure convergent validity among the four frameworks. Intraclass correlation coefficients were used to measure inter-rater reliability among the ASCO, ESMO, and ICER frameworks. Sensitivity analyses were conducted. Results Drugs were ranked similarly by the four frameworks, with Kendall's W of 0.703 ( P = 0.006) across all the four frameworks. Pairwise, Kendall's W was the highest for ESMO-ICER ( W = 0.974; P = 0.007) and ASCO-NCCN ( W = 0.944; P = 0.022) and the lowest for ICER-NCCN ( W = 0.647; P = 0.315) and ESMO-NCCN ( W = 0.611; P = 0.360). Intraclass correlation coefficients (confidence interval [CI]) for the ASCO, ESMO, and ICER frameworks were 0.786 (95% CI 0.517–0.970), 0.804 (95% CI 0.545–0.973), and 0.281 (95% CI 0.055–0.799), respectively. When scores were rescaled to 0 to 100, the ICER framework provided the narrowest band of scores. Conclusions The ASCO, ESMO, ICER, and NCCN frameworks demonstrated convergent validity, despite differences in conceptual approaches used. The ASCO inter-rater reliability was high, although potentially at the cost of user burden. The ICER inter-rater reliability was poor, possibly because of its failure to distinguish differential value among the sample of drugs tested. Refinements of all frameworks should continue on the basis of further testing and stakeholder feedback.

The optimal method of screening for thyroid cancer in survivors of childhood and young adult cancer exposed to neck radiation remains controversial. Outcome data for a physical exam-based screening approach are lacking. We conducted a retrospective review of adult survivors of childhood and young adult cancer with a history of neck radiation followed in the Adult Long-Term Follow-Up Clinic at Memorial Sloan Kettering between November 2005 and August 2014. Eligible patients underwent a physical exam of the thyroid and were followed for at least 1 year afterwards. Ineligible patients were those with prior diagnosis of benign or malignant thyroid nodules. During a median follow-up of 3.1 years (range 0–9.4 years), 106 ultrasounds and 2277 physical exams were performed among 585 patients. Forty survivors had an abnormal thyroid physical exam median of 21 years from radiotherapy; 50% of those with an abnormal exam were survivors of Hodgkin lymphoma, 60% had radiation at ages 10–19, and 53% were female. Ultimately, 24 underwent fine needle aspiration (FNA). Surgery revealed papillary carcinoma in seven survivors; six are currently free of disease and one with active disease is undergoing watchful waiting. Among those with one or more annual visits, representing 1732 person-years of follow-up, no cases of thyroid cancer were diagnosed within a year of normal physical exam. These findings support the application of annual physical exam without routine ultrasound for thyroid cancer screening among survivors with a history of neck radiation. Survivors with a history of neck radiation may not require routine thyroid ultrasound for thyroid cancer screening. Among adult survivors of childhood and young adult cancer with a history of radiation therapy to the neck, annual physical exam is an acceptable thyroid cancer screening strategy.

PURPOSE: IBM Watson for Oncology trained by Memorial Sloan Kettering (WFO) is a clinical decision support tool designed to assist physicians in choosing therapies for patients with cancer. Although substantial technical and clinical expertise has guided the development of WFO, patients’ perspectives of this technology have not been examined. To facilitate the optimal delivery and implementation of this tool, we solicited patients’ perceptions and preferences about WFO. METHODS: We conducted nine focus groups with 46 patients with breast, lung, or colorectal cancer with various treatment experiences: neoadjuvant/adjuvant chemotherapy, chemotherapy for metastatic disease, or systemic therapy through a clinical trial. In-depth qualitative and quantitative data were collected and analyzed to describe patients’ attitudes and perspectives concerning WFO and how it may be used in clinical care. RESULTS: Analysis of the qualitative data identified three main themes: patient acceptance of WFO, physician competence and the physician-patient relationship, and practical and logistic aspects of WFO. Overall, participant feedback suggested high levels of patient interest, perceived value, and acceptance of WFO, as long as it was used as a supplementary tool to inform their physicians’ decision making. Participants also described important concerns, including the need for strict processes to guarantee the integrity and completeness of the data presented and the possibility of physician overreliance on WFO. CONCLUSION: Participants generally reacted favorably to the prospect of WFO being integrated into the cancer treatment decision-making process, but with caveats regarding the comprehensiveness and accuracy of the data powering the system and the potential for giving WFO excessive emphasis in the decision-making process. Addressing patients’ perspectives will be critical to ensuring the smooth integration of WFO into cancer care.

PURPOSE: To compare the effectiveness of personalized treatment for small (≤4 cm) renal tumors versus routine partial nephrectomy (PN), accounting for various competing causes of mortality. MATERIALS AND METHODS: A state-transition microsimulation model was constructed to compare life expectancy of management strategies for small renal tumors by using 1 000 000 simulations in the following ways: routine PN or personalized treatment involving percutaneous ablation for risk factors for worsening chronic kidney disease (CKD), and otherwise PN; biopsy, with triage of renal cell carcinoma (RCC) to PN or ablation depending on risk factors for worsening CKD; active surveillance for growth; and active surveillance when MRI findings are indicative of papillary RCC. Transition probabilities were incorporated from the literature. Effects of parameter variability were assessed in sensitivity analysis. RESULTS: In patients of all ages with normal renal function, routine PN yielded the longest life expectancy (eg, 0.67 years in 65-year-old men with nephrometry score [NS] of 4). Otherwise, personalized strategies extended life expectancy versus routine PN: in CKD stages 2 or 3a, moderate or high NS, and no comorbidities, MRI guidance for active surveillance extended life expectancy (eg, 2.60 years for MRI vs PN in CKD 3a, NS 10); and with Charlson comorbidity index of 1 or more, biopsy or active surveillance for growth extended life expectancy (eg, 2.70 years for surveillance for growth in CKD 3a, NS 10). CKD 3b was most effectively managed by using MRI to help predict papillary RCC for surveillance. CONCLUSION: For patients with chronic kidney disease and small renal tumors, personalized treatment selection likely extends life expectancy. © RSNA, 2019 Online supplemental material is available for this article.

Screening mammography is generally recommended for women in their 50s and 60s and may also be appropriate for many women in their 40s and 70s. Federal regulation of mammography facilities in the 1990s, prompted by growing use and increased insurance coverage of screening, raised concerns about women’s access to mammography. Since that time, a number of investigators have studied the relationship between geographic access to mammography and the use and outcomes of screening. A review of this literature finds some association between geographic access and use of screening mammography. There is less evidence for an association between geographic access to mammography and breast cancer stage at diagnosis. Despite methodologic challenges to studying these relationships and interpreting findings, results of such studies can help identify areas where geographic access to mammography can be improved. Targeted efforts to enhance geographic access to mammography may increase screening uptake in women for whom it is recommended and reduce disparities in screening use and outcomes.

Introduction Minimally invasive radical prostatectomy has become the most common surgical treatment for prostate cancer. In this study we describe patterns of minimally invasive radical prostatectomy adoption among surgeons who performed open radical prostatectomy before their first minimally invasive radical prostatectomy and those who did not. Methods We performed a retrospective cohort study using the population based SEER (Surveillance, Epidemiology, and End Results)-Medicare data set. We identified all surgeons who performed minimally invasive radical prostatectomy in 2003 to 2010 in men with prostate cancer 66 years old or older. Surgeons were classified as “converters” if they performed open radical prostatectomy before their first minimally invasive radical prostatectomy or “de novos” if they had not. We estimated annual minimally invasive radical prostatectomy volume and the proportion of prostatectomies performed minimally invasively. We used logistic regression to identify predictors of minimally invasive radical prostatectomy discontinuation. Results A total of 11,511 minimally invasive radical prostatectomies were performed by 738 minimally invasive radical prostatectomy surgeons (converters 337 and de novos 401). Converters performed 55% of all minimally invasive radical prostatectomies and had higher median annual minimally invasive radical prostatectomy volume than de novos (4 vs 2). About 34% of converters and 54% of de novos discontinued minimally invasive radical prostatectomy after their first year. Second year discontinuation of minimally invasive radical prostatectomy was more likely among de novo surgeons (OR 1.9, 95% CI 1.3–2.7) and less likely among surgeons with higher minimally invasive radical prostatectomy volume in their first year (OR 0.5, 95% CI 0.5–0.6). Conclusions During the years of the greatest growth in minimally invasive radical prostatectomy, surgeon adoption of this technique varied by surgeon type and volume. Many surgeons discontinued, and possibly abandoned, minimally invasive radical prostatectomy. Based on these observations, experienced and higher volume surgeons will be most successful adopting new surgical technology.

PURPOSE: During ongoing controversies about mammography screening, many investigators have stated that performance improvements in screening mammography may mitigate concerns about harms. However, there have been few attempts to quantify performance improvements required to recommend mammography screening. Based on USPSTF benchmarks, we utilized revealed preference methods to ascertain quantitative thresholds at which screening mammography would be recommended beyond biennial screening in women 50 and older. METHODS: Benefits of routine screening mammography (breast cancer deaths averted) were from published USPSTF meta-analyses. Potential harms (10-year cumulative probability of at least one false-positive) were from published Breast Cancer Surveillance Consortium estimates. We identified the implicit threshold (benefit/harm ratio) to recommend biennial screening starting at age 50. Using this threshold, we ascertained reductions of false-positives required to recommend more frequent screening and screening initiation under age 50 using revealed preference analyses. RESULTS: Using USPSTF implied benefit/harm ratio, routine biennial screening would be recommended starting at 40 if false-positives declined by at least 62%. Reductions of false-positive proportions of 74% would be required to recommend annual screening starting at 40 and reductions of false-positive proportions of 31% would be required to support annual screening starting at 50. CONCLUSIONS: Using USPSTF revealed preferences, 31–74% reductions in false-positives would be required to recommend mammography screening beyond biennial screening starting at age 50. Widespread implementation of tomosynthesis and reducing recall rates to the lower end of recommended recall rates (5–12%) would provide support for expanding screening beyond biennial screening in women age 50.

Purpose To assess the association between geographic access to mammography facilities and women's mammography utilization frequency. Methods Using data from the population-based 1995–2007 Wisconsin Women's Health study, we used proportional odds and logistic regression to test whether driving times to mammography facilities and the number of mammography facilities within 10 km of women's homes were associated with mammography frequency among women aged 50–74 years and whether associations differed between Rural-Urban Commuting Areas and income and education groups. Results We found evidence for nonlinear relationships between geographic access and mammography utilization (nonlinear effects of driving times and facility density, P -values .01 and .005, respectively). Having at least one nearby mammography facility was associated with greater mammography frequency among urban women (1 vs. 0 facilities, odds ratio 1.26, 95% confidence interval, 1.09–1.47), with similar effects among rural women. Adding more facilities had decreasing marginal effects. Long driving times tended to be associated with lower mammography frequency. We found no effect modification by income, education, or urbanicity. In rural settings, mammography nonuse was higher, facility density smaller, and driving times to facilities were longer. Conclusions Having at least one mammography facility near one's home may increase mammography utilization, with decreasing effects per each additional facility.

Purpose: Despite some advantages to their use, long-term central venous catheters (CVCs) are associated with complications for patients who require chemotherapy. Understanding of these risks in commercially insured populations is limited. This information can inform medical policies that ensure the appropriate use of venous access devices. This study’s objectives were to assess the extent of variation in use of long-term CVCs in a cohort of commercially insured women with breast cancer, and to assess risks of associated complications. Methods: Retrospective cohort analysis was conducted using health insurance claims between January 2006 and October 2013. The cohort included commercially insured women age 18 years diagnosed with breast cancer who received infusion chemotherapy (N 31,047). We conducted matched and casemix adjusted Cox proportional hazard modeling to assess differences in bloodstream infections and thrombovascular complications between patients using long-term CVCs and those using temporary intravenous catheters. Results: Approximately two thirds of the cohort had a longterm CVC, although rates varied across regions (57% to 75%), health plans (65% to 70%), and insurance coverage (63% to 68%). After propensity score matching, the adjusted hazard ratio for infection was 2.70 (95% CI, 2.31 to 3.16) and thrombovascular complications, 2.61 (95% CI, 2.33 to 2.93) in patients with long-term CVCs compared with those with temporary intravenous catheters. Conclusion: Although long-term CVCs may have benefits, they are associated with increased morbidity. Regional and health plan variation in long-term CVC insertion suggests that some of their use reflects provider- or institution-driven variation in practice. Evidence-based guidelines and tools may help decrease discretionary use of long-term CVCs.

Background Facing rising incidence of basal cell carcinoma (BCC) and increasing pressure to contain health care spending, physicians need to contemplate cost-effective paradigms for managing BCC. Objective We sought to perform a cost analysis comparing the traditional BCC management scheme with a simplified detect-and-treat scheme that eliminates the biopsy before initiating definitive treatment. Methods A decision analytic model was developed to compare the costs of traditional BCC management with the detect-and-treat scheme, under which qualifying lesions diagnosed clinically were either treated with shave removal or referred to Mohs micrographic surgery for on-site histologic check. Values for model parameters were based on literature and our institutional data analysis. Costs were based on 2014 Medicare fee schedule. Results The average cost per lesion with detect-and-treat scheme was $449 for non-Mohs micrographic surgery–indicated lesions (vs $566 with traditional management, $117 in savings) and $819 for Mohs micrographic surgery–indicated lesions (vs $864 with traditional management, $45 in savings). The combined weighted average savings per case was $95 (15% of total average cost). Conclusions were similar under various plausible scenarios. Limitations Model parameter values may vary based on individual practices. Conclusions A simplified management strategy eliminating routine pretreatment biopsy can reduce BCC treatment cost without compromising quality of care.

Background Cetuximab was approved for use in chemoradiation therapy (CRT) for locally advanced head and neck squamous cell carcinoma (HNSCC) in 2006. Methods Among 3705 patients with locally advanced HNSCC identified in the linked Surveillance Epidemiology and End Results (SEER) Medicare database, we assessed treatment trends, including surgery, radiation therapy (RT), CRT, and specific agents used in CRT. We examined the influence of demographic and clinical characteristics on the likelihood of receiving CRT before and after 2006. Results Chemoradiation use increased from 29% of patients diagnosed in 2001 to 61% in 2009 (p

Objectives To characterize patterns of imaging surveillance after nephrectomy in a population-based cohort of older patients with kidney cancer. Patients and Methods Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified patients aged ≥66 years who underwent partial or radical nephrectomy for localized kidney cancer diagnosed between 2000 and 2009. Primary outcomes were chest imaging (X-ray or computed tomography [CT]) and abdominal imaging (CT, MRI or ultrasonography) in Medicare claims from 4 to 36 months after surgery. We estimated the frequency of imaging in three time periods (postoperative months 4–12, 13–24, 25–36), stratified by tumour stage. Repeated-measures logistic regression was used to identify the patient and disease characteristics associated with imaging. Results Rates of chest imaging were 65–80%, with chest X-ray surpassing CT in each time period. Rates of abdominal imaging were 58–76%, and cross-sectional imaging was more common than ultrasonography in each time period. Use of cross-sectional chest and abdominal imaging increased over time, while the use of chest X-ray decreased (P < 0.01). Ultrasonography use remained stable for patients with T1 and T2 disease, but the rate of use decreased in patients with T3 disease (P < 0.05). Rates of chest and abdominal imaging increased with tumour stage (P < 0.001). Conclusions Patterns of imaging suggest possible overuse in patients at low risk of recurrence and underuse in those at greater risk. New surveillance imaging guidelines may reduce unwarranted variability and promote risk-based, cost-effective management after nephrectomy.

Although breast-conserving surgery is oncologically safe for women with early-stage breast cancer, mastectomy rates are increasing. The objective of this study was to examine the role of breast reconstruction in the surgical management of unilateral early-stage breast cancer.A retrospective cohort study of women diagnosed with unilateral early-stage breast cancer (1998 to 2011) identified in the National Cancer Data Base was conducted. Rates of breast-conserving surgery, unilateral and bilateral mastectomy with contralateral prophylactic procedures (per 1000 early-stage breast cancer cases) were measured in relation to breast reconstruction. The association between breast reconstruction and surgical treatment was evaluated using a multinomial logistic regression, controlling for patient and disease characteristics.A total of 1,856,702 patients were included. Mastectomy rates decreased from 459 to 360 per 1000 from 1998 to 2005 (p0.01), increasing to 403 per 1000 in 2011 (p0.01). The mastectomy rates rise after 2005 reflects a 14 percent annual increase in contralateral prophylactic mastectomies (p0.01), as unilateral mastectomy rates did not change significantly. Each percentage point of increase in reconstruction rates was associated with a 7 percent increase in the probability of contralateral prophylactic mastectomies, with the greatest variation explained by young age(32 percent), breast reconstruction (29 percent), and stage 0 (5 percent).Since 2005, an increasing proportion of early-stage breast cancer patients have chosen mastectomy instead of breast-conserving surgery. This trend reflects a shift toward bilateral mastectomy with contralateral prophylactic procedures that may be facilitated by breast reconstruction availability.

BACKGROUND Despite advantages in terms of cancer control and organ preservation, the benefits of chemotherapy and radiation therapy (CTRT) may be offset by potentially severe treatment-related toxicities, particularly in older patients. The objectives of this study were to assess the types and frequencies of toxicities in older adults with locally or regionally advanced head and neck squamous cell carcinoma (HNSCC) who were receiving either primary CTRT or radiation therapy (RT) alone. METHODS With Surveillance, Epidemiology, and End Results cancer registry data linked with Medicare claims, patients who were 66 years old or older with locally advanced HNSCC, were diagnosed from 2001 to 2009, and received CTRT or RT alone were identified. Differences in the frequency of toxicity-related hospital admissions and emergency room visits as well as feeding tube use were examined, and controlling for demographic and disease characteristics, this study estimated the impact of chemotherapy on the likelihood of toxicity. RESULTS Among patients who received CTRT (n = 1502), 62% had a treatment-related toxicity, whereas 46% of patients who received RT alone (n = 775) did. When the study controlled for demographic and disease characteristics, CTRT patients were twice as likely to experience an acute toxicity in comparison with their RT-only peers. Fifty-five percent of CTRT patients had a feeding tube placed during or after treatment, whereas 28% of the RT-only group did. CONCLUSIONS In this population-based cohort of older adults with HNSCC, the rates of acute toxicities and feeding tube use in patients receiving CTRT were considerable. It is possible that for certain older patients, the potential benefit of adding chemotherapy to RT does not outweigh the harms of this combined-modality therapy. Cancer 2015. © 2015 American Cancer Society. Cancer 2015;121:2083–2089. © 2015 American Cancer Society.

Importance Postoperative complications are associated with increased hospital costs following major surgery, but the mechanism by which they increase cost and the categories of care that drive this increase are poorly described. Objective To describe the association of postoperative complications with hospital costs following total gastrectomy for gastric adenocarcinoma. Design, Setting, and Participants This retrospective analysis of a prospectively collected gastric cancer surgery database at a single National Cancer Institute–designated comprehensive cancer center included all patients undergoing curative-intent total gastrectomy for gastric adenocarcinoma between January 2009 and December 2012 and was conducted in 2015 and 2016. Main Outcomes and Measures Ninety-day normalized postoperative costs. Hospital accounting system costs were normalized to reflect Medicare reimbursement levels using the ratio of hospital costs to Medicare reimbursement and categorized into major cost categories. Differences between costs in Medicare proportional dollars (MP $) can be interpreted as the amount that would be reimbursed to an average hospital by Medicare if it paid differentially based on types and extent of postoperative complications. Results In total, 120 patients underwent curative-intent total gastrectomy for stage I through III gastric adenocarcinoma between 2009 and 2012. Of these, 79 patients (65.8%) were men, and the median (interquartile range) age was 64 (52-70) years. The 51 patients (42.5%) who underwent an uncomplicated total gastrectomy had a mean (SD) normalized cost of MP $12 330 (MP $2500), predominantly owing to the cost of surgical care (mean [SD] cost, MP $6830 [MP $1600]). The 34 patients (28.3%) who had a major complication had a mean (SD) normalized cost of MP $37 700 (MP $28 090). Surgical care was more expensive in these patients (mean [SD] cost, MP $8970 [MP $2750]) but was a smaller contributor to total cost (24%) owing to increased costs from room and board (mean [SD] cost, MP $11 940 [MP $8820]), consultations (mean [SD] cost, MP $3530 [MP $2410]), and intensive care unit care (mean [SD] cost, MP $7770 [MP $14 310]). Conclusions and Relevance Major complications were associated with tripled normalized costs following curative-intent total gastrectomy. Most of the excess costs were related to the treatment of complications. Interventions that decrease the number or severity of postoperative complications could result in substantial cost savings.

Background Expert groups and national guidelines recommend individualized decision making about screening mammography for women in their 40s at low-to-average risk of breast cancer. We created Breast Screening Decisions (BSD), a personalized, web-based decision aid, to help women decide when to start and how often to have routine screening mammograms. We evaluated BSD in a large, prospective pilot trial of women and their clinicians. Methods Women ages 40–49 were invited to use BSD before a scheduled preventive care visit. One month post-visit, users were asked about decisional conflict, knowledge, perceptions and worry about breast cancer and screening. They were also asked whether they had a screening mammogram since their visit, scheduled an appointment for a screening mammogram, or if they were planning to schedule an appointment within the next six months. Women who responded “no” to each of these successive questions were considered to have no plan for a screening mammogram within the next 6 months, unless they explicitly stated that they were unsure about screening mammography. Clinicians were surveyed regarding mammography discussions and perceived patient knowledge and anxiety. Results Of 1,100 women invited to use BSD, 253 accessed the website, and 168 were eligible to participate in the pilot study. One-fifth had a family history of breast cancer, and at least 76% had any prior mammogram. At follow-up, 88% of BSD users reported discussing mammography at their visit, and 77% said they had a screening mammogram since the visit or that they made or were planning to make a screening mammogram appointment. The average decisional conflict score was 22.5, within the threshold for implementing decisions. Decisional conflict scores were lowest in women who said that they had or planned to have a mammogram (mean 21.4, 95% CI 18.3-24.6), higher in those who did not (mean 24.8, 95% CI 19.2-30.5), and highest in those who were unsure (mean 31.5, 95% CI 13.9-49.1). Most BSD users expressed accurate perceptions of their breast cancer risk and the benefits and limitations of screening. Conclusions A web-based decision aid may support informed, individualized decisions about screening mammography and facilitate discussions about screening between women in their 40s and their clinicians. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0423-7) contains supplementary material, which is available to authorized users.

Purpose Radical cystectomy and urinary diversion may cause chronic metabolic acidosis, leading to long-term bone loss in patients with bladder cancer. However, the risk of fractures after radical cystectomy has not been defined. We assessed whether radical cystectomy and intestinal urinary diversion are associated with increased risk of fracture. Patients and Methods Population-based study using SEER-Medicare–linked data from 2000 through 2007 for patients with stage 0-III bladder cancer. We evaluated the association between radical cystectomy and risk of fracture at any site, controlling for patient and disease characteristics. Results The cohort included 50,520 patients, of whom 4,878 had cystectomy and urinary diversion. The incidence of fracture in the cystectomy group was 6.55 fractures per 100 person-years, compared with 6.39 fractures per 100 person-years in those without cystectomy. Cystectomy was associated with a 21% greater risk of fracture (adjusted hazard ratio, 1.21; 95% CI, 1.10 to 1.32) compared with no cystectomy, controlling for patient and disease characteristics. There was no evidence of an interaction between radical cystectomy and age, sex, comorbidity score, or cancer stage. Conclusion Patients with bladder cancer who have radical cystectomy and urinary diversion are at increased risk of fracture.

Objectives/Hypothesis Primary curative treatment of advanced laryngeal cancer may include surgery or chemoradiation, although recommendations vary and both are associated with complications. We evaluated predictors and trends in the use of these modalities and compared rates of complications and overall survival in a population-based cohort of older adults. Study Design Retrospective population-based cohort study. Methods Using Surveillance Epidemiology and End Results (SEER) cancer registry data linked with Medicare claims, we identified patients over 65 with advanced laryngeal cancer diagnosed 1999 to 2007 who had total laryngectomy (TL) or chemoradiation (CTRT) within 6 months following diagnosis. We identified complications and estimated the impact of treatment on overall survival, using propensity score methods. Results The proportion of patients receiving TL declined from 74% in 1999 to 26% in 2007 (P

Objectives Surveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database. Methods and materials The Surveillance, Epidemiology, and End Results–Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics. Results Of 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60–0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68–0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70–2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27–1.82). We also observed significant geographic variability in adherence. Conclusion Patterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.