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Marty Coyne,1,2 Amy Rinaldi,1 Katherine Brigham,1 James Hawthorne,1,2 Dimos Katsaros,1,2 Morgan Perich,2 Nicholas Carrara,1 Flore Pericaud,3 Chris Franzese,1,2 Graham Jones4 1Matchstick, Boonton, NJ, USA; 2University of Rhode Island School of Pharmacy, Kingston, RI, USA; 3Technical Research and Development, Novartis Pharmaceuticals, Basel, Switzerland; 4Technical Research and Development, Novartis Pharmaceuticals, East Hanover, NJ, USACorrespondence: Graham Jones, Technical Research and Development, Novartis Pharmaceuticals, East Hanover, NJ, USA, Email graham.jones@novartis.comBackground: Self-injection of biologics is a mainstay of chronic disease treatment, yet the process of self-injection often causes persistent apprehension and anxiety, distinct from needle phobia. While literature alludes to the role that routines and rituals play in self-injection, there is no comprehensive study on the routines and rituals self-injectors employ, nor of the process by which they are discovered and ingrained.Methods: We conducted a mixed-method, observational pilot ethnography study of 27 patients with plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis with and without prior biologic self-injection experience. Patients submitted self-made videos, photos, and projective exercises of an actual biologic self-injection and completed validated instruments to assess burden of treatment. Videos and photos containing routine and ritual elements were thematically categorized based on functional and emotional benefit, and analyzed for differences based on current biologic, dosing frequency, time on current biologic, and burden of treatment measures.Results: During patients’ initial at-home injections, training gaps became apparent, leading to a process of experimentation aimed at reducing pain/anxiety, increasing confidence, and building a consistent injection process. Routines were present in 27/27 (100%) patients and anchored the time, place, and process for injection, and incorporated approved use steps for the injection device. Ritual elements served as emotional coping strategies for patients and were present in 21/27 (77.8%) of patients.Conclusion: Our findings suggest that providing patients device training using adult learning principles, teaching routines and rituals concurrently, and providing at-home opportunities for practice with a device trainer may be useful strategies to reduce anxiety, avoid unnecessary experimentation, and improve adherence to injection therapy. While further studies are needed to generalize our findings, we posit that routine and ritual elements can be incorporated into existing patient-clinician interactions or novel digital interventions through mobile medical applications, smart training devices, and connected injection ecosystems.Keywords: training, drug delivery device, combination product, patient support, routines, rituals, burden of treatment, chronic disease, injection trainer, mixed methods research

Eloisa de Sá Moreira,1 David Robinson,2 Stephanie Hawthorne,2 Linda Zhao,2 Madelyn Hanson,2 Gena Kanas,2 Matthew Turnure,2 Christine Davis,2 Otavio Clark2 1Health Division, Kantar, São Paulo, Brazil; 2Health Division, Kantar, New York, NY, USACorrespondence: Matthew TurnureKantar 175 Greenwich St, WTC 3, 35th Floor, New York, NY, 10007, USATel +1 314-221-4323Email matthew.turnure@Kantar.comPurpose: We describe patterns of care and treatment outcomes for non-metastatic PCa (nmPCA), either hormone-sensitive or castration-resistant, in the United States of America (USA) in 2018.Methods: A survey (CancerMPact®) recruited physicians nationwide to answer an online questionnaire about how they treated patients with nmPCA. Questions covered aspects of treatment at all disease stages. Board-certified urologists and oncologists with at least five years of clinical practice and who treated at least 30 PCa patients monthly were included.Results: The survey included responses from ninety-four physicians with an average of 17.5 years of clinical practice, who had treated a combined average of 4415 patients with nmPCA per month in 2018. Approximately 40% of patients in stage I were managed with either active surveillance or observation/no therapy, decreasing to 20%, 8% and 6% in stages II, III and IV(M0), respectively. Intensity-modulated radiotherapy was favored over other radiotherapy modalities, with rates of use ranging between 60% and 69% depending on disease stage. Leuprolide as monotherapy or in combination with enzalutamide, abiraterone or bicalutamide were the most common systemic treatment options for non-metastatic hormone-sensitive PCa (nmHSPC) patients with the first or second recurrence. Only 16.5% of non-metastatic castration-resistant PCa (nmCRPC) patients did not relapse within five years of initial therapy for nmCRPC.Conclusion: While PCa treatment recommendations are rapidly changing due to advances in treatment, we observed great concordance between their most current versions and real-world data treatment patterns reported by US physicians.Keywords: real-world evidence, treatment, physician reported, questionnaire

Stephanie Hawthorne, Linda Zhao, Madelyn Hanson, Gena Kanas, Christine Davis, David Robinson, Matthew Turnure, Otavio Clark Kantar, Health Division, New York, NY, USACorrespondence: Otavio ClarkKantar, 175 Greenwich St, WTC 3, 35th Floor, New York, NY 10007, USAEmail otavio.clark@kantar.comContext: Melanoma treatment has substantially changed over the last several years, yet little information regarding physician’s preferences around treatment exists.Objective: Our aim is to describe the results of the CancerMPact (CMP) survey performed in 2019 about the treatment of advanced/metastatic melanoma.Methods: CMP is a data source from Kantar, Health Division, containing data on cancer epidemiology and treatment. Once a year, Kantar performs a series of surveys with specialists in the field of interest in the United States of America (USA), Western Europe (WE), Japan, and China. The results of the survey reported in this work comprise the answers from 94 USA and 99 WE physicians about the treatment of melanoma.Results: In the first-line for the BRAF wild-type population, immuno-oncology (IO) drugs including nivolumab, ipilimumab or pembrolizumab (alone or in combination) were used in 80.1% of the cases in the USA and 70.6% in WE. Conventional chemotherapy or cytokine-based treatments were used in 16.4% of the USA patients and 28.2% in WE. In the second-line in the USA, 45.8% of BRAF wild-type patients received IO drugs, while 45.0% of patients received conventional chemotherapy or cytokine-based treatments. The majority of patients with BRAF mutant advanced/metastatic melanoma were treated in the first-line with BRAF-targeted therapy (61.3% USA, 71.9% WE), and few patients received conventional chemotherapy or cytokine-based treatments (11.9% USA, 12.4% WE); the most commonly used BRAF-targeted therapy was the combination of dabrafenib plus trametinib. In the second-line, BRAF mutant patients received IO drugs (45.1% USA, 53.7% WE), targeted therapy (37.6% USA, 32% WE) or conventional chemotherapy/cytokine-based treatments (14.4% USA, 11.7% WE).Conclusion: The use of IO or targeted therapy for patients with advanced/metastatic melanoma is the preferred treatment strategy by physicians in the USA and WE based on BRAF mutation status. Many patients still receive conventional chemotherapies or cytokines with unsubstantial benefit, especially in recurrent patients of BRAF wild type.Keywords: melanoma, immunotherapy, chemotherapy, variations in practice, survey

Abstract Sustainable alternatives to fossil fuels are urgently needed to avoid severe climate impacts and further environmental degradation. Microalgae are one of the most productive crops globally and do not need to compete for arable land or freshwater resources. Hence, they may become a promising, more sustainable cultivation alternative for the large‐scale production of biofuels provided that substantial reductions are achieved in their production costs. In this study, we identify the most suitable areas globally for siting microalgal farms for biodiesel production that maximize profitability and minimize direct competition with food production and direct impacts on biodiversity, based on a spatially explicit multiple‐criteria decision analysis. We further explore the relationships between microalgal production, agricultural value, and biodiversity, and propose several solutions for siting microalgal production farms, based on current and future targets in energy production using integer linear programming. If using seawater for microalgal cultivation, biodiesel production could reach 5.85 × 1011 L/year based on top suitable lands (i.e., between 13% and 16% of total transport energy demands in 2030) without directly competing with food production and areas of high biodiversity value. These areas are particularly abundant in the dry coasts of North and East Africa, the Middle East, and western South America. This is the first global analysis that incorporates economic and environmental feasibility for microalgal production sites. Our results can guide the selection of best locations for biofuel production using microalgae while minimizing conflicts with food production and biodiversity conservation.

Abstract High costs of tree planting are a barrier to meeting global forest restoration targets. Natural forest regeneration is more cost‐effective than tree planting, but its potential to foster restoration at scale is poorly understood. We predict, map, and quantify natural regeneration potential within 75.5 M ha of deforested lands in the Brazilian Atlantic Forest. Of 34.1 M ha (26.4%) of current forest cover, 2.7 M ha (8.0%) regenerated naturally from 1996 to 2015. We estimate that another 2.8 M ha could naturally regenerate by 2035, and a further 18.8 M ha could be restored using assisted regeneration methods, thereby reducing implementation costs by US$ 90.6 billion (77%) compared to tree planting. These restored forests could sequester 2.3 GtCO2 of carbon, reduce the mean number of expected species at risk of extinction by 63.4, and reduce fragmentation by 44% compared to current levels. Natural regeneration planning is key for achieving cost‐effective large‐scale restoration.

Abstract Human activities are altering natural areas worldwide. While our ability to map these activities at fine scales is improving, a simplistic binary characterization of habitat and non‐habitat with a focus on change in habitat extent has dominated conservation assessments across different spatial scales. Here, we provide a metric that captures both habitat loss, quality and fragmentation effects which, when combined, we call intactness. We identify nine categories of intactness of the world's terrestrial ecoregions based on changes in intactness across a 16‐year period. We found that highly impacted and degraded categories are predominant (74%) and just 6% of ecoregions are on improving trajectories. It is essential that management of degrading processes be targeted in international agendas in order to ensure that Earth's remaining intact ecosystems are effectively conserved and restored in order to achieve effective conservation outcomes.