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PURPOSE: The financial toxicity of cancer care is a source of significant distress for patients with cancer. The purpose of this study is to understand factors associated with financial toxicity in three distinct care systems. METHODS: We conducted a cross-sectional survey of patients in three care systems, Stanford Cancer Institute (SCI), VA Palo Alto Health Care System (VAPAHCS), and Santa Clara Valley Medical Center (SCVMC), from October 2017 to May 2019. We assessed demographic factors, employment status, and out-of-pocket costs (OOPCs) and administered the validated COmprehensive Score for financial Toxicity tool. We calculated descriptive statistics and conducted linear regression models to analyze factors associated with financial toxicity. RESULTS: Four hundred forty-four of 578 patients (77%) completed the entire COmprehensive Score for financial Toxicity tool and were included in the analysis. Most respondents at SCI were White, with annual household income (AHI) > $50,000 USD and Medicare insurance. At the VAPAHCS, most were White, with AHI ≤ $50,000 USD and insured by the Veterans Administration. At SCVMC, most were Asian and/or Pacific Islander, with AHI ≤ $25,000 USD and Medicaid insurance. Low AHI ( P < .0001), high OOPCs ( P = .003), and employment changes as a result of cancer diagnosis ( P < .0001) were associated with financial toxicity in the pooled analysis. There was variation in factors associated with financial toxicity by site, with employment changes significant at SCI, OOPCs at SCVMC, and no significant factors at the VAPAHCS. CONCLUSION: Low AHI, high OOPCs, and employment changes contribute to financial toxicity; however, there are variations based on site of care. Future studies should tailor financial toxicity interventions within care delivery systems.

PURPOSE: Patient-reported outcome measurements (PROMs) are increasingly used for cancer patients receiving active treatment, but little is known about the implementation and usefulness of PROMs in cancer survivorship care. This systematic review evaluates how cancer survivors and healthcare providers (HCPs) perceive PROM implementation in survivorship care, and how PROM implementation impacts cancer survivors' health outcomes.METHODS: We systematically searched PubMed/MEDLINE, Embase, CINAHL, Web of Science, and Cochrane Database of Systematic Reviews from database inception to February 2022 to identify randomized and nonrandomized studies of PROM implementation in cancer survivors.RESULTS: Based on prespecified eligibility criteria, we included 29 studies that reported on 26 unique PROMs. The studies were heterogeneous in study design, PROM instrument, patient demographics, and outcomes. Several studies found that cancer survivors and HCPs had favorable impressions of the utility of PROMs, and a few studies demonstrated that PROM implementation led to improvements in patient quality of life (QoL), with small to moderate effect sizes.CONCLUSIONS: We found implementation of PROMs in cancer survivorship care improved health outcomes for select patient populations. Future research is needed to assess the real-world utility of PROM integration into clinical workflows and the impact of PROMs on measurable health outcomes.IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors accepted PROMs. When successfully implemented, PROMs can improve health outcomes after completion of active treatment. We identify multiple avenues to strengthen PROM implementation to support cancer survivors.

Globally, cancer care delivery is marked by inequalities, where some economic, demographic, and sociocultural groups have worse outcomes than others. In this review, we sought to identify patient-facing interventions designed to reduce disparities in cancer care in both high- and low-income countries. We found two broad categories of interventions that have been studied in the current literature: Patient navigation and telehealth. Navigation has the strongest evidence base for reducing disparities, primarily in cancer screening. Improved outcomes with navigation interventions have been seen in both high- and low-income countries. Telehealth interventions remain an active area of exploration, primarily in high income countries, with the best evidence being for the remote delivery of palliative care. Ongoing research is needed to identify the most efficacious, cost-effective, and scalable interventions to reduce barriers to the receipt of cancer care globally.

OBJECTIVEDeep vein thrombosis (DVT) is a major focus of patient safety indicators and a common cause of morbidity and mortality. Many practices have employed lower-extremity screening ultrasonography in addition to chemoprophylaxis and the use of sequential compression devices in an effort to reduce poor outcomes. However, the role of screening in directly decreasing pulmonary emboli (PEs) and mortality is unclear. At the University of Mississippi Medical Center, a policy change provided the opportunity to compare independent groups: patients treated under a prior paradigm of weekly screening ultrasonography versus a post–policy change group in which weekly surveillance was no longer performed.METHODSA total of 2532 consecutive cases were reviewed, with a 4-month washout period around the time of the policy change. Criteria for inclusion were admission to the neurosurgical service or consultation for ≥ 72 hours and hospitalization for ≥ 72 hours. Patients with a known diagnosis of DVT on admission or previous inferior vena cava (IVC) filter placement were excluded. The primary outcome examined was the rate of PE diagnosis, with secondary outcomes of all-cause mortality at discharge, DVT diagnosis rate, and IVC filter placement rate. A p value < 0.05 was considered significant.RESULTSA total of 485 patients met the criteria for the pre–policy change group and 504 for the post–policy change group. Data are presented as screening (pre–policy change) versus no screening (post–policy change). There was no difference in the PE rate (2% in both groups, p = 0.72) or all-cause mortality at discharge (7% vs 6%, p = 0.49). There were significant differences in the lower-extremity DVT rate (10% vs 3%, p < 0.01) or IVC filter rate (6% vs 2%, p < 0.01).CONCLUSIONSBased on these data, screening Doppler ultrasound examinations, in conjunction with standard-of-practice techniques to prevent thromboembolism, do not appear to confer a benefit to patients. While the screening group had significantly higher rates of DVT diagnosis and IVC filter placement, the screening, additional diagnoses, and subsequent interventions did not appear to improve patient outcomes. Ultimately, this makes DVT screening difficult to justify.

Despite advances in testing for heritable cancer susceptibility gene mutations, health disparities persist. We review racial/ethnic and socioeconomic factors that affect access to genetic counseling and testing, which may influence the validity of results among diverse populations and the clinical utility of genetic testing. Differential access to genetic testing among racial/ethnic minorities including Hispanics and blacks compared with whites drives disparities in the clinical validity of results: specifically, variants of unknown significance (VUS) are notably more prevalent in minorities. Deficiencies in results interpretation by patients and providers are common with VUS, which may engender disparities in clinical utility. There is evidence of racial/ethnic disparities in genetic testing access and the clinical validity of results, which are threats to the clinical utility of testing for all populations. Concerted efforts are needed to decrease disparities in germline cancer genetic testing and results’ interpretation and management.

PURPOSE As access to cancer care expands in low-income countries, developing tools to educate patients is paramount. We took a picture booklet, which was initially developed by the nonprofit Global Oncology for Malawi and Rwanda, and adapted it for use in Nigeria. The primary goal was to assess acceptability and provide education. The secondary goals were (1) to describe the collaboration, (2) to assess knowledge gained from the intervention, (3) to assess patient understanding of their therapy intent, and (4) to explore patient's experiences via qualitative analysis. METHODS We piloted the original English booklet at a single site and requested feedback from patients and providers. The booklet was updated; translated into Hausa, Yoruba, Igbo, and Pidgin English; and used at three additional sites. For the three-site cohort, we collected basic demographics, pretest and post-test assessing content in the booklet, and performed a qualitative analysis. RESULTS The original booklet was widely acceptable and recommended by patients at site one (n = 31) and by providers (N = 26) representing all four sites. In the three-site cohort (n = 103), 94% of patients recommended the booklet. An immediate post-test focusing on when patients should present to care showed a statistically significant improvement in one of the seven questions. Fifty-one percent of the patients (n = 103) knew their treatment intent (curative v palliative). Qualitative analysis highlighted that the patient's thoughts on cancer are dominated by negative associations, although curability and modern therapy are also frequently cited. CONCLUSION We adapted an educational booklet to a novel context and had it delivered by local partners. The booklet was widely recommended to future patients. The booklet had an impact on patient's knowledge of cancer treatment, potentially allowing for decreased abandonment., In this cross-continent collaboration supported by @StanfordCIGH, low literacy-friendly cancer education booklets developed by @GlobalOnc increased awareness and knowledge about cancer treatment in 4 diverse sites in Nigeria.

e18643 Background: Breast cancer is the most common cancer in low and middle-income countries. Belize, a middle-income country in the Caribbean with significant inequality, lacks a national screening program and has limited treatment capacity. There are no studies describing breast cancer characteristics in Belize in the available literature. We collected data from the sole public oncology clinic in the country, established in 2018 at Karl Heusner Memorial Hospital (KHMH), to describe the characteristics of breast cancer patients and establish baseline measurements of time to chemotherapy initiation for the curative intent treatment population; the aim being to identify potential areas for quality improvement. Methods: We performed a retrospective chart review of available patient data from December 2020 to December 2021. We examined the time from a patient’s initial visit at KHMH until chemotherapy initiation (TCI) in the neoadjuvant setting with patients stratified by stage. Significant outliers (predominantly patients with misclassified data or those with private access to physicians and therapeutics) were excluded. Results: The clinic provided care for 80 patients with biopsy-proven breast cancer between December 2020 to December 2021. Patients were 97% female with a median age of 55 (Range: 34-81). For stageable patients (n=75), 33% presented with clinically localized disease, 49% with locally advanced, and 17% with recurrent or metastatic disease. Of the 51 patients on chemotherapy, 57% were receiving preoperative treatment, 31% were on adjuvant therapy, and 12% on palliative therapy. Patients not on therapy (n=29) at KHMH were either in surveillance, referred to a private cancer center, or deceased. Neoadjuvant TCI was calculated for 21 patients after the removal of outliers (n=5). The majority of these patients arrived at their initial clinic visit with a biopsy-proven diagnosis. Mean TCI for early stage disease was 49 days (n=7, 95% CI [9, 89]) and locally advanced disease was 36 days (n=14, 95% CI [12, 61]). Aggregate mean TCI was 40 days (n=21, 95% CI [19, 62]). Conclusions: In Belize, breast cancer affects younger women and patients present with later stages of disease than in high-income countries; however, time to chemotherapy initiation in a small sample of neoadjuvant patients at the Belizean clinic was comparable. Given the inherent limitations of small samples of data, additional investigation is needed to support these findings, as well as to delineate patient barriers to access and potential for improvements in clinic follow-up. Nevertheless, indications of a robust TCI call for further characterization of this newly established cancer clinic and its practices.

e18787 Background: Belize is a middle-income Caribbean country without comprehensive cancer care capacity and poorly described cancer epidemiology. In 2020, we reported some of the first cancer demographics from the country. This was made possible by a capacity building partnership with the only public oncology clinic in the country at Karl Heusner Memorial Hospital (KHMH). Here we provide an update on demographic trends at this clinic. Methods: We performed a retrospective chart review of all available patient data at the KHMH clinic from December 2020 to December 2021. This was compared to data from the clinic’s founding in 2018 through its first 12 months. Results: From December 2020 through December 2021, the clinic saw 332 patients, an increase of 141% from the 236 patients seen over the first 12-month period of the clinic. In 2021, 250 (75%) patients had a confirmed pathologic diagnosis of cancer, with 78 (23%) remaining under clinical suspicion. This is in comparison to 63% of patients with a pathologic diagnosis in 2018. H&E staining alone remained the only publicly available pathologic service. Patients were predominantly female (67%) with a median age of 54 (Range: 2-95). The most common histologies (n = 332) were breast (29%), cervical (11%), colorectal (8%), prostate (4%), gastric (4%), and lung (3%). Of patients with histologically confirmed cancer, 221 (66%) were able to be fully staged. Patients predominantly presented with later stage disease (25% Stage III, 34% Stage IV). At the end of 2021, out of all patients tracked longitudinally over the year (n = 332), 24% remained in need of full diagnostic assessment, 34% were on curative treatment (predominantly cytotoxic chemotherapy), 22% were under surveillance, and 18% were receiving palliative chemotherapy or best supportive care due to advanced disease. This is in comparison to 2018, when there was no capacity to administer chemotherapy at KHMH and patients were referred to either private clinics or out of the country. Conclusions: The burden of cancer in Belize is significant and diverse. Compared to 2018, in 2021, the number of patients seen at KHMH increased 141%, as did the percentage of patients with histologically confirmed cancer (120% increase). Chemotherapy treatment was made possible through procurement of a chemotherapeutic stock at KHMH due to key partnerships with the Belizean government, hospital administration, and crucially, the only medical oncologist in the nation. This has led to chemotherapy being available at a public clinic in the country for the first time. Despite this progress, patients continue to present at late stages and many cannot access cancer care due to limited resources, cost, and low public awareness. This further affirms the need for infrastructure investment and early detection programs to improve cancer outcomes in Belize.

11011 Background: For new fellows, learning clinical oncology represents an enormous challenge. Few data support specific didactic approaches. The senior author (TPJ) developed a novel curriculum, emphasizing deliberate practice as part of a design grounded in Ericsson’s “expert performance approach”. These noon conferences are case based with a focus on key clinical trials and NCCN guidelines. In comparison to didactics given directly by faculty, these conferences are primarily presented by a senior teaching fellow with an invited faculty member adding additional commentary as an “expert discussant”. We surveyed fellows to assess perception of efficacy and also created a board style test to evaluate knowledge gains. Methods: The curriculum began in 2020. After one year, we surveyed fellows with a five-point likert scale survey to quantify their perception of the curriculum. In 2022, we created a pair of 18-question lung cancer specific board style tests for the five teaching sessions on lung cancer. Prior to the first conference, the pre-test was sent to fellows electronically; after the final lecture the other 18-question test was sent out. Differences in the overall cohort’s test score were examined via a paired student t-test. Results: On the 2021 survey, 59% of fellows responded (17 of 29). Of the respondents, 83% attended at least half of the lectures (14 of 17). When asked to compare this conference series to traditional lecture-based series, 59% (10 of 17) agreed with the statement that "this series is one of the very best I've encountered" and all said it was at least “better than average.” 94% of respondents (16 of 17) said the series equipped them for clinical practice to either a “significant” or “remarkable” degree. 94% of respondents (16 of 17) agreed the conferences helped them learn to “think like oncologists.” For the five session lung cancer block, fellows reported attending an average of 3.6 ± 1.4 sessions (n = 13). On the 18-question pre-test (n = 19), the average score ± one standard deviation was 73% ± 15%. For the post-test (n = 13), the average was 68% ± 17% (p = 0.48). Conclusions: We developed a novel curriculum to replace traditional didactics. Fellows perceived the curriculum to be exceptionally strong as compared to traditional lecture series, felt it prepared them well for practice, and said it taught them to think like oncologists. Pre/post knowledge assessments did not show an improvement in knowledge. Distribution to larger numbers of fellows–especially early learners–may better power a study to detect improvements in learning.

Context Immune checkpoint inhibitors (ICIs) are increasingly used to treat a variety of cancers, but comparatively little is known about patient-reported outcomes (PROs) and health-related quality of life (HRQoL) among patients receiving these novel therapies. Objectives We performed a systematic review to examine PROs and HRQoL among cancer patients receiving ICIs as compared to other anticancer therapies. Methods We systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing ICIs, PROs, and HRQoL on August 10, 2018. Eligible articles were required to involve cancer patients treated with ICIs and to report PROs and/or HRQoL data. Results We screened 1453 references and included 15 publications representing 15 randomized controlled trials in our analysis. Studies included several cancer types (melanoma, lung cancer, genitourinary cancer, and head/neck cancer), used four different ICIs (nivolumab, pembrolizumab, atezolizumab, and ipilimumab), and compared ICIs to a wide range of therapies (chemotherapy, targeted therapies, other immunotherapy strategies, and placebo). Studies used a total of seven different PROs to measure HRQOL, most commonly the European Organisation for the Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) (n = 12, 80%). PRO data were reported in a variety of formats and at a variety of time points throughout treatment, which made direct comparison challenging. Some trials (n = 11, 73%) reported PROs on specific symptoms. In general, patients receiving ICIs had similar-to-improved HRQoL and experiences when compared to other therapies. Conclusion Despite the broad clinical trials experience of ICI therapies across cancer types, relatively few randomized studies reported PROs and patient HRQoL data. Available data suggest that ICIs are well tolerated in terms of HRQoL compared to other anticancer therapies although the conclusions are limited by the heterogeneity of trial designs and outcomes. Currently used instruments may fail to capture important symptomatology unique to ICIs, underscoring a need for PROs designed specifically for ICIs.

e23160 Background: Immune checkpoint inhibitors (ICIs) have been met with a wave of excitement due to their novel mechanism. We hypothesized that this may impact how patients (via PROs) report treatment tolerability in comparison to traditional therapies. We sought to examine if there was a notable difference in PROs in blinded vs unblinded trials of ICIs. Methods: We systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus in August 2018 for publications with quantitative PRO data comparing ICIs to cytotoxic chemotherapy. Case series, narrative reviews, and publications lacking original data were excluded. Eligible publications were reviewed to assess if patients were blinded to the agent received, and a comparison for common PRO metrics was performed. Results: Of the 1,450 unique references identified, eight met inclusion criteria: 1 double blinded placebo-controlled trial and 7 trials where patients were aware of the assigned arm. The blinded trial had quantitative PRO data in the form of the European Organisation for Research and Treatment of Cancer (EORTC) global health status (GHS) score and patient reported symptom burden at week 12. Most (6 of 7; 86%) unblinded trials reported the GHS at either week 12 or 15, and patient symptom burden at these time points as well (5 of 7; 71%). For the EORTC GHS, the blinded trial showed no inter-arm difference at week 12. 4 of 6 (67%) open label trials noted statistically significant differences in GHS favoring the ICI arm. For symptom burden at week 12 or 15, there was no difference found in the blinded study. In unblinded trials, there were domains where patients receiving ICIs reported a statistically significant lower symptom burden than those receiving chemotherapy: fatigue (4 of 5 trials favoring ICIs; 80%), dyspnea (2 of 5; 40%), insomnia (1 of 4; 25%), appetite loss (1 of 4; 25%), and diarrhea (1 of 5; 20%). There were no differences in pain (n = 5), nausea/vomit (n = 5), and constipation (n = 5). Conclusions: We found a trend towards more favorable reporting on common symptoms in unblinded studies of patients receiving ICIs. Our analysis is limited by the lack of available comparisons in the published literature.

11579 Background: PROs are increasingly used as a key tool in patient-focused treatment decisions. However, many cancer PROs were designed to capture the patient experience of those treated with chemotherapeutic agents. Less is known about the utility of PRO instruments in assessing symptoms from ICIs. Methods: We systematically searched the literature to identify peer-reviewed publications that reported PROs for patients receiving ICIs. We excluded case reports/series, narrative reviews, and publications without original data. We then selected the studies that compared ICIs to cytotoxic chemotherapy. Clinician-documented adverse events (AEs) occurring in at least 10% of patients in a study arm were extracted and examined for concordance with symptoms included in the PROs administered to study patients. Results: Of 1,450 identified studies, eight met criteria for inclusion. Seven assessed PROs with the European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), six used the EuroQOL EQ-5D, and one used the Lung Cancer Symptom Scale (LCSS). Across the studies, fatigue, nausea, vomiting, appetite loss, diarrhea, constipation, pruritus, rash, and pyrexia were among the most common clinician-documented AEs. Of these AEs, six are directly correlated with questions on the PRO instruments, and three (pruritus, rash, and pyrexia) are not. AEs with corresponding PRO questions were more common in chemotherapy patients. Pruritus, rash, and pyrexia – AEs without corresponding PRO questions – were more common in patients treated with ICIs (see Table). Conclusions: Existing PRO instruments do not specifically query important symptoms associated with ICIs, underscoring the need to revise the instruments to more appropriately reflect the toxicity profiles of novel agents. [Table: see text]

e18202 Background: Patient-reported outcomes (PROs) are increasingly valued as a key tool in patient-focused treatment decisions. However, a lack of standardization leads to significant variability in PRO collection and reporting in ground-breaking clinical trials of novel agents. We sought to characterize the mechanisms of assessment and variability by which PROs are reported for newly approved anti-cancer therapies. Methods: We reviewed the U.S. Food and Drug Administration (FDA) approvals between 2011 and 2017 for anti-cancer new molecular entities (NMEs) and new biologic approvals (BLAs). For each therapy, the pivotal clinical trial leading to FDA approval was identified using the national clinical trial (NCT) number and assessed for inclusion of PROs. A separate PubMed search was conducted to evaluate for PRO publication distinct from the original trial based on national clinical trial registry number. Results: From 2011 to 2017, the FDA approved 66 NMEs/BLAs based on 74 clinical trials for cancer treatment. Of the 74 clinical trial publications, 21 (28%) of the trials published PRO data in their original clinical publication, 18 (24%) published a separate PRO analysis, and 35 (47%) did not publish PRO data in either format. Among the 32 clinical trials (43%) that listed PROs as pre-specified outcomes, 72% published PROs (23/32). The separate PRO analyses (N = 18) were published considerably later following FDA approval (mean 605 days) than the original clinical trials (mean 20 days, N = 74, P < 0.001). Conclusions: As cancer treatment options expand, therapy decisions become increasingly nuanced. PROs assist decision-making by providing detailed information on important aspects of quality of life and tolerability. Our research has identified a significant lag in the publication of companion studies of PRO data associated with pivotal clinical trials, representing a meaningful gap in information critical to patients and oncologists in the process of making informed decisions.

This project systematically identified evidence-based interventions using photography in mental health practice. The initial search of the literature produced 4,929 hits, title reviews reduced this set to 225 possible studies, abstract examination refined this list to 81, and analyzing the articles determined that only 23 meet selection criteria for inclusion in this project: psychosocial-oriented intervention within the domain of social work practice with supporting empirical data. The majority of interventions involved assignments that included taking photographs or creating some kind of photographic product (e.g., collages, time-series of snapshots). Typically, these photographic activities were done in group or individual therapy and focused on social skills, coping skills, self-esteem, or identity for adults and adolescents. The empirical support for these protocols was usually from case studies or single-group design evaluations, all reported practical or theoretically significant improvements, and ...

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After the landmark Brown v. Board of Education ruling in 1954 mandated the desegregation of schools nationwide, the legislature in the state of Mississippi created the Mississippi State Sovereignty Commission, the basic mission of which was to prevent integration in that state. This book is an investigative history of the Commission, other government agencies (including the FBI), and organized crime, all of which conspired to break the law in dealing with civil-rights and antiwar activists during the 1950s and 1960s. The author uncovers new information about the efforts of FBI agents to combat integration and exposes the longest-running conspiracy in American history.