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BACKGROUND The COVID-19 pandemic led to the rapid implementation of remote work, but few studies have examined the impact. We evaluated clinical staff experience with working remotely at a large, urban comprehensive cancer center in Toronto, Canada. METHODS An electronic survey was disseminated between June 2021, and August 2021, via e-mail to staff who had completed at least some remote work during the COVID-19 pandemic. Factors associated with a negative experience were examined with binary logistic regression. Barriers were derived from a thematic analysis of open-text fields. RESULTS Most respondents (N = 333; response rate, 33.2%) were age 40-69 years (46.2%), female (61.3%), and physicians (24.6%). Although the majority of respondents wished to continue remote work (85.6%), relative to administrative staff (admin), physicians (odds ratio [OR], 16.6; 95% CI, 1.45 to 190.14) and pharmacists (OR, 12.6; 95% CI, 1.0 to 158.9) were more likely to want to return on-site. Physicians were approximately eight times more likely to report dissatisfaction with remote work (OR, 8.4; 95% CI, 1.4 to 51.6) and 24 times more likely to report that remote work negatively affected efficiency (OR, 24.0; 95% CI, 2.7 to 213.0); nurses were approximately seven times more likely to report the need for additional resources (OR, 6.5; 95% CI, 1.71 to 24.48) and/or training (OR, 7.02; 95% CI, 1.78 to 27.62). The most common barriers were the absence of fair processes for allocation of remote work, poor integration of digital applications and connectivity, and poor role clarity. CONCLUSION Although overall satisfaction with working remotely was high, work is needed to overcome barriers to implementation of remote and hybrid work models in the health care setting.

Due to the ramping down of cancer surgery in early pandemic, many newly diagnosed patients received other treatments first. We aimed to quantify the pandemic-related shift in rate of surgery following chemotherapy. This is a retrospective population-based cohort study involving adults diagnosed with cancer between 3 January 2016 and 7 November 2020 in Ontario, Canada who received chemotherapy as first treatment within 6-months of diagnosis. Competing-risks regression models with interaction effects were used to quantify the association between COVID-19 period (receiving a cancer diagnosis before or on/after 15 March 2020) and receipt of surgical reSection 9-months after first chemotherapy. Among 51,653 patients, 8.5% (n = 19,558) of them ultimately underwent surgery 9-months after chemotherapy initiation. Receipt of surgery was higher during the pandemic than before (sHR 1.07, 95% CI 1.02–1.13). Material deprivation was independently associated with lower receipt of surgery (least vs. most deprived quintile: sHR 1.11, 95% CI 1.04–1.17), but did not change with the pandemic. The surgical rate increase was most pronounced for breast cancer (sHR 1.13, 95% CI 1.06–1.20). These pandemic-related shifts in cancer treatment requires further evaluations to understand the long-term consequences. Persistent material deprivation-related inequity in cancer surgical access needs to be addressed.

Background We sought to estimate the proportion of patients with cancer treated with immune checkpoint inhibitors (ICI) who die soon after starting ICI in the real world and to examine factors associated with early mortality (EM). Methods We conducted a retrospective cohort study using linked health administrative data from Ontario, Canada. EM was defined as death from any cause within 60 days of ICI initiation. Patients with melanoma, lung, bladder, head and neck or kidney cancer treated with ICI between 2012 and 2020 were included. Results A total of 7,126 patients treated with ICI were evaluated. Fifteen percent (1,075/7,126) died within 60 days of initiating ICI. The highest mortality was observed in patients with bladder and head and neck tumors (≈21% each). In multivariable analysis previous hospital admission or emergency department visit, prior chemotherapy or radiation therapy, stage 4 disease at diagnosis, lower hemoglobin, higher white blood cell count, and higher symptom burden were associated with higher risk of EM. Conversely, patients with lung and kidney cancer (compared to melanoma), lower neutrophil-to-lymphocytes ratio, and with higher body-mass index were less likely to die within 60 days post ICI initiation. In a sensitivity analysis, 30 and 90-day mortality were 7% (519/7,126) and 22% (1,582/7,126), respectively with comparable clinical factors associated with EM identified. Conclusion EM is common among patients treated with ICI in the real-world setting and is associated with several patient and tumor characteristics. Development of a validated tool to predict EM may facilitate better patient selection for treatment with ICI in routine practice.

Improving technology has promised to improved health care delivery and the lives of patients. The realized benefits of technology, however, are delayed or less than anticipated. Three recent technology initiatives are reviewed: the Clinical Trials Rapid Activation Consortium (CTRAC), minimal Common Oncology Data Elements (mCODE), and electronic Patient-Reported Outcomes. Each initiative is at a different stage of maturity but promises to improve the delivery of cancer care. CTRAC is an ambitious initiative funded by the National Cancer Institute (NCI) to develop processes across multiple NCI-supported cancer centers to facilitate the development of centralized electronic health record (EHR) treatment plans. Facilitating interoperability of treatment regimens has the potential to improve sharing between centers and decrease the time to begin clinical trials. The mCODE initiative began in 2019 and is currently Standard for Trial Use version 2. This data standard provides an abstraction layer on top of EHR data and has been implemented across more than 60 organizations. Patient-reported outcomes have been shown to improve patient care in numerous studies. Best practices for how to leverage these in an oncology practice continue to evolve. These three examples show how innovative has diffused into practice and evolved cancer care delivery and highlight a movement toward patient-centered data and interoperability.

No population-based study exists to demonstrate the full-spectrum impact of COVID-19 on hindering incident cancer detection in a large cancer system. Building upon our previous publication in JNCCN, we conducted an updated analysis using 12 months of new data accrued in the pandemic era (extending the study period from September 26, 2020, to October 2, 2021) to demonstrate how multiple COVID-19 waves affected the weekly cancer incidence volume in Ontario, Canada, and if we have fully cleared the backlog at the end of each wave.

Early Warning Score (EWS) systems are tools that use alterations in vital signs to rapidly identify clinically deteriorating patients and escalate care accordingly. Since its conception in 1997, EWSs have been used in several settings, including the general inpatient ward, intensive care units, and the emergency department. Several iterations of EWSs have been developed with varying levels of sensitivity and specificity for use in different populations. There are multiple strengths of these tools, including their simplicity and their ability to standardize communication and to reduce inappropriate or delayed referrals to the intensive care unit. Although early identification of deteriorating patients in the oncology population is vital to reduce morbidity and mortality and to improve long-term prognosis, the application in the oncology setting has been limited. Patients with an oncological diagnosis are usually older, medically complex, and can have increased susceptibility to infections, end-organ damage, and death. A search using PubMed and Scopus was conducted for articles published between January 1997 and November 2020 pertaining to EWSs in the oncology setting. Seven relevant studies were identified and analyzed. The most commonly used EWS in this setting was the Modified Early Warning Score. Of the seven studies, only two included prospective validation of the EWS in the oncology population and the other five only included a retrospective assessment of the data. The majority of studies were limited by their small sample size, single-institution analysis, and retrospective nature. Future studies should assess dynamic changes in scores over time and evaluate balance measures to identify use of health care resources.

CCR Translation for This Article from Phase II Efficacy and Pharmacogenomic Study of Selumetinib (AZD6244; ARRY-142886) in Iodine-131 Refractory Papillary Thyroid Carcinoma with or without Follicular Elements

Purpose: A multicenter, open-label, phase II trial was conducted to evaluate the efficacy, safety, and tolerability of selumetinib in iodine-refractory papillary thyroid cancer (IRPTC).Experimental Design: Patients with advanced IRPTC with or without follicular elements and documented disease progression within the preceding 12 months were eligible to receive selumetinib at a dose of 100 mg twice daily. The primary endpoint was objective response rate using Response Evaluation Criteria in Solid Tumors. Secondary endpoints were safety, overall survival, and progression-free survival (PFS). Tumor genotype including mutations in BRAF, NRAS, and HRAS was assessed.Results: Best responses in 32 evaluable patients out of 39 enrolled were 1 partial response (3%), 21 stable disease (54%), and 11 progressive disease (28%). Disease stability maintenance occurred for 16 weeks in 49%, 24 weeks in 36%. Median PFS was 32 weeks. BRAF V600E mutants (12 of 26 evaluated, 46%) had a longer median PFS compared with patients with BRAF wild-type (WT) tumors (33 versus 11 weeks, respectively, HR = 0.6, not significant, P = 0.3). The most common adverse events and grades 3 to 4 toxicities included rash, fatigue, diarrhea, and peripheral edema. Two pulmonary deaths occurred in the study and were judged unlikely to be related to the study drug.Conclusions: Selumetinib was well tolerated but the study was negative with regard to the primary outcome. Secondary analyses suggest that future studies of selumetinib and other mitogen-activated protein (MAP)/extracellular signal-regulated kinase (ERK; MEK) inhibitors in IRPTC should consider BRAF V600E mutation status in the trial design based on differential trends in outcome. Clin Cancer Res; 18(7); 2056–65. ©2012 AACR.

PURPOSE Antibiotic exposure before immune checkpoint inhibitor (ICI) treatment can negatively affect outcomes through alteration in the gut microbiome, but large-scale evaluations are lacking. We performed a population-level retrospective cohort study to evaluate the impact of antibiotic exposure before starting ICI on overall survival (OS). PATIENT AND METHODS Patients with cancer, age 65 years or older, who initiated treatment with ICIs between June 2012 and October 2018 in Ontario, Canada, were identified using systemic therapy administration data. The cohort was deterministically linked to other health care databases to obtain covariates and antibiotic prescription claim data at both 1 year and 60 days before ICI therapy. Multivariable Cox models evaluated the association between exposure and OS. RESULTS Among the 2,737 patients with cancer who received ICIs, 59% and 19% of patients received antibiotics 1 year and 60 days before ICI therapy, respectively. Median OS was 306 days. Any antibiotic exposure within 1 year before ICI was associated with worse OS (adjusted hazard ratio [aHR], 1.12; 95% CI, 1.12 to 1.23; P = .03). In antibiotic class analysis, exposure to fluoroquinolones within 1 year (aHR, 1.26; 95% CI, 1.13 to 1.40; P < .001) or 60 days before ICI (aHR, 1.20; 95% CI, 0.99 to 1.45; P = .06) was associated with worse OS, with a dose effect seen on the basis of total weeks of exposure over 1 year (aHR, 1.07 per week; 95% CI, 1.03 to 1.11; P < .001) and 60 days (aHR, 1.12 per week; 95% CI, 1.03 to 1.23; P = .01). CONCLUSION In this population-level study, exposure to antibiotics and specifically fluoroquinolones before ICI therapy was observed to be associated with worse OS among older adults with cancer. Interventions aimed at altering the gut microbiome to boost immunogenicity may help improve outcomes for patients receiving ICIs with prior antibiotic exposure.

Emergency department (ED) use is a concern for surgery patients, physicians and health administrators particularly during a pandemic. The objective of this study was to assess the impact of the pandemic on ED use following cancer-directed surgeries. This is a retrospective cohort study of patients undergoing cancer-directed surgeries comparing ED use from 7 January 2018 to 14 March 2020 (pre-pandemic) and 15 March 2020 to 27 June 2020 (pandemic) in Ontario, Canada. Logistic regression models were used to (1) determine the association between pandemic vs. pre-pandemic periods and the odds of an ED visit within 30 days after discharge from hospital for surgery and (2) to assess the odds of an ED visit being of high acuity (level 1 and 2 as per the Canadian Triage and Acuity Scale). Of our cohort of 499,008 cancer-directed surgeries, 468,879 occurred during the pre-pandemic period and 30,129 occurred during the pandemic period. Even though there was a substantial decrease in the general population ED rates, after covariate adjustment, there was no significant decrease in ED use among surgical patients (OR 1.002, 95% CI 0.957–1.048). However, the adjusted odds of an ED visit being of high acuity was 23% higher among surgeries occurring during the pandemic (OR 1.23, 95% CI 1.14–1.33). Although ED visits in the general population decreased substantially during the pandemic, the rate of ED visits did not decrease among those receiving cancer-directed surgery. Moreover, those presenting in the ED post-operatively during the pandemic had significantly higher levels of acuity.

Timely treatment of epithelial ovarian cancer (EOC) by gynecologic oncologists (GOs) with a combination of surgery and/or chemotherapy has been advocated. Nonetheless, some patients are not assessed by GOs prior to starting their treatment or have surgery by non-GOs. This study aims to determine trends over time in non-mucinous EOC care and to evaluate the impact of care on survival.Using province-wide administrative data, patients diagnosed with non-mucinous EOC between 2007 and 2018 were identified. Multivariate Cox proportional hazards regression models were used to evaluate the impact of GO assessment prior to initiating treatment or having surgery done by a non-GO on mortality.A total of 10,086 EOC patients were included between 2007 and 2018. During the study period, there was an 8% increase in GO assessment (79% in 2007 to 87% in 2018-19, p ≤ 0.001) and a 19% increase in surgeries performed by GOs (69% in 2007 to 88% in 2018-19, p ≤ 0.001). On multivariate analysis, there was an increased hazard of all-cause mortality for patients not assessed by GOs before first treatment (Hazard ratio (HR): 1.61; 95% CI 1.46-1.79). There was an increased hazard of all-cause mortality if ovarian cancer surgery was performed by non-GOs (HR 2.03; 95% CI 1.80-2.30).Assessment by GO before starting initial treatment is associated with improved survival in women with non-mucinous EOC as the type of surgeon performing primary ovarian cancer surgery. Assessment by GO for all patients with new or suspected ovarian cancer diagnosis before initiation of primary treatment should be advocated.

Anal adenocarcinoma is a rare clinical entity for which the optimal management is not defined.This study aimed to describe the multidisciplinary management and outcomes of patients with anal adenocarcinoma.This is a retrospective cohort study.This study was conducted at a quaternary cancer center.Men and women with anal adenocarcinoma treated between 1995 and 2016 were selected.Fifty-two patients were treated with either chemoradiotherapy or trimodality therapy including radiation therapy, chemotherapy, and surgical resection.Local failure, regional failure, and distant metastasis rates were estimated using the cumulative incidence method. The Kaplan-Meier method was used to estimate progression-free survival and overall survival. The multivariable Cox proportional hazards model was used to evaluate the clinical predictors of outcome.There was a higher 5-year rate of local failure in patients treated with chemoradiotherapy compared with trimodality therapy (53% vs 10%; p0.01). The 5-year incidence of distant metastases was 29% (trimodality therapy) versus 30% (chemoradiotherapy; p = 0.9); adjuvant chemotherapy did not reduce the incidence of distant metastases (p = 0.8). Five-year overall survival was 73% (trimodality therapy) versus 49.4% (chemoradiotherapy; p = 0.1). On multivariable analysis, factors associated with worse overall survival were treatment with chemoradiotherapy, cT3-4 category disease, and node-positive disease.This study is limited by its small sample size and retrospective nature.Although treatment may continue to be tailored to individual patients, better outcomes with a trimodality therapy approach were observed. See Video Abstract at http://links.lww.com/DCR/B708.ADENOCARCINOMA ANAL: UNA ENTIDAD POCO FRECUENTE EN NECESIDAD DE UN MANEJO MULTIDISCIPLINARIO.El adenocarcinoma anal es una entidad clínica poco frecuente por lo que aún no se define el manejo óptimo.Describir el manejo multidisciplinario y los resultados de los pacientes con adenocarcinoma anal.Estudio de cohorte retrospectivo.Centro de cáncer cuaternario.Hombres y mujeres con adenocarcinoma anal tratados entre 1995 y 2016.Cincuenta y dos pacientes fueron tratados con quimiorradioterapia o terapia trimodal que incluyó: radioterapia, quimioterapia y resección quirúrgica.Se estimaron las tasas de falla local, falla regional y metástasis a distancia mediante el método de incidencia acumulada. Se utilizó el método de Kaplan-Meier para estimar la supervivencia libre de progresión y la supervivencia global. Los riesgos proporcionales de multivariable Cox se utilizaron para evaluar los predictores clínicos de los resultados.Hubo una mayor tasa de falla local a cinco años en pacientes tratados con quimiorradioterapia en comparación con terapia trimodal (53% vs 10%; p0,01). La incidencia a cinco años de metástasis a distancia fue del 29% (terapia trimodal) versus 30% (quimiorradioterapia) (p = 0,9); la quimioterapia adyuvante no redujo la incidencia de metástasis a distancia (p = 0,8). La supervivencia global a cinco años fue del 73% (terapia trimodal) versus 49,4% (quimiorradioterapia); p = 0,1. En el análisis multivariable, los factores asociados con una peor supervivencia general fueron el tratamiento con quimiorradioterapia, enfermedad de categoría cT3-4 y enfermedad con ganglios positivos.Este estudio está limitado por su pequeño tamaño de muestra y su naturaleza retrospectiva.Aunque el tratamiento puede seguir adaptándose a pacientes individuales, se observaron mejores resultados con un enfoque TTM. Conslute Video Resumen en http://links.lww.com/DCR/B708. (Traducción- Dr. Francisco M. Abarca-Rendon).

(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients, however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.

Purpose We investigated relationships between domains of quality of dying and death in patients with advanced cancer and their caregivers’ bereavement outcomes and the moderating effect of patient age at death. Methods Bereaved caregivers of deceased patients with advanced cancer who had participated in an early palliative care trial completed measures of grief (Texas Revised Inventory of Grief [TRIG]), complicated grief (Prolonged Grief Inventory [PG-13]), and depression (Center for Epidemiologic Studies-Depression [CESD-10]). They also completed the Quality of Dying and Death measure (QODD), which assesses patients’ symptom control, preparation for death, connectedness with loved ones, and sense of peace with death. Results A total of 157 bereaved caregivers completed the study. When patient age × QODD subscale interactions were included, greater death preparation was related to less grief at patient death (past TRIG: β = − .25, p = .04), less current grief (present TRIG: β = − .26, p = .03), less complicated grief (PG-13: β = − .37, p = .001), and less depression (CESD-10: β = − .35, p = .005). Greater symptom control was related to less current grief (present TRIG: β = − .27, p = .02), less complicated grief (PG-13: β = − .24, p = .03), and less depression (CESD-10: β = − .29, p = .01). Significant patient age × connectedness interaction effects for current grief (present TRIG: β = .30, p = .02) and complicated grief (PG-13: β = .29, p = .007) indicated that, with less connectedness, younger patient age at death was associated with greater caregiver grief. Conclusion Better end-of-life death preparation and symptom control for patients with cancer may attenuate later caregiver grief and depression. Less connectedness between younger patients and their families may adversely affect caregiver grief.

In the phase 2 double-blind Study 211, a starting dose of lenvatinib 18 mg/day was compared with the approved starting dose of 24 mg/day in patients with radioiodine-refractory differentiated thyroid cancer (RR-DTC). Predefined criteria for noninferiority for efficacy in the 18 mg arm were not met; safety was similar in both arms. Impact of lenvatinib treatment on health-related quality-of-life (HRQoL) was a secondary endpoint of Study 211.Patients with RR-DTC were randomly assigned to a blinded starting dose of lenvatinib 18 mg/day or 24 mg/day. HRQoL was assessed at baseline, every 8 weeks until Week 24, then every 16 weeks, and at the off-treatment visit, using the EQ-5D-3L and FACT-G instruments. Completion and compliance rates, mean change from baseline, and times to first and definitive deterioration were evaluated.Baseline EQ-5D and FACT-G scores, and overall changes from baseline, were comparable between patients in the lenvatinib 18 mg/day (n = 77) and 24 mg/day arms (n = 75). For the 18 mg versus 24 mg arms, least squares mean differences were -0.42 (95% CI -4.88, 4.03) for EQ-5D-VAS and 0.47 (95% CI -3.45, 4.39) for FACT-G total. Time to first deterioration did not significantly favor either arm; EQ-5D-VAS HR [18 mg/24 mg] 0.93 (95% CI 0.61-1.40), EQ-5D-HUI HR [18 mg/24 mg] 0.68 (95% CI 0.44-1.05), FACT-G total HR [18 mg/24 mg] 0.73 (95% CI 0.48-1.12). Time to definitive deterioration did not significantly favor either arm, though EQ-5D-VAS showed a trend in favor of the 24 mg arm (HR [18 mg/24 mg] 1.72; 95% CI 0.99-3.01); EQ-5D-HUI HR [18 mg/24 mg] was 0.96 (95% CI 0.57-1.63), FACT-G total HR [18 mg/24 mg] was 0.72 (95% CI 0.43-1.21).In Study 211, HRQoL for patients in the lenvatinib 18 mg/day arm was not statistically different from that of patients in the 24 mg/day arm. These data further support the use of the approved lenvatinib starting dose of 24 mg/day in patients with RR-DTC.NCT02702388.

BACKGROUND Major advances in different cancer treatment modalities have been made, and people are now living longer with cancer. However, patients with cancer experience a range of physical and psychological symptoms during and beyond cancer treatment. New models of care are needed to combat this rising challenge. A growing body of evidence supports the effectiveness of eHealth interventions in the delivery of supportive care to people living with the complexities of chronic health conditions. However, reviews on the effects of eHealth interventions are scarce in the field of cancer-supportive care, particularly for interventions with the aim of empowering patients to manage cancer treatment–related symptoms. For this reason, this protocol has been developed to guide a systematic review and meta-analysis to assess the effectiveness of eHealth interventions for supporting patients with cancer in managing cancer-related symptoms. OBJECTIVE This systematic review with meta-analysis is conducted with the aim of identifying eHealth-based self-management intervention studies for adult patients with cancer and evaluating the efficacy of eHealth-based self-management tools and platforms in order to synthesize the empirical evidence on self-management and patient activation through eHealth. METHODS A systematic review with meta-analysis and methodological critique of randomized controlled trials is conducted following Cochrane Collaboration methods. Multiple data sources are used to identify all potential research sources for inclusion in the systematic review: (1) electronic databases such as MEDLINE, (2) forward reference searching, and (3) gray literature. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for conducting the review were followed. The PICOS (Population, Interventions, Comparators, Outcomes, and Study Design) framework is used to identify relevant studies. RESULTS The literature search yielded 10,202 publications. The title and abstract screening were completed in May 2022. Data will be summarized, and if possible, meta-analyses will be performed. It is expected to finalize this review by Winter 2023. CONCLUSIONS The results of this systematic review will provide the latest data on leveraging eHealth interventions and offering effective and sustainable eHealth care, both of which have the potential to improve quality and efficiency in cancer-related symptoms. CLINICALTRIAL PROSPERO 325582; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325582 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/38758

BackgroundMedication reconciliation (MedRec) is a process where providers work with patients to document and communicate comprehensive medication information by creating a complete medication list (best possible medication history (BPMH)) then reconciling it against what patient is actually taking to identify potential issues such as drug-drug interactions. We undertook an environmental scan of current MedRec practices in outpatient cancer care to inform a quality improvement project at our centre with the aim of 30% of patients having a BPMH or MedRec within 30 days of initiating treatment with systemic therapy.MethodsWe conducted semi-structured interviews with key stakeholders from 21 cancer centres across Canada, probing on current policies, and barriers and facilitators to MedRec. Guided by the findings of the scan, we then undertook a quality improvement project at our cancer centre, comprising six iterative improvement cycles.ResultsMost institutions interviewed had a process in place for collecting a BPMH (81%) and targeted patients initiating systemic therapy (59%); however, considerable practice variation was noted and completion of full MedRec was uncommon. Lack of resources, high patient volumes, lack of a common medical record spanning institutions and settings which limits access to medication records from external institutions and community pharmacies were identified as significant barriers. Despite navigating challenges related to the COVID-19 pandemic, we achieved 26.6% of eligible patients with a documented BPMH. However, uptake of full MedRec remained low whereby 4.7% of patients had a documented MedRec.ConclusionsRealising improvements to completion of MedRec in outpatient cancer care is possible but takes considerable time and iteration as the process is complex. Resource allocation and information sharing remain major barriers which need to be addressed in order to observe meaningful improvements in MedRec.

Objectives The optimal systemic therapy strategy for advanced epithelial ovarian cancer (EOC) remains unclear. We performed a systematic review and meta-analysis to assess oncologic outcomes and toxicity of bevacizumab combination treatment in advanced EOC. Methods We conducted an electronic search of all phase 2 and 3 clinical trials involving bevacizumab combination therapy in advanced-stage EOC between 2010 and March 2020, using Embase, Medline, Epub Ahead of Print, Cochrane for clinical trials, Cochrane Database of Systematic Reviews, Web of Science and clinicaltrials.gov databases. Progression-free survival (PFS), overall survival (OS), and their hazard ratios (HR) when available were extracted. Pooled HR were calculated for each efficacy endpoint in the meta-analysis using inverse variance weighted method. Bias was assessed using the Cochrane Collaboration Risk of Bias I (ROB1) tool for randomized controlled trials. Results Thirty-five studies were included in the qualitative analysis and eight studies in the quantitative synthesis. In the first-line setting, bevacizumab combined with chemotherapy revealed a significant improvement in PFS (pooled HR = 0.72, 95% CI 0.65–0.81) when compared to chemotherapy alone but no significant OS benefit (pooled HR = 0.88, 95% CI 0.72–1.06). In the recurrent setting, bevacizumab combinations showed significant PFS (pooled HR = 0.52, 95% CI 0.47–0.58) and OS benefits (pooled HR = 0.88, 95% CI 0.79–0.99) compared with non-bevacizumab regimens. Rate of bowel perforation was low at 1.24% (range 0–4.2%). Conclusions Bevacizumab-containing regimens are associated with significant PFS benefit in advanced and recurrent epithelial ovarian cancer. While the difference in OS did not reach statistical significance in the first-line setting, bevacizumab was associated with improved survival in the recurrent setting.

Background In many jurisdictions, cancer patients were prioritized for COVID-19 vaccination because of increased risk of infection and death. To understand sociodemographic disparities that affected timely receipt of COVID-19 vaccination among cancer patients, we undertook a population-based study in Ontario, Canada. Methods Patients older than 18 years and diagnosed with cancer January 2010 to September 2020 were identified using administrative data; vaccination administration was captured between approval (December 2020) up to February 2022. Factors associated with time to vaccination were evaluated using multivariable Cox proportional hazards regression. Results The cohort consisted of 356 535 patients, the majority of whom had solid tumor cancers (85.9%) and were not on active treatment (74.1%); 86.8% had received at least 2 doses. The rate of vaccination was 25% lower in recent (hazard ratio [HR] = 0.74, 95% confidence interval [CI] = 0.72 to 0.76) and nonrecent immigrants (HR = 0.80, 95% CI = 0.79 to 0.81). A greater proportion of unvaccinated patients were from neighborhoods with a high concentration of new immigrants or self-reported members of racialized groups (26.0% vs 21.3%, standardized difference = 0.111, P Conclusions Despite funding of vaccines and prioritization of high-risk populations, marginalized patients were less likely to be vaccinated. Differences are likely due to the interplay between systemic barriers to access and cultural or social influences affecting uptake.

IntroductionImproving the quality of self-management support (SMS) for treatment-related toxicities is a priority in cancer care. Successful implementation of SMS programmes depends on tailoring implementation strategies to organisational readiness factors and barriers/enablers, however, a systematic process for this is lacking. In this formative phase of our implementation-effectiveness trial, Self-Management and Activation to Reduce Treatment-Related Toxicities, we evaluated readiness based on constructs in the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) and developed a process for mapping implementation strategies to local contexts.MethodsIn this convergent mixed-method study, surveys and interviews were used to assess readiness and barriers/enablers for SMS among stakeholders in 3 disease site groups at 3 regional cancer centres (RCCs) in Ontario, Canada. Median survey responses were classified as a barrier, enabler or neutral based on a priori cut-off values. Barriers/enablers at each centre were mapped to CFIR and then inputted into the CFIR-Expert Recommendations for Implementing Change Strategy Matching Tool V.1.0 (CFIR-ERIC) to identify centre-specific implementation strategies. Qualitative data were separately analysed and themes mapped to CFIR constructs to provide a deeper understanding of barriers/enablers.ResultsSMS in most of the RCCs was not systematically delivered, yet most stakeholders (n=78; respondent rate=50%) valued SMS. For centre 1, 7 barriers/12 enablers were identified, 14 barriers/9 enablers for centre 2 and 11 barriers/5 enablers for centre 3. Of the total 46 strategies identified, 30 (65%) were common across centres as core implementation strategies and 5 tailored implementation recommendations were identified for centres 1 and 3, and 4 for centre 2.ConclusionsThe CFIR and CFIR-ERIC were valuable tools for tailoring SMS implementation to readiness and barriers/enablers, whereas NPT helped to clarify the clinical work of implementation. Our approach to tailoring of implementation strategies may have relevance for other studies.

Background: Poorly managed cancer treatment toxicities negatively impact quality of life, but little research has examined patient activation in self-management (SM) early in cancer treatment. Methods: We undertook a pilot randomized trial to evaluate the feasibility, acceptability, and preliminary effectiveness of the SMARTCare (Self-Management and Activation to Reduce Treatment Toxicities) intervention. This intervention included an online SM education program (I-Can Manage) plus 5 sessions of telephone cancer coaching in patients initiating systemic therapy for lymphoma or colorectal or lung cancer at 3 centers in Ontario, Canada, relative to a usual care control group. Patient-reported outcomes included patient activation (Patient Activation Measure [PAM]), symptom or emotional distress, self-efficacy, and quality of life. Descriptive statistics and Wilcoxon rank-sum tests were used to examine changes over time (baseline and at 2, 4, and 6 months) within and between groups. We used general estimating equations to compare outcomes between groups over time. The intervention group completed an acceptability survey and qualitative interviews. Results: Of 90 patients approached, 62 (68.9%) were enrolled. Mean age of the sample was 60.5 years. Most patients were married (77.1%), were university educated (71%), had colorectal cancer (41.9%) or lymphoma (42.0%), and had stage III or IV disease (75.8%). Attrition was higher in the intervention group than among control subjects (36.7% vs 25%, respectively). Adherence to I-Can Manage was low; 30% of intervention patients completed all 5 coaching calls, but 87% completed ≥1. Both the continuous PAM total score (PP=.002) were significantly improved in the intervention group. Conclusions: SM education and coaching early during cancer treatment may improve patient activation, but a larger trial is needed. ClinicalTrials.gov Identifier: NCT03849950

The tyrosine receptor kinase (TRK) inhibitors larotrectinib and entrectinib were recently approved in Canada for the treatment of solid tumours harbouring neurotrophic tyrosine receptor kinase (NTRK) gene fusions. These NTRK gene fusions are oncogenic drivers found in most tumour types at a low frequency (80%) in a small number of rare tumours (e.g., secretory carcinoma of the salivary gland and of the breast). They are generally mutually exclusive of other common oncogenic drivers. Larotrectinib and entrectinib have demonstrated impressive overall response rates and tolerability in Phase I/II trials in patients with TRK fusion cancer with no other effective treatment options. Given the low frequency of TRK fusion cancer and the heterogeneous molecular testing landscape in Canada, identifying and optimally managing such patients represents a new challenge. We provide a Canadian consensus on when and how to test for NTRK gene fusions and when to consider treatment with a TRK inhibitor. We focus on five tumour types: thyroid carcinoma, colorectal carcinoma, non-small cell lung carcinoma, soft tissue sarcoma, and salivary gland carcinoma. Based on the probability of the tumour harbouring an NTRK gene fusion, we also suggest a tumour-agnostic consensus for NTRK gene fusion testing and treatment. We recommend considering a TRK inhibitor in all patients with TRK fusion cancer with no other effective treatment options.

Background Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence. Materials and Methods Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral. Results Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to Conclusions Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care. Implications for Practice Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists’ referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.

BACKGROUND: Patients with cancer frequently require emergency medical care during treatment. The objective of this study was to characterize emergency department visits made by patients with cancer receiving chemotherapy and to describe associated outcomes. METHODS: This retrospective cohort study used population-based administrative data from Ontario, Canada. Patients aged 18 years and older, with a cancer diagnosis, and who received chemotherapy in the 30 days before being seen in an emergency department between 2013 and 2017 were included. Emergency department discharge diagnosis codes were categorized to identify the most frequent emergency department diagnoses. We examined the proportion of patients admitted to hospital and 30-day mortality. We used logistic regression to identify predictors of hospital admission. RESULTS: We identified 218 459 emergency department visits made by 87 555 patients. The median number of emergency department visits per patient was 2 (interquartile range 1–3). Hematological, gastrointestinal, breast and lung cancer were the most common malignancies represented. The most common emergency department diagnoses were infection or fever (57 036 [26.1%]) and gastrointestinal diagnoses (26 456 [12.2%]). Of all visits, 77 978 (35.7%) resulted in admission to hospital. Thirty-day mortality after an emergency department visit was 9.8%. There was an increased odds of admission among patients who previously received palliative consultation, patients with bone or soft tissue or hematological malignancies, and patients with infection, gastrointestinal, pulmonary, cardiac, weakness or genitourinary and nephrology diagnoses. INTERPRETATION: Patients with cancer frequently used the emergency department during chemotherapy, and 1 in 4 emergency department visits were for infection or fever. These results highlight opportunities to optimize care for certain patients being actively treated for cancer, particularly around infectious complaints.

PURPOSE: Unplanned emergency department (ED) visits and hospitalizations are common during systemic cancer therapy. To determine how patients with cancer trade off treatment benefit with risk of experiencing an ED visit or hospitalization when deciding about systemic therapy, we undertook a discrete choice experiment. MATERIALS AND METHODS: Patients with breast, colorectal, or head and neck cancer contemplating, receiving, or having previously received systemic therapy were presented with 10 choice tasks (5 in the curative and 5 in the palliative setting) that varied on 3 attributes: benefit, risk of ED visit, and risk of hospitalization. Preferences for attributes and levels were measured using part-worth utilities, estimated using hierarchical Bayes analysis. Segmentation analysis was conducted to identify subgroups with different preferences. RESULTS: A total of 293 patients completed the survey; most were female (76%), had breast cancer (63%), and were currently receiving systemic therapy (72%) with curative intent (59%). Benefit was the most important decision attribute regardless of treatment intent, followed by risk of hospitalization, then risk of ED visit. Two segments were observed: one large cluster exhibiting logical and consistent choices, and a smaller segment exhibiting illogical and inconsistent choices. Patients in the latter segment were more likely to have metastatic head and neck cancer, be male, were older, and reported fewer prior ED visits. CONCLUSION: Although the risk of ED visit or hospitalization contributes to patient treatment preferences, benefit was the most important attribute. Segmentation suggests that a subset of patients may lack cognitive abilities, engagement, or literacy to consistently evaluate treatment choices. Understanding this subset may provide insight into patients’ decision making and understanding of treatment options.

A 64-year-old male with lung cancer presents to the emergency department with one week of cough and increasing shortness of breath. At triage, his temperature is 37.3° Celsius, heart rate 106 beats per minute, blood pressure 136/80, and oxygen saturation 87% on room air, which improves to 94% with 3 L of oxygen via nasal prongs. He has a chest X-ray that demonstrates bilateral patchy infiltrates. He is treated for pneumonia with antibiotics. His respiratory status worsens, with an increasing oxygen requirement. Additional history reveals that the patient recently finished treatment for lung cancer with an immune checkpoint inhibitor.

Maintaining and improving quality of life (QOL) are important goals of anal cancer management. This disease is generally curable, with many long-term survivors.Long-term QOL after chemoradiation for patients with anal cancer was evaluated.This was a prospective cohort study.This study used data from a prospective study of patients with anal cancer who were treated with chemoradiation between 2008 and 2013.Patients with anal cancer who were treated with image-guided intensity-modulated radiation therapy were included.English-speaking patients completed European Organization for Research and Treatment of Cancer cancer-specific (C30) and site-specific (CR29) QOL questionnaires at baseline, at end of radiation, at 3 and 6 months, and then annually.Long-term QOL was evaluated clinically (a change in score of ≥10 points was considered clinically significant) and statistically (using repeated-measurement analysis) by comparing the subscale scores at 1, 2, and 3 years with baseline scores. Subanalysis compared patients who received a radiation dose of 45 to 54 Gy versus 63 Gy.Ninety-six patients were included (median follow-up of 56.5 months). The symptom and functional scales showed a clinically significant decline at the end of treatment with improvement by 3 months after treatment. There was a long-term statistically significant decline in dyspnea, body image, bowel embarrassment, fecal incontinence, and hair loss, and there was long-term statistically and clinically significant worsening of impotence. Higher radiation dose (63 Gy) was not associated with significantly worse QOL.Limitations included single-institution, single-arm study design, and lack of dose reconstruction (ie, analyses were based on prescribed, rather than delivered, dose).Patients with anal cancer treated with chemoradiation reported recovery of overall QOL to baseline levels. Specific symptoms remained bothersome, emphasizing the need to address and manage the chemoradiation-induced symptoms, during treatment and in the long term. See Video Abstract at http://links.lww.com/DCR/B905.ANTECEDENTES:Mantener y mejorar la calidad de vida son objetivos importantes del tratamiento del cáncer anal, ya que esta enfermedad generalmente es curable, con muchos sobrevivientes a largo plazo.OBJETIVO:Se evaluó la calidad de vida a largo plazo después de la quimiorradiación en pacientes con cáncer anal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Utilizamos datos de un estudio prospectivo en pacientes con cáncer anal tratados con quimiorradiación entre 2008-2013.PACIENTES:Los pacientes con cáncer anal fueron tratados con radioterapia de intensidad modulada guiada por imágenes.INTERVENCIONES:Los pacientes de habla inglesa completaron los cuestionarios de calidad de vida específicos de cáncer (C30) y específicos del sitio (CR29) de la Organización Europea para la Investigación y el Tratamiento del Cáncer al inicio, al final de la radiación, 3 y 6 meses, y luego anualmente.PRINCIPALES MEDIDAS DE RESULTADOS:Se evaluó a largo plazo la calidad de vida clínicamente (un cambio en la puntuación de ≥10 puntos se consideraron clínicamente significativo) y estadísticamente (usando análisis de medición repetida) comparando las subescalas de puntuación al 1, 2, y 3 años. Con puntuaciones de referencia. El subanálisis comparó pacientes que recibieron 45-54 Gy versus 63 Gy.RESULTADOS:Se incluyeron un total de 96 pacientes (mediana de seguimiento: 56,5 meses). La mayoría de las escalas funcionales y de síntomas mostraron una disminución clínicamente significativa al final del tratamiento con una mejoría a los 3 meses posteriores al tratamiento. Hubo una disminución estadísticamente significativa a largo plazo en disnea, imagen corporal, vergüenza intestinal, incontinencia fecal y pérdida de cabello; y hubo un empeoramiento a largo plazo estadística y clínicamente significativo en impotencia. La dosis de radiación más alta (63 Gy) no se asoció con una calidad de vida significativamente peor.LIMITACIONES:Institución única, diseño de estudio de un solo brazo y falta de recomposición de la dosis (es decir, los análisis se basan en la dosis prescrita, en lugar de la administrada).CONCLUSIÓNES:Los pacientes con cáncer anal tratados con quimiorradiación reportaron una recuperación de la QOL en general a los niveles de base. Síntomas específicos siguieron siendo molestos, lo que enfatiza la necesidad de resolver y tartar los síntomas inducidos por la quimiorradiación no solo durante el tratamiento, sino a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B905. (Traducción- Dr. Francisco M. Abarca-Rendon).

ImportanceThe impact of COVID-19 on the modality and timeliness of first-line cancer treatment is unclear yet critical to the planning of subsequent care.ObjectiveTo explore the association of the COVID-19 pandemic with modalities of and wait times for first cancer treatment.Design, Setting, and ParticipantsThis retrospective population-based cohort study using administrative data was conducted in Ontario, Canada, among adults newly diagnosed with cancer between January 3, 2016, and November 7, 2020. Participants were followed up from date of diagnosis for 1 year, until death, or until June 26, 2021, whichever occurred first, to ensure a minimum of 6-month follow-up time.ExposuresReceiving a cancer diagnosis in the pandemic vs prepandemic period, using March 15, 2020, the date when elective hospital procedures were halted.Main Outcomes and MeasuresThe main outcome was a time-to-event variable describing number of days from date of diagnosis to date of receiving first cancer treatment (surgery, chemotherapy, or radiation) or to being censored. For each treatment modality, a multivariable competing-risk regression model was used to assess the association between time to treatment and COVID-19 period. A secondary continuous outcome was defined for patients who were treated 6 months after diagnosis as the waiting time from date of diagnosis to date of treatment.ResultsAmong 313 499 patients, the mean (SD) age was 66.4 (14.1) years and 153 679 (49.0%) were male patients. Those who were diagnosed during the pandemic were less likely to receive surgery first (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99) but were more likely to receive chemotherapy (sHR, 1.26; 95% CI, 1.23-1.30) or radiotherapy (sHR, 1.16; 95% CI, 1.13-1.20) first. Among patients who received treatment within 6 months from diagnosis (228 755 [73.0%]), their mean (SD) waiting time decreased from 35.1 (37.2) days to 29.5 (33.6) days for surgery, from 43.7 (34.1) days to 38.4 (30.6) days for chemotherapy, and from 55.8 (41.8) days to 49.0 (40.1) days for radiotherapy.Conclusions and RelevanceIn this cohort study, the pandemic was significantly associated with greater use of nonsurgical therapy as initial cancer treatment. Wait times were shorter in the pandemic period for those treated within 6 months of diagnosis. Future work needs to examine how these changes may have affected patient outcomes to inform future pandemic guideline development.

Geriatric assessment (GA) provides information on key health domains of older adults and is recommended to help inform cancer treatment decisions and cancer care. However, GA is not feasible in many health institutions due to lack of geriatric staff and/or resources. To increase accessibility to GA and improve treatment decision making for older adults with cancer (≥65 years), we developed a self-reported, electronic geriatric assessment tool: Comprehensive Assessment for My Plan (CHAMP).Older adults with cancer were invited to join user-centered design sessions to develop the layout and content of the tool. Subsequently, they participated in usability testing to test the usability of the tool (ease of use, acceptability, etc.). Design sessions were also conducted with oncology clinicians (oncologists and nurses) to develop the tool's clinician interface. GA assessment questions and GA recommendations were guided by a systematic review and Delphi expert panel.A total of seventeen older adults participated in the study. Participants were mainly males (82.4%) and 75% were aged 75 years and older. Nine oncology clinicians participated in design sessions. Older adults and clinicians agreed that the tool was user-friendly. Domains in the final CHAMP tool (with questions and recommendations) included functional status, falls risk, cognitive impairment, nutrition, medication review, social supports, depression, substance use disorder, and miscellaneous items.CHAMP was designed for use by older adults and oncologists and may enhance access to GA for older adults with cancer. The next phase of the CHAMP study will involve field validation in oncology clinics.

Background: Evidence supporting early palliative care is based on trials of specialised palliative care, but a more sustainable model might involve mainly primary providers. Aim: The aim of this study was to compare the characteristics of physicians providing primary and specialised palliative care, their attitudes towards early palliative care and their perception of having sufficient resources for its provision. Design: Survey distributed by mail and e-mail. Specialised providers were defined as both receiving palliative care referrals from other physicians and not providing palliative care only for their own patients. Setting/participants: A total of 531 physicians providing palliative care in Canada (71% participation) participated in the study. Results: Of the participants, 257 (48.4%) provided specialised and 274 (51.6%) primary care. Specialists were more likely to have palliative care training (71.8% vs 35.2%), work in urban areas (94.1% vs 75.6%), academic centres (47.8% vs 26.0%) and on teams (82.4% vs 16.8%), and to provide mainly cancer care (84.4% vs 65.1%) (all p Conclusion: Despite strongly favouring the concept, both specialists and primary providers lack resources to deliver early palliative care; its provision may be facilitated by team-based care with appropriate support. Opinions differ regarding the value of renaming palliative care.

Introduction The introduction of immunotherapy (IO) in the treatment of patients with cancer has significantly improved clinical outcomes. Population level information on actual IO utilization is limited. Methods We conducted a retrospective cohort study using provincial health administrative data from Ontario, Canada to: (1) assess the extent of IO use from 2011 (pre-IO funding) to 2019; and (2) identify factors associated with IO use in patients with advanced cancers for which IO is reimbursed including melanoma, bladder, lung, head and neck, and kidney tumors. The datasets were linked using a unique encoded identifier. A Fine and Gray regression model with death as a competing risk was used to identify factors associated with IO use. Results Among 59 510 patients assessed, 8771 (14.7%) received IO between 2011 and 2019. Use of IO increased annually from 2011 (3.3%) to 2019 (39.2%) and was highest in melanoma (52%) and lowest in head and neck cancer (6.6%). In adjusted analysis, factors associated with lower IO use included older age (hazard ratio (HR) 0.91 (95% CI, 0.89-0.93)), female sex (HR 0.85 (95% CI, 0.81-0.89)), lower-income quintile, hospital admission (HR 0.78 (95% CI, 0.75-0.82)), high Charlson score and de novo stage 4 cancer. IO use was heterogeneous across cancer centers and regions. Conclusion IO utilization for advanced cancers rose substantially since initial approval albeit use is associated with patient characteristics and system-level factors even in a universal healthcare setting. To optimize IO utilization in routine practice, survival estimates and potential inequity in access should be further investigated and addressed.

Background: Resource restrictions were established in many jurisdictions to maintain health system capacity during the COVID-19 pandemic. Disrupted healthcare access likely impacted early cancer detection. The objective of this study was to assess the impact of the pandemic on weekly reported cancer incidence. Patients and Methods: This was a population-based study involving individuals diagnosed with cancer from September 25, 2016, to September 26, 2020, in Ontario, Canada. Weekly cancer incidence counts were examined using segmented negative binomial regression models. The weekly estimated backlog during the pandemic was calculated by subtracting the observed volume from the projected/expected volume in that week. Results: The cohort consisted of 358,487 adult patients with cancer. At the start of the pandemic, there was an immediate 34.3% decline in the estimated mean cancer incidence volume (relative rate, 0.66; 95% CI, 0.57–0.75), followed by a 1% increase in cancer incidence volume in each subsequent week (relative rate, 1.009; 95% CI, 1.001–1.017). Similar trends were found for both screening and nonscreening cancers. The largest immediate declines were seen for melanoma and cervical, endocrinologic, and prostate cancers. For hepatobiliary and lung cancers, there continued to be a weekly decline in incidence during the COVID-19 period. Between March 15 and September 26, 2020, 12,601 fewer individuals were diagnosed with cancer, with an estimated weekly backlog of 450. Conclusions: We estimate that there is a large volume of undetected cancer cases related to the COVID-19 pandemic. Incidence rates have not yet returned to prepandemic levels.

389 Background: The COVID-19 pandemic catalyzed rapid implementation of virtual care (VC), resulting in new opportunities to integrate technology and a need to evaluate patient and provider experiences. To inform sustainment beyond COVID-19, we evaluated perceptions of VC at a comprehensive cancer centre in Toronto, Canada. Methods: Physicians who provided VC during the pandemic, and patients with a valid email address on file and at least one visit with centre in the preceding 12 months were eligible to participate. Survey invitations were disseminated between May and July 2021 via email using a modified Dillman approach. The survey examined the implementation outcomes of acceptability, adoption, and appropriateness. Unadjusted associations between patient demographic variables and preference for in-person visits were evaluated using univariate logistic regression models. Results: 41% (100/246) of physicians and 15% (2,343/15,169) of patients completed the survey. The majority of patients were Caucasian (77%), college or university educated (78%), had solid malignancies (73%), and were in the follow-up phase (47%); 50% were male. The median age was 66 (IQR: 58-74). A greater proportion of patients expressed satisfaction with VC than providers (81% and 53%). Conversely, a greater proportion of providers felt that care delivered virtually was worse than care delivered in-person (45% vs 26%). Interestingly, many patients (69%) and physicians (40%) reported feeling they could maintain a good relationship through VC while at the same time reporting concerns that VC would detract from the human interaction they value as part of care (patients: 60%; providers: 82%). Patients expressed relatively equal preference for phone vs video visits (40% vs 31%), but indicated concerns about wait times for VC visits. The majority of physicians (37%) estimated that 10-29% of their practice would remain virtual post-COVID, however physicians expressed concerns with increased workload (72%), decreased efficiency (40%), and increased worry about missing relevant clinical information (61%). The majority of patients and physicians reported that VC was not appropriate for first consultations and discussions of prognosis, and most appropriate for long-term follow-up. Being born outside of Canada, primary language other than English, lower income, lower functional health literacy, and greater physical mobility were associated with preferring in-person over VC visits. Conclusions: Patients and physicians were satisfied with VC but expressed concerns with the impacts on care quality and experience and highlighted the need for guidelines on appropriate use. Providers expressed greater concerns with VC than patients. More research is needed to formally evaluate the impact of VC on quality performance and clinical outcomes as well as investigate the patient, disease and system factors that are associated with effective virtual cancer care.

28 Background: The reorganization of cancer care delivery during the COVID pandemic had the potential to catalyze improvement in CWR adherence by reducing provision of low value care to minimize in-person visits and mitigate potential issues with staff and resource shortages. We evaluated the impact of COVID on adherence with CWR for supportive care, relevant to colorectal and anal cancer patients with stage IV disease at Princess Margaret Cancer Centre (PM) in Canada and AC Camargo Cancer Center (AC) in Brazil. Methods: Eligible patients had a new patient consult 02/2020- 12/2020 (COVID) or the same period in 2019 (control). Performance on individual CWR in the 6 months following initial consultation was calculated as the proportion of eligible patients meeting the recommendation. Results: The PM and AC cohorts each consisted of 100 patients; demographic and disease characteristics of COVID and control cohorts were similar within each centre. Marginally fewer patients received surgery during COVID (PM: 38.3 vs 49.1%, p = 0.28; AC: 54.8 vs 55.2%, p = 0.97). At PM, more patients received radiation therapy during COVID (36.2 vs 24.5%, p = 0.21), whereas the opposite occurred at AC (7.1 vs 17.2%, p = 0.14). A higher proportion of both PM and AC patients treated during COVID died within 6 months of initial consult than in 2019 (PM: 10.6 vs 7.5%, p = 0.015; AC: 21.4 vs 8.6%, p = 0.029). Adherence to selected CWR is summarized below; whereby a higher proportion means higher concordance with CWR. Conclusions: There was low overall adherence to CWR across both centers with no significant changes to patterns of care for patients with stage IV disease during the COVID-19 pandemic.[Table: see text]

41 Background: The COVID-19 pandemic led to the rapid implementation of remote work, but few studies have evaluated the impact on staff and care delivery in healthcare settings. Utilizing a cross-sectional survey, we evaluated the experience of working remotely among clinical staff at the Princess Margaret Cancer Centre, Toronto, Canada. Methods: “Remote work” was defined as any work (tasks, projects, healthcare delivery) performed from home. A Qualtrics survey was disseminated via email three times from June-August 2021 to 1,168 physicians, nurses, allied health, and administrative staff involved in patient care. The survey evaluated staff perceptions of productivity, efficiency, patient safety, quality, and personal experiences. Results were summarized using descriptive statistics. Associations between respondent demographics and responses on perceived efficiency, desire to work remotely, support and safety/quality were evaluated using multivariable binary logistic regression models. Free-text responses were categorized into facilitators and barriers, and summarized using qualitative descriptive analysis. Results: Most respondents (n = 333; response rate: 28.5%) were female (61.3%) and physicians (23.1%). Few respondents (1.5%) worked remotely more than half the time pre-COVID which increased to 66.6% during COVID-19. Majority reported that remote work positively impacted productivity (61.8%) and efficiency (57.6%) and expressed interest in continuing (79.0%) beyond the pandemic. While most respondents agreed with the switch to remote work (89.2%), few were provided with the necessary equipment (14.1%). Some respondents perceived a negative impact on the safety (13.8%) or quality of care (18.6%) delivered remotely. Across clinical roles, compared to administrative staff, physicians were more likely to report remote work having a negative impact on productivity (OR = 24.04, 95% CI: 2.71-213.00), being dissatisfied with remote work (OR: 8.41, 95% CI: 1.37-51.64), being dissatisfied with training available (OR: 2.70, 95% CI: 0.95-7.67), and disagreed with continuing to utilize remote work beyond the pandemic (OR: 16.61, 95% CI: 1.45-190.14). Improved efficiency, less commuting, and improved work-life balance were perceived as facilitators of remote work. Barriers included a lack of clear role expectations, issues accessing clinical applications and out-of-pocket expenses. Conclusions: Our findings indicate that remote work may be a viable model in hospitals beyond the pandemic. Given the variation in experience and perceptions depending on clinical role, addressing barriers and formal evaluation of the impact of working remotely on productivity, efficiency and quality of care should be considered to inform long-term adoption.