Annual Meeting Proceedings Part 1 - American Society of Clinical ...

388s Health Services Research
6024 Poster Discussion Session (Board #12), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Improving the quality of breast cancer surgical treatment decisions.
Presenting Author: Steven J. Katz, University of Michigan Medical School,
Ann Arbor, MI
Background: Ensuring breast cancer treatment decisions are high quality
(i.e., informed and preference-concordant) is a key component of patient
centered care. Methods: A web-based decision tool, including an interactive
preference clarification exercise, was developed over a one-year period with
input from health communication experts, clinicians, and women with
breast cancer. Newly diagnosed early stage breast cancer patients from two
cancer centers were recruited and randomized to view the tool before or
after completing a survey. Mean scores for key outcome measures,
including surgical treatment knowledge (4 true/false questions), decision
satisfaction (12 questions each with a 5-point Likert scale from strongly
agree to strongly disagree), and preference-concordant decisions, were
compared between the groups using t-tests. Concordance between preferences
and surgical choices was evaluated using the chi-square test.
Results: 110 subjects were recruited and 105 completed the study. Their
mean age was 57 years, 60% had a college degree or more, and 81% were
white. Those viewing the website first had higher scores on several decision
outcomes than those taking the survey first (Table). Knowledge scores were
also higher among those viewing the website before the survey (3.0 vs.
2.61, p�.23). The risk of recurrence was the most important treatment
attribute, followed by retaining the natural breast, in both groups. Concordance
between treatment choice and computer generated treatment was
65% for website first and 61% for survey first groups. Conclusions: A tool
focused on improving knowledge and preference-concordant decisions
produced positive results on breast cancer surgical treatment decision
making. Further work should assess the impact of the tool in larger and
more diverse populations.
Website first Survey first
Response 1-5
Decision outcomes
(strongly agree – strongly disagree)
I’m unsure what decision to make 4.12 3.35*
The surgical treatment decision is hard 3.76 2.80
for me
I’m aware of the choices I have to treat 1.61 1.83*
my breast cancer
I am satisfied with my surgical treatment 1.44 1.65
decision
I feel the surgical treatment decision
matches my values
*P�0.05, ^P�0.10.
1.32 1.77^
6026 Poster Discussion Session (Board #14), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Is care coordination associated with improved care quality for comorbid
conditions in cancer survivors? Presenting Author: Claire Frances Snyder,
The Johns Hopkins University School of Medicine and Sidney Kimmel
Comprehensive Cancer Center, Baltimore, MD
Background: Many cancer survivors have comorbid conditions, adding
complexity to their already complicated care and requiring greater care
coordination. We assessed the role of care coordination in comorbid
condition care for cancer survivors. Methods: Using SEER-Medicare, we
examined 7 published indicators of quality comorbid condition care in
survivors of loco-regional breast, prostate, or colorectal cancer who were
diagnosed in 2004, in fee-for-service Medicare, and survived �3 years.
Comorbid condition care was evaluated during the transition from initial
cancer treatment to survivorship (i.e. days 366-1095 post-diagnosis).
Coordination risk was categorized as Likely, Possible, or Unlikely using an
index developed and tested as part of the ACG case-mix adjustment and
predictive modeling tool. The index factors in the number of unique
providers, number of specialties, the percentage majority source of care,
and generalist visits. We tested the hypothesis that lower coordination risk
would be associated with better comorbid condition care using logistic
regression, adjusting for socio-demographics, cancer type, and comorbidity.
Results: The sample included 8661 survivors (53% prostate, 22%
breast, 26% colorectal; mean age 75; 65% male, 85% white). Our
hypothesis was not supported. Compared to patients with Unlikely coordination
issues, patients with Likely coordination issues were more likely to
receive appropriate care on 4 indicators and less likely on 1. Possible
coordination issues were associated with better care on 1 indicator and
worse care on 1 indicator. To explore this finding further, we conducted
post-hoc analyses examining the role of each component of the coordination
risk index. Having more unique providers was generally associated with
better comorbid condition care, in contrast to the calculation of the index
which considers more unique providers a greater risk for coordination
issues. Conclusions: These findings suggest that traditional metrics of care
coordination may not be valid for survivors of cancer. Understanding the
role of care coordination in cancer survivorship care requires development
and application of alternative coordination measures.
6025 Poster Discussion Session (Board #13), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Does unblinding of treatment assignment impact participant perceptions in
clinical trials? Presenting Author: Ann H. Partridge, Dana-Farber Cancer
Institute, Boston, MA
Background: Blinding patients to treatment regimen is an important
component of high quality randomized clinical trials although concern
exists about how receipt of a placebo will impact participants’ views. In
ECOG5103, patients were randomized to receive adjuvant chemotherapy
for breast cancer with either placebo (arm A) or bevacizumab (arms B and
C) and treatment assignment was unblinded by 24 weeks. We sought to
determine if unblinding was associated with differential changes in
participants’ views. Methods: The Decision-Making/Quality of Life component
(DM-QOL) included all patients enrolling on E5103 between 1/5-
6/8/10. Women were surveyed pretreatment and after unblinding. Wilcoxon
rank sum testing was used to examine differences. Results: 572 patients on
DM-QOL started protocol therapy; 118 on arm A, 454 on arm B/C; the two
groups (arm A vs. B/C) were well balanced. 516 patients participated in
pretreatment, 514 in unblinding survey. Pretreatment, 32% reported
�moderate chance of recurrence in 5 years, 27% �moderate chance of
serious problem from treatment, 99% feeling at least somewhat informed,
98% at least somewhat confident in study participation, most “extremely”
confident. Overall, median response scores did not change over time, with
no statistically significant differences between the groups in changes in
perceptions of: recurrence risk (p�0.45); chances of a serious problem
(p�0.12), feeling informed (p�0.99). However, they differed in confidence
about study participation (p�0.04): after unblinding, a higher % of
placebo-treated patients had increased confidence (38% vs. 25%), and a
higher % of bevacizumab-treated patients had decreased confidence (29%
vs. 22%), although 44% across all arms had no change. Conclusions: In a
placebo-controlled, double-blinded RCT, unblinding did not significantly
affect most participants’ views, regardless of receipt of placebo or experimental
drug. However, confidence in study participation may have been
affected by knowledge of receipt of bevacizumab; publicity surrounding
this experimental therapy may have affected results.
6027 Poster Discussion Session (Board #15), Tue, 8:00 AM-12:00 PM and
11:30 AM-12:30 PM
Patterns of diagnostic imaging and cumulative radiation exposure among
long-term young adult cancer survivors. Presenting Author: Corinne Daly,
Clinical Decision Making & Healthcare, Toronto, ON, Canada
Background: Young adults surviving a diagnosis of malignancy have a
considerable life expectancy, however, little is known about radiation
exposure from diagnostic imaging in these patients. This study aims to
describe patterns of imaging and radiation exposure in young adult cancer
survivors (YAS) and cancer-free controls in Ontario, Canada. Methods: We
conducted a population-based retrospective study. Young adults aged
20-44 diagnosed with an invasive malignancy between 1992 and 1999
who lived at least 5 years without recurrent disease were identified in the
Ontario Cancer Registry. YAS were matched 1:5 to randomly selected
cancer-free controls on calendar year of birth, sex, and geographic location.
Radiological procedures were identified through Ontario Health Insurance
Plan administrative data. The rate at which individuals underwent diagnostic
procedures after surviving 5-years was compared between survivors and
controls using Poisson regression. Cumulative radiation exposure due to
computed tomography (CT) and standard x-ray were calculated. Results:
20,911 YAS and 104,524 controls had a median of 13.5 years observation
time after cancer diagnosis/referent date. The rate of CT scanning after 5
year survival was higher in YAS (rate ratio� 3.59, 95% CI: 3.46 – 3.73)
and varied according to malignancy type (Table). Over the course of
diagnosis, treatment and surveillance to 10 years, the average YAS was
exposed to 33.8 mSv of radiation, 4.4 times the radiation exposure an
individual in the general population received. 47% of YAS cumulative dose
was attributed to exposure 5 years or more after diagnosis. Conclusions: YAS
undergo imaging and are exposed to diagnostic irradiation at a significantly
higher rate than controls even after 5 years of recurrence free survival.
Alternative imaging techniques not associated with exposure to radiation
should be considered for these patients.
CT after 5 years
n
post-diagnosis
YAS Rate ratio 95% CI
All malignancy types 20,911 3.59 3.46 - 3.73
Breast 4,581 3.21 2.96 - 3.48
Gynecological 2,782 2.38 2.12 - 2.67
Hodgkin’s lymphoma 1,071 6.69 5.82 - 7.69
Melanoma 2,088 2.23 1.94 - 2.57
Non-Hodgkin’s lymphoma 1,277 8.56 7.60 - 9.63
Thyroid 2,388 1.74 1.55 - 1.96
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