Victoria S. Blinder

PURPOSE: Patients with cancer take different types of medications with varying schedules and settings. They are also sometimes instructed to stop medications due to toxicity. To measure self-reported nonadherence in this heterogeneous population, we modified and evaluated a measure originally developed to assess nonadherence to daily oral antihypertensives, the Domains of Subjective Extent of Nonadherence (DOSE-Nonadherence). METHODS: The measure was refined in an iterative process incorporating feedback from patient investigators and participant interviews in English and Spanish. Branching logic was added for participant selection of medication administration setting: (1) only home, (2) only clinic, or (3) partly home/partly clinic. Participants reported their adherence to medications taken over a setting-specific reference period (1 week for home, 1 month for clinic medications). Participants who missed medications then reported on reasons for nonadherence. Adherence was dichotomized for analysis (complete adherence v any nonadherence). For participants who received clinic-administered medications, concordance between chart-abstracted and self-reported adherence was evaluated. RESULTS: Seventy-three participants completed the measure (68% English; 32% Spanish; 86% female; 44% age ≥60 years). The majority had breast cancer; 64% had metastatic disease. Twenty-six percent (15/58) of participants who received medication in clinic and 24% (11/46) of those who took medication at home reported nonadherence. Participants felt able to respond accurately to both reference periods and perceived all reasons for nonadherence to be relevant. Among participants who completed the final version of the measure for clinic-administered medication, 96% (26/27) accurately reported their adherence compared with chart-abstracted data. CONCLUSION: Our results support the validity of the DOSE-Nonadherence-Cancer for assessing cancer treatment nonadherence. This measure can be used to assess nonadherence in patients with cancer receiving a broad array of systemic therapies.

PURPOSE: Remote symptom monitoring using patient-reported outcomes (PROs) has been shown to improve symptom control and physical function among patients with advanced cancer. However, it is unclear whether these benefits are similar across demographic groups. This exploratory analysis of the PRO-TECT trial examined whether the effects of electronic symptom monitoring varied by race, age, sex, and educational attainment. METHODS: PRO-TECT was a cluster randomized trial conducted across 52 US community oncology practices comparing weekly electronic symptom monitoring with usual care (UC). Adult patients with metastatic solid tumors receiving systemic therapy were enrolled (N = 1,191). Participants in the PRO arm completed weekly symptom surveys including the PRO-CTCAE, triggering alerts to the care team for severe or worsening symptoms. Patients chose whether to complete weekly PROs online or via telephone-based interactive voice response not requiring Internet access. Outcomes were measured using the European Organisation for Research and Treatment of Cancer QLQ-C30 symptom control and physical function scales. Subgroup analyses were performed by race (Black v White), age (high school). RESULTS: From baseline to 3 months, PRO participants showed greater improvements in symptom control (+2.37 v −0.20, P = .002) and physical function (+1.54 v −0.93, P = .02) versus UC. Benefits were most pronounced among younger, female, Black, and less educated participants. Black participants in the PRO arm were more likely to report that symptom reporting made them feel more in control of their care compared with White participants. CONCLUSION: Electronic symptom monitoring improved quality-of-life outcomes overall, including among groups who have historically experienced higher symptom burden or barriers to communication. Remote PRO systems may represent an equitable strategy to enhance cancer care delivery.

Background: Receiving work accommodations is associated with job retention among women at high-risk of job loss during cancer treatment. However, there is a lack of consensus on what constitutes an accommodation. Understanding accommodations relevant to cancer is essential to creating inclusive patient-centered interventions. Objective: We aimed to better understand patient perceptions of work accommodations relevant to cancer diagnosis and treatment. Methods: As part of a survey pilot, we interviewed a diverse cohort of women undergoing treatment for stage 0-III breast cancer at five New York City cancer centers. We asked participants to list examples of what they considered to be work accommodations when completing the survey. Content analysis was used to describe accommodation types listed. Associations between participant characteristics and accommodation types were explored using significance tests. Results: Sixty-one women (79% non-White race/ethnicity; 41% employed in service, manufacturing, or transportation industries) described nine accommodation types. Accommodations included leave time, schedule flexibility, social support, benefits, employer expectations, working from home, job security, physical accommodations, and confidentiality; 63% described more than one accommodation type. Women from groups at high risk of job loss described accommodation types not commonly assessed in cancer-employment research including job security (non-White race/ethnicity, less educated) and social support (low self-efficacy in approaching employers). Conclusions: Work accommodations provided to women during breast cancer treatment vary. A multi-item instrument is needed to assess accommodations relevant to cancer. Women at high risk of job loss (non-White, less education) consider novel accommodations and therefore must be included in instrument development.

The National Cancer Institute (NCI) awarded administrative supplements to 11 NCI-designated cancer centers to build capacity for financial navigation services and collect preliminary data to implement and evaluate financial navigation programs. Preliminary findings from the projects were shared during a virtual conference in October 2022. This paper reflects major themes from the conference, the now completed projects, and findings from scientific literature to propose a set of recommendations for addressing financial hardship as part of cancer care delivery. Recommendations include the following principles. Healthcare systems should implement financial hardship screening using validated, culturally appropriate tools, considering patient literacy and language needs. Screening programs should be universal with assessments repeated over time. Financial navigation services should be available to help patients manage direct and indirect costs of care, access financial assistance and navigate employment-related challenges. Financial navigators should receive specialized training to build their knowledge of healthcare billing, insurance, financial assistance, and patient advocacy while also preparing them to support patients and leverage local and regional resources. A multidisciplinary care team approach should be applied to developing and implementing financial hardship screening and navigation services. Finally, health systems should harmonize information technology and workflows across departments involved in screening and financial navigation service delivery and automate screening, referral, and care team notification processes. Future research should address outstanding knowledge gaps, including the optimal interval for screening, how to identify patient needs early to mitigate downstream financial hardship, and the ideal components and timing of financial navigation for different settings and populations.

Background: Chemotherapy dose reductions are associated with poorer survival. To better understand the role of clinician- and facility-level factors in chemotherapy dosing, we conducted an analysis within a large, real-world cohort of women with stages I-IIIA breast cancer. Methods: Our cohort included 8540 breast cancer patients receiving chemotherapy at Kaiser Permanente Northern California between 2006 and 2019. Patients were treated across 22 facilities by 198 clinicians. We evaluated associations between clinician- and facility-level factors related to dose reductions at the start of chemotherapy (first cycle dose proportion, FCDP, <90%) and throughout treatment (average relative dose intensity, ARDI, <90%). Prevalence ratios (PR) and corresponding 95% confidence intervals (CI) were estimated for the clinician and facility factors in relation to chemotherapy dose reductions. Results: Factors associated with an increased likelihood of dose reduction were increased clinician years since medical school (FCDP < 90%: PR≥30 vs. <10 years = 1.78, P-trend = .03; ARDI < 90%: PR≥30 vs <10 years = 1.29, P-trend = .03) and treatment at less urban facilities (ARDI < 90%: PR<100% vs 100% urban = 1.38, P-trend = .002). Factors associated with a decreased likelihood of dose reduction were higher annual clinician volume of stage I-IIIA breast cancer patients (FCDP < 90%: PR≥30 vs ≤15 patients = 0.64, P-trend = .03; ARDI < 90%: PR≥30 vs ≤15 patients = 0.76, P-trend = .01), higher treatment facility annual volume of stage I-IIIA breast cancer patients (ARDI < 90%: PR≥200 vs <75 patients = 0.85, P-trend = .03), and a larger practice size (FCDP < 90%: PR≥10 vs ≤5 oncologists = 0.53, P-trend = .02). Conclusions: Clinician- and facility-level factors were associated with chemotherapy dose reductions. Practice-level changes, such as increasing breast cancer patient volumes and practice size, may support optimal dosing practices.

PURPOSE: We examined clinician- and facility-level factors associated with selection of nonguideline chemotherapy at treatment initiation in women with stage I-IIIA breast cancer (BC). METHODS: The Optimal Breast Cancer Chemotherapy Dosing Study collected information on chemotherapy delivery in an integrated health care delivery system. This analysis included 9,758 women treated with chemotherapy for stage I-IIIA BC between 2006 and 2019 at Kaiser Permanente Northern California (KPNC). Prevalence ratios (PRs) and corresponding 95% CIs were estimated for the clinician and facility factors in relation to nonguideline regimen (NGR) use. Analyses were stratified by time (pre- and post-2015) to reflect the period before and after KPNC's transition to a subspecialized care model. Secondary outcomes focused on nonguideline drug combinations (NGDCs) and nonguideline administration schedules (NGASs). RESULTS: Women treated by clinicians with substantially greater time since medical school (30+ years v P trend = .01) with significant associations observed for both NGDC and NGAS. While not associated in the primary analysis, larger practice size (10+ oncologists) was associated with a lower likelihood of NGDC use compared with smaller practices (P trend = .01). Time stratification revealed that, in the study's early years, clinician sex and years since medical school were associated with NGR use, but neither association remained post-2015. CONCLUSION: Clinician and facility characteristics significantly influenced the use of NGR in stage I-IIIA BC treatment. Notably, associations diminished over time, suggesting that health system changes in care delivery may enhance guideline adherence and reduce the impact of nonclinical factors on treatment decisions.

PURPOSE: Financial toxicity can negatively affect treatment adherence, quality of life, and survival in patients with cancer. Although screening for financial toxicity is increasingly implemented across oncology practices and cancer centers, less is known about challenges in delivering timely interventions after a positive screen. We evaluated outcomes and barriers in a systematic financial toxicity screening and referral program at a large comprehensive cancer center. METHODS: From March 2023 to December 2024, patients in breast, gynecologic, GI, and thoracic oncology clinics at Memorial Sloan Kettering Cancer Center completed an electronic survey assessing health-related social risks and the 12-item Comprehensive Score for Financial Toxicity (COST). A positive screen was defined as COST <16, unmet essential need, or new loan/borrowing for treatment. Patients screening positive and requesting assistance were referred to Patient Financial Services (PFS) for follow-up. Outcomes included proportions with documented outreach, receipt of any intervention, intervention types, and barriers. RESULTS: A total of 83,978 patients were eligible; of whom 50,949 (61%) completed screening. Of 9,724 positive screens, 8,004 (82%) requested follow-up, and 6,987 referrals were placed. PFS attempted follow-up in 3,383 patients (of the 6,987 = 48%), with documented interventions in 1,510 of 3,383 (45%). Counseling on financial resources (983/3,383 = 29%) was most common, followed by insurance-related counseling (402/3,383 = 12%) and formal program referrals (823/3,383 = 24%). Among patients referred to assistance programs, this was most often to the institutional Financial Assistance Program (438/796 = 55%) or social work (318/796 = 40%). The most frequent barrier was the inability to contact patients (1,464/3,383 = 43%). CONCLUSION: Routine financial toxicity screening was implemented at scale and connected many patients to meaningful financial support. However, 81% of those who screened positive did not receive an intervention, underscoring the need for expanded infrastructure and policy reforms to address financial toxicity in cancer care.

Objective To estimate the association between the billing (profit) margin and clinical benefit of cancer treatments and use by oncologists. Design Retrospective population based cohort study Setting Population based sample using fee-for-service Medicare claims data. Participants Medicare beneficiaries with an incident cancer diagnosis from 2015 to 2020; included all patients with cancer treatment indications for which the available treatment options varied in clinical benefit and billing margin. Main outcomes and measures The primary outcome was the cancer treatment each patient received among treatment options recommended by the National Comprehensive Cancer Network (NCCN). The characteristics of interest were provider billing margin (defined at the patient treatment level, using Medicare reimbursement rates corresponding to the patient’s diagnosis date) and a proxy measure of clinical benefit (rank order of treatments based on Evidence Blocks scores developed by the NCCN, corresponding to the patient’s diagnosis date). The association between treatment received, billing margin, and clinical benefit was modeled using a conditional logit model with inverse probability-of-treatment weights applied at the patient treatment level to control for patient and provider characteristics. Results Twelve cancer indications were examined comprising 19 397 individual patients. Provider billing margin ranged from $0 to $12 692 (£9440; €10 800) for each course of treatment. No association was found between a $100 increase in provider billing margin and the likelihood of treatment use (odds ratio 0.97, 95% confidence interval 0.91 to 1.03). Higher clinical benefit was associated with greater treatment use (1.62, 1.15 to 2.29). Conclusions In this observational study of Medicare beneficiaries, selection of cancer treatments was associated with the treatment’s clinical benefit but not billing margin. Therefore, it is unlikely that policy and price changes that affect the billing margin of cancer treatments would shift patterns of use.

Background: Older women (>65 years) diagnosed with breast cancer may be at risk for chemotherapy dose reductions. We evaluated associations of age at diagnosis with 2 measures of chemotherapy dose reductions: first cycle dose proportion (FCDP) < 90% and average relative dose intensity (ARDI) < 90%. Methods: From the Optimal Breast Cancer Chemotherapy Dosing study, we included 10 166 women aged 18+ years treated with adjuvant chemotherapy for stage I-IIIA breast cancer at Kaiser Permanente Northern California (KPNC) and Washington (KPWA) between 2004 and 2019. We examined associations between age at diagnosis with FCDP < 90% (reflecting clinician intent at chemotherapy initiation) and ARDI < 90% (reflecting average dose across the chemotherapy course). We used generalized linear models of the Poisson family with a log-link function and robust standard errors to calculate prevalence ratios (PR) for FCDP < 90% and ARDI < 90% with 95% confidence intervals (CI) adjusted for patient and tumor characteristics, with and without adjusting for pre-existing comorbidities. All tests for statistical significance were 2-sided. Results: The proportion of women with FCDP < 90% ranged from 2.9% among women aged 18-39 years to 18.6% among women aged 75+ years. Before adjusting for comorbidities, women aged 75+ years were more likely to have FCDP < 90% (PR = 4.88; 95% CI = 3.58 to 6.66) and ARDI < 90% (PR = 1.91; 95% CI = 1.58 to 2.32) versus women aged 40-49 years. Results were similar after adjusting for comorbidities as a composite comorbidity score or individual comorbidities. Conclusion: Older age at diagnosis was strongly associated with chemotherapy dose reductions in this population-based cohort, particularly at chemotherapy initiation but also across the course of treatment.

Background: Lymphedema is a common problem that adversely impacts quality of life in breast cancer survivors. Although lymphedema risk is modifiable through behavior change, there is no standardized approach to educate survivors about risk-lowering strategies. Furthermore, misconceptions about lymphedema risk factors and risk-lowering strategies are common. The aim of this study was to evaluate the effect of lymphedema therapy referral on knowledge about lymphedema risk. Methods: This was a cross-sectional single institution study in which breast cancer survivors at a National Cancer Institute-designated cancer center completed an anonymous questionnaire between 2014 and 2015. Eligibility criteria were age ≥ 18, female sex, English-speaking, > 6 months post definitive breast cancer surgery, no cancer recurrence, and no prior or subsequent second cancer. The questionnaire included sociodemographic variables, clinical factors including prior lymphedema therapy referral, and 10 true/false questions assessing knowledge about lymphedema risk. Multivariable logistic regression analyses assessed the relationship between prior lymphedema therapy referral and correctly answering questions about lymphedema risk. Results: Of 209 participants, 53 (25%) had been referred to lymphedema therapy. Those who had undergone sentinel lymph node biopsy were less frequently referred to lymphedema therapy [15 (14%)] than those who had undergone axillary lymph node dissection [38 (39%)]. Five of the true/false questions had a correct response rate of < 80%. After controlling for age, race/ethnicity, education, type of axillary surgery, and receipt of radiation therapy, referral for lymphedema therapy was associated with correctly answering two questions about lymphedema: weight gain increases lymphedema risk [odds ratio, 95% confidence interval: 3.63 (1.66–7.96)] and patients are recommended to exercise their arm on an airplane [2.65 (1.15–6.13)]. Conclusions: Misconceptions about lymphedema prevention and management are common among breast cancer survivors. Lymphedema therapy referral is a potential opportunity to debunk misunderstandings and educate at-risk patients regarding lymphedema.