Safiya Karim

Choosing Wisely (CW) campaign addresses the global challenge of reducing waste in healthcare by discouraging unnecessary interventions, minimizing harm, and promoting evidence-based care. Barriers like limited awareness among healthcare professionals and the lack of global mapping of recommendations hinder its implementation. We conducted a comprehensive scoping review mapping the literature on CW recommendations in oncology from 2012 to 2024. A total of 220 recommendations were gathered from 19 studies and 20 recognized international websites. These recommendations explored the importance of personalizing screening, staging, and treatment based on individual risk factors, such as life expectancy and biomarker status. The findings suggest a global shift toward patient-centered oncology care, focusing on personalized, evidence-based treatments and minimizing unnecessary interventions. Developing recommendations based on resource-stratified guidelines is vital for improving the adoption of CW, particularly in low- and middle-income countries, as it ensures that recommendations are aligned with local healthcare needs and available resources.

PURPOSE: The International Duration Evaluation of Adjuvant Chemotherapy (IDEA) collaboration showed no significant clinical difference in outcomes in patients with stage III colon cancer (CC) treated with 3 versus 6 months of oxaliplatin-based adjuvant chemotherapy (O-ACT). We aimed to assess change in real-world practice patterns before and after publication of the IDEA study. METHODS: This retrospective cohort study included patients age ≥18 years with stage III CC diagnosed between January 1, 2012, and December 31, 2020. Eligible patients received >1 dose of ACT between March 20, 2012, and May 10, 2021 inclusive. They were categorized into pre-IDEA (diagnosed before March 31, 2018) and post-IDEA (diagnosed on or after April 1, 2018) groups. The primary outcome was the median duration and type of ACT and factors associated with a shorter duration. Secondary outcomes were 2-year overall survival (OS) and cancer-specific survival (CSS). RESULTS: In total, 740 patients were included (median age, 64 years, range, 27-90; 52.7% male). 48.8% had pT4 and/or pN2 disease. 77% received O-ACT. In the post-IDEA era, capecitabine plus oxaliplatin (CAPOX) ACT use increased (22.8%-50.7%, P < .001), and median duration of treatment was significantly shorter (2.7 v 4.8 months, P < .001). Factors associated with shorter O-ACT duration included diagnosis in the post-IDEA era (odds ratio, 2.08, P = .002), absence of pT4 and/or pN2 disease (hazard ratio [HR], 1.71, P = .01), and receipt of CAPOX (HR, 2.58, P < .001). Two-year OS and CSS were comparable between pre- and post-IDEA eras (OS 95% v 94%; CSS 96% v 96%). CONCLUSION: Our study shows that the results of the IDEA trial have been largely adopted in clinical practice with shorter duration of ACT in low-risk stage III CC.

Cancer patients’ attitudes toward progression-free survival (PFS) gains offered by treatment are not well understood, particularly in the absence of overall survival (OS) gains. The objectives were to describe patients’ willingness to accept treatment that offers PFS gains without OS gains, to compare these findings with treatments offering OS gains, and to qualitatively summarize patients’ reasons for their preferences. A multicenter, cross-sectional, convergent mixed-methods study design recruited patients who had received at least 3 months of systemic therapy for incurable solid tumors. A treatment trade-off exercise determined the gains in imaging PFS that patients require to prefer additional systemic treatment for a scenario of a newly diagnosed, asymptomatic, incurable abdominal tumor. A qualitative, descriptive, thematic analysis explored factors influencing patients’ decisions, and a narrative method integrated the quantitative and qualitative findings. In total, 100 patients participated (63% were older than 60 years of age). If additional treatment with added toxicity offered no OS advantage, 17% would prefer it for no PFS benefit; 26% for some PFS benefit (range, 3-9 months), whereas 51% would decline it regardless of PFS benefit. Similarly, 71% preferred additional treatment offering a 6-month OS advantage dependent on described toxicity levels (P = .03). A spectrum of reasons for these preferences reflected the complexity of participants’ attitudes and values. Prolongation of time to progression was not universally valued. Most patients did not prefer treatments that negatively affect quality of life for PFS gains alone. Implications for individual decision making, policy, and trials research are discussed.

228 Background: Medical cannabis (MC) and prescription opioid medication (POM) use is common among cancer patients. There is conflicting evidence on the association of cannabis with POM as to whether cannabis can help decrease/ cease opioid use. In this population-based study, we examine the association between MC authorization and cessation or reduction in POM use among patients with early stage cancer. Methods: This is a retrospective, population-based study of patients with early stage (stage I-III) cancer diagnosed between January 1, 2014 and December 31, 2018 in the province of Alberta, Canada. Cases were identified from the Alberta Cancer Registry (ACR) and linked to the provincial pharmacy information network (PIN) and the database from the College of Physician and Surgeons of Alberta (CPSA). Patient and treatment characteristic were used to identify a comparable non-MC group with prior POM use via probabilistic modelling. Descriptive statistics were used to describe differences between patients with and without a MC authorization. Modified Poisson regression was used to compare the likelihood of opioid cessation and reduction among groups. Results: We identified 8,801 patients of whom 326 (3.7%) had a MC authorization. Patients with a MC authorization were younger, had higher stage disease, underwent radiation and/or systemic therapy and had a higher total oral morphine equivalent (OME) use at baseline (p < 0.01). Patients with a MC authorization were less likely to cease POM at 9-12 months post MC authorization (RR 0.63, 95% CI 0.57-0.70), and less likely to reduce their POM dose by 25% (RR 0.79, 95% CI 0.74-0.85) and 50%. (RR 0.73, 95% CI 0.67-0.79). Conclusions: Patients with early stage, non-metastatic cancer with a MC authorization have higher rates of baseline POM use and are less likely to cease or reduce their POM use up to 1 year after MC authorization. Further study is required to understand the harms of concomitant MC and POM use and the impact on survivorship care.

Globally, there is increasing emphasis on value-based cancer care. Rising healthcare costs and reduced health care spending and budgets, especially in low- and middle-income countries (LMICs), call for patients, providers, and healthcare systems to apply the Choose Wisely (CW) approach. This approach seeks to advance a dialogue on avoiding unnecessary medical tests, treatments, and procedures. Several factors have been described as barriers and facilitators to the implementation of the Choosing Wisely recommendations in high-income countries but none for LMICs. In this review, we attempt to classify potential barriers to the Choose Wisely implementation relative to the sources of behavior and potential intervention functions that can be implemented in order to reduce these barriers.

In the era of rapid development of new, expensive cancer therapies, value frameworks have been developed to quantify clinical benefit (CB). We assessed the evolution of CB since the 2015 introduction of The American Society of Clinical Oncology and The European Society of Medical Oncology value frameworks. Randomized clinical trials (RCTs) assessing systemic therapies for solid malignancies from 2010 to 2020 were evaluated and CB (Δ) in 2010–2014 (pre-value frameworks (PRE)) were compared to 2015–2020 (POST) for overall survival (OS), progression-free survival (PFS), response rate (RR), and quality of life (QoL). In the 485 studies analyzed (12% PRE and 88% POST), the most common primary endpoint was PFS (49%), followed by OS (20%), RR (12%), and QoL (6%), with a significant increase in OS and decrease in RR as primary endpoints in the POST era (p = 0.011). Multivariable analyses revealed significant improvement in ΔOS POST (OR 2.86, 95% CI 0.46 to 5.26, p = 0.02) while controlling for other variables. After the development of value frameworks, median ΔOS improved minimally. The impact of value frameworks has yet to be fully realized in RCTs. Efforts to include endpoints shown to impact value, such as QoL, into clinical trials are warranted.

Oncology training and education initiatives in low and middle income countries: a scoping review Safiya Karim1, Zahra Sunderji2, Matthew Jalink3, S

Purpose: Guidelines suggest that advance care planning (ACP) and goals-of-care discussions should be conducted for patients with advanced cancer early in the course of their disease. A recent audit of our health system found that these discussions were rarely being documented in the electronic medical record (EMR). We conducted a quality improvement initiative to improve rates of documentation of goals and wishes among patients with advanced cancer. Methods: On the basis of previous analyses of this problem, we determined that provider capability and opportunity were the main barriers to conducting and documenting serious illness conversations. We implemented the serious illness care program (SICP), a systematic multicomponent intervention that has shown potential for conducting and documenting ACP discussions in two oncology clinics. Our goal was to conduct at least 24 serious illness conversations over the implementation period, with documentation of at least 95% of all conversations. Results: The SICP was implemented in two outpatient medical oncology clinics. A total of 15 serious illness care conversations occurred and 14 (93%) of these conversations were documented in the EMR. Total rates of documentation increased between the preimplementation and implementation period (4.2%–5.4% for clinician A and 0%–7.3% for clinician B). Conclusion: Implementation of the SICP resulted in increased rates of documentation, but the target number of conversations was not met. Further improvement cycles are required to address barriers to conducting and documenting routine serious illness conversations.

Background: Identifying optimal chemotherapy (CT) utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of perioperative CT for muscle‐invasive bladder cancer (MIBC).Methods: The Ontario Cancer Registry and linked treated records were used to identify neoadjuvant and adjuvant CT rates among patients with MIBC during 2004‐2013. Monte Carlo simulation was used to estimate the proportion of observed rate variation that could be due to chance alone. The criterion‐based benchmarking approach was used to explore whether social and health‐system factors were associated with CT rates. We also used the “pared‐mean” approach to identify a benchmark population of hospitals with the highest treatment rates. Hospital CT rates were adjusted for case mix and simulated using a multi‐level multivariable model and a parametric bootstrapping approach.Results: The study population included 2581 patients; perioperative CT was delivered to 31% (798/2581). Multivariate analysis showed that treatment was strongly associated with patient socioeconomic status and hospital teaching status. The benchmark rate was 36%. Unadjusted CT rates were significantly different across hospitals (range 0%‐52%, P < .001). The unadjusted benchmark perioperative CT rate was 45% (95% CI 40%‐50%); utilization rate in nonbenchmark hospitals was 28% (95% CI 26%‐30%). When using simulated CT rates adjusted for case mix, the benchmark CT rate was 41% (95% CI 35%‐47%) and the nonbenchmark hospital CT rate was 30% (95% CI 28%‐32%). The simulation analysis suggested that the observed component of variation (38%) was outside the 95% CI (22%‐28%) of what could be expected due to chance alone.Conclusions: There is significant systematic variation in perioperative CT rates for MIBC across hospitals in routine practice. The benchmark perioperative CT rate for MIBC is 36%‐41%.

Background: Identifying optimal chemotherapy utilization rates can drive improvements in quality of care. We report a benchmarking approach to estimate the optimal rate of adjuvant chemotherapy (ACT) for stage III colon cancer.Methods: The Ontario Cancer Registry and linked treated records were used to identify ACT utilization. Monte Carlo simulation was used to estimate the proportion of ACT rate variation that could be due to chance alone. The criterion‐based benchmarking approach was used to explore whether socioeconomic or system‐level factors were associated with ACT. We also used the “pared‐mean” approach to identify a benchmark population of hospitals with the highest ACT rates.Results: The study population included 2801 patients; ACT was delivered to 66% (1861/2801). Monte Carlo simulation suggested that the observed component of variation (15.6%) in ACT rates was within the 95% CI (11.5%‐17.3%) of what could be expected due to chance alone; the nonrandom component of ACT rate variation across hospitals was only 1.5%. There was no difference in hospital ACT rate by teaching status (P = .107), cancer center status (P = .362), or having medical oncology on site (P = .840). Unadjusted ACT rates varied across hospitals (range 44%‐91%, P = .017). The unadjusted benchmark ACT rate was 81% (95%CI 76%‐86%); utilization rate in non‐benchmark hospitals was 65% (95%CI 63%‐66%). However, after adjusting for case mix, the difference in ACT utilization between benchmark and non‐benchmark populations was significantly smaller.Conclusions: We did not find any system‐level factors associated with the utilization of ACT. Our results suggest that the observed variation in hospital ACT rate is not significantly different from variation due to chance alone. Using the “pared‐mean” approach may significantly overestimate optimal treatment rates if case mix is not considered.