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Zafar, Syed Yousuf

Overview:

Dr. Zafar is a health services researcher with a focus in improving care delivery for patients with advanced cancer. He has obtained advanced training in health services research and has participated in single-institution, multi-institution and national studies focusing on access to care, cost of care, and comparative effectiveness of care delivery between health systems. His primary area of interest is in the cost of cancer care. He has conducted institutional and national studies on how treatment-related costs impact cancer patients' experience. His current work in this arena is focused on patient preferences regarding cost-related communication and decision-making.

A second field of interest is palliative care. Dr. Zafar has collaborated with national and international palliative care leaders to improve the design and delivery of palliative care in cancer clinical trials. Methodologically, this work has centered around systematic literature reviews, iterative surveys, and prospective clinical trials.

Dr. Zafar is a member of the American Society of Clinical Oncology’s Health Disparities and Clinical Practice Guideline Committees. He is a member of the Alliance for Clinical Trials in Oncology's Health Disparities and Health Outcomes Committees. Dr. Zafar's work has been funded by the American Cancer Society, the HealthWell Foundation, the Duke Cancer Prevention and Control Program, the Duke Clinical Research Institute, and the CALGB Foundation.

Positions:

Associate Professor of Medicine

Medicine, Medical Oncology
School of Medicine

Associate Professor in the Sanford School of Public Policy

Sanford School of Public Policy
Sanford School of Public Policy

Affiliate, Duke Global Health Institute

Duke Global Health Institute
Institutes and Provost's Academic Units

Member of the Duke Cancer Institute

Duke Cancer Institute
School of Medicine

Member in the Duke Clinical Research Institute

Duke Clinical Research Institute
School of Medicine

Education:

M.D. 2002

M.D. — University of Toledo

Resident, Medicine

University of Cincinnati

Fellow In Hematology Oncology, Medicine

Duke University

News:

Grants:

PAPNavigator STTR (Fast-Track)

Administered By
Duke Cancer Institute
AwardedBy
Vivor, LLC
Role
Principal Investigator
Start Date
September 09, 2016
End Date
April 30, 2018

Couple Communication in Cancer: A Multi-method Examination

Administered By
Psychiatry & Behavioral Sciences, Behavioral Medicine
AwardedBy
Arizona State University
Role
Co Investigator
Start Date
September 20, 2016
End Date
August 31, 2017

Financial Assistance, Navigation, and Communication Education (FinANCE): Development

Administered By
Duke Clinical Research Institute
AwardedBy
Brigham and Women's Hospital
Role
Principal Investigator
Start Date
June 01, 2013
End Date
May 31, 2015

Does Comparative Effectiveness Research Promote Rationing or Rational Cancer Care?

Administered By
Medicine, Medical Oncology
AwardedBy
Greenwall Foundation
Role
Co Investigator
Start Date
November 01, 2013
End Date
October 31, 2014

CTSA KL2

Administered By
Institutes and Centers
AwardedBy
National Institutes of Health
Role
Junior Faculty
Start Date
September 30, 2006
End Date
June 30, 2013

Duke CTSA-KL2

Administered By
Institutes and Centers
AwardedBy
National Institutes of Health
Role
Scholar
Start Date
September 30, 2006
End Date
June 30, 2012
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Publications:

Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters.

ASCO identified oncologist-patient conversations about cancer costs as an important component of high-quality care. However, limited data exist characterizing the content of these conversations. We sought to provide novel insight into oncologist-patient cost conversations by determining the content of cost conversations in breast cancer clinic visits.We performed content analysis of transcribed dialogue from 677 outpatient appointments for breast cancer management. Encounters featured 677 patients with breast cancer visiting 56 oncologists nationwide from 2010 to 2013.Cost conversations were identified in 22% of visits (95% CI, 19 to 25) and had a median duration of 33 seconds (interquartile range, 19 to 62). Fifty-nine percent of cost conversations were initiated by oncologists (95% CI, 51 to 67), who most commonly brought up costs for antineoplastic agents. By contrast, patients most frequently brought up costs for diagnostic tests. Thirty-eight percent of cost conversations mentioned cost-reducing strategies (95% CI, 30 to 46), which most commonly sought to lower patient costs for endocrine therapies and symptom-alleviating treatments. The three most commonly discussed cost-reducing strategies were: switching to a lower-cost therapy/diagnostic, changing logistics of the intervention, and facilitating copay assistance.We identified cost conversations in approximately one in five breast cancer visits. Cost conversations were mostly oncologist initiated, lasted < 1 minute, and dealt with a wide range of health care expenses. Cost-reducing strategies were mentioned in more than one third of cost conversations and often involved switching antineoplastic agents for lower-cost alternatives or altering logistics of diagnostic tests.

Authors
Hunter, WG; Zafar, SY; Hesson, A; Davis, JK; Kirby, C; Barnett, JA; Ubel, PA
MLA Citation
Hunter, WG, Zafar, SY, Hesson, A, Davis, JK, Kirby, C, Barnett, JA, and Ubel, PA. "Discussing Health Care Expenses in the Oncology Clinic: Analysis of Cost Conversations in Outpatient Encounters." Journal of oncology practice (August 23, 2017): JOP2017022855-.
PMID
28834684
Source
epmc
Published In
Journal of Oncology Practice
Publish Date
2017
Start Page
JOP2017022855
DOI
10.1200/jop.2017.022855

Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care.

Authors
Chino, F; Peppercorn, JM; Rushing, C; Kamal, AH; Altomare, I; Samsa, G; Zafar, SY
MLA Citation
Chino, F, Peppercorn, JM, Rushing, C, Kamal, AH, Altomare, I, Samsa, G, and Zafar, SY. "Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care." JAMA oncology (August 10, 2017).
PMID
28796862
Source
epmc
Published In
JAMA oncology
Publish Date
2017
DOI
10.1001/jamaoncol.2017.2148

A randomized pilot trial of a videoconference couples communication intervention for advanced GI cancer.

This study aims to test the feasibility and preliminary efficacy of a couple-based communication intervention for advanced GI cancer delivered via videoconference.Thirty-two couples were randomly assigned to either couples communication skills training (CCST) or an education comparison intervention, both delivered via videoconference. Participation was limited to couples who reported communication difficulties at screening. Patients and partners completed measures of relationship functioning and individual functioning at baseline and post-intervention.Eighty-eight percent of randomized dyads completed all six sessions and reported high levels of satisfaction with the intervention. Between-group effect sizes suggested that the CCST intervention led to improvements in relationship satisfaction for patients and partners and to improvements in intimacy and communication for patients.A couples-based communication intervention delivered via videoconference is feasible and acceptable in the context of advanced cancer. Preliminary findings suggest that the intervention shows promise in contributing to enhanced relationship functioning. Copyright © 2016 John Wiley & Sons, Ltd.

Authors
Porter, LS; Keefe, FJ; Baucom, DH; Olsen, M; Zafar, SY; Uronis, H
MLA Citation
Porter, LS, Keefe, FJ, Baucom, DH, Olsen, M, Zafar, SY, and Uronis, H. "A randomized pilot trial of a videoconference couples communication intervention for advanced GI cancer." Psycho-oncology 26.7 (July 2017): 1027-1035.
PMID
28691761
Source
epmc
Published In
Psycho-Oncology
Volume
26
Issue
7
Publish Date
2017
Start Page
1027
End Page
1035
DOI
10.1002/pon.4121

Patient Financial Assistance Programs: A Path to Affordability or a Barrier to Accessible Cancer Care?

Authors
Zafar, SY; Peppercorn, JM
MLA Citation
Zafar, SY, and Peppercorn, JM. "Patient Financial Assistance Programs: A Path to Affordability or a Barrier to Accessible Cancer Care?." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 35.19 (July 2017): 2113-2116.
PMID
28459612
Source
epmc
Published In
Journal of Clinical Oncology
Volume
35
Issue
19
Publish Date
2017
Start Page
2113
End Page
2116
DOI
10.1200/jco.2016.71.7280

Neoadjuvant long-course chemoradiation remains strongly favored over short-course radiotherapy by radiation oncologists in the United States.

Short-course radiotherapy (SC-RT) and long-course chemoradiotherapy (LC-CRT) are accepted neoadjuvant treatments of rectal cancer. In the current study, the authors surveyed US radiation oncologists to assess practice patterns and attitudes regarding SC-RT and LC-CRT for patients with rectal cancer.The authors distributed a survey to 1701 radiation oncologists regarding treatment of neoadjuvant rectal cancer. Respondents were asked questions regarding the number of patients with rectal cancer treated, preference for SC-RT versus LC-CRT, and factors influencing regimen choice.Of 1659 contactable physicians, 182 responses (11%) were received. Approximately 83% treated at least 5 patients with rectal cancer annually. The majority of responding radiation oncologists (96%) preferred neoadjuvant LC-CRT for the treatment of patients with locally advanced rectal cancer and 44% never used SC-RT. Among radiation oncologists using SC-RT, respondents indicated they would not recommend this regimen for patients with low (74%) or bulky tumors (70%) and/or concern for a positive circumferential surgical resection margin (69%). The most frequent reasons for not offering SC-RT were insufficient downstaging for sphincter preservation (53%) and a desire for longer follow-up (45%). Many radiation oncologists indicated they would prescribe SC-RT for patients not receiving chemotherapy (62%) or patients with a geographic barrier to receiving LC-CRT (82%). Patient comorbidities appeared to influence regimen preferences for 79% of respondents. Approximately 20% of respondents indicated that altered oncology care reimbursement using capitated payment by diagnosis would impact their consideration of SC-RT.US radiation oncologists rarely use neoadjuvant SC-RT despite 3 randomized controlled trials demonstrating no significant differences in outcome compared with LC-CRT. Further research is necessary to determine whether longer follow-up coupled with the benefits of lower cost, increased patient convenience, and lower acute toxicity will increase the adoption of SC-RT by radiation oncologists in the United States. Cancer 2017;123:1434-1441. © 2016 American Cancer Society.

Authors
Mowery, YM; Salama, JK; Zafar, SY; Moore, HG; Willett, CG; Czito, BG; Hopkins, MB; Palta, M
MLA Citation
Mowery, YM, Salama, JK, Zafar, SY, Moore, HG, Willett, CG, Czito, BG, Hopkins, MB, and Palta, M. "Neoadjuvant long-course chemoradiation remains strongly favored over short-course radiotherapy by radiation oncologists in the United States." Cancer 123.8 (April 2017): 1434-1441.
PMID
27984651
Source
epmc
Published In
Cancer
Volume
123
Issue
8
Publish Date
2017
Start Page
1434
End Page
1441
DOI
10.1002/cncr.30461

The Role of Patient Financial Assistance Programs in Reducing Costs for Cancer Patients.

Limited transparency exists regarding eligibility and benefits for patient financial assistance programs (PAPs).To describe oral anticancer medication costs, insurance coverage, and the degree of financial assistance provided by PAPs.This was a retrospective study of prescription anticancer medication costs and PAP coverage. The study used data from an academic cancer center's specialty pharmacy. Medication, cost, and coverage data were collected from the specialty pharmacy database for prescriptions filled from January 2013 to November 2015. Prescriptions with missing copayments, insurance, or financial assistance amounts were excluded. Descriptive statistics summarized prescription characteristics.Of 9,388 anticancer medication prescriptions filled, 8,212 (87%) had complete cost data and were included. The 5 most common medications prescribed were capecitabine (20%), temozolomide (13%), enzalutamide (10%), letrozole (6%), and tamoxifen (4%). Most prescriptions were covered by commercial insurance or Part D (41.6%, n = 3,418). The median copayment was $20 per prescription (interquartile range [IQR] = $10.00-$80.30). When considering all prescriptions that received PAP assistance, the median amount of financial assistance provided by PAPs per prescription was $411.0 (IQR = $302.80-$523.40), amounting to 15% of the median prescription cash price. When considering all prescriptions, the median amount of financial assistance provided by PAPs per prescription was $0, and the mean was $79.30 (SD = $389.90).A minority of prescriptions received financial assistance from PAPs. The proportion of financial assistance was small relative to the price billed to insurance. PAPs play a modest role in reducing anticancer prescription-related costs.Support of this project by The Duke Biostatistics Core was made possible by Grant Number UL1TR001117 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Zullig is supported by a VA Health Services Research and Development (HSR&D) Career Development Award (CDA 13-025). Zullig also reports a financial relationship with Novartis. Zafar reports financial relationships with Novartis, Genentech-Roche, and Vivor. Vlastelica, Shankaran, and Wolf have nothing to disclose. The views in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, Duke University, NCATS, or NIH. This abstract was previously presented at the 2016 ASCO Annual Meeting; Chicago, Illinois; June 3-7, 2016. Study concept and design were contributed by Zafar, Zullig, and Vlastelica, with assistance from Shankaran. Vlastelica and Wolf took the lead in data collection, along with Zafar, and data interpretation was performed by Zullig, Zafar, and Wolf, along with Vlastelica and Shankaran. The manuscript was written and revised by Zullig and Zafar, along with the other authors.

Authors
Zullig, LL; Wolf, S; Vlastelica, L; Shankaran, V; Zafar, SY
MLA Citation
Zullig, LL, Wolf, S, Vlastelica, L, Shankaran, V, and Zafar, SY. "The Role of Patient Financial Assistance Programs in Reducing Costs for Cancer Patients." Journal of managed care & specialty pharmacy 23.4 (April 2017): 407-411.
PMID
28345445
Source
epmc
Published In
Journal of managed care & specialty pharmacy
Volume
23
Issue
4
Publish Date
2017
Start Page
407
End Page
411
DOI
10.18553/jmcp.2017.23.4.407

Transparency of Industry-Sponsored Oncology Patient Financial Assistance Programs Using a Patient-Centered Approach.

Pharmaceutical manufacturers sponsor drug-specific patient assistance programs that provide eligible patients with financial assistance, either in the form of providing the drug free of charge or copayment assistance. Describing these programs and determining who receives assistance is an important first step in understanding the impact and role of financial assistance in cancer care. Our objective was to describe eligibility criteria and benefits for cancer-specific, manufacturer-sponsored patient assistance programs.We conducted a prospective review of patient assistance program Web sites and called patient assistance program telephone hotlines from the perspective of a patient or caregiver requesting program details.We identified 24 manufacturers with patient assistance programs, covering 87% of Food and Drug Administration-approved oncology drugs. For free drug programs, the average maximum annual income for qualification was $86,279. For copayment assistance programs, the average was $104,790. Thirty-five percent of free drug programs and 53% of copayment assistance programs declined to provide details on how financial need was determined. None of the programs shared details on patient usage statistics.Variation exists in the quality and quantity of data available to patients seeking financial assistance for cancer treatment via manufacturer Web sites and hotlines. Greater transparency among patient assistance programs would enhance utility for patients and help to determine the net impact on costs and adherence.

Authors
Zafar, SY; Peppercorn, J; Asabere, A; Bastian, A
MLA Citation
Zafar, SY, Peppercorn, J, Asabere, A, and Bastian, A. "Transparency of Industry-Sponsored Oncology Patient Financial Assistance Programs Using a Patient-Centered Approach." Journal of oncology practice 13.3 (March 2017): e240-e248.
PMID
28140745
Source
epmc
Published In
Journal of Oncology Practice
Volume
13
Issue
3
Publish Date
2017
Start Page
e240
End Page
e248
DOI
10.1200/jop.2016.017509

How Should We Intervene on the Financial Toxicity of Cancer Care? One Shot, Four Perspectives.

The median price of a month of chemotherapy has increased by an order of magnitude during the past 20 years, far exceeding inflation over the same period. Along with rising prices, increases in cost sharing have forced patients to directly shoulder a greater portion of those costs, resulting in undue financial burden and, in some cases, cost-related nonadherence to treatment. What can we do to intervene on treatment-related financial toxicity of patients? No one party can single-handedly solve the problem, and the solution must be multifaceted and creative. A productive discussion of the problem must avoid casting blame and, instead, must look inward for concrete starting points toward improvement in the affordability and value of cancer care. With these points in mind, the authors-representatives from the pharmaceutical industry, insurance providers, oncologists, and patient advocacy-have each been asked to respond with a practical answer to the provocative hypothetical question, "If you could propose one thing, and one thing only, in terms of an action or change by the constituency you represent in this discussion, what would that be?"

Authors
Zafar, SY; Newcomer, LN; McCarthy, J; Fuld Nasso, S; Saltz, LB
MLA Citation
Zafar, SY, Newcomer, LN, McCarthy, J, Fuld Nasso, S, and Saltz, LB. "How Should We Intervene on the Financial Toxicity of Cancer Care? One Shot, Four Perspectives." American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Meeting 37 (January 2017): 35-39.
PMID
28561659
Source
epmc
Published In
American Society of Clinical Oncology educational book / ASCO. American Society of Clinical Oncology. Meeting
Volume
37
Publish Date
2017
Start Page
35
End Page
39
DOI
10.14694/edbk_174893

Validation and Quality Assessment of the Kilimanjaro Cancer Registry.

Global cancer burden has increasingly shifted to low- and middle-income countries and is particularly pronounced in Africa. There remains a lack of comprehensive cancer information as a result of limited cancer registry development. In Moshi, Tanzania, a regional cancer registry exists at Kilimanjaro Christian Medical Center. Data quality is unknown. Our objective was to evaluate the completeness and quality of the Kilimanjaro Cancer Registry (KCR).In October 2015, we conducted a retrospective review of KCR by validating the internal consistency of registry records with medical and pathology records. We randomly sampled approximately 100 total registry cases. Four reviewers not associated with the KCR manually collected data elements from medical records and compared them with KCR data.All 100 reviewed registry cases had complete cancer site and morphology included in the registry. Six had a recorded stage. For the majority (n = 92), the basis of diagnosis was pathology. Pathology reports were found in the medical record for 40% of patients; for the remainder, these were stored separately in the pathology department. Of sampled registry cases, the KCR and medical records were 98% and 94% concordant for primary cancer site and morphology, respectively. For 28%, recorded diagnosis dates were within 14 days of what was found in the medical record, and for 32%, they were within 30 days.The KCR has a high level of concordance for classification and coding when data are retrieved for validation. This parameter is one of the most important for measuring data quality in a regional cancer registry.

Authors
Zullig, LL; Schroeder, K; Nyindo, P; Namwai, T; Silayo, E; Msomba, A; Munishi, MO; Karia, F; Muiruri, C; Bartlett, J; Maro, V; Zafar, SY
MLA Citation
Zullig, LL, Schroeder, K, Nyindo, P, Namwai, T, Silayo, E, Msomba, A, Munishi, MO, Karia, F, Muiruri, C, Bartlett, J, Maro, V, and Zafar, SY. "Validation and Quality Assessment of the Kilimanjaro Cancer Registry." Journal of global oncology 2.6 (December 2016): 381-386.
Website
http://hdl.handle.net/10161/15102
PMID
28717724
Source
epmc
Published In
Journal of Global Oncology
Volume
2
Issue
6
Publish Date
2016
Start Page
381
End Page
386
DOI
10.1200/jgo.2015.002873

Radiation Oncologists' Practice Patterns and Attitudes Regarding Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer in the United States

Authors
Mowery, YM; Salama, JK; Zafar, SY; Moore, HG; Willett, CG; Czito, B; Hopkins, MB; Palta, M
MLA Citation
Mowery, YM, Salama, JK, Zafar, SY, Moore, HG, Willett, CG, Czito, B, Hopkins, MB, and Palta, M. "Radiation Oncologists' Practice Patterns and Attitudes Regarding Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer in the United States." October 1, 2016.
Source
wos-lite
Published In
International Journal of Radiation Oncology, Biology, Physics
Volume
96
Issue
2
Publish Date
2016
Start Page
S203
End Page
S203

"Going for Broke": Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care

Authors
Chino, F; Peppercorn, JM; Rushing, C; Samsa, G; Nicolla, J; Altomare, I; Zafar, SY
MLA Citation
Chino, F, Peppercorn, JM, Rushing, C, Samsa, G, Nicolla, J, Altomare, I, and Zafar, SY. ""Going for Broke": Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care." October 1, 2016.
Source
wos-lite
Published In
International Journal of Radiation Oncology, Biology, Physics
Volume
96
Issue
2
Publish Date
2016
Start Page
S135
End Page
S136

Radiation Oncologists' Practice Patterns and Attitudes Regarding Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer in the United States

Authors
Mowery, YM; Salama, JK; Zafar, SY; Moore, HG; Willett, CG; Czito, B; Hopkins, MB; Palta, M
MLA Citation
Mowery, YM, Salama, JK, Zafar, SY, Moore, HG, Willett, CG, Czito, B, Hopkins, MB, and Palta, M. "Radiation Oncologists' Practice Patterns and Attitudes Regarding Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer in the United States." October 1, 2016.
Source
wos-lite
Published In
International Journal of Radiation Oncology, Biology, Physics
Volume
96
Issue
2
Publish Date
2016
Start Page
S203
End Page
S203

"Going for Broke": Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care

Authors
Chino, F; Peppercorn, JM; Rushing, C; Samsa, G; Nicolla, J; Altomare, I; Zafar, SY
MLA Citation
Chino, F, Peppercorn, JM, Rushing, C, Samsa, G, Nicolla, J, Altomare, I, and Zafar, SY. ""Going for Broke": Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care." October 1, 2016.
Source
wos-lite
Published In
International Journal of Radiation Oncology, Biology, Physics
Volume
96
Issue
2
Publish Date
2016
Start Page
S135
End Page
S136

A Touchy Subject: Can Physicians Improve Value by Discussing Costs and Clinical Benefits With Patients?

Authors
Wollins, DS; Zafar, SY
MLA Citation
Wollins, DS, and Zafar, SY. "A Touchy Subject: Can Physicians Improve Value by Discussing Costs and Clinical Benefits With Patients?." The oncologist 21.10 (October 2016): 1157-1160.
PMID
27551014
Source
epmc
Published In
The oncologist
Volume
21
Issue
10
Publish Date
2016
Start Page
1157
End Page
1160
DOI
10.1634/theoncologist.2016-0207

Radiation Oncologists' Practice Patterns and Attitudes Regarding Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer in the United States.

Authors
Mowery, YM; Salama, JK; Zafar, SY; Moore, HG; Willett, CG; Czito, B; Hopkins, MB; Palta, M
MLA Citation
Mowery, YM, Salama, JK, Zafar, SY, Moore, HG, Willett, CG, Czito, B, Hopkins, MB, and Palta, M. "Radiation Oncologists' Practice Patterns and Attitudes Regarding Neoadjuvant Short-Course Radiation Therapy for Rectal Cancer in the United States." International journal of radiation oncology, biology, physics 96.2S (October 2016): S203-.
PMID
27675787
Source
epmc
Published In
International Journal of Radiation Oncology, Biology, Physics
Volume
96
Issue
2S
Publish Date
2016
Start Page
S203
DOI
10.1016/j.ijrobp.2016.06.505

"Going for Broke": Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care.

Authors
Chino, F; Peppercorn, JM; Rushing, C; Samsa, G; Nicolla, J; Altomare, I; Zafar, SY
MLA Citation
Chino, F, Peppercorn, JM, Rushing, C, Samsa, G, Nicolla, J, Altomare, I, and Zafar, SY. ""Going for Broke": Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care." International journal of radiation oncology, biology, physics 96.2S (October 2016): S135-S136.
PMID
27675612
Source
epmc
Published In
International Journal of Radiation Oncology, Biology, Physics
Volume
96
Issue
2S
Publish Date
2016
Start Page
S135
End Page
S136
DOI
10.1016/j.ijrobp.2016.06.330

Identifying cancer patients who alter care or lifestyle due to treatment-related financial distress.

Cancer patients may experience financial distress as a side effect of their care. Little is known about which patients are at greatest risk for altering their care or lifestyle due to treatment-related financial distress.We conducted a cross-sectional survey study to determine which patients are at greatest risk for altering their care or lifestyle due to treatment-related financial distress. Eligible patients were adults receiving cancer treatment enrolled between June 2010 and May 2011. We grouped coping strategies as lifestyle altering or care altering. We assessed coping strategies and relationships between covariates using descriptive statistics and analysis of variance.Among 174 participants, 89% used at least one lifestyle-altering coping strategy, while 39% used a care-altering strategy. Care-altering coping strategies adopted by patients included the following: not filling a prescription (28%) and taking less medication than prescribed (23%). Lifestyle-altering strategies included the following: spending less on leisure activities (77%), spending less on basics like food and clothing (57%), borrowing money (54%), and spending savings (50%). Younger patients were more likely than older patients to use coping strategies (p < 0.001). Lower-income patients adopted care-altering strategies more than higher-income patients (p = 0.03). Participants with more education and shorter duration of chemotherapy used lifestyle-altering strategies more than their counterparts (both p < 0.05).As a means of coping with treatment-related financial distress, patients were more likely to use lifestyle-altering approaches, but more than one-third adopted potentially harmful care-altering strategies. Younger age, lower income, higher education, and shorter duration of chemotherapy were characteristics associated with greater use of coping strategies. Copyright © 2015 John Wiley & Sons, Ltd.

Authors
Nipp, RD; Zullig, LL; Samsa, G; Peppercorn, JM; Schrag, D; Taylor, DH; Abernethy, AP; Zafar, SY
MLA Citation
Nipp, RD, Zullig, LL, Samsa, G, Peppercorn, JM, Schrag, D, Taylor, DH, Abernethy, AP, and Zafar, SY. "Identifying cancer patients who alter care or lifestyle due to treatment-related financial distress." Psycho-oncology 25.6 (June 2016): 719-725.
PMID
26149817
Source
epmc
Published In
Psycho-Oncology
Volume
25
Issue
6
Publish Date
2016
Start Page
719
End Page
725
DOI
10.1002/pon.3911

Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations.

Palliative care (PC) consultation services are available in most hospitals; outpatient services are rapidly growing to meet the needs of patients at earlier stages of the disease trajectory.We aimed to compare the unmet needs of PC patients by location of care to better characterize these populations.This cross-sectional secondary analysis examined patients receiving hospital and outpatient-based PC across 10 community and academic organizations in the Global Palliative Care Quality Alliance. We identified unmet symptom, advance care planning, and functional needs within our database from October 23, 2012 to January 22, 2015. Kruskal-Wallis, chi-square, and Fisher exact tests were performed.We evaluated 633 unique patients. Inpatients (n = 216) were older than outpatients (n = 417; 73 vs. 64 years, P < 0.0001). Seventy-six inpatients (38%) had a Palliative Performance Scale score ≤30%; no outpatients did (P < 0.0001). More inpatients rated their quality of life as poor compared with outpatients (39% vs. 21%, P = 0.0001). We found that outpatients presented with more unresolved pain than inpatients (58.5% vs. 4.1%, P < 0.0001). Conversely, more inpatients presented with unresolved anorexia (52.3% vs. 35.8%, P = 0.002) and dysphagia (28.1% vs. 5.4%, P < 0.0001) than outpatients. We found that inpatient setting was independently associated with lower performance status (odds ratio = 0.068, 95% confidence interval = 0.038-0.120, P < 0.0001).Compared with inpatients, outpatients are more burdened by pain at first PC encounter yet experience higher quality of life and better performance status. These findings suggest different clinician skillsets, and assessments are needed depending on the setting of PC consultation.

Authors
Hochman, MJ; Wolf, S; Zafar, SY; Portman, D; Bull, J; Kamal, AH
MLA Citation
Hochman, MJ, Wolf, S, Zafar, SY, Portman, D, Bull, J, and Kamal, AH. "Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations." Journal of pain and symptom management 51.6 (June 2016): 1033-1039.e3.
PMID
27046299
Source
epmc
Published In
Journal of Pain and Symptom Management
Volume
51
Issue
6
Publish Date
2016
Start Page
1033
End Page
1039.e3
DOI
10.1016/j.jpainsymman.2015.12.338

Association of Financial Strain With Symptom Burden and Quality of Life for Patients With Lung or Colorectal Cancer.

To measure the association between patient financial strain and symptom burden and quality of life (QOL) for patients with new diagnoses of lung or colorectal cancer.Patients participating in the Cancer Care Outcomes Research and Surveillance study were interviewed about their financial reserves, QOL, and symptom burden at 4 months of diagnosis and, for survivors, at 12 months of diagnosis. We assessed the association of patient-reported financial reserves with patient-reported outcomes including the Brief Pain Inventory, symptom burden on the basis of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30, and QOL on the basis of the EuroQoL-5 Dimension scale. Multivariable linear regression models were fit for each outcome and cancer type, adjusting for age, race/ethnicity, sex, income, insurance, stage at diagnosis, and comorbidity.Among patients with lung and colorectal cancer, 40% and 33%, respectively, reported limited financial reserves (≤ 2 months). Relative to patients with more than 12 months of financial reserves, those with limited financial reserves reported significantly increased pain (adjusted mean difference, 5.03 [95% CI, 3.29 to 7.22] and 3.45 [95% CI, 1.25 to 5.66], respectively, for lung and colorectal), greater symptom burden (5.25 [95% CI, 3.29 to .22] and 5.31 [95% CI, 3.58 to 7.04]), and poorer QOL (4.70 [95% CI, 2.82 to 6.58] and 5.22 [95% CI, 3.61 to 6.82]). With decreasing financial reserves, a clear dose-response relationship was present across all measures of well-being. These associations were also manifest for survivors reporting outcomes again at 1 year and persisted after adjustment for stage, comorbidity, insurance, and other clinical attributes.Patients with cancer and limited financial reserves are more likely to have higher symptom burden and decreased QOL. Assessment of financial reserves may help identify patients who need intensive support.

Authors
Lathan, CS; Cronin, A; Tucker-Seeley, R; Zafar, SY; Ayanian, JZ; Schrag, D
MLA Citation
Lathan, CS, Cronin, A, Tucker-Seeley, R, Zafar, SY, Ayanian, JZ, and Schrag, D. "Association of Financial Strain With Symptom Burden and Quality of Life for Patients With Lung or Colorectal Cancer." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 34.15 (May 2016): 1732-1740.
PMID
26926678
Source
epmc
Published In
Journal of Clinical Oncology
Volume
34
Issue
15
Publish Date
2016
Start Page
1732
End Page
1740
DOI
10.1200/jco.2015.63.2232

Financial Toxicity of Cancer Care: It's Time to Intervene.

Evidence suggests that a considerably large proportion of cancer patients are affected by treatment-related financial harm. As medical debt grows for some with cancer, the downstream effects can be catastrophic, with a recent study suggesting a link between extreme financial distress and worse mortality. At least three factors might explain the relationship between extreme financial distress and greater risk of mortality: 1) overall poorer well-being, 2) impaired health-related quality of life, and 3) sub-par quality of care. While research has described the financial harm associated with cancer treatment, little has been done to effectively intervene on the problem. Long-term solutions must focus on policy changes to reduce unsustainable drug prices and promote innovative insurance models. In the mean time, patients continue to struggle with high out-of-pocket costs. For more immediate solutions, we should look to the oncologist and patient. Oncologists should focus on the value of care delivered, encourage patient engagement on the topic of costs, and be better educated on financial resources available to patients. For their part, patients need improved cost-related health literacy so they are aware of potential costs and resources, and research should focus on how patients define high-value care. With a growing list of financial side effects induced by cancer treatment, the time has come to intervene on the "financial toxicity" of cancer care.

Authors
Zafar, SY
MLA Citation
Zafar, SY. "Financial Toxicity of Cancer Care: It's Time to Intervene." Journal of the National Cancer Institute 108.5 (May 2016).
PMID
26657334
Source
epmc
Published In
Journal of the National Cancer Institute
Volume
108
Issue
5
Publish Date
2016
DOI
10.1093/jnci/djv370

Physician Experience and Attitudes Toward Addressing the Cost of Cancer Care.

We surveyed US cancer doctors to examine current attitudes toward cost discussions and how they influence decision making and practice management.We conducted a self-administered, anonymous, electronic survey of randomly selected physician ASCO members to evaluate the frequency and nature of cost discussions reported by physicians, attitudes toward discussions of cost in clinics, and potential barriers.A total of 333 of 2,290 physicians responded (response rate [RR], 15%; adjusted RR after omitting nonpracticing physician ASCO members, 25%), Respondent practice settings were 45% academic and 55% community/private practice. Overall, 60% reported addressing costs frequently/always in clinic, whereas 40% addressed costs rarely/never. The largest reported barrier was lack of resources to guide discussions. Those who reported frequent discussions were significantly more likely to prioritize treatments in terms of cost and believed doctors should explain patient and societal costs. A total of 36%did not believe that doctors should discuss costs with patients. Academic practitioners were significantly less likely to discuss costs (odds ratio [OR], 0.41; P = .001) and felt less prepared for such discussions (OR, 0.492; P = .005) but were more likely to consider costs to the patient (OR, 2.68; P = .02) and society (OR, 1.822; P = .02).Although the majority of respondents believe it is important to consider out-of-pocket costs to patients, a substantial proportion do not discuss or consider costs of cancer care. Lack of consensus on the importance of such discussions and uncertainty regarding the optimal timing and content appear to be barriers to addressing costs of care with patients.

Authors
Altomare, I; Irwin, B; Zafar, SY; Houck, K; Maloney, B; Greenup, R; Peppercorn, J
MLA Citation
Altomare, I, Irwin, B, Zafar, SY, Houck, K, Maloney, B, Greenup, R, and Peppercorn, J. "Physician Experience and Attitudes Toward Addressing the Cost of Cancer Care." Journal of oncology practice 12.3 (March 2016): e281-248.
PMID
26883407
Source
epmc
Published In
Journal of Oncology Practice
Volume
12
Issue
3
Publish Date
2016
Start Page
e281
End Page
248
DOI
10.1200/jop.2015.007401

Abstract IA09: Intervening on the financial toxicity of cancer care

Authors
Zafar, SY
MLA Citation
Zafar, SY. "Abstract IA09: Intervening on the financial toxicity of cancer care." March 2016.
Source
crossref
Published In
Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology
Volume
25
Issue
3 Supplement
Publish Date
2016
Start Page
IA09
End Page
IA09
DOI
10.1158/1538-7755.DISP15-IA09

Ascertainment, classification, and impact of neoplasm detection during prolonged treatment with dual antiplatelet therapy with prasugrel vs. clopidogrel following acute coronary syndrome.

Studies have suggested increased cancer incidence associated with long-term dual antiplatelet therapy (DAPT) for acute coronary syndrome (ACS). We evaluated cancer incidence and treatment-related differences in an analysis of DAPT for ACS.The Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes trial enrolled 9326 participants with ACS, who received aspirin plus clopidogrel or prasugrel. Median treatment exposure was 15 months. Cancer history and screening procedures were collected. Suspected non-benign neoplasm events were reported and adjudicated. The primary outcome was detection of new, non-benign neoplasm. Factors associated with neoplasm events, the relationship of these events to cardiovascular and bleeding endpoints, and treatment-related differences in neoplasm detection were studied. Among 9240 participants who received ≥1 dose of study drug, 1.8% had a confirmed neoplasm event. The efficacy composite of cardiovascular death, myocardial infarction, or stroke occurred more frequently among those with a neoplasm event vs. those without (18.2 vs. 13.5%) as did Global Use of Strategies to Open Occluded Coronary Arteries severe/moderate bleeding (11.2 vs. 1.5%). Screening rates were substantially higher in North America and Western Europe/Scandinavia vs. other regions. Factors most strongly associated with detection of neoplasm events were older age, region, male sex, and current/recent smoking. Among the pre-specified population without a history of neoplasm or previous curative treatment for neoplasm (n = 9105), the incidence of neoplasm events was similar with prasugrel vs. clopidogrel (1.8 vs. 1.7%; HR = 1.04; 95% CI 0.77-1.42; P = 0.79).Neoplasm events were infrequent during long-term DAPT after ACS, were associated with differential cancer-screening practices across regions, and the frequency of neoplasm detection was similar with prasugrel vs. clopidogrel.ClinicalTrials.gov identifier: NCT00699998.

Authors
Roe, MT; Cyr, DD; Eckart, D; Schulte, PJ; Morse, MA; Blackwell, KL; Ready, NE; Zafar, SY; Beaven, AW; Strickler, JH; Onken, JE; Winters, KJ; Houterloot, L; Zamoryakhin, D; Wiviott, SD; White, HD; Prabhakaran, D; Fox, KAA; Armstrong, PW; Ohman, EM; TRILOGY ACS Investigators,
MLA Citation
Roe, MT, Cyr, DD, Eckart, D, Schulte, PJ, Morse, MA, Blackwell, KL, Ready, NE, Zafar, SY, Beaven, AW, Strickler, JH, Onken, JE, Winters, KJ, Houterloot, L, Zamoryakhin, D, Wiviott, SD, White, HD, Prabhakaran, D, Fox, KAA, Armstrong, PW, Ohman, EM, and TRILOGY ACS Investigators, . "Ascertainment, classification, and impact of neoplasm detection during prolonged treatment with dual antiplatelet therapy with prasugrel vs. clopidogrel following acute coronary syndrome." European heart journal 37.4 (January 2016): 412-422.
PMID
26637834
Source
epmc
Published In
European Heart Journal (Elsevier)
Volume
37
Issue
4
Publish Date
2016
Start Page
412
End Page
422
DOI
10.1093/eurheartj/ehv611

The Parity Paradigm: Can Legislation Help Reduce the Cost Burden of Oral Anticancer Medications?

Over the last decade, there has been increased development and use of oral anticancer medications, which sometimes leads to high cost sharing for patients. Drug parity laws require insurance plans to cover oral anticancer medications with the same cost sharing as intravenous/injected chemotherapy or have a capped limit on out-of-pocket costs. There are currently 36 enacted state laws (plus the District of Columbia) addressing drug parity, but no federal laws. In this policy perspective piece, we discuss the history, opportunities, and limitations of drug parity laws in oncology. We also discuss the implications of provisions of the Affordable Care Act and other proposed policy reforms on financing oral chemotherapy.

Authors
Kircher, SM; Meeker, CR; Nimeiri, H; Geynisman, DM; Zafar, SY; Shankaran, V; de Souza, J; Wong, Y-N
MLA Citation
Kircher, SM, Meeker, CR, Nimeiri, H, Geynisman, DM, Zafar, SY, Shankaran, V, de Souza, J, and Wong, Y-N. "The Parity Paradigm: Can Legislation Help Reduce the Cost Burden of Oral Anticancer Medications?." Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research 19.1 (January 2016): 88-98.
PMID
26797241
Source
epmc
Published In
Value in Health
Volume
19
Issue
1
Publish Date
2016
Start Page
88
End Page
98
DOI
10.1016/j.jval.2015.10.005

Adjuvant Chemotherapy for Stage II Rectal Cancer.

Authors
Deming, D; Uboha, N; Zafar, SY; Rosenberg, S; Bassetti, M; Glasgow, S; Borden, EC; Lubner, S
MLA Citation
Deming, D, Uboha, N, Zafar, SY, Rosenberg, S, Bassetti, M, Glasgow, S, Borden, EC, and Lubner, S. "Adjuvant Chemotherapy for Stage II Rectal Cancer." Seminars in oncology 42.6 (December 2015): e99-107. (Review)
PMID
26615141
Source
epmc
Published In
Seminars in Oncology
Volume
42
Issue
6
Publish Date
2015
Start Page
e99
End Page
107
DOI
10.1053/j.seminoncol.2015.09.033

The utility of cost discussions between patients with cancer and oncologists.

Patients with cancer can experience substantial financial burden. Little is known about patients' preferences for incorporating cost discussions into treatment decision making or about the ramifications of those discussions. The objective of this study was to determine patient preferences for and benefits of discussing costs with doctors.Cross-sectional, survey study.We enrolled insured adults with solid tumors on anticancer therapy who were treated at a referral cancer center or an affiliated rural cancer clinic. Patients were surveyed at enrollment and again 3 months later about cost discussions with doctors, decision making, and financial burden. Medical records were abstracted for disease and treatment data. Logistic regression investigated characteristics associated with greater desire to discuss costs.Of 300 patients (86% response rate), 52% expressed some desire to discuss treatment-related out-of-pocket costs with doctors and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. However, only 19% had talked to their doctor about costs. Of those, 57% reported lower out-of-pocket costs as a result of cost discussions. In multivariable logistic regression, higher subjective financial distress was associated with greater likelihood to desire cost discussions (odds ratio [OR], 1.22; 95% CI, 1.10-1.36). Nonwhite race was associated with lower likelihood to desire cost discussions (OR, 0.53; 95% CI, 0.30-0.95).Patients with cancer varied in their desire to discuss costs with doctors, but most who discussed costs believed the conversations helped reduce their expenses. Patient-physician cost communication might reduce out-of-pocket costs even in oncology where treatment options are limited.

Authors
Zafar, SY; Chino, F; Ubel, PA; Rushing, C; Samsa, G; Altomare, I; Nicolla, J; Schrag, D; Tulsky, JA; Abernethy, AP; Peppercorn, JM
MLA Citation
Zafar, SY, Chino, F, Ubel, PA, Rushing, C, Samsa, G, Altomare, I, Nicolla, J, Schrag, D, Tulsky, JA, Abernethy, AP, and Peppercorn, JM. "The utility of cost discussions between patients with cancer and oncologists." The American journal of managed care 21.9 (September 2015): 607-615.
PMID
26618364
Source
epmc
Published In
American Journal of Managed Care
Volume
21
Issue
9
Publish Date
2015
Start Page
607
End Page
615

Best supportive care in clinical trials: review of the inconsistency in control arm design.

Best supportive care (BSC) as a control arm in clinical trials is poorly defined. We conducted a review to evaluate clinical trials' concordance with published, consensus-based framework for BSC delivery in trials.A consensus-based Delphi panel previously identified four key domains of BSC delivery in trials: multidisciplinary care; supportive care documentation; symptom assessment; and symptom management. We reviewed trials including BSC control arms from 2002 to 2014 to assess concordance to BSC standards and to selected items from the CONSORT 2010 guidelines.Of 408 articles retrieved, we retained 18 after applying exclusion criteria. Overall, trials conformed to the CONSORT guidelines better than the BSC standards (28% vs 16%). One-third of articles offered a detailed description of BSC, 61% reported regular symptom assessment, and 44% reported using validated symptom assessment measures. One-third reported symptom assessment at identical intervals in both arms. None documented evidence-based symptom management. No studies reported educating patients about symptom management or goals of therapy. No studies reported offering access to palliative care specialists.Reporting of BSC in trials is incomplete, resulting in uncertain internal and external validity. Such studies risk systematically over-estimating the net clinical effect of the comparator arms.

Authors
Nipp, RD; Currow, DC; Cherny, NI; Strasser, F; Abernethy, AP; Zafar, SY
MLA Citation
Nipp, RD, Currow, DC, Cherny, NI, Strasser, F, Abernethy, AP, and Zafar, SY. "Best supportive care in clinical trials: review of the inconsistency in control arm design." British journal of cancer 113.1 (June 11, 2015): 6-11. (Review)
PMID
26068397
Source
epmc
Published In
British Journal of Cancer
Volume
113
Issue
1
Publish Date
2015
Start Page
6
End Page
11
DOI
10.1038/bjc.2015.192

Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.

For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy.To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting.This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach.Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins.Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings.A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient.This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted.clinicaltrials.gov Identifier: NCT01415934.

Authors
Kutner, JS; Blatchford, PJ; Taylor, DH; Ritchie, CS; Bull, JH; Fairclough, DL; Hanson, LC; LeBlanc, TW; Samsa, GP; Wolf, S; Aziz, NM; Currow, DC; Ferrell, B; Wagner-Johnston, N; Zafar, SY; Cleary, JF; Dev, S; Goode, PS; Kamal, AH; Kassner, C; Kvale, EA; McCallum, JG; Ogunseitan, AB; Pantilat, SZ; Portenoy, RK; Prince-Paul, M; Sloan, JA; Swetz, KM; Von Gunten, CF; Abernethy, AP
MLA Citation
Kutner, JS, Blatchford, PJ, Taylor, DH, Ritchie, CS, Bull, JH, Fairclough, DL, Hanson, LC, LeBlanc, TW, Samsa, GP, Wolf, S, Aziz, NM, Currow, DC, Ferrell, B, Wagner-Johnston, N, Zafar, SY, Cleary, JF, Dev, S, Goode, PS, Kamal, AH, Kassner, C, Kvale, EA, McCallum, JG, Ogunseitan, AB, Pantilat, SZ, Portenoy, RK, Prince-Paul, M, Sloan, JA, Swetz, KM, Von Gunten, CF, and Abernethy, AP. "Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial." JAMA internal medicine 175.5 (May 2015): 691-700.
PMID
25798575
Source
epmc
Published In
JAMA Internal Medicine
Volume
175
Issue
5
Publish Date
2015
Start Page
691
End Page
700
DOI
10.1001/jamainternmed.2015.0289

Cost-related health literacy: a key component of high-quality cancer care.

Authors
Zafar, SY; Ubel, PA; Tulsky, JA; Pollak, KI
MLA Citation
Zafar, SY, Ubel, PA, Tulsky, JA, and Pollak, KI. "Cost-related health literacy: a key component of high-quality cancer care." Journal of oncology practice 11.3 (May 2015): 171-173.
PMID
25829522
Source
epmc
Published In
Journal of Oncology Practice
Volume
11
Issue
3
Publish Date
2015
Start Page
171
End Page
173
DOI
10.1200/jop.2015.004408

Population-based assessment of cancer survivors' financial burden and quality of life: a prospective cohort study.

The impact of financial burden among patients with cancer has not yet been measured in a way that accounts for inter-relationships between quality of life, perceived quality of care, disease status, and sociodemographic characteristics.In a national, prospective, observational, population- and health care systems-based cohort study, patients with colorectal or lung cancer were enrolled from 2003 to 2006 within 3 months of diagnosis. For this analysis, surviving patients who were either disease free or had advanced disease were resurveyed a median 7.3 years from diagnosis. Structural equation modeling was used to investigate relationships between financial burden, quality of life, perceived quality of care, and sociodemographic characteristics.Among 1,000 participants enrolled from five geographic regions, five integrated health care systems, or 15 Veterans Administration Hospitals, 89% (n = 889) were cancer free, and 11% (n = 111) had advanced cancer. Overall, 48% (n = 482) reported difficulties living on their household income, and 41% (n = 396) believed their health care to be "excellent." High financial burden was associated with lower household income (adjusted odds ratio [OR] = 0.61 per $20k per year, P < .001) and younger age (adjusted OR = 0.63 per 10 years; P < .001). High financial burden was also associated with poorer quality of life (adjusted beta = -0.06 per burden category; P < .001). Better quality of life was associated with fewer perceptions of poorer quality of care (adjusted OR = 0.85 per 0.10 EuroQol units; P < .001).Financial burden is prevalent among cancer survivors and is related to patients' health-related quality of life. Future studies should consider interventions to improve patient education and engagement with regard to financial burden.

Authors
Zafar, SY; McNeil, RB; Thomas, CM; Lathan, CS; Ayanian, JZ; Provenzale, D
MLA Citation
Zafar, SY, McNeil, RB, Thomas, CM, Lathan, CS, Ayanian, JZ, and Provenzale, D. "Population-based assessment of cancer survivors' financial burden and quality of life: a prospective cohort study." Journal of oncology practice 11.2 (March 2015): 145-150.
PMID
25515717
Source
epmc
Published In
Journal of Oncology Practice
Volume
11
Issue
2
Publish Date
2015
Start Page
145
End Page
150
DOI
10.1200/jop.2014.001542

Is obesity an advantage in patients with colorectal cancer?

Obesity/higher BMI appears to be important determinants in the development of colon cancer as well as in predicting outcomes in the adjuvant setting in these patients. These associations seem to be stronger for men and tend to be 'J-shaped', with worse outcomes in both lower and upper BMI categories than in the middle categories. How this factors in the metastatic setting is less clear. A recent pooled analysis of patients with metastatic colorectal cancer receiving bevacizumab in the first-line setting observed that patients with the lowest BMI had the lowest median overall survival. An incremental BMI increase of 5 kg/m(2) led to actually a decrease in the risk of death (hazard ratio, 0.911 [95% CI, 0.879-0.944]). The observed association does not necessarily mean that obesity is an advantage for patients with metastatic colorectal cancer. More likely, it is conceivable that, in patients with metastatic colorectal cancer with a lower BMI, the effects of cancer-related cachexia may be more deleterious than the potential adverse events related to a higher BMI. In patients already diagnosed with metastatic disease, studying how body weight affects tumor biology and treatment-related decisions are important considerations.

Authors
Kasi, PM; Zafar, SY; Grothey, A
MLA Citation
Kasi, PM, Zafar, SY, and Grothey, A. "Is obesity an advantage in patients with colorectal cancer?." Expert review of gastroenterology & hepatology 9.11 (January 2015): 1339-1342. (Review)
PMID
26366838
Source
epmc
Published In
Expert review of gastroenterology & hepatology
Volume
9
Issue
11
Publish Date
2015
Start Page
1339
End Page
1342
DOI
10.1586/17474124.2015.1089170

The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature (vol 10, pg 2189, 2014)

Authors
Bestvina, CM; Zullig, LL; Zafar, SY
MLA Citation
Bestvina, CM, Zullig, LL, and Zafar, SY. "The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature (vol 10, pg 2189, 2014)." FUTURE ONCOLOGY 11.3 (2015): 544-544.
Source
wos-lite
Published In
Future oncology (London, England)
Volume
11
Issue
3
Publish Date
2015
Start Page
544
End Page
544
DOI
10.2217/fon.14.304

Patient experience and attitudes toward addressing the cost of breast cancer care.

The American Society of Clinical Oncology views patient-physician discussion of costs as a component of high-quality care. Few data exist on patients' views regarding how cost should be addressed in the clinic.We distributed a self-administered, anonymous, paper survey to consecutive patients with breast cancer presenting for a routine visit within 5 years of diagnosis at an academic cancer center. Survey questions addressed experience and preferences concerning discussions of cost and views on cost control. Results are primarily descriptive, with comparison among participants on the basis of disease stage, using chi-square and Fisher's exact tests. All p values are two-sided.We surveyed 134 participants (response rate 86%). Median age was 61 years, and 28% had stage IV disease. Although 44% of participants reported at least a moderate level of financial distress, only 14% discussed costs with their doctor; 94% agreed doctors should talk to patients about costs of care. Regarding the impact of costs on decision making, 53% felt doctors should consider direct costs to the patient, but only 38% felt doctors should consider costs to society. Moreover, 88% reported concern about costs of care, but there was no consensus on how to control costs.Most breast cancer patients want to discuss costs of care, but there is little consensus on the desired content or goal of these discussions. Further research is needed to define the role of cost discussions at the bedside and how they will contribute to the goal of high-quality and sustainable cancer care.

Authors
Irwin, B; Kimmick, G; Altomare, I; Marcom, PK; Houck, K; Zafar, SY; Peppercorn, J
MLA Citation
Irwin, B, Kimmick, G, Altomare, I, Marcom, PK, Houck, K, Zafar, SY, and Peppercorn, J. "Patient experience and attitudes toward addressing the cost of breast cancer care." November 2014.
PMID
25273078
Source
epmc
Published In
The oncologist
Volume
19
Issue
11
Publish Date
2014
Start Page
1135
End Page
1140
DOI
10.1634/theoncologist.2014-0117

The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature.

Advances in cancer diagnosis and treatment have led to increased societal costs and out-of-pocket patient cost. We reviewed the literature on the impact of out-of-pocket cancer care costs on the patient experience, and described efforts made to address these costs. A critical appraisal of articles published in the USA from 2004 to 2014 was performed. The literature revealed that even insured patients receiving anticancer therapy are vulnerable to financial distress, which can impel patients to borrow money, deplete their savings, or engage in cost-coping strategies including nonadherence to prescribed treatment. Additional research is required to define financial distress risk factors, patient-physician communication of the costs of cancer care, and supportive care models for patients and survivors with substantial financial burdens.

Authors
Bestvina, CM; Zullig, LL; Yousuf Zafar, S
MLA Citation
Bestvina, CM, Zullig, LL, and Yousuf Zafar, S. "The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature." Future oncology (London, England) 10.14 (November 2014): 2189-2199. (Review)
PMID
25471033
Source
epmc
Published In
Future oncology (London, England)
Volume
10
Issue
14
Publish Date
2014
Start Page
2189
End Page
2199
DOI
10.2217/fon.14.130

Patient Experience and Attitudes Toward Addressing the Cost of Breast Cancer Care

Authors
Irwin, B; Kimmick, G; Altomare, I; Marcom, PK; Houck, K; Zafar, SY; Peppercorn, J
MLA Citation
Irwin, B, Kimmick, G, Altomare, I, Marcom, PK, Houck, K, Zafar, SY, and Peppercorn, J. "Patient Experience and Attitudes Toward Addressing the Cost of Breast Cancer Care." ONCOLOGIST 19.11 (November 2014): 1135-1140.
Source
wos-lite
Published In
The oncologist
Volume
19
Issue
11
Publish Date
2014
Start Page
1135
End Page
1140
DOI
10.1634/theoncologist.2014-0117

There is a mismatch between the medicare benefit package and the preferences of patients with cancer and their caregivers.

To identify insured services that are most important to Medicare beneficiaries with cancer and their family caregivers when coverage is limited.A total of 440 participants (patients, n = 246; caregivers, n = 194) were enrolled onto the CHAT (Choosing Health Plans All Together) study from August 2010 to March 2013. The exercise elicited preferences about what benefits Medicare should cover for patients with cancer in their last 6 months of life. Facilitated sessions lasted 2.5 hours, included 8 to 10 participants, and focused on choices about Medicare health benefits within the context of a resource-constrained environment.Six of 15 benefit categories were selected by > 80% of participants: cancer care, prescription drugs, primary care, home care, palliative care, and nursing home coverage. Only 12% of participants chose the maximum level of cancer benefits, a level of care commonly financed in the Medicare program. Between 40% and 50% of participants chose benefits not currently covered by Medicare: unrestricted cash, concurrent palliative care, and home-based long-term care. Nearly one in five participants picked some level of each of these three benefit categories and allocated on average 30% of their resources toward them.The mismatch between covered benefits and participant preferences shows that addressing quality of life and the financial burden of care is a priority for a substantial subset of patients with cancer in the Medicare program. Patient and caregiver preferences can be elicited, and the choices they express could suggest potential for Medicare benefit package reform and flexibility.

Authors
Taylor, DH; Danis, M; Zafar, SY; Howie, LJ; Samsa, GP; Wolf, SP; Abernethy, AP
MLA Citation
Taylor, DH, Danis, M, Zafar, SY, Howie, LJ, Samsa, GP, Wolf, SP, and Abernethy, AP. "There is a mismatch between the medicare benefit package and the preferences of patients with cancer and their caregivers." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32.28 (October 2014): 3163-3168.
PMID
25154830
Source
epmc
Published In
Journal of Clinical Oncology
Volume
32
Issue
28
Publish Date
2014
Start Page
3163
End Page
3168
DOI
10.1200/jco.2013.54.2605

Bridging the gap between financial distress and available resources for patients with cancer: a qualitative study.

Cancer treatment-related out-of-pocket costs create substantial financial distress for many patients. However, little work has been done to describe available financial resources and barriers to connecting those resources to patients.This was a single-center, qualitative study that used semistructured interviews and focus groups with social workers and financial care counselors. Interview guides were used to elicit feedback from study participants pertaining to the types of financial problems that their patients were experiencing, the process for addressing these issues, patient assistance resources, and access barriers.Four interviews and two focus group sessions (n = 15) were conducted in which four themes emerged among the social work and financial care counselor samples. Participants cited (1) frustration over the lack of financial resources and increasingly stringent eligibility criteria, (2) barriers to providing assistance such as process inefficiencies, (3) limited resources to identify at- risk patients and refer them for services, and (4) inadequate insurance coverage and availability. To bridge the gap between increasing patient need and limited resources, participants suggested development of interventions designed to aid in patient screening and resource identification.Oncology social workers and financial care counselors reported inadequate financial resources and faced barriers to matching appropriate resources with patients in need. Limited social work resources hindered early screening for financial distress. Interventions that focus on screening for early identification of financial distress and identification of resources are needed.

Authors
Smith, SK; Nicolla, J; Zafar, SY
MLA Citation
Smith, SK, Nicolla, J, and Zafar, SY. "Bridging the gap between financial distress and available resources for patients with cancer: a qualitative study." Journal of oncology practice 10.5 (September 2014): e368-e372.
PMID
24865219
Source
epmc
Published In
Journal of Oncology Practice
Volume
10
Issue
5
Publish Date
2014
Start Page
e368
End Page
e372
DOI
10.1200/jop.2013.001342

Phase I study of capecitabine, oxaliplatin, bevacizumab, and everolimus in advanced solid tumors.

To define maximum tolerated dose (MTD), toxicities, and pharmacodynamics of capecitabine, oxaliplatin, bevacizumab, and everolimus in advanced solid tumor patients.This was a standard "3 + 3" dose-escalation trial. All subjects received bevacizumab 7.5 mg/kg on day 1 of each cycle. Doses for capecitabine, oxaliplatin and everolimus were modified per dose limiting toxicity (DLT). Baseline and on-treatment plasma biomarkers were analyzed. Archived tumor mRNA levels were evaluated for NRP1, NRP2 and VEGF-A isoforms.Twenty-nine patients were evaluable for toxicity and 30 for efficacy. Two DLTs were observed in cohort 1 and one DLT each was observed in cohort -1 and -1b. Grade ≥3 toxicities included neutropenia, hypertension, perforation/fistula/hemorrhage, hypertriglyceridemia, diarrhea, and thromboembolism. Twelve subjects experienced partial response (PR); 12 had stable disease as best response. Three of seven chemorefractory metastatic colorectal cancer (mCRC) subjects experienced PR; 8 of 15 chemonaive mCRC subjects experienced PR. Plasma TβRIII and IL-6 increased on treatment but without correlation to outcome. Increased VEGF165 levels significantly correlated with longer progression free survival.Everolimus with full dose capecitabine, oxaliplatin, and bevacizumab had unacceptable toxicity. MTD was: everolimus 5 mg daily; capecitabine 680 mg/m(2) BID days 1-14; oxaliplatin 100 mg/m(2) and bevacizumab 7.5 mg/kg, day 1. Activity was noted in mCRC.

Authors
Rangwala, F; Bendell, JC; Kozloff, MF; Arrowood, CC; Dellinger, A; Meadows, J; Tourt-Uhlig, S; Murphy, J; Meadows, KL; Starr, A; Broderick, S; Brady, JC; Cushman, SM; Morse, MA; Uronis, HE; Hsu, SD; Zafar, SY; Wallace, J; Starodub, AN; Strickler, JH; Pang, H; Nixon, AB; Hurwitz, HI
MLA Citation
Rangwala, F, Bendell, JC, Kozloff, MF, Arrowood, CC, Dellinger, A, Meadows, J, Tourt-Uhlig, S, Murphy, J, Meadows, KL, Starr, A, Broderick, S, Brady, JC, Cushman, SM, Morse, MA, Uronis, HE, Hsu, SD, Zafar, SY, Wallace, J, Starodub, AN, Strickler, JH, Pang, H, Nixon, AB, and Hurwitz, HI. "Phase I study of capecitabine, oxaliplatin, bevacizumab, and everolimus in advanced solid tumors." Investigational new drugs 32.4 (August 2014): 700-709.
PMID
24711126
Source
epmc
Published In
Investigational New Drugs
Volume
32
Issue
4
Publish Date
2014
Start Page
700
End Page
709
DOI
10.1007/s10637-014-0089-2

A decision exercise to engage cancer patients and families in deliberation about Medicare coverage for advanced cancer care.

Concerns about unsustainable costs in the US Medicare program loom as the number of retirees increase and experiences serious and costly illnesses like cancer. Engagement of stakeholders, particularly cancer patients and their families, in prioritizing insured services offers a valuable strategy for informing Medicare coverage policy. We designed and evaluated a decision exercise that allowed cancer patients and family members to choose Medicare benefits for advanced cancer patients.The decision tool, Choosing Health plans All Together (CHAT) was modified to select services for advanced cancer patients. Patients with a cancer history (N = 246) and their family members (N = 194) from North Carolina participated in 70 CHAT sessions. Variables including participants' socio-demographic characteristics, health status, assessments of the exercise and results of group benefit selections were collected. Routine descriptive statistics summarized participant characteristics and Fisher's exact test compared group differences. Qualitative analysis of group discussions were used to ascertain reasons for or against selecting benefits.Patients and family members (N = 440) participated in 70 CHAT exercises. Many groups opted for such services as palliative care, nursing facilities, and services not currently covered by the Medicare program. In choosing among four levels of cancer treatment coverage, no groups chose basic coverage, 27 groups (39%) selected intermediate coverage, 39 groups (56%) selected high coverage, and 4 groups (6%) chose the most comprehensive cancer coverage. Reasons for or against benefit selection included fairness, necessity, need for prioritizing, personal experience, attention to family needs, holistic health outlook, preference for comfort, freedom of choice, and beliefs about the proper role of government. Participants found the exercise very easy (59%) or fairly easy (39%) to understand and very informative (66%) or fairly informative (31%). The majority agreed that the CHAT exercise led to fair decisions about priorities for coverage by which they could abide.It is possible to involve cancer patients and families in explicit discussions of their priorities for affordable advanced cancer care through the use of decision tools designed for this purpose. A key question is whether such a conversation is possible on a broader, national level.

Authors
Danis, M; Abernethy, AP; Zafar, SY; Samsa, GP; Wolf, SP; Howie, L; Taylor, DH
MLA Citation
Danis, M, Abernethy, AP, Zafar, SY, Samsa, GP, Wolf, SP, Howie, L, and Taylor, DH. "A decision exercise to engage cancer patients and families in deliberation about Medicare coverage for advanced cancer care." BMC health services research 14 (July 19, 2014): 315-.
PMID
25038783
Source
epmc
Published In
BMC Health Services Research
Volume
14
Publish Date
2014
Start Page
315
DOI
10.1186/1472-6963-14-315

It's time to have 'the talk': cost communication and patient-centered care.

Authors
Zafar, SY; Tulsky, JA; Abernethy, AP
MLA Citation
Zafar, SY, Tulsky, JA, and Abernethy, AP. "It's time to have 'the talk': cost communication and patient-centered care." Oncology (Williston Park, N.Y.) 28.6 (June 2014): 479-480.
PMID
25134320
Source
epmc
Published In
Oncology
Volume
28
Issue
6
Publish Date
2014
Start Page
479
End Page
480

Patient-oncologist cost communication, financial distress, and medication adherence.

Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care.We surveyed insured adults receiving anticancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication nonadherence was defined as skipping doses or taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions because of cost. Multivariable analysis assessed the association between nonadherence and cost discussions.Among 300 respondents (86% response), 16% (n = 49) reported high or overwhelming financial distress. Nineteen percent (n = 56) reported talking to their oncologist about cost. Twenty-seven percent (n = 77) reported medication nonadherence. To make a prescription last longer, 14% (n = 42) skipped medication doses, and 11% (n = 33) took less medication than prescribed; 22% (n = 66) did not fill a prescription because of cost. Five percent (n = 14) reported chemotherapy nonadherence. To make a prescription last longer, 1% (n = 3) skipped chemotherapy doses, and 2% (n = 5) took less chemotherapy; 3% (n = 10) did not fill a chemotherapy prescription because of cost. In adjusted analyses, cost discussion (odds ratio [OR] = 2.58; 95% CI, 1.14 to 5.85; P = .02), financial distress (OR = 1.64, 95% CI, 1.38 to 1.96; P < .001) and higher financial burden than expected (OR = 2.89; 95% CI, 1.41 to 5.89; P < .01) were associated with increased odds of nonadherence.Patient-oncologist cost communication and financial distress were associated with medication nonadherence, suggesting that cost discussions are important for patients forced to make cost-related behavior alterations. Future research should examine the timing, content, and quality of cost-discussions.

Authors
Bestvina, CM; Zullig, LL; Rushing, C; Chino, F; Samsa, GP; Altomare, I; Tulsky, J; Ubel, P; Schrag, D; Nicolla, J; Abernethy, AP; Peppercorn, J; Zafar, SY
MLA Citation
Bestvina, CM, Zullig, LL, Rushing, C, Chino, F, Samsa, GP, Altomare, I, Tulsky, J, Ubel, P, Schrag, D, Nicolla, J, Abernethy, AP, Peppercorn, J, and Zafar, SY. "Patient-oncologist cost communication, financial distress, and medication adherence." Journal of oncology practice 10.3 (May 2014): 162-167.
PMID
24839274
Source
epmc
Published In
Journal of Oncology Practice
Volume
10
Issue
3
Publish Date
2014
Start Page
162
End Page
167
DOI
10.1200/jop.2014.001406

Self-reported financial burden and satisfaction with care among patients with cancer.

Health care-related costs and satisfaction are compelling targets for quality improvement in cancer care delivery; however, little is known about how financial burden affects patient satisfaction.This was an observational, cross-sectional, survey-based study assessing patient-reported financial burden (FB). Eligible patients were ≥ 21 years with solid tumor malignancy and were receiving chemotherapy or hormonal therapy for ≥ 1 month. The Patient Satisfaction Questionnaire Short-Form assessed patient satisfaction with health care. Subjective FB related to cancer treatment was measured on a 5-point Likert scale.Of 174 participants (32% response rate), 47% reported significant/catastrophic FB. Participants reported highest satisfaction with interpersonal manner and lowest satisfaction with financial aspects of care. In adjusted analysis, high FB was negatively associated with general satisfaction (coefficient: -.29), satisfaction with technical quality (coefficient: -.26), and satisfaction with financial aspects of care (coefficient: -.62). Older age was associated with higher scores in all satisfaction subscales except patient-physician communication and financial aspects. Annual household income of <$20,000 was associated with lower satisfaction scores in all subscales except time spent with doctor. High FB was not associated with patient satisfaction scores for accessibility and convenience, communication, interpersonal manner, or time spent with doctor.FB is a potentially modifiable correlate of poor satisfaction with cancer care including general satisfaction and satisfaction with the technical quality of care. Addressing cancer-associated FB may lead to improved satisfaction, which in turn can influence adherence, outcomes, and quality of life.

Authors
Chino, F; Peppercorn, J; Taylor, DH; Lu, Y; Samsa, G; Abernethy, AP; Zafar, SY
MLA Citation
Chino, F, Peppercorn, J, Taylor, DH, Lu, Y, Samsa, G, Abernethy, AP, and Zafar, SY. "Self-reported financial burden and satisfaction with care among patients with cancer." The oncologist 19.4 (April 2014): 414-420.
PMID
24668333
Source
epmc
Published In
The oncologist
Volume
19
Issue
4
Publish Date
2014
Start Page
414
End Page
420
DOI
10.1634/theoncologist.2013-0374

Phase I study of dasatinib in combination with capecitabine, oxaliplatin and bevacizumab followed by an expanded cohort in previously untreated metastatic colorectal cancer.

PURPOSE: Dasatinib inhibits src family kinases and has anti-angiogenic properties. We conducted a phase I study of dasatinib, capecitabine, oxaliplatin, and bevacizumab (CapeOx/bevacizumab), with an expansion cohort in metastatic colorectal cancer (CRC). METHODS: Patients were enrolled in a dose escalation cohort to establish the maximum tolerated dose (MTD) and the recommended phase II dose (RP2D). Using a "3 + 3" design, twelve patients with advanced solid tumors received dasatinib (50 mg twice daily or 70 mg daily), capecitabine (850 mg/m(2) twice daily, days 1-14), oxaliplatin (130 mg/m(2) on day 1) and bevacizumab (7.5 mg/kg on day1), every 3 weeks. Ten patients with previously untreated metastatic CRC were then enrolled in an expansion cohort. Activated src (src(act)) expression was measured by immunohistochemistry, using an antibody that selectively recognizes the active conformation of src (clone 28). RESULTS: Twenty-two patients were enrolled between June 2009 and May 2011. Two DLTs were observed in the 50 mg bid dasatinib cohort, and one DLT was observed in the 70 mg daily dasatinib cohort. The MTD and RP2D for dasatinib was 70 mg daily. The most common treatment-related adverse events were fatigue (20; 91 %) and diarrhea (18; 82 %). Biomarker analysis of src(act) expression demonstrated that the overall response rate (ORR) was 75 % (6/8) for patients with high src(act) expression (IHC ≥ 2), compared to 0 % (0/8) for patients with low srcact expression (IHC 0 or 1); (p = 0.007). CONCLUSIONS: The RP2D of dasatinib is 70 mg daily in combination with CapeOx/bevacizumab. High levels of srcact expression may predict those patients most likely to benefit from dasatinib.

Authors
Strickler, JH; McCall, S; Nixon, AB; Brady, JC; Pang, H; Rushing, C; Cohn, A; Starodub, A; Arrowood, C; Haley, S; Meadows, KL; Morse, MA; Uronis, HE; Blobe, GC; Hsu, SD; Zafar, SY; Hurwitz, HI
MLA Citation
Strickler, JH, McCall, S, Nixon, AB, Brady, JC, Pang, H, Rushing, C, Cohn, A, Starodub, A, Arrowood, C, Haley, S, Meadows, KL, Morse, MA, Uronis, HE, Blobe, GC, Hsu, SD, Zafar, SY, and Hurwitz, HI. "Phase I study of dasatinib in combination with capecitabine, oxaliplatin and bevacizumab followed by an expanded cohort in previously untreated metastatic colorectal cancer." Invest New Drugs 32.2 (April 2014): 330-339.
PMID
24173967
Source
pubmed
Published In
Investigational New Drugs
Volume
32
Issue
2
Publish Date
2014
Start Page
330
End Page
339
DOI
10.1007/s10637-013-0042-9

Does comparative effectiveness research promote rationing of cancer care?

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care. © 2014 Elsevier Ltd.

Authors
Peppercorn, J; Zafar, SY; Houck, K; Ubel, P; Meropol, NJ
MLA Citation
Peppercorn, J, Zafar, SY, Houck, K, Ubel, P, and Meropol, NJ. "Does comparative effectiveness research promote rationing of cancer care?." The Lancet Oncology 15.3 (March 1, 2014). (Review)
Source
scopus
Published In
The Lancet Oncology
Volume
15
Issue
3
Publish Date
2014
DOI
10.1016/S1470-2045(13)70597-7

Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System.

High-quality supportive care is an essential component of comprehensive cancer care. We implemented a patient-centered quality of cancer care survey to examine and identify predictors of quality of supportive care for bowel problems, pain, fatigue, depression, and other symptoms among 1,109 patients with colorectal cancer.Patients with new diagnosis of colorectal cancer at any Veterans Health Administration medical center nationwide in 2008 were ascertained through the Veterans Affairs Central Cancer Registry and sent questionnaires assessing a variety of aspects of patient-centered cancer care. We received questionnaires from 63% of eligible patients (N = 1,109). Descriptive analyses characterizing patient experiences with supportive care and binary logistic regression models were used to examine predictors of receipt of help wanted for each of the five symptom categories.There were significant gaps in patient-centered quality of supportive care, beginning with symptom assessment. In multivariable modeling, the impact of clinical factors and patient race on odds of receiving wanted help varied by symptom. Coordination of care quality predicted receipt of wanted help for all symptoms, independent of patient demographic or clinical characteristics.This study revealed substantial gaps in patient-centered quality of care, difficult to characterize through quality measurement relying on medical record review alone. It established the feasibility of collecting patient-reported quality measures. Improving quality measurement of supportive care and implementing patient-reported outcomes in quality-measurement systems are high priorities for improving the processes and outcomes of care for patients with cancer.

Authors
van Ryn, M; Phelan, SM; Arora, NK; Haggstrom, DA; Jackson, GL; Zafar, SY; Griffin, JM; Zullig, LL; Provenzale, D; Yeazel, MW; Jindal, RM; Clauser, SB
MLA Citation
van Ryn, M, Phelan, SM, Arora, NK, Haggstrom, DA, Jackson, GL, Zafar, SY, Griffin, JM, Zullig, LL, Provenzale, D, Yeazel, MW, Jindal, RM, and Clauser, SB. "Patient-reported quality of supportive care among patients with colorectal cancer in the Veterans Affairs Health Care System." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 32.8 (March 2014): 809-815.
PMID
24493712
Source
epmc
Published In
Journal of Clinical Oncology
Volume
32
Issue
8
Publish Date
2014
Start Page
809
End Page
815
DOI
10.1200/jco.2013.49.4302

Does comparative effectiveness research promote rationing of cancer care?

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care.

Authors
Peppercorn, J; Zafar, SY; Houck, K; Ubel, P; Meropol, NJ
MLA Citation
Peppercorn, J, Zafar, SY, Houck, K, Ubel, P, and Meropol, NJ. "Does comparative effectiveness research promote rationing of cancer care?." The Lancet. Oncology 15.3 (March 2014): e132-e138.
PMID
24534292
Source
epmc
Published In
The Lancet Oncology
Volume
15
Issue
3
Publish Date
2014
Start Page
e132
End Page
e138
DOI
10.1016/s1470-2045(13)70597-7

Does comparative effectiveness research promote rationing of cancer care?

Authors
Peppercorn, J; Zafar, SY; Houck, K; Ubel, P; Meropol, NJ
MLA Citation
Peppercorn, J, Zafar, SY, Houck, K, Ubel, P, and Meropol, NJ. "Does comparative effectiveness research promote rationing of cancer care?." The Lancet Oncology 15.3 (March 2014): e132-e138.
Source
crossref
Published In
The Lancet Oncology
Volume
15
Issue
3
Publish Date
2014
Start Page
e132
End Page
e138
DOI
10.1016/S1470-2045(13)70597-7

Template for reporting results of biomarker testing of specimens from patients with carcinoma of the colon and rectum.

Authors
Bartley, AN; Hamilton, SR; Alsabeh, R; Ambinder, EP; Berman, M; Collins, E; Fitzgibbons, PL; Gress, DM; Nowak, JA; Samowitz, WS; Zafar, SY; Members of the Cancer Biomarker Reporting Workgroup, College of American Pathologists,
MLA Citation
Bartley, AN, Hamilton, SR, Alsabeh, R, Ambinder, EP, Berman, M, Collins, E, Fitzgibbons, PL, Gress, DM, Nowak, JA, Samowitz, WS, Zafar, SY, Members of the Cancer Biomarker Reporting Workgroup, and College of American Pathologists, . "Template for reporting results of biomarker testing of specimens from patients with carcinoma of the colon and rectum." Arch Pathol Lab Med 138.2 (February 2014): 166-170.
PMID
23808403
Source
pubmed
Published In
Archives of Pathology and Laboratory Medicine
Volume
138
Issue
2
Publish Date
2014
Start Page
166
End Page
170
DOI
10.5858/arpa.2013-0231-CP

Comparative effectiveness research: Moving medical oncology forward

Comparative effectiveness research (CER) is critically needed in medical oncology to improve the care being delivered to oncology patients. As medical oncologists are forced to rely on insufficient data as a part of daily treatment decision making, and as the cancer treatment landscape evolves quickly relative to other areas of medicine, CER is particularly pressing in our field. Continued reliance on randomized clinical trials is a part of the solution, but it cannot be the sole answer. As new and richer data sources become available addressing quality of life, resource utilization, and other critical elements, the implementation of CER will advance. Its true power will lie in linkages to "learning health systems" and real-time application to the day-to-day practice of medicine. © 2014.

Authors
Hirsch, BR; Yousuf Zafar, S
MLA Citation
Hirsch, BR, and Yousuf Zafar, S. "Comparative effectiveness research: Moving medical oncology forward." Seminars in Radiation Oncology 24.1 (January 1, 2014): 49-53.
PMID
24314342
Source
scopus
Published In
Seminars in Radiation Oncology
Volume
24
Issue
1
Publish Date
2014
Start Page
49
End Page
53
DOI
10.1016/j.semradonc.2013.08.005

Phase i study of dasatinib in combination with capecitabine, oxaliplatin and bevacizumab followed by an expanded cohort in previously untreated metastatic colorectal cancer

Purpose Dasatinib inhibits src family kinases and has anti-angiogenic properties. We conducted a phase I study of dasatinib, capecitabine, oxaliplatin, and bevacizumab (CapeOx/bevacizumab), with an expansion cohort in metastatic colorectal cancer (CRC). Methods Patients were enrolled in a dose escalation cohort to establish the maximum tolerated dose (MTD) and the recommended phase II dose (RP2D). Using a "3 + 3" design, twelve patients with advanced solid tumors received dasatinib (50 mg twice daily or 70 mg daily), capecitabine (850 mg/m 2 twice daily, days 1-14), oxaliplatin (130 mg/m 2 on day 1) and bevacizumab (7.5 mg/kg on day1), every 3 weeks. Ten patients with previously untreated metastatic CRC were then enrolled in an expansion cohort. Activated src (src act ) expression was measured by immunohistochemistry, using an antibody that selectively recognizes the active conformation of src (clone 28). Results Twenty-two patients were enrolled between June 2009 and May 2011. Two DLTs were observed in the 50 mg bid dasatinib cohort, and one DLT was observed in the 70 mg daily dasatinib cohort. The MTD and RP2D for dasatinib was 70 mg daily. The most common treatment-related adverse events were fatigue (20; 91 %) and diarrhea (18; 82 %). Biomarker analysis of src act expression demonstrated that the overall response rate (ORR) was 75 % (6/8) for patients with high src act expression (IHC ≥ 2), compared to 0 % (0/8) for patients with low src act expression (IHC 0 or 1); (p = 0.007). Conclusions The RP2D of dasatinib is 70 mg daily in combination with CapeOx/bevacizumab. High levels of src act expression may predict those patients most likely to benefit from dasatinib. © 2013 Springer Science+Business Media New York.

Authors
Strickler, JH; McCall, S; Nixon, AB; Brady, JC; Pang, H; Rushing, C; Cohn, A; Starodub, A; Arrowood, C; Haley, S; Meadows, KL; Morse, MA; Uronis, HE; Blobe, GC; Hsu, SD; Zafar, SY; Hurwitz, HI
MLA Citation
Strickler, JH, McCall, S, Nixon, AB, Brady, JC, Pang, H, Rushing, C, Cohn, A, Starodub, A, Arrowood, C, Haley, S, Meadows, KL, Morse, MA, Uronis, HE, Blobe, GC, Hsu, SD, Zafar, SY, and Hurwitz, HI. "Phase i study of dasatinib in combination with capecitabine, oxaliplatin and bevacizumab followed by an expanded cohort in previously untreated metastatic colorectal cancer." Investigational New Drugs 32.2 (January 1, 2014): 330-339.
Source
scopus
Published In
Investigational New Drugs
Volume
32
Issue
2
Publish Date
2014
Start Page
330
End Page
339
DOI
10.1007/s10637-013-0042-9

It's time to have 'The talk': Cost communication and patient-centered care

Authors
Yousuf Zafar, S; Tulsky, JA; Abernethy, AP
MLA Citation
Yousuf Zafar, S, Tulsky, JA, and Abernethy, AP. "It's time to have 'The talk': Cost communication and patient-centered care." ONCOLOGY (United States) 28.6 (January 1, 2014): 13-.
Source
scopus
Published In
Oncology
Volume
28
Issue
6
Publish Date
2014
Start Page
13

Phase I study of capecitabine, oxaliplatin, bevacizumab, and everolimus in advanced solid tumors

Purpose: To define maximum tolerated dose (MTD), toxicities, and pharmacodynamics of capecitabine, oxaliplatin, bevacizumab, and everolimus in advanced solid tumor patients. Design: This was a standard "3 + 3" dose-escalation trial. All subjects received bevacizumab 7.5 mg/kg on day 1 of each cycle. Doses for capecitabine, oxaliplatin and everolimus were modified per dose limiting toxicity (DLT). Baseline and on-treatment plasma biomarkers were analyzed. Archived tumor mRNA levels were evaluated for NRP1, NRP2 and VEGF-A isoforms. Results: Twenty-nine patients were evaluable for toxicity and 30 for efficacy. Two DLTs were observed in cohort 1 and one DLT each was observed in cohort -1 and -1b. Grade ≥3 toxicities included neutropenia, hypertension, perforation/fistula/hemorrhage, hypertriglyceridemia, diarrhea, and thromboembolism. Twelve subjects experienced partial response (PR); 12 had stable disease as best response. Three of seven chemorefractory metastatic colorectal cancer (mCRC) subjects experienced PR; 8 of 15 chemonaive mCRC subjects experienced PR. Plasma TβRIII and IL-6 increased on treatment but without correlation to outcome. Increased VEGF 165 levels significantly correlated with longer progression free survival. Conclusions: Everolimus with full dose capecitabine, oxaliplatin, and bevacizumab had unacceptable toxicity. MTD was: everolimus 5 mg daily; capecitabine 680 mg/m 2 BID days 1-14; oxaliplatin 100 mg/m 2 and bevacizumab 7.5 mg/kg, day 1. Activity was noted in mCRC. © 2014 Springer Science+Business Media.

Authors
Rangwala, F; Bendell, JC; Kozloff, MF; Arrowood, CC; Dellinger, A; Meadows, J; Tourt-Uhlig, S; Murphy, J; Meadows, KL; Starr, A; Broderick, S; Brady, JC; Cushman, SM; Morse, MA; Uronis, HE; Hsu, SD; Zafar, SY; Wallace, J; Starodub, AN; Strickler, JH; Pang, H; Nixon, AB; Hurwitz, HI
MLA Citation
Rangwala, F, Bendell, JC, Kozloff, MF, Arrowood, CC, Dellinger, A, Meadows, J, Tourt-Uhlig, S, Murphy, J, Meadows, KL, Starr, A, Broderick, S, Brady, JC, Cushman, SM, Morse, MA, Uronis, HE, Hsu, SD, Zafar, SY, Wallace, J, Starodub, AN, Strickler, JH, Pang, H, Nixon, AB, and Hurwitz, HI. "Phase I study of capecitabine, oxaliplatin, bevacizumab, and everolimus in advanced solid tumors." Investigational New Drugs 32.4 (January 1, 2014): 700-709.
Source
scopus
Published In
Investigational New Drugs
Volume
32
Issue
4
Publish Date
2014
Start Page
700
End Page
709
DOI
10.1007/s10637-014-0089-2

Prognosis and delay of diagnosis among Kaposi's sarcoma patients in Uganda: a cross-sectional study.

BACKGROUND: In low- and middle-income countries, the association between delay to treatment and prognosis for Kaposi's sarcoma (KS) patients is yet to be studied. METHODS: This is a prospective study of HIV-infected adults with histologically-confirmed KS treated at the Uganda Cancer Institute (UCI). Standardized interviews were conducted in English or Luganda. Medical records were abstracted for KS stage at admission to UCI. Multivariable logistic regression assessed relationships between diagnostic delay and stage at diagnosis. RESULTS: Of 161 patients (90% response rate), 69% were men, and the mean age was 34.0 years (SD 7.7). 26% had been seen in an HIV clinic within 3 months, 72% were on antiretroviral therapy, and 26% had visited a traditional healer prior to diagnosis. 45% delayed seeking care at UCI for ≥3 months from symptom onset. Among those who delayed, 36% waited 6 months, and 25% waited 12 months. Common reasons for delay were lack of pain (48%), no money (32%), and distance to UCI (8%). In adjusted analysis patients who experienced diagnostic delay were more likely than those who did not delay to have poor-risk KS stage (OR 3.41, p = 0.002, 95% CI: 1.46-7.45). In adjusted analyses visiting a traditional healer was the only variable associated with greater likelihood of delay (OR 2.69, p = 0.020, 95% CI: 1.17-6.17). CONCLUSIONS: Diagnostic delay was associated with poor-risk stage at diagnosis, and visiting a traditional healer was associated with higher odds of delay. The relationship between traditional and Western medicine presents a critical intervention point to improve KS-related outcomes in Uganda.

Authors
De Boer, C; Niyonzima, N; Orem, J; Bartlett, J; Zafar, SY
MLA Citation
De Boer, C, Niyonzima, N, Orem, J, Bartlett, J, and Zafar, SY. "Prognosis and delay of diagnosis among Kaposi's sarcoma patients in Uganda: a cross-sectional study." Infectious agents and cancer 9 (January 2014): 17-.
PMID
24904686
Source
epmc
Published In
Infectious Agents and Cancer
Volume
9
Publish Date
2014
Start Page
17
DOI
10.1186/1750-9378-9-17

Prognosis and delay of diagnosis among Kaposi’s sarcoma patients in Uganda: a cross-sectional study

Authors
De Boer, C; Niyonzima, N; Orem, J; Bartlett, J; Zafar, S
MLA Citation
De Boer, C, Niyonzima, N, Orem, J, Bartlett, J, and Zafar, S. "Prognosis and delay of diagnosis among Kaposi’s sarcoma patients in Uganda: a cross-sectional study." Infectious Agents and Cancer 9.1 (2014): 17-17.
Source
crossref
Published In
Infectious Agents and Cancer
Volume
9
Issue
1
Publish Date
2014
Start Page
17
End Page
17
DOI
10.1186/1750-9378-9-17

Full disclosure--out-of-pocket costs as side effects.

Authors
Ubel, PA; Abernethy, AP; Zafar, SY
MLA Citation
Ubel, PA, Abernethy, AP, and Zafar, SY. "Full disclosure--out-of-pocket costs as side effects." N Engl J Med 369.16 (October 17, 2013): 1484-1486.
PMID
24131175
Source
pubmed
Published In
The New England journal of medicine
Volume
369
Issue
16
Publish Date
2013
Start Page
1484
End Page
1486
DOI
10.1056/NEJMp1306826

Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer.

The relationship between prescription medication adherence and financial burden is understudied, particularly in patients seeking financial assistance.

Authors
Zullig, LL; Peppercorn, JM; Schrag, D; Taylor, DH; Lu, Y; Samsa, G; Abernethy, AP; Zafar, SY
MLA Citation
Zullig, LL, Peppercorn, JM, Schrag, D, Taylor, DH, Lu, Y, Samsa, G, Abernethy, AP, and Zafar, SY. "Financial Distress, Use of Cost-Coping Strategies, and Adherence to Prescription Medication Among Patients With Cancer." J Oncol Pract (August 20, 2013).
PMID
23981344
Source
pubmed
Published In
Journal of Oncology Practice
Publish Date
2013
DOI
10.1200/JOP.2013.000971

Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration.

Clinical practice guidelines can be used to help develop measures of quality of cancer care. This article describes the use of a Cancer Care Quality Measurement System (CCQMS) to monitor these measures for colorectal cancer in the Veterans Health Administration (VHA). The CCQMS assessed practice guideline concordance primarily based on colon (14 indicators) and rectal (11 indicators) cancer care guidelines of the NCCN. Indicators were developed with input from VHA stakeholders with the goal of examining the continuum of diagnosis, neoadjuvant therapy, surgery, adjuvant therapy, and survivorship surveillance and/or end-of-life care. In addition, 9 measures of timeliness of cancer care were developed. The measures/indicators formed the basis of a computerized data abstraction tool that produced reports on quality of care in real-time as data were entered. The tool was developed for a 28-facility learning collaborative, the Colorectal Cancer Care Collaborative (C4), aimed at improving colorectal cancer (CRC) care quality. Data on 1373 incident stage I-IV CRC cases were entered over approximately 18 months and were used to target and monitor quality improvement activities. The primary opportunity for improvement involved surveillance colonoscopy and services in patients after curative-intent treatment. NCCN Clinical Practice Guidelines in Oncology were successfully used to develop a measurement system for a VHA research-operations quality improvement partnership.

Authors
Jackson, GL; Zullig, LL; Zafar, SY; Powell, AA; Ordin, DL; Gellad, ZF; Abbott, D; Schlosser, JM; Hersh, J; Provenzale, D
MLA Citation
Jackson, GL, Zullig, LL, Zafar, SY, Powell, AA, Ordin, DL, Gellad, ZF, Abbott, D, Schlosser, JM, Hersh, J, and Provenzale, D. "Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration." Journal of the National Comprehensive Cancer Network : JNCCN 11.4 (April 2013): 431-441.
PMID
23584346
Source
epmc
Published In
Journal of the National Comprehensive Cancer Network : JNCCN
Volume
11
Issue
4
Publish Date
2013
Start Page
431
End Page
441
DOI
10.6004/jnccn.2013.0058

Financial Toxicity, Part II: How Can We Help With the Burden of Treatment-Related Costs?

Authors
Zafar, SY; Abernethy, AP
MLA Citation
Zafar, SY, and Abernethy, AP. "Financial Toxicity, Part II: How Can We Help With the Burden of Treatment-Related Costs?." ONCOLOGY-NEW YORK 27.4 (April 2013): 253-+.
PMID
23781687
Source
wos-lite
Published In
Oncology
Volume
27
Issue
4
Publish Date
2013
Start Page
253
End Page
+

Enrollment of patients with lung and colorectal cancers onto clinical trials.

PURPOSE: Only 2% to 5% of adult patients with cancer enroll onto clinical trials. We assessed simultaneously characteristics of patients and their physicians that may be independently associated with participation. METHODS: CanCORS, a National Cancer Institute (NCI) -funded population-based observational cohort study of newly diagnosed patients with lung and colorectal cancers, sampled patients across five geographic areas, five health care delivery systems, and 15 Veterans Administration hospitals. We linked patient survey and medical record data with physician survey data to examine correlates of trial enrollment. RESULTS: Among 9,901 patients, 5.3% enrolled onto trials. Of the 9,901 patients, we linked 6,506 patients to one medical oncologist, surgeon, or radiation oncologist (physicians, N = 1,325) who responded to the physician survey and was considered their primary cancer clinician decision maker. Patient age, race, disease stage, geographic region, and health insurance were independently associated with trial enrollment. Physician factors independently associated with patient trial enrollment were being a medical oncologist, practicing at an NCI-designated cancer center, taking the lead in discussing trials with patients, and receiving increased income from trial enrollment. After simultaneously adjusting for patient and physician characteristics, only being a physician practicing at an NCI-designated cancer center (odds ratio [OR], 1.65; 95% CI, 1.19 to 2.27) and patient female sex (OR, 1.36; 95% CI, 1.10 to 1.68), age > 70 versus < 50 years (OR, 0.28; 95% CI, 0.16 to 0.48), and advanced disease (OR, 1.85; 95% CI, 1.45 to 2.37) remained independently associated with trial enrollment. CONCLUSION: Both practice environment and patient clinical and demographic characteristics are associated with cancer clinical trial enrollment; simultaneous intervention may be required when trying to increase enrollment rates.

Authors
Fouad, MN; Lee, JY; Catalano, PJ; Vogt, TM; Zafar, SY; West, DW; Simon, C; Klabunde, CN; Kahn, KL; Weeks, JC; Kiefe, CI
MLA Citation
Fouad, MN, Lee, JY, Catalano, PJ, Vogt, TM, Zafar, SY, West, DW, Simon, C, Klabunde, CN, Kahn, KL, Weeks, JC, and Kiefe, CI. "Enrollment of patients with lung and colorectal cancers onto clinical trials." J Oncol Pract 9.2 (March 2013): e40-e47.
PMID
23814523
Source
pubmed
Published In
Journal of Oncology Practice
Volume
9
Issue
2
Publish Date
2013
Start Page
e40
End Page
e47
DOI
10.1200/JOP.2012.000598

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study.

The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens.

Authors
Zafar, SY; Malin, JL; Grambow, SC; Abbott, DH; Kolimaga, JT; Zullig, LL; Weeks, JC; Ayanian, JZ; Kahn, KL; Ganz, PA; Catalano, PJ; West, DW; Provenzale, D; Cancer Care Outcomes Research & Surveillance CanCORS Consortium,
MLA Citation
Zafar, SY, Malin, JL, Grambow, SC, Abbott, DH, Kolimaga, JT, Zullig, LL, Weeks, JC, Ayanian, JZ, Kahn, KL, Ganz, PA, Catalano, PJ, West, DW, Provenzale, D, and Cancer Care Outcomes Research & Surveillance CanCORS Consortium, . "Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study." Cancer 119.4 (February 2013): 854-862.
PMID
22972673
Source
epmc
Published In
Cancer
Volume
119
Issue
4
Publish Date
2013
Start Page
854
End Page
862
DOI
10.1002/cncr.27815

Financial toxicity, Part I: a new name for a growing problem.

Authors
Zafar, SY; Abernethy, AP
MLA Citation
Zafar, SY, and Abernethy, AP. "Financial toxicity, Part I: a new name for a growing problem." Oncology (Williston Park) 27.2 (February 2013): 80-149.
PMID
23530397
Source
pubmed
Published In
Oncology
Volume
27
Issue
2
Publish Date
2013
Start Page
80
End Page
149

Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer.

BACKGROUND: We measured the prevalence of stigma, self-blame, and perceived blame from others for their illness among men with colorectal cancer (CRC) and examined whether these factors were associated with depressive symptoms, independent of clinical and sociodemographic factors. METHODS: Self-administered questionnaires were returned in the fall of 2009 by 1109 eligible male US veterans who were diagnosed with CRC at any Veterans Affairs facility in 2008. Questionnaires assessed stigma, feelings of blame, and depressive symptoms as well as other facets of health, cancer characteristics, and quality and type of medical care. We report the prevalence of cancer stigma, self-blame, and perceived blame from others. We used multivariate linear regression to assess the association between these factors and a measure of depressive symptoms. Covariates included several measures of overall health, cancer progression, symptom severity, and sociodemographic factors. RESULTS: Thirty one percent of respondents endorsed at least one item in a measure of cancer stigma and 25% reported feeling that it was at least 'a little true' that they were to blame for their illness. All three independent variables were associated with depressive symptoms in bivariate models; cancer stigma and self-blame were significantly associated with depressive symptoms in the multivariate model. CONCLUSIONS: Cancer stigma and self-blame are problems for a significant minority of men with CRC and are independent predictors of depressive symptoms. They may represent an important source of stress in men with CRC.

Authors
Phelan, SM; Griffin, JM; Jackson, GL; Zafar, SY; Hellerstedt, W; Stahre, M; Nelson, D; Zullig, LL; Burgess, DJ; van Ryn, M
MLA Citation
Phelan, SM, Griffin, JM, Jackson, GL, Zafar, SY, Hellerstedt, W, Stahre, M, Nelson, D, Zullig, LL, Burgess, DJ, and van Ryn, M. "Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer." Psycho-oncology 22.1 (January 2013): 65-73.
PMID
21954081
Source
epmc
Published In
Psycho-Oncology
Volume
22
Issue
1
Publish Date
2013
Start Page
65
End Page
73
DOI
10.1002/pon.2048

Cancer registration needs assessment at a tertiary medical centre in Kilimanjaro, Tanzania.

Cancer burden is increasing in Africa more than in any other continent, but population-based tracking of cancer incidence is incomplete. Cancer registries can improve understanding of cancer incidence. To assess organizational readiness to sustain registry development, we conducted a survey assessing change efficacy, resource availability and change commitment at the Kilimanjaro Christian Medical Centre (KCMC), an academic hospital in Moshi, Tanzania. Fifty-two surveys were returned (80% response rate). There was strong reliability among change efficacy and commitment survey items, with Cronbach's alphas of 0.93 and 0.77, respectively. Clinicians, nurses and administrators conveyed similar responses regarding change efficacy. Clinicians had similar responses for change commitment. Echoing opinion in many low- and middle-income countries, approximately one-third of respondents indicated there were no funds to maintain the registry, and funds were not obtainable. For most resources, respondents felt that resources were sufficient or attainable. Respondents were generally confident and committed to registry implementation. Lessons learned at KCMC may be more broadly relevant.

Authors
Zullig, LL; Muiruri, C; Abernethy, A; Weiner, BJ; Bartlett, J; Oneko, O; Zafar, SY
MLA Citation
Zullig, LL, Muiruri, C, Abernethy, A, Weiner, BJ, Bartlett, J, Oneko, O, and Zafar, SY. "Cancer registration needs assessment at a tertiary medical centre in Kilimanjaro, Tanzania." World health & population 14.2 (January 2013): 12-23.
PMID
23713208
Source
epmc
Published In
Journal of World Health and Population
Volume
14
Issue
2
Publish Date
2013
Start Page
12
End Page
23
DOI
10.12927/whp.2013.23271

The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience.

PURPOSE: Cancer patients carry rising burdens of health care-related out-of-pocket expenses, and a growing number of patients are considered "underinsured." Our objective was to describe experiences of insured cancer patients requesting copayment assistance and to describe the impact of health care expenses on well-being and treatment. METHODS: We conducted baseline and follow-up surveys regarding the impact of health care costs on well-being and treatment among cancer patients who contacted a national copayment assistance foundation along with a comparison sample of patients treated at an academic medical center. RESULTS: Among 254 participants, 75% applied for drug copayment assistance. Forty-two percent of participants reported a significant or catastrophic subjective financial burden; 68% cut back on leisure activities, 46% reduced spending on food and clothing, and 46% used savings to defray out-of-pocket expenses. To save money, 20% took less than the prescribed amount of medication, 19% partially filled prescriptions, and 24% avoided filling prescriptions altogether. Copayment assistance applicants were more likely than nonapplicants to employ at least one of these strategies to defray costs (98% vs. 78%). In an adjusted analysis, younger age, larger household size, applying for copayment assistance, and communicating with physicians about costs were associated with greater subjective financial burden. CONCLUSION: Insured patients undergoing cancer treatment and seeking copayment assistance experience considerable subjective financial burden, and they may alter their care to defray out-of-pocket expenses. Health insurance does not eliminate financial distress or health disparities among cancer patients. Future research should investigate coverage thresholds that minimize adverse financial outcomes and identify cancer patients at greatest risk for financial toxicity.

Authors
Zafar, SY; Peppercorn, JM; Schrag, D; Taylor, DH; Goetzinger, AM; Zhong, X; Abernethy, AP
MLA Citation
Zafar, SY, Peppercorn, JM, Schrag, D, Taylor, DH, Goetzinger, AM, Zhong, X, and Abernethy, AP. "The financial toxicity of cancer treatment: a pilot study assessing out-of-pocket expenses and the insured cancer patient's experience." Oncologist 18.4 (2013): 381-390.
PMID
23442307
Source
pubmed
Published In
The oncologist
Volume
18
Issue
4
Publish Date
2013
Start Page
381
End Page
390
DOI
10.1634/theoncologist.2012-0279

A phase II study of capecitabine, oxaliplatin, and bevacizumab in the treatment of metastatic esophagogastric adenocarcinomas.

BACKGROUND: Esophageal and gastric cancers often present at an advanced stage. Systemic chemotherapy is the mainstay of treatment, but survival with current regimens remains poor. We evaluated the safety, tolerability, and efficacy of the combination capecitabine, oxaliplatin, and bevacizumab in the treatment of metastatic esophagogastric adenocarcinomas. METHODS: Thirty-seven patients with metastatic or unresectable gastric/gastroesophageal junction tumors were enrolled and treated with capecitabine 850 mg/m(2) BID on days 1-14, and oxaliplatin 130 mg/m(2) with bevacizumab 15 mg/kg on day 1 of a 21-day cycle. The primary endpoint was progression-free survival (PFS). Secondary endpoints included response rate (RR) and overall survival (OS). Neuropilin-1 (NRP1) and -2 (NRP2) mRNA expression was evaluated in archived tumor. RESULTS: Thirty-five patients were evaluable for efficacy. Median PFS was 7.2 months; median OS was 10.8 months. RR was estimated at 51.4%. The regimen was tolerable with expected drug class-related toxicities. NRP2 mRNA levels significantly correlated with PFS (p = 0.042) and showed a trend toward significance with OS (p = 0.051). Nonsignificant trends for NRP1 were noted for higher expression levels and worse outcome. CONCLUSIONS: Bevacizumab can be given safely with chemotherapy in patients with metastatic esophagogastric adenocarcinomas. The combination of capecitabine, oxaliplatin, plus bevacizumab has activity comparable to other bevacizumab-containing regimens in metastatic gastroesophageal cancer.

Authors
Uronis, HE; Bendell, JC; Altomare, I; Blobe, GC; Hsu, SD; Morse, MA; Pang, H; Zafar, SY; Conkling, P; Favaro, J; Arrowood, CC; Cushman, SM; Meadows, KL; Brady, JC; Nixon, AB; Hurwitz, HI
MLA Citation
Uronis, HE, Bendell, JC, Altomare, I, Blobe, GC, Hsu, SD, Morse, MA, Pang, H, Zafar, SY, Conkling, P, Favaro, J, Arrowood, CC, Cushman, SM, Meadows, KL, Brady, JC, Nixon, AB, and Hurwitz, HI. "A phase II study of capecitabine, oxaliplatin, and bevacizumab in the treatment of metastatic esophagogastric adenocarcinomas." Oncologist 18.3 (2013): 271-272.
PMID
23485624
Source
pubmed
Published In
The oncologist
Volume
18
Issue
3
Publish Date
2013
Start Page
271
End Page
272
DOI
10.1634/theoncologist.2012-0404

Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer

Background We measured the prevalence of stigma, self-blame, and perceived blame from others for their illness among men with colorectal cancer (CRC) and examined whether these factors were associated with depressive symptoms, independent of clinical and sociodemographic factors. Methods Self-administered questionnaires were returned in the fall of 2009 by 1109 eligible male US veterans who were diagnosed with CRC at any Veterans Affairs facility in 2008. Questionnaires assessed stigma, feelings of blame, and depressive symptoms as well as other facets of health, cancer characteristics, and quality and type of medical care. We report the prevalence of cancer stigma, self-blame, and perceived blame from others. We used multivariate linear regression to assess the association between these factors and a measure of depressive symptoms. Covariates included several measures of overall health, cancer progression, symptom severity, and sociodemographic factors. Results Thirty one percent of respondents endorsed at least one item in a measure of cancer stigma and 25% reported feeling that it was at least 'a little true' that they were to blame for their illness. All three independent variables were associated with depressive symptoms in bivariate models; cancer stigma and self-blame were significantly associated with depressive symptoms in the multivariate model. Conclusions Cancer stigma and self-blame are problems for a significant minority of men with CRC and are independent predictors of depressive symptoms. They may represent an important source of stress in men with CRC. Copyright © 2011 John Wiley & Sons, Ltd.

Authors
Phelan, SM; Griffin, JM; Jackson, GL; Zafar, SY; Hellerstedt, W; Stahre, M; Nelson, D; Zullig, LL; Burgess, DJ; Ryn, MV
MLA Citation
Phelan, SM, Griffin, JM, Jackson, GL, Zafar, SY, Hellerstedt, W, Stahre, M, Nelson, D, Zullig, LL, Burgess, DJ, and Ryn, MV. "Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer." Psycho-Oncology 22.1 (2013): 65-73.
Source
scival
Published In
Psycho-Oncology
Volume
22
Issue
1
Publish Date
2013
Start Page
65
End Page
73
DOI
10.1002/pon.2048

Chemotherapy use and patient treatment preferences in advanced colorectal cancer: A prospective cohort study

Background: The objective of this study was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. METHODS: Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained through medical record abstraction and patient surveys. Logistic regression analysis was used to evaluate patient characteristics associated with visiting medical oncology and receiving chemotherapy and patient characteristics, beliefs, and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy. RESULTS: Among 702 patients with mCRC, 91% consulted a medical oncologist; and among those, 82% received chemotherapy. Patients ages 65 to 75 years and aged ≥75 years were less likely to visit an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses, patients aged ≥75 years who had moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed that chemotherapy would not extend their life (90%) or that chemotherapy would not likely help with cancer-related problems (89%), or patients preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy. CONCLUSIONS: The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with the intensity or number of chemotherapy regimens. Cancer 2013. © 2012 American Cancer Society. The authors investigate how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer. The majority of patients receive such treatment even if they express negative or marginal preferences or beliefs regarding chemotherapy. Copyright © 2012 American Cancer Society.

Authors
Zafar, SY; Malin, JL; Grambow, SC; Abbott, DH; Kolimaga, JT; Zullig, LL; Weeks, JC; Ayanian, JZ; Kahn, KL; Ganz, PA; Catalano, PJ; West, DW; Provenzale, D
MLA Citation
Zafar, SY, Malin, JL, Grambow, SC, Abbott, DH, Kolimaga, JT, Zullig, LL, Weeks, JC, Ayanian, JZ, Kahn, KL, Ganz, PA, Catalano, PJ, West, DW, and Provenzale, D. "Chemotherapy use and patient treatment preferences in advanced colorectal cancer: A prospective cohort study." Cancer 119.4 (2013): 854-862.
Source
scival
Published In
Cancer
Volume
119
Issue
4
Publish Date
2013
Start Page
854
End Page
862
DOI
10.1002/cncr.27815

Financial toxicity, Part I: a new name for a growing problem.

Authors
Zafar, SY; Abernethy, AP
MLA Citation
Zafar, SY, and Abernethy, AP. "Financial toxicity, Part I: a new name for a growing problem." Oncology (Williston Park, N.Y.) 27.2 (2013): 80-149.
Source
scival
Published In
Oncology
Volume
27
Issue
2
Publish Date
2013
Start Page
80
End Page
149

Financial toxicity, Part II: how can we help with the burden of treatment-related costs?

Authors
Zafar, SY; Abernethy, AP
MLA Citation
Zafar, SY, and Abernethy, AP. "Financial toxicity, Part II: how can we help with the burden of treatment-related costs?." Oncology (Williston Park, N.Y.) 27.4 (2013): 253-256.
Source
scival
Published In
Oncology
Volume
27
Issue
4
Publish Date
2013
Start Page
253
End Page
256

SURVIVAL AMONG METASTATIC COLORECTAL CANCER (MCRC) PATIENTS TREATED IN A RANDOMIZED CONTROLLED TRIAL (RCT) VS AN OBSERVATIONAL COHORT STUDY (OCS)

Authors
Zafar, SY; Grothey, A; Bekaii-Saab, T; Bendell, J; Sherrill, B; Bennett, L; Mun, Y; Sersch, M; Dalal, D; Hurwitz, HI
MLA Citation
Zafar, SY, Grothey, A, Bekaii-Saab, T, Bendell, J, Sherrill, B, Bennett, L, Mun, Y, Sersch, M, Dalal, D, and Hurwitz, HI. "SURVIVAL AMONG METASTATIC COLORECTAL CANCER (MCRC) PATIENTS TREATED IN A RANDOMIZED CONTROLLED TRIAL (RCT) VS AN OBSERVATIONAL COHORT STUDY (OCS)." September 2012.
Source
wos-lite
Published In
Annals of Oncology
Volume
23
Publish Date
2012
Start Page
191
End Page
191

Phase I study of bevacizumab, everolimus, and panobinostat (LBH-589) in advanced solid tumors.

PURPOSE: To define the maximum tolerated dose, clinical toxicities, and pharmacodynamics of bevacizumab, everolimus, and panobinostat (LBH-589) when administered in combination to patients with advanced solid tumor malignancies. EXPERIMENT DESIGN: Subjects received 10 mg of panobinostat three times weekly, 5 or 10 mg everolimus daily, and bevacizumab at 10 mg/kg every 2 weeks. Dose-limiting toxicities (DLTs) were assessed in cycle 1; toxicity evaluation was closely monitored throughout treatment. Treatment continued until disease progression or undesirable toxicity. Protein acetylation was assessed in peripheral blood mononuclear cells (PBMC) both at baseline and on treatment. RESULTS: Twelve subjects were evaluable for toxicity and nine subjects for response. DLTs in cohort 1 included grade 2 esophagitis and grade 3 oral mucositis; DLTs in cohort -1 were grade 2 ventricular arrhythmia and grade 2 intolerable skin rash. Common adverse events were diarrhea (50 %), headache (33 %), mucositis/stomatitis (25 %), hyperlipidemia (25 %), and thrombocytopenia (25 %). There was 1 partial response; an additional 2 subjects had stable disease as best response. No consistent changes in protein acetylation in PBMC were observed in samples available from eight patients on treatment compared with baseline. CONCLUSIONS: Bevacizumab, everolimus, and panobinostat in combination at the lowest proposed doses did not have an acceptable safety and tolerability profile and did not consistently inhibit HDAC activity; therefore, we do not recommend further evaluation.

Authors
Strickler, JH; Starodub, AN; Jia, J; Meadows, KL; Nixon, AB; Dellinger, A; Morse, MA; Uronis, HE; Marcom, PK; Zafar, SY; Haley, ST; Hurwitz, HI
MLA Citation
Strickler, JH, Starodub, AN, Jia, J, Meadows, KL, Nixon, AB, Dellinger, A, Morse, MA, Uronis, HE, Marcom, PK, Zafar, SY, Haley, ST, and Hurwitz, HI. "Phase I study of bevacizumab, everolimus, and panobinostat (LBH-589) in advanced solid tumors." Cancer Chemother Pharmacol 70.2 (August 2012): 251-258.
PMID
22744359
Source
pubmed
Published In
Cancer Chemotherapy and Pharmacology
Volume
70
Issue
2
Publish Date
2012
Start Page
251
End Page
258
DOI
10.1007/s00280-012-1911-1

A phase I study of bevacizumab, everolimus and panitumumab in advanced solid tumors.

PURPOSE: Preclinical data suggest concurrent inhibition of VEGF, mTOR and EGFR pathways may augment antitumor and antiangiogenic effects compared to inhibition of each pathway alone. This study evaluated the maximum tolerated dose/recommended phase II dose and safety and tolerability of bevacizumab, everolimus and panitumumab drug combination. METHODS: Subjects with advanced solid tumors received escalating doses of everolimus and flat dosing of panitumumab at 4.8 mg/kg and bevacizumab at 10 mg/kg every 2 weeks. Dose-limiting toxicities (DLTs) were assessed in cycle 1; toxicity evaluation was closely monitored throughout treatment. Treatment continued until disease progression or undesirable toxicity. RESULTS: Thirty-two subjects were evaluable for toxicity; 31 subjects were evaluable for tumor response. DLTs were observed in cohorts with everolimus at 10 and 5 mg daily and included grade 3 mucositis, skin rash and thrombocytopenia. Therefore, everolimus was dose-reduced to 5 mg three times weekly, which improved the tolerability of the treatment regimen. Common adverse events were skin rash/pruritus (91 %), mucositis/stomatitis (75 %), hypomagnesemia (72 %), hypocalcemia (56 %) and hypokalemia (50 %). There were 3 partial responses; an additional 10 subjects had stable disease ≥6 months. Three subjects with ovarian cancer and one with endometrial cancer achieved prolonged disease control ranging from 11 to >40 months. CONCLUSIONS: The recommended phase II dose is everolimus at 5 mg three times weekly plus panitumumab at 4.8 mg/kg and bevacizumab at 10 mg/kg every 2 weeks. This dosing regimen has an acceptable safety and tolerability profile and appears to have moderate the clinical activity in refractory tumors.

Authors
Vlahovic, G; Meadows, KL; Uronis, HE; Morse, MA; Blobe, GC; Riedel, RF; Zafar, SY; Alvarez-Secord, A; Gockerman, J; Starodub, AN; Ready, NE; Anderson, EL; Bendell, JC; Hurwitz, HI
MLA Citation
Vlahovic, G, Meadows, KL, Uronis, HE, Morse, MA, Blobe, GC, Riedel, RF, Zafar, SY, Alvarez-Secord, A, Gockerman, J, Starodub, AN, Ready, NE, Anderson, EL, Bendell, JC, and Hurwitz, HI. "A phase I study of bevacizumab, everolimus and panitumumab in advanced solid tumors." Cancer Chemother Pharmacol 70.1 (July 2012): 95-102.
PMID
22638798
Source
pubmed
Published In
Cancer Chemotherapy and Pharmacology
Volume
70
Issue
1
Publish Date
2012
Start Page
95
End Page
102
DOI
10.1007/s00280-012-1889-8

Carcinoma of the ampulla of Vater: patterns of failure following resection and benefit of chemoradiotherapy.

BACKGROUND: Ampullary carcinoma is a rare malignancy. Despite radical resection, survival rates remain low with high rates of local failure. We performed a single-institution outcomes analysis to define the role of concurrent chemoradiotherapy (CRT) in addition to surgery. METHODS: A retrospective analysis was performed of all patients undergoing potentially curative pancreaticoduodenectomy for adenocarcinoma of the ampulla of Vater at Duke University Hospitals between 1976 and 2009. Time-to-event analysis was performed comparing all patients who underwent surgery alone to the cohort of patients receiving CRT in addition to surgery. Local control (LC), disease-free survival (DFS), overall survival (OS), and metastases-free survival (MFS) were estimated using the Kaplan-Meier method. RESULTS: A total of 137 patients with ampullary carcinoma underwent Whipple procedure. Of these, 61 patients undergoing resection received adjuvant (n = 43) or neoadjuvant (n = 18) CRT. Patients receiving chemoradiotherapy were more likely to have poorly differentiated tumors (P = .03). Of 18 patients receiving neoadjuvant therapy, 67% were downstaged on final pathology with 28% achieving pathologic complete response (pCR). With a median follow-up of 8.8 years, 3-year local control was improved in patients receiving CRT (88% vs 55%, P = .001) with trend toward 3-year DFS (66% vs 48%, P = .09) and OS (62% vs 46%, P = .074) benefit in patients receiving CRT. CONCLUSIONS: Long-term survival rates are low and local failure rates high following radical resection alone. Given patterns of relapse with surgery alone and local control benefit in patients receiving CRT, the use of chemoradiotherapy in selected patients should be considered.

Authors
Palta, M; Patel, P; Broadwater, G; Willett, C; Pepek, J; Tyler, D; Zafar, SY; Uronis, H; Hurwitz, H; White, R; Czito, B
MLA Citation
Palta, M, Patel, P, Broadwater, G, Willett, C, Pepek, J, Tyler, D, Zafar, SY, Uronis, H, Hurwitz, H, White, R, and Czito, B. "Carcinoma of the ampulla of Vater: patterns of failure following resection and benefit of chemoradiotherapy." Ann Surg Oncol 19.5 (May 2012): 1535-1540.
PMID
22045467
Source
pubmed
Published In
Annals of Surgical Oncology
Volume
19
Issue
5
Publish Date
2012
Start Page
1535
End Page
1540
DOI
10.1245/s10434-011-2117-1

Refining a checklist for reporting patient populations and service characteristics in hospice and palliative care research.

CONTEXT: In specialist hospice and palliative care services, variations occur in diagnoses and prognoses of subpopulations referred, service configuration, and the health systems delivering care. These three levels of variation limit the ability to generalize study findings. OBJECTIVES: This article reports on coding one year of palliative care research using a previously developed checklist. The aims were to 1) quantify current reporting of factors related to generalizability in specialist palliative care research; 2) review and potentially refine the checklist in light of the first aim; 3) demonstrate the feasibility of collecting these data; and 4) set out simple processes to aid researchers in reporting, and clinicians in applying, new research evidence in hospice and palliative care. METHODS: A previously published checklist (five domains, 14 core subdomains, and 24 noncore subdomains) was used to code all research articles (n=189) published in 2007 in the three leading palliative care research journals. RESULTS: The most frequently reported subdomains were patient age, gender, and diagnosis; model of service delivery; and patient performance status. Data in subdomains, including time from referral to death, socioeconomic indices, and ethnicity, were rarely reported; none reported whole-of-service or whole-of-population data. In total, 2646 (189×14) core subdomains could have been reported. Data were provided in 28% (746/2646). CONCLUSION: Checklists such as the Consolidated Standards of Reporting Trials evaluate study design, focusing mainly on internal validity. The proposed checklist deals with specific content of hospice and palliative care, focusing on external validity.

Authors
Currow, DC; Tieman, JJ; Greene, A; Zafar, SY; Wheeler, JL; Abernethy, AP
MLA Citation
Currow, DC, Tieman, JJ, Greene, A, Zafar, SY, Wheeler, JL, and Abernethy, AP. "Refining a checklist for reporting patient populations and service characteristics in hospice and palliative care research." J Pain Symptom Manage 43.5 (May 2012): 902-910.
PMID
22445274
Source
pubmed
Published In
Journal of Pain and Symptom Management
Volume
43
Issue
5
Publish Date
2012
Start Page
902
End Page
910
DOI
10.1016/j.jpainsymman.2011.05.015

Gastrointestinal symptoms in cancer patients with advanced disease: new methodologies, insights, and a proposed approach.

PURPOSE OF REVIEW: This review summarizes recent developments in the management of gastrointestinal symptoms experienced by cancer patients and provides a framework for education, assessment and monitoring, and treatment. RECENT FINDINGS: Although many viable treatment options exist, gastrointestinal symptoms - particularly nausea and vomiting, constipation, and diarrhea - continue to challenge both patients and clinicians. Current clinical guidelines now recommend that patients treated with moderate emetic risk chemotherapy regimens be preferentially treated with the 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, palonosetron, in combination with dexamethasone. A large randomized trial has also recently validated that single-dose fosaprepitant is equivalent to the standard 3-day, aprepitant regimen. New medications, such as skin patch delivery of granisetron for nausea or methylnaltrexone for constipation, show promise in both the management of symptoms and as preventive agents. The integration of complementary and alternative therapies, such as relaxation techniques, ginger, and electroacupuncture may also assist with symptom relief. Accurate assessment is essential, but often problematic, especially as the patient's experience of gastrointestinal distress is often disproportionate with objective measures. New methodologies that harness technology to collect patient-reported outcomes may improve the accuracy of assessment, provide a better picture of the patient's experience of gastrointestinal symptoms, and deliver a means to simultaneously monitor symptoms, educate patients, and collect longitudinal data. SUMMARY: Palliative management of gastrointestinal symptoms in advanced cancer patients requires a multipronged approach that entails effective assessment, judicious use of latest evidence-based approaches, and monitoring that incorporates both clinical measures and patient-reported outcomes. When combined with refinements in the overall clinical approach to symptom management, standardized instruments that streamline data collection and enable data warehousing will support better symptom management.

Authors
Rangwala, F; Zafar, SY; Abernethy, AP
MLA Citation
Rangwala, F, Zafar, SY, and Abernethy, AP. "Gastrointestinal symptoms in cancer patients with advanced disease: new methodologies, insights, and a proposed approach." Curr Opin Support Palliat Care 6.1 (March 2012): 69-76. (Review)
PMID
22228030
Source
pubmed
Published In
Current Opinion in Supportive and Palliative Care
Volume
6
Issue
1
Publish Date
2012
Start Page
69
End Page
76
DOI
10.1097/SPC.0b013e32834f689d

Consensus-based standards for best supportive care in clinical trials in advanced cancer.

Best supportive care is poorly defined in clinical trials, and a standard framework for delivery of such care is needed, using best available evidence and allowing replication of studies. We convened a panel of 36 experts to develop consensus statements via the Delphi method. The first round included open-ended questions; subsequent rounds sought to develop consensus-based standards. Consensus was assessed by use of a 5-point Likert agreement scale; more than 70% of panellists had to give a score of 5 to meet a-priori levels of consensus. The panel identified four key domains of best supportive care in clinical trials: multidisciplinary care; supportive care documentation; symptom assessment; and symptom management. Consensus was reached on 11 statements within these four domains. For example, 24 (96%) panellists recommended that the intervals between symptom assessments should be identical for control and experimental groups. Availability of resources was cited as a challenge to implementation of best supportive care standards.

Authors
Zafar, SY; Currow, DC; Cherny, N; Strasser, F; Fowler, R; Abernethy, AP
MLA Citation
Zafar, SY, Currow, DC, Cherny, N, Strasser, F, Fowler, R, and Abernethy, AP. "Consensus-based standards for best supportive care in clinical trials in advanced cancer." Lancet Oncol 13.2 (February 2012): e77-e82. (Review)
PMID
22300862
Source
pubmed
Published In
The Lancet Oncology
Volume
13
Issue
2
Publish Date
2012
Start Page
e77
End Page
e82
DOI
10.1016/S1470-2045(11)70215-7

Early dissemination of bevacizumab for advanced colorectal cancer: a prospective cohort study.

We describe early dissemination patterns for first-line bevacizumab given for metastatic colorectal cancer treatment.We analyzed patient surveys and medical records for a population-based cohort with metastatic colorectal cancer treated in multiple regions and health systems in the United States (US). Eligible patients were diagnosed with metastatic colorectal cancer and initiated first-line chemotherapy after US Food & Drug Administration (FDA) bevacizumab approval in February 2004. First-line bevacizumab therapy was defined as receiving bevacizumab within 8 weeks of starting chemotherapy for metastatic colorectal cancer. We evaluated factors associated with first-line bevacizumab treatment using logistic regression.Among 355 patients, 31% received first-line bevacizumab in the two years after FDA approval, including 26% of men, 41% of women, and 16% of those ≥ 75 years. Use rose sharply within 6 months after FDA approval, then plateaued. 20% of patients received bevacizumab in combination with irinotecan; 53% received it with oxaliplatin. Men were less likely than women to receive bevacizumab (adjusted OR 0.55; 95% CI 0.32-0.93; p = 0.026). Patients ≥ 75 years were less likely to receive bevacizumab than patients < 55 years (adjusted OR 0.13; 95% CI 0.04-0.46; p = 0.001).One-third of eligible metastatic colorectal cancer patients received first-line bevacizumab shortly after FDA approval. Most patients did not receive bevacizumab as part of the regimen used in the pivotal study leading to FDA approval.

Authors
Zafar, SY; Malin, JL; Grambow, SC; Abbott, DH; Schrag, D; Kolimaga, JT; Zullig, LL; Weeks, JC; Fouad, MN; Ayanian, JZ; Wallace, R; Kahn, KL; Ganz, PA; Catalano, P; West, DW; Provenzale, D; Cancer Care and Outcomes Research and Surveillance (CanCORS) Consortium,
MLA Citation
Zafar, SY, Malin, JL, Grambow, SC, Abbott, DH, Schrag, D, Kolimaga, JT, Zullig, LL, Weeks, JC, Fouad, MN, Ayanian, JZ, Wallace, R, Kahn, KL, Ganz, PA, Catalano, P, West, DW, Provenzale, D, and Cancer Care and Outcomes Research and Surveillance (CanCORS) Consortium, . "Early dissemination of bevacizumab for advanced colorectal cancer: a prospective cohort study." BMC cancer 11 (August 16, 2011): 354-.
PMID
21846341
Source
epmc
Published In
BMC Cancer
Volume
11
Publish Date
2011
Start Page
354
DOI
10.1186/1471-2407-11-354

The need for a re-evaluation of best supportive care studies reported to date.

Authors
Currow, DC; Foley, K; Zafar, SY; Wheeler, JL; Abernethy, AP
MLA Citation
Currow, DC, Foley, K, Zafar, SY, Wheeler, JL, and Abernethy, AP. "The need for a re-evaluation of best supportive care studies reported to date." Br J Cancer 104.3 (February 1, 2011): 390-391.
PMID
21285970
Source
pubmed
Published In
British Journal of Cancer
Volume
104
Issue
3
Publish Date
2011
Start Page
390
End Page
391
DOI
10.1038/sj.bjc.6606081

A phase I study of bevacizumab (B) in combination with everolimus (E) and erlotinib (E) in advanced cancer (BEE).

PURPOSE: VEGF, mTOR, and EGFR inhibitors have demonstrated anti-tumor and anti-angiogenic effects alone and in combination with each other. This study evaluated the safety, tolerability, and pharmacokinetics of bevacizumab, everolimus, and erlotinib combination. METHODS: Doublet therapy consisted of bevacizumab at 10 mg/kg every 14 days and everolimus 5 mg daily which escalated to 10 mg daily. Erlotinib 75 mg daily was added to the phase II dose recommended phase II dose (RPTD) of bevacizumab and everolimus. Dose-limiting toxicity (DLT) was assessed in cycle 1. RESULTS: Forty-eight patients with advanced solid malignancies were evaluable for DLT and efficacy. No DLTs were observed in the doublet dose escalation. Two DLTs (grade 3 mucositis and grade 3 rash) were observed with the addition of erlotinib 75 mg daily. Consequently, triplet doses were adjusted and were better tolerated. Four patients had a partial response. Median progression-free survival (PFS) for the doublet therapy was 6.0 months (0.5 to 32+ months) and 5.5 months (0.8 to 27+ months) for the triplet therapy. Systemic exposure of everolimus was significantly higher in combination with erlotinib (476 ± 161 ng h/mL) compared to when given alone (393 ± 156 ng h/mL; P = 0.020). CONCLUSIONS: The RPTD for the doublet therapy is bevacizumab 10 mg/kg every 14 days and everolimus 10 mg daily, and the RPTD for the triplet therapy is bevacizumab 5 mg/kg every 14 days, everolimus 5 mg and erlotinib 75 mg daily. Prolonged disease stability was demonstrated in tumors known to respond to mTOR inhibition and potentially resistant to VEGF blockade.

Authors
Bullock, KE; Petros, WP; Younis, I; Uronis, HE; Morse, MA; Blobe, GC; Zafar, SY; Gockerman, JP; Lager, JJ; Truax, R; Meadows, KL; Howard, LA; O'Neill, MM; Broadwater, G; Hurwitz, HI; Bendell, JC
MLA Citation
Bullock, KE, Petros, WP, Younis, I, Uronis, HE, Morse, MA, Blobe, GC, Zafar, SY, Gockerman, JP, Lager, JJ, Truax, R, Meadows, KL, Howard, LA, O'Neill, MM, Broadwater, G, Hurwitz, HI, and Bendell, JC. "A phase I study of bevacizumab (B) in combination with everolimus (E) and erlotinib (E) in advanced cancer (BEE)." Cancer Chemother Pharmacol 67.2 (February 2011): 465-474.
PMID
21079958
Source
pubmed
Published In
Cancer Chemotherapy and Pharmacology
Volume
67
Issue
2
Publish Date
2011
Start Page
465
End Page
474
DOI
10.1007/s00280-010-1507-6

Capecitabine in the management of colorectal cancer.

5-Fluorouracil has been a mainstay in the treatment of colorectal cancer for nearly five decades; however, the use of oral formulations of the medication has been gaining increasing traction since capecitabine was approved for use in adjuvant settings by the US Food and Drug Administration in 2005. The use of capecitabine has since spread to a number of off-label indications, including the treatment of advanced or metastatic colorectal cancer and the neoadjuvant treatment of rectal cancer. In light of increasing utilization, it is critical that clinicians have a firm understanding of the literature supporting capecitabine across various settings as well as the attributes of the drug, such as its dosing recommendations, side-effect profile, and use in the elderly. The purpose of this review is to synthesize the literature in a fashion that can be used to help guide decisions. In a setting of increasing focus on cost, the pharmacoeconomic literature is also briefly reviewed.

Authors
Hirsch, BR; Zafar, SY
MLA Citation
Hirsch, BR, and Zafar, SY. "Capecitabine in the management of colorectal cancer." Cancer Manag Res 3 (2011): 79-89.
PMID
21629830
Source
pubmed
Published In
Cancer Management and Research
Volume
3
Publish Date
2011
Start Page
79
End Page
89
DOI
10.2147/CMR.S11250

A phase II trial of bevacizumab plus everolimus for patients with refractory metastatic colorectal cancer.

PURPOSE: For patients with metastatic colorectal cancer (mCRC), no standard therapy exists after progression on 5-fluorouracil, oxaliplatin, irinotecan, bevacizumab, and cetuximab or panitumumab. Preclinical data demonstrated that combined vascular endothelial growth factor and mammalian target of rapamycin inhibition has greater antiangiogenic and antitumor activity than either monotherapy. A phase I study of bevacizumab plus everolimus demonstrated that the combination is safe; activity was seen in several patients with refractory mCRC. METHODS: Fifty patients with refractory mCRC were enrolled and received bevacizumab at 10 mg/kg every 2 weeks and everolimus at 10 mg orally daily. RESULTS: Of the 50 patients enrolled, the median age was 56 years and the median number of prior regimens was four. Forty-seven patients (96%) had prior bevacizumab exposure and 42 patients (84%) had documented progression on prior bevacizumab-based therapy. Forty-nine patients were evaluable for response; eight patients had minor responses (16%) and an additional 15 patients (30%) had stable disease (SD). No complete or partial responses were seen. The median progression-free survival interval was 2.3 months; however, 26% of patients achieved prolonged SD for ≥6 months, and three patients (6%) were on study for >1 year. The median overall survival duration was 8.1 months. The most common grade 1-2 toxicities were mucositis (68%) and hyperlipidemia (64%). Clinically significant grade ≥3 toxicities included hypertension (14%), fistula/abscess/perforation (8%), mucositis (6%), and hemorrhage (2%). CONCLUSIONS: Bevacizumab plus everolimus is generally tolerable but may have risks related to mucosal damage and/or wound healing. Bevacizumab plus everolimus appears to have modest activity in refractory mCRC in patients.

Authors
Altomare, I; Bendell, JC; Bullock, KE; Uronis, HE; Morse, MA; Hsu, SD; Zafar, SY; Blobe, GC; Pang, H; Honeycutt, W; Sutton, L; Hurwitz, HI
MLA Citation
Altomare, I, Bendell, JC, Bullock, KE, Uronis, HE, Morse, MA, Hsu, SD, Zafar, SY, Blobe, GC, Pang, H, Honeycutt, W, Sutton, L, and Hurwitz, HI. "A phase II trial of bevacizumab plus everolimus for patients with refractory metastatic colorectal cancer." Oncologist 16.8 (2011): 1131-1137.
PMID
21795432
Source
pubmed
Published In
The oncologist
Volume
16
Issue
8
Publish Date
2011
Start Page
1131
End Page
1137
DOI
10.1634/theoncologist.2011-0078

A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group.

BACKGROUND: Palliative medicine has made rapid progress in establishing its scientific and clinical legitimacy, yet the evidence base to support clinical practice remains deficient in both the quantity and quality of published studies. Historically, the conduct of research in palliative care populations has been impeded by multiple barriers including health care system fragmentation, small number and size of potential sites for recruitment, vulnerability of the population, perceptions of inappropriateness, ethical concerns, and gate-keeping. METHODS: A group of experienced investigators with backgrounds in palliative care research convened to consider developing a research cooperative group as a mechanism for generating high-quality evidence on prioritized, clinically relevant topics in palliative care. RESULTS: The resulting Palliative Care Research Cooperative (PCRC) agreed on a set of core principles: active, interdisciplinary membership; commitment to shared research purposes; heterogeneity of participating sites; development of research capacity in participating sites; standardization of methodologies, such as consenting and data collection/management; agile response to research requests from government, industry, and investigators; focus on translation; education and training of future palliative care researchers; actionable results that can inform clinical practice and policy. Consensus was achieved on a first collaborative study, a randomized clinical trial of statin discontinuation versus continuation in patients with a prognosis of less than 6 months who are taking statins for primary or secondary prevention. This article describes the formation of the PCRC, highlighting processes and decisions taken to optimize the cooperative group's success.

Authors
Abernethy, AP; Aziz, NM; Basch, E; Bull, J; Cleeland, CS; Currow, DC; Fairclough, D; Hanson, L; Hauser, J; Ko, D; Lloyd, L; Morrison, RS; Otis-Green, S; Pantilat, S; Portenoy, RK; Ritchie, C; Rocker, G; Wheeler, JL; Zafar, SY; Kutner, JS
MLA Citation
Abernethy, AP, Aziz, NM, Basch, E, Bull, J, Cleeland, CS, Currow, DC, Fairclough, D, Hanson, L, Hauser, J, Ko, D, Lloyd, L, Morrison, RS, Otis-Green, S, Pantilat, S, Portenoy, RK, Ritchie, C, Rocker, G, Wheeler, JL, Zafar, SY, and Kutner, JS. "A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group." J Palliat Med 13.12 (December 2010): 1407-1413.
Website
http://hdl.handle.net/10161/3239
PMID
21105763
Source
pubmed
Published In
Journal of Palliative Medicine
Volume
13
Issue
12
Publish Date
2010
Start Page
1407
End Page
1413
DOI
10.1089/jpm.2010.0261

Validation of the Patient Care Monitor (Version 2.0): a review of system assessment instrument for cancer patients.

CONTEXT: The Patient Care Monitor (PCM) is a review of systems survey delivered by means of an electronic patient-reported outcomes (ePRO) data capture system that uses wireless tablet computers. Although the PCM 1.0 is validated, the updated PCM 2.0 has not been validated nor tested in the academic setting. OBJECTIVES: To validate and test the PCM 2.0 in three cancer populations. METHODS: Two hundred seventy-five individuals participated in three clinical trials enrolling breast (n=65), gastrointestinal (n=113), and lung (n=97) cancer patients. Internal consistency was evaluated using Cronbach's alpha coefficients calculated for six PCM subscales (general physical symptoms, treatment side effects, distress, despair, impaired performance, and impaired ambulation) and a Quality-of-Life Index. Construct validity was evaluated through Pearson's correlation between PCM subscales and subscales of the Functional Assessment of Cancer Therapy--General (FACT-G), the M.D. Anderson Symptom Inventory (MDASI), and the Functional Assessment of Chronic Illness Therapy--Fatigue (FACIT-F). The participants had the following characteristics: mean age was 58 years (standard deviation: 11), 52% were females, 79% were whites, 17% were blacks, 62% had no college degree, and 78% had metastatic or recurrent disease. RESULTS: Raw and normalized scores for PCM 2.0 subscales were internally consistent across study cohorts. PCM 2.0 subscales correlated significantly (P<0.05) with the corresponding subscales on FACT-G, MDASI, and FACIT-F, with the exception of FACT-G social well-being, particularly for the lung cancer population. These correlations demonstrated construct validity. PCM 2.0 results followed expected patterns by cancer etiology. Prior reports demonstrate patient satisfaction with PCM 2.0. CONCLUSION: Within three unique academic oncology populations, PCM 2.0 is a valid ePRO instrument for assessing symptoms with seven patient-centered subscale or index domains.

Authors
Abernethy, AP; Zafar, SY; Uronis, H; Wheeler, JL; Coan, A; Rowe, K; Shelby, RA; Fowler, R; Herndon, JE
MLA Citation
Abernethy, AP, Zafar, SY, Uronis, H, Wheeler, JL, Coan, A, Rowe, K, Shelby, RA, Fowler, R, and Herndon, JE. "Validation of the Patient Care Monitor (Version 2.0): a review of system assessment instrument for cancer patients." J Pain Symptom Manage 40.4 (October 2010): 545-558.
PMID
20579839
Source
pubmed
Published In
Journal of Pain and Symptom Management
Volume
40
Issue
4
Publish Date
2010
Start Page
545
End Page
558
DOI
10.1016/j.jpainsymman.2010.01.017

Standards for palliative care delivery in oncology settings.

This review aims to describe available standards for delivery of palliative and supportive care for cancer patients and discuss to what extent these guidelines have been evaluated and disseminated into standard care. Ovid searches were conducted to identify relevant guidelines, randomized studies comparing guideline-based care to usual care, and articles describing the use of guidelines in the usual care setting. Published guidelines address specific issues related to symptom management. Broader consensus statements have presented a framework for the delivery of palliative care for cancer patients. Dissemination of guidelines into standard care has been limited. Limited data suggest that implementation of palliative and supportive care guidelines can improve patient outcomes. Clinical trial publications rarely address supportive care in detail. Guideline efficacy has not been evaluated, and their dissemination into standard care has been poor. A conceptual framework for better implementation of existing guidelines might improve usage and outcomes.

Authors
Zafar, SY; Currow, DC; Daugherty, CK; Abernethy, AP
MLA Citation
Zafar, SY, Currow, DC, Daugherty, CK, and Abernethy, AP. "Standards for palliative care delivery in oncology settings." Cancer J 16.5 (September 2010): 436-443. (Review)
PMID
20890139
Source
pubmed
Published In
Cancer Journal
Volume
16
Issue
5
Publish Date
2010
Start Page
436
End Page
443
DOI
10.1097/PPO.0b13e3181f289f7

Establishing a regional, multisite database for quality improvement and service planning in community-based palliative care and hospice.

BACKGROUND: Outpatient palliative care, an evolving delivery model, seeks to improve continuity of care across settings and to increase access to services in hospice and palliative medicine (HPM). It can provide a critical bridge between inpatient palliative care and hospice, filling the gap in community-based supportive care for patients with advanced life-limiting illness. Low capacities for data collection and quantitative research in HPM have impeded assessment of the impact of outpatient palliative care. APPROACH: In North Carolina, a regional database for community-based palliative care has been created through a unique partnership between a HPM organization and academic medical center. This database flexibly uses information technology to collect patient data, entered at the point of care (e.g., home, inpatient hospice, assisted living facility, nursing home). HPM physicians and nurse practitioners collect data; data are transferred to an academic site that assists with analyses and data management. Reports to community-based sites, based on data they provide, create a better understanding of local care quality. CURRENT STATUS: The data system was developed and implemented over a 2-year period, starting with one community-based HPM site and expanding to four. Data collection methods were collaboratively created and refined. The database continues to grow. Analyses presented herein examine data from one site and encompass 2572 visits from 970 new patients, characterizing the population, symptom profiles, and change in symptoms after intervention. CONCLUSION: A collaborative regional approach to HPM data can support evaluation and improvement of palliative care quality at the local, aggregated, and statewide levels.

Authors
Bull, J; Zafar, SY; Wheeler, JL; Harker, M; Gblokpor, A; Hanson, L; Hulihan, D; Nugent, R; Morris, J; Abernethy, AP
MLA Citation
Bull, J, Zafar, SY, Wheeler, JL, Harker, M, Gblokpor, A, Hanson, L, Hulihan, D, Nugent, R, Morris, J, and Abernethy, AP. "Establishing a regional, multisite database for quality improvement and service planning in community-based palliative care and hospice." J Palliat Med 13.8 (August 2010): 1013-1020.
Website
http://hdl.handle.net/10161/3333
PMID
20649439
Source
pubmed
Published In
Journal of Palliative Medicine
Volume
13
Issue
8
Publish Date
2010
Start Page
1013
End Page
1020
DOI
10.1089/jpm.2010.0017

Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs.

The Veterans Affairs (VA) healthcare system treats approximately 3% of patients with cancer in the United States each year. We measured the quality of nonmetastatic colorectal cancer (CRC) care in VA as indicated by concordance with National Comprehensive Cancer Network practice guidelines (six indicators) and timeliness of care (three indicators).A retrospective medical record abstraction was done for 2,492 patients with incident stages I to III CRC diagnosed between October 1, 2003, and March 31, 2006, who underwent definitive CRC surgery. Patients were treated at one or more of 128 VA medical centers. The proportion of patients receiving guideline-concordant care and time intervals between care processes were calculated.More than 80% of patients had preoperative carcinoembryonic antigen determination (ie, stages II to III disease) and documented clear surgical margins (ie, stages II to III disease). Between 72% and 80% of patients had appropriate referral to a medical oncologist (ie, stages II to III disease), preoperative computed tomography scan of the abdomen and pelvis (ie, stages II to III disease), and adjuvant fluorouracil-based chemotherapy (ie, stage III disease). Less than half of patients with stages I to III CRC (43.5%) had a follow-up colonoscopy 7 to 18 months after surgery. The mean number of days between major treatment events included the following: 26.6 days (standard deviation [SD], 38.2; median, 20 days) between diagnosis and initiation of treatment (in stages II to III disease); 64.8 [corrected] days (SD, 54.9; median, 50 days) between definitive surgery and start of adjuvant chemotherapy (in stages II to III disease); and 444.2 [corrected] days (SD, 182.1; median, 393 days) between definitive surgery and follow-up colonoscopies (in stages I to III disease).Although there is opportunity for improvement in the area of cancer surveillance, the VA performs well in meeting established guidelines for diagnosis and treatment of CRC.

Authors
Jackson, GL; Melton, LD; Abbott, DH; Zullig, LL; Ordin, DL; Grambow, SC; Hamilton, NS; Zafar, SY; Gellad, ZF; Kelley, MJ; Provenzale, D
MLA Citation
Jackson, GL, Melton, LD, Abbott, DH, Zullig, LL, Ordin, DL, Grambow, SC, Hamilton, NS, Zafar, SY, Gellad, ZF, Kelley, MJ, and Provenzale, D. "Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 28.19 (July 2010): 3176-3181.
PMID
20516431
Source
epmc
Published In
Journal of Clinical Oncology
Volume
28
Issue
19
Publish Date
2010
Start Page
3176
End Page
3181
DOI
10.1200/jco.2009.26.7948

Electronic patient-reported data capture as a foundation of rapid learning cancer care.

BACKGROUND: "Rapid learning healthcare" presents a new infrastructure to support comparative effectiveness research. By leveraging heterogeneous datasets (eg, clinical, administrative, genomic, registry, and research), health information technology, and sophisticated iterative analyses, rapid learning healthcare provides a real-time framework in which clinical studies can evaluate the relative impact of therapeutic approaches on a diverse array of measures. PURPOSE: This article describes an effort, at 1 academic medical center, to demonstrate what rapid learning healthcare might look like in operation. The article describes the process of developing and testing the components of this new model of integrated clinical/research function, with the pilot site being an academic oncology clinic and with electronic patient-reported outcomes (ePROs) being the foundational dataset. RESEARCH DESIGN: Steps included: feasibility study of the ePRO system; validation study of ePRO collection across 3 cancers; linking ePRO and other datasets; implementation; stakeholder alignment and buy in, and; demonstration through use cases. SUBJECTS: Two use cases are presented; participants were metastatic breast cancer (n = 65) and gastrointestinal cancer (n = 113) patients at 2 academic medical centers. RESULTS: (1) Patient-reported symptom data were collected with tablet computers; patients with breast and gastrointestinal cancer indicated high levels of sexual distress, which prompted multidisciplinary response, design of an intervention, and successful application for funding to study the intervention's impact. (2) The system evaluated the longitudinal impact of a psychosocial care program provided to patients with breast cancer. Participants used tablet computers to complete PRO surveys; data indicated significant impact on psychosocial outcomes, notably distress and despair, despite advanced disease. Results return to the clinic, allowing iterative update and evaluation. CONCLUSIONS: An ePRO-based rapid learning cancer clinic is feasible, providing real-time research-quality data to support comparative effectiveness research.

Authors
Abernethy, AP; Ahmad, A; Zafar, SY; Wheeler, JL; Reese, JB; Lyerly, HK
MLA Citation
Abernethy, AP, Ahmad, A, Zafar, SY, Wheeler, JL, Reese, JB, and Lyerly, HK. "Electronic patient-reported data capture as a foundation of rapid learning cancer care." Med Care 48.6 Suppl (June 2010): S32-S38.
PMID
20473201
Source
pubmed
Published In
Medical Care
Volume
48
Issue
6 Suppl
Publish Date
2010
Start Page
S32
End Page
S38
DOI
10.1097/MLR.0b013e3181db53a4

Management of gastrointestinal symptoms in advanced cancer patients: the rapid learning cancer clinic model.

PURPOSE OF REVIEW: Gastrointestinal symptoms are prevalent, often persistent, and detrimental to patients' quality of life. This review discusses evaluation of gastrointestinal symptoms as patient-reported outcomes (PROs) and presents an information technology-based system for symptom monitoring and management. The electronic PRO (ePRO) system is then placed within the larger context of rapid learning healthcare, a concept currently under development in which data obtained through both research and clinical care continuously build large datasets for analysis, seed future research, fuel expansion of the evidence base, and support clinical decision-making. RECENT FINDINGS: PROs are increasingly recognized as valid measures of symptoms, functional status, and quality of life. They have demonstrated prognostic significance and are being developed as a component of toxicity reporting in clinical trials. Recent studies have validated an information technology-based approach for collecting ePROs in routine clinical care. The system is feasible and acceptable; electronic and paper-based data, collected on validated assessment instruments, are equivalent; ePRO collection supports real-time symptom monitoring and management. The ePRO system represents a first step toward implementing rapid learning healthcare at the clinic level. SUMMARY: ePROs provide a rich source of information to support monitoring and clinical management of troubling symptoms such as gastrointestinal complaints.

Authors
Abernethy, AP; Wheeler, JL; Zafar, SY
MLA Citation
Abernethy, AP, Wheeler, JL, and Zafar, SY. "Management of gastrointestinal symptoms in advanced cancer patients: the rapid learning cancer clinic model." Curr Opin Support Palliat Care 4.1 (March 2010): 36-45. (Review)
PMID
19952928
Source
pubmed
Published In
Current Opinion in Supportive and Palliative Care
Volume
4
Issue
1
Publish Date
2010
Start Page
36
End Page
45
DOI
10.1097/SPC.0b013e32833575fd

Adverse events among the elderly receiving chemotherapy for advanced non-small-cell lung cancer.

PURPOSE: To describe chemotherapy use and adverse events (AEs) for advanced-stage, non-small-cell lung cancer (NSCLC) in community practice, including descriptions according to variation by age. METHODS: We interviewed patients with newly diagnosed, stages IIIB and IV NSCLC in the population-based cohort studied by the Cancer Care Outcomes Research and Surveillance Consortium, and we abstracted the patient medical records. AEs were medical events occurring during chemotherapy. Using logistic regression, we assessed the association between age and chemotherapy; with Poisson regression, we estimated event rate ratios and adjusted the analysis for age, sex, ethnicity, radiation therapy, stage, histology, and presence and grade of 27 comorbidities. RESULTS: Of 1,371 patients, 58% (95% CI, 55% to 61%) received chemotherapy and 35% (95% CI, 32% to 38%) had AEs. After adjustment, 72% (95% CI, 65% to 79%) of those younger than 55 years and 47% (95% CI, 42% to 52%) of those age 75 years and older received chemotherapy. Platinum-based therapies were less common in the older-age groups. Pretreatment medical event rates were 18.6% for patients younger than 55 years and were only 9.2% for those age 75 years and older (adjusted rate ratio, 0.49; 95% CI, 0.26 to 0.91). In contrast, older adults were more likely to have AEs during chemotherapy. The adjusted rate ratios compared with age younger than 55 years were 1.70 for 65- to 74-year-olds (95% CI, 1.19 to 2.43) and 1.34 for those age 75 years and older (95% CI, 0.90 to 2.00). CONCLUSION: Older patients who received chemotherapy had fewer pretherapy events than younger patients and were less likely to receive platinum-based regimens. Nevertheless, older patients had more adverse events during chemotherapy, independent of comorbidity. Potential implicit trade-offs between symptom management and treatment toxicity should be made explicit and additionally studied.

Authors
Chrischilles, EA; Pendergast, JF; Kahn, KL; Wallace, RB; Moga, DC; Harrington, DP; Kiefe, CI; Weeks, JC; West, DW; Zafar, SY; Fletcher, RH
MLA Citation
Chrischilles, EA, Pendergast, JF, Kahn, KL, Wallace, RB, Moga, DC, Harrington, DP, Kiefe, CI, Weeks, JC, West, DW, Zafar, SY, and Fletcher, RH. "Adverse events among the elderly receiving chemotherapy for advanced non-small-cell lung cancer." J Clin Oncol 28.4 (February 1, 2010): 620-627.
PMID
20038726
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
28
Issue
4
Publish Date
2010
Start Page
620
End Page
627
DOI
10.1200/JCO.2009.23.8485

Treatment-related toxicity and supportive care in metastatic colorectal cancer.

As survival of metastatic colorectal cancer (mCRC) increases, patients have more exposure to chemotherapy and related toxicity. The objective is to determine how toxicity patterns affect care. Via a population-based strategy, mCRC cases diagnosed between June 2003 and June 2006 were identified from one academic and nine community oncology practices in the southeastern United States. Demographic, disease, treatment, hospitalization, and toxicity data were abstracted by retrospective chart review, double-entered, and verified for accuracy. Of the 738 charts screened, 110 were eligible based upon preidentified inclusion criteria. As part of first-line chemotherapy, 87% received oxaliplatin, 12% received irinotecan, and 74% received bevacizumab. Gastrointestinal toxicity was the most common toxicity-related cause of drug discontinuation (16 of 61 events) and hospitalization (19 of 54 events). Both neurologic and hematologic toxicities were identified more frequently when oxaliplatin-containing regimens were administered (50% and 48%, respectively) than with irinotecan-containing regimens (10% and 24%, respectively). Dose reduction was most commonly associated with hematologic toxicity (22 of 55 events). Oxaliplatin and irinotecan required similar rates of antidiarrheal, antinausea, erythropoiesis-stimulating, and granulocyte-stimulating treatments. These data, obtained from a usual-practice setting, provide benchmarks to improve clinical practice.

Authors
Zafar, SY; Marcello, JE; Wheeler, JL; Rowe, KL; Morse, MA; Herndon, JE; Abernethy, AP
MLA Citation
Zafar, SY, Marcello, JE, Wheeler, JL, Rowe, KL, Morse, MA, Herndon, JE, and Abernethy, AP. "Treatment-related toxicity and supportive care in metastatic colorectal cancer." J Support Oncol 8.1 (January 2010): 15-20.
PMID
20235419
Source
pubmed
Published In
The Journal of Supportive Oncology
Volume
8
Issue
1
Publish Date
2010
Start Page
15
End Page
20

Improving the methodologic and ethical validity of best supportive care studies in oncology: lessons from a systematic review.

PURPOSE: To systematically review the best supportive care (BSC) literature and to evaluate the ethical and methodologic validity issues by using widely acknowledged criteria. METHODS: Two search strings that included both cancer and supportive as terms (with random article type, or review or meta-analysis) explored databases from 1966 to 2008. Citations, abstracts, and papers were reviewed for inclusion criteria, and relevant data were extracted by two independent researchers. Data were validated for accuracy. Ethical and methodologic validity were evaluated by using the criteria derived from the Helsinki Requirements of the WMA; CONSORT statements for the evaluation of reports of randomized, controlled trials; and the universal requirements for ethical clinical research. RESULTS: Forty-three published papers were identified that described 32 studies, 20 of which incorporated the design of treatment plus supportive care (SC) versus SC alone, and 12 of which incorporated the design of treatment versus SC. Most of the studies had poor compliance to critical Helsinki requirements, to methodologic precautions derived from the CONSORT statement for studies involving a nonpharmacologic arm, and to four of seven universal requirements for ethical clinical research. CONCLUSION: Lack of rigor in BSC studies has contributed to a generation of research with widespread ethical and methodologic shortcomings. Ad hoc SC and lack of standardization of SC delivery may be sources of systematic bias or error in BSC trials. Rectifying these shortcomings in future studies demands greater vigilance toward these issues by researchers, institutional review boards, editors, and peer reviewers. Given the prevalence of overlooked problems that are later identified, currently open BSC studies should be reevaluated by institutional review boards and researchers to check for ethical and methodologic validity, and identified shortcomings should be addressed.

Authors
Cherny, NI; Abernethy, AP; Strasser, F; Sapir, R; Currow, D; Zafar, SY
MLA Citation
Cherny, NI, Abernethy, AP, Strasser, F, Sapir, R, Currow, D, and Zafar, SY. "Improving the methodologic and ethical validity of best supportive care studies in oncology: lessons from a systematic review." J Clin Oncol 27.32 (November 10, 2009): 5476-5486. (Review)
PMID
19564538
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
27
Issue
32
Publish Date
2009
Start Page
5476
End Page
5486
DOI
10.1200/JCO.2009.21.9592

Longitudinal patterns of chemotherapy use in metastatic colorectal cancer.

Multiple agents and combination therapies available to patients with advanced colorectal cancer have significantly improved survival and provided an opportunity for individualization of care, allowing clinicians and patients to prioritize risks and benefits of comparable regimens.

Authors
Zafar, SY; Marcello, JE; Wheeler, JL; Rowe, KL; Morse, MA; Herndon, JE; Abernethy, AP
MLA Citation
Zafar, SY, Marcello, JE, Wheeler, JL, Rowe, KL, Morse, MA, Herndon, JE, and Abernethy, AP. "Longitudinal patterns of chemotherapy use in metastatic colorectal cancer." J Oncol Pract 5.5 (September 2009): 228-233.
PMID
20856733
Source
pubmed
Published In
Journal of Oncology Practice
Volume
5
Issue
5
Publish Date
2009
Start Page
228
End Page
233
DOI
10.1200/JOP.091010

Quality management of potential chemotherapy-induced neutropenic complications: evaluation of practice in an academic medical center.

GOALS: Management of the risk of potential chemotherapy-induced neutropenic complications such as febrile neutropenia (FN) and severe neutropenia (SN) is a quality of care priority. How frequently does care at our institution conform to established guidelines? MATERIALS AND METHODS: This retrospective chart review study included a random sample of 305 cancer patients receiving care at a single US academic medical center. Abstracted data included demographics, risk factors, and outcome variables (e.g., development of FN/SN, administration of myeloid growth factors). To evaluate quality of care, we assessed conformance between actual practice and established clinical practice guidelines for the use of myeloid growth factors from the National Comprehensive Cancer Network (NCCN). MAIN RESULTS: Of the 305 cases reviewed, 8% were classified as low risk (<10%), 48% as intermediate risk (10-20%), and 44% as high risk (>20%), using the risk classifications in the NCCN guidelines modified to accommodate illness and other risk factors. Thirty-four percent received prophylactic administration of myeloid growth factors. Half of the cases had adequate documentation of mid-cycle absolute neutrophil count to determine whether FN/SN developed. Among these cases with adequate documentation, 21% developed FN/SN. Use of growth factors did not conform to established quality guidelines. Overall, 77 of 133 (58%) high-risk cases received myeloid growth factors, whereas six of 25 (24%) low-risk cases received myeloid growth factors. CONCLUSIONS: Routine clinical practice in this academic oncology setting was poorly aligned with established guidelines; there is substantial opportunity to standardize clinical strategies and increase conformance with evidence-based guidelines.

Authors
Abernethy, AP; Barbour, SY; Uronis, H; Zafar, SY; Coan, A; Rowe, K; Pupa, MR; Wheeler, JL; Herndon, JE
MLA Citation
Abernethy, AP, Barbour, SY, Uronis, H, Zafar, SY, Coan, A, Rowe, K, Pupa, MR, Wheeler, JL, and Herndon, JE. "Quality management of potential chemotherapy-induced neutropenic complications: evaluation of practice in an academic medical center." Support Care Cancer 17.6 (June 2009): 735-744.
PMID
19096882
Source
pubmed
Published In
Supportive Care in Cancer
Volume
17
Issue
6
Publish Date
2009
Start Page
735
End Page
744
DOI
10.1007/s00520-008-0562-6

Bevacizumab (B) plus everolimus (E) in refractory metastatic colorectal cancer (mCRC)

Authors
Bullock, KE; Hurwitz, HI; Uronis, HE; Morse, MA; Blobe, GC; Hsu, SD; Zafar, SY; Nixon, AB; Howard, LA; Bendell, JC
MLA Citation
Bullock, KE, Hurwitz, HI, Uronis, HE, Morse, MA, Blobe, GC, Hsu, SD, Zafar, SY, Nixon, AB, Howard, LA, and Bendell, JC. "Bevacizumab (B) plus everolimus (E) in refractory metastatic colorectal cancer (mCRC)." May 20, 2009.
Source
wos-lite
Published In
Journal of Clinical Oncology
Volume
27
Issue
15
Publish Date
2009

Electronic patient-reported data capture as the foundation of a learning health care system

Authors
Abernethy, AP; Zafar, SY; Coeytaux, R; Rowe, K; Wheeler, JL; Lyerly, HK
MLA Citation
Abernethy, AP, Zafar, SY, Coeytaux, R, Rowe, K, Wheeler, JL, and Lyerly, HK. "Electronic patient-reported data capture as the foundation of a learning health care system." May 20, 2009.
Source
wos-lite
Published In
Journal of Clinical Oncology
Volume
27
Issue
15
Publish Date
2009

Bevacizumab (B) plus everolimus (E) in refractory metastatic colorectal cancer (mCRC).

4080 Background: For patients (pts) with mCRC, no standard therapy exists after progression on 5-FU, oxaliplatin, irinotecan, bevacizumab, and/or cetuximab/panitumumab. Preclinical data demonstrate combined VEGF and mTOR inhibition has greater anti-angiogenic and anti-tumor activity than either monotherapy. B inhibits VEGF; E inhibits mTOR. Phase I data in patients demonstrated B + E was safe and activity was seen in several pts with refractory mCRC.25 pts with refractory mCRC were enrolled in an expanded cohort of B + E. Doses: B 10 mg/kg q2 wks; E 10 mg PO QD. Blood, skin, and tumor biopsies pre- and on-treatment were collected for markers of response and resistance.At this time, 19 pts (10M: 9F) are evaluable for toxicity; 17 for efficacy. Median age 57 years (range 35-78). Median number prior regimens 3. All pts had prior B exposure; 17 pts had progressive disease on prior B-based therapy. There was one Grade (Gr) 4 adverse event (AE) of hypokalemia. Grade 3 AE related to treatment were bowel perforation/fistula, (n=2), hyperglycemia (3), hypokalemia (3), hypertension (2), fatigue (1), alk phos elevation (1; lab only), hypoalbuminemia (1), and volume depletion (1). Other events of interest were: Gr1-2 mucositis (n=10), Gr1 hyperlipidemia (11). Of 17 pts evaluable for response, 4 pts had SD as best response (median 24 wks, range 17-31+ wks); there were 3 minor responses in pts who had progressed on B (median 16 wks, range 16-27 wks). No CR or PR were seen. Biomarker data is pending.B+E has activity in refractory mCRC in pts who had progressed on a B-based regimen, suggesting B+E may overcome resistance to B. Patient accrual is continuing and updated data will be presented. [Table: see text].

Authors
Bullock, KE; Hurwitz, HI; Uronis, HE; Morse, MA; Blobe, GC; Hsu, SD; Zafar, SY; Nixon, AB; Howard, LA; Bendell, JC
MLA Citation
Bullock, KE, Hurwitz, HI, Uronis, HE, Morse, MA, Blobe, GC, Hsu, SD, Zafar, SY, Nixon, AB, Howard, LA, and Bendell, JC. "Bevacizumab (B) plus everolimus (E) in refractory metastatic colorectal cancer (mCRC)." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 27.15_suppl (May 2009): 4080-.
PMID
27961646
Source
epmc
Published In
Journal of Clinical Oncology
Volume
27
Issue
15_suppl
Publish Date
2009
Start Page
4080

Electronic patient-reported data capture as the foundation of a learning health care system.

6522 Background: In a "learning healthcare system" clinical decisions are supported by accurate information delivered at point of care; information gathered today iteratively informs future care and research.Customized software on wireless tablet personal computers presented a review of systems (ROS) instrument, validated research surveys (e.g., quality of life [QOL]), and a satisfaction survey, tailored by user. The system was piloted in the Duke Cancer Clinics and affiliated hospitals. We previously demonstrated equivalence of electronic and paper survey data. We conducted a series of studies using similar procedures to evaluate feasibility, acceptability, and utility.First, we assessed the ability to collect ROS data at point of care to inform the clinic visit for participating breast (n = 65), gastrointestinal (n = 113), and lung (n = 97) cancer patients. Duke physicians reported that the system's clinical reports informed care and increased dictation efficiency. Second, we assessed patient satisfaction in the breast cancer cohort. Participants found the computers easy to read (94%), navigate (99%), and use (98%); the system helped 74% remember forgotten concerns to report to their clinician. Third, we assessed whether these data could contribute to current research. If the patient was on another clinical trial, PRO data (e.g., pain, QOL) were delivered to the investigator for research purposes in real time; data governance rules provided assurance to investigators. Fourth, we identified whether the PRO data could inform future research directions. Symptoms monitored longitudinally in aggregate uncovered unmet needs. Sexual distress was an underserved concern; intervention studies were initiated. Warehoused PRO data were integrated with clinical trials, genomic, biomarker, radiology, and administrative datasets for analyses. The approach has been scaled to 4 clinics and 3 hospitals.An integrated, real-time, electronic data capture system that interdigitates PROs with clinical and other data allows creation of a learning oncology environment that continuously improves care and research. Advantages include: patient-centeredness, description of the PRO phenotype, interoperability, and interface with caBIG infrastructure. No significant financial relationships to disclose.

Authors
Abernethy, AP; Zafar, SY; Coeytaux, R; Rowe, K; Wheeler, JL; Lyerly, HK
MLA Citation
Abernethy, AP, Zafar, SY, Coeytaux, R, Rowe, K, Wheeler, JL, and Lyerly, HK. "Electronic patient-reported data capture as the foundation of a learning health care system." Journal of clinical oncology : official journal of the American Society of Clinical Oncology 27.15_suppl (May 2009): 6522-.
PMID
27964028
Source
epmc
Published In
Journal of Clinical Oncology
Volume
27
Issue
15_suppl
Publish Date
2009
Start Page
6522

Use of tablet personal computers for sensitive patient-reported information.

Notebook-style computers (e/Tablets) are increasingly replacing paper methods for collecting patient-reported information. Discrepancies in data between these methods have been found in oncology for sexuality-related questions. A study was performed to formulate hypotheses regarding causes for discrepant responses and to analyze whether electronic data collection adds value over paper-based methods when collecting data on sensitive topics. A total of 56 breast cancer patients visiting Duke Breast Clinic (North Carolina) participated by responding to 12 subscales of 5 survey instruments in electronic (e/Tablet) format and to a paper version of 1 of these surveys, at each visit. Twenty-one participants (38%) provided dissimilar responses on paper and electronic surveys to one item of the Functional Assessment of Cancer Therapy-General (FACT-G) Social Well-Being scale that asked patients to rate their satisfaction with their current sex life. Among these 21 patients were 8 patients who answered the question in the electronic environment, and 13 patients who answered both paper and electronic versions but with different responses. Eleven patients (29%) did not respond to the item on either e/Tablet or paper; 45 patients (80%) answered it on e/Tablet; and 37 patients (66%) responded on the paper version. The e/Tablet electronic system may provide a "safer" environment than paper questionnaires for cancer patients to answer private or highly personal questions on sensitive topics such as sexuality.

Authors
Dupont, A; Wheeler, J; Herndon, JE; Coan, A; Zafar, SY; Hood, L; Patwardhan, M; Shaw, HS; Lyerly, HK; Abernethy, AP
MLA Citation
Dupont, A, Wheeler, J, Herndon, JE, Coan, A, Zafar, SY, Hood, L, Patwardhan, M, Shaw, HS, Lyerly, HK, and Abernethy, AP. "Use of tablet personal computers for sensitive patient-reported information." J Support Oncol 7.3 (May 2009): 91-97.
PMID
19507456
Source
pubmed
Published In
The Journal of Supportive Oncology
Volume
7
Issue
3
Publish Date
2009
Start Page
91
End Page
97

Detailing of gastrointestinal symptoms in cancer patients with advanced disease: new methodologies, new insights, and a proposed approach.

PURPOSE OF REVIEW: This review summarizes recent developments in the palliative management of gastrointestinal symptoms experienced by advanced cancer patients and provides a framework for detailing that encompasses education, assessment and monitoring, and treatment. RECENT FINDINGS: Although many viable treatment options exist, gastrointestinal symptoms, particularly nausea and vomiting, constipation, and diarrhea, continue to challenge both patients and clinicians. New medications, such as skin patch delivery of granisetron for nausea or methylnaltrexone for constipation, show promise of better symptom management, and are advancing alongside an increasing emphasis on prevention. The integration into care plans of complementary and alternative therapies, such as relaxation techniques and electroacupuncture, may also assist with symptom relief. Accurate assessment is essential but often problematic, especially as the patient's experience of gastrointestinal distress is often incommensurate with objective measures. New methodologies that harness technology to collect patient-reported outcomes may improve the accuracy of assessment, better capture the patient's experience of gastrointestinal symptoms, and provide a means to simultaneously monitor symptoms, educate patients, and collect longitudinal data. SUMMARY: Palliative management of gastrointestinal symptoms in advanced cancer patients requires a multipronged approach that entails effective assessment, judicious use of latest evidence-based approaches, and monitoring that incorporates both clinical measures and patient-reported outcomes. In combination with refinements in the overall clinical approach to symptom management, the deployment of standardized instruments that streamline data collection and enable data warehousing will support better symptom management.

Authors
Abernethy, AP; Wheeler, JL; Zafar, SY
MLA Citation
Abernethy, AP, Wheeler, JL, and Zafar, SY. "Detailing of gastrointestinal symptoms in cancer patients with advanced disease: new methodologies, new insights, and a proposed approach." Curr Opin Support Palliat Care 3.1 (March 2009): 41-49. (Review)
PMID
19365160
Source
pubmed
Published In
Current Opinion in Supportive and Palliative Care
Volume
3
Issue
1
Publish Date
2009
Start Page
41
End Page
49
DOI
10.1097/SPC.0b013e32832531ce

Decision making and quality of life in the treatment of cancer: a review.

INTRODUCTION: Complexity in decision making for cancer treatment arises from many factors. When considering how to treat patients, physicians prioritize factors such as stage of disease, patient age, and comorbid illnesses. However, physicians must balance these priorities with the patient's preferences, quality of life, social responsibilities, and fear of uncertainty. Although these factors are important, physicians are often unable to effectively judge their patients' preferences. Patients are often unable to fully understand their prognoses and the treatment intent. DISCUSSION: These differences influence how patients and physicians make treatment-related decisions. Partially due to these differences, patients are initially more likely than their physicians to accept greater risk for lesser benefit from treatment. As time progresses and as they experience treatment, a patient's preference changes, yet little is known about this process since few studies have examined it in a prospective longitudinal manner. We present an overview of the literature related to patient and physician decision making and quality of life in patients with advanced cancer, and we propose approaches to future decision-making models in cancer treatment.

Authors
Zafar, SY; Alexander, SC; Weinfurt, KP; Schulman, KA; Abernethy, AP
MLA Citation
Zafar, SY, Alexander, SC, Weinfurt, KP, Schulman, KA, and Abernethy, AP. "Decision making and quality of life in the treatment of cancer: a review." Support Care Cancer 17.2 (February 2009): 117-127. (Review)
PMID
18802727
Source
pubmed
Published In
Supportive Care in Cancer
Volume
17
Issue
2
Publish Date
2009
Start Page
117
End Page
127
DOI
10.1007/s00520-008-0505-2

To the editor

Authors
Zafar, SY; Abernethy, AP; Currow, D
MLA Citation
Zafar, SY, Abernethy, AP, and Currow, D. "To the editor." Journal of Clinical Oncology 27.5 (2009): 829--.
Source
scival
Published In
Journal of Clinical Oncology
Volume
27
Issue
5
Publish Date
2009
Start Page
829-
DOI
10.1200/JCO.2008.20.6029

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems

Authors
Zafar, SY; Abernethy, AP; Abbott, DH; Grambow, SC; Marcello, JE; Herndon, JE; Rowe, KL; Kolimaga, JT; Zullig, LL; Patwardhan, MB; Provenzale, DT
MLA Citation
Zafar, SY, Abernethy, AP, Abbott, DH, Grambow, SC, Marcello, JE, Herndon, JE, Rowe, KL, Kolimaga, JT, Zullig, LL, Patwardhan, MB, and Provenzale, DT. "Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems." BMC Cancer 8.1 (December 2008).
Source
crossref
Published In
BMC Cancer
Volume
8
Issue
1
Publish Date
2008
DOI
10.1186/1471-2407-8-345

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems.

Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis.Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-2007. We assessed metastatic CRC patients treated from 2003-2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression.342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58-1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82-1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race.Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

Authors
Zafar, SY; Abernethy, AP; Abbott, DH; Grambow, SC; Marcello, JE; Herndon, JE; Rowe, KL; Kolimaga, JT; Zullig, LL; Patwardhan, MB; Provenzale, DT
MLA Citation
Zafar, SY, Abernethy, AP, Abbott, DH, Grambow, SC, Marcello, JE, Herndon, JE, Rowe, KL, Kolimaga, JT, Zullig, LL, Patwardhan, MB, and Provenzale, DT. "Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems." BMC cancer 8 (November 25, 2008): 345-.
PMID
19032772
Source
epmc
Published In
BMC Cancer
Volume
8
Publish Date
2008
Start Page
345
DOI
10.1186/1471-2407-8-345

Defining best supportive care.

Authors
Zafar, SY; Currow, D; Abernethy, AP
MLA Citation
Zafar, SY, Currow, D, and Abernethy, AP. "Defining best supportive care." J Clin Oncol 26.31 (November 1, 2008): 5139-5140. (Letter)
PMID
18838696
Source
pubmed
Published In
Journal of Clinical Oncology
Volume
26
Issue
31
Publish Date
2008
Start Page
5139
End Page
5140
DOI
10.1200/JCO.2008.19.7491

Malignancy after solid organ transplantation: an overview.

With improving survival following solid organ transplantation, clinicians must be aware of post-transplant complications. One increasingly frequent complication is the development of malignancy after transplantation. The most common malignancies encountered in the post-solid organ transplant setting are nonmelanoma skin cancers, post-transplant lymphoproliferative disorders, and Kaposi's sarcoma (KS). The pathogenesis of these tumors is likely related to the immunosuppressive drugs used post-transplantation and subsequent viral infection. Treatment involves modification of the immunosuppressive drug regimen, resection of localized disease, and chemotherapy. We present the second reported case of a patient with lung transplantation who developed KS in the lung graft.

Authors
Zafar, SY; Howell, DN; Gockerman, JP
MLA Citation
Zafar, SY, Howell, DN, and Gockerman, JP. "Malignancy after solid organ transplantation: an overview." Oncologist 13.7 (July 2008): 769-778. (Review)
PMID
18614590
Source
pubmed
Published In
The oncologist
Volume
13
Issue
7
Publish Date
2008
Start Page
769
End Page
778
DOI
10.1634/theoncologist.2007-0251

Monoclonal antibodies to EGFR: What does the future hold?

Authors
Zafar, Y; Hurwitz, HI
MLA Citation
Zafar, Y, and Hurwitz, HI. "Monoclonal antibodies to EGFR: What does the future hold?." ONCOLOGY 21.8 (2007): 976-977.
Source
scival
Published In
Oncology
Volume
21
Issue
8
Publish Date
2007
Start Page
976
End Page
977
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Research Areas:

  • Academic Medical Centers
  • Adenocarcinoma
  • Administration, Oral
  • Adult
  • Africa
  • Age Factors
  • Aged
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  • Ambulatory Care
  • Ampulla of Vater
  • Angiogenesis Inhibitors
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  • Communication
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  • Cooperative Behavior
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  • Cost-Benefit Analysis
  • DNA Methylation
  • Data Collection
  • Decision Making
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  • Delivery of Health Care
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  • Sarcoma, Kaposi
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