Improving Surgical Care and Outcomes in Older Cancer Patients Through Implementation of a Pre-Surgical Toolkit (OPTI-Surg)-Final Results of a Phase III Cluster Randomized Trial (Alliance A231601CD).

OBJECTIVE: To assess the effect of a practice-level preoperative frailty screening and optimization toolkit (OPTI-Surg) on postoperative functional recovery and complications in elderly cancer patients undergoing major surgery. SUMMARY BACKGROUND DATA: Frailty is common in older adults. it increases risk for poor postoperative functional recovery and complications. The potential for a practice-level screening/optimization intervention to improve outcomes is unknown. METHODS: Thoracic, gastrointestinal, and urologic oncological surgery practices within the NCI Community Oncology Research Program (NCORP) were randomized 1:1:1, to usual care (UC), OPTI-Surg, or OPTI-Surg with implementation coach. OPTI-Surg consisted of the Edmonton Frail Scale and guided recommendations for referral interventions. Patients ≥70 years old undergoing curative intent surgery were eligible. Primary outcome was 8 weeks postoperative function (kCal/week). Key secondary outcome was complications within 90 days. Mixed models were used to compare UC to the 2 OPTI-Surg arms combined. RESULTS: From 7/2019 to 9/2022, 325 patients were enrolled from 29 practices. 199 (64 UC, 135 OPTI-Surg) and 279 (78 UC, 201 OPTI-Surg) were evaluable for primary and secondary analysis, respectively. UC and OPTI-Surg patients did not significantly differ on total caloric expenditure (2.2 UC, 2.0 OPTI-Surg) after adjusting for baseline function (P=0.53). UC and OPTI-Surg patients did not significantly differ on postoperative complications (25.6% UC, 35.3% OPTI-Surg, P=0.5). CONCLUSIONS: Frailty assessment was successfully performed, but the OPTI-Surg intervention did not improve postoperative function nor reduce postoperative complications compared to UC. Future analysis will explore practice-level factors associated with toolkit implementation and differences between the coaching and non-coaching arms.

Implementing a tobacco-free workplace program at a substance use treatment center: a case study.

BACKGROUND: People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center. METHODS: This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice. RESULTS: Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center. CONCLUSIONS: Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Leveraging the Multidisciplinary Tumor Board for Dissemination of Evidence-Based Recommendations on the Staging and Treatment of Gastric Cancer: A Pilot Study.

BACKGROUND: Compliance with evidence-based treatment guidelines for gastric cancer across the United States is poor. This pilot study aimed to create and evaluate a change package for disseminating information on the staging and treatment of gastric cancer during multidisciplinary tumor boards and for identifying barriers to implementation. METHODS: The change package included a 10-min video, a brief knowledge assessment, and a discussion guide. Commission on Cancer-accredited sites that perform gastrectomy were invited to participate. Participants completed the Organizational Readiness for Implementing Change (ORIC) scale (range, 12-60) and scales to measure the feasibility, acceptability, and appropriateness (score range, 4-20). Semi-structured interviews were conducted to further define inner and outer setting barriers. RESULTS: Seven centers participated in the study. A total of 74 participants completed the pre-video knowledge assessment, and 55 participants completed the post-video assessment. The recommendations found to be most controversial were separate staging laparoscopy and modified D2 lymphadenectomy. Sum scores were calculated for acceptability (mean, 17.43 ± 2.51) appropriateness (mean, 16.86 ± 3.24), and feasibility (mean, 16.14 ± 3.07) of the change package. The ORIC scores (mean, 46.57 ± 8.22) correlated with responses to the open-ended questions. The key barriers identified were patient volume, skills in the procedures, and attitudes and beliefs. CONCLUSIONS: The change package was moderately to highly feasible, appropriate, and acceptable. The activity identified specific recommendations for gastric cancer care that are considered controversial and local barriers to implementation. Future efforts could focus on building skills and knowledge as well as the more difficult issue of attitudes and beliefs.

Smoking cessation services and shared decision-making practices among lung cancer screening facilities: A cross-sectional study.

BACKGROUND: Little is known about how screening facilities are meeting the requirements for the reimbursement of lung cancer screening from the Centers for Medicare & Medicaid Services (CMS), including 1) the collection and submission of data to the CMS-approved registry (American College of Radiology [ACR] Lung Cancer Screening Registry), 2) the verification of a counseling and shared decision-making (SDM) visit having occurred as part of the written order for lung cancer screening with low-dose computed tomography, and 3) the offering of smoking cessation interventions. METHODS: The authors identified facilities in a southwestern state that were listed by either the ACR Lung Cancer Screening Registry or the GO2 Foundation Centers of Excellence. To select facilities, they used 2 purposive sampling approaches: maximum variation sampling and snowball sampling. They surveyed facilities from February to November 2019. RESULTS: There were 87 facilities contacted, and a total of 63 facilities representing 32 counties across Texas completed the survey. Nearly all facilities used Lung-RADS to classify nodules (92%; n = 58) and submitted data to a CMS-approved registry (92%; n = 57). Most facilities verified that the counseling and SDM visit had occurred (86%; n = 54). Although slightly more than half of the facilities reported always providing self-help cessation materials (68%; n = 42), similar or higher proportions of facilities reported that they never referred smokers to onsite cessation services (68%; n = 42) or quitlines (77%; n = 47), provided cessation counseling (81%; n = 50), or recommended medications (85%; n = 52). CONCLUSIONS: In general, screening facilities are meeting CMS requirements for screening, but they are struggling to offer smoking cessation interventions other than providing self-help materials.

Predicting Risk of Recurrence After Colorectal Cancer Surgery in the United States: An Analysis of a Special Commission on Cancer National Study.

BACKGROUND: Several factors can affect the risk of recurrence after curative resection of colorectal cancer (CRC). We aimed to develop a risk model for recurrence after definitive treatment of Stage I-III CRC using data from a nationally representative database and to develop an individualized web-based risk calculator. METHODS: A random sample of patients who underwent resection for Stage I-III CRC between 2006 and 2007 at Commission on Cancer (CoC) accredited centers were included. Primary data regarding first recurrence was abstracted from medical records and merged with the National Cancer Database. Multivariable cox regression analysis was used to test for factors associated with cancer recurrence, stratified by stage. Model performance was tested by c statistic and calibration plots. Hazard Ratios were utilized to develop an individualized web-based recurrence prediction tool. RESULTS: A total of 8249 patients from 1175 CoC centers were included. Of these, 1656 (20.1%) patients had a recurrence during 5 years of follow-up. Median time to recurrence was 16 months. The final predictive models displayed excellent discrimination and calibration with concordance indexes of 0.7. The online calculator included 12 variables, including tumor site, stage, time since surgery, and surveillance intensity. Output is displayed numerically and graphically with an icon array. CONCLUSIONS: Using primarily abstracted recurrence data from a random sample of patients treated for CRC at CoC accredited centers across the United States, we successfully created an individualized CRC recurrence risk assessment tool. This web-based calculator can be used by physicians and patients in shared decision making to guide management discussions. TRIAL REGISTRATION: ClinicalTrials.gov Registration Number: NCT02217865.

Limitations of the S-TOFHLA in measuring poor numeracy: a cross-sectional study.

BACKGROUND: Although the Short Test of Functional Health Literacy in Adults (S-TOFHLA) is widely used, misidentification of individuals with low health literacy (HL) in specific HL dimensions, like numeracy, is a concern. We examined the degree to which individuals scored as "adequate" HL on the S-TOFHLA would be considered as having low HL by two additional numerical measures. METHODS: English-speaking adults aged 45-75 years were recruited from a large, urban academic medical center and a community foodbank in the United States. Participants completed the S-TOFHLA, the Subjective Numeracy Scale (SNS), and the Graphical Literacy Measure (GL), an objective measure of a person's ability to interpret numeric information presented graphically. Established cut-points or a median split classified participants and having high and low numeracy. RESULTS: Participants (n = 187), on average were: aged 58 years; 63% female; 70% Black/African American; and 45% had a high school degree or less. Of those who scored "adequate" on the S-TOFHLA, 50% scored low on the SNS and 40% scored low on GL. Correlation between the S-TOFHLA and the SNS Total was moderate (r = 0.22, n = 186, p = 0.01), while correlation between the S-TOFHLA and the GL Total was large (r = 0.53, n = 187, p ≤ 0.01). CONCLUSIONS: Findings suggest that the S-TOFHLA may not capture an individuals' HL in the dimension of numeracy. Efforts are needed to develop more encompassing and practical strategies for identifying those with low HL for use in research and clinical practice. TRIAL REGISTRATION: NCT02151032 (retrospectively registered: May 30, 2014).

Responsiveness of a Brief Measure of Lung Cancer Screening Knowledge.

Our aim was to examine the responsiveness of a lung cancer screening brief knowledge measure (LCS-12). Eligible participants were aged 55-80 years, current smokers or had quit within 15 years, and English speaking. They completed a baseline pretest survey, viewed a lung cancer screening video-based patient decision aid, and then filled out a follow-up posttest survey. We performed a paired samples t-test, calculated effect size, and calculated absolute and relative percent improvement for each item. Participants (n = 30) were primarily White (63%) with less than a college degree (63%), and half were female (50%). Mean age was 61.5 years (standard deviation [SD] = 4.67) and average smoking history was 30.4 pack-years (range = 4.6-90.0). Mean score on the 12-item measure increased from 47.3% correct on the pretest to 80.3% correct on the posttest (mean pretest score = 5.67 vs. mean posttest score = 9.63; mean score difference = 3.97, SD = 2.87, 95% CI = 2.90, 5.04). Total knowledge scores improved significantly and were responsive to the decision aid intervention (paired samples t-test = 7.57, p < .001; Cohen's effect size = 1.59; standard response mean [SRM] = 1.38). All individual items were responsive, yet two items had lower absolute responsiveness than the others (item 8: "Without screening, is lung cancer often found at a later stage when cure is less likely?" pretest correct = 83.3% vs. posttest = 96.7%, responsiveness = 13.4%; and item 10: "Can a CT scan find lung disease that is not cancer?" pretest correct = 80.0% vs. posttest = 93.3%, responsiveness = 13.3%). The LCS-12 knowledge measure may be a useful outcome measure of shared decision making for lung cancer screening.

An entertainment-education colorectal cancer screening decision aid for African American patients: A randomized controlled trial.

BACKGROUND: Colorectal cancer screening rates for African American patients remain suboptimal. Patient decision aids designed with an entertainment-education approach have been shown to improve saliency and foster informed decision making. The purpose of this study was to assess whether an entertainment-education decision aid tailored for African American patients improved patients' decision making, attitudes, intentions, or colorectal cancer screening behavior. METHODS: Eighty-nine participants were randomized to view 1) a patient decision aid video containing culturally tailored information about colorectal cancer screening options and theory-based support in decision making presented in an entertainment-education format or 2) an attention control video about hypertension that contained similarly detailed information. Participants met with their clinician and then completed follow-up questionnaires assessing their knowledge, decisional conflict, self-advocacy, attitudes, perceived social norms, and intentions. At 3 months, completion of screening was assessed by chart review. RESULTS: Viewing the culturally tailored decision aid significantly increased African American patients' knowledge of colorectal cancer screening recommendations and options. It also significantly reduced their decisional conflict and improved their self-advocacy. No significant differences were observed in participants' attitudes, norms, or intentions. At three months, 23% of all patients had completed a colonoscopy. CONCLUSIONS: Designing targeted, engaging patient decision aids for groups that receive suboptimal screening holds promise for improving patient decision making and self-advocacy. Additional research is warranted to investigate the effectiveness of such aids in clinical practices with suboptimal screening rates and on downstream behaviors (such as repeat testing). Cancer 2017;123:1401-1408. © 2016 American Cancer Society.

Tobacco quitline staffs' knowledge and attitudes about connecting quitline callers to lung cancer screening educational materials.

OBJECTIVE: To evaluate the impact of training quitline staff in lung cancer screening (LCS) on knowledge and attitudes towards connecting quitline callers to LCS educational materials. METHODS: We conducted a pre-post evaluation within a larger implementation project in the U.S. to support LCS among quitline callers. From July 2020 to June 2021, staff from four quitline service providers completed surveys before and after training on LCS knowledge. After training, staff completed the acceptability of intervention measure, intervention appropriateness measure, and feasibility of the intervention measure. RESULTS: A total of 245 staff completed the initial demographic survey (analytic sample), 130 completed the pre-training survey, and 225 completed the post-training survey. Staff were on average 47.4 years old and 76.7% were female. LCS knowledge improved after the training (n = 120, mean difference = +26.5%, 95% CI 21.6, 31.4, p < 0.001). Overall, staff felt that connecting quitline callers to LCS education materials was acceptable (M = 4.0, SD = 0.8), appropriate (M = 4.1, SD = 0.7), and feasible (M = 4.0, SD = 0.7). CONCLUSIONS: Receiving training about LCS eligibility and the benefits and harms of screening improved LCS knowledge among quitline staff. Quitline staff found that connecting callers with LCS educational materials is acceptable, appropriate, and feasible, and aligned with their primary mission.

The TELEhealth Shared decision-making Coaching and Navigation in Primary carE (TELESCOPE) intervention: a study protocol for delivering shared decision-making for lung cancer screening by patient navigators.

Background: Lung cancer screening (LCS) can reduce lung cancer mortality but has potential harms for patients. A shared decision-making (SDM) conversation about LCS is required by the Centers for Medicare & Medicaid Services (CMS) for LCS reimbursement. To overcome barriers to SDM in primary care, this protocol describes a telehealth decision coaching intervention for LCS in primary care clinics delivered by patient navigators. The objective of the study is to evaluate the effectiveness of the intervention and its implementation potential, compared with an enhanced usual care (EUC) arm. Methods: Patients (n = 420) of primary care clinicians (n = 120) are being recruited to a cluster randomized controlled trial. Clinicians are randomly assigned to 1) TELESCOPE intervention: prior to an upcoming non-acute clinic visit, patients participate in a telehealth decision coaching session about LCS delivered by trained patient navigators and nurse navigators place a low-dose CT scan (LDCT) order for each TELESCOPE patient wanting LCS, or 2) EUC: patients receive enhanced usual care from a clinician. Usual care is enhanced by providing clinicians in both arms with access to a Continuing Medical Education (CME) webinar about LCS and an LCS discussion guide. Patients complete surveys at baseline and 1-week after the scheduled clinic visit to assess quality of the SDM process. Re-navigation is attempted with TELESCOPE patients who have not completed the LDCT within 3 months. One month before being due for an annual screening, TELESCOPE patients whose initial LCS showed low-risk findings are randomly assigned to receive a telehealth decision coaching booster session with a navigator or no booster. Electronic health records are abstracted at 6, 12 and 18 months after the initial decision coaching session (TELESCOPE) or clinic visit (EUC) to assess initial and annual LCS uptake, imaging results, follow-up testing for abnormal findings, cancer diagnoses, treatment, and tobacco treatment referrals. This study will evaluate factors that facilitate or interfere with program implementation using mixed methods. Discussion: We will assess whether a decision coaching and patient navigation intervention can feasibly support high-quality SDM for LCS and guideline-concordant LCS uptake for patients in busy primary care practices serving diverse patient populations. Trial Registration: This study was registered at ClinicalTrials.gov (NCT05491213) on August 4, 2022.

Lung Cancer Screening Eligibility and Referral Practices in Texas Organizations Serving People with Substance Use Disorders.

For people at elevated risk for lung cancer, lung cancer screening (LCS) reduces lung cancer mortality. People with non-nicotine substance use disorders (SUDs) have elevated rates of smoking compared with the general population, highlighting them as a priority population for LCS consideration. Although research has shown LCS is underutilized, there is little literature to inform whether organizations that serve individuals with SUDs have existing clinical protocols surrounding LCS. In the current study, we examine the LCS eligibility and referral practices among these organizations. We conducted a statewide needs assessment survey in 2021 to discern how tobacco use was being addressed at Texas organizations that provide treatment or services to individuals with SUDs. Respondents were asked to report on their center's LCS eligibility and referral practices. The analytic sample consists of 125 respondents who represented 23 federally qualified health centers, 29 global local mental health authorities (LMHAs), 12 substance use treatment programs in LMHAs, and 61 standalone substance use treatment centers. Very few respondents indicated that healthcare providers at their center made referrals to LCS for patients (8.8%); a few respondents indicated that their healthcare providers assessed patients' eligibility for LCS but did not make referrals (3.2%). Intervention and implementation efforts are needed in these and other SUD healthcare settings to bolster organizational capacity and ensure that patients are being navigated to lung cancer screening at multiple touch points across the care continuum.

Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center.

Background: Veterans suffer substantial morbidity and mortality from lung cancer. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality. Guidelines recommend counseling and shared decision-making (SDM) to address the benefits and harms of screening and the importance of tobacco cessation before patients undergo screening. Observations: We implemented a centralized LCS program at the Iowa City Veterans Affairs Medical Center with a nurse program coordinator (NPC)-led telephone visit. Our multidisciplinary team ensured that veterans referred from primary care met eligibility criteria, that LDCT results were correctly coded by radiology, and that pulmonary promptly evaluated abnormal LDCT. The NPC mailed a decision aid to the veteran and scheduled a SDM telephone visit. We surveyed veterans after the visit using validated measures to assess knowledge, decisional conflict, and quality of decision making. We conducted 105 SDM visits, and 91 veterans agreed to LDCT. Overall, 84% of veterans reported no decisional conflict, and 59% reported high-quality decision making. While most veterans correctly answered questions about the harms of radiation, false-positive results, and overdiagnosis, few knew when to stop screening, and most overestimated the benefit of screening and the predictive value of an abnormal scan. Tobacco cessation interventions were offered to 72 currently smoking veterans. Conclusions: We successfully implemented an LCS program that provides SDM and tobacco cessation support using a centralized telehealth model. While veterans were confident about screening decisions, knowledge testing indicated important deficits, and many did not engage meaningfully in SDM. Clinicians should frame the decision as patient centered at the time of referral, highlight the importance of SDM, and be able to provide adequate decision support.

A protocol for a cluster randomized trial of care delivery models to improve the quality of smoking cessation and shared decision making for lung cancer screening.

BACKGROUND: Patients eligible for lung cancer screening (LCS) are those at high risk of lung cancer due to their smoking histories and age. While screening for LCS is effective in lowering lung cancer mortality, primary care providers are challenged to meet beneficiary eligibility for LCS from the Centers for Medicare & Medicaid Services, including a patient counseling and shared decision-making (SDM) visit with the use of patient decision aid(s) prior to screening. METHODS: We will use an effectiveness-implementation type I hybrid design to: 1) identify effective, scalable smoking cessation counseling and SDM interventions that are consistent with recommendations, can be delivered on the same platform, and are implemented in real-world clinical settings; 2) examine barriers and facilitators of implementing the two approaches to delivering smoking cessation and SDM for LCS; and 3) determine the economic implications of implementation by assessing the healthcare resources required to increase smoking cessation for the two approaches by delivering smoking cessation within the context of LCS. Providers from different healthcare organizations will be randomized to usual care (providers delivering smoking cessation and SDM on site) vs. centralized care (smoking cessation and SDM delivered remotely by trained counselors). The primary trial outcomes will include smoking abstinence at 12-weeks and knowledge about LCS measured at 1-week after baseline. CONCLUSION: This study will provide important new evidence about the effectiveness and feasibility of a novel care delivery model for addressing the leading cause of lung cancer deaths and supporting high-quality decisions about LCS. GOV PROTOCOL REGISTRATION: NCT04200534 TRIAL REGISTRATION: ClinicalTrials.govNCT04200534.

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update.

PURPOSE: To update the ASCO guideline (2018) on the practical assessment and management of age-associated vulnerabilities in older patients undergoing systemic cancer therapy. METHODS: An Expert Panel conducted a systematic review to identify relevant randomized clinical trials (RCTs), systematic reviews, and meta-analyses from January 2016 to December 2022. RESULTS: A total of 26 publications met eligibility criteria and form the evidentiary basis for the update. RECOMMENDATIONS: The Expert Panel reiterates its overarching recommendation from the prior guideline that geriatric assessment (GA), including all essential domains, should be used to identify vulnerabilities or impairments that are not routinely captured in oncology assessments for all patients over 65 years old with cancer. Based on recently published RCTs demonstrating significantly improved clinical outcomes, all older adults with cancer (65+ years old) receiving systemic therapy with GA-identified deficits should have GA-guided management (GAM) included in their care plan. GAM includes using GA findings to inform cancer treatment decision-making as well as to address impairments through appropriate interventions, counseling, and/or referrals. A GA should include high priority aging-related domains known to be associated with outcomes in older adults with cancer: physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support. Clinical adaptation of the GA based on patient population, resources, and time is appropriate.The Panel recommends the Practical Geriatric Assessment as one option for this purpose (https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf; https://youtu.be/jnaQIjOz2Dw; https://youtu.be/nZXtwaGh0Z0).Additional information is available at www.asco.org/supportive-care-guidelines.

Patients' Preferences for Androgen Deprivation Therapy in the Treatment of Intermediate-Risk Prostate Cancer.

Background. For men with intermediate-risk prostate cancer (IRPC), adding short-term androgen deprivation therapy (ADT) to external beam radiation therapy (EBRT) has shown efficacy, but men are often reluctant to accept it because of its impact on quality of life. Methods. We conducted time tradeoffs (score of 1 = perfect health and 0 = death) and probability tradeoffs with patients aged 51 to 78 y who had received EBRT for IRPC within the past 2 y. Of 40 patients, 20 had received 6 mo of ADT and 20 had declined. Utility assessments explored 4 ADT-related side effects: hot flashes, fatigue, loss of libido/erectile dysfunction, and weight gain. Results. The most commonly reported "worst" treatment-related complication of ADT was fatigue (50% in both cohorts) followed by reduced libido/erectile dysfunction (40% in both cohorts). The utilities for fatigue were mean = 0.71 and median = 0.92 and for reduced libido/erectile dysfunction were mean = 0.81 and median = 0.92. Utilities did not differ significantly between cohorts. Assuming a 6-mo course of ADT, men reported being willing to trade 3 mo of life expectancy to avoid fatigue due to ADT and 1.8 mo to avoid sexual side effects. Patients in the ADT cohort were willing to accept the side effects of ADT in exchange for a mean 8% absolute increase in survival, whereas patients in the no ADT cohort required a 16% increase (P < 0.001). Conclusions. When considering treatment with ADT, men with IRPC identified fatigue and sexual dysfunction as the most bothersome side effects. Patients who declined ADT expected a larger survival benefit than those who opted for treatment. Both groups expected a survival benefit exceeding that shown by recent trials, suggesting some men may be selecting treatments inconsistent with their preferences. Highlights: This study demonstrates that prostate cancer patients receiving radiation therapy are reluctant to receive androgen deprivation therapy (ADT) most commonly due to anticipated fatigue and loss of libido/erectile dysfunction.Men who had received ADT reported they would require an average 8% absolute increase in survival to tolerate its side effects, whereas those who declined ADT would require an average 16% increase.Required thresholds are well above the estimated absolute survival benefit for ADT demonstrated in recent clinical trials, suggesting an unmet need for improved patient education regarding the risks and benefits of ADT.

Impact of the shared decision-making process on lung cancer screening decisions.

BACKGROUND: Professional organizations recommend the use of shared decision-making (SDM) in supporting patients' decisions about lung cancer screening (LCS). The objective of this study was to assess the impact of the SDM process on patient knowledge about LCS, decisional conflict, intentions to adhere to screening recommendations, and its role in how the patient made the final decision. METHODS: This study surveyed patients screened for lung cancer within 12 months of the survey, recruited from two academic tertiary care centers in the South Central Region of the U.S. (May to July 2018). RESULTS: Two hundred and sixty-four patients completed the survey (87.9% White, 52% male, and mean age of 64.81). Higher SDM process scores (which indicates a better SDM process reported by patients) were significantly associated with greater knowledge of LCS (b = 0.17 p < 0.01). Higher SDM process scores were associated with less decisional conflict about their screening choice (b = 0.45, p < 0.001), greater intentions to make the same decision again (OR = 1.42, 95% CI = [1.06-1.89]), and greater intentions to undergo LCS again (OR = 1.32, 95% CI = [1.08-1.62]). The SDM process score was not associated with patients' report of whether or not they shared the final decision with the healthcare provider (OR = 1.07, 95% CI = [0.85-1.35]). CONCLUSION(S): This study found that a better SDM process was associated with better affective-cognitive outcomes among patients screened for lung cancer.

Short-form adaptive measure of financial toxicity from the Economic Strain and Resilience in Cancer (ENRICh) study: Derivation using modern psychometric techniques.

OBJECTIVES: This study sought to evaluate advanced psychometric properties of the 15-item Economic Strain and Resilience in Cancer (ENRICh) measure of financial toxicity for cancer patients. METHODS: We surveyed 515 cancer patients in the greater Houston metropolitan area using ENRICh from March 2019 to March 2020. We conducted a series of factor analyses alongside parametric and non-parametric item response theory (IRT) assessments using Mokken analysis and the graded response model (GRM). We utilized parameters derived from the GRM to run a simulated computerized adaptive test (CAT) assessment. RESULTS: Among participants, mean age was 58.49 years and 278 (54%) were female. The initial round factor analysis results suggested a one-factor scale structure. Negligible levels of differential item functioning (DIF) were evident between eight items. Three items were removed due to local interdependence (Q3>+0.4). The original 11-point numerical rating scale did not function well, and a new 3-point scoring system was implemented. The final 12-item ENRICh had acceptable fit to the GRM (p<0.001; TLI = 0.94; CFI = 0.95; RMSEA = 0.09; RMSR = 0.06) as well as good scalability and dimensionality. We observed high correlation between CAT version scores and the 12-item measure (r = 0.98). During CAT, items 2 (money you owe) and 4 (stress level about finances) were most frequently administered, followed by items 1 (money in savings) and 5 (ability to pay bills). Scores from these four items alone were strongly correlated with that of the 12-item ENRICh (r = 0.96). CONCLUSION: These CAT and 4-item versions provide options for quick screening in clinical practice and low-burden assessment in research.

Factors that influence clinicians' decisions to decrease active surveillance monitoring frequency or transition to watchful waiting for localised prostate cancer: a qualitative study.

OBJECTIVE: Little is known about clinicians' decision-making about decreasing active surveillance (AS) testing/converting patients to watchful waiting (WW), nor are there any guidelines. The objective of this study was to identify factors that clinicians consider when decreasing AS testing/converting to WW for men with prostate cancer. DESIGN: Exploratory qualitative study. SETTING: All participants practiced in various institutions in the USA. PARTICIPANTS: Eligible clinicians had to provide clinical care for patients with prostate cancer in the USA and speak English. Clinicians could be either urologists or radiation oncologists. Of the 24 clinicians, 83% were urologists representing 11 states, 92% were men and 62% were white. METHODS: This qualitative study used data from semi-structured interviews. Purposive sampling was used to ensure geographical variation in the USA. Data collection continued until thematic saturation was achieved. Framework analysis guided coding and identification of themes. Two researchers coded all transcripts independently, met to discuss and reached consensus. RESULTS: Interviews with clinicians demonstrated that testing or monitoring for AS or transitioning to WW is happening in practice, whether intentionally or unintentionally. Decisions to decrease AS were personalised and tailored to patients' health status. Life expectancy was the dominant factor that influenced decision, but clinicians were generally hesitant to specify an age when they would decrease AS or transition to WW. Fear that poor adherence could lead to missed progression and concerns about the medico-legal issue of not doing enough were cited as barriers to decreasing AS. CONCLUSIONS: These findings suggest that in certain situations, AS frequency is reduced or transitioned to WW, yet decisions appear to be inconsistent and there are no significant barriers. These findings could inform further areas to explore when drafting recommendations that consider patients' values and preferences when making decisions about decreasing AS/converting to WW.

Financial Hardship in Survivorship Care Delivery.

Cancer-related financial hardship is highly prevalent and affects individuals in the setting of cancer care delivery across the survivorship trajectory. Mitigating financial hardship requires multi-level solutions at the policy, payer, health-care system, provider, and individual patient levels. At the highest level, strategies for intervention include enacting policies to improve price transparency and expand insurance coverage. Also needed are implementing systematic screening and financial navigation in cancer care delivery; improving cost communication by provider care teams; developing patient-reported measures that incorporate the multiple, complex dimensions of financial hardship, as reflected in the Economic Strain and Resilience in Cancer tool; and advancing electronic medical record infrastructure to manage data on patient financial hardship. For individual patients, activating their social networks, community resources, and employers provides patient-level support resources to enhance coping. The proposed multi-level approach is needed to overcome financial hardship in the setting of high-quality, high-value cancer care delivery.