Screening and Intervention for Skin Cancer in the Galapagos.

OBJECTIVE: This study aimed to assess the general dermatological needs and correlation of tentative skin cancer screening diagnoses with histopathological confirmation in the highly sun-exposed locals of the Galapagos Islands. METHODS: An institutional review board-approved prospective study was performed at Blanca's House, a nonprofit surgical volunteer organization, free clinics in the Galapagos. After consent, a 40-item modified SPOTme-inspired questionnaire was completed. Partial or total body skin examinations were conducted by board-certified dermatologists. Board-certified plastic and general surgeons performed excisional biopsies on suspicious lesions. Individuals younger than 18 years, and non-Spanish or non-English speakers were excluded. RESULTS: A total of 273 patients were included in the study, of which 202 reported skin concerns. Benign nevi (n = 76), seborrheic keratosis (n = 42), melasma (n = 19), actinic keratosis (n = 16), acne (n = 15), eczema (n = 13), fungal infections (n = 12), seborrheic dermatitis (n = 5), and psoriasis (n = 5) were most commonly identified.Twelve patients (4.4%) had presumptive skin cancer after screening. Six of 8 biopsies confirmed cancer (group 1), 2 declined a biopsy and 2 were unresectable. Seven basal cell carcinomas and one squamous cell carcinoma were excised with clear margins. A right lower eyelid melanoma was diagnosed and subsequently treated in the United States where invasive melanoma with a Breslow thickness of 0.3 mm was found.Compared with the noncancer group (group 2: n = 265), group 1 had significantly higher likelihood of reporting having seen a dermatologist (P = 0.02), taking any medications (P = 0.0001), having blonde or red hair (P = 0.01), having blue or green eyes (P < 0.0001), and having used indoor tanning equipment (P < 0.0001). Group 1 was also more likely to report 4 or more blistering sunburns (P = 0.08), which approached significance. When evaluated by a dermatologist, group 1 was significantly more likely to be classified as "high risk" for developing cancerous lesions (P < 0.0001) compared with group 2. CONCLUSIONS: Skin concerns in the Galapagos included benign and malignant conditions. There is a need for dermatological care in this medically underserved population. This modified SPOTme-inspired skin cancer questionnaire, confirmed by histology, is a useful tool in identifying high-risk patients and detecting skin cancer in international communities that would have otherwise experienced delays in diagnosis or treatment.

Trends in Checkpoint Inhibitor Therapy for Advanced Urothelial Cell Carcinoma at the End of Life: Insights from Real-World Practice.

Several immune checkpoint inhibitor therapies (CPIs) have been approved to treat metastatic urothelial cell carcinoma (mUC). Because of the favorable toxicity profile of CPI compared with chemotherapy, oncologists may have a low threshold to prescribe CPI to patients near the end of life. We evaluated trends in initiation of end-of-life systemic therapy in 1,637 individuals in the Flatiron Health Database who were diagnosed with mUC between 2015 and 2017 and who died. Rates of systemic therapy initiation in the last 30 and 60 days of life were 17.0% and 29.8%, respectively. The quarterly proportion of patients who initiated CPI within 60 days of death increased from 1.0% to 23% during the study period (p trend < .001). After CPI approval, end-of-life CPI initiation significantly increased among patients with poor performance status (p trend = .020) and did not significantly change among individuals with good performance status. The quarterly proportion of patients who initiated any systemic therapy at the end of life doubled (17.4% to 34.8%) during the study period, largely explained by increased CPI use. These findings suggest a dramatic rise in CPI use at the end of life in patients with mUC, a finding that may have important guideline and policy implications.

Identification of Patient-Reported Outcome Phenotypes Among Oncology Patients With Palliative Care Needs.

PURPOSE: Despite evidence-based guidelines recommending early palliative care, it remains unclear how to identify and refer oncology patients, particularly in settings with constrained access to palliative care. We hypothesize that patient-reported outcome (PRO) data can be used to characterize patients with palliative care needs. To determine if PRO data can identify latent phenotypes that characterize indications for specialty palliative care referral. METHODS: We conducted a retrospective study of self-reported symptoms on the Edmonton Symptom Assessment System collected from solid tumor oncology patients (n = 745) referred to outpatient palliative care. Data were collected as part of routine clinical care from October 2012 to March 2018 at eight community and academic sites. We applied latent profile analysis to identify PRO phenotypes and examined the association of phenotypes with clinical and demographic characteristics using multinomial logistic regression. RESULTS: We identified four PRO phenotypes: (1) Low Symptoms (n = 295, 39.6%), (2) Moderate Pain/Fatigue + Mood (n = 180, 24.2%), (3) Moderate Pain/Fatigue + Appetite + Dyspnea (n = 201, 27.0%), and (4) High Symptoms (n = 69, 9.3%). In a secondary analysis of 421 patients, we found that two brief items assessing social and existential needs aligned with higher severity symptom and psychological distress phenotypes. CONCLUSION: Oncology patients referred to outpatient palliative care in a real-world setting can be differentiated into clinically meaningful phenotypes using brief, routinely collected PRO measures. Latent modeling provides a mechanism to use patient-reported data on a population level to identify distinct subgroups of patients with unmet palliative needs.

Views From Patients With Cancer in the Setting of Unplanned Acute Care: Informing Approaches to Reduce Health Care Utilization.

PURPOSE: New oncology care delivery models that avoid preventable acute care are needed, yet it is unclear which interventions best meet the needs of patients and caregivers. Perspectives from patients who experienced unplanned acute care events may inform the successful development and implementation of care delivery models. METHODS: We performed a qualitative interview study of patients with solid tumors on active treatment who experienced the following 3 types of unplanned acute care events: emergency department visits, first hospitalizations, and multiple hospitalizations. Patients were prospectively recruited within a large academic health system from August 2018 to January 2019. Interviews followed a semi-structured guide developed from the Consolidated Framework for Implementation Research. The constant comparative approach was used to identify themes. RESULTS: Forty-nine patients were interviewed; 51% were men, 75% were non-Hispanic White, and the mean age was 57.4 years (standard deviation, 1.9 years). Fifty-five percent of patients had metastatic disease, and 33% had an Eastern Cooperative Oncology Group performance status of 3-4. We identified the following key themes: drivers of the decision to seek acute care, patients' emotional concerns that influence interactions with the oncology team, and strategies used to avoid acute care. Patients' recommendations for interventions included anticipatory guidance, peer support, improved triage methods, and enhanced symptom management. Patients preferred options for virtual and home-based outpatient care. CONCLUSION: Patient-centered care models should focus on early delivery of supportive interventions that help patients and caregivers navigate the unexpected issues that come with cancer treatment. Patients advocate for proactive, multidisciplinary supportive interventions that enable home-based care and are led by the primary oncology team.

Oncology and Palliative Care Integration: Cocreating Quality and Value in the Era of Health Care Reform.

Recent payment reforms in health care have spurred thinking regarding how strengthened partnerships can cocreate quality and value. Oncology is an important area in which to consider further collaborations in patient care, as a result of increasing treatment complexity from an expanding armamentarium of interventions, large resource expenditures related to cancer care, and a growing disease prevalence related to an aging population. Many have highlighted the important role of palliative care in the routine care of patients with advanced cancer and high symptom burden. Yet, how integration can occur that translates research into usual clinical practice while prioritizing the right patients and settings to maximize outcomes of interest has been inadequately described. We review the evidence for integration of palliative care into routine oncology care and then map the benefits to the requirements put forward by the Centers for Medicare and Medicaid Services Oncology Care Model as a use case; we also discuss applications to other evolving payment models.