ASIA: Automated Social Identity Assessment using linguistic style.

The various group and category memberships that we hold are at the heart of who we are. They have been shown to affect our thoughts, emotions, behavior, and social relations in a variety of social contexts, and have more recently been linked to our mental and physical well-being. Questions remain, however, over the dynamics between different group memberships and the ways in which we cognitively and emotionally acquire these. In particular, current assessment methods are missing that can be applied to naturally occurring data, such as online interactions, to better understand the dynamics and impact of group memberships in naturalistic settings. To provide researchers with a method for assessing specific group memberships of interest, we have developed ASIA (Automated Social Identity Assessment), an analytical protocol that uses linguistic style indicators in text to infer which group membership is salient in a given moment, accompanied by an in-depth open-source Jupyter Notebook tutorial ( https://github.com/Identity-lab/Tutorial-on-salient-social-Identity-detection-model ). Here, we first discuss the challenges in the study of salient group memberships, and how ASIA can address some of these. We then demonstrate how our analytical protocol can be used to create a method for assessing which of two specific group memberships-parents and feminists-is salient using online forum data, and how the quality (validity) of the measurement and its interpretation can be tested using two further corpora as well as an experimental study. We conclude by discussing future developments in the field.

Assessment of Day-7 Postexposure Testing of Asymptomatic Contacts of COVID-19 Patients to Evaluate Early Release from Quarantine - Vermont, May-November 2020.

On May 8, 2020, the Vermont Department of Health (VDH) issued a Health Update* recommending shortening the duration of quarantine for persons exposed to SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Exposed persons who were in quarantine could be tested by polymerase chain reaction (PCR) on or after quarantine day 7. Those who had remained asymptomatic throughout quarantine and who received a negative SARS-CoV-2 PCR test result on or after day 7 could end quarantine. This policy was based on a report suggesting that symptom onset occurs within this time frame in approximately three quarters of COVID-19 cases (1) and on consultation of the Vermont Health Commissioner with the U.S. Surgeon General. VDH implemented this policy to minimize restrictions on state residents, recognizing that some reduction could occur in the prevention benefit of quarantine to contain the spread of SARS-CoV-2. State-run SARS-CoV-2 testing sites were made available to increase access to no-cost testing and facilitate implementation of this policy. During August 1-December 1, among persons seeking testing at a VDH SARS-CoV-2 testing site, 36% stated that their reason for seeking testing was to end quarantine early (VDH, unpublished data, December 7, 2020), indicating that persons were aware of and following the policy and using the testing services provided. To assess the effectiveness of this policy, VDH analyzed testing data for contacts of persons with a COVID-19 diagnosis. During May 8-November 16, VDH identified 8,798 exposed contacts of COVID-19 patients; 3,983 (45%) had sought testing within 14 days of their exposure, with day 0 defined as the date of last exposure noted in the case investigation record. Among these persons, 2,200 (55%) who received testing on days 7-10 were included in this analysis; 977 (44.9%) of these contacts had a specimen collected for testing on day 7. Among these, 34 (3%) had test results that were positive, 940 (96%) had results that were negative, and three (<1%) had results that were indeterminate (Table). Among the 34 contacts who received a positive SARS-CoV-2 PCR test result on day 7 after exposure, 12 (35%) were asymptomatic. The remaining 22 contacts with positive test results were symptomatic at the time of testing; approximately one half had developed symptoms on days 4-7 after exposure. Among the 940 contacts who received negative test results on specimens collected on day 7 after exposure, 154 (16%) had a subsequent test within the next 7 days (i.e., days 8-14); among these, 152 (99%) had tests that remained negative, and two (1%) had results that were indeterminate.

Population-Based Study to Determine the Health System Costs of Using the 21-Gene Assay.

Purpose The 21-gene assay Oncotype Dx (Genomic Health, Redwood City, CA) test is used to aid the decision about chemotherapy in patients with hormone receptor-positive breast cancer who received endocrine therapy. Economic studies to support test adoption used decision-analytic models with assumptions and data derived from disparate sources. The objective was to evaluate whether the 21-gene assay test resulted in an overall cost expense or saving to the health system. Patients and Methods One thousand participants enrolled in a field evaluation study, were linked to population-level health system administrative databases, and were observed for 20 months. The cost for the cohort, which included the cost of the test, subsequent treatments received, and health care encounters, was determined. The cost in the absence of the test was compared with the pretest recommendation about chemotherapy from the field study for a base case and under scenarios that reflected different adjuvant chemotherapy use. Overall health system costs and incremental costs were calculated. Results The 21-gene assay resulted in a net decrease in chemotherapy use of 23%. For the base case incremental analysis, the actual overall health system cost of this cohort, including the cost of 21-gene assay, was $29.2 million compared with $26.2 million in the absence of the test-an increase of $3.1 million. For three of the four scenario analyses, the actual overall cost to the health system exceeded the estimated cost in the absence of the test. Results showed that, when at least half of the population received adjuvant chemotherapy, the cost increased to $30.2 million. Conclusion The use of real-world administrative data showed that, despite lower rates of chemotherapy use, the 21-gene assay test results in an overall incremental cost to the health care system in the short-term under most assumptions.

State of the Science: Cancer Complementary and Alternative Medicine Therapeutics Research-NCI Strategic Workshop Highlights of Discussion Report.

In May 2016, the Office of Cancer Complementary and Alternative Medicine, Division of Cancer Diagnosis and Treatment, of the National Cancer Institute convened a special workshop focused on the State of the Science: Cancer Complementary and Alternative Medicine Therapeutics Research. The current state of the science, gaps, and future opportunities were reviewed and discussed by a distinguished panel of experts in this field of research, and the highlights of this meeting are reported herein.

Positron Emission Tomography-Computed Tomography (PET-CT) Versus No PET-CT in the Management of Potentially Resectable Colorectal Cancer Liver Metastases: Cost Implications of a Randomized Controlled Trial.

PURPOSE: To evaluate whether positron emission tomography (PET) combined with computed tomography (PET-CT) is cost saving, or cost neutral, compared with conventional imaging in management of patients with resectable colorectal cancer liver metastases. METHODS: Cost evaluation of a randomized trial that compared the effect of PET-CT on surgical management of patients with resectable colorectal cancer liver metastases. Health care use data ≤ 1 year after random assignment was obtained from administrative databases. Cost analysis was undertaken from the perspective of a third-party payer (ie, Ministry of Health). Mean costs with 95% credible intervals (CrI) were estimated by using a Bayesian approach. RESULTS: The estimated mean cost per patient in the 263 patients who underwent PET-CT was $45,454 CAD (range, $1,340 to $181,420) and in the 134 control patients, $40,859 CAD (range, $279 to $293,558), with a net difference of $4,327 CAD (95% CrI, -$2,207 to $10,614). The primary cost driver was hospitalization for liver surgery (difference of $2,997 CAD for PET-CT; 95% CrI, -$2,144 to $8,010), which was mainly a result of a longer length of hospital stay for the PET-CT arm (median, 7 v 6 days; P = .03) and a higher postoperative complication rate (20% v 10%; P = .01). Baseline characteristics were similar between groups, including the number of liver segments involved with cancer, number of segments resected, and type of liver resection performed. No difference in survival was detected between arms. CONCLUSION: PET-CT was associated with limited clinical benefit and a nonsignificant increased cost. Universal funding of PET-CT in the management of patients with resectable colorectal cancer liver metastases does not seem justified.

Preclinical pharmacokinetics, biodistribution, radiation dosimetry and acute toxicity studies required for regulatory approval of a Clinical Trial Application for a Phase I/II clinical trial of (111)In-BzDTPA-pertuzumab.

INTRODUCTION: (111)In-BzDTPA-pertuzumab is a novel imaging probe for detecting changes in HER2 expression in breast cancer (BC) caused by treatment with trastuzumab (Herceptin). Our aim was to evaluate the pharmacokinetics, normal tissue biodistribution, radiation dosimetry and acute toxicity of (111)In-BzDTPA-pertuzumab in non-tumor bearing mice in order to obtain regulatory approval to advance this agent to a first-in-humans Phase I/II clinical trial. METHODS: Biodistribution and pharmacokinetic studies were performed in non-tumor bearing Balb/c mice injected i.v. with (111)In-BzDTPA-pertuzumab (2.5MBq; 2µg). The cumulative number of disintegrations per source organ derived from the biodistribution data was used to predict the radiation absorbed doses in humans using OLINDA/EXM software. Acute toxicity was studied at two weeks post-injection of (111)In-BzDTPA-pertuzumab (1.0MBq, 20µg) with comparison to control mice injected with unlabeled BzDTPA-pertuzumab (20µg) or Sodium Chloride Injection USP. The dose of (111)In-BzDTPA-pertuzumab corresponded to 23-times the human radioactivity dose and 10-times the protein dose on a MBq/kg and mg/kg basis, respectively. Toxicity was assessed by monitoring body mass, complete blood cell count (CBC), hematocrit (Hct), hemoglobin (Hb), serum creatinine (SCr) and alanine aminotransferease (ALT) and by histopathological examination of tissues at necropsy. RESULTS: (111)In-BzDTPA-pertuzumab exhibited a biphasic elimination from the blood with a distribution half-life (t1/2α) of 3.8h and an elimination half-life (t1/2ß) of 228.2h. The radiopharmaceutical was distributed mainly in the blood, heart, lungs, liver, kidneys and spleen. The projected whole-body radiation absorbed dose in humans was 0.05mSv/MBq corresponding to a total of 16.8mSv for three separate administrations of (111)In-BzDTPA-pertuzumab (111MBq) planned for the Phase I/II trial. There were slight changes in Hb and SCr levels associated with administration of multiples of the human dose in healthy Balb/c mice but no histopathological abnormalities were noted in any tissues. There were no significant differences in body mass between mice injected with (111)In-BzDTPA-pertuzumab or control mice. CONCLUSION: Preclinical studies predicted that (111)In-BzDTPA-pertuzumab is safe to administer to humans at a dose of 111MBq (5mg). The radiopharmaceutical exhibited preclinical pharmacokinetic, biodistribution and radiation dosimetry properties suitable for advancement to a first-in-humans clinical trial. ADVANCES IN KNOWLEDGE AND IMPLICATIONS FOR PATIENT CARE: The results of these studies supported the regulatory approval by Health Canada of (111)In-BzDTPA-pertuzumab for a Phase I/II clinical trial of for imaging the response of patients with metastatic BC to treatment with trastuzumab combined with chemotherapy (PETRA trial; ClinicalTrials.gov identifier: NCT01805908).

Cost effectiveness of a survivorship care plan for breast cancer survivors.

PURPOSE: Survivorship care plans (SCPs) are recommended for patients who have completed primary treatment and are transitioning to routine follow-up care. However, SCPs may be costly, and their effectiveness is unproven. The study objective was to assess the cost effectiveness of an SCP for breast cancer survivors transitioning to routine follow-up care with their own primary care physician (PCP) using data from a recent randomized controlled trial (RCT). METHODS: Resource use and utility data for 408 patients with breast cancer enrolled in the RCT comparing an SCP with standard care (no SCP) were used. The intervention group received a 30-minute educational session with a nurse and their SCP, and their PCPs received the SCP plus a full guideline on follow-up. Analysis assessed the societal costs and quality-adjusted life years (QALYs) for the intervention group and the control group over the 2-year follow-up of the RCT. Uncertainty concerning cost effectiveness was assessed through nonparametric bootstrapping and deterministic sensitivity analysis. RESULTS: The no-SCP group had better outcomes than the SCP group: total costs per patient were lower for standard care (Canadian $698 v $765), and total QALYs were almost equivalent (1.42 for standard care v 1.41 for the SCP). The probability that the SCP was cost effective was 0.26 at a threshold value of a QALY of $50,000. A variety of sensitivity analyses did not change the conclusions of the analysis. CONCLUSION: This SCP would be costly to introduce and would not be a cost effective use of scarce health care resources.

Beyond prejudice: are negative evaluations the problem and is getting us to like one another more the solution?

For most of the history of prejudice research, negativity has been treated as its emotional and cognitive signature, a conception that continues to dominate work on the topic. By this definition, prejudice occurs when we dislike or derogate members of other groups. Recent research, however, has highlighted the need for a more nuanced and "inclusive" (Eagly 2004) perspective on the role of intergroup emotions and beliefs in sustaining discrimination. On the one hand, several independent lines of research have shown that unequal intergroup relations are often marked by attitudinal complexity, with positive responses such as affection and admiration mingling with negative responses such as contempt and resentment. Simple antipathy is the exception rather than the rule. On the other hand, there is mounting evidence that nurturing bonds of affection between the advantaged and the disadvantaged sometimes entrenches rather than disrupts wider patterns of discrimination. Notably, prejudice reduction interventions may have ironic effects on the political attitudes of the historically disadvantaged, decreasing their perceptions of injustice and willingness to engage in collective action to transform social inequalities. These developments raise a number of important questions. Has the time come to challenge the assumption that negative evaluations are inevitably the cognitive and affective hallmarks of discrimination? Is the orthodox concept of prejudice in danger of side-tracking, if not obstructing, progress towards social justice in a fuller sense? What are the prospects for reconciling a prejudice reduction model of change, designed to get people to like one another more, with a collective action model of change, designed to ignite struggles to achieve intergroup equality?

Prospective study of 2-[¹8F]fluorodeoxyglucose positron emission tomography in the assessment of regional nodal spread of disease in patients with breast cancer: an Ontario clinical oncology group study.

PURPOSE: 2-[(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is potentially useful in assessing lymph nodes and detecting distant metastases in women with primary breast cancer. PATIENTS AND METHODS: Women diagnosed with operable breast cancer within 3 months underwent FDG-PET at one of five Ontario study centers followed by axillary lymph node assessment (ALNA) consisting of sentinel lymph node biopsy (SLNB) alone if sentinel lymph nodes (SLNs) were negative, SLNB with axillary lymph node dissection (ALND) if SLNB or PET was positive, or ALND alone if SLNs were not identified. RESULTS: Between January 2005 and March 2007, 325 analyzable women entered this study. Sentinel nodes were found for 312 (96%) of 325 women and were positive for tumor in 90 (29%) of 312. ALND was positive in seven additional women. Using ALNA as the gold standard, sensitivity for PET was 23.7% (95% CI, 15.9% to 33.6%), specificity was 99.6% (95% CI, 97.2% to 99.9%), positive predictive value was 95.8% (95% CI, 76.9% to 99.8%), negative predictive value was 75.4% (95% CI, 70.1% to 80.1%), and prevalence was 29.8% (95% CI, 25.0% to 35.2%). Using logistic regression, tumor size was predictive for prevalence of tumor in the axilla and for PET sensitivity. PET scan was suspicious for distant metastases in 13 patients; three (0.9%) were confirmed as metastatic disease and 10 (3.0%) were false positive. CONCLUSION: FDG-PET is not sufficiently sensitive to detect positive axillary lymph nodes, nor is it sufficiently specific to appropriately identify distant metastases. However, the very high positive predictive value (96%) suggests that PET when positive is indicative of disease in axillary nodes, which may influence surgical care.

Funding oncology clinical trials: are cooperative group trials sustainable?

PURPOSE: Many oncology clinical trials departments (CTDs) are in serious fiscal deficit and their sustainability is in jeopardy. This study investigates whether the payment models used to fund industry versus cooperative group trials contribute to the fiscal deficit of a CTD. METHODS: We examined the lifetime costs of all cooperative group and industry trials activated in the CTD of a cancer center between 2007 and 2011. A trial's lifetime is defined as being from the date the first patient was accrued until the last patient's actual or projected final follow-up visit. For each trial, we calculated the lifetime monthly net income, which was defined as monthly revenue minus monthly costs. Data sources included study protocols, trial budgets, and accrual data. RESULTS: Of the 97 trials analyzed, 64 (66%) were cooperative group trials. The pattern of lifetime net income for cooperative group trials has a positive peak during patient accrual followed by a negative trough during follow-up. In contrast, the pattern for industry trials resembled an "l" shape. The patterns reflect the differing payment models: upfront lump-sum payments (cooperative group) versus milestone payments (industry). CONCLUSION: The negative trough in the lifetime net income of a cooperative group trial occurs because follow-up costs are typically not funded or are underfunded. CTDs accrue more patients in new trials to offset that deficit. The CTD uses revenue from accrual to existing trials to cross-subsidize past trials in follow-up. As the number of patients on follow-up increases, the fiscal deficit grows larger each year, perpetuating the cycle.

Beyond prejudice: relational inequality, collective action, and social change revisited.

This response clarifies, qualifies, and develops our critique of the limits of intergroup liking as a means of challenging intergroup inequality. It does not dispute that dominant groups may espouse negative attitudes towards subordinate groups. Nor does it dispute that prejudice reduction can be an effective way of tackling resulting forms of intergroup hostility. What it does dispute is the assumption that getting dominant group members and subordinate group members to like each other more is the best way of improving intergroup relations that are characterized by relatively stable, institutionally embedded, relations of inequality. In other words, the main target of our critique is the model of change that underlies prejudice reduction interventions and the mainstream concept of "prejudice" on which they are based.

Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial.

BACKGROUND: Guidelines recommend that patients receiving warfarin undergo international normalized ratio (INR) monitoring every 4 weeks. OBJECTIVE: To investigate whether assessment of warfarin dosing every 12 weeks is as safe as assessment every 4 weeks. DESIGN: Noninferiority randomized trial. The randomization schedule (in a 1:1 ratio) was computer-generated, and allocation was concealed until the database was locked by using a centralized schedule. Patients, study and clinical personnel, adjudicators of clinical events, and the study statistician were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00356759) SETTING: Single center in Hamilton, Ontario, Canada. PATIENTS: 250 patients receiving long-term warfarin therapy, whose dose was unchanged for at least 6 months; 226 completed the study. INTERVENTION: Dosing assessment every 12 weeks (n = 124) compared with every 4 weeks (n = 126) for 12 months. Patients in the 12-week group were tested every 4 weeks; sham INRs within the target range were reported for two of the three 4-week periods. MEASUREMENTS: Percentage of time in the therapeutic range (primary outcome) and number of extreme INRs, changes in maintenance dose, major bleeding events, objectively verified thromboembolism, and death (secondary outcomes). RESULTS: The percentage of time in the therapeutic range was 74.1% (SD, 18.8%) in the 4-week group compared with 71.6% (SD, 20.0%) in the 12-week group (absolute difference, 2.5 percentage points [1-sided 97.5% upper confidence bound, 7.3 percentage points]; noninferiority P = 0.020 for a 7.5-percentage point margin). Fewer patients in the 12-week group than in the 4-week group had any dose changes (37.1% vs. 55.6%; absolute difference, 18.5 percentage points [95% CI, 6.1 to 30.0 percentage points]; P = 0.004). Secondary outcomes did not differ between groups. LIMITATIONS: Patients in the 12-week group had testing and contact with clinic staff every 4 weeks. The study was conducted at a single center and used surrogate outcomes. CONCLUSION: Assessment of warfarin dosing every 12 weeks seems to be safe and noninferior to assessment every 4 weeks. A comparison of INR testing, patient contact, and warfarin dose assessment every 12 weeks versus every 4 weeks is necessary before INR testing every 12 weeks can be routinely recommended for practice. PRIMARY FUNDING SOURCE: Physicians' Services Incorporated Foundation.

Coverage with evidence development: the Ontario experience.

BACKGROUND: For non-drug technologies, there is often residual uncertainty following systematic review, mainly due to inadequate evidence of efficacy. The unwillingness to make decisions in the presence of uncertainty may lead to passive diffusion and intuitive decision making with or without public pressure. This may affect health system sustainability. There is increasing interest in post-market evaluation through processes that include coverage with evidence development (CED) to address residual uncertainty regarding effectiveness and cost-effectiveness. Global experience of CED has been slow to develop despite their potential contribution to decision making. METHODS: Ontario's field evaluation program to better inform decision making represents a collaboration between physicians, policy decision makers and academic centers. We report results of the first ten CEDs from this program to assess whether they achieved their objective of influencing policy by addressing residual uncertainty following systematic review. RESULTS: Since 2003, nineteen field evaluation studies to resolve residual uncertainty following systematic review have been completed, ten of which met the criteria of CED and are the focus of this report. There was more than one patient subgroup or intervention in three of the CEDs. This provided the basis for evaluating thirteen outcomes. In each case, the CED addressed the uncertainty and led to a decision based on the systematic review and CED result. The CEDs led to adoption of the technology in six instances, modified adoption in three instances and withdrawal in four instances. CONCLUSIONS: CED makes an important contribution to translating evidence to decision making. Methodologies are needed to increase the scope and reduce timelines for CEDs, such as the use of linked comprehensive and robust data sets and collaborative studies with other jurisdictions. CED before making long-term funding decisions, especially where there is uncertainty of effectiveness, safety or cost-effectiveness, should be increasingly funded by health systems.

Assessing the volume-outcome hypothesis and region-level quality improvement interventions: pancreas cancer surgery in two Canadian Provinces.

BACKGROUND: The volume-outcome hypothesis suggests that if increased provider procedure volume is associated with improved patient outcomes, then greater regionalization to high-volume providers should improve region-level outcomes. Quality improvement interventions for pancreas cancer surgery implemented in year 1999 in Ontario, Canada were designed to regionalize surgery to high-volume hospitals and decrease operative mortality. Similar interventions were not used in Quebec, Canada. We assessed the volume-outcome hypothesis and the impact of the Ontario quality improvement interventions. MATERIALS AND METHODS: Administrative databases helped identify pancreatic resections from years 1994 to 2004 and relevant patient and hospital characteristics. Hospitals were high-volume if they provided ≥10 procedures in a given calendar year. Outcomes were regionalization of surgery to high-volume providers and rates of operative mortality. RESULTS: From 1994 to 2004 the percentage of cases in high-volume hospitals increased from 33 to 71% in Ontario and from 36 to 76% in Quebec. Annual rates of operative mortality dropped in Ontario (10.4-2.2% or less) and changed little in Quebec (7.2-9.8%). Changes in measures over time in both provinces were similar before and after year 1999. CONCLUSIONS: Regionalization was associated with improved operative mortality in Ontario but not in Quebec, undermining the volume-outcome hypothesis. The Ontario quality improvement interventions likely were of little influence since patterns in regionalization and operative mortality were similar before and after year 1999.

Evidence-based approach to the introduction of positron emission tomography in ontario, Canada.

PURPOSE: The uptake of new health care technologies is usually driven by industry promotion, physician interest, patient demand, and institutional ability to acquire the technology. The introduction of positron emission tomography (PET) scanning in the province of Ontario, Canada, followed a different path. METHODS: The Ontario provincial government, through its Ministry of Health and Long-Term Care, commissioned a systematic review of the literature. When this found only weak evidence that PET has a positive impact on clinical outcomes, the Ministry introduced a provincial PET evaluation program to close the evidence gap. RESULTS: This article describes the challenges encountered establishing the PET evaluation program. These included the design and conduct of the initial clinical trials, the establishment of a PET cancer registry, standardizing how PET scans were performed and reported, and gaining acceptance by health professionals for the evaluative program. CONCLUSION: The proliferation of health technologies is a key driver of increasing health care costs. The Ontario approach to the introduction of PET is a model worth consideration by health systems seeking to ensure that they receive value for money based on a strong evidentiary base when introducing new health technologies.

The Initial Health Assessment: an intervention to identify the supportive care needs of cancer patients.

BACKGROUND: The first step in effective supportive care delivery is an assessment of patient needs. The Initial Health Assessment Form (IHA) was developed to aid clinicians in recognition and documentation of a patient's supportive care needs during their first visit to a comprehensive cancer centre. The purpose of this study was to determine the relative effectiveness of this instrument as compared to routine practice. METHODS: A before-after study was performed. Charts of consecutive patients with newly diagnosed cancer attending the Hamilton Regional Cancer Centre were selected randomly. Each chart was reviewed to determine the documentation at the initial patient assessment of 22 supportive care items under eight domains of need: physical, psychological, daily living, social, financial, informational, special needs and personal resources. The pre-intervention evaluation (T1) occurred over a 3-month period followed by the introduction of the IHA into clinical practice. Three months after its introduction, the post-intervention (T2) evaluation took place over the ensuing 3 months. RESULTS: A total of 306 charts were evaluated (153 each in T1 and T2). Patients from the two time periods were comparable with respect to background demographic variables. Introduction of the IHA increased the mean documentation of supportive care needs and resources from 26% in T1 to 49% in T2 ( p=0.001). Significant improvements were found in all domains of need. Despite improvements, documentation of assessment continued to remain low for daily living, social, financial, and informational needs. CONCLUSIONS: The IHA improved documentation of supportive care needs and resources. There is still room for improvement.