Enhancing Readability of Online Patient-Facing Content: The Role of AI Chatbots in Improving Cancer Information Accessibility.

BACKGROUND: Internet-based health education is increasingly vital in patient care. However, the readability of online information often exceeds the average reading level of the US population, limiting accessibility and comprehension. This study investigates the use of chatbot artificial intelligence to improve the readability of cancer-related patient-facing content. METHODS: We used ChatGPT 4.0 to rewrite content about breast, colon, lung, prostate, and pancreas cancer across 34 websites associated with NCCN Member Institutions. Readability was analyzed using Fry Readability Score, Flesch-Kincaid Grade Level, Gunning Fog Index, and Simple Measure of Gobbledygook. The primary outcome was the mean readability score for the original and artificial intelligence (AI)-generated content. As secondary outcomes, we assessed the accuracy, similarity, and quality using F1 scores, cosine similarity scores, and section 2 of the DISCERN instrument, respectively. RESULTS: The mean readability level across the 34 websites was equivalent to a university freshman level (grade 13±1.5). However, after ChatGPT's intervention, the AI-generated outputs had a mean readability score equivalent to a high school freshman education level (grade 9±0.8). The overall F1 score for the rewritten content was 0.87, the precision score was 0.934, and the recall score was 0.814. Compared with their original counterparts, the AI-rewritten content had a cosine similarity score of 0.915 (95% CI, 0.908-0.922). The improved readability was attributed to simpler words and shorter sentences. The mean DISCERN score of the random sample of AI-generated content was equivalent to "good" (28.5±5), with no significant differences compared with their original counterparts. CONCLUSIONS: Our study demonstrates the potential of AI chatbots to improve the readability of patient-facing content while maintaining content quality. The decrease in requisite literacy after AI revision emphasizes the potential of this technology to reduce health care disparities caused by a mismatch between educational resources available to a patient and their health literacy.

Characteristics of self-triaged emergency department visits by adults with cancer.

OBJECTIVES: Adults with a new diagnosis of cancer frequently visit emergency departments (EDs) for disease- and treatment-related issues, although not exclusively. Many cancer care providers have 24/7 clinician phone triage available, but initial recorded phone messages tend to advise patients to go to the nearest ED if they are "experiencing a medical emergency." It is unclear how well patients triage themselves to the optimal site of care. STUDY DESIGN: Cross-sectional study of tumor registry records (university patients diagnosed 2008-2018 and safety-net patients diagnosed 2012-2018) identifiably linked to electronic health records and a regional health information exchange. METHODS: We geoprocessed addresses to calculate driving time distance from the patient's home to the ED. We used mixed-effects regression to predict the diagnosis code-based severity for ED visits within 6 months of diagnosis, clustering visits within patients and hospitals. RESULTS: A total of 39,498 adults made 38,944 ED visits to 67 different hospitals. Patients self-referred for 85.5% of visits and bypassed a median (IQR) of 13 (4-33) closer EDs. Visits closer to home were not significantly more clinically severe; visits were significantly less severe if the patient self-referred (adjusted odds ratio [AOR], 0.89; 95% CI, 0.81-0.97) or they were on weekends (AOR, 0.93; 95% CI, 0.87-0.99). Reanalyzing within each individual health system also showed similar findings. CONCLUSIONS: Adults with cancer infrequently use available clinician advice before visiting the ED and may use factors other than clinical severity to determine their need for emergency care. Future work should explore the challenges that patients face navigating unplanned acute care, including reasons for underusing existing resources.

NCCN Policy Summit: Cancer Care in the Workplace: Building a 21st Century Workplace for Patients, Survivors, and Caretakers.

Survival rates for people with cancer and quality of life for survivors have increased significantly as a result of innovations in cancer treatment, improvements in early detection, and improved healthcare access. In the United States, 1 in 2 men and 1 in 3 women will be diagnosed with cancer in their lifetime. As more cancer survivors and patients remain in the workforce, employers must evaluate how they can adjust workplace policies to meet employee and business needs. Unfortunately, many people still encounter barriers to remaining in the workplace following a cancer diagnosis for themselves or a loved one. In an effort to explore the impacts of contemporary employment policies on patients with cancer, cancer survivors, and caregivers, NCCN hosted the Policy Summit "Cancer Care in the Workplace: Building a 21st Century Workplace for Cancer Patients, Survivors, and Caretakers" on June 17, 2022. This hybrid event, through keynotes and multistakeholder panel discussions, explored issues regarding employer benefit design, policy solutions, current best and promising practices for return to work, and how these issues impact treatment, survivorship, and caregiving in the cancer community.

Impact of the Immediate Release of Clinical Information Rules on Health Care Delivery to Patients With Cancer.

PURPOSE: The 21st Century Cures Act mandates the immediate release of clinical information (IRCI) to patients. Immediate sharing of sensitive test results to patients with cancer might have serious unintended consequences for patients and providers. METHODS: A 22-question REDCap survey was designed by the Association of American Cancer Institutes Physician Clinical Leadership Initiative Steering Committee to explore oncology providers' opinions on IRCI policy implementation. It was administered twice in 2021 with a 3-month interval. A third survey with a single question seeking providers' opinions about their adaptation to the IRCI mandate was administered 1 year later to those who had responded to the earlier surveys. The data were analyzed using descriptive statistics such as chi-squared or Fisher's exact tests for categorical variables. The survey was sent to all Association of American Cancer Institutes cancer center members. In the first or second administration, 167 practitioners answered the survey; 31 responded to the third survey. RESULTS: Three quarters of the providers did not favor the new requirement for IRCI and 62% encountered questions from patients about results being sent to them without provider interpretation. Only half of the hospitals had a plan in place to deal with the new IRCI requirements. A third survey, for longitudinal follow-up, indicated a more favorable trend toward adoption of IRCI. CONCLUSION: IRCI for patients with cancer was perceived negatively by academic oncology providers after its implementation. It was viewed to be associated with higher levels of patient anxiety and complaints about the care delivered. Providers preferred to discuss test results with patients before release.

COVID-19 Communication From Seven Health Care Institutions in North Texas for English- and Spanish-Speaking Cancer Patients: Mixed Method Website Study.

BACKGROUND: The COVID-19 pandemic has created an urgent need to rapidly disseminate health information, especially to those with cancer, because they face higher morbidity and mortality rates. At the same time, the pandemic's disproportionate impact on Latinx populations underscores the need for information to reach Spanish speakers. However, the equity of COVID-19 information communicated through institutions' online media to Spanish-speaking cancer patients is unknown. OBJECTIVE: We conducted a multimodal, mixed method document review study to evaluate the equity of online information about COVID-19 and cancer available to English- and Spanish-speaking populations from seven health care institutions in North Texas, where one in five adults is Spanish-speaking. Our focus was less on the "digital divide," which conveys disparities in access to computers and the internet based on the race/ethnicity, education, and income of at-risk populations; rather, our study asks the following question: to what extent is online content useful and culturally appropriate in meeting Spanish speakers' information needs? METHODS: We reviewed 50 websites (33 English and 17 Spanish) over a period of 1 week in the middle of May 2020. We sampled seven institutions' main oncology and COVID web pages, and both internal (institutional) and external (noninstitutional) linked content. We conducted several analyses for each sampled page, including (1) thematic content analysis, (2) literacy level analysis using Readability Studio software, (3) coding using the Patient Education and Materials Assessment Tool (PEMAT), and (4) descriptive analysis of video and diversity content. RESULTS: The themes most frequently addressed on English and Spanish websites differed. While "resources/FAQs" were frequently cited themes on both websites, English websites more frequently addressed "news/updates" and "cancer+COVID," and Spanish websites addressed "protection" and "COVID data." Spanish websites had on average a lower literacy level (11th grade) than English websites (13th grade), although still far above the recommended guideline of 6th to 8th grade. The PEMAT's overall average accessibility score was the same for English (n=33 pages) and Spanish pages (n=17 pages) at 82%. Among the Dallas-Fort Worth organizations, the average accessibility of Spanish pages (n=7) was slightly lower than that of English pages (n=19) (77% vs 81%), due mostly to the discrepancy in English-only videos and visual aids. Of the 50 websites, 12 (24%) had embedded videos; however, 100% of videos were in English, including one on a Spanish website. CONCLUSIONS: We identified an uneven response among the seven health care institutions for providing equitable information to Spanish-speaking Dallas-Fort Worth residents concerned about COVID and cancer. Spanish speakers lack equal access in both diversity of content about COVID-19 and access to other websites, leaving an already vulnerable cancer patient population at greater risk. We recommend several specific actions to enhance content and navigability for Spanish speakers.

Prior Frequent Emergency Department Use as a Predictor of Emergency Department Visits After a New Cancer Diagnosis.

PURPOSE: To determine whether emergency department (ED) visit history prior to cancer diagnosis is associated with ED visit volume after cancer diagnosis. METHODS: This was a retrospective cohort study of adults (≥ 18 years) with an incident cancer diagnosis (excluding nonmelanoma skin cancers or leukemia) at an academic medical center between 2008 and 2018 and a safety-net hospital between 2012 and 2016. Our primary outcome was the number of ED visits in the first 6 months after cancer diagnosis, modeled using a multivariable negative binomial regression accounting for ED visit history in the 6-12 months preceding cancer diagnosis, electronic health record proxy social determinants of health, and clinical cancer-related characteristics. RESULTS: Among 35,090 patients with cancer (49% female and 50% non-White), 57% had ≥ 1 ED visit in the 6 months immediately following cancer diagnosis and 20% had ≥ 1 ED visit in the 6-12 months prior to cancer diagnosis. The strongest predictor of postdiagnosis ED visits was frequent (≥ 4) prediagnosis ED visits (adjusted incidence rate ratio [aIRR]: 3.68; 95% CI, 3.36 to 4.02). Other covariates associated with greater postdiagnosis ED use included having 1-3 prediagnosis ED visits (aIRR: 1.32; 95% CI, 1.28 to 1.36), Hispanic (aIRR: 1.12; 95% CI, 1.07 to 1.17) and Black (aIRR: 1.21; 95% CI, 1.17 to 1.25) race, homelessness (aIRR: 1.95; 95% CI, 1.73 to 2.20), advanced-stage cancer (aIRR: 1.30; 95% CI, 1.26 to 1.35), and treatment regimens including chemotherapy (aIRR: 1.44; 95% CI, 1.40 to 1.48). CONCLUSION: The strongest independent predictor for ED use after a new cancer diagnosis was frequent ED visits before cancer diagnosis. Efforts to reduce potentially avoidable ED visits among patients with cancer should consider educational initiatives that target heavy prior ED users and offer them alternative ways to seek urgent medical care.

Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer.

PURPOSE: Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care. METHODS: We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity. RESULTS: From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred. CONCLUSION: Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

A Better Pathway? Building Consensus and Engaging Providers with Feedback to Improve and Standardize Cancer Care.

INTRODUCTION: Unwanted clinical variation is common across the United States health care system and is particularly vexing in oncology owing to the complexity, morbidity, and high cost of the disease. Efforts to standardize care including guidelines and continuing medical education have had only limited impact. Disease-specific oncology clinical pathways hold the promise of reducing variation but have been hampered by a lack of ownership and accountability among oncology providers. MATERIALS AND METHODS: We describe the utility of combining a patient simulation-based clinical variation measurement with the in-house development of multidisciplinary breast cancer pathways at a National Cancer Institute-designated cancer center. RESULTS: At baseline, we found high variation in care decisions across the multidisciplinary team and within individual specialties in the management of simulated patients. Development and introduction of breast cancer clinical pathways combined with individual and group feedback on pathway adherence led to significant increases in pathway-aligned care decisions and decreases in measured variation. Overall quality scores increased from 47.5% to 61.1% (P < .001), with the largest improvement in diagnostic accuracy (+22.1%). Providers also ordered fewer unnecessary tests, saving an estimated $305 per patient case. Adherence to preferred chemotherapy regimens increased for both medical oncologists (+16%) and other members of the multidisciplinary team (+19%). CONCLUSION: Our work shows that a structured process to measure clinical variation and provide personalized feedback to an oncology multidisciplinary team drives adoption of evidence-based pathways, less unneeded spending, and higher quality care for patients.

Five-year PFS from the AETHERA trial of brentuximab vedotin for Hodgkin lymphoma at high risk of progression or relapse.

The phase 3 AETHERA trial established brentuximab vedotin (BV) as a consolidative treatment option for adult patients with classical Hodgkin lymphoma (cHL) at high risk of relapse or progression after autologous hematopoietic stem-cell transplantation (auto-HSCT). Results showed that BV significantly improved progression-free survival (PFS) vs placebo plus best supportive care alone. At 5-year follow-up, BV continued to provide patients with sustained PFS benefit; 5-year PFS was 59% (95% confidence interval [CI], 51-66) with BV vs 41% (95% CI, 33-49) with placebo (hazard ratio [HR], 0.521; 95% CI, 0.379-0.717). Similarly, patients with ≥2 risk factors in the BV arm experienced significantly higher PFS at 5 years than patients in the placebo arm (HR, 0.424; 95% CI, 0.302-0.596). Upfront consolidation with BV significantly delayed time to second subsequent therapy, an indicator of ongoing disease control, vs placebo. Peripheral neuropathy, the most common adverse event in patients receiving BV, continued to improve and/or resolve in 90% of patients. In summary, consolidation with BV in adult patients with cHL at high risk of relapse or progression after auto-HSCT confers a sustained PFS benefit and is safe and well tolerated. Physicians should consider each patient's HL risk factor profile when making treatment decisions. This trial was registered at www.clinicaltrials.gov as #NCT01100502.

Safety Analysis of Brentuximab Vedotin from the Phase III AETHERA Trial in Hodgkin Lymphoma in the Post-Transplant Consolidation Setting.

The phase III AETHERA trial demonstrated the efficacy of brentuximab vedotin (BV) as consolidation therapy in patients with classical Hodgkin lymphoma (HL) at high risk of relapse or progression after autologous hematopoietic stem cell transplantation (auto-HSCT; hazard ratio, .57; P < .001). The objective of this analysis is to provide further detail on the most common and clinically important treatment-emergent adverse events (AEs) in the AETHERA BV arm including their occurrence and management. AEs of clinical importance occurring in patients who participated in AETHERA (BV + best supportive care [BSC], n = 165; placebo + BSC, n = 164) were evaluated for time to onset, manageability through dose modification, and resolution. As previously reported, peripheral neuropathy (PN; 67%), infections (60%), and neutropenia (35%) were the most common BV-associated treatment-emergent AEs. Neutropenia was managed with dose delays and granulocyte colony-stimulating factor; no dose reductions or discontinuations were required. Most PN cases (57%) were managed with dose delays and reductions. The median time to PN onset was 13.7 weeks (range, .1 to 47.4). After the end of treatment, PN continued to resolve; symptom resolution was similar to that in the placebo arm at 3 years, demonstrating reversibility. BV had no significant impact on pre-existing PN. Patients with PN-related dose modifications had progression-free survival (PFS) comparable with patients without. Other less common but serious AEs, including pulmonary toxicities, hepatotoxicity, and cardiotoxicity, were rare in both arms and were managed with BV dose modifications or discontinuations. Secondary malignancies were rare and reported in patients with comorbidities or other risk factors. Consolidation therapy with BV for patients with HL at high risk of relapse after auto-HSCT is associated with sustained PFS. The most common AEs in the BV arm were manageable and reversible. Awareness of these AEs and management approaches will enable healthcare providers and patients to plan the safest and most effective treatment plan.

A phase I trial of bortezomib in combination with everolimus for treatment of relapsed/refractory non-Hodgkin lymphoma.

B-cell non-Hodgkin lymphomas (NHL) display dysregulation of pathways controlling cell proliferation and apoptosis. Combined proteasome and mTOR inhibition, demonstrated with bortezomib and everolimus in a preclinical model, thus warrants evaluation in humans. We conducted a phase I study to identify the maximum tolerated dose (MTD) and safety of this combination in relapsed/refractory (r/r) NHL. Twenty-nine patients were enrolled from July 2008 to March, 2015. Toxicities were primarily hematologic, and dose-limiting thrombocytopenia defined the MTD as 5 mg everolimus daily with 1.3 mg/m2 bortezomib d1, 4, 8, and 11 every 21 days. Of 25 response-evaluable patients there was one complete response in a patient with MCL and three partial responses (two MCL, one FL) for an overall response rate of 16%. In conclusion, the combination of everolimus and bortezomib results in dose limiting thrombocytopenia, but is tolerable. This combination has limited clinical activity in heavily pretreated NHL.

Quality of life results from a phase 3 study of brentuximab vedotin consolidation following autologous haematopoietic stem cell transplant for persons with Hodgkin lymphoma.

Brentuximab vedotin (BV) significantly improved progression-free survival in a phase 3 study in patients with relapsed or refractory Hodgkin lymphoma (RR-HL) post-autologous-haematopoietic stem cell transplant (auto-HSCT); we report the impact of BV on quality of life (QOL) from this trial. The European Quality of Life five dimensions questionnaire was administered at the beginning of each cycle, end of treatment, and every 3 months during follow-up; index value scores were calculated using the time trade-off (TTO) method for UK-weighted value sets. Questionnaire adherence during the trial was 87·5% (N = 329). In an intent-to-treat analysis, compared with placebo, TTO scores in the BV arm did not exceed the minimally important difference (MID) of 0·08 except at month 15 (-0·084; 95% confidence interval, -0·143 to -0·025). On-treatment index scores were similar between arms and did not reach the MID at any time point; mixed-effect modelling showed that BV treatment effect was not significant (P = 0·2127). BV-associated peripheral neuropathy did not meaningfully impact QOL. Utility scores for patients who progressed declined compared with those who did not; TTO scores between these patients exceeded the MID beginning at month 15. In conclusion, QOL decreased modestly with BV consolidation treatment in patients with RR-HL at high risk of relapse after auto-HSCT.

US Intergroup Trial of Response-Adapted Therapy for Stage III to IV Hodgkin Lymphoma Using Early Interim Fluorodeoxyglucose-Positron Emission Tomography Imaging: Southwest Oncology Group S0816.

PURPOSE: Four US National Clinical Trials Network components (Southwest Oncology Group, Cancer and Leukemia Group B/Alliance, Eastern Cooperative Oncology Group, and the AIDS Malignancy Consortium) conducted a phase II Intergroup clinical trial that used early interim fluorodeoxyglucose positron emission tomography (FDG-PET) imaging to determine the utility of response-adapted therapy for stage III to IV classic Hodgkin lymphoma. PATIENTS AND METHODS: The Southwest Oncology Group S0816 (Fludeoxyglucose F 18-PET/CT Imaging and Combination Chemotherapy With or Without Additional Chemotherapy and G-CSF in Treating Patients With Stage III or Stage IV Hodgkin Lymphoma) trial enrolled 358 HIV-negative patients between July 1, 2009, and December 2, 2012. A PET scan was performed after two initial cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and was labeled PET2. PET2-negative patients (Deauville score 1 to 3) received an additional four cycles of ABVD, whereas PET2-positive patients (Deauville score 4 to 5) were switched to escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (eBEACOPP) for six cycles. Among 336 eligible and evaluable patients, the median age was 32 years (range, 18 to 60 years), with 52% stage III, 48% stage IV, 49% International Prognostic Score 0 to 2, and 51% score 3 to 7. RESULTS: Three hundred thirty-six of the enrolled patients were evaluable. Central review of the interim PET2 scan was performed in 331 evaluable patients, with 271 (82%) PET2-negative and 60 (18%) PET2-positive. Of 60 eligible PET2-positive patients, 49 switched to eBEACOPP as planned and 11 declined. With a median follow-up of 39.7 months, the Kaplan-Meier estimate for 2-year overall survival was 98% (95% CI, 95% to 99%), and the 2-year estimate for progression-free survival (PFS) was 79% (95% CI, 74% to 83%). The 2-year estimate for PFS in the subset of patients who were PET2-positive after two cycles of ABVD was 64% (95% CI, 50% to 75%). Both nonhematologic and hematologic toxicities were greater in the eBEACOPP arm than in the continued ABVD arm. CONCLUSION: Response-adapted therapy based on interim PET imaging after two cycles of ABVD seems promising with a 2-year PFS of 64% for PET2-positive patients, which is much higher than the expected 2-year PFS of 15% to 30%.

Managing Risk in Hodgkin Lymphoma.

Approximately 90% of patients with limited-stage Hodgkin lymphoma are cured. The cure rate in advanced-stage Hodgkin lymphoma is dramatically better than it once was, but it is still lower than the rate in patients with limited disease. The choice of treatment is based on several factors, including symptoms, disease stage, extent of tumor burden, and prognosis. Positron emission tomography scanning can be used to assess the patient's stage of disease, which can allow further individualization of therapy. Traditional frontline treatment options include doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and, for high-risk patients, bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP). Autologous stem cell transplantation cures approximately 50% of patients. The antibody-drug conjugate brentuximab vedotin is very active in relapsed/refractory Hodgkin lymphoma. Data presented at the 2014 meeting of the American Society of Hematology (ASH) showed that brentuximab vedotin was beneficial in several settings, including as consolidation therapy posttransplant in patients at high risk for relapse, as first-line salvage therapy in relapsed/refractory Hodgkin lymphoma prior to autologous hematopoietic cell transplantation, and in combination with bendamustine in relapsed/refractory disease. The ASH meeting also offered promising data on novel agents, such as the programmed cell death 1 (PD-1) inhibitors. In this monograph, 4 experts in the management of Hodgkin lymphoma discuss various aspects of the disease and provide their perspectives on the new data presented at the ASH meeting.

Following aggressive B-cell lymphoma.

In this issue of Blood, Kurtz et al report the potential clinical utility of immunoglobulin high-throughput sequencing as a tool for disease monitoring and surveillance in aggressive B-cell lymphoma.