James Dickerson's research while affiliated with Stanford University and other places

11157 Background: Pre-menopausal women with early-stage ER-positive BC often desire the option for future fertility. The POSITIVE trial demonstrated that a pause in ET to conceive is safe. However, the real-world durations of these pauses, as well as how many patients resume ET, are unclear. Additionally, there are limited data about when and if women reestablish imaging surveillance after childbirth. Methods: We generated a cohort of BC patients with a pregnancy-related ICD diagnosis from the Oncoshare registry. This registry merges EMR and California Cancer Registry data for patients treated in the Stanford Health Care Alliance which includes an academic hospital, a community hospital, and a community practice network. Included patients had ≥1 pregnancy after a diagnosis of stage 0-3 ER-positive BC. Chart review confirmed pregnancy and was used to abstract treatment information. Data are presented as unadjusted percentages or medians with interquartile ranges (IQR). Among patients without bilateral mastectomies, we compared time from delivery to first imaging (MRI or mammogram) for those who breastfed vs not and those who restarted ET vs not using the Wilcoxon rank sum test. Results: Of the 317 charts reviewed, 71 were included. Most exclusions were due to no pregnancy (46%) or ER-negative disease (25%). Year of diagnosis ranged from 1994 to 2020, with the majority (79%) from 2010 to 2020. Median age at diagnosis was 33 years (IQR 30-35). The distribution of stages was 18% in situ disease, 51% stage 1, 17% stage 2, 14% stage 3. 23% (16/71) of women never started ET, with 14 attributing this decision to desiring pregnancy. Among the 55 women who started ET, 75% received tamoxifen without ovarian suppression (OS). After 2015, use of OS became more prevalent (45% of ET), coinciding with the emergence of the SOFT/TEXT data. The median time from ET onset to a pause for pregnancy was 32 months (IQR 22-53), and the median ET pause to delivery was 23 months (IQR 14-48). We recorded 90 pregnancies resulting in 85 live births. After delivery of their first child, the median follow-up was 3.8 years (IQR 2.0-6.8). 40% of patients never restarted ET. Those who did restart did so at a median of 5 months (IQR 3-11) post-delivery. Imaging surveillance resumed for 42% (27/64) at a median of 6 months post-delivery [IQR 3-11]. Time from delivery to imaging was similar between those who restarted ET and those who did not (p=0.91), and between those who breastfeed and those who did not (p=0.42). Conclusions: These data support prior work showing that fertility concerns strongly influence adjuvant therapy choice in ER-positive BC. The ET resumption rate after pregnancy was lower in our analysis compared to the POSITIVE trial (73% vs. 40%). Only 42% of women resumed surveillance imaging. This points to clear gaps between the clinical trial population and the real-world clinical setting.

1590 Background: In the U.S., locoregional surgery for de novo mBC was common in the 1990s and 2000s, but subsequent prospective data did not show a survival advantage. Current guidelines recommend surgery only for symptom control. We investigated trends in the use of surgery (lumpectomy or mastectomy) for mBC from 2010 to 2019 using SEER and institutional data, aiming to identify factors that correlate with variability in surgery use. Methods: We included all de novo mBC diagnoses from SEER-17 from 2010-2019. The primary outcome was receipt of surgery, and we included year of diagnosis, demographic (race/ethnicity, age, marital status, median household income in the patient’s county, and urban/rural residence), and disease factors (estrogen receptor (ER) and HER2 status, tumor size, and presence of visceral metastases) in the multivariable logistic regression. We similarly identified all de novo mBC diagnoses from Oncoshare, which merges EMR and California Cancer Registry (CCR) data for patients treated in the Stanford Health Care Alliance. For Oncoshare inclusion a patient must have an encounter with Stanford and be in CCR; however, a patient does not have to receive all cancer care at Stanford. In this analysis, we included distance to the cancer center and insurance status. Results are presented as unadjusted percentages or odds ratios with 95% confidence intervals. Results: In SEER (n = 24,146), the use of surgery for mBC declined from 41% in 2010 to 22% in 2019, a trend also observed in the institutional data (n = 785). Surgery rates were highest in younger patients and declined with each decade of life (44% for those in their 30s vs 19% for those > 80). Surgery was more common in tumors > 2 cm, ER-negative disease, and in patients without visceral metastases. In SEER, patients from counties with median incomes < $50,000 were more likely to have surgery than those from counties with incomes > $75,000 (36% vs 27%; OR: 1.3 [1.2-1.5]). Rural patients were more likely to have surgery than urban patients (34% vs 30%; OR: 1.1 [1.0-1.3]). Unmarried persons had lower odds of surgery than married persons (OR: 0.8 [0.7-0.9]). The institutional data reproduced the findings of the SEER analysis, except that a relationship between surgery and marital status and income was not observed. In the institutional data, patients living farther from the Stanford Cancer Center ( > 100 km) were more likely to have surgery (40% vs 32%; OR 2.1 [1.2-3.8]). Conclusions: The use of surgery for de novomBC decreased dramatically in the 2010s from 41% to 22%. All demographics saw a reduction; however, younger, and married patients underwent surgery at higher rates. Patients from lower-income and rural counties—areas typically with less access to care—were also more likely to have surgery. The institutional analysis showed that a greater distance from an urban hospital network correlated with increased odds of surgery. These patterns suggest differential care provision in rural areas for patients with mBC.

e24188 Background: Discordance between patient understanding and physician recorded treatment intent is well documented in high income countries. A large fraction of patients report their palliative intent therapy is curative. We sought to find the discordance rate between patient and physician reported intent in Belize, a low- and middle-income country (LMIC) with a single public oncology clinic, founded in 2018, staffed by a single bilingual medical oncologist who is undertaking additional training in palliative care. In 2022, we surveyed established patients on chemotherapy to assess their understanding of treatment purpose. Methods: Approval was obtained at the Karl Heusner Memorial Hospital and the University of Rochester IRB prior to the study. Between February and March 2022, patients who consented were given a 21-question survey. Here we report on one portion of this survey. Patients with both patient and physician reported data were compared with a McNamar's exact test; a pre-specified exact logistic regression was run to examine potential predictors of patient/provider discordance (age, race, number of days from first chemotherapy to survey administration, patient's primary language). A p-value of 0.05 was used for significance. Results: 29 surveyed patients had both physician- and patient-reported treatment intent; surveys were administered a median of 42 days after first chemotherapy (IQR 26 – 116). 61% (18 of 29) of the sample was on palliative intent treatment. Median age was 51 (IQR 43 – 62) and cancer types were as follows: 45% breast, 24% GI, 24% gynecological, 3.4% head/neck, 3.4% lymphoma. 97% agreed their doctor spoke medical language they understand and 90% agreed they had enough information about their treatment. 31% mis-classified their treatment intent (p = 0.004). All 9 patients who mis-classified stated their palliative intent treatment was curative; this was 50% (9 of 18) of the palliative intent patients. We found no relationship between patient/provider discordance and age, race, number of days from first chemotherapy to survey administration, or patient’s primary language. Conclusions: We surveyed cancer patients in Belize and found that half of the patients on palliative intent therapy thought their treatment was curative. Despite this gap in understanding, 97% reported they understood the medical language being spoken and 90% of the patients agreed that they had good knowledge of their treatment. The amount of discordance described here is similar to reports in high income countries. Most palliative care, and palliative care research, is performed in high income settings. Implementation research with the aim of reducing physician/patient discordance in high-income countries should consider design elements that allow for adaptation to LMICs.

Purpose: Belize is a middle-income Caribbean country with a fragmented healthcare system. In 2018, the first and only public medical oncology clinic was opened through a capacity building partnership with the Ministry of Health. Little is known about the country’s referral infrastructure for cancer. Here we report on the stage at presentation to the clinic, and the time from symptom development to various care milestones (biopsy, oncology clinic visit, chemo, upfront surgery), referred to as time-to-care, to establish a base timeline. Methods: We performed a retrospective review of available data at the Karl Heusner Memorial Hospital (KHMH) oncology clinic from 2018 - 2022, gathering cancer type, stage, and the dates of care milestones (biopsy, initial clinic visit, chemo, upfront surgery). Date of symptom development was consistently documented by the treating physician (RY). Results: The most common presenting malignancies (n=465) were breast (28%), cervical (12%), hematologic (8%), and colorectal (7%). For staged patients (n=352), the most common presentations were stage III (28%) and IV (40%). For time-to-care, patients with available data (n=208) were seen for an initial oncology clinic visit a median of 180 days (IQR 87-382) after self-reported symptom development. For time-to-chemo at any site (ex. Belize, Mexico, Guatemala), the median was 189 days (IQR 108-404). For upfront surgery at any site the median was 188 days (IQR 60-352). In contrast to these long lead times, once established at the KHMH clinic, the time from the initial oncology clinic visit to a biopsy (if not done previously) was 22 days (IQR 11-47, n=42), 18 days (IQR 5-60, n=115) to begin chemo, and 40 days (IQR 24-72, n=22) to surgery. Conclusion: Patients were seen at the KHMH oncology clinic with predominantly late stage disease around six months after symptoms started. This is a higher fraction of stage III/IV disease than previously reported in Central America. Understanding drivers of these delays will allow for the creation of targeted public health interventions. As a marker that building infrastructure in Belize is possible, the partnership between the Belizean government and hospital administration has netted time-to-care intervals comparable to high-income nations. Citation Format: Wayne Wong, James Dickerson, Martha Habet, Margaret Bernard, Lorna Kelly, John Lattin, Philip Garrity, Franklin Huang, Ramon Yacab. Time From Symptom Development to Care Milestones at the Only Public Oncology Clinic in Belize [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 87.

e24007 Background: In low- and middle-income countries (LMICs) such as Belize, large fractions of healthcare costs are borne directly by patients. In these settings of minimal insurance coverage and a fragmented healthcare system, evaluating the extent of financial toxicity is paramount to understanding direct barriers to care delivery. We surveyed Belizean cancer patients in 2022 who were receiving chemotherapy at the only public oncology clinic in the country, established at the Karl Heusner Memorial Hospital (KHMH) in 2018, to quantify financial toxicity. Methods: A convenience sample of patients at the KHMH oncology clinic were surveyed between February and March 2022. Patients who consented during their infusion appointment were given a tablet with a 21-question survey (English or Spanish). This survey was developed from the FACT-G and COST tools adapted specifically for LMIC settings. Answers were on a 5-point Likert scale. We provide descriptive statistics of the population and survey responses. Results: Median age of survey participants (n = 32) was 51 (IQR 43 – 62), 84% were female and 53% unemployed. 71% were uninsured. Those insured were covered by the Belizean government’s National Health Insurance which does not include oncologic care. Most patients (72%) had traveled from another district for treatment at the clinic in Belize City. Cancer types represented were breast (42%), gastrointestinal (27%), gynecologic (27%), and lymphoma (4%); 75% of patients had either stage 3 or 4 disease. 56% agreed with the statement “I am having financial problems with cancer treatment,” 31% disagreed, and 13% neither agreed nor disagreed. Patients were allowed to indicate multiple contributors to financial hardship during treatment, with costs of chemotherapy cited most often (50% of patients), followed by transportation costs (38%), hospital fees (22%), food (12%), and housing (9%). 25% of respondents agreed with the prompt “It is difficult to come to all of my appointments,” with transportation being the most cited reason (88%). Conclusions: In our survey, more than half of Belizean cancer patients on chemotherapy reported financial hardship with their treatment. Drivers of toxicity were the cost of chemotherapy and travel. Our sample, predominately female, unemployed, uninsured, and from less wealthy districts, had sociodemographic factors that suggest a high risk for financial toxicity during cancer treatment. Though limited by the small sample size, this study prompts further investigation and more precise quantification of financial toxicity in Belize. These preliminary data have begun conversations within the Ministry of Health for inclusion of chemotherapy under the covered medications list by public health institutions.

Background Belize is a middle-income Caribbean country with poorly described cancer epidemiology and no comprehensive cancer care capacity. In 2018, GO, Inc., a US-based NGO, partnered with the Ministry of Health and the national hospital in Belize City to create the first public oncology clinic in the country. Here, we report demographics from the clinic and describe time intervals to care milestones to allow for public health targeting of gaps. Patients and Methods Using paper charts and a mobile health platform, we performed a retrospective chart review at the Karl Heusner Memorial Hospital (KHMH) clinic from 2018 to 2022. Results During this time period, 465 patients with cancer presented to the clinic. Breast cancer (28%) and cervical cancer (12%) were most common. Most patients (68%) presented with stage 3 or 4 disease and were uninsured (78%) and unemployed (79%). Only 21% of patients ever started curative intent treatment. Median time from patient-reported symptoms to a biopsy or treatment was 130 and 189 days. For the most common cancer, breast, similar times were seen at 140 and 178 days. Time intervals at the clinic: <30 days from initial visit to biopsy (if not previously performed) and <30 days to starting chemotherapy. Conclusion This study reports the first clinic-based cancer statistics for Belize. Many patients have months between symptom onset and treatment. In this setting, the clinic has built infrastructure allowing for minimal delays in care despite an underserved population. This further affirms the need for infrastructure investment and early detection programs to improve outcomes in Belize.

e18643 Background: Breast cancer is the most common cancer in low and middle-income countries. Belize, a middle-income country in the Caribbean with significant inequality, lacks a national screening program and has limited treatment capacity. There are no studies describing breast cancer characteristics in Belize in the available literature. We collected data from the sole public oncology clinic in the country, established in 2018 at Karl Heusner Memorial Hospital (KHMH), to describe the characteristics of breast cancer patients and establish baseline measurements of time to chemotherapy initiation for the curative intent treatment population; the aim being to identify potential areas for quality improvement. Methods: We performed a retrospective chart review of available patient data from December 2020 to December 2021. We examined the time from a patient’s initial visit at KHMH until chemotherapy initiation (TCI) in the neoadjuvant setting with patients stratified by stage. Significant outliers (predominantly patients with misclassified data or those with private access to physicians and therapeutics) were excluded. Results: The clinic provided care for 80 patients with biopsy-proven breast cancer between December 2020 to December 2021. Patients were 97% female with a median age of 55 (Range: 34-81). For stageable patients (n=75), 33% presented with clinically localized disease, 49% with locally advanced, and 17% with recurrent or metastatic disease. Of the 51 patients on chemotherapy, 57% were receiving preoperative treatment, 31% were on adjuvant therapy, and 12% on palliative therapy. Patients not on therapy (n=29) at KHMH were either in surveillance, referred to a private cancer center, or deceased. Neoadjuvant TCI was calculated for 21 patients after the removal of outliers (n=5). The majority of these patients arrived at their initial clinic visit with a biopsy-proven diagnosis. Mean TCI for early stage disease was 49 days (n=7, 95% CI [9, 89]) and locally advanced disease was 36 days (n=14, 95% CI [12, 61]). Aggregate mean TCI was 40 days (n=21, 95% CI [19, 62]). Conclusions: In Belize, breast cancer affects younger women and patients present with later stages of disease than in high-income countries; however, time to chemotherapy initiation in a small sample of neoadjuvant patients at the Belizean clinic was comparable. Given the inherent limitations of small samples of data, additional investigation is needed to support these findings, as well as to delineate patient barriers to access and potential for improvements in clinic follow-up. Nevertheless, indications of a robust TCI call for further characterization of this newly established cancer clinic and its practices.

e18787 Background: Belize is a middle-income Caribbean country without comprehensive cancer care capacity and poorly described cancer epidemiology. In 2020, we reported some of the first cancer demographics from the country. This was made possible by a capacity building partnership with the only public oncology clinic in the country at Karl Heusner Memorial Hospital (KHMH). Here we provide an update on demographic trends at this clinic. Methods: We performed a retrospective chart review of all available patient data at the KHMH clinic from December 2020 to December 2021. This was compared to data from the clinic’s founding in 2018 through its first 12 months. Results: From December 2020 through December 2021, the clinic saw 332 patients, an increase of 141% from the 236 patients seen over the first 12-month period of the clinic. In 2021, 250 (75%) patients had a confirmed pathologic diagnosis of cancer, with 78 (23%) remaining under clinical suspicion. This is in comparison to 63% of patients with a pathologic diagnosis in 2018. H&E staining alone remained the only publicly available pathologic service. Patients were predominantly female (67%) with a median age of 54 (Range: 2-95). The most common histologies (n = 332) were breast (29%), cervical (11%), colorectal (8%), prostate (4%), gastric (4%), and lung (3%). Of patients with histologically confirmed cancer, 221 (66%) were able to be fully staged. Patients predominantly presented with later stage disease (25% Stage III, 34% Stage IV). At the end of 2021, out of all patients tracked longitudinally over the year (n = 332), 24% remained in need of full diagnostic assessment, 34% were on curative treatment (predominantly cytotoxic chemotherapy), 22% were under surveillance, and 18% were receiving palliative chemotherapy or best supportive care due to advanced disease. This is in comparison to 2018, when there was no capacity to administer chemotherapy at KHMH and patients were referred to either private clinics or out of the country. Conclusions: The burden of cancer in Belize is significant and diverse. Compared to 2018, in 2021, the number of patients seen at KHMH increased 141%, as did the percentage of patients with histologically confirmed cancer (120% increase). Chemotherapy treatment was made possible through procurement of a chemotherapeutic stock at KHMH due to key partnerships with the Belizean government, hospital administration, and crucially, the only medical oncologist in the nation. This has led to chemotherapy being available at a public clinic in the country for the first time. Despite this progress, patients continue to present at late stages and many cannot access cancer care due to limited resources, cost, and low public awareness. This further affirms the need for infrastructure investment and early detection programs to improve cancer outcomes in Belize.

11011 Background: For new fellows, learning clinical oncology represents an enormous challenge. Few data support specific didactic approaches. The senior author (TPJ) developed a novel curriculum, emphasizing deliberate practice as part of a design grounded in Ericsson’s “expert performance approach”. These noon conferences are case based with a focus on key clinical trials and NCCN guidelines. In comparison to didactics given directly by faculty, these conferences are primarily presented by a senior teaching fellow with an invited faculty member adding additional commentary as an “expert discussant”. We surveyed fellows to assess perception of efficacy and also created a board style test to evaluate knowledge gains. Methods: The curriculum began in 2020. After one year, we surveyed fellows with a five-point likert scale survey to quantify their perception of the curriculum. In 2022, we created a pair of 18-question lung cancer specific board style tests for the five teaching sessions on lung cancer. Prior to the first conference, the pre-test was sent to fellows electronically; after the final lecture the other 18-question test was sent out. Differences in the overall cohort’s test score were examined via a paired student t-test. Results: On the 2021 survey, 59% of fellows responded (17 of 29). Of the respondents, 83% attended at least half of the lectures (14 of 17). When asked to compare this conference series to traditional lecture-based series, 59% (10 of 17) agreed with the statement that "this series is one of the very best I've encountered" and all said it was at least “better than average.” 94% of respondents (16 of 17) said the series equipped them for clinical practice to either a “significant” or “remarkable” degree. 94% of respondents (16 of 17) agreed the conferences helped them learn to “think like oncologists.” For the five session lung cancer block, fellows reported attending an average of 3.6 ± 1.4 sessions (n = 13). On the 18-question pre-test (n = 19), the average score ± one standard deviation was 73% ± 15%. For the post-test (n = 13), the average was 68% ± 17% (p = 0.48). Conclusions: We developed a novel curriculum to replace traditional didactics. Fellows perceived the curriculum to be exceptionally strong as compared to traditional lecture series, felt it prepared them well for practice, and said it taught them to think like oncologists. Pre/post knowledge assessments did not show an improvement in knowledge. Distribution to larger numbers of fellows–especially early learners–may better power a study to detect improvements in learning.

Purpose Patient-reported outcome measurements (PROMs) are increasingly used for cancer patients receiving active treatment, but little is known about the implementation and usefulness of PROMs in cancer survivorship care. This systematic review evaluates how cancer survivors and healthcare providers (HCPs) perceive PROM implementation in survivorship care, and how PROM implementation impacts cancer survivors’ health outcomes. Methods We systematically searched PubMed/MEDLINE, Embase, CINAHL, Web of Science, and Cochrane Database of Systematic Reviews from database inception to February 2022 to identify randomized and nonrandomized studies of PROM implementation in cancer survivors. Results Based on prespecified eligibility criteria, we included 29 studies that reported on 26 unique PROMs. The studies were heterogeneous in study design, PROM instrument, patient demographics, and outcomes. Several studies found that cancer survivors and HCPs had favorable impressions of the utility of PROMs, and a few studies demonstrated that PROM implementation led to improvements in patient quality of life (QoL), with small to moderate effect sizes. Conclusions We found implementation of PROMs in cancer survivorship care improved health outcomes for select patient populations. Future research is needed to assess the real-world utility of PROM integration into clinical workflows and the impact of PROMs on measurable health outcomes. Implications for Cancer Survivors. Cancer survivors accepted PROMs. When successfully implemented, PROMs can improve health outcomes after completion of active treatment. We identify multiple avenues to strengthen PROM implementation to support cancer survivors.