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P. Connor Johnson, Netana H. Markovitz, Tamryn F. Gray, Sunil Bhatt, Ryan D. Nipp, Nneka Ufere, Julia Rice, Matthew J. Reynolds, Mitchell W. Lavoie, Carlisle E.W. Topping, Madison A. Clay, Charlotta Lindvall, and Areej El-Jawahri

Background: Social support plays a crucial role for patients with aggressive hematologic malignancies as they navigate their illness course. The aim of this study was to examine associations of social support with overall survival (OS) and healthcare utilization in this population. Methods: A cross-sectional secondary analysis was conducted using data from a prospective longitudinal cohort study of 251 hospitalized patients with aggressive hematologic malignancies at Massachusetts General Hospital from 2014 through 2017. Natural Language Processing (NLP) was used to identify the extent of patients’ social support (limited vs adequate as defined by NLP-aided chart review of the electronic health record). Multivariable regression models were used to examine associations of social support with (1) OS, (2) death or readmission within 90 days of discharge from index hospitalization, (3) time to readmission within 90 days, and (4) index hospitalization length of stay. Results: Patients had a median age of 64 years (range, 19–93 years), and most were White (89.6%), male (68.9%), and married (65.3%). A plurality of patients had leukemia (42.2%) followed by lymphoma (37.9%) and myelodysplastic syndrome/myeloproliferative neoplasm (19.9%). Using NLP, we identified that 8.8% (n=22) of patients had limited social support. In multivariable analyses, limited social support was associated with worse OS (hazard ratio, 2.00; P=.042) and a higher likelihood of death or readmission within 90 days of discharge (odds ratio, 3.11; P=.043), but not with time to readmission within 90 days or with index hospitalization length of stay. Conclusions: In this cohort of hospitalized patients with aggressive hematologic malignancies, we found associations of limited social support with lower OS and a higher likelihood of death or readmission within 90 days of hospital discharge. These findings underscore the utility of NLP for evaluating the extent of social support and the need for larger studies evaluating social support in patients with aggressive hematologic malignancies.

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Julie E.M. Swillens, Quirinus J.M. Voorham, Iris D. Nagtegaal, and Rosella P.M.G. Hermens

Background: Standardized structured reporting (SSR) improves quality of diagnostic cancer reporting and interdisciplinary communication in multidisciplinary team (MDT) meetings, resulting in more adequate treatment decisions and better health outcomes. However, use of SSR varies widely among pathologists, but might be encouraged by MDT members (MDTMs). Our objectives were to identify barriers and facilitators (influencing factors) for SSR implementation in oncologic pathology from the perspective of MDTMs and their determinants. Methods: In a multimethod design, we identified influencing factors for SSR implementation related to MDT meetings, using 5 domains: (1) innovation factors, (2) individual professional factors, (3) social setting factors, (4) organizational factors, and (5) political and legal factors. Four focus groups with MDTMs in urologic, gynecologic, and gastroenterologic oncology were conducted. We used an eSurvey among MDTMs to quantify the qualitative findings and to analyze determinants affecting these influencing factors. Results: Twenty-three MDTMs practicing in 9 oncology-related disciplines participated in the focus groups and yielded 28 barriers and 28 facilitators in all domains. The eSurvey yielded 211 responses. Main barriers related to lack of readability of SSR: difficulties with capturing nuances (66%) and formulation of the conclusion (43%); lack of transparency in the development (50%) and feedback processes of SSR templates (38%); and lack of information exchange about SSR between pathologists and other MDTMs (45%). Main facilitators were encouragement of pathologists’ SSR use by MDTMs (90%) and expanding the recommendation of SSR use in national guidelines (80%). Oncology-related medical discipline and MDT type were the most relevant determinants for SSR implementation barriers. Conclusions: Although SSR makes diagnostic reports more complete, this study shows important barriers in implementing SSR in oncologic pathology. The next step is to use these factors for developing and testing implementation tools to improve SSR implementation.

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Yao Zhu, Yu Wei, Hao Zeng, Yonghong Li, Chi-Fai Ng, Fangjian Zhou, Caiyun He, Guangxi Sun, Yuchao Ni, Peter K.F. Chiu, Jeremy Y.C. Teoh, Beihe Wang, Jian Pan, Fangning Wan, Bo Dai, Xiaojian Qin, Guowen Lin, Hualei Gan, Junlong Wu, and Dingwei Ye

Background: Although China accounts for 7.8% of worldwide new prostate cancer (PCa) cases and 14.5% of new deaths according to GLOBOCAN 2020, the risk of PCa associated with germline mutations is poorly defined, hampered in part by lack of nationwide evidence. Here, we sequenced 19 PCa predisposition genes in 1,836 Chinese patients with PCa and estimated disease risk associated with inherited mutations. Patients and Methods: Patients were recruited from 4 tertiary cancer centers (n=1,160) and a commercial laboratory (n=676). Germline DNA was sequenced using a multigene panel, and pathogenic/likely pathogenic (P/LP) mutation frequencies in patients with PCa were compared with populations from the gnomAD (Genome Aggregation Database) and ChinaMAP (China Metabolic Analytics Project) databases. Clinical characteristics and progression-free survival were assessed by mutation status. Results: Of 1,160 patients from hospitals, 89.7% had Gleason scores ≥8, and 65.6% had metastases. P/LP mutations were identified in 8.49% of Chinese patients with PCa. Association with PCa risk was significant for mutations in ATM (odds ratio [OR], 5.9; 95% CI, 3.1–11.1), BRCA2 (OR, 15.3; 95% CI, 10.0–23.2), MSH2 (OR, 15.8; 95% CI, 4.2–59.6), and PALB2 (OR, 5.9; 95% CI, 2.7–13.2). Compared with those without mutations, patients with mutations in ATM, BRCA2, MSH2, or PALB2 showed a poor outcome with treatment using androgen deprivation therapy and abiraterone (hazard ratio, 2.19 [95% CI, 1.34–3.58] and 2.47 [95% CI, 1.23–4.96], respectively) but similar benefit from docetaxel. Conclusions: The present multicenter study confirmed that a significant proportion of Chinese patients with PCa had inherited mutations and identified predisposition genes in this underreported ethnicity. These data provide empirical evidence for precision prevention and prognostic estimation in Chinese patients with PCa.

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Aida Bujosa, Consolación Moltó, Thomas J. Hwang, José Carlos Tapia, Kerstin N. Vokinger, Arnoud J. Templeton, Ignasi Gich, Agustí Barnadas, Eitan Amir, and Ariadna Tibau

Background: Most anticancer drugs are approved by regulatory agencies based on surrogate measures. This article explores the variables associated with overall survival (OS), quality of life (QoL), and substantial clinical benefit among anticancer drugs at the time of approval and in the postmarketing period. Methods: Anticancer drugs approved by the FDA between January 2006 and December 2015 and with postmarketing follow-up until April 2019 were identified. We evaluated trial-level data supporting approval and any updated OS and/or QoL data. We applied the ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) and the ASCO Value Framework (ASCO-VF) to initial and follow-up studies. Results: We found that 58 drugs were approved for 96 indications based on 96 trials. At registration, approval was based on improved OS in 39 trials (41%) and improved QoL in 16 of 45 indications (36%). Postmarketing data showed an improvement in OS for 28 of 59 trials (47%) and in QoL for 22 of 48 indications (46%). At the time of approval, 25 of 94 (27%) and 26 of 80 scorable trials (33%) met substantial benefit thresholds using the ESMO-MCBS and ASCO-VF, respectively. In the postmarketing period, 37 of 69 (54%) and 35 of 65 (54%) trials met the substantial benefit thresholds. Drugs with companion diagnostics and immune checkpoint inhibitors were associated significantly with substantial clinical benefit. Conclusions: Compared with the time of approval, more anticancer drugs showed improved OS and QoL and met the ESMO-MCBS or ASCO-VF thresholds for substantial benefit over the course of postmarketing time. However, only approximately half of the trials met the threshold for substantial benefit. Companion diagnostic drugs and immunotherapy seemed to be associated with greater clinical benefit.

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Anusha Ponduri, David Z. Liao, Nicolas F. Schlecht, Gregory Rosenblatt, Michael B. Prystowsky, Rafi Kabarriti, Madhur Garg, Thomas J. Ow, Bradley A. Schiff, Richard V. Smith, and Vikas Mehta

Background: Nonadherence to NCCN Guidelines during time from surgery to postoperative radiotherapy (S-PORT) can alter survival outcomes in head and neck squamous cell carcinomna (HNSCC). There is a need to validate this impact in an underserved urban population and to understand risk factors and reasons for delay. We sought to investigate the impact of delayed PORT with outcomes of overall survival (OS) in HNSCC, to analyze predictive factors of delayed PORT, and to identify reasons for delay. Methods: We conducted a retrospective cohort study in an urban, community-based academic center. A total of 184 patients with primary HNSCC were identified through the Montefiore Medical Center cancer registry who had been treated between March 1, 2005, and March 8, 2017, and met the inclusion and exclusion criteria. The primary exposure was S-PORT. OS, recurrence, and risk factors and reasons for treatment delay were the main outcomes and measures. Results: Among 184 patients with HNSCC treated with PORT, the median S-PORT was 48.5 days (interquartile range, 41–67 days). The S-PORT threshold that optimally differentiated worse OS outcomes was >50 days (46.7% of our cohort; n=86). Independent of other relevant factors, patients with HNSCC and S-PORT >50 days had worse OS (hazard ratio, 2.30; 95% CI, 1.34–3.95) and greater recurrence (odds ratio, 3.51; 95% CI, 1.31–9.39). Predictors of delayed S-PORT included being underweight or obese, prolonged postoperative length of stay, and age >70 years. The most frequent reasons for PORT delay were complications related to surgery (22.09%), unrelated medical comorbidities (18.60%), and nonadherence/missed appointments (6.98%). Conclusions: Delayed PORT beyond 50 days after surgery was associated with decreased OS and greater recurrence. Identification of predictive factors and reasons for treatment delay helps to target at-risk patients and facilitates interventions in underserved populations.

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Patrick A. Brown, Bijal Shah, Anjali Advani, Patricia Aoun, Michael W. Boyer, Patrick W. Burke, Daniel J. DeAngelo, Shira Dinner, Amir T. Fathi, Jordan Gauthier, Nitin Jain, Suzanne Kirby, Michaela Liedtke, Mark Litzow, Aaron Logan, Selina Luger, Lori J. Maness, Stephanie Massaro, Ryan J. Mattison, William May, Olalekan Oluwole, Jae Park, Amanda Przespolewski, Sravanti Rangaraju, Jeffrey E. Rubnitz, Geoffrey L. Uy, Madhuri Vusirikala, Matthew Wieduwilt, Beth Lynn, Ryan A. Berardi, Deborah A. Freedman-Cass, and Mallory Campbell

The NCCN Guidelines for Acute Lymphoblastic Leukemia (ALL) focus on the classification of ALL subtypes based on immunophenotype and cytogenetic/molecular markers; risk assessment and stratification for risk-adapted therapy; treatment strategies for Philadelphia chromosome (Ph)-positive and Ph-negative ALL for both adolescent and young adult and adult patients; and supportive care considerations. Given the complexity of ALL treatment regimens and the required supportive care measures, the NCCN ALL Panel recommends that patients be treated at a specialized cancer center with expertise in the management of ALL This portion of the Guidelines focuses on the management of Ph-positive and Ph-negative ALL in adolescents and young adults, and management in relapsed settings.

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Efrat Dotan, Louise C. Walter, Ilene S. Browner, Katherine Clifton, Harvey Jay Cohen, Martine Extermann, Cary Gross, Sumati Gupta, Genevieve Hollis, Joleen Hubbard, Reshma Jagsi, Nancy L. Keating, Elizabeth Kessler, Thuy Koll, Beatriz Korc-Grodzicki, June M. McKoy, Sumi Misra, Dominic Moon, Tracey O’Connor, Cynthia Owusu, Ashley Rosko, Marcia Russell, Mina Sedrak, Fareeha Siddiqui, Amy Stella, Derek L. Stirewalt, Ishwaria M. Subbiah, William P. Tew, Grant R. Williams, Liz Hollinger, Giby V. George, and Hema Sundar

The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.

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Terrell Johnson, Michelle McMurry-Heath, Ted Okon, David Rubin, and Robert W. Carlson

The cost of delivering high-quality healthcare in America now consumes 17.7% of the nation’s gross domestic product according to Centers for Medicare & Medicaid Services National Health Expenditure Data. With costs threatening to disrupt accessible and equitable care for patients, policymakers are reassessing all matters and functions of the healthcare system to excise waste, redundancies, and costly services. To explore this subjects’ impact on oncology, NCCN hosted the NCCN Policy Summit: Innovative Solutions to Drive Down Healthcare Costs: Implications for Access to High Quality Cancer Care. This virtual summit featured multidisciplinary panel discussions and keynote addresses. Seeking to address barriers to low-cost, high-quality cancer care, panelists and keynotes presented innovative policy solutions to sustain high-quality oncologic care at lower costs to the health system. This article encapsulates the discussions held during the summit and expounds upon salient points where appropriate.