Are cancer patients receiving biomarker tests? How is remote patient monitoring working in a real-world setting? Beyond results from major randomized clinical trials, the 2021 annual meeting of the American Society of Clinical Oncology (ASCO) offered an opportunity to present findings from everyday clinical practice, including studies presented by Strategic Alliance Partners of The American Journal of Managed Care®. A sampling of the results are below.
MYLUNG Consortium Finds Gaps
The first set of results presented by the MYLUNG Consortium, which includes members of The US Oncology Network, major pharmaceutical partners, and advocacy groups, revealed significant gaps in biomarker testing in non–small cell lung cancer (NSCLC), found that most cancers are detected at stage IV, and showed that the time from diagnosis to the start of first-line therapy takes about 5 weeks.1
Makenzi Evangelist, MD, the principal investigator for the MYLUNG Consortium Protocol 2 and an oncologist with New York Oncology Hematology, who presented the results at ASCO, said the retrospective, observational chart study found that testing gaps and delays are keeping patients from getting treatment they need in timely manner.
“There are already several targeted therapies to treat subsets of populations, and many more are in the pipeline that hold incredible potential,” she said. “Unfortunately, barriers exist that prevent the necessary comprehensive biomarker testing that enables the use of these treatments.”
The MYLUNG Consortium is a collaborative study that will conduct 3 protocols over a 5-year period. Protocol 1, presented at ASCO, is a retrospective study of more than 3500 patients with metastatic NSCLC that investigated the following areas: testing rates for ALK, BRAF, EGFR, ROS1, and PD-L1 mutations; use of the full next-generation sequencing panel (NGS); time from NSCLC diagnosis to first-line therapy; turnaround times from biomarker orders to results; and time from NSCLC diagnosis to test results.
Protocol 1 found that while 90% of patients were given at least 1 biomarker test, only 46% received testing for 5 or more biomarkers. As a result, many missed out on the chance for a targeted therapy. Also, the median time from diagnosis to first-line therapy was about 5 weeks. Turnaround time from testing orders to results was about 2 weeks, which shows a need to get results to physicians more quickly to develop a treatment regimen. NGS testing improved over time, suggesting that comprehensive testing is increasing. Most of the population was diagnosed with advanced disease, with roughly 80% detected at stage IV.
Texas Oncology Highlights Tech Improvements to Help Patients
In a pair of presentations, Texas Oncology’s Lalan Wilfong, MD; and Debra Patt, MD, PhD, MBA, highlighted implementation of patient management technologies to reduce trips to the emergency department (ED)2 and to implement electronic patient-reported outcomes (ePROs)3 across more
than 200 sites in the community oncology network.
Through a partnership with Navigating Cancer, Texas Oncology first implemented a new protocol and tracking system to reduce call-back times, which were a consistent source of complaints; failure to respond to patient calls often resulted in patient ED visits during business hours. Wilfong presented data to show that implementation of a new tracking system in February 2020, which tracked 1 million calls for through the end of the year. Average response time for each incident fell from 3.2 hours to 2.2 hours by December 2020. The goal was to resolve most calls in 90 minutes, and by December 2020, 60% of calls were resolved in less than 1 hour. Of note, 8% of symptom-related incidents that would likely have otherwise resulted in an ED visit were averted by nurse intervention.
Patt discussed use of Navigating Cancer technology for collection of ePROs, as many value-based care models encourage the collection of these data to improve patient outcomes, patient satisfaction, and adherence to therapeutic regimens. Texas Oncology began using the platform in July 2020, and data collection reflects the period through December 2020. Patients were given
a choice to be prompted via text or email to self-report common symptoms and well-being status on a web site or by smartphone. Severe symptoms could be reported in real time, and such reports triggered an alert to a nurse to address the symptom. Compliance was addressed each week, with an evaluation of barriers to reporting. Over the study period, 4375 patients enrolled in the program
and entered baseline data; 61% of the patients were female, and 75% of the patients were older than 55 years. Compliance with weekly reporting began at 72% and fell to 52% over 10 weeks.
Patients taking oral therapy had better compliance rates. Items about implementation that were addressed included the lack of a second prompt; inconsistent discussion of ePROs during clinic visits; and COVID-19–related changes in the workfl ow that may affect data collection. The authors concluded, “Utilization of ePROs is high, but [it] diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.” Patients taking oral therapy had better compliance rates. Items about implementation that were addressed included the lack of a second prompt; inconsistent discussion of ePROs during clinic visits; and COVID-19–related changes in the workflow that may affect data collection.
In OCM, Costs in Clinical Trials Were Less Than Those in Routine Care
Does participation in a clinical trial add to a payer’s costs? A study by Tennessee Oncology that
examined data from 90 oncologists over a 2-year period suggests that trial participation can, in
fact, save money.4 Investigators created matched comparator groups for patients in the Oncology
Care Model (OCM) to measure the impact of trial participation on total cost, compared with costs of routine care. Variables considered included cancer type, metastatic status, comorbidities, performance status, and age. Among other factors measured were whether trial participation affected receipt of active treatment in the last 14 days of life.
During the study period (2016-2018), 8026 completed OCM episodes met the study criteria;
of these, 459 episodes included patients who were participating in a trial. Episodes with trial enrollment cost $5976 less than nontrial episodes on average, with most savings coming from decreased drug costs. There were no differences in end-of-life costs, hospitalization rates, or hospice use in trial vs nontrial episodes.
Remote Monitoring Enables Nurse Intervention in Arkansas Cancer Group
Highlands Oncology Group, which includes 19 medical oncologists in northwest Arkansas,
presented results from its implementation of the Expain ePRO system integrated with the electronic
medical record.5 Starting in June 2020, the practice offered patients who were being treated with
parenteral cancer therapy the opportunity to enroll in the system to monitor symptoms during therapy.
According to the abstract, patients could report symptoms based on the National Comprehensive
Cancer Network (NCCN) Distress Thermometer and Problem List instrument. A predefined protocol had threshold points to trigger notifications to a nurse. A review would determine whether nurses would handle the situation remotely or if a patient needed an urgent office visit or trip to the ED.
Through January 2021, the practice treated 1261 patients with intravenous chemotherapy; 769 were
offered enrollment in Expain and 569 (73.9%) were enrolled, including 419 who were in the OCM. For the most part, those who did not enroll had low symptom burden, did not speak English, or were near the end of treatment.
Patients used the mobile app (89.1%) or interactive voice response interface (10.1%) at the following intervals: once a month (12%), twice a month (30%), 3 times a month (35%), and 4 times or more a month (23%). Of those enrolled, 52.7% were still giving reports after 3 months.
Of the reports made, 50% met the threshold for a nurse to be notified. The nursing staff followed up with a call for 78.8% of the notifications, and of these calls, 21.2% required an urgent office visit (7% of overall reports). Typical reasons for a visit were high NCCN Distress score (17.1%), fatigue (16.1%), pain (11.5%), nausea (9.4%), and dyspnea (4.5%). The main reasons reports stopped were death, hospice admission, and the end of treatment.
Highlands Oncology Group is a member of the Quality Cancer Care Alliance.
1. Robert NJ, Nwokeji ED, Espirito JL, et al; MYLUNG Consortium Collaborators: The U.S. Oncology Network and sponsors. Biomarker tissue journey among patients (pts) with untreated metastatic non–small cell lung cancer (mNSCLC) in the U.S. Oncology Network community practices. J Clin Oncol. 2021;39(Suppl 15):abstr 9004. doi:10.1200/JCO.2021.39.15_suppl.9004
2. Wilfong LS, Patel A, Ortega L, et al. Improvement in incident resolution time with implementation of an electronic patient management solution at a community oncology practice. J Clin Oncol. 2021;39(Suppl 15):abstr 1578. doi:10.1200/JCO.2021.39.15_suppl.1578
3. Patt DA, Wilfong LS, Hudson KE, et al. Implementation of electronic patient-reported outcomes for symptom monitoring in a large multi-site community oncology practice. J Clin Oncol. 2021;39(Suppl 15):abstr 12103. doi:10.1200/JCO.2021.39.15_suppl.12103
4. Young G, Bilbrey LE, Arrowsmith E, et al. Impact of clinical trial enrollment on episode costs in the Oncology Care Model (OCM). J Clin Oncol. 2021;39(Suppl 15):abstr 6513. doi:10.1200/JCO.2021.39.15_suppl.6513
5. Kolodziej MA, Kwiatkowsky L, Hunnicutt J, et al. Successful implementation of an ePRO remote monitoring system in patients receiving chemotherapy in a community oncology practice. J Clin Oncol. 2021;39(Suppl 15):abstr 1526. doi:10.1200/JCO.2021.39.15_suppl.1526