Adolescent and young adult cancer patient and survivor employment changes during COVID-19 are associated with financial toxicity

Purpose: Describe associations between changes in employment during the COVID-19 pandemic and financial toxicity among adolescent and young adult (AYA) cancer patients and survivors. Methods: Eligible individuals were diagnosed between 15-39 years of age, currently age ≥18, and recruited through the Huntsman-Intermountain Adolescent and Young Adult Cancer Care Program. We sent the survey to N=709. Survey questions included demographics, employment, and the 11-item COmprehensive Score for financial Toxicity (COST) which captures financial toxicity in the last four weeks. COST is scored from 0 to 44 with lower scores indicating greater financial toxicity. Scores were dichotomized as high (0-21) or low (22-44). Changes in employment since March 2020 were categorized as no change, increase in hours, and decrease in hours/lost job. We calculated descriptive statistics and fit a multivariable logistic regression to examine the association between employment change and financial toxicity controlling for current age, gender, and treatment status. Results: Of 280 respondents (39.5% participation), 198 (70.7%) were employed prior to the pandemic and were thus included in analyses. Employed individuals were a mean of 29.4 years of age (range 18-58), 64.3% were female, and 50.5% had received cancer treatment since March 2020. Nearly a third (31.3%) had lost their job or reported reduced hours;50.3% reported high financial toxicity. Among those previously employed, participants who lost their job or had their hours reduced had nearly six times the odds of high financial toxicity than those who reported no change in hours (Odds Ratio [OR]=5.8, 95% Confidence Interval [CI]: 2.6-12.9). In the same model, the odds of reporting high financial toxicity was over twice as high among females than males (OR=2.3, 95% CI: 1.2-4.5). Treatment status and age were not significant. Conclusions: Employment changes during the COVID-19 pandemic resulted in increased financial toxicity among a population already susceptible to high financial hardship. Societal gender inequity appears to be mirrored in participants' financial toxicity during the pandemic. Employment interventions for patients and survivors of AYA cancers who have experienced job loss or reduction in work hours during the pandemic are needed and may particularly benefit females.

Telehealth experiences of adolescent and young adult cancer patients and survivors during the COVID-19 pandemic

Purpose: To describe adolescent and young adult (AYA) cancer patients' and survivors' experiences with telehealth during the COVID-19 pandemic. Methods: Eligible participants were identified through the Huntsman Intermountain Adolescent and Young Adult Cancer Care Program, which provides age-specific programming and patient navigation to AYA cancer patients and survivors in Utah and surrounding Mountain West states. Participants were emailed an online survey if they were currently age 18 or older and had been diagnosed with cancer between the ages of 15-39 years. We applied descriptive statistics to summarize demographics, comfortability with technology, access to reliable internet connection, and perceived quality of care while using telehealth. Results: AYAs (N=280) were an average of 29.4 years old at survey (range 18-58);65.2% were female and 82.4% non-Hispanic white. Over half (54.2%) had received cancer treatment since March 2020. All participants reported owning a computer, tablet, and/or smart phone they could use for telehealth appointments. The majority (93.5%) reported almost always or always having a reliable internet connection. AYAs felt most comfortable having a telehealth appointment in their own home (96.4%);only 12.5% felt comfortable using telehealth at work. Since March 2020, (N=183) 65.4% had a health care visit moved to a telehealth platform due to COVID-19. Of those who recently moved to telehealth, 60.1% had an oncology visit, 33.9% had a primary care visit, and 31.1% had a mental health visit. Additionally over one-third (35.2%) reported the quality of their medical care had decreased since moving to telehealth. This was most commonly due to 1) troubles with audio, video, or connecting through telehealth platforms;2) telehealth visits feeling impersonal;and 3) feeling that providers more easily dismissed or did not fully address their symptoms. Conclusions: Although AYAs are digital natives, over one third of AYAs feel the quality of their medical care has decreased since moving to telehealth for COVID-19. Further research should explore medical provider training in using telehealth systems and encourage telehealth practices that help AYAs feel more supported and understood.

Doctors' and nurses' social media ads reduced holiday travel and COVID-19 infections: a cluster randomized controlled trial

During the COVID-19 epidemic, many health professionals started using mass communication on social media to relay critical information and persuade individuals to adopt preventative health behaviors. Our group of clinicians and nurses developed and recorded short video messages to encourage viewers to stay home for the Thanksgiving and Christmas Holidays. The researchers then conducted a two-stage clustered randomized controlled trial in 820 counties (covering 13 States) in the United States of a large-scale Facebook ad campaign disseminating these messages. In the first level of randomization, the researchers randomly divided the counties into two groups: high intensity and low intensity. In the second level, the researchers randomly assigned zip codes to either treatment or control such that 75% of zip codes in high intensity counties received the treatment, while 25% of zip codes in low intensity counties received the treatment. In each treated zip code, the researchers sent the ad to as many Facebook subscribers as possible (11,954,109 users received at least one ad at Thanksgiving and 23,302,290 users received at least one ad at Christmas). The first primary outcome was aggregate holiday travel, measured using mobile phone location data, available at the county level: the researchers find that average distance travelled in high-intensity counties changed by -0.993 percentage points (95% CI -1.616, -0.371, p-value 0.002) the three days before each holiday. The second primary outcome was COVID-19 infection at the zip-code level: COVID-19 infections recorded in the two-week period starting five days post-holiday declined by 3.5 percent (adjusted 95% CI [-6.2 percent, -0.7 percent], p-value 0.013) in intervention zip codes compared to control zip codes.

Impact of age, race, and family history on COVID-19 related changes in breast cancer screening among the Boston Mammography Cohort Study

The COVID-19 pandemic has placed an unprecedented burden on the healthcare system, disrupting routine care including breast cancer screening. We used data from 2392 women without a history of breast cancer enrolled in the Boston Mammography Cohort Study (BMCS) to investigate whether subgroups defined by age, race, or family history of breast cancer: 1) experienced greater declines in screening or diagnostic imaging during the lockdown;or 2) had slower rebound during reopening. In this interrupted time series analysis, we used Poisson regression with robust standard errors to model expected monthly rates of breast cancer screening and diagnostic imaging from January 2019 through December 2020. We defined the pre-COVID-19 period as January 1, 2019, to February 29, 2020;the lockdown period as March 1 to May 30, 2020;and the reopening period as June 1 to December 31, 2020. We examined changes in trends overall and tested for the difference in trends by age (<50 vs ≤50), race (white vs non-white), and first-degree family history of breast cancer (yes or no). The mean monthly rate of breast cancer screening in the BMCS cohort was 45 per 1000 people during the pre-COVID-19 period, 7 per 1000 people during the lockdown period, and 50 per 1000 people during the reopening period. The mean monthly rate of breast cancer diagnostic imaging was 6 per 1000 people during the pre-COVID-19 period, 3 per 1000 people during the lockdown period, and 6 per 1000 people during the reopening period. During the pre-COVID-19 period, those who are age 50 or older had 5.3% higher monthly trend in breast cancer screening rates (p=0.005) and 9.8% higher monthly trend in diagnostic imaging rates (p=0.0389). During the lockdown period, those who were age 50 or older had a lower monthly trend in breast cancer screening rates compared to those who were younger than 50 (p<0.0001), while those who were white and those with family history have higher monthly trends of breast cancer screening rates compared to their respective counterparts (p<0.0001). During the reopening phase, those who are age 50 or older have 18.5% lower monthly trend in breast cancer screening rates in comparison to those who are younger than 50 (p=0.0008) and those who were white have 36.2% higher monthly trend in breast cancer diagnostic procedure rates in comparison to those who are non-white (p=0.018). Overall, we observed a significant decline in breast cancer screening rates with the advent of the COVID-19 pandemic. For the most part, screening and diagnostic imaging rates during the reopening phase equaled or exceeded those of the pre-COVID-19 period. However, the rate of return to screening was lower in women age 50 or older and the rebound in diagnostic imaging was lower in nonwhite women. Careful attention must be paid as the COVID-19 recovery continues to ensure equitable resumption of care. Future work will examine other factors including insurance status, breast cancer risk scores, and geographic location.

Subglottic and tracheal stenosis associated with coronavirus disease 2019.

BACKGROUND: Coronavirus disease 2019 critical care patients endure prolonged periods of intubation. Late tracheostomy insertion, large endotracheal tubes and high cuff pressures increase their risk of subglottic and tracheal stenosis. This patient cohort also often appears to have co-morbidities associated with laryngotracheal stenosis, including high body mass index and laryngopharyngeal reflux. METHODS: This paper presents three coronavirus disease 2019 patients who were intubated for a mean of 28 days before tracheostomy, leading to complex multi-level stenoses. RESULTS: All patients underwent multiple endoscopic tracheoplasty procedures and two required tracheal resections. There was a mean of 33.9 days between interventions. Coronavirus disease 2019 patients do not appear to respond as well to steroid, laser and balloon dilatation as other adult stenosis patients. CONCLUSION: Intubated coronavirus disease 2019 patients have an increased risk of laryngotracheal stenosis, as a result of multiple factors. Otolaryngology teams should be vigilant in investigating for this complication. International guidelines on time to tracheostomy should be followed, despite a diagnosis of coronavirus disease 2019.

Patient-reported impact of the COVID-19 pandemic on breast cancer screening, diagnosis, andtreatment: A national survey

Introduction: The COVID-19 pandemic has altered the health care delivery system. The purpose of this study wasto determine the impact of the COVID-19 pandemic on breast cancer screening, diagnosis, and treatment. Methods: Potential survey respondents were identified through partnerships with breast cancer organizationsincluding Dr. Susan Love Foundation for Breast Cancer Research, SHARE, Survivingbreastcancer.org, SistersNetwork Inc., the African American Breast Cancer Alliance, and through ResearchMatch.org. Study information wasshared via social media, websites, or email. Individuals were eligible for this study if they: 1) receive routine breastcancer screening, or 2) are undergoing diagnostic evaluation for breast cancer, or 3) had ever been diagnosed withbreast cancer. Participants accessed and completed the 10-15-minute REDCap survey either by emailing theresearch team and receiving a private survey link or by clicking a public link. The survey collected information onrespondent demographics;breast cancer screening and diagnosis;the extent to which screening, diagnosis, ortreatment had been changed, delayed, or canceled because of COVID-19;personal protective practices;extent ofworry about financial and health implications of COVID-19;and use of telemedicine. We used descriptive statisticalanalyses to better understand the impact of the COVID-19 pandemic on respondents. Results: There are currently 415 survey respondents, 404 of whom agreed to participate in the study. 46.8%(N=189) of respondents were white, 26.7% (N=108) Black, 6.7% (N=27) Asian, and 5.5% Hispanic or Latino (N=22).Most respondents were between the ages of 50 and 69 years (52.2%, N=211). 43.3% (N=175) of respondents hadbeen diagnosed with breast cancer and, of those, 36% (N=63) were in active treatment. More than a quarter ofparticipants (26.5%, N=107) reported delayed or canceled breast cancer care due to COVID-19;the most frequentlyaffected care was screening mammogram, ultrasound, or MRI (97.2%, N=104). 20.6% (N=13) of women in activetreatment reported delayed or canceled surgery, chemotherapy, or radiation visits. 22.3% (N=90) of respondentsreported that an in-person visit was changed to a phone call or videoconference, and 39.1% (N=158) said they haddiscussed COVID-19 with a health care provider. 29.1% (N=51) of those with breast cancer were worried or veryworried that the COVID-19 pandemic would make it harder for them to get cancer care;among those without breastcancer, 34.9% (N=80) were worried that COVID-19 would make it harder to obtain health care, including breastcancer screening and diagnosis. Conclusions: The COVID-19 pandemic continues to disrupt breast cancer-related care, primarily screening.Planning and coordination are necessary to ensure the timely return of these patients to care. Most participantsagreed to be contacted for follow-up, allowing us to investigate the long-term effects of delayed breast cancerscreening, diagnostic evaluation, and treatment on health outcomes.

North East London coronavirus disease 2019 protocol for diagnostics in two-week wait head and neck cancer patients.

BACKGROUND: The coronavirus disease 2019 pandemic requires urgent modification to existing head and neck cancer diagnosis and management practices. A protocol was established that utilises risk stratification, early investigation prior to clinical review and a reduction in aerosol generating procedures to lessen the risk of coronavirus disease 2019 spread. METHODS: Two-week wait referrals were stratified into low, intermediate and high risk. Low risk patients were referred back to primary care with advice; intermediate and high risk patients underwent investigation. Clinical encounters and aerosol generating procedures were minimised. A combined diagnostic and therapeutic surgical approach was undertaken where possible. RESULTS: Forty-one patients were used to assess feasibility. Thirty-one per cent were low risk, 35 per cent were intermediate and 33 per cent were high risk. Thirty-three per cent were discharged with no imaging. CONCLUSION: Implementing this protocol reduces the future burden on tertiary services, by empowering primary care physicians to re-refer low risk patients. The protocol is applicable across the UK and avoids diagnostic delay.