Depression, anxiety, & loneliness among cancer survivors during the COVID-19 pandemic.

PURPOSE: To assess the impact of the COVID-19 pandemic on depression, anxiety, and loneliness between those with and without a history of cancer. DESIGN: This prospective observational study used a quantitative approach. PARTICIPANTS: Adult members of the Kaiser Permanente Research Bank (N = 104,640). METHODS: Participants completed a series of surveys from May to December 2020. The difference in score of depression, anxiety, and loneliness were estimated using linear mixed regression. FINDINGS: Among cancer survivors, 21% and 19% met the thresholds for increased risk of depression and anxiety. Among cancer survivors, younger age groups and females reported increased depression, anxiety, and loneliness scores. CONCLUSIONS: This study highlights the continued necessity of addressing mental health needs and social support in cancer survivors during and after a public health emergency. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Cancer survivors may need particular resources after cancer treatment to strengthen resilience and improve quality of life.

SARS-CoV-2 Infection and Related Hospitalization among Cancer Survivors.

BACKGROUND: Little is known about SARS-CoV-2 infection and COVID-19 severity among a growing population of cancer survivors. We describe the association of infection and related hospitalization by recency of cancer diagnosis in a large U.S. cohort. METHODS: Participants were sent electronic surveys between April 2020 and January 2021 to collect information on SARS-CoV-2 infection and potential COVID-19-related risk factors. SARS-CoV-2 infections were identified using survey report of a COVID-19-positive test and electronic health record data. Cumulative incidence of SARS-CoV-2 infection was estimated up to 365 days from baseline survey and stratified by recency of cancer diagnosis. Among those with SARS-CoV-2 infection, we used logistic regression to estimate the association between recency of cancer diagnosis and hospitalization within 30 days of infection. RESULTS: Cumulative incidence of SARS-CoV-2 infection at 365 days was 3.3% [95% confidence interval (CI), 3.2%-3.5%] among those without cancer history and ranged from 2.8% (95% CI, 2.3%-3.5%) to 3.7% (95% CI, 2.9%-4.7%) among those with a history of cancer depending on recency. There was no statistically significant difference in odds of hospitalization within 30 days following SARS-CoV-2 infection by cancer diagnosis recency. CONCLUSIONS: Our null findings are consistent with other studies on COVID-19 infection risk in cancer survivors, where COVID-19 severity and sequelae were independent of cancer history and were likely associated with factors such as intensive care unit admission, noncancer comorbid conditions, and long-term care residency. IMPACT: This study can inform COVID-19 risk-counseling of cancer survivors and their caregivers as we continue to contend with COVID-19.

Patient characteristics associated with definitive diagnosis of metastatic pancreatic cancer in those initially diagnosed with cancer of unknown primary.

Cancer of unknown primary (CUP) and pancreatic cancer (PC) are malignancies associated with poor prognosis. CUP is the fourth most common cause of cancer mortality in the US, and median survival time is 3-4 months. PC is the third most common cause of cancer mortality in the US, and median survival time for patients with stage 3 or 4 PC is 2-3 months. The present study aimed to understand the patient characteristics of those initially misdiagnosed with CUP who ultimately received a diagnosis of PC. The present study used 2010-2015 Surveillance, Epidemiology, and End Results-Medicare data, a US population-based cancer registry linked to Medicare health insurance claims. Odds ratios (ORs) and 95% confidence intervals were calculated using two binary logistic regression models to compare the characteristics of patients who received definitive diagnosis between the CUP-PC group (those with an initial diagnosis of CUP who eventually received a stage 3 or 4 PC diagnosis) and the PC group (those diagnosed with stage 3 or 4 PC only). Approximately 26% of patients who received a definitive diagnosis of metastatic PC started with an initial diagnosis of CUP (n=17,565). The odds of definitive PC diagnosis in patients with CUP were lower for those with a comorbidity score of 0 [OR, 0.85 (95% CI: 0.79, 0.91)] and epithelial/unspecified histology [OR, 0.76 (95% CI: 0.71, 0.82)]. The odds of definitive PC diagnosis in patients with CUP were higher for patients of other race [OR, 1.27 (95% CI: 1.13, 1.43)] compared with white patients. Definitive diagnosis of PC in patients with CUP was lower in patients who were older with fewer or no comorbidities and unspecified histology. The complexity of CUP diagnosis and patient performance status may influence delays in diagnosis to a known primary site.

Evaluating cancer genetic services in a safety net system: overcoming barriers for a lasting impact beyond the CHARM research project.

Underserved patients face substantial barriers to receiving cancer genetic services. The Cancer Health Assessments Reaching Many (CHARM) study evaluated ways to increase access to genetic testing for individuals in underserved populations at risk for hereditary cancer syndromes (HCS). Here, we report the successful implementation of CHARM in a low-resource environment and the development of sustainable processes to continue genetic risk assessment in this setting. The research team involved key clinical personnel and patient advisors at Denver Health to provide input on study methods and materials. Through iterative and collaborative stakeholder engagement, the team identified barriers and developed solutions that would both facilitate participation in CHARM and be feasible to implement and sustain long term in clinical care. With a focus on infrastructure building, educational modules were developed to increase awareness among referring providers, and standard methods of identifying and managing HCS patients were implemented in the electronic medical record. Three hundred sixty-four DH patients successfully completed the risk assessment tool within the study, and we observed a sustained increase in referrals to genetics for HCS (from 179 in 2017 to 427 in 2021 post-intervention). Implementation of the CHARM study at a low-resourced safety net health system resulted in sustainable improvements in access to cancer genetic risk assessment and services that continue even after the study ended.Trial registration NCT03426878.

Patient Characteristics Associated with Definitive Diagnosis of Metastatic Pancreatic Cancer in Those Initially Diagnosed with Cancer of Unknown Primary.

Purpose: Cancer of unknown primary (CUP) is the fourth most common cause of cancer mortality in the U.S. Median survival after CUP diagnosis is 3-4 months. As CUP and metastatic pancreatic cancer (PC) are comparable in prevalence and survival, PC diagnosis is a useful endpoint to assess patient characteristics associated with definitive diagnosis in older patients who initially present with CUP. Methods: This study used 2010-2015 SEER-Medicare data. Logistic regression models compared patient characteristics who received definitive diagnosis in two subsets: CUP-PC and PC only. Results: Approximately 26% of patients who received a definitive diagnosis of metastatic pancreatic cancer started with an initial diagnosis of CUP (n=17,565). The odds of definitive diagnosis in CUP-PC were lower for those with a comorbidity score of 0 (OR 0.85 [0.79, 0.91]) and epithelial/unspecified histology (OR 0.76 [0.71, 0.82]). The odds of definitive diagnosis in CUP-PC were higher for patients of Other race (OR 1.27 [1.13, 1.43]) compared to White patients. Conclusion: Definitive diagnosis of CUP-PC was favorable in patients in the Other race category with fewer or no comorbidities. Unfavorable characteristics included older patients and those with epithelial/unspecified histology. Future studies will focus on patterns of care and survival in patients with CUP-PC.

Social risk factors among individuals with a history of cancer during the COVID-19 pandemic.

PURPOSE: The coronavirus disease (COVID-19) pandemic and its economic consequences may disproportionately impact cancer survivors and their overall health-related quality of life. The objective of this study was to examine whether cancer survivors experienced higher levels of financial strain or food insecurity compared to those without a history of cancer. METHODS: Kaiser Permanente Research Bank (KPRB) study participants were invited to complete a series of electronic surveys starting April 2020 to assess the impact of the COVID-19 pandemic. Participants who completed the initial survey and one follow-up survey were included. The odds of financial strain and food insecurity in those with and without a history of cancer were estimated using multinomial logistic regression. RESULTS: Cancer survivors (n = 16,231) had lower odds of reporting "somewhat hard" (AOR = 0.77) and "very hard" (AOR = 0.67) financial strain, and food insecurity "sometimes" (AOR = 0.70) and "often" (AOR = 0.55) compared to those with no history of cancer (n = 88,409). Non-Hispanic (NH) Black and Hispanic cancer survivors had higher odds compared to NH Whites of reporting financial strain and food insecurity. Smokers and those with multiple comorbidities had higher odds of reporting financial strain and food insecurity among cancer survivors. CONCLUSIONS: While cancer survivors overall did not report greater financial strain or food insecurity than individuals without a history of cancer, subsets of cancer survivors are experiencing greater social risks during the pandemic and should be prioritized for screening for social risk factors. IMPLICATIONS FOR CANCER SURVIVORS: Incorporating screening for social risk factors into care coordination workflows for subsets of cancer survivors should be a priority.

Developing an algorithm across integrated healthcare systems to identify a history of cancer using electronic medical records.

OBJECTIVE: Tumor registries in integrated healthcare systems (IHCS) have high precision for identifying incident cancer but often miss recently diagnosed cancers or those diagnosed outside of the IHCS. We developed an algorithm using the electronic medical record (EMR) to identify people with a history of cancer not captured in the tumor registry to identify adults, aged 40-65 years, with no history of cancer. MATERIALS AND METHODS: The algorithm was developed at Kaiser Permanente Colorado, and then applied to 7 other IHCS. We included tumor registry data, diagnosis and procedure codes, chemotherapy files, oncology encounters, and revenue data to develop the algorithm. Each IHCS adapted the algorithm to their EMR data and calculated sensitivity and specificity to evaluate the algorithm's performance after iterative chart review. RESULTS: We included data from over 1.26 million eligible people across 8 IHCS; 55 601 (4.4%) were in a tumor registry, and 44848 (3.5%) had a reported cancer not captured in a registry. The common attributes of the final algorithm at each site were diagnosis and procedure codes. The sensitivity of the algorithm at each IHCS was 90.65%-100%, and the specificity was 87.91%-100%. DISCUSSION: Relying only on tumor registry data would miss nearly half of the identified cancers. Our algorithm was robust and required only minor modifications to adapt to other EMR systems. CONCLUSION: This algorithm can identify cancer cases regardless of when the diagnosis occurred and may be useful for a variety of research applications or quality improvement projects around cancer care.

The Kaiser Permanente Research Bank Cancer Cohort: a collaborative resource to improve cancer care and survivorship.

BACKGROUND: The Kaiser Permanente Research Bank (KPRB) is collecting biospecimens and surveys linked to electronic health records (EHR) from approximately 400,000 adult KP members. Within the KPRB, we developed a Cancer Cohort to address issues related to cancer survival, and to understand how genetic, lifestyle and environmental factors impact cancer treatment, treatment sequelae, and prognosis. We describe the Cancer Cohort design and implementation, describe cohort characteristics after 5 years of enrollment, and discuss future directions. METHODS: Cancer cases are identified using rapid case ascertainment algorithms, linkage to regional or central tumor registries, and direct outreach to KP members with a history of cancer. Enrollment is primarily through email invitation. Participants complete a consent form, survey, and donate a blood or saliva sample. All cancer types are included. RESULTS: As of December 31, 2020, the cohort included 65,225 cases (56% female, 44% male) verified in tumor registries. The largest group was diagnosed between 60 and 69 years of age (31%) and are non-Hispanic White (83%); however, 10,076 (16%) were diagnosed at ages 18-49 years, 4208 (7%) are Hispanic, 3393 (5%) are Asian, and 2389 (4%) are Black. The median survival time is 14 years. Biospecimens are available on 98% of the cohort. CONCLUSIONS: The KPRB Cancer Cohort is designed to improve our understanding of treatment efficacy and factors that contribute to long-term cancer survival. The cohort's diversity - with respect to age, race/ethnicity and geographic location - will facilitate research on factors that contribute to cancer survival disparities.

An Examination of the Ethical and Legal Limits in Implementing "Traceback Testing" for Deceased Patients.

This paper examines the legal and ethical aspects of traceback testing, a process in which patients who have been previously diagnosed with ovarian cancer are identified and offered genetic testing so that their family members can be informed of their genetic risk and can also choose to undergo testing. Specifically, this analysis examines the ethical and legal limits in implementing traceback testing in cases when the patient is deceased and can no longer consent to genetic testing.

Immediate Unrestricted Weightbearing With Simple Stirrup Brace Following Single Anchor Lateral Ankle Ligament Stabilization.

OBJECTIVE: To report on a series of patients treated with immediate unrestricted weightbearing with limited protection following single anchor lateral ligament stabilization. METHODS: Patients with chronic lateral ankle ligament instability who underwent modified Broström-Gould lateral ligament reconstruction with a single double-loaded anchor were identified. Immediate unrestricted full weightbearing in a stirrup brace was allowed the first postoperative day and accelerated physical therapy was initiated from 2 weeks. Subsequent assessment was performed at a minimum of 1-year follow-up. RESULTS: Thirteen patients with a mean age at final follow-up of 49 years (range 21-70 years). Average follow-up was 21 months (16 to 26). American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and visual analogue scale (VAS) score improved significantly (P < .05) from preoperative to postoperative, respectively (57 to 91, 5.7 to 1.5). Average postoperative Foot and Ankle Outcome Score (FAOS) was 82 (range 52-100). Short Form-12 (SF-12) scores averaged 55 and 49 on mental component and physical components, respectively, consistent with US age-matched averages. No measurable differences in range of motion, ligamentous stability, or Star Excursion Balance Test in the anterior, posterolateral, or posteromedial planes compared to the contralateral side (P > .05) were observed. No recurrence was reported. CONCLUSION: Immediate unrestricted weightbearing in a stirrup brace following single anchor lateral ligament reconstruction is a successful protocol for the treatment of chronic lateral ankle instability. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Feasibility of a Traceback Approach for Using Pathology Specimens to Facilitate Genetic Testing in the Genetic Risk Analysis in Ovarian Cancer (GRACE) Study Protocol.

Guidelines currently state that genetic testing is clinically indicated for all individuals diagnosed with ovarian cancer. Individuals with a prior diagnosis of ovarian cancer who have not received genetic testing represent missed opportunities to identify individuals with inherited high-risk cancer variants. For deceased individuals, post-mortem genetic testing of pathology specimens allows surviving family members to receive important genetic risk information. The Genetic Risk Assessment in Ovarian Cancer (GRACE) study aims to address this significant healthcare gap using a "traceback testing" approach to identify individuals with a prior diagnosis of ovarian cancer and offer genetic risk information to them and their family members. This study will assess the potential ethical and privacy concerns related to an ovarian cancer traceback testing approach in the context of patients who are deceased, followed by implementation and evaluation of the feasibility of an ovarian cancer traceback testing approach using tumor registries and archived pathology tissue. Descriptive and statistical analyses will assess health system and patient characteristics associated with the availability of pathology tissue and compare the ability to contact and uptake of genetic testing between patients who are living and deceased. The results of this study will inform the implementation of future traceback programs.

Extent of diagnostic inquiry among a population-based cohort of patients with cancer of unknown primary.

PURPOSE: Current cancer registry data cannot distinguish a justified cancer of unknown primary (CUP) diagnosis, where the patient received a complete diagnostic evaluation that was unable to identify the primary tumor, from potentially misclassified patients, documented as CUP but not based on a complete diagnostic evaluation. This misclassification may skew population-based cancer registry surveillance research used to frame and guide translational CUP research. We identified characteristics of patients who received justified vs. potentially misclassified CUP diagnoses in cancer registry data. METHODS: We developed a conceptual definition of a complete diagnostic evaluation from professional society-recommended guidelines. We translated this definition into procedure codes in the Medicare encounter data. We assessed age, gender, comorbidities, urban or rural residence, income, race, and tumor pathology by receipt of a complete diagnostic evaluation and palliative therapy among 10,575 elderly CUP patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset. We calculated odds ratios and adjusted probabilities using marginal standardization. RESULTS: Only 35% of elderly CUP patients identified in the cancer registry received a complete diagnostic evaluation. After adjustment for age and comorbidities, socioeconomic barriers to a complete diagnostic evaluation persisted: adjusted odds ratio and 95% confidence interval (AOR) for rural vs. urban 0.8(0.8,0.9) and for highest income vs. lowest income 1.2(1.1,1.4). Patients with vague or undocumented tumor pathology in SEER had 80% lower odds of receiving a complete diagnostic evaluation AOR(95%CI)=0.2(0.2,0.2). Although patients with a complete diagnostic evaluation were twice as likely to receive palliative therapy than those without a complete evaluation, AOR(95%CI)=2.0(1.7,2.3), they only had a 46.7% probability of receiving therapy, 95%CI=(44.4,49.1). CONCLUSION: Patients without a complete diagnostic evaluation are not limited to the frail and underserved. For accurate assessment of the CUP burden and disparities in utilization of diagnostic care, we recommend that the SEER definition of CUP include the extent of diagnostic inquiry.

In vitro antifungal activity of Myrcia ovata essential oils and their major compounds against pathogens of citrus, sweet potato, and coconut / Atividade antifungica in vitro de óleos essenciais de myrcia ovata e seus compostos majoritários sobre patógenos de citros, batata-doce e coqueiro

Myrcia ovata, an endemic species to the Brazilian Atlantic Forest, presents antifungal properties. The phytopathogens Colletotrichum acutatum, Plenodomus destruens,and Thielaviopsis paradoxa are responsible for the diseases citrus postbloom fruit drop, sweet potato foot rot, and coconut stem bleeding, respectively. The antifungal activity of the essential oils of five M. ovata chemotypes (MYRO-159, nerolic acid chemotype; MYRO-180, nerolic acid + linalool chemotype; MYRO-388, geraniol chemotype; MYRO-157, citral + (E)-nerolidol chemotype; and MYRO-174, isopulegol + linalool chemotype), four major compounds (nerolic acid, nerolic acid + linalool, geraniol, and citral + (E)-nerolidol), and threepure compounds (citral, (E)-nerolidol, and linalool) against the fungi C. acutatum, P. destruens,and T. paradoxawere evaluated. For this, in vitro tests were conducted in a completely randomized design with three replications, testing concentrations (v/v) ranging from 0.01 to 1.0 µL.mL-1. All treatments presented toxicity at different levels to the three fungi. For C. acutatum,the essential oil from the individual MYRO-180 (nerolic acid + linalool chemotype) and its major compound showed the lowest Minimal Inhibitory Concentration (MIC) and Minimum Fungicidal Concentration (MFC) of 0.03 and 0.1 µL.mL-1, respectively. For P. destruens, the essential oil from the individual MYRO-159 (nerolic acid chemotype) presented the lowest MIC of 0.05 µL.mL-1. The nerolic acid + linalool chemotype and its major compound presented an MFC of 0.07 µL.mL-1. For T. paradoxa, the major compound citral + (E)-nerolidol stood out with the lowest MIC and MFC of 0.03 and 0.2 µL.mL-1, respectively. Linalool presented the lowest toxicity to the three tested fungi.

Myrcia ovata, uma espécie nativa de fitofisionomia de Restinga, possui atividade antifúngica. Os fitopatógenos Colletotrichum acutatum, Plenodomus destruens e Thielaviopsis paradoxa são responsáveis pelas doenças podridão floral de citros, mal-do-pé da batata doce e resinose do coqueiro, respectivamente. A atividade antifúngica de cinco quimiotipos de M. ovata (MYRO-159, quimiotipo ácido nerólico; MYRO-180, ácido nerólico + linalol; MYRO-388, quimiotipo geraniol; MYRO-157, quimiotipo citral + (E)-nerolidol; e, MYRO-174, quimiotipo isopulegol + linalol), quatro compostos majoritários (ácido nerólico, ácido nerólico + linalol, geraniol e citral + (E)-nerolidol) e três compostos isolados (citral, (E)-nerolidol e linalol) foram avaliados sobre os fungos C. acutatum, P. destruens e T. paradoxa. Testes in vitro foram conduzidos em delineamento inteiramente casualizado com três repetições e concentrações (v/v), que variaram de 0,01 a 1,0 µL.mL-1. Todos os tratamentos testados apresentaram atividade antifúngica. Para o fungo C. acutatum, o óleo essencial do indivíduo MYRO-180, de quimiotipo ácido nerólico + linalol, e seu composto majoritário apresentaram menores Concentração Mínima Inibitória (CMI) e Concentração Mínima Fungicida (CMF) de 0,03 e 0,1 µL.mL-1, respectivamente. Para o fungo P. destruens, o óleo essencial do indivíduo MYRO-159, de quimiotipo ácido nerólico, apresentou menor CMI de 0,05 µL.mL-1, e o quimiotipo ácido nerólico + linalol e seu composto majoritário apresentaram a menor CMF de 0,07 µL.mL-1. Para o fungo T. paradoxa,a combinação de citral + (E)-nerolidol destacou-se com CMI e CMF de 0,03 e 0,2 µL.mL-1, respectivamente. Linalol foi o menos tóxico sobre os três fungos testados.

Scope-of-practice laws and expanded health services: the case of underserved women and advanced cervical cancer diagnoses.

BACKGROUND: Underserved women (rural, minority or poor) are disproportionally diagnosed with late-stage cervical cancer, indicative of inadequate access to, and use of, preventative healthcare. The Institute of Medicine (IOM) has proposed that nurse practitioners (NP) can address provider shortages among underserved populations, but to reduce shortages, scope-of-practice laws that restrict the delivery of care, must be revised. We examined the IOM recommendation of NP expanded scope-of-practice laws on reducing the disparity of underserved women diagnosed with late-stage cervical cancer. METHODS: We examined the cohort of 10 673 women diagnosed with cervical cancer between 2010 and 2014 and reported to the Surveillance, Epidemiology and End Results cancer registry. We linked state-level laws regarding NP scope-of-practice to patients with cancer by their state of residence, diagnosis date and law enactment date. Hierarchical regression was used to explore NP full scope-of-practice law's impact on late-stage cancer diagnoses considering the moderating effect of women living in medically underserved areas. We adjusted for known confounders available in this population-based data set. RESULTS: Medically underserved women living in states with laws that restrict NP full scope-of-practice are twofold more likely to be diagnosed with late-stage cancer; adjusted OR and 95% CI (OR 2.08, 95% CI 1.4 to 3.1). These disparities were not observed among underserved women living in areas with NP full scope-of-practice laws (OR 0.95, 95% CI 0.7 to 1.3). CONCLUSIONS: NP full scope-of-practice laws could provide a pragmatic and cost-effective solution to healthcare provider shortages associated with late stage of cervical cancer diagnoses among underserved women.