Black Patients Experience Highest Rates of Specific Cancer-Associated Venous Thromboembolism: A Study Based at a Large Safety-Net Hospital in New England

Abstract Background: Several studies have shown that cancer is associated with a 2 to 9-fold increased risk of venous thromboembolism (VTE) (Heit 2000; Hutton 2000; Hansson 2000; Prandoni 2002; Descourt 2006), with an absolute risk ranging from 1%-8% (Timp 2013). Importantly, the presence of VTE significantly reduces the 1-year survival rate from 36% in cancer patients without VTE to 12% in cancer patients with VTE (Sorensen 2000). Large cohort studies in the general population have suggested that Blacks compared to Whites are at higher risk of developing VTE (Zakai 2014). However, studies examining the influence of race on specific cancer-associated VTE have been scarce. To address racial disparities in cancer-associated VTE, we conducted a retrospective study in the largest safety-net hospital in New England, Boston Medical Center, with a large cancer cohort consisting of a substantial number of Black patients. This has provided a unique opportunity to directly compare the risk of specific cancer-associated VTE between Black and White cancer patients which could lead to future mechanisms-based studies. Methods: Summary statistics were performed and presented as mean, proportion and their respective standard deviation. Differences between blacks and whites for various variables were tested using Student's t-test, Pearson's Chi-square, and Fisher's exact test as appropriate using RStudio software (v1.0.153). Logistic regression was then used to estimate and compare odds of VTE occurrence in Lung cancer after adjusting for other confounders. Statistical significance was assessed at p <0.05. Results: We analyzed 16,498 cases with all types of solid organ and hematologic malignancies from 2004 to present (2018) with case mix characterized by Whites (53%) and Blacks (33%) and Others (11.7%). Our review of the electronic medical record revealed that 238 (1.4%) of 16,498 cancer patients had VTE, either at presentation or within one year following the cancer diagnosis. Since some VTE cases might have been undiagnosed prior to cancer development/manifestation, we used the term cancer-associated VTE to denote co-existence of these pathologies. The proportion of VTE cases were similar among male (55.5%) and female patients (44.1%). Of 238 cases of cancer presenting with VTE, Blacks predominated with 121 cases (51.3%) compared to 65 cases of Whites (27.5%). Interestingly, selected cancers were more associated with VTE in Blacks. As shown in Table 1, a significantly higher proportion of cancer-associated VTE was observed in Black patients with lung cancer, >breast cancer, >prostate cancer, >colorectal cancer and gastric/small bowel cancer; in descending order. VTE occurrence was observed predominantly in the pulmonary artery (36.9%) and femoral/iliac vein (16.1%). Sixteen percent of patients with cancer-associated VTE experienced recurrent VTE, however, no statistical difference in race was seen (p= 0.6). Given the high number of cases of lung cancer with VTE, we examined the influence of race with adjustment for confounders. Our logistic regression model showed that Black lung cancer patients have a significantly higher odds of developing cancer-associated VTE even after adjusting for cancer stage, age, and sex (OR- 2.39, CI = 1.26-4.60, p = 0.0079). Interestingly, the proportions of VTE in cancers such as pancreatic cancer, head and neck cancer and glioblastoma, were equally observed in Black and White patients, which can be ascribed to low event rates of VTE in these cancers in this series. Conclusions: This single-center study suggests that a higher proportion of Black cancer patients exhibited cancer-associated VTE compared to White cancer patients. Importantly, this significant difference was especially reflected in specific cancer subtypes. Race had an independent effect on cancer-associated VTE but showed no significant influence on recurrent VTE. Our current investigation motivates additional large-scale studies of cohorts with substantial representation of Blacks and ethnic minorities to further identify factors that contribute to racial disparities in the context of cancer-associated VTE, thus guiding necessary interventions to maximize outcome. Our study also lays the ground for mechanistic cause-and-effect inquiries related to intricate associations of specific cancers with VTE in a certain races. Disclosures Brophy: Novartis: Research Funding.

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Reducing delays to lung cancer treatment through systematic consult scheduling: A multidisciplinary quality improvement initiative at a safety-net hospital.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.e18640 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. e18640-e18640

Author(s):

Yue Lin ◽

Muhammad M. Qureshi ◽

Umit Tapan ◽

Kei Suzuki ◽

Ehab Billatos ◽

...

Keyword(s):

Lung Cancer ◽

Cancer Patients ◽

Median Time ◽

Safety Net ◽

Appointment Scheduling ◽

Treatment Delays ◽

Cause Analysis ◽

Lung Cancer Patients ◽

Root Cause ◽

Safety Net Hospital

e18640 Background: Delays in diagnosis and treatment have been identified as practice gaps in lung cancer management. At our large safety-net hospital, 2016-2018 data provided by the Commission on Cancer (CoC) indicated that 58-66% of lung cancer patients began treatment > 30 days after their diagnosis, compared to a median of 30 days for CoC-accredited hospitals. A quality improvement (QI) project was performed to identify causes for treatment delays, and to implement changes to reduce the median time from diagnosis to treatment to < 30 days. Methods: Root cause analysis was performed on a cohort of lung cancer patients identified and abstracted by the CoC Registry with diagnosis in October 2018-September 2019, to provide more recent data on treatment delays and to identify actionable interventions. Subsequently, a multidisciplinary QI initiative through Thoracic Surgery, Hematology Oncology, and Radiation Oncology was implemented using the Plan-Do-Study-Act (PDSA) tool. The initiative was tracked for 6 months starting in August 2020, with time from referral to consult and time from diagnosis to treatment calculated via chart review. Results: For the root cause analysis, 36 patients were identified. Eleven cases were excluded as they did not receive treatment at our institution. For the remaining 25 patients, the median time from referral to consult across all three oncology specialties was 13 days. The most common barriers to initiating treatment were appointment scheduling delays (37.5%), patient factors including synchronous malignancies or insurance, geographic or cultural barriers (31.3%), and multiple factors including appointment scheduling delays (25%). Median time from diagnosis to treatment was 31 days, with 36% (N = 9) starting treatment in < 30 days. While appointment scheduling delays included both work-up (imaging, procedures) and consults as well as follow-ups, multidisciplinary discussions identified time from referral to consult as the most actionable QI initiative. With support from Patient Navigation, the three oncology specialties jointly implemented a system whereby suspected or confirmed new lung cancer patients were scheduled for consult ideally in < 7 days, and no more than 14 days from the referral date. Of 28 new lung cancer patients who started treatment after the QI intervention, median time from referral to consult decreased to 7 days. Median time from diagnosis to treatment decreased to 26.5 days, with 53.6% (N = 15) of patients starting treatment in < 30 days. Conclusions: By decreasing time from referral to consult, this multidisciplinary QI intervention facilitated earlier initiation of treatment for lung cancer patients. Similar actions to decrease other scheduling delays and mitigate the impact of social determinants of health could further promote improvements in timely patient care.

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Improving timeliness of care for breast, GYN, and aerodigestive cancer patients with nurse navigators in a safety net hospital.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.183 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 183-183

Author(s):

Christine Rehr ◽

Teralyn Carter ◽

Eric Flenaugh ◽

Zhensheng Wang ◽

Gail Ohaegbulam ◽

...

Keyword(s):

Lung Cancer ◽

Cancer Patients ◽

Cancer Survival ◽

Stage Iv ◽

Safety Net ◽

Cancer Center ◽

Inclusion Criteria ◽

Safety Net Hospital ◽

Aerodigestive Cancer ◽

Timeliness Of Care

183 Background: The Georgia Cancer Center for Excellence (GCCE) at Grady received a 5-year MERCK Patient Centered Grant in 2017 that focuses on improving care to vulnerable cancer patients (pts) through the introduction of nurse (RN) navigators, a dietician and a part time exercise coach. A review of the literature shows improved patient outcomes and satisfaction with decreased time to treatment for breast and lung cancer pts. [1-2] RN navigation has been shown to expedite care and one of our goals for the MERCK grant was to study the effect of introducing RN navigation in a safety net hospital for three cancer sites. Methods: Three RN navigators were hired for the Breast, GYN and Aerodigestive cancer programs since 2017. RN navigators meet all newly diagnosed cancer pts during clinic and track their progression of care, often intervening for timeliness of work up and treatment. Each RN navigator keeps a record of pts navigated. An audit of this prospectively collected data measuring time from diagnosis to treatment for breast, GYN and aerodigestive cancer pts took place for 2018 and 2019. Inclusion criteria: diagnosed and treated at Grady, navigated by RN, and not Stage IV disease. Results: The total numbers of cancer pts navigated over the past two years were 244 breast, 131 GYN, and 265 aerodigestive pts. Using the inclusion criteria described in the methods section, the time from diagnosis to treatment decreased for these three cancer sites (see Table). Conclusions: Implementation of RN navigators within the cancer program trended towards decreases in time from diagnosis to treatment for our breast, GYN, and aerodigestive cancer patients. These measurable improvements over three cancer sites are largely attributed to RN navigation and suggest that cancer outcomes will improve over time for our patients treated in our safety net hospital. We plan to study patients who were retained in the system or were adherent to care to better understand the importance of RN navigation in our system. References: (1)Bleicher RJ, Ruth K, Sigurdson ER, et al. Time to Surgery and Breast Cancer Survival in the US. JAMA Oncol 2016;2(3):330–339. (2) Olsson JK, Schultz EM, Gould MK. Timeliness of care in patients with lung cancer. Thorax 2009;64:749-756. [Table: see text]

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PO-16 Venous thromboembolism in small cell lung cancer patients: an epidemiological study

Thrombosis Research ◽

10.1016/s0049-3848(21)00189-4 ◽

2021 ◽

Vol 200 ◽

pp. S25-S26

Author(s):

E. Dimakakos ◽

K. Livanios ◽

E. Kainis ◽

A. Vassias ◽

D. Stefanou ◽

...

Keyword(s):

Lung Cancer ◽

Venous Thromboembolism ◽

Small Cell Lung Cancer ◽

Cancer Patients ◽

Epidemiological Study ◽

Cell Lung Cancer ◽

Small Cell ◽

Small Cell Lung ◽

Lung Cancer Patients

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Venous thromboembolism incidence and risk factors in non-small cell lung cancer patients receiving first-line systemic therapy

Thrombosis Research ◽

10.1016/j.thromres.2021.10.014 ◽

2021 ◽

Author(s):

Hailey Hill ◽

Myra Robinson ◽

Lauren Lu ◽

Daniel Slaughter ◽

Asim Amin ◽

...

Keyword(s):

Risk Factors ◽

Lung Cancer ◽

Venous Thromboembolism ◽

Small Cell Lung Cancer ◽

Cancer Patients ◽

Systemic Therapy ◽

Small Cell ◽

Small Cell Lung ◽

First Line ◽

Lung Cancer Patients

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Prevalence of Advanced Colorectal Neoplasia in White and Black Patients Undergoing Screening Colonoscopy in a Safety-Net Hospital

Annals of Internal Medicine ◽

10.7326/0003-4819-159-1-201307020-00004 ◽

2013 ◽

Vol 159 (1) ◽

pp. 13 ◽

Cited By ~ 40

Author(s):

Paul C. Schroy ◽

Alison Coe ◽

Clara A. Chen ◽

Michael J. O’Brien ◽

Timothy C. Heeren

Keyword(s):

Colorectal Neoplasia ◽

Safety Net ◽

Screening Colonoscopy ◽

Black Patients ◽

Advanced Colorectal Neoplasia ◽

Safety Net Hospital

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Utilization of glucocorticoids among White and Black patients with systemic lupus erythematosus: Observations from the enrollment visit of a prospective registry

Lupus ◽

10.1177/09612033211055817 ◽

2021 ◽

pp. 096120332110558

Author(s):

James K Sullivan ◽

Emily A Littlejohn

Keyword(s):

Systemic Lupus Erythematosus ◽

Logistic Regression ◽

Health Outcomes ◽

Lupus Erythematosus ◽

Cleveland Clinic ◽

Systemic Lupus ◽

Black And White ◽

Black Patients ◽

White Patients

Background Black patients with systemic lupus erythematosus (SLE) face higher rates of morbidity and mortality compared to White patients. Long-term glucocorticoid use has been associated with worse health outcomes among patients with SLE. We sought to quantify chronic glucocorticoid use among Black and White patients with SLE within a prospective registry. Methods Using enrollment data from a registry at a large academic institution, we compared glucocorticoid use among Black and White patients with SLE. Multivariable logistic regression of race and glucocorticoid use was performed, adjusting for covariates exhibiting a bivariate association with glucocorticoids at significance level p < 0.10. Results 114 White participants (mean age 45; standard deviation (SD) 15) and 59 Black participants (mean age 42; SD 14) were analyzed. White participants had mean SLEDAI-2K score of 3.7 (SD 5.2). Black participants had mean SLEDAI-2K scores of 6.3 (SD 6.0). Among Black participants, 43 (72%) utilized glucocorticoids compared to White participants 39 (34%) (unadjusted odds ratio (OR) 5.17; 95% confidence interval (CI) 2.59–10.33). We did not observe differences between unadjusted hydroxychloroquine (OR 0.69; 95% CI 0.28–1.65) or conventional disease-modifying anti-rheumatic drug (cDMARD) (OR 1.07; 95% CI 0.57–2.01) utilization among Black and White participants. SLEDAI-2K, disability, recent hospitalization, and past or present hydroxychloroquine or cDMARD use were included in a logistic regression model. Adjusting for covariates, Black participants were more likely to be on glucocorticoids (adjusted OR 5.69; 95% CI 2.17–14.96); p = 0.0004). Conclusion Adjusting for disease activity and other medications, Black patients had more exposure to chronic glucocorticoids than White patients in the Cleveland Clinic SLE registry. These patients may face increased glucocorticoid-related morbidity, which could contribute significantly to long-term health outcomes and utilization of health care resources. Future research in larger, more diverse registries should be conducted to further characterize patterns of glucocorticoid use.

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Venous thromboembolism in non-small cell lung cancer patients who underwent surgery after induction therapy

General Thoracic and Cardiovascular Surgery ◽

10.1007/s11748-020-01351-0 ◽

2020 ◽

Vol 68 (10) ◽

pp. 1156-1162

Author(s):

Yasunori Kaminuma ◽

Masayuki Tanahashi ◽

Eriko Suzuki ◽

Naoko Yoshii ◽

Hiroshi Niwa

Keyword(s):

Lung Cancer ◽

Venous Thromboembolism ◽

Small Cell Lung Cancer ◽

Cancer Patients ◽

Induction Therapy ◽

Small Cell ◽

Small Cell Lung ◽

Free Survival ◽

Lung Cancer Patients ◽

Significant Difference

Abstract Objectives Lung cancer patients have been reported to have a high incidence of venous thromboembolism (VTE) and a high recurrence rate of VTE. However, there are no detailed reports of VTE in lung cancer patients who underwent surgery after induction therapy. We examined the incidence and clinical features of VTE in these patients. Methods We retrospectively evaluated 89 patients with non-small cell lung cancer who underwent surgery after induction therapy at our department between April 2009 and March 2018. The incidence of VTE, clinical features, and long-term prognosis were retrospectively examined. Results Among the 89 patients, 4 (4.5%) developed VTE, and there was no significant difference in the background characteristics between patients with and without VTE. All four patients developed VTE during preoperative treatment. In the patients with VTE, anticoagulant therapy with oral anticoagulants was administered after heparinization, and the median duration of anticoagulant therapy was 18.7 months. There were no cases of symptomatic VTE recurrence after surgery, regardless of lung cancer recurrence. Although the overall survival (OS) showed no significant difference between patients with and without VTE, the disease-free survival was significantly shorter in patients with VTE than in those without it (median 6.3 vs. 71.6 months, p < 0.01). Conclusions In induction cases, the incidence of VTE was 4.5%, and it can at least be stated that no symptomatic VTE developed or recurred after surgery. Patients with VTE in induction therapy had short progression-free survival and required careful follow-up after surgery.

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