1. Samson, Kurt

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SAN DIEGO-An interactive web-based tool presenting National Comprehensive Cancer Network (NCCN) guidelines, tailored to individual clinical and pathological characteristics, dramatically increased smoking cessation inquiries by NSCLC patients, a researcher reported at the 2019 Multidisciplinary Thoracic Cancers Symposium (Abstract 5).

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The tool, which also included information about gene sequencing and a timeline to help patients visualize their treatment trajectory, likewise increased participation in biomarker testing and more patient involvement in chemotherapy decisions in those with early-stage cancer with negative margins.


"In patients newly diagnosed with cancer, discussions of various treatment options and their side effects are complex," Susan Wu, MD, first author of the study told a March 12 press briefing.


A radiation oncology resident at the University of California, San Francisco, Wu noted that, while the NCCN guidelines are readily available to physicians, they often are difficult for patients to access.


"The process of making treatment decisions can be extremely stressful for lung cancer patients, as treatment options are nuanced and may change significantly over the course of their staging workup," she said. "Educational tools can guide patients through the decision-making process and help them to synthesize the large amount of information available and help them to be more active partners in the decision-making process."


Similar online guideline-based treatment tools are already in place for patients newly diagnosed with breast and prostate cancers.


A total of 76 patients were introduced to the aid by a trained coordinator, who also used the tool to facilitate discussion during patient consultation with an oncologist. A separate cohort of 159 patients before the tool was available served as a control cohort.


Fully 80 percent of active smokers sought smoking cessation counseling and/or intervention after being exposed to the tool compared with just 4 percent of patients in a control group. Exposure to the learning aid increased molecular testing for EGFR and ALK mutations prior to systemic therapy among patients with metastatic disease (96% vs. 68%) and decreased by half the use of chemotherapy following surgery for stage IB-IIB NSCLC, particularly among patients with negative margins following resection.


The findings demonstrate how evidence-based patient decision and communication aids can improve cancer care, Wu stated.


Exposure did not impact some outcomes, however, including the frequency of pathologic mediastinal staging performed prior to surgery or nonsurgical treatment in patients with stage III disease. Nor did it influence upfront chemoradiation therapy in stage III patients that were not eligible for surgery.


"We can empower patients to make decisions that align with their priorities and goals for treatment with evidence-based tools. For example, data from patients with breast cancer suggests that those who may derive limited benefit from adjuvant therapy are more likely to forego it. We similarly found that patients with completely resected early-stage NSCLC had a tendency not to pursue additional chemotherapy," said Wu.


"Our goal was to help patients feel more comfortable making treatment decisions and become more active participants in the decision-making process. While implementing a decision support tool does require substantial resources, such as the time and effort to develop the tool and introduce it to patients, these tools can help empower our patients and in some cases meaningfully impact their care."


Methodology, Other Findings

Wu and her colleagues evaluated differences in guideline concordance, based on six metrics assessed before and after the tool was implemented, in patients with newly diagnosed NSCLC or new disease progression. Patients were assisted in accessing the tool during and after initial consultation and concordance with the guidelines.


Rates were determined for smoking cessation/intervention; adjuvant chemotherapy for stage IB-IIB patients undergoing surgery; pathologic mediastinal staging in stage III patients prior to either surgery or nonsurgical treatment; upfront definitive chemoradiation for stage III patients; and biomarker molecular testing for EGFR and ALK mutations prior to systemic therapy for stage IV disease.


The median age of participants in the study group was 67.5 years and the most common tumor histologies were adenocarcinoma and squamous cell carcinoma (78% and 18%), respectively.


In addition to the increase in smoking cessation counseling/intervention in active smokers, there was a 50 percent decrease in use of adjuvant chemotherapy following surgery for stage IB-IIB disease, from 0 to 50 percent. This was mostly driven by decreased use for stage IB NSCLC resected with negative margins.


The increase in molecular testing prior to initiation of systemic therapy in patients with metastatic NSCLC was 96 percent versus 68 percent in controls. In patients with stage III NSCLC, there were no differences in the frequency of pathologic mediastinal staging performed prior to surgery or nonsurgical treatment. The researchers reported no difference between the two groups in upfront chemoradiation in non-operative candidates.



"The results of this study can inform both oncologists and their patients," said George Rodrigues, MD, PhD, FASTRO, a radiation oncologist and clinician scientist at Lawson Health Research Institute and London Health Sciences Centre in Ontario. "For oncologists, the use of standardized tools can lead to better patient information and engagement in shared decision-making. Additionally, the highlighted areas of smoking cessation and medically appropriate biomarker testing may be areas for potential clinical practice improvement both at the oncologist and cancer clinic levels.


"From the patient perspective, access to an evidence-based educational intervention led to statistically significant differences in utilization in guideline-supported diagnostic and therapeutic interventions. This study illustrates that the cancer patient's specific disease situation may be important in receiving medically appropriate care."


Historically, patients have not routinely been referred to evidence-based guidelines, which are usually designed for and targeted to a medically trained audience, noted Rodrigues, who has served as expert panelist on several ASTRO guidelines.


"What this research team has done in this work is to convert a lung cancer guideline from a physician-centric document to a web-based tool with coordinator support," he concluded.


Kurt Samson is a contributing writer.