Manali Patel

All Publications

• Healthcare delivery interventions to reduce cancer disparities worldwide. World journal of clinical oncology Dickerson, J. C., Ragavan, M. V., Parikh, D. A., Patel, M. I. 2020; 11 (9): 705–22

  Abstract

  Globally, cancer care delivery is marked by inequalities, where some economic, demographic, and sociocultural groups have worse outcomes than others. In this review, we sought to identify patient-facing interventions designed to reduce disparities in cancer care in both high- and low-income countries. We found two broad categories of interventions that have been studied in the current literature: Patient navigation and telehealth. Navigation has the strongest evidence base for reducing disparities, primarily in cancer screening. Improved outcomes with navigation interventions have been seen in both high- and low-income countries. Telehealth interventions remain an active area of exploration, primarily in high income countries, with the best evidence being for the remote delivery of palliative care. Ongoing research is needed to identify the most efficacious, cost-effective, and scalable interventions to reduce barriers to the receipt of cancer care globally.

  View details for DOI 10.5306/wjco.v11.i9.705

  View details for PubMedID 33033693

• Cancer Disparities and Health Equity: A Policy Statement From the American Society of Clinical Oncology. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Patel, M. I., Lopez, A. M., Blackstock, W., Reeder-Hayes, K., Moushey, A., Phillips, J., Tap, W. 2020: JCO2000642

  Abstract

  ASCO strives, through research, education, and promotion of the highest quality of patient care, to create a world where cancer is prevented and every survivor is healthy. In this pursuit, cancer health equity remains the guiding institutional principle that applies to all its activities across the cancer care continuum. In 2009, ASCO committed to addressing differences in cancer outcomes in its original policy statement on cancer disparities. Over the past decade, despite novel diagnostics and therapeutics, together with changes in the cancer care delivery system such as passage of the Affordable Care Act, cancer disparities persist. Our understanding of the populations experiencing disparate outcomes has likewise expanded to include the intersections of race/ethnicity, geography, sexual orientation and gender identity, sociodemographic factors, and others. This updated statement is intended to guide ASCO's future activities and strategies to achieve its mission of conquering cancer for all populations. ASCO acknowledges that much work remains to be done, by all cancer stakeholders at the systems level, to overcome historical momentum and existing social structures responsible for disparate cancer outcomes. This updated statement affirms ASCO's commitment to moving beyond descriptions of differences in cancer outcomes toward achievement of cancer health equity, with a focus on improving equitable access to care, improving clinical research, addressing structural barriers, and increasing awareness that results in measurable and timely action toward achieving cancer health equity for all.

  View details for DOI 10.1200/JCO.20.00642

  View details for PubMedID 32783672

• Understanding sex disparities in lung cancer incidence: are women more at risk? Lung cancer management Ragavan, M. V., Patel, M. I. 2020; 9 (3): LMT34

  View details for DOI 10.2217/lmt-2020-0013

  View details for PubMedID 32774466

• Lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander women: The development of a multilevel integrated dataset of EHR, cancer registry, and environmental data DeRouen, M. C., Shariff-Marco, S., Lichtensztajn, D., Jin, A., Daida, Y. G., Canchola, A. J., Li, Y., Jain, J., Allen, L., Nie, S., Wong, C., Haile, R., Patel, M., Reynolds, P., Wakelee, H., Luft, H., Thompson, C., Liang, S., Waitzfelder, B. E., Cheng, I., Gomez, S. L. AMER ASSOC CANCER RESEARCH. 2020

  View details for DOI 10.1158/1538-7755.DISP18-IA37

  View details for Web of Science ID 000577495000725

• Lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander women: A multilevel dataset of electronic health record, cancer registry, and environmental data DeRouen, M. C., Thompson, C., Canchola, A. J., Jin, A., Nie, S., Jain, J., Shariff-Marco, S., Lichetensztajn, D. Y., Daida, Y., Wong, C., Li, Y., Patel, M., Wakelee, H. A., Liang, S., Waitzfelder, B. E., Cheng, I., Gomez, S. L. AMER ASSOC CANCER RESEARCH. 2020

  View details for DOI 10.1158/1538-7755.DISP19-PR07

  View details for Web of Science ID 000580647800528

• Census tract-level income inequality and colorectal cancer survival Chun, K. A., Robinson, J. R., Kroenke, C. H., Lane, D. S., Corbie-Smith, G., Hastert, T., Sealy-Jefferson, S., Patel, M. I., Pan, K., Beresford, S. A., Newcomb, P. A. AMER ASSOC CANCER RESEARCH. 2020

  View details for DOI 10.1158/1538-7755.DISP18-C068

  View details for Web of Science ID 000577495000418

• Census tract-level income inequality and colorectal cancer survival Chun, K. A., Robinson, J. R., Kroenke, C. H., Lane, D. S., Corbie-Smith, G., Hastert, T., Sealy-Jefferson, S., Patel, M. I., Pan, K., Beresford, S. A., Newcomb, P. A. AMER ASSOC CANCER RESEARCH. 2020

  View details for Web of Science ID 000577495000644

• Potentially avoidable hospitalizations after chemotherapy: Differences across medicare and the Veterans Health Administration. Cancer Gidwani-Marszowski, R., Faricy-Anderson, K., Asch, S. M., Illarmo, S., Ananth, L., Patel, M. I. 2020

  Abstract

  BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) has released quality measures regarding potentially avoidable hospitalizations visits in the 30days after receipt of outpatient chemotherapy. This study evaluated the proportions of patients treated by Medicare-reimbursed clinicians and Veterans Health Administration (VA) clinicians who experienced avoidable acute care in orderto evaluate differences in health system performance.METHODS: This retrospective evaluation of Medicare and VA administrative data used a cohort of cancer decedents (fiscal years 2010-2014). Cohort members were veterans aged 66years or older at death who were dually enrolled in Medicare and the VA. Chemotherapy was identified through International Classification of Diseases, Ninth Revision and Current Procedural Terminology(ICD-9) codes. CMS definesavoidable hospitalizations as those related to anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, or sepsis in the 30days after chemotherapy. Following CMS guidance, this study compared the proportions of patients with potentially avoidable hospitalizations, using hierarchicalgeneralized estimating equations.RESULTS: There were 27,443 patients who received outpatient chemotherapy. Patients receiving Medicare chemotherapy were significantly more likely to have potentially avoidable hospitalizations than patients receiving VA chemotherapy (adjusted odds ratio, 1.58; 95% confidence interval, 1.41-1.78; P<.001). In predicted estimates, 7.1% of Medicare-treated veterans had potentially avoidable hospitalizations in the 30days after chemotherapy, compared with4.6% of VA-treated veterans.CONCLUSIONS: Results indicate veterans with cancer receiving chemotherapy in the VA have higher quality care with respect to avoidable hospitalizations than veterans receiving chemotherapy through Medicare. As more veterans seek care in the private sector under the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, concerted efforts may be warranted to ensure that veterans do not experience a decline in care quality.

  View details for DOI 10.1002/cncr.32896

  View details for PubMedID 32401340

• Health Insurance Coverage Disruptions and Cancer Care and Outcomes: Systematic Review of Published Research. Journal of the National Cancer Institute Yabroff, K. R., Reeder-Hayes, K., Zhao, J., Halpern, M. T., Lopez, A. M., Bernal-Mizrachi, L., Collier, A. B., Neuner, J., Phillips, J., Blackstock, W., Patel, M. 2020

  Abstract

  BACKGROUND: Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations; but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival.METHODS: We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively.RESULTS: Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%) and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios 1.2 to 3.8) and worse survival (hazard ratios 1.28 to 2.43) than patients without disruptions.CONCLUSION: Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.

  View details for DOI 10.1093/jnci/djaa048

  View details for PubMedID 32337585

• COPD and lung cancer incidence in the Women's Health Initiative Observational Study: A brief report. Lung cancer (Amsterdam, Netherlands) Nagasaka, M., Lehman, A., Chlebowski, R., Haynes, B. M., Ho, G., Patel, M., Sakoda, L. C., Schwartz, A. G., Simon, M. S., Cote, M. L. 2020; 141: 78–81

  Abstract

  Lung cancer is the leading cause of cancer mortality in both men and women in the United States. COPD is associated with lung cancer independently of cigarette smoking, but remains understudied in women. Utilizing data from the Women's Health Initiative Observational Study (WHI-OS), this report investigates the association between COPD and development of lung cancer, with a focus on ethnicity and cancer subtype.The WHI-OS, part of the larger Women's Health Initiative (WHI), is comprised of postmenopausal women between ages 50 and 79 years old at enrollment. Self-administered questionnaires were utilized to gather baseline demographic, socioeconomic, and behavioral information from participants. For this analysis, COPD status was determined at study entry (baseline) and on annual survey (incident). Information on the primary outcome of interest, diagnosis of lung cancer, was also collected annually.Of the 92,789 women examined, 1,536 developed lung cancer. Overall, women with COPD were 1.64 times more likely to develop lung cancer than those without COPD, after adjusting for smoking status and intensity, ethnicity, education, body mass index, and income (HR = 1.64, 95 % CI: 1.43, 1.89). The relationship between COPD and lung cancer was not found to be significantly different between ethnic groups (p-value = 0.697). The associations between COPD and lung cancer was similar across subtypes (HR range 1.31-2.16), after adjusting for smoking status and intensity. COPD increases risk of lung cancer in women, thus they may benefit from more intensive surveillance compared to similar women without COPD.

  View details for DOI 10.1016/j.lungcan.2020.01.006

  View details for PubMedID 31958598

• A randomized trial of a multi-level intervention to improve advance care planning and symptom management among low-income and minority employees diagnosed with cancer in outpatient community settings. Contemporary clinical trials Patel, M. I., Khateeb, S., Coker, T. 2020: 105971

  Abstract

  Equitable delivery of advance care planning and symptom management among patients is crucial to improving cancer care. Existing interventions to improve the uptake of these services have predominantly occurred in clinic settings and are limited in their effectiveness, particularly among low-income and minority populations.The "Lay health worker Educates Engages and Activates Patients to Share (LEAPS)" intervention was developed to improve advance care planning and symptom management among low-income and minority hourly-wage workers with cancer, in two community settings. The intervention provides a lay health worker to all patients newly diagnosed with cancer and aims to educate and activate patients to engage in advance care planning and symptom management with their oncology providers. In this randomized clinical trial, we will evaluate the effect on quality of life (primary outcome) using the validated Functional Assessment of Cancer Therapy - General Survey, at enrollment, 4- and 12- months post-enrollment. We will examine between-group differences on our secondary outcomes of patient activation, patient satisfaction with healthcare decision-making, and symptom burden (at enrollment, 4- and 12-months post-enrollment), and total healthcare use and healthcare costs (at 12-months post-enrollment).Multilevel approaches are urgently needed to improve cancer care delivery among low-income and minority patients diagnosed with cancer in community settings. The current study describes the LEAPS intervention, the study design, and baseline characteristics of the community centers participating in the study. ClinicalTrials.gov Registration #NCT03699748.

  View details for DOI 10.1016/j.cct.2020.105971

  View details for PubMedID 32145441

• Association of a Lay Health Worker Intervention With Symptom Burden, Survival, Health Care Use, and Total Costs Among Medicare Enrollees With Cancer. JAMA network open Patel, M. I., Ramirez, D., Agajanian, R., Agajanian, H., Coker, T. 2020; 3 (3): e201023

  Abstract

  Undertreated patient symptoms require approaches that improve symptom burden.To determine the association of a lay health worker-led symptom screening and referral intervention with symptom burden, survival, health care use, and total costs among Medicare Advantage enrollees with a new diagnosis of solid or hematologic malignant neoplasms.This quality improvement study conducted at 9 community oncology practices from November 1, 2016, to October 31, 2018, compared newly diagnosed Medicare Advantage enrollees with solid or hematologic malignant neoplasms with patients diagnosed and treated 1 year prior. Analysis was conducted from August 1, 2019, to January 11, 2020.Usual care augmented by a lay health worker trained to screen symptoms and refer patients to palliative care and behavioral medicine.The primary outcome was change in symptoms using the Edmonton Symptom Assessment Scale and the 9-item Patient Health Questionnaire at baseline and 6 and 12 months after enrollment. Secondary outcomes were between-group comparison of survival, 12-month health care use, and costs.Among 425 patients in the intervention group and 407 patients in the control group, the mean (SD) age was 78.8 (8.3) years, 345 (41.5%) were female, and 407 (48.9%) were non-Hispanic white. Patients in the intervention group experienced a lower symptom burden as measured by the Edmonton Symptom Assessment Scale score over time compared with patients in the control group (mean [SD] difference, -1.9 [14.2]; 95% CI, -3.77 to -0.19; P = .01 for the intervention group and 2.32 [17.7]; 95% CI, 0.47 to 4.19; P = .02 for the control group). Similar findings were noted in 9-item Patient Health Questionnaire depression scores (mean [SD] difference, -0.63 [3.99]; 95% CI, -1.23 to -0.028; P = .04 for the intervention group and 1.67 [5.49]; 95% CI, 0.95 to 2.37; P = .01 for the control group). Patients in the intervention group compared with patients in the control group had fewer mean (SD) inpatient visits (0.54 [0.77]; 95% CI, 0.47-0.61 vs 0.72 [1.12]; 95% CI, 0.61-0.83; P = .04) and emergency department visits (0.43 [0.76]; 95% CI, 0.36-0.50 vs 0.57 [1.00]; 95% CI, 0.48-0.67; P = .002) per 1000 patients per year and lower total costs (median, $17 869 [interquartile range, $6865-$32 540] vs median, $18 473 [interquartile range, $6415-$37 910]; P = .02). A total of 180 patients in the intervention group and 189 patients in the control group died within 12 months. Among those who died, patients in the intervention group had greater hospice use (125 of 180 [69.4%] vs 79 of 189 [41.8%]; odds ratio, 3.16; 95% CI, 2.13-4.69; P < .001), fewer mean (SD) emergency department and hospital visits (emergency department: 0.10 [0.30]; 95% CI, 0.06-0.14 vs 0.30 [0.46]; 95% CI, 0.24-0.38; P = .001; hospital: 0.27 [0.44]; 95% CI, 0.21-0.34 vs 0.43 [0.82]; 95% CI, 0.32-0.55; P = .02), and lower costs (median, $3602 [interquartile range, $1076-$9436] vs median, $12 726 [interquartile range, $5259-$22 170]; P = .002), but there was no significant difference in inpatient deaths (18 of 180 [10.0%] vs 30 of 189 [15.9%]; P = .14).This study suggests that a lay health worker-led intervention may be one way to improve burdensome and costly care.

  View details for DOI 10.1001/jamanetworkopen.2020.1023

  View details for PubMedID 32176306

• A Call to Action: Ethics Committee Roundtable Recommendations for Addressing Burnout and Moral Distress in Oncology. JCO oncology practice Hlubocky, F. J., Taylor, L. P., Marron, J. M., Spence, R. A., McGinnis, M. M., Brown, R. F., McFarland, D. C., Tetzlaff, E. D., Gallagher, C. M., Rosenberg, A. R., Popp, B., Dragnev, K., Bosserman, L. D., Dudzinski, D. M., Smith, S., Chatwal, M., Patel, M. I., Markham, M. J., Levit, K., Bruera, E., Epstein, R. M., Brown, M., Back, A. L., Shanafelt, T. D., Kamal, A. H. 2020: JOP1900806

  Abstract

  Oncologist well-being is critical to initiating and maintaining the physician-patient relationship, yet many oncologists suffer from symptoms of burnout. Burnout has been linked to poor physical and mental health, as well as increased medical errors, patient dissatisfaction, and workforce attrition. In this Call to Action article, we discuss causes of and interventions for burnout and moral distress in oncology, highlight existing interventions, and provide recommendations for addressing burnout and improving well-being at the individual and organizational levels to deliver ethical, quality cancer care.

  View details for DOI 10.1200/JOP.19.00806

  View details for PubMedID 32223701

• Successful Strategies to Address Disparities: Insurer and Employer Perspectives. American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting Patel, M. I., Snyder, R., Brawley, O. 2020; 40: 1–9

  Abstract

  Disparities in cancer have been documented for decades and continue to persist despite clinical advancements in cancer prevention, detection, and treatment. Disparate cancer outcomes continue to affect many populations in the United States and globally, including racial and ethnic minorities, populations with low income and education, and residents of rural areas or low socioeconomic neighborhoods, among others. Addressing cancer disparities requires approaches that are multilevel. Addressing social determinants of health, such as removing obstacles to health (e.g., poverty, discrimination, access to housing and education, jobs with fair pay, and health care) can reduce cancer disparities. However, to achieve cancer health equity, multilevel approaches are required to ensure that access to high-quality cancer care and equitable receipt of evidence-based services can reduce cancer disparities. Policy, health system interventions, and innovative delivery and health care coverage approaches by private and public payers, employer-based payers, and labor union organizations can assist in ensuring access to and receipt of high-quality cancer care while addressing the high costs of care delivery. Partnerships among patients, caregivers, employers, health care providers, and health care payers can make impactful changes in the way in which cancer care is delivered and, in turn, can assist in reducing cancer disparities.

  View details for DOI 10.1200/EDBK_279959

  View details for PubMedID 32239980

• End-of-Life Cancer Care Redesign: Patient and Caregiver Experiences in a Lay Health Worker-Led Intervention AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE Patel, M., Moore, D., Coker, T. R. 2019; 36 (12): 1081–88

  View details for DOI 10.1177/1049909119847967

  View details for Web of Science ID 000484508100006

• A Community-Partnered, Evidence-Based Approach to Improving Cancer Care Delivery for Low-Income and Minority Patients with Cancer JOURNAL OF COMMUNITY HEALTH Patel, M., Andrea, N., Jay, B., Coker, T. R. 2019; 44 (5): 912–20

  View details for DOI 10.1007/s10900-019-00632-x

  View details for Web of Science ID 000482993400008

• Financial toxicity among veterans with cancer. Parikh, D., Ragavan, M., Khateeb, S., Patel, M. I. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.27_suppl.103

  View details for Web of Science ID 000518223100101

• Enhancing community capacity to deliver value-based cancer care at the end-of-life. Patel, M. I., Ramirez, D., Agajanian, R., Agajanian, H. H., Coker, T. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.27_suppl.4

  View details for Web of Science ID 000518223100005

• Sex disparities in lung cancer incidence: validation of a long-observed trend TRANSLATIONAL LUNG CANCER RESEARCH Hellyer, J. A., Patel, M. I. 2019; 8 (4): 543–45

  View details for DOI 10.21037/tlcr.2019.04.06

  View details for Web of Science ID 000484264600023

• Perspectives and practices of oncology providers in addressing financial toxicity. Ragavan, M., Parikh, D., Patel, M. I. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.15_suppl.e18342

  View details for Web of Science ID 000487345802278

• Demographic factors associated with financial toxicity: Results from the multisite cost study. Parikh, D., Ragavan, M., Dutta, R., Edwards, J., Maitra, D., Patel, M. I. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.15_suppl.e18362

  View details for Web of Science ID 000487345802295

• Enhancing community capacity to improve cancer care delivery and the effect on patient-reported outcomes, healthcare utilization and total costs of care. Patel, M. I., Ramirez, D., Agajanian, R., Agajanian, H. H., Bhattacharya, J., Coker, T. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.15_suppl.6522

  View details for Web of Science ID 000487345806076

• Collaborative Telerehabilitation-A Smart Move for Patients With Advanced Cancer JAMA ONCOLOGY Patel, M. I. 2019; 5 (5): 652–53

  View details for DOI 10.1001/jamaoncol.2019.0021

  View details for Web of Science ID 000467495600012

• Collaborative Telerehabilitation-A Smart Move for Patients With Advanced Cancer. JAMA oncology Patel, M. I. 2019

  View details for PubMedID 30946443

• A Community-Partnered, Evidence-Based Approach to Improving Cancer Care Delivery for Low-Income and Minority Patients with Cancer. Journal of community health Patel, M., Andrea, N., Jay, B., Coker, T. R. 2019

  Abstract

  Community-engaged adaptations of evidence-based interventions are needed to improve cancer care delivery for low-income and minority populations with cancer. The objective of this study was to adapt an intervention to improve end-of-life cancer care delivery using a community-partnered approach. We used a two-step formative research process to adapt the evidence-based lay health workers educate engage andencourage patients to share (LEAPS) cancer care intervention. The first step involved obtaining a series of adaptations through focus groups with 15 patients, 12 caregivers, and 6 leaders and staff of the Unite Here Health (UHH) payer organization, and 12 primary care and oncology care providers. Focus group discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. The second step involved finalization of adaptations from a community advisory board comprised of 4 patients, 2 caregivers, 4 oncology providers, 2 lay health workers and 4 UHH healthcare payer staff and executive leaders. Using this community-engaged approach, stakeholders identified critical barriers and solutions to intervention delivery which included: (1) expanding the intervention to ensure patient recruitment; (2) including caregivers; (3) regular communication between UHH staff, primary care and oncology providers; and (4) selecting outcomes that reflect patient-reported quality of life. This systematic and community-partnered approach to adapt an end-of-life cancer care intervention strengthened this existing intervention to promote the needs and preferences of patients, caregivers, providers, and healthcare payer leaders. This approach can be used to address cancer care delivery for low-income and minority patients with cancer.

  View details for PubMedID 30825097

• Questioning Lay Health Worker Influence on Goals-of-Care Documentation and Patient Satisfaction-In Reply. JAMA oncology Patel, M. I. 2019

  View details for PubMedID 30730550

• End-of-Life Cancer Care Redesign: Patient and Caregiver Experiences in a Lay Health Worker-Led Intervention. The American journal of hospice & palliative care Patel, M. I., Moore, D., Coker, T. R. 2019: 1049909119847967

  Abstract

  The Engagement of Patients with Advanced Cancer (EPAC), comprised of a lay health worker (LHW) who assists patients with advance care planning, is an effective intervention for improving patient experiences and reducing acute care use and total health-care costs. The objective of this study was to assess patients' and caregivers' experiences with the intervention.We invited all patients enrolled in EPAC and their caregivers to complete an 8-item survey at the end of the intervention and a random 35% sample to participate in a qualitative interview to assess their experiences. At 15-month follow-up, we invited all caregivers of patients who died during the study to participate in a qualitative interview. We analyzed survey responses using bivariate methods and recorded, transcribed, and analyzed interviews using qualitative content analysis.Sixty-nine patients were alive at completion of the intervention and all 30 identified caregivers completed the survey. All viewed the intervention as a critical part of cancer care and recommended the intervention for other patients. In qualitative interviews, among 30 patients, all reported improved comfort in discussing their end-of-life care preferences. In qualitative interviews with 24 bereaved caregivers, all viewed the intervention as critical in ensuring that their loved ones' wishes were adhered to at the end of life.Incorporating an LHW into end-of-life cancer care is an approach supported and viewed as highly effective in improving care by patients and caregivers. The LHW-led EPAC intervention is one solution that can significantly impact patient and caregiver experiences.

  View details for PubMedID 31046401

• Characteristics of Patients With ROS1+ Cancers: Results From the First Patient-Designed, Global, Pan-Cancer ROS1 Data Repository. Journal of oncology practice Parikh, D. A., Walia, G., Freeman-Daily, J., Hennink, M., Tomalia, T., Buonanno, L., Goldman, L., Addario, B., Patel, M. I. 2019: JOP1900135

  Abstract

  The discovery of driver oncogenes, such as ROS1, has led to the development of targeted therapies. Despite clinical advancements, gaps remain in our understanding of characteristics of patients with ROS1-positive (ROS1+) cancers. The purpose of this study was to comprehensively assess demographic, clinical, and environmental characteristics associated with ROS1+ cancers worldwide.In collaboration with a panel of patients with ROS1+ cancer, we designed and conducted a 204-question online assessment regarding the demographic, clinical, and environmental factors of patients with ROS1+ cancers. We invited patients with ROS1+ cancers to participate in the study from May 2016 to December 2018.A total of 277 patients from 18 countries worldwide responded and completed at least 90% of the survey. The majority of respondents were female (n = 191; 69%), non-Hispanic white (n = 202; 73%), never-smokers (n = 180/240; 75%). Most were diagnosed with lung cancer (n = 261/277; 94%) and stage IV disease (n = 201/277; 76%). The majority received chemotherapy in first (n = 137/199; 69%) and second (n = 103/199; 52%) lines of therapy. For patients diagnosed with lung cancer after the availability of crizotinib (n = 199), only a minority (n = 55/199; 28%) reported receiving crizotinib in the first line of therapy.This study is the first global, patient-designed approach, to our knowledge, to comprehensively assess demographic, clinical, and environmental characteristics associated with ROS1+ cancers. Future efforts include assessing these characteristics as well as patient-reported outcomes and treatment responses longitudinally.

  View details for DOI 10.1200/JOP.19.00135

  View details for PubMedID 31880972

• Sex disparities in lung cancer incidence: validation of a long-observed trend. Translational lung cancer research Hellyer, J. A., Patel, M. I. 2019; 8 (4): 543–45

  View details for DOI 10.21037/tlcr.2019.04.06

  View details for PubMedID 31555528

  View details for PubMedCentralID PMC6749120

• Health System and Beneficiary Costs Associated With Intensive End-of-Life Medical Services. JAMA network open Gidwani-Marszowski, R., Asch, S. M., Mor, V., Wagner, T. H., Faricy-Anderson, K., Illarmo, S., Hsin, G., Patel, M. I., Ramchandran, K., Lorenz, K. A., Needleman, J. 2019; 2 (9): e1912161

  Abstract

  Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services.To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life.This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019.American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days.Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region.Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P < .001). The biggest contributor to these differences was $21 093 (95% CI, $20 364-$21 689) for intensive care unit stay, while the smallest contributor was $3460 (95% CI, $2927-$3880) for chemotherapy. Mean (SD) expected beneficiary costs for the last month of life were $133 ($50) for patients with no medically intensive service and $1257 ($408) for patients with at least 1 medically intensive service (P < .001).Given the low income of many elderly patients in the United States, the financial consequences of medically intensive services may be substantial. Costs of medically intensive services at the end of life, including patient financial consequences, should be considered by both physicians and families.

  View details for DOI 10.1001/jamanetworkopen.2019.12161

  View details for PubMedID 31560384

• Lay Health Worker-Led Cancer Symptom Screening Intervention and the Effect on Patient-Reported Satisfaction, Health Status, Health Care Use, and Total Costs: Results From a Tri-Part Collaboration. Journal of oncology practice Patel, M. I., Ramirez, D., Agajanian, R., Agajanian, H., Bhattacharya, J., Bundorf, K. M. 2019: JOP1900152

  Abstract

  Poor patient experiences and increasing costs from undertreated symptoms require approaches that improve patient-reported outcomes and lower expenditures. We developed and evaluated the effect of a lay health worker (LHW)-led symptom screening intervention on satisfaction, self-reported overall and mental health, health care use, total costs, and survival.From November 1, 2015, to September 30, 2016, we enrolled in this study all newly diagnosed Medicare Advantage enrollees with stage 3 or 4 solid tumors or hematologic malignancies who were receiving care in a community oncology practice. We evaluated symptom changes from baseline to 12 months for the intervention group. We compared with a control group (a historical cohort of Medicare Advantage enrollees diagnosed with cancer from November 1, 2014, to October 31, 2015) changes in satisfaction and overall and mental health with validated assessments at diagnosis and 5 months postdiagnosis, 12-month health care use, total costs, and survival.Among 186 patients in the intervention group and 102 in the control group, most were female and non-Hispanic white or Hispanic, and the mean age was 79 years. There were no survival differences between the groups. Relative to the control group, the intervention group experienced improvements in satisfaction with care (difference-in-difference: 1.35; 95% CI, 1.08 to 1.63), overall health (odds ratio, 2.23; 95% CI, 1.49 to 3.32), and mental or emotional health (odds ratio, 2.22; 95% CI, 1.46 to 3.38) over time; fewer hospitalizations (mean ± standard deviation: 0.72 ± 0.96 v 1.02 ± 1.44; P = .03) and emergency department visits per 1,000 members per year (0.61 ± 0.98 v 0.92 ± 1.53; P = .03), and lower median (interquartile range) total health care costs ($21,266 [$8,102-$47,900] v $31,946 [$15,754-$57,369]; P = .02).An LHW-led symptom screening intervention could be one solution to improve value-based cancer care.

  View details for DOI 10.1200/JOP.19.00152

  View details for PubMedID 31550213

• Perspectives of Health Care Payer Organizations on Cancer Care Delivery Redesign: A National Study. Journal of oncology practice Patel, M. I., Moore, D., Bhattacharya, J., Milstein, A., Coker, T. R. 2018: JOP1800331

  Abstract

  INTRODUCTION:: Despite advancements in cancer care, persistent gaps remain in the delivery of high-value end-of-life cancer care. The aim of this study was to examine views of health care payer organization stakeholders on approaches to the redesign of end-of-life cancer care delivery strategies to improve care.METHODS:: We conducted semistructured interviews with 34 key stakeholders (eg, chief medical officers, medical directors) in 12 health plans and 22 medical group organizations across the United States. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis.RESULTS:: Participants endorsed strategies to redesign end-of-life cancer care delivery to improve end-of-life care. Participants supported the use of nonprofessionals to deliver some cancer services through alternative formats (eg, telephone, Internet) and delivery of services in nonclinical settings. Participants reported that using nonprofessional providers to offer some services, such as goals of care discussions and symptom assessments, via telephone in community-based settings or in patients' homes, may be more effective and efficient ways to deliver high-value cancer care services. Participants described challenges to redesign, including coordination with and acceptance by oncology providers and payment models required to financially support clinical changes. Some participants suggested solutions, including providing funding and logistic support to encourage implementation of care delivery innovations and to financially reward practices for delivery of high-value end-of-life cancer care services.CONCLUSION:: Stakeholders from payer organizations endorsed opportunities to redesign cancer care delivery, and some are willing to provide logistic, design, and financial support to practices interested in improving end-of-life cancer care.

  View details for PubMedID 30444666

• The Employers Centers of Excellence in Cancer Care: A collaboration of employers and providers to improve cancer care. Patel, M. I., Lee, R. V., Smithline, N., Ross, O. AMER SOC CLINICAL ONCOLOGY. 2018

  View details for DOI 10.1200/JCO.2018.36.30_suppl.141

  View details for Web of Science ID 000464875300139

• Financial toxicity of cancer treatment at a diverse county hospital. Parikh, D., Ragavan, M., Maitra, D., Aggarwal, S., Patel, M. I. AMER SOC CLINICAL ONCOLOGY. 2018

  View details for DOI 10.1200/JCO.2018.36.30_suppl.76

  View details for Web of Science ID 000464875300075

• Oncologists' Views on Using Value to Guide Cancer Treatment Decisions VALUE IN HEALTH Gidwani-Marszowski, R., Nevedal, A. L., Blayney, D. W., Patel, M., Kelly, P., Timko, C., Ramchandran, K., Murrell, S. S., Asch, S. M. 2018; 21 (8): 931–37

  Abstract

  Cancer costs have increased substantially in the past decades, prompting specialty societies to urge oncologists to consider value in clinical decision making. Despite oncologists' crucial role in guiding cancer care, current literature is sparse with respect to the oncologists' views on value. Here, we evaluated oncologists perceptions of the use and measurement of value in cancer care.We conducted in-depth, open-ended interviews with 31 US oncologists practicing nationwide in various environments. Oncologists discussed the definition, measurement, and implementation of value. Transcripts were analyzed using matrix and thematic analysis.Oncologists' definitions of value varied greatly. Some described versions of the standard health economic definition of value, that is, cost relative to health outcomes. Many others did not include cost in their definition of value. Oncologists considered patient goals and quality of life as important components of value that they perceived were missing from current value measurement. Oncologists prioritized a patient-centric view of value over societal or other perspectives. Oncologists were inclined to consider the value of a treatment only if they perceived treatment would pose a financial burden to patients. Oncologists had differing opinions regarding who should be responsible for determining whether care is low value but generally felt this should remain within the purview of the oncology community.Oncologists agreed that cost was an important issue, but disagreed about whether cost was involved in value as well as the role of value in guiding treatment. Better clarity and alignment on the definition of and appropriate way to measure value is critical to the success of efforts to improve value in cancer care.

  View details for PubMedID 30098670

• Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA oncology Patel, M. I., Sundaram, V., Desai, M., Periyakoil, V. S., Kahn, J. S., Bhattacharya, J., Asch, S. M., Milstein, A., Bundorf, M. K. 2018

  Abstract

  Importance: Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited.Objective: To determine whether an LHW program can increase documentation of patients' care preferences after cancer diagnosis.Design, Setting, and Participants: Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017.Interventions: Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care.Main Outcomes and Measures: The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (on a scale of 0 [worst] to 10 [best possible]), health care use, and costs.Results: Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.]; P<.001) and larger increases in satisfaction with care on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (difference-in-difference, 1.53; 95% CI, 0.67-2.41; P<.001). The number of patients who died within 15 months of enrollment did not differ between groups (intervention, 60 of 105 [57.1%] vs control, 60 of 108 [55.6%]; P=.68). In the 30 days before death, patients in the intervention group had greater hospice use (46 [76.7%] vs 29 [48.3%]; P=.002), fewer emergency department visits (mean [SD], 0.05 [0.22] vs 0.60 [0.76]; P<.001), fewer hospitalizations (mean [SD], 0.05 [0.22] vs 0.50 [0.62]; P<.001), and lower costs (median [interquartile range], $1048 [$331-$8522] vs $23 482 [$9708-$55 648]; P<.001) than patients in the control group.Conclusions and Relevance: Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces health care use and costs at the end of life.Trial Registration: ClinicalTrials.gov Identifier: NCT02966509.

  View details for PubMedID 30054634

• Development of a multilevel integrated dataset to study lung cancer incidence and risk factors in never-smoking Asian American, Native Hawaiian, and Pacific Islander females. DeRouen, M. C., Shariff-Marco, S., Lichtensztajn, D., Jin, A., Daide, Y., Canchola, A. J., Li, Y., Jain, J., Hertz, A., Allen, L., Nie, S., Wong, C. P., Haile, R., Patel, M. I., Nelson, D., Reynolds, P., Wakelee, H. A., Luft, H., Thompson, C., Waitzfelder, B. E., Cheng, I., Gomez, S. L. AMER ASSOC CANCER RESEARCH. 2018: 81–82

  View details for Web of Science ID 000437526000094

• The Global ROS1 Initiative: A patient-researcher partnership generating open-source, oncogene-driven cancer models and data Freeman-Daily, J., Goldman, L., Tomalia, T., Lovly, C. M., Patel, M. I., Shaw, A. T., Addario, B. J., Walia, G., Young, S. W., Doebele, R. C., ROS1ders AMER ASSOC CANCER RESEARCH. 2018

  View details for DOI 10.1158/1538-7445.AM2018-4766

  View details for Web of Science ID 000468819503386

• An advance care plan decision support video before major surgery: a patient- and family-centred approach. BMJ supportive & palliative care Isenberg, S. R., Crossnohere, N. L., Patel, M. I., Conca-Cheng, A., Bridges, J. F., Swoboda, S. M., Smith, T. J., Pawlik, T. M., Weiss, M., Volandes, A. E., Schuster, A., Miller, J. A., Pastorini, C., Roter, D. L., Aslakson, R. A. 2018; 8 (2): 229–36

  Abstract

  OBJECTIVE: Video-based advanc care planning (ACP) tools have been studied in varied medical contexts; however, none have been developed for patients undergoing major surgery. Using a patient- and family-centredness approach, our objective was to implement human-centred design (HCD) to develop an ACP decision support video for patients and their family members when preparing for major surgery.DESIGN AND METHODS: The study investigators partnered with surgical patients and their family members, surgeons and other health professionals to design an ACP decision support video using key HCD principles. Adapting Maguire's HCD stages from computer science to the surgical context, while also incorporating Elwyn et al's specifications for patient-oriented decision support tool development, we used a six-stage HCD process to develop the video: (1) plan HCD process; (2) specify where video will be used; (3) specify user and organisational requirements; (4) produce and test prototypes; (5) carry out user-based assessment; (6) field test with end users.RESULTS: Over 450 stakeholders were engaged in the development process contributing to setting objectives, applying for funding, providing feedback on the storyboard and iterations of the decision tool video. Throughout the HCD process, stakeholders' opinions were compiled and conflicting approaches negotiated resulting in a tool that addressed stakeholders' concerns.CONCLUSIONS: Our patient- and family-centred approach using HCD facilitated discussion and the ability to elicit and balance sometimes competing viewpoints. The early engagement of users and stakeholders throughout the development process may help to ensure tools address the stated needs of these individuals.TRIAL REGISTRATION NUMBER: NCT02489799.

  View details for PubMedID 29555812

• Incidence of lung cancer histologic cell-types according to neighborhood factors: A population based study in California PLOS ONE DeRouen, M. C., Hu, L., McKinley, M., Gali, K., Patel, M., Clarke, C., Wakelee, H., Haile, R., Gomez, S., Cheng, I. 2018; 13 (5): e0197146

  Abstract

  The relationships between neighborhood factors (i.e., neighborhood socioeconomic status (nSES) and ethnic enclave) and histologic subtypes of lung cancer for racial/ethnic groups, particularly Hispanics and Asian American/Pacific Islanders (AAPIs), are poorly understood.We conducted a population-based study of 75,631 Californians diagnosed with lung cancer from 2008 through2012. We report incidence rate ratios (IRRs) for lung cancer histologic cell-types by nSES among racial/ethnic groups (non-Hispanic (NH) Whites, NH Blacks, Hispanics and AAPIs) and according to Hispanic or Asian neighborhood ethnic enclave status among Hispanics and AAPIs, respectively. In addition, we examined incidence jointly by nSES and ethnic enclave.Patterns of lung cancer incidence by nSES and ethnic enclave differed across race/ethnicity, sex, and histologic cell-type. For adenocarcinoma, Hispanic males and females, residing in both low nSES and high nSES neighborhoods that were low enclave, had higher incidence rates compared to those residing in low nSES, high enclave neighborhoods; males (IRR, 1.17 [95% CI, 1.04-1.32] and IRR, 1.15 [95% CI, 1.02-1.29], respectively) and females (IRR, 1.29 [95% CI, 1.15-1.44] and IRR, 1.51 [95% CI, 1.36-1.67], respectively). However, AAPI males residing in both low and high SES neighborhoods that were also low enclave had lower adenocarcinoma incidence.Neighborhood factors differentially influence the incidence of lung cancer histologic cell-types with heterogeneity in these associations by race/ethnicity and sex. For Hispanic males and females and AAPI males, neighborhood ethnic enclave status is strongly associated with lung adenocarcinoma incidence.

  View details for PubMedID 29791458

• Population-based differences in the outcome and presentation of lung cancer patients based upon racial, histologic, and economic factors in all lung patients and those with metastatic disease CANCER MEDICINE Varlotto, J., Voland, R., McKie, K., Flickinger, J. C., DeCamp, M. M., Maddox, D., Rava, P., Fitzgerald, T. J., Graeber, G., Rassaei, N., Oliveira, P., Ali, S., Belani, C., Glanzman, J., Wakelee, H. A., Patel, M., Baima, J., Zhang, J., Walsh, W. 2018; 7 (4): 1211–20

  Abstract

  To investigate the interrelation between economic, marital, and known histopathologic/therapeutic prognostic factors in presentation and survival of patients with lung cancer in nine different ethnic groups. A retrospective review of the SEER database was conducted through the years 2007-2012. Population differences were assessed via chi-square testing. Multivariable analyses (MVA) were used to detect overall survival (OS) differences in the total population (TP, N = 153,027) and for those patients presenting with Stage IV (N = 70,968). Compared to Whites, Blacks were more likely to present with younger age, male sex, lower income, no insurance, single/widowed partnership, less squamous cell carcinomas, and advanced stage; and experience less definitive surgery, lower OS, and lung cancer-specific (LCSS) survival. White Hispanics presented with younger age, higher income, lower rates of insurance, single/widowed partnership status, advanced stage, more adenocarcinomas, and lower rates of definitive surgery, but no difference in OS and LCSS than Whites. In the TP and Stage IV populations, MVAs revealed that OS was better or equivalent to Whites for all other ethnic groups and was positively associated with insurance, marriage, and higher income. Blacks presented with more advanced disease and were more likely to succumb to lung cancer, but when adjusted for prognostic factors, they had a better OS in the TP compared to Whites. Disparities in income, marital status, and insurance rather than race affect OS of patients with lung cancer. Because of their presentation with advanced disease, Black and Hispanics are likely to have increased benefit from lung cancer screening.

  View details for PubMedID 29533006

• Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare HEALTH AFFAIRS Gidwani-Marszowski, R., Needleman, J., Mor, V., Faricy-Anderson, K., Boothroyd, D. B., Hsin, G., Wagner, T. H., Lorenz, K. A., Patel, M. I., Joyce, V. R., Murrell, S. S., Ramchandran, K., Asch, S. M. 2018; 37 (1): 95–103

  Abstract

  Congressional and Veterans Affairs (VA) leaders have recommended the VA become more of a purchaser than a provider of health care. Fee-for-service Medicare provides an example of how purchased care differs from the VA's directly provided care. Using established indicators of overly intensive end-of-life care, we compared the quality of care provided through the two systems to veterans dying of cancer in fiscal years 2010-14. The Medicare-reliant veterans were significantly more likely to receive high-intensity care, in the form of chemotherapy, hospital stays, admission to the intensive care unit, more days spent in the hospital, and death in the hospital. However, they were significantly less likely than VA-reliant patients to have multiple emergency department visits. Higher-intensity end-of-life care may be driven by financial incentives present in fee-for-service Medicare but not in the VA's integrated system. To avoid putting VA-reliant veterans at risk of receiving lower-quality care, VA care-purchasing programs should develop coordination and quality monitoring programs to guard against overly intensive end-of-life care.

  View details for PubMedID 29309227

• Distribution of global health measures from routinely collected PROMIS surveys in patients with breast cancer or prostate cancer. Cancer Seneviratne, M. G., Bozkurt, S., Patel, M. I., Seto, T., Brooks, J. D., Blayney, D. W., Kurian, A. W., Hernandez-Boussard, T. 2018

  Abstract

  The collection of patient-reported outcomes (PROs) is an emerging priority internationally, guiding clinical care, quality improvement projects and research studies. After the deployment of Patient-Reported Outcomes Measurement Information System (PROMIS) surveys in routine outpatient workflows at an academic cancer center, electronic health record data were used to evaluate survey completion rates and self-reported global health measures across 2 tumor types: breast and prostate cancer.This study retrospectively analyzed 11,657 PROMIS surveys from patients with breast cancer and 4411 surveys from patients with prostate cancer, and it calculated survey completion rates and global physical health (GPH) and global mental health (GMH) scores between 2013 and 2018.A total of 36.6% of eligible patients with breast cancer and 23.7% of patients with prostate cancer completed at least 1 survey, with completion rates lower among black patients for both tumor types (P < .05). The mean T scores (calibrated to a general population mean of 50) for GPH were 48.4 ± 9 for breast cancer and 50.6 ± 9 for prostate cancer, and the GMH scores were 52.7 ± 8 and 52.1 ± 9, respectively. GPH and GMH were frequently lower among ethnic minorities, patients without private health insurance, and those with advanced disease.This analysis provides important baseline data on patient-reported global health in breast and prostate cancer. Demonstrating that PROs can be integrated into clinical workflows, this study shows that supportive efforts may be needed to improve PRO collection and global health endpoints in vulnerable populations.

  View details for PubMedID 30512191

• Lung cancer incidence trends in California by race/ethnicity, histology, sex, and neighborhood socioeconomic status: An analysis spanning 28 years LUNG CANCER Patel, M. I., McKinley, M., Cheng, I., Haile, R., Wakelee, H., Gomez, S. 2017; 108: 140–49

  Abstract

  Lung cancer incidence trends by histology, sex, race/ethnicity, and neighborhood socioeconomic status (nSES) have not been previously reported. We conducted a population-based study of lung cancer incidence over three peri-censal periods: 1988-1992, 1998-2002, and 2008-2012.We abstracted lung cancer cases from the California Cancer Registry and used US Census and American Community Survey data to develop multidimensional nSES indices for each census period. We calculated nSES tertile-specific incidence rates and rate ratios for each peri-censal period and used incidence rate ratios (IRR) to assess changes in rates from 1988 to 1992 to 1998-2002 and 2008-2012.There were a total of 231,205 lung cancer cases. Males: Among males, incidence rates of lung cancer decreased over time, all race/ethnicities, and all nSES tertiles, with larger declines among males in higher nSES areas. Rates either declined or were stable for adenocarcinoma, with larger declines for other histologic subtypes. Females: Among females, declines in incidence rates of lung cancer were more pronounced for females in higher nSES areas, but diverged more so than for males, with variations by histology and race/ethnicity. Incidence rates of adenocarcinoma increased over time among all females, with greater increase among females in low nSES areas.Our findings demonstrate differences in incidence trends over three decades by histology, gender, race/ethnicity, and nSES. While incidence rates consistently declined over time for males, there were greater declines in incidence for high nSES populations. In contrast, among females, there was evidence of increases in lung cancer incidence among low SES API females, and for adenocarcinoma.

  View details for PubMedID 28625626

• A population-based comparative effectiveness study of chemoradiation regimens and sequences in stage III non-small cell lung cancer LUNG CANCER Harris, J. P., Patel, M. I., Loo, B. W., Wakelee, H. A., Diehn, M. 2017; 108: 173–82

  Abstract

  In patients receiving concurrent chemoradiation for locally advanced non-small cell lung cancer (NSCLC), consolidation chemotherapy is frequently given even though several randomized trials have failed to show a benefit. We explored the potential benefits of consolidation chemotherapy using a population-based comparative effectiveness approach.Surveillance, Epidemiology, and End Results-Medicare was used to identify patients with Stage III NSCLC aged ≥65 and diagnosed 2002-2009. We selected patients who received concurrent chemoradiotherapy and determined whether they were (concurrent-consolidation) or were not (concurrent-alone) treated with consolidation chemotherapy. Outcomes were overall and cancer specific survival using a conditional landmark analysis approach.1688 patients treated with concurrent-alone or concurrent-consolidation were identified with a median follow up of 29 months. Choice of chemotherapy agents did not correlate with outcome. For concurrent-consolidation versus concurrent-alone, the median overall survival was 21 months versus 18 months, respectively (log-rank p=0.008) and the median cancer specific survival was 23 months versus 19 months, respectively (log-rank p=0.03). On multivariate analysis, concurrent-consolidation remained associated with improved overall survival (HR 0.85, p=0.04), and there was a trend for improved cancer specific survival (HR 0.87, p=0.12). Inverse probability of treatment weighting using propensity scores demonstrated similar findings. Importantly, the benefit of concurrent-consolidation held only for patients treated with carboplatin-taxane but not with cisplatin-etoposide.Survival outcomes were similar among the five most commonly employed platinum-based doublets. We found that patients receiving cisplatin during radiation do not appear to benefit from additional chemotherapy. However, for patients receiving carboplatin, consolidation chemotherapy was associated with improved overall and cancer specific survival.

  View details for PubMedID 28625632

• Real-world treatment patterns for patients receiving second-line and third-line treatment for advanced non-small cell lung cancer: A systematic review of recently published studies PLOS ONE Davies, J., Patel, M., Gridelli, C., De Marinis, F., Waterkamp, D., McCusker, M. E. 2017; 12 (4)

  Abstract

  Most patients with advanced non-small cell lung cancer (NSCLC) have a poor prognosis and receive limited benefit from conventional treatments, especially in later lines of therapy. In recent years, several novel therapies have been approved for second- and third-line treatment of advanced NSCLC. In light of these approvals, it is valuable to understand the uptake of these new treatments in routine clinical practice and their impact on patient care. A systematic literature search was conducted in multiple scientific databases to identify observational cohort studies published between January 2010 and March 2017 that described second- or third-line treatment patterns and clinical outcomes in patients with advanced NSCLC. A qualitative data synthesis was performed because a meta-analysis was not possible due to the heterogeneity of the study populations. A total of 12 different study cohorts in 15 articles were identified. In these cohorts, single-agent chemotherapy was the most commonly administered treatment in both the second- and third-line settings. In the 5 studies that described survival from the time of second-line treatment initiation, median overall survival ranged from 4.6 months (95% CI, 3.8-5.7) to 12.8 months (95% CI, 10.7-14.5). There was limited information on the use of biomarker-directed therapy in these patient populations. This systematic literature review offers insights into the adoption of novel therapies into routine clinical practice for second- and third-line treatment of patients with advanced NSCLC. This information provides a valuable real-world context for the impact of recently approved treatments for advanced NSCLC.

  View details for DOI 10.1371/journal.pone.0175679

  View details for Web of Science ID 000399955600034

  View details for PubMedID 28410405

• Redesigning Cancer Care Delivery: Views From Patients and Caregivers. Journal of oncology practice Patel, M. I., Periyakoil, V. S., Blayney, D. W., Moore, D., Nevedal, A., Asch, S., Milstein, A., Coker, T. R. 2017; 13 (4): e291-e302

  Abstract

  Cancer is a leading cause of death in the United States. Although treatments have improved, patients and caregivers continue to report significant gaps in their care. The objective of this study was to examine the views of patients and caregivers on their experiences with current cancer care delivery and identify key strategies to improve the delivery of care.Semistructured interviews were conducted with 75 patients and 45 caregivers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis.Participants reported multiple gaps in care delivery, including barriers in health communication with health care providers, lack of elucidation of care goals, lack of care coordination, and challenges in accessing care. Participants identified that greater use of nonphysician providers and alternative formats, such as telephone-based care and home and community-based care, would narrow these gaps.Understanding patients' and caregivers' experiences with gaps in cancer care delivery can inform cancer care delivery redesign efforts and lead to targeted interventions that result in patient-centered and family-oriented care.

  View details for DOI 10.1200/JOP.2016.017327

  View details for PubMedID 28399387

• The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives JOURNAL OF PALLIATIVE MEDICINE Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2017; 20 (4): 395-403

  Abstract

  Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC.To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC.In-depth interviews with practicing oncologists.Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration.Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches.Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members.Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

  View details for DOI 10.1089/jpm.2016.0399

  View details for Web of Science ID 000398452000016

• Overview of Thoracic Oncology Trials in Cooperative Groups Around the Globe. Clinical lung cancer Salahudeen, A. A., Patel, M. I., Baas, P., Curran, W. J., Bradley, J. D., Gandara, D. R., Goss, G. D., Mok, T. S., Ramalingam, S. S., Vokes, E. E., Malik, S. M., Wakelee, H. A. 2017; 18 (1): 5-12

  Abstract

  Survival rates of patients with either early and advanced stage non-small-cell lung cancer (NSCLC) have improved with newer systemic therapy and radiation techniques, including combination regimens, targeted therapies, and immunotherapies. The cancer cooperative groups have historically played a critical role in the advancement of NSCLC therapy. Annually, representatives from cooperative groups worldwide convene at the International Lung Cancer Congress (ILCC). In summer 2015, the ILCC reached its 16th anniversary. This article highlights the NSCLC studies presented by participating groups in 2015.

  View details for DOI 10.1016/j.cllc.2016.06.007

  View details for PubMedID 27473736

• Enhanced Quality Measurement Event Detection: An Application to Physician Reporting. EGEMS (Washington, DC) Tamang, S. R., Hernandez-Boussard, T., Ross, E. G., Gaskin, G., Patel, M. I., Shah, N. H. 2017; 5 (1): 5

  Abstract

  The wide-scale adoption of electronic health records (EHR)s has increased the availability of routinely collected clinical data in electronic form that can be used to improve the reporting of quality of care. However, the bulk of information in the EHR is in unstructured form (e.g., free-text clinical notes) and not amenable to automated reporting. Traditional methods are based on structured diagnostic and billing data that provide efficient, but inaccurate or incomplete summaries of actual or relevant care processes and patient outcomes. To assess the feasibility and benefit of implementing enhanced EHR- based physician quality measurement and reporting, which includes the analysis of unstructured free- text clinical notes, we conducted a retrospective study to compare traditional and enhanced approaches for reporting ten physician quality measures from multiple National Quality Strategy domains. We found that our enhanced approach enabled the calculation of five Physician Quality and Performance System measures not measureable in billing or diagnostic codes and resulted in over a five-fold increase in event at an average precision of 88 percent (95 percent CI: 83-93 percent). Our work suggests that enhanced EHR-based quality measurement can increase event detection for establishing value-based payment arrangements and can expedite quality reporting for physician practices, which are increasingly burdened by the process of manual chart review for quality reporting.

  View details for PubMedID 29881731

• Delivering End-of-Life Cancer Care: Perspectives of Providers. The American journal of hospice & palliative care Patel, M. I., Periyakoil, V. S., Moore, D., Nevedal, A., Coker, T. R. 2017: 1049909117719879

  Abstract

  Persistent gaps in end-of-life cancer care delivery and growing associated expenditures remain imminent US public health issues. The objective of this study was to understand clinical providers' experiences delivering cancer care for patients at the end of life and their perspectives on potential solutions to improve quality of care.Semistructured interviews were conducted with 75 cancer care providers across the United States. The interviews were recorded, transcribed, and analyzed using constant comparative method of qualitative analysis.Providers identified 3 major cancer care delivery challenges including lack of time to educate patients and caregivers due to clinical volume and administrative burdens, ambiguity in determining both prognosis and timing of palliative care at the end-of-life, and lack of adequate systems to support non-face-to-face communication with patients. To address these challenges, providers endorsed several options for clinical practice redesign in their settings. These include use of a lay health worker to assist in addressing early advance care planning, proactive non-face-to-face communication with patients specifically regarding symptom management, and community and in-home delivery of cancer care services.Specific strategies for cancer care redesign endorsed by health-care providers may be used to create interventions that can more efficiently and effectively address gaps in end-of-life cancer care.

  View details for PubMedID 28691498

• The Appropriate Provision of Primary Versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives. Journal of palliative medicine Gidwani, R., Nevedal, A., Patel, M., Blayney, D. W., Timko, C., Ramchandran, K., Kelly, P. A., Asch, S. M. 2016

  Abstract

  Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC.To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC.In-depth interviews with practicing oncologists.Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration.Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches.Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members.Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.

  View details for DOI 10.1089/jpm.2016.0399

  View details for PubMedID 27997278

• PS01.71: Patient-Driven Epidemiologic Assessment of ROS1-Fusion Driven Cancers: Topic: Medical Oncology. Journal of thoracic oncology Walia, G., Addario, B. J., Patel, M. 2016; 11 (11S): S315-?

  View details for DOI 10.1016/j.jtho.2016.09.106

  View details for PubMedID 27969538

• PS01.79: Epidemiology and Characteristics of US Veterans with NSCLC Using US Veterans Affairs (VA) Database: Topic: Medical Oncology. Journal of thoracic oncology Patel, M. I., Parisi, M., Patel, M., Pelletier, C., Bennett, C. L., Georgantopoulos, P. 2016; 11 (11S): S320-S321

  View details for DOI 10.1016/j.jtho.2016.09.114

  View details for PubMedID 27969546

• The Burden of Cancer in Asian Americans: A Report of National Mortality Trends by Asian Ethnicity CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Thompson, C. A., Gomez, S. L., Hastings, K. G., Kapphahn, K., Yu, P., Shariff-Marco, S., Bhatt, A. S., Wakelee, H. A., Patel, M. I., Cullen, M. R., Palaniappan, L. P. 2016; 25 (10): 1371-1382

  Abstract

  Asian Americans (AA) are the fastest growing U.S. population, and when properly distinguished by their ethnic origins, exhibit substantial heterogeneity in socioeconomic status, health behaviors, and health outcomes. Cancer is the second leading cause of death in the United States, yet trends and current patterns in the mortality burden of cancer among AA ethnic groups have not been documented.We report age-adjusted rates, standardized mortality ratios, and modeled trends in cancer-related mortality in the following AA ethnicities: Asian Indians, Chinese, Filipinos, Japanese, Koreans, and Vietnamese, from 2003 to 2011, with non-Hispanic whites (NHW) as the reference population.For most cancer sites, AAs had lower cancer mortality than NHWs; however, mortality patterns were heterogeneous across AA ethnicities. Stomach and liver cancer mortality was very high, particularly among Chinese, Koreans, and Vietnamese, for whom these two cancer types combined accounted for 15% to 25% of cancer deaths, but less than 5% of cancer deaths in NHWs. In AA women, lung cancer was a leading cause of death, but (unlike males and NHW females) rates did not decline over the study period.Ethnicity-specific analyses are critical to understanding the national burden of cancer among the heterogeneous AA population.Our findings highlight the need for disaggregated reporting of cancer statistics in AAs and warrant consideration of tailored screening programs for liver and gastric cancers. Cancer Epidemiol Biomarkers Prev; 25(10); 1371-82. ©2016 AACR.

  View details for DOI 10.1158/1055-9965.EPI-16-0167

  View details for PubMedID 27694108

• Acceptance of Advance Directives and Palliative Care Referral for Veterans With Advanced Cancer: A Retrospective Analysis. The American journal of hospice & palliative care Patel, M. I., Bhattacharya, J., Asch, S. M., Kahn, J. 2016; 33 (8): 742-747

  Abstract

  To evaluate the documentation of advance directive (ADs) and physician orders for life-sustaining treatment (POLST) with acceptance of palliative care (PC) services referral among patients with cancer.We retrospectively reviewed veterans with advanced cancers at the Veterans Administration Palo Alto Health Care System. Chi-square tests estimated AD and POLST documentation and referral to PC. Logistic regression models estimated the odds of AD and POLST documentation and PC referral.Two hundred and forty-six veterans were diagnosed with cancer. In all, 53% had a documented AD, 5% had a POLST, and 47% accepted referral to PC. The AD documentation was not associated with acceptance of PC.We found no association of AD documentation and PC referral. Future studies should evaluate other factors that influence referral to these services.

  View details for DOI 10.1177/1049909115595216

  View details for PubMedID 26169523

• Scientific Achievements May Not Reach Everyone: Understanding Disparities in Acute Leukemia. Current hematologic malignancy reports Patel, M. I. 2016; 11 (4): 265-270

  Abstract

  Over the past decade, scientific advancements have resulted in improved survival from acute leukemia. Continued advancements are expected given the attention to precision medicine and the resulting growth in development and adoption of risk-stratified, personalized therapies. While precision medicine has great potential to improve acute leukemia outcomes, there remain significant barriers to ensuring equitable access to these technologies and receipt of these prescribed targeted, personalized therapies. Over the past 3 years, studies report persistent outcome disparities among patients from specific racial and ethnic backgrounds, insurance and socioeconomic status, and other socio-demographic factors after a diagnosis of acute leukemia. A few recent studies examine etiologies for acute leukemia disparities and highlight the importance of ensuring access and equitable delivery of scientific advancements. In the context of continued scientific progress, future strategies require thoughtfully considered improvements in the delivery of care that can overcome the current challenges our patients face.

  View details for DOI 10.1007/s11899-016-0329-y

  View details for PubMedID 27209407

• Gene by Environment Investigation of Incident Lung Cancer Risk in African-Americans. EBioMedicine David, S. P., Wang, A., Kapphahn, K., Hedlin, H., Desai, M., Henderson, M., Yang, L., Walsh, K. M., Schwartz, A. G., Wiencke, J. K., Spitz, M. R., Wenzlaff, A. S., Wrensch, M. R., Eaton, C. B., Furberg, H., Mark Brown, W., Goldstein, B. A., Assimes, T., Tang, H., Kooperberg, C. L., Quesenberry, C. P., Tindle, H., Patel, M. I., Amos, C. I., Bergen, A. W., Swan, G. E., Stefanick, M. L. 2016; 4: 153-161

  Abstract

  Genome-wide association studies have identified polymorphisms linked to both smoking exposure and risk of lung cancer. The degree to which lung cancer risk is driven by increased smoking, genetics, or gene-environment interactions is not well understood.We analyzed associations between 28 single nucleotide polymorphisms (SNPs) previously associated with smoking quantity and lung cancer in 7156 African-American females in the Women's Health Initiative (WHI), then analyzed main effects of top nominally significant SNPs and interactions between SNPs, cigarettes per day (CPD) and pack-years for lung cancer in an independent, multi-center case-control study of African-American females and males (1078 lung cancer cases and 822 controls).Nine nominally significant SNPs for CPD in WHI were associated with incident lung cancer (corrected p-values from 0.027 to 6.09 × 10(- 5)). CPD was found to be a nominally significant effect modifier between SNP and lung cancer for six SNPs, including CHRNA5 rs2036527[A](betaSNP*CPD = - 0.017, p = 0.0061, corrected p = 0.054), which was associated with CPD in a previous genome-wide meta-analysis of African-Americans.These results suggest that chromosome 15q25.1 variants are robustly associated with CPD and lung cancer in African-Americans and that the allelic dose effect of these polymorphisms on lung cancer risk is most pronounced in lighter smokers.

  View details for DOI 10.1016/j.ebiom.2016.01.002

  View details for PubMedID 26981579

• Racial and Ethnic Variations in Lung Cancer Incidence and Mortality: Results From the Women's Health Initiative. Journal of clinical oncology Patel, M. I., Wang, A., Kapphahn, K., Desai, M., Chlebowski, R. T., Simon, M. S., Bird, C. E., Corbie-Smith, G., Gomez, S. L., Adams-Campbell, L. L., Cote, M. L., Stefanick, M. L., Wakelee, H. A. 2016; 34 (4): 360-368

  Abstract

  This study aimed to evaluate racial/ethnic differences in lung cancer incidence and mortality in the Women's Health Initiative Study, a longitudinal prospective cohort evaluation of postmenopausal women recruited from 40 clinical centers.Lung cancer diagnoses were centrally adjudicated by pathology review. Baseline survey questionnaires collected sociodemographic and health information. Logistic regression models estimated incidence and mortality odds by race/ethnicity adjusted for age, education, calcium/vitamin D, body mass index, smoking (status, age at start, duration, and pack-years), alcohol, family history, oral contraceptive, hormones, physical activity, and diet.The cohort included 129,951 women--108,487 (83%) non-Hispanic white (NHW); 10,892 (8%) non-Hispanic black (NHB); 4,882 (4%) Hispanic; 3,696 (3%) Asian/Pacific Islander (API); 534 (< 1%) American Indian/Alaskan Native; and 1,994 (1%) other. In unadjusted models, Hispanics had 66% lower odds of lung cancer compared with NHW (odds ratio [OR], 0.34; 95% CI, 0.2 to 0.5), followed by API (OR, 0.45; 95% CI, 0.27 to 0.75) and NHB (OR, 0.75; 95% CI, 0.59 to 0.95). In fully adjusted multivariable models, the decreased lung cancer risk for Hispanic compared with NHW women attenuated to the null (OR, 0.59; 95% CI, 0.35 to 0.99). In unadjusted models Hispanic and API women had decreased risk of death compared with NHW women (OR, 0.30 [95% CI, 0.15 to 0.62] and 0.34 [95% CI, 0.16 to 0.75, respectively); however, no racial/ethnic differences were found in risk of lung cancer death in fully adjusted models.Differences in lung cancer incidence and mortality are associated with sociodemographic, clinical, and behavioral factors. These findings suggest modifiable exposures and behaviors may contribute to differences in incidence of and mortality by race/ethnicity for postmenopausal women. Interventions focused on these factors may reduce racial/ethnic differences in lung cancer incidence and mortality.

  View details for DOI 10.1200/JCO.2015.63.5789

  View details for PubMedID 26700122

• Reply to M.H. Kanter et al. Journal of clinical oncology Rhoads, K. F., Patel, M. I., Ma, Y., Schmidt, L. A. 2015; 33 (30): 3519-?

  View details for DOI 10.1200/JCO.2015.62.5640

  View details for PubMedID 26215958

• Incidence Trends of Lung Cancer by Immigration Status among Chinese Americans CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Gomez, S. L., Yang, J., Lin, S., McCusker, M., Sandler, A., Cheng, I., Wakelee, H. A., Patel, M., Clarke, C. A. 2015; 24 (8): 1157-1164

  Abstract

  Lung cancer is the leading cause of cancer-related death among Chinese Americans. A detailed examination of incidence trends by immigration status and histology may inform the etiology of lung cancer in this growing population.California Cancer Registry data were enhanced with data on patient nativity. Lung cancer incidence rates for Chinese males and females were computed for the years 1990-2010, and rates by immigration status and histology were computed for 1990-2004. Trends were assessed with annual percentage change (APC) statistics (two-sided P values) based on linear regression.A total of 8,167 lung cancers were diagnosed among California Chinese from 1990 to 2010. Overall incidence increased nonstatistically among U.S.-born males (APC, 2.1; 95% CI, -4.9 to 9.7), but decreased significantly among foreign-born (APC, -1.7; 95% CI, -2.9 to -0.6). Statistically significant decreasing trends were observed for non-small cell lung cancer (NSCLC), specifically the squamous cell and large cell carcinoma subtypes among foreign-born males. Among females, incidence decreased nonsignificantly among U.S.-born (APC, -2.8; 95% CI, -9.1 to 4.0) but was stable among foreign-born (APC, -0.4; 95% CI, -1.7 to 1.0). A statistically significant decreasing trend was observed for squamous cell among foreign-born females.These data provide critical evidence base to inform screening, research, and public health priorities in this growing population.Given the low smoking prevalence among Chinese Americans, especially females, and few known lung cancer risk factors in U.S. never-smoker populations, additional research of etiologic genetic or biologic factors may elucidate knowledge regarding lung cancer diagnosed in never smokers. Cancer Epidemiol Biomarkers Prev; 24(8); 1157-64. ©2015 AACR.

  View details for DOI 10.1158/1055-9965.EPI-15-0123

  View details for Web of Science ID 000359320500002

  View details for PubMedID 25990553

• Redesigning Advanced Cancer Care Delivery: Three Ways to Create Higher Value Cancer Care. Journal of oncology practice / American Society of Clinical Oncology Patel, M. I., Moore, D., Milstein, A. 2015; 11 (4): 280-284

  View details for DOI 10.1200/JOP.2014.001065

  View details for PubMedID 25991638

• Detecting unplanned care from clinician notes in electronic health records. Journal of oncology practice / American Society of Clinical Oncology Tamang, S., Patel, M. I., Blayney, D. W., Kuznetsov, J., Finlayson, S. G., Vetteth, Y., Shah, N. 2015; 11 (3): e313-9

  Abstract

  Reduction in unplanned episodes of care, such as emergency department visits and unplanned hospitalizations, are important quality outcome measures. However, many events are only documented in free-text clinician notes and are labor intensive to detect by manual medical record review.We studied 308,096 free-text machine-readable documents linked to individual entries in our electronic health records, representing care for patients with breast, GI, or thoracic cancer, whose treatment was initiated at one academic medical center, Stanford Health Care (SHC). Using a clinical text-mining tool, we detected unplanned episodes documented in clinician notes (for non-SHC visits) or in coded encounter data for SHC-delivered care and the most frequent symptoms documented in emergency department (ED) notes.Combined reporting increased the identification of patients with one or more unplanned care visits by 32% (15% using coded data; 20% using all the data) among patients with 3 months of follow-up and by 21% (23% using coded data; 28% using all the data) among those with 1 year of follow-up. Based on the textual analysis of SHC ED notes, pain (75%), followed by nausea (54%), vomiting (47%), infection (36%), fever (28%), and anemia (27%), were the most frequent symptoms mentioned. Pain, nausea, and vomiting co-occur in 35% of all ED encounter notes.The text-mining methods we describe can be applied to automatically review free-text clinician notes to detect unplanned episodes of care mentioned in these notes. These methods have broad application for quality improvement efforts in which events of interest occur outside of a network that allows for patient data sharing.

  View details for DOI 10.1200/JOP.2014.002741

  View details for PubMedID 25980019

  View details for PubMedCentralID PMC4438112

• Age and Genetics How Do Prognostic Factors at Diagnosis Explain Disparities in Acute Myeloid Leukemia? AMERICAN JOURNAL OF CLINICAL ONCOLOGY-CANCER CLINICAL TRIALS Patel, M. I., Ma, Y., Mitchell, B. S., Rhoads, K. F. 2015; 38 (2): 159-164

  Abstract

  OBJECTIVES:: Survival disparities in acute myeloid leukemia (AML) among blacks and Hispanics have been described but not studied extensively in adults. Although younger age and cytogenetic profiles of t(8;21) and acute promyelocytic leukemia (APL) subtypes of AML are associated with improved survival, these factors have not been investigated by race. The purpose is to evaluate whether the observed survival differences for blacks and Hispanics with AML are attributable to older age at diagnosis or lower rates of favorable cytogenetic profiles at diagnosis. The hypothesis is that survival disparities for blacks and Hispanics with AML will be explained by older age at diagnosis and lower rates of favorable cytogenetics. METHODS:: Patients with AML were identified in the Surveillance Epidemiology and End Results database (1999 to 2008). Kaplan-Meier (KM) survival curves predicted survival by race/ethnicity, stratified by age. Cox proportional hazard models estimated mortality by race with adjustment for age, sex, year of diagnosis, t(8;21), and APL subtypes. RESULTS:: A total of 25,692 patients were included. Blacks and Hispanics were diagnosed at younger ages (younger than 61 y), and had higher rates of t(8;21) and APL compared with non-Hispanic whites (NHWs). The overall KM curve shows that NHWs had a worse survival compared with other races/ethnicities. However, when KM curves were stratified by age, blacks and Hispanics had worse survival in younger age categories (younger than 61 y). In multivariable models, black race was associated with an increased risk of death compared with NHWs (HR, 1.10; 95% CI, 1.04-1.16). Adjustment for t(8;21) and APL subtypes did not attenuate the disparity. CONCLUSIONS:: Despite younger age and higher prevalence of favorable cytogenetics at diagnosis, blacks and Hispanics have an increased mortality from AML compared with other racial/ethnic groups. Future studies should investigate other factors that may influence outcomes among minority populations.

  View details for DOI 10.1097/COC.0b013e31828d7536

  View details for PubMedID 23608826

• US lung cancer trends by histologic type. Cancer Patel, M. I., Cheng, I., Gomez, S. L. 2015; 121 (7): 1150-1152

  View details for DOI 10.1002/cncr.29180

  View details for PubMedID 25470142

• How do integrated health care systems address racial and ethnic disparities in colon cancer? Journal of clinical oncology Rhoads, K. F., Patel, M. I., Ma, Y., Schmidt, L. A. 2015; 33 (8): 854-860

  Abstract

  Colorectal cancer (CRC) disparities have persisted over the last two decades. CRC is a complex disease requiring multidisciplinary care from specialists who may be geographically separated. Few studies have assessed the association between integrated health care system (IHS) CRC care quality, survival, and disparities. The purpose of this study was to determine if exposure to an IHS positively affects quality of care, risk of mortality, and disparities.This retrospective secondary-data analysis study, using the California Cancer Registry linked to state discharge abstracts of patients treated for colon cancer (2001 to 2006), compared the rates of National Comprehensive Cancer Network (NCCN) guideline-based care, the hazard of mortality, and racial/ethnic disparities in an IHS versus other settings.More than 30,000 patient records were evaluated. The IHS had overall higher rates of adherence to NCCN guidelines. Propensity score-matched Cox models showed an independent and protective association between care in the IHS and survival (hazard ratio [HR], 0.87; 95% CI, 0.85 to 0.90). This advantage persisted across stage groups. Black race was associated with increased hazard of mortality in all other settings (HR, 1.15; 95% CI, 1.04 to 1.27); however, there was no disparity within the IHS for any minority group (P > .11 for all groups) when compared with white race.The IHS delivered higher rates of evidence-based care and was associated with lower 5-year mortality. Racial/ethnic disparities in survival were absent in the IHS. Integrated systems may serve as the cornerstone for developing accountable care organizations poised to improve cancer outcomes and eliminate disparities under health care reform.

  View details for DOI 10.1200/JCO.2014.56.8642

  View details for PubMedID 25624437

  View details for PubMedCentralID PMC4348634

• How do integrated health care systems address racial and ethnic disparities in colon cancer? Journal of clinical oncology Rhoads, K. F., Patel, M. I., Ma, Y., Schmidt, L. A. 2015; 33 (8): 854-860

  View details for DOI 10.1200/JCO.2014.56.8642

  View details for PubMedID 25624437

• How do differences in treatment impact racial and ethnic disparities in acute myeloid leukemia? Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Patel, M. I., Ma, Y., Mitchell, B., Rhoads, K. F. 2015; 24 (2): 344-349

  Abstract

  We previously demonstrated disparate acute myelogenous leukemia (AML) survival for black and Hispanic patients; these differences persisted despite younger ages and higher prevalence of favorable cytogenetics in these groups. This study determined: (i) whether there are differences in treatment delivered to minorities, and (ii) how these differences affect outcomes in AML. We hypothesize that differences in treatment explain some proportion of survival disparities.We used California Cancer Registry data linked to hospital discharge abstracts for patients with AML (1998-2008). Logistic regression models estimated odds of treatment (chemotherapy and/or hematopoietic stem cell transplant) by race/ethnicity. Cox proportional hazard models estimated mortality by race after adjustment for treatment.We analyzed 11,084 records. Black race was associated with lower odds of chemotherapy [OR, 0.74; 95% confidence interval (CI), 0.61-0.91]. Black and Hispanic patients had decreased odds of transplant [(OR, 0.64; 95% CI, 0.46-0.87); (OR, 0.74; 95% CI, 0.62-0.89), respectively]. Black patients had increased hazard of mortality (HR, 1.14; 95% CI, 1.04-1.25) compared with whites. Adjustment for receipt of any treatment resulted in decreased mortality (HR, 1.09; 95% CI, 1.00-1.20) for black patients.AML treatment differences for black patients explain some proportion of the disparity. Future AML disparities studies should investigate socioeconomic and other characteristics.Study findings may better elucidate drivers of disparities in AML. Cancer Epidemiol Biomarkers Prev; 24(2); 344-9. ©2015 AACR.

  View details for DOI 10.1158/1055-9965.EPI-14-0963

  View details for PubMedID 25662426

• Integrated health systems and evidence-based care: standardizing treatment to eliminate cancer disparities. Future oncology Patel, M. I., Rhoads, K. F. 2015; 11 (12): 1715-1718

  View details for DOI 10.2217/fon.15.90

  View details for PubMedID 26075439

• Are Patients With Thoracic Malignancies at Risk for Uncontrolled Symptoms? Journal of oncology practice / American Society of Clinical Oncology Patel, M. I., Williams, D. C., Wohlforth, C., Fisher, G., Wakelee, H. A., Blayney, D. W. 2015; 11 (1): e98-e102

  Abstract

  Patients with cancer often develop symptoms and contact their oncologists and care teams after normal clinic operating hours. Better understanding of these after-hours telephone calls can inform efforts to improve cancer care and to reduce health care spending. We sought to evaluate after-hours calls at Stanford Cancer Institute (SCI) Thoracic Oncology Clinic.We retrospectively analyzed content of telephone call notes made to SCI during weekends and from 5 pm to 8 am on weekdays. Chief complaint, caller and patient demographics, patient diagnosis, advice given, and disposition were analyzed. χ(2) tests were used to analyze differences in proportions.There were a total of 263 after-hours telephone calls during the 6 months of the study. After exclusions, there were 241 telephone calls for analysis. The majority of calls occurred between 5 pm to 11 pm (n = 175 [73%]; P < .001), followed by daytime calls on weekends (n = 157 [65%]; P < .001). Common symptoms were cough (28%) and dyspnea (27%). Of the calls, 62% (150 patients) resulted in emergency department (ED) referral, and 77% of patients (115 of 150) evaluated in the ED were admitted to the hospital.Most after-hours telephone calls from patients with lung cancer are related to symptoms. Many patients were referred to the ED and subsequently required hospitalization. Analysis of call content and prior events leading to after-hours calls may predict hospital admissions in this group of patients and can inform development of proactive interventions to improve quality of care and patient-centered outcomes.

  View details for DOI 10.1200/JOP.2014.001502

  View details for PubMedID 25271246

• Lung Cancer Incidence Trends by Histology Type among Asian American, Native Hawaiian, and Pacific Islander Populations in the United States, 1990-2010 CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Cheng, I., Le, G. M., Noone, A., Gali, K., Patel, M., Haile, R. W., Wakelee, H. A., Gomez, S. L. 2014; 23 (11): 2250-2265

  Abstract

  Lung cancer is one of the leading cancer sites diagnosed among Asian Americans, Pacific Islanders, and Native Hawaiians (AANHPI). To better understand the patterns of lung cancer incidence among AANHPIs, we examined the incidence trends of five histologic cell types of lung cancer across ten AANHPI populations in comparison with non-Hispanic Whites.Lung cancer incidence data from 1990 through 2010 were obtained from 13 U.S. population-based cancer registries. Age-adjusted histologic cell-type-specific incidence rates and 95% confidence intervals were calculated. Joinpoint regression models and annual percentage change (APC) statistics were used to characterize the magnitude and direction of trends.From 1990 through 2010, incidence rates of adenocarcinoma increased significantly for Filipino and Korean women with a 2.6% and 3.0% annual percentage increase, respectively. More recently, a significant rise in the incidence of adenocarcinoma was observed for Chinese men (1996-2010; APC = 1.3%). Squamous cell carcinoma (SCC) increased 2.4% per year among Japanese women. For SCC, small cell lung carcinoma, large cell and other specified carcinoma, and unspecified types, stable or decreasing trends were observed in most AANHPI groups and non-Hispanic Whites.AANHPIs demonstrate a range in the burden of lung cancer across histologies and specific populations.These findings illustrate the importance of disaggregating AANHPIs into their specific populations. The rise in incidence of adenocarcinoma and SCC among certain AANHPIs demonstrates the need for research into non-tobacco associated risk factors for these populations and targeted efforts for tobacco prevention.

  View details for DOI 10.1158/1055-9965.EPI-14-0493

  View details for Web of Science ID 000345279600007

  View details for PubMedCentralID PMC5738466

• Transforming cancer care: are transdisciplinary approaches using design-thinking, engineering, and business methodologies needed to improve value in cancer care delivery? Journal of oncology practice / American Society of Clinical Oncology Patel, M. I., Moore, D., Blayney, D. W., Milstein, A. 2014; 10 (2): e51-4

  View details for DOI 10.1200/JOP.2013.000928

  View details for PubMedID 24371302

• Lung cancer incidence trends by histology type among Asian American, Native Hawaiian, and Pacific Islander populations in the United States, 1990-2010. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Cheng, I., Le, G. M., Noone, A. M., Gali, K., Patel, M., Haile, R. W., Wakelee, H. A., Gomez, S. L. 2014; 23 (11): 2250–65

  Abstract

  Lung cancer is one of the leading cancer sites diagnosed among Asian Americans, Pacific Islanders, and Native Hawaiians (AANHPI). To better understand the patterns of lung cancer incidence among AANHPIs, we examined the incidence trends of five histologic cell types of lung cancer across ten AANHPI populations in comparison with non-Hispanic Whites.Lung cancer incidence data from 1990 through 2010 were obtained from 13 U.S. population-based cancer registries. Age-adjusted histologic cell-type-specific incidence rates and 95% confidence intervals were calculated. Joinpoint regression models and annual percentage change (APC) statistics were used to characterize the magnitude and direction of trends.From 1990 through 2010, incidence rates of adenocarcinoma increased significantly for Filipino and Korean women with a 2.6% and 3.0% annual percentage increase, respectively. More recently, a significant rise in the incidence of adenocarcinoma was observed for Chinese men (1996-2010; APC = 1.3%). Squamous cell carcinoma (SCC) increased 2.4% per year among Japanese women. For SCC, small cell lung carcinoma, large cell and other specified carcinoma, and unspecified types, stable or decreasing trends were observed in most AANHPI groups and non-Hispanic Whites.AANHPIs demonstrate a range in the burden of lung cancer across histologies and specific populations.These findings illustrate the importance of disaggregating AANHPIs into their specific populations. The rise in incidence of adenocarcinoma and SCC among certain AANHPIs demonstrates the need for research into non-tobacco associated risk factors for these populations and targeted efforts for tobacco prevention.

  View details for PubMedID 25368400

• How do social factors explain outcomes in non-small-cell lung cancer among Hispanics in California? Explaining the Hispanic paradox. Journal of clinical oncology Patel, M. I., Schupp, C. W., Gomez, S. L., Chang, E. T., Wakelee, H. A. 2013; 31 (28): 3572-3578

  Abstract

  Hispanics in the United States have lower age-adjusted mortality resulting from non-small-cell lung cancer (NSCLC) compared with non-Hispanic whites (NHWs). The purpose of this study was to evaluate individual, clinical, and neighborhood factors in survival among Hispanics with NSCLC.We performed a retrospective analysis of NHWs and Hispanics with NSCLC between 1998 and 2007 in the California Cancer Registry (follow-up to December 2009). Kaplan-Meier curves depict survival by nativity for Hispanics with NSCLC. Cox proportional hazards models estimated hazard of mortality by race with adjustment for individual (age, sex, marital status), clinical (histologic grade, surgery, irradiation, chemotherapy), and neighborhood factors (neighborhood socioeconomic status, ethnic enclave).We included 14,280 Hispanic patients with NSCLC. Foreign-born Hispanics had 15% decreased risk of disease-specific mortality resulting from NSCLC compared with NHWs (hazard ratio [HR], 0.85; 95% CI, 0.83 to 0.88) after adjustment for individual, clinical, and neighborhood factors. After adjustment for individual factors, compared with US-born Hispanics, foreign-born Hispanics had 10% decreased risk of disease-specific mortality (HR, 0.90; 95% CI, 0.87 to 0.96). Clinical and neighborhood factors slightly moderated the survival benefit for foreign-born patients. A modestly more pronounced survival advantage was seen for foreign-born Hispanics living in low socioeconomic and high Hispanic enclave neighborhoods as compared with US-born Hispanics (HR, 0.86; 95% CI, 0.81 to 0.90).Foreign-born Hispanics with NSCLC have a decreased risk of disease-specific mortality compared with NHWs and US-born Hispanics with NSCLC. Neighborhood factors slightly moderate this survival advantage. This survival advantage is slightly more pronounced in lower socioeconomic and higher Hispanic enclave neighborhoods.

  View details for DOI 10.1200/JCO.2012.48.6217

  View details for PubMedID 23960183

• How do social factors explain outcomes in non-small-cell lung cancer among hispanics in california? Explaining the Hispanic paradox. Journal of clinical oncology Patel, M. I., Schupp, C. W., Gomez, S. L., Chang, E. T., Wakelee, H. A. 2013; 31 (28): 3572-3578

  Abstract

  Hispanics in the United States have lower age-adjusted mortality resulting from non-small-cell lung cancer (NSCLC) compared with non-Hispanic whites (NHWs). The purpose of this study was to evaluate individual, clinical, and neighborhood factors in survival among Hispanics with NSCLC.We performed a retrospective analysis of NHWs and Hispanics with NSCLC between 1998 and 2007 in the California Cancer Registry (follow-up to December 2009). Kaplan-Meier curves depict survival by nativity for Hispanics with NSCLC. Cox proportional hazards models estimated hazard of mortality by race with adjustment for individual (age, sex, marital status), clinical (histologic grade, surgery, irradiation, chemotherapy), and neighborhood factors (neighborhood socioeconomic status, ethnic enclave).We included 14,280 Hispanic patients with NSCLC. Foreign-born Hispanics had 15% decreased risk of disease-specific mortality resulting from NSCLC compared with NHWs (hazard ratio [HR], 0.85; 95% CI, 0.83 to 0.88) after adjustment for individual, clinical, and neighborhood factors. After adjustment for individual factors, compared with US-born Hispanics, foreign-born Hispanics had 10% decreased risk of disease-specific mortality (HR, 0.90; 95% CI, 0.87 to 0.96). Clinical and neighborhood factors slightly moderated the survival benefit for foreign-born patients. A modestly more pronounced survival advantage was seen for foreign-born Hispanics living in low socioeconomic and high Hispanic enclave neighborhoods as compared with US-born Hispanics (HR, 0.86; 95% CI, 0.81 to 0.90).Foreign-born Hispanics with NSCLC have a decreased risk of disease-specific mortality compared with NHWs and US-born Hispanics with NSCLC. Neighborhood factors slightly moderate this survival advantage. This survival advantage is slightly more pronounced in lower socioeconomic and higher Hispanic enclave neighborhoods.

  View details for DOI 10.1200/JCO.2012.48.6217

  View details for PubMedID 23960183

• Seventh Edition (2010) of the AJCC/UICC Staging System for Gastric Adenocarcinoma: Is there Room for Improvement? ANNALS OF SURGICAL ONCOLOGY Patel, M. I., Rhoads, K. F., Ma, Y., Ford, J. M., Visser, B. C., Kunz, P. L., Fisher, G. A., Chang, D. T., Koong, A., Norton, J. A., Poultsides, G. A. 2013; 20 (5): 1631-1638

  Abstract

  The gastric cancer AJCC/UICC staging system recently underwent significant revisions, but studies on Asian patients have reported a lack of adequate discrimination between various consecutive stages. We sought to validate the new system on a U.S. population database.California Cancer Registry data linked to the Office of Statewide Health Planning and Development discharge abstracts were used to identify patients with gastric adenocarcinoma (esophagogastric junction and gastric cardia tumors excluded) who underwent curative-intent surgical resection in California from 2002 to 2006. AJCC/UICC stage was recalculated based on the latest seventh edition. Overall survival probabilities were calculated using the Kaplan-Meier method.Of 1905 patients analyzed, 54 % were males with a median age of 70 years. Median number of pathologically examined lymph nodes was 12 (range, 1-90); 40 % of patients received adjuvant chemotherapy, and 31 % received adjuvant radiotherapy. The seventh edition AJCC/UICC system did not distinguish outcome adequately between stages IB and IIA (P = 0.40), or IIB and IIIA (P = 0.34). By merging stage II into 1 category and moving T2N1 to stage IB and T2N2, T1N3 to stage IIIA, we propose a new grouping system with improved discriminatory abilityIn this first study validating the new seventh edition AJCC/UICC staging system for gastric cancer on a U.S. population with a relatively limited number of lymph nodes examined, we found stages IB and IIA, as well as IIB and IIIA to perform similarly. We propose a revised stage grouping for the AJCC/UICC staging system that better discriminates between outcomes.

  View details for DOI 10.1245/s10434-012-2724-5

  View details for PubMedID 23149854

• The influence of Hispanic ethnicity on nonsmall cell lung cancer histology and patient survival An Analysis of the Surveillance, Epidemiology, and End Results Database CANCER Gomez, S. L., Schupp, C. W., Patel, M. 2013; 119 (6): 1286-1287

  View details for DOI 10.1002/cncr.27799

  View details for Web of Science ID 000315696600027

  View details for PubMedID 23027432

• Are Disparities in Acute Myelogenous Leukemia Due to Poor Prognostic Factors At Diagnosis? A National Study 54th Annual Meeting and Exposition of the American-Society-of-Hematology (ASH) Patel, M. I., Ma, Y., Mitchell, B. S., Rhoads, K. AMER SOC HEMATOLOGY. 2012

  View details for Web of Science ID 000314049603234

• Understanding disparities in leukemia: a national study CANCER CAUSES & CONTROL Patel, M. I., Ma, Y., Mitchell, B. S., Rhoads, K. F. 2012; 23 (11): 1831-1837

  Abstract

  Disparities in solid tumors have been well studied. However, disparities in hematologic malignancies have been relatively unexplored on population-based levels. The purpose of this study is to examine the relationship between race/ethnicity and acute leukemia mortality.All patients with acute leukemia [acute lymphoblastic leukemia (ALL) and acute myelogenous leukemia (AML)] were identified in the Surveillance Epidemiology and End Results database, 1999-2008. Kaplan-Meier curves were generated to reflect survival probabilities by race/ethnicity. Multivariable Cox proportional hazard models estimated hazard of mortality by race with adjustment for individual (age, gender, year of diagnosis) and select genetic factors.A total of 39,002 patients with acute leukemia were included in the study. Overall, there was a mortality disparity in acute leukemia for blacks (HR 1.17, p < 0.0001) and Hispanics (HR 1.13, p < 0.0001) compared with non-Hispanic whites. In stratified analysis, disparities in ALL were greater than AML; blacks (HR[ALL]1.45, p < 0.0001; HR[AML]1.12, p < 0.0011); Hispanics (HR[ALL]1.46, p < 0.0001; HR[AML]1.06, p < 0.0001). Adjustment for individual patient and select genetic factors did not explain disparities.Blacks and Hispanics suffer decreased survival in acute leukemia as compared to others. Further investigation is needed to understand the drivers of poor cancer outcomes in these populations.

  View details for DOI 10.1007/s10552-012-0062-3

  View details for Web of Science ID 000309671300009

  View details for PubMedID 22971999

• How Do Social Factors Explain Outcomes In Non-small Cell Lung Cancer Among Hispanic/latinos In California? Patel, M. I., Chang, E., Gomez, S., Wakelee, H. A. LIPPINCOTT WILLIAMS & WILKINS. 2012: S216–S216

  View details for Web of Science ID 000317035000036

• How do social factors explain outcomes in non-small cell lung cancer among Hispanics/Latinos in California? 48th Annual Meeting of the American-Society-of-Clinical-Oncology (ASCO) Patel, M. I., Chang, E. T., Gomez, S. L., Schupp, C., Wakelee, H. A. AMER SOC CLINICAL ONCOLOGY. 2012

  View details for Web of Science ID 000318009801334

• Adjuvant chemotherapy for early stage non-small cell lung cancer. Frontiers in oncology Patel, M. I., Wakelee, H. A. 2011; 1: 45-?

  Abstract

  For many years adjuvant chemotherapy has been a standard treatment after complete resection in malignancies such as breast and colon but only recently has its use become standard in early stage non-small cell lung cancer (NSCLC). Although surgery is regarded as the best possible treatment for early stage NSCLC, only 20-25% of patients have resectable disease at presentation. Despite optimal surgical treatment, 5-year survival rates for NSCLC remain 50-60% for stage IB, 40-50% for stage II, and 20-30% for stage III (Kohler et al., 2011; Siegel et al., 2011). Adjuvant chemotherapy provides additional survival benefit in resected NSCLC but questions remain as to how to select patients for therapy and which regimen is best. Other than work with tegafur/uracil in Japan, the positive adjuvant trials have all utilized a cisplatin backbone, but the drug(s) to pair with cisplatin are a matter of debate and will be discussed further in this manuscript.

  View details for DOI 10.3389/fonc.2011.00045

  View details for PubMedID 22655247