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Alternative payment and care-delivery models in oncology: A systematic review: Payment and Care-Delivery Models

Rising US health care costs have led to the creation of alternative payment and care‐delivery models designed to maximize outcomes and/or minimize costs through changes in reimbursement and care delivery. The impact of these interventions in cancer care is unclear. This review was undertaken to describe the landscape of new alternative payment and care‐delivery models in cancer care. In this systematic review, 22 alternative payment and/or care‐delivery models in cancer care were identified. These included 6 bundled payments, 4 accountable care organizations, 9 patient‐centered medical homes, and 3 other interventions. Only 12 interventions reported outcomes; the majority (nu2009=u20097; 58%) improved value, 4 had no impact, and 1 reduced value, but only initially. Heterogeneity of outcomes precluded a meta‐analysis. Despite the growth in alternative payment and delivery models in cancer, there is limited evidence to evaluate their efficacy. Cancer 2018.

Racial disparities in chemotherapy administration for early-stage breast cancer: a systematic review and meta-analysis.

PurposeWe conducted a systematic review and meta-analysis to measure the extent to which race is associated with delayed initiation or receipt of inadequate chemotherapy among women with early-stage breast cancer.MethodsWe performed a systematic search of all articles published from January 1987 until June 2017 within four databases: PubMed/Medline, EMBASE, CINAHL, and Cochrane CENTRAL. Eligible studies were US-based and examined the influence of race on chemotherapy delays, cessation, or dose reductions among women with stage I, II, or III breast cancer. Data were pooled using a random effects model.ResultsA total of twelve studies were included in the quantitative analysis. Blacks were significantly more likely than whites to have delays to initiation of adjuvant therapy of 90 days or more (OR 1.41, 95% CI 1.06–1.87; X² = 31.05, pu2009<u20090.00001; I² = 90%). There was no significant association between race and chemotherapy dosing. Due to overlap between studies assessing the relationship between race and completion of chemotherapy, we conducted two separate analyses. Black patients were significantly more likely to discontinue chemotherapy, however, this was no longer statistically significant when larger numbers of patients with more advanced (stage III) breast cancer were included.ConclusionsThese results suggest that black breast cancer patients experience clinically relevant delays in the initiation of adjuvant chemotherapy more often than white patients, which may in part explain the increased mortality observed among black patients.

A call to standardize our approach to fertility-sparing surgery in patients with gynecologic cancers

When a patient of reproductive age is diagnosed with a gynecologic cancer, her provider is tasked with balancing her desire for future fertility andmaximizing oncologic outcomes. The decision to offer a fertilitysparing surgery (FSS) can be straightforward in some cases; in others, particularly those involving patients with more advanced-stage disease or advanced age, such decisions are far more complicated. Over the past two decades, there have been practice-changing advancements in fertility-sparing treatments for women with gynecologic cancers. Notable innovations include fertility-sparing surgical management of earlystage epithelial ovarian cancer [1–3], novel fertility-sparing surgical techniques for patients with early-stage cervical cancer [4–6], the use of progestin therapy in early-stage endometrial cancer [7,8], and enhanced artificial reproductive technologies, including cryopreservation of ovarian tissue. With these innovations have come a host of new options, and new questions. Long before fertility preservation became a topic of interest for the more common gynecologic cancers, researchers were studying the safety of FSS in patientswithmalignant ovarian germ cell tumors (MOGCTs) [9]. Unlike other gynecologic cancers, MOGCTs are most commonly diagnosed during early reproductive years [10], during which time future fertility is usually an important consideration. Fortunately, approximately 60% of patients with MOGCTs are diagnosed with stage I disease [10,11], and cases are almost always unilateral (with the exception of dysgerminomas, which are bilateral in 10-15% of cases) [10], and highly sensitive to platinum-based chemotherapy [12,13]. These factors, combined with high 5-year overall survival (OS) rates (98% and 86% for patients with stage I-II and stage III-IV disease, respectively), have led providers to consider FSS in patients with MOGCT, regardless of disease stage [11]. Fertility-sparing surgery for patients with MOGCT has been described for nearly half a century. In 1969, Asadourian et al. published an analysis of 105 cases of dysgerminoma [9]. In their report, 46 of 71 patients with early-stage disease underwent FSS; 10-year OS was not significantly different based on type of surgery. The authors concluded that in young patients with unilateral, localized disease, FSS did not compromise survival outcomes. In the series, 10 of 17 patients with advanced disease underwent FSS. However, OS based on type of surgery was not compared for advanced-stage patients. Since 1969, FSS has beenwidely adopted for early-stageMOGCT, and increasingly used in patients with advanced disease. According to the National Comprehensive Cancer Network (NCCN) guidelines for ovarian cancer, FSS should be considered in all patientswithMOGCTwhodesire future fertility, regardless of disease stage [14]. Despite the increased use of FSS, data regarding its safety in patients with advanced-stage disease remain sparse. Studies addressing FSS in patients with advanced-stage MOGCT have included retrospective case