OBJECTIVE: In recent decades scientific advancements and improvements in treatment options have significantly reduced breast cancer mortality. Unfortunately, not all have experienced these improvements; there is a widening gap in mortality rates between Black and Non-Hispanic, White women. While race may be one factor in this disparity, the interactions between social, environmental, and economic circumstances and their differential impact across racial and ethnic groups invariably contribute to observed mortality differences. Socio-legal concerns are experienced often by patients at safety-net hospitals and have the potential to become barriers to care and impact the receipt of timely care. Regarded as basic life needs, socio-legal barriers are amenable to legal intervention but if the needs remain unmet, negative health outcomes may results. Understanding the burden of socio-legal concerns in at-risk populations is necessary to address these barriers to care. To date, systematic assessment of socio-legal concerns among newly diagnosed breast cancer patients has not been well documented. METHODS: We conducted a secondary analysis of I-HELP survey data collected for Project SUPPORT, an RCT comparative effectiveness study that compared standard navigation to legally enhanced navigation at Boston Medical Center. The survey, administered in English, Spanish or Haitian Creole by trained Research Assistants at baseline, 3 and 6 months, systematically assessed participants socio-legal concerns within four categories: Employment, Disability Benefits, Housing and Utilities and Personal and Family Stability. Demographic information was extracted from participants’ electronic medical records, supplemented by surveys on health literacy and employment. Means, medians, frequencies and percentages were used to describe and quantify the burden, type and change in concern at each follow-up point. T-tests and Fischer exact tests were used to evaluate differences in socio-demographic characteristics on the presence, type and trends among the concerns. RESULTS: Overall 262 breast cancer patients enrolled in Project SUPPORT and completed the baseline I-HELP survey. The racial distribution of the participants reflects the diverse population served by Boston Medical Center with the majority of the participants (n=200, 76%) being non-white. Overall, 77% (201/262) of participants reported 1 or more concerns across all categories with 44% (115/262) reporting 3 or more concerns. Among the four categories of concern, the most frequently reported concern was related to housing with 61% (161/262) reporting at least one housing concern. Participants most likely to express any concern were 50 years old or younger, non-English speaking and employed. For the majority of participants, the burden of concern remained constant or increased during the first 6-months of treatment. Non-white women were most likely to experience a persistent concern over the first six months. CONCLUSIONS: Our findings confirmed that the majority of breast cancer patients experience some kind of socio-legal concern at the time of diagnosis. Also, socio-legal concerns persist throughout the course of treatment. The reported results emphasize the continued need for systematic assessment during cancer treatment. Additionally, collaboration between the medical and legal sectors in cancer care delivery at safety-net hospitals offers a means to address barriers to care and improve health outcomes.

acase@tulane.edu

BACKGROUND: Patient reported outcomes (PROs) are important cancer outcomes that can be measured electronically but are understudied in the safety-net hospital setting. Routine electronic screening to address social determinants of health (SDH) has been established in primary care clinics and the emergency department of New England’s largest safety-net hospital. The burden of SDH in safety-net oncology patients is less well-studied. This study aimed to determine the feasibility and challenges of routine administration of ePROMs in a safety-net Radiation Oncology clinic, describe treatment toxicities and quality of life (QOL) experienced by this vulnerable population during radiotherapy, and evaluate SDH and the need for SDH screening in the oncology clinic. METHODS: Patients with lung or head and neck cancer scheduled for radiation oncology consultation from 3/2019–1/2020 were deemed eligible for electronic questionnaire participation based on primary language spoken and absence of metastases. At consultation, patients were administered a set of baseline ePROMs (EQ-5D-3L, FACT, PRO-CTCAE) and a social needs screener (THRIVE) using a widely-used cloud-based, patient-centered outcomes platform. Associations between patient demographics and questionnaire completion were retrospectively evaluated. The set of ePROMs were collected at the end of treatment to characterize treatment-related toxicities and changes in self-reported QOL. RESULTS: In total, 99 eligible head and neck cancer (51.5%) and lung cancer (48.5%) patients were identified. Median age was 65. The majority of patients were male (71.7%), and English-speaking (82.8%). Whites, Blacks, and Asians/Others comprised 42.4%, 38.4%, and 6.1% of patients, respectively. Fifteen patients were Hispanic (15.2%). Patients were most likely to have private health insurance (39.4%), followed by joint Medicare-Medicaid (25.3%), Medicaid (17.2%), and Medicare (16.2%). Two patients were insured by Corrections (2.0%). Eight patients (8.1%) no-showed or cancelled, while 91 patients were seen in consultation. Forty-four patients (48.4%) completed the initial questionnaires. For the remaining 47 patients (51.6%), the most common reason for lack of ePROM completion was clinic understaffing and/or clinical decision based on the absence of indication for radiotherapy (n=27, 57.4%). Ten patients refused to complete questionnaires (21.3%), with reasons cited including length of questionnaires and low energy. Ten patients were physically unable to attempt questionnaires (21.3%), for reasons including disabilities and low-literacy. Age, language, race, ethnicity, insurance, marital status, gender, and disease site were not significantly associated with ePROM completion (P≥0.05). For patients who completed the general (QOL) questionnaire EQ-5D-3L, there was no significant difference in general QOL domains nor self-reported overall health score at baseline vs. end of treatment. For head and neck cancer patients, FACT-H&N Total scores, measuring disease-specific QOL, were significantly worse at end of treatment vs. baseline (P=0.006). For lung cancer patients, FACT-L Total scores at the end of radiation treatment were not significantly worse at end of treatment vs. baseline (P=0.953). For head and neck cancer patients who completed PRO-CTCAE, there was a significant increase in the number with moderate to very severe taste issues (P=0.008) and decrease in appetite (P=0.025) by end of treatment. For lung cancer patients, there was a trend towards an increase in the number reporting moderate to very severe nausea (P=0.083). Eighty-one of 99 patients (81.8%) were screened for at least one SDH domain using the THRIVE screener at the study hospital. Nineteen patients (19.1%) had all 8 THRIVE social determinants of health statuses documented. Only housing status was documented for 61 patients (61.6%). There was a trend for married individuals (P=0.068) and females (P=0.074) to be associated with the completion of at least one THRIVE domain. Age, race, language, and insurance status were not associated with THRIVE screening (P>0.05). Transportation to appointments (21.1%), food insecurity (20%), and affording medications (10.5%) were the most prevalent concerns among these oncology patients, with 100% of patients who reported insecurities with medication and transportation requesting resources for these needs. CONCLUSION: Routine ePROs collection in a busy safety-net oncology setting is feasible, but challenging and labor-intensive. Implementation was met with both patient and staff challenges and revealed the need for dedicated project management, staff training, and opportunities to increase patient accessibility. Preliminary PROs analyses revealed several significant detriments in quality of life and increased symptoms for this patient population during treatment, but additional data collection is required. Safety-net oncology patients report significant social needs. Routine SDH screening and resource referral should be considered in these vulnerable patients. Efforts in a specialized department such as Radiation Oncology could fill gaps in existing efforts in a large safety-net hospital. Safety-net oncology clinics can likely help vulnerable cancer patients access available community resources and reduce disparities due to SDH.