PURPOSE Sequential drug treatments in metastatic breast cancer (MBC) are disparate. Clinical trial data includes limited reporting of treatment context, primarily including the number of prior therapies. This study evaluates the relationship between prior treatment time, prior lines of treatment, and survival using a novel visualization technique coupled with statistical analyses. PATIENTS AND METHODS This retrospective cohort study used a nationwide, de-identified electronic health record–derived database to identify women with hormone receptor–positive, human epidermal growth factor receptor 2–negative MBC diagnosed in 2014 who subsequently received paclitaxel. Images were created, with individual patients represented on the y-axis and time, on the x-axis. Specific treatments were represented by colored bars, with Kaplan-Meier curves overlaying the image. Separate images assessed progression-free survival and overall survival (OS). Hazard ratios (HRs) and 95% CIs from Cox proportional hazards models evaluated the association between prior treatment time and OS. RESULTS Of 234 patients, median survival from first paclitaxel administration was 20 months (interquartile range, 8-53 months). An inverse relationship was observed between OS after paclitaxel and timing of administration. In adjusted models, each year on treatment prior to paclitaxel was associated with a 16% increased hazard of death after paclitaxel (HR, 1.16; 95% CI, 1.05 to 1.29). CONCLUSION OS after a specific treatment is dependent on when a drug is given in the disease context, highlighting the potential for an overall OS benefit to be observed on the basis of treatment timing. Prior time on treatment should be considered as a stratifying factor in randomized trials and a confounding factor when examining survival in observational data.

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93 Background: Time-driven activity-based costing (TDABC) can be used by health systems to identify inefficiencies and improve the patient experience in clinical encounters. This quality improvement project utilized a Plan, Do, Study, Act (PDSA) cycle to evaluate routine clinic-based care for women with metastatic breast cancer (MBC). Methods: A project plan was developed to directly observe the time spent by MBC patients in clinic (Plan). Patient clinical encounters could include a physician visit along with scans, infusion, and/or labs. We then created process maps of typical patient clinical experiences (Do). Next, we tabulated times (mean, standard deviation [SD]) that patients spent in waiting areas and with each clinical team member (physician, fellow, nurse practitioner, registered nurse, medical assistant, chaplain, social worker, pharmacist, navigator) to identify care inefficiencies (Study). Lastly, we discussed results with providers and identified and implemented strategies for improving efficiency (Act). Results: We directly observed clinic visits (n = 33) for MBC patients from November 2016 to June 2017. On average, patients spent 219 minutes (SD 108) at clinic visits including 71 minutes (SD 45) spent with clinical team members and 85 minutes (SD 43) spent in waiting areas. We identified several opportunities for efficiency improvement, including the delay prior to rooming by medical assistants (n = 31; mean 22, SD 20 minutes), delays with port lab draws in infusion (n = 5; mean 22, SD 13 minutes), and delays awaiting drug from pharmacy (n = 22; mean 15, SD 29 minutes). To improve efficiency, we implemented strategies including having a dedicated infusion nurse assigned to draw labs from patient ports and modifications to medical assistants’ workflow. Conclusions: In this PDSA cycle, we found that patients spend a substantial amount of time at clinic visits, and the majority of this time is spent in waiting areas. Our use of process mapping and evaluation of time spent receiving care identified important opportunities for improving care delivery and efficiency for patients with MBC.

243 Background: The Oncology Care Model (OCM) has set several initiatives to improve payment and care delivery in the Medicare patient population, including screening for depression in cancer patients. We evaluated the prevalence of depression in OCM patients and the relationship between depression and healthcare utilization. Methods: This cross-sectional study used patient-reported outcome (PRO) surveys administered in the outpatient setting as part of OCM at the University of Alabama at Birmingham (UAB). Depression scores and Eastern Cooperative Oncology Group performance status were obtained from PRO surveys. Moderate to severe depression was defined as a score ≥10 on the Patient Health Questionnaire 2/9 (PHQ-2/9). Sex, marital status, phase of care, race, disease aggressiveness (stage, progression, cancer type), number of emergency department (ED) visits and inpatient admissions within a 3-month period from survey completion were abstracted from the electronic health record. The relationship between depression and hospital visits was assessed using rate ratios and 95% confidence limits from Poisson regression models adjusting for clinical and demographic characteristics. Results: Of 856 patients surveyed, 68% of patients were female, and 27% of patients were non-Caucasian. Notably, almost 14% of patients had moderate to severe depression (PHQ-2/9≥10). The cancer-specific prevalence of at least moderate depression was 2% in breast, 1% in gastrointestinal, 2% in genitourinary, 5% in gynecologic, and 2% in hematologic cancers. In adjusted models, the inpatient admission and ED visit rate in the 3 months following PRO survey completion did not differ by depression category (RR: 1.22; CI: 0.93-1.61). Conclusions: Over 13% of cancer patients report clinically significant depression during routine screening, which highlights the continued need for outpatient counseling and behavioral services. Although rates of inpatient admissions and ED visits were not impacted by the presence of depression, further analysis is needed to evaluate the impact of treating depression on healthcare utilization over time.

after sentinel lymph node (SLN) biopsy in preoperative low-grade endometrial cancers. (2) To prospectively evaluate the ability of intraoperative (IO) assessment to predict the final pathologic size of an endometrial malignancy. Methods: From March to August 2015, patients with low-grade endometrial cancer who underwent minimally invasive surgery with SLN injection were included in a prospective study. Institutional management of low-grade endometrial cancer during the study period was SLN mapping and biopsy followed by total laparoscopic hysterectomy/bilateral salpingo-oophorectomy with frozen section evaluation of the uterus; additional lymph node sampling was based on Mayo criteria and surgeon preference. After hysterectomy, the uterus was bivalved and the largest diameter of tumor was recorded by the surgical team. After the frozen section report, including a tumor size assessment by pathology, the surgeon completed an intraoperative questionnaire on factors influencing the decision to perform or withhold FPL. Results: All patients underwent injection for SLN mapping. Of 26 patients, 19 (73%) underwent bilateral mapping, 5 (19%) unilateral, and 2 (8%) had no mapping. Four patients (15%) underwent FPL, with the following reasons listed: tumor size greater than 2 cm (n = 3), depth of invasion (n = 2), failure of SLN mapping (n = 2), grade (n = 1), and age greater than 70 years (n = 1). Twenty-one patients did not undergo FPL; the reasons cited were low grade (81%), invasion less than 1/2 (81%), tumor size (76%), SLN mapping (71%), age (14%), body mass index (10%), poor visualization (5%), patient preference (5%), and comorbidities (5%). Using Mayo criteria, the final pathologic tumor size would have stratified a few patients to different management (n = 5 [19%], based on intraoperative surgeon assessment, and n = 4 [15%], based on intraoperative pathologist assessment). Conclusions: Intraoperative assessment of tumor size by the surgeon or pathologist incorrectly classifies risk of lymph node metastasis using the Mayo criteria in 1 of 5 cases. A prospective assessment of intraoperative factors that affect the decision to perform FPL in apparent early-stage EC demonstrates significant variability at one institution. These data highlight the need to develop a consensus algorithm that integrates SLN mapping into clinical decisions to proceed to FPL in endometrial cancer.