Board Certification: American Board of Internal Medicine, Oncology (2021)
Fellowship: Stanford University Hematology and Oncology Fellowship (2021) CA
Board Certification: American Board of Internal Medicine, Internal Medicine (2018)
Residency: Stanford University Internal Medicine Residency (2018) CA
Medical Education: Boston University School of Medicine (2015) MA
- Long-term cost comparisons of radical cystectomy versus trimodal therapy for muscle-invasive bladder cancer. LIPPINCOTT WILLIAMS & WILKINS. 2022
- Re: Pembrolizumab Monotherapy for the Treatment of High-risk Non-muscle-invasive Bladder Cancer Unresponsive to BCG (KEYNOTE-057): An Open-label, Single-arm, Multicentre, Phase 2 Study. European urology 2022
- Use of a computer model and care coaches to increase advance care planning conversations for patients with metastatic cancer LIPPINCOTT WILLIAMS & WILKINS. 2021
- Coaches Activating Reaching and Engaging Patients (CAREPlan): A randomized controlled trial combining two evidence-based interventions to improve goals of care documentation LIPPINCOTT WILLIAMS & WILKINS. 2021
- Evolving oncology provider perspectives on care delivery during the COVID-19 pandemic. LIPPINCOTT WILLIAMS & WILKINS. 2021
Financial Toxicity of Cancer Care: An Analysis of Financial Burden in Three Distinct Health Care Systems.
JCO oncology practice
PURPOSE: The financial toxicity of cancer care is a source of significant distress for patients with cancer. The purpose of this study is to understand factors associated with financial toxicity in three distinct care systems.METHODS: We conducted a cross-sectional survey of patients in three care systems, Stanford Cancer Institute (SCI), VA Palo Alto Health Care System (VAPAHCS), and Santa Clara Valley Medical Center (SCVMC), from October 2017 to May 2019. We assessed demographic factors, employment status, and out-of-pocket costs (OOPCs) and administered the validated COmprehensive Score for financial Toxicity tool. We calculated descriptive statistics and conducted linear regression models to analyze factors associated with financial toxicity.RESULTS: Four hundred forty-four of 578 patients (77%) completed the entire COmprehensive Score for financial Toxicity tool and were included in the analysis. Most respondents at SCI were White, with annual household income (AHI) > $50,000 USD and Medicare insurance. At the VAPAHCS, most were White, with AHI ≤ $50,000 USD and insured by the Veterans Administration. At SCVMC, most were Asian and/or Pacific Islander, with AHI ≤ $25,000 USD and Medicaid insurance. Low AHI (P < .0001), high OOPCs (P = .003), and employment changes as a result of cancer diagnosis (P < .0001) were associated with financial toxicity in the pooled analysis. There was variation in factors associated with financial toxicity by site, with employment changes significant at SCI, OOPCs at SCVMC, and no significant factors at the VAPAHCS.CONCLUSION: Low AHI, high OOPCs, and employment changes contribute to financial toxicity; however, there are variations based on site of care. Future studies should tailor financial toxicity interventions within care delivery systems.
View details for DOI 10.1200/OP.20.00890
View details for PubMedID 33826366
- Addressing financial toxicity in urologic oncology patients. LIPPINCOTT WILLIAMS & WILKINS. 2021
Defining the clinician's role in mitigating financial toxicity: an exploratory study.
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer
BACKGROUND: Financial toxicity describes the financial burden imposed onto patients by a cancer diagnosis and is a growing concern. Many clinicians do not currently address financial toxicity despite patients' desire for them to do so. Current literature explores physicians' perspectives but does not clearly define an actionable role clinicians can take to address financial toxicity. We sought to fill this gap by first assessing clinicians' perspective on their role in alleviating financial toxicity at our institution. We subsequently aimed to identify current barriers to mitigating financial toxicity and to garner feedback on clinician-oriented interventions to address this growing problem.METHODS: We developed an 18-item electronic, anonymous survey through Redcap. We invited all oncology clinicians including attending physicians, advance practice providers, and trainees at our institution to participate.RESULTS: A total of 72 clinicians (30%) completed the survey. The majority agreed that clinicians have a role in addressing cost. The top three barriers to discussing cost with patients were knowledge of out of pocket costs, time, and awareness of resources. Less than half of respondents used an existing comparative cost tool to incorporate cost consciousness into treatment decisions. The most desired intervention was an institutional resource guide. In open-ended comments, the most common barrier described was transparency of out of pocket costs, and the most common solution proposed was a multi-disciplinary approach to addressing financial concerns patient face.DISCUSSION: Improving price transparency, incorporating existing resources into clinical practice, and streamlining multi-disciplinary support may help overcome barriers to addressing financial toxicity.
View details for DOI 10.1007/s00520-021-05984-6
View details for PubMedID 33544246
Comparison of perspectives and practices to mitigate financial toxicity between advance practice providers and attending oncologists.
AMER SOC CLINICAL ONCOLOGY. 2020
View details for Web of Science ID 000607202800084
Understanding patient perspectives on window of opportunity clinical trials.
AMER SOC CLINICAL ONCOLOGY. 2020
View details for Web of Science ID 000607202800180
Healthcare delivery interventions to reduce cancer disparities worldwide.
World journal of clinical oncology
2020; 11 (9): 705–22
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
Cost-effectiveness of first-line therapy for advanced renal cell carcinoma in the immunotherapy era.
LIPPINCOTT WILLIAMS & WILKINS. 2020
View details for Web of Science ID 000560368307310
Health Disparities in Germline Genetic Testing for Cancer Susceptibility
Current Breast Cancer Reports
View details for DOI 10.1007/s12609-020-00354-3
- Financial toxicity among veterans with cancer. AMER SOC CLINICAL ONCOLOGY. 2019
- Perspectives and practices of oncology providers in addressing financial toxicity. AMER SOC CLINICAL ONCOLOGY. 2019
- Demographic factors associated with financial toxicity: Results from the multisite cost study. AMER SOC CLINICAL ONCOLOGY. 2019
Characteristics of Patients With ROS1+ Cancers: Results From the First Patient-Designed, Global, Pan-Cancer ROS1 Data Repository.
Journal of oncology practice
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
To Take or Not to Take a Side: That Is the Question.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology
View details for PubMedID 31046550
Pathogenic Variants in Less Familiar Cancer Susceptibility Genes: What Happens After Genetic Testing?
JCO precision oncology
2018; 2: 1-10
As genetic testing expands, patients are increasingly found to carry pathogenic variants in cancer susceptibility genes that are less familiar to most clinicians, specifically genes other than those causing hereditary breast ovarian cancer syndrome (BRCA1 and BRCA2) and Lynch syndrome. Little is known about the subsequent behaviors of such patients in terms of managing cancer risks and informing relatives.All adult patients who were counseled and tested at the Stanford Cancer Genetics Clinic from January 2013 to July 2015 and had a pathogenic variant in a non-BRCA1/2, non-Lynch syndrome gene were invited to participate in a telephone interview about adherence to risk-reducing recommendations, genetic testing by relatives, and new cancer incidence.Fifty-seven (40%) of 142 eligible patients were successfully contacted, and all 57 patients participated; median follow-up was 677 days (range, 247 to 1,401 days). Most patients (82%; 95% CI, 70% to 90%) recalled that a risk-reducing intervention (screening, medication, or surgery) was recommended, and most patients (85%; 95% CI, 72% to 93%) adhered to the recommendation. Nearly all patients (91%; 95% CI, 81% to 97%) shared results with relatives, and most patients (78%; 95% CI, 64% to 88%) reported that a relative was subsequently tested. During the follow-up period, 9% of patients (95% CI, 3% to 19%) developed second cancers, and in 14% of patients (95% CI, 7% to 26%), a first-degree relative developed cancer, some of which were detected by recommended screening.Patients with a pathogenic variant in a less familiar cancer susceptibility gene report high adherence to risk-reducing interventions. Furthermore, in the 57 carriers and subsequently tested relatives with two years of follow-up, a total of three cancers (one in a proband and two in relatives) were detected through interventions recommended on the basis of the pathogenic variant. These results suggest a potential benefit of genetic counseling and testing for pathogenic variants in less familiar genes.
View details for DOI 10.1200/PO.18.00167
View details for PubMedID 35135157
- Financial toxicity of cancer treatment at a diverse county hospital. AMER SOC CLINICAL ONCOLOGY. 2018
Pathogenic variants in less familiar cancer susceptibility genes: what happens after genetic testing?
JCO Precision Oncology
View details for DOI 10.1200/PO.18.00167
Impact of patient demographics, tumor characteristics, and treatment type on treatment delay throughout breast cancer care at a diverse academic medical center.
International journal of women's health
2017; 9: 887-896
The aim of this study was to examine the impact of patient demographics, tumor characteristics, and treatment type on time to treatment (TTT) in patients with breast cancer treated at a safety net medical center with a diverse patient population.A total of 1,130 patients were diagnosed and treated for breast cancer between 2004 and 2014 at our institution. We retrospectively collected data on patient age at diagnosis, race/ethnicity, primary language spoken, marital status, insurance coverage, American Joint Committee on Cancer (AJCC) stage, hormone receptor status, and treatment dates. TTT was determined from the date of breast cancer biopsy to treatment start date. Nonparametric Mann-Whitney U-test (or Kruskal-Wallis test when appropriate) and multivariable quantile regression models were employed to assess for significant differences in TTT associated with each factor.Longer median TTT was noted for Black (P=0.002) and single (P=0.002) patients. AJCC stage IV patients had shorter TTT (27.5 days) compared to earlier AJCC patients (36, 35, 37, 37 days for stage 0, I, II, III, respectively), P=0.028. Age, primary language spoken, insurance coverage, and hormone receptor status had no significant impact on TTT. On multivariate analysis, race/ethnicity remained the only significant factor with Black reporting longer TTT, P=0.025. However, race was not a significant factor for time from first to second treatment. More Black patients were noted to be single (P<0.0001) and received chemotherapy as first treatment (P=0.008) compared to White, Hispanic, or other race/ethnicity patients.In this retrospective analysis, Black patients had longer TTT, were more likely to receive chemotherapy as first treatment, and have a single marital status. These patient factors will help identify vulnerable patients and guide further research to understand the barriers to care and the impact of treatment delays on outcomes.
View details for DOI 10.2147/IJWH.S150064
View details for PubMedID 29255374
View details for PubMedCentralID PMC5723124
- Pathogenic germline mutations in emerging cancer genes: What happens after panel testing? AMER SOC CLINICAL ONCOLOGY. 2017
Race/Ethnicity, Primary Language, and Income Are Not Demographic Drivers of Mortality in Breast Cancer Patients at a Diverse Safety Net Academic Medical Center.
International journal of breast cancer
2015; 2015: 835074
Objective. To examine the impact of patient demographics on mortality in breast cancer patients receiving care at a safety net academic medical center. Patients and Methods. 1128 patients were diagnosed with breast cancer at our institution between August 2004 and October 2011. Patient demographics were determined as follows: race/ethnicity, primary language, insurance type, age at diagnosis, marital status, income (determined by zip code), and AJCC tumor stage. Multivariate logistic regression analysis was performed to identify factors related to mortality at the end of follow-up in March 2012. Results. There was no significant difference in mortality by race/ethnicity, primary language, insurance type, or income in the multivariate adjusted model. An increased mortality was observed in patients who were single (OR = 2.36, CI = 1.28-4.37, p = 0.006), age > 70 years (OR = 3.88, CI = 1.13-11.48, p = 0.014), and AJCC stage IV (OR = 171.81, CI = 59.99-492.06, p < 0.0001). Conclusions. In this retrospective study, breast cancer patients who were single, presented at a later stage, or were older had increased incidence of mortality. Unlike other large-scale studies, non-White race, non-English primary language, low income, or Medicaid insurance did not result in worse outcomes.
View details for DOI 10.1155/2015/835074
View details for PubMedID 26605089
View details for PubMedCentralID PMC4641184
Patient demographic characteristics and disease stage as drivers of disparities in mortality in prostate cancer patients who receive care at a safety net academic medical center.
Clinical genitourinary cancer
2014; 12 (6): 455-60
The purpose of this study was to examine the effect of patient demographic characteristics and tumor stage at diagnosis on mortality in prostate cancer patients who receive care at a safety net, academic medical center with a diverse patient population.Eight hundred sixty-nine patients were diagnosed with prostate cancer at our institution between August 2004 and October 2011. Patient demographic characteristics were determined as follows: race and/or ethnicity, primary language, insurance type, age at diagnosis, marital status, income (determined by zip code), and American Joint Committee on Cancer (AJCC) tumor stage. Fisher exact or Pearson χ(2) test was used to test for differences in categorical variables. Multivariate logistic regression analysis was performed to identify factors related to mortality recorded at the end of follow-up in March of 2012.Mortality was significantly decreased in patients who spoke Haitian Creole (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.04-0.74; P = .017). Distribution of insurance type, age, income, and prostate-specific antigen level differed between English and Haitian Creole speakers. Increased mortality was observed in patients who were single (OR, 1.99; 95% CI, 1.06-3.73; P = .032), older than 70 (OR, 15.5; 95% CI, 3.03-79.45; P = .001), had Medicaid and/or free care (OR, 4.98; 95% CI, 1.72-14.4; P = .003), or had AJCC stage IV cancer (OR, 9.56; 95% CI, 4.89-18.69; P < .001). There was no significant difference in mortality according to race and/or ethnicity or income in the multivariate-adjusted model.In this retrospective study, prostate cancer patients who spoke Haitian Creole had a lower incidence of mortality compared with English speakers. Consistent with similar large-scale studies, being single or having Medicaid and/or free care insurance predicted worse outcomes, reinforcing their roles as drivers of disparities.
View details for DOI 10.1016/j.clgc.2014.04.005
View details for PubMedID 24998045
Devising the optimal preclinical oncology curriculum for undergraduate medical students in the United States.
Journal of cancer education : the official journal of the American Association for Cancer Education
2013; 28 (2): 228-36
A third of women and a near majority of men in the United States will be diagnosed with cancer in their lifetimes. To prepare future physicians for this reality, we have developed a preclinical oncology curriculum that introduces second-year medical students to essential concepts and practices in oncology to improve their abilities to appropriately care for these patients. We surveyed the oncology and education literature and compiled subjects important to students' education including basic science and clinical aspects of oncology and addressing patients' psychosocial needs. Along with the proposed curriculum content, scheduling, independent learning exercises, and case studies, we discuss practical considerations for curriculum implementation based on experience at our institution. Given the changing oncology healthcare landscape, all (new) physicians must competently address their cancer patients' needs, regardless of chosen specialty. A thorough and logically organized cancer curriculum for preclinical medical students should help achieve these aims. This new model curriculum, with accompanying strategies to evaluate its efforts, is essential to update how medical students are educated about cancer.
View details for DOI 10.1007/s13187-012-0442-0
View details for PubMedID 23681770