Patients with metastatic cancer benefit from advance care planning (ACP) conversations. We aimed to improve ACP using a computer model to select high-risk patients, with shorter predicted survival, for conversations with providers and lay care coaches. Outcomes included ACP documentation frequency and end-of-life quality measures.

In this study of a quality improvement initiative, providers in four medical oncology clinics received Serious Illness Care Program training. Two clinics (thoracic/genitourinary) participated in an intervention, and two (cutaneous/sarcoma) served as controls. ACP conversations were documented in a centralized form in the electronic medical record. In the intervention, providers and care coaches received weekly e-mails highlighting upcoming clinic patients with < 2 year computer-predicted survival and no prior prognosis documentation. Care coaches contacted these patients for an ACP conversation (excluding prognosis). Providers were asked to discuss and document prognosis.

In the four clinics, 4,968 clinic visits by 1,251 patients met inclusion criteria (metastatic cancer with no prognosis previously documented). In their first visit, 28% of patients were high-risk (< 2 year predicted survival). Preintervention, 3% of both intervention and control clinic patients had ACP documentation during a visit. By intervention end (February 2021), 35% of intervention clinic patients had ACP documentation compared with 3% of control clinic patients. Providers' prognosis documentation rate also increased in intervention clinics after the intervention (2%-27% in intervention clinics, P < .0001; 0%-1% in control clinics). End-of-life care intensity was similar in intervention versus control clinics, but patients with ≥ 1 provider ACP edit met fewer high-intensity care measures (P = .04).

Combining a computer prognosis model with care coaches increased ACP documentation.

© 2022 by American Society of Clinical Oncology

Presented as an oral presentation at the 2021 ASCO Quality Care Symposium in Boston MA, on September 24, 2021.

Conception and design: Michael F. Gensheimer, Manali I. Patel, Winifred Teuteberg, Briththa Seevaratnam, Jennifer Hansen, Jan DeNofrio, Divya Parikh, Heather Wakelee, Kavitha Ramchandran

Financial support: Briththa Seevaratnam, Kavitha Ramchandran

Administrative support: Rachel Hildebrand, Briththa Seevaratnam, Jennifer Hansen, Kaidi Moore, Kavitha Ramchandran

Provision of study materials or patients: Manali I. Patel, Rachel Hildebrand, Kaidi Moore, Sandhya Srinivas, Heather Wakelee, Kavitha Ramchandran

Collection and assembly of data: Michael F. Gensheimer, Divya Gupta, Manali I. Patel, Touran Fardeen, Rachel Hildebrand, Mary Khay Asuncion, Nina Alves, Brian Rogers, Jennifer Hansen, Joel Neal, Alice C. Fan, Kaidi Moore, Shann Ruiz, Connie Li, Ali Raza Khaki, Joanne Chien, Tiffany Brown, Alison Holmes Tisch, Sandhya Srinivas, Heather Wakelee, Howard Lee, Kavitha Ramchandran

Data analysis and interpretation: Michael F. Gensheimer, Divya Gupta, Manali I. Patel, Rachel Hildebrand, Mary Khay Asuncion, Nina Alves, Nigam H. Shah, Joel Neal, Alice C. Fan, Judy Pagtama, Millie Das, Sandhya Srinivas, Mohana Roy, Heather Wakelee, Nathaniel J. Myall, Jane Huang, Sumit Shah, Kavitha Ramchandran

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

Use of Machine Learning and Lay Care Coaches to Increase Advance Care Planning Conversations for Patients With Metastatic Cancer

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to or

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).

Michael F. Gensheimer

Employment: Roche/Genentech (I)

Stock and Other Ownership Interests: Roche/Genentech

Research Funding: Varian Medical Systems

Open Payments Link:

Nigam H. Shah

Leadership: Prealize, Atropos

Consulting or Advisory Role: Curai

Research Funding: Google (Inst)

Joel Neal

Honoraria: CME Matters, Clinical Care Options, Research to Practice, Medscape, Biomedical Learning Institute, Peerview, Prime Oncology, Projects in Knowledge, Rockpointe CME, MJH Life Sciences, Medical Educator Consortium, HMP Education

Consulting or Advisory Role: AstraZeneca, Genentech/Roche, Exelixis, Jounce Therapeutics, Takeda, Lilly, Calithera Biosciences, Amgen, Iovance Biotherapeutics, Blueprint Pharmaceuticals, Regeneron, Natera, Sanofi/Regeneron, D2G Oncology, Surface Oncology, Turning Point Therapeutics, Mirati Therapeutics, Gilead Sciences

Research Funding: Genentech/Roche (Inst), Merck (Inst), Novartis (Inst), Boehringer Ingelheim (Inst), Exelixis (Inst), Nektar (Inst), Takeda (Inst), Adaptimmune (Inst), GlaxoSmithKline (Inst), Janssen (Inst), AbbVie (Inst)

Patents, Royalties, Other Intellectual Property: UpToDate—Royalties

Alice C. Fan

Employment: Silverado Hospice, BeiGene

Stock and Other Ownership Interests: Molecular Decisions, Antelope Valley Care Center

Consulting or Advisory Role: Verily

Research Funding: Earli (Inst), Filtricine (Inst), MagARRAY (Inst), Calithera Biosciences (Inst)

Patents, Royalties, Other Intellectual Property: Stanford Patent has been licensed

Ali Raza Khaki

Honoraria: OncLive/MJH Life Sciences

Uncompensated Relationships: Seattle Genetics/Astellas

Joanne Chien

Honoraria: Janssen Oncology, Seattle Genetics, Coherus Biosciences

Consulting or Advisory Role: Coherus Biosciences, Seattle Genetics, Janssen Oncology

Travel, Accommodations, Expenses: Coherus Biosciences

Millie Das

Honoraria: Plexus

Consulting or Advisory Role: Jazz Pharmaceuticals, AstraZeneca, BeiGene, Sanofi

Research Funding: Novartis, Verily, Varian Medical Systems, AbbVie, United Therapeutics, Cellsight Technologies

Sandhya Srinivas

Consulting or Advisory Role: Eisai, Bayer, Bristol Myers Squibb, Merck, AstraZeneca, Seattle Genetics, Janssen Oncology, Novartis

Research Funding: Bristol Myers Squibb (Inst), Genentech (Inst), Merck (Inst), Exelixis (Inst), Eisai (Inst), Bayer (Inst), AstraZeneca (Inst), Seattle Genetics/Astellas (Inst)

Other Relationship: Pfizer

Mohana Roy

Speakers' Bureau: MJH Life Sciences

Research Funding: Varian Medical Systems (Inst)

Heather Wakelee

Consulting or Advisory Role: AstraZeneca, Mirati Therapeutics, Blueprint Medicines

Research Funding: Genentech/Roche (Inst), Celgene (Inst), AstraZeneca/MedImmune (Inst), Novartis (Inst), Clovis Oncology (Inst), Xcovery (Inst), Bristol Myers Squibb (Inst), ACEA Biosciences (Inst), Arrys Therapeutics (Inst), Merck (Inst), Seattle Genetics (Inst), Helsinn Therapeutics (Inst)

Uncompensated Relationships: Merck, Genentech/Roche

Nathaniel J. Myall

Honoraria: Patient Power

Jane Huang

Employment: Beigene, Prelude Therapeutics

Leadership: 858 Therapeutics, Protara Therapeutics, Prelude Therapeutics, BeiGene

Stock and Other Ownership Interests: Protara Therapeutics, BeiGene, 858 Therapeutics, Prelude Therapeutics

Consulting or Advisory Role: BeiGene

Sumit Shah

Honoraria: Janssen

Consulting or Advisory Role: Natera, Grand Rounds/Included Health

Research Funding: Genentech

Howard Lee

Employment: Silverado Hospice

Leadership: AV Supportive Care & Hospice

Stock and Other Ownership Interests: AV Supportive Care & Hospice

Consulting or Advisory Role: BeiGene

Patents, Royalties, Other Intellectual Property: Stanford patent licensed

Kavitha Ramchandran

Consulting or Advisory Role: Drishti, GroupWell, Varian Medical Systems

No other potential conflicts of interest were reported.


No companion articles


DOI: 10.1200/OP.22.00128 JCO Oncology Practice 19, no. 2 (February 01, 2023) e176-e184.

Published online November 17, 2022.

PMID: 36395436

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