Syed Zafar


Dr. Zafar is a health services researcher with a focus in improving care delivery for patients with advanced cancer. He has obtained advanced training in health services research and has participated in single-institution, multi-institution and national studies focusing on access to care, cost of care, and comparative effectiveness of care delivery between health systems. His primary area of interest is in the cost of cancer care. He has conducted institutional and national studies on how treatment-related costs impact cancer patients' experience. His current work in this arena is focused on patient preferences regarding cost-related communication and decision-making.

A second field of interest is palliative care. Dr. Zafar has collaborated with national and international palliative care leaders to improve the design and delivery of palliative care in cancer clinical trials. Methodologically, this work has centered around systematic literature reviews, iterative surveys, and prospective clinical trials.

Dr. Zafar is a member of the American Society of Clinical Oncology’s Health Disparities and Clinical Practice Guideline Committees. He is a member of the Alliance for Clinical Trials in Oncology's Health Disparities and Health Outcomes Committees. Dr. Zafar's work has been funded by the American Cancer Society, the HealthWell Foundation, the Duke Cancer Prevention and Control Program, the Duke Clinical Research Institute, and the CALGB Foundation.


Associate Professor of Medicine

Medicine, Medical Oncology
School of Medicine

Associate Professor in the Sanford School of Public Policy

Sanford School of Public Policy
Sanford School of Public Policy

Associate Professor in Population Health Sciences

Population Health Sciences
School of Medicine

Affiliate, Duke Global Health Institute

Duke Global Health Institute
Institutes and Provost's Academic Units

Core Faculty Member, Duke-Margolis Center for Health Policy

Duke - Margolis Center For Health Policy
Institutes and Provost's Academic Units

Member of the Duke Cancer Institute

Duke Cancer Institute
School of Medicine

Member in the Duke Clinical Research Institute

Duke Clinical Research Institute
School of Medicine


M.D. 2002

University of Toledo

Resident, Medicine

University of Cincinnati

Fellow in Hematology-Oncology, Medicine

Duke University


Couple Communication in Cancer: A Multi-method Examination

Administered By
Psychiatry & Behavioral Sciences, Behavioral Medicine
Awarded By
Arizona State University
Co Investigator
Start Date
End Date

Examining Best Practices for Factoring Out-Of-Pocket Expenses into Patients' Health Care Decisions

Administered By
Institutes and Provost's Academic Units
Co Investigator
Start Date
End Date

Improving Advance Care Planning in Oncology: A Pragmatic, Cluster-Randomized Trial Integrating Patient Videos and Clinician Communication Training

Administered By
Duke Cancer Institute
Awarded By
Dana Farber Cancer Institute
Co Investigator
Start Date
End Date

PAPNavigator STTR (Fast-Track)

Administered By
Duke Cancer Institute
Principal Investigator
Start Date
End Date

Using AACT - to answer Oncology landscape portfolio of open trials

Administered By
Duke Clinical Research Institute
Principal Investigator
Start Date
End Date


Financial Toxicity and Equitable Access to Clinical Trials.

Financial barriers to clinical trial enrollment are an area of active investigation. Financial toxicity as a concept describes how high costs and financial burden can lead to compromised care and outcomes. Despite the potential to yield large survival benefits and improved access to cutting-edge therapies, less than 5% of adult patients with cancer are enrolled in a clinical trial. Disparities in trial enrollment exist along age, ethnic, and sociodemographic lines, with younger, poorer, nonwhite patients with private insurance-the exact population who may be at highest risk for financial toxicity-less likely to participate. Cost and insurance concerns remain an obstacle for clinical trial enrollment for certain patient populations. Changing the clinical trial paradigm with a focus on addressing structural and clinical barriers to clinical trial enrollment is paramount. This includes expanding access to clinical trials within community populations, advocating for health policy changes to guarantee insurance coverage of clinical trial standard-of-care health care, and considering noncoercive financial assistance (particularly for indirect costs like travel and lodging) for participants to defray their additional costs of participation. Additional steps toward education, cost transparency, and expansion of foundation assistance may also improve equitable access to clinical trials for all.
MLA Citation
Chino, Fumiko, and S. Yousuf Zafar. “Financial Toxicity and Equitable Access to Clinical Trials.Am Soc Clin Oncol Educ Book, vol. 39, Jan. 2019, pp. 11–18. Pubmed, doi:10.1200/EDBK_100019.
Published In
Am Soc Clin Oncol Educ Book
Published Date
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End Page

Changing the Course of Cancer Care With Greater Precision.

Zafar, SY; Sanoff, HK
MLA Citation
Zafar, S. Yousuf, and Hanna K. Sanoff. “Changing the Course of Cancer Care With Greater Precision.Jama Oncol, Mar. 2020. Pubmed, doi:10.1001/jamaoncol.2019.6843.
Published In
Jama Oncol
Published Date

Feasibility of Cancer Clinical Trial Enrollment Goals Based on Cancer Incidence.

PURPOSE: More than 20% of US clinical trials fail to accrue sufficiently. Our purpose was to provide a benchmark for better understanding clinical trial enrollment feasibility and to assess relative levels of competition for patients by cancer diagnosis. METHODS: The Database for Aggregate Analysis of, up to date as of September 3, 2017, was used to identify actively recruiting, interventional oncology trials with US sites. Observational studies were excluded because not all are registered. Trials were categorized through Medical Subject Headings or free-text condition terms and sorted by cancer diagnosis. Trials that included more than one cancer diagnosis were included in the overall cohort but excluded when evaluating enrollment by cancer type. Trial enrollment slot availability was estimated between September 1, 2017, and August 31, 2018. Availability was estimated from total anticipated enrollment and duration, assuming a constant recruitment rate. Estimates for studies with both foreign and domestic sites were then prorated to calculate available enrollment in the United States alone. Ratios of the number of newly diagnosed patients in the United States available per trial slot were estimated using the American Cancer Society cancer incidence estimates for 2017. RESULTS: A total of 4,598 interventional oncology trials were identified. Overall, the estimated ratio of newly diagnosed patients available per trial slot was 12.6. Estimated ratios of patients per trial slot for six cancer diagnoses with the highest potential of 12-month US enrollment were as follows: colorectal, 24.7; lung and bronchus, 20.1; prostate, 17.6; breast (female), 13.8; leukemia, 11.6; and brain and other nervous system, 6.0. CONCLUSION: For all cancers, successfully accruing trials currently open would require that more than one in every 13 recently diagnosed patients (7.9%) enroll. This ratio and relative difficulty of accrual varies among cancers examined.
Tran, G; Harker, M; Chiswell, K; Unger, JM; Fleury, ME; Hirsch, B; Miller, K; d'Almada, P; Tibbs, S; Zafar, SY
MLA Citation
Tran, George, et al. “Feasibility of Cancer Clinical Trial Enrollment Goals Based on Cancer Incidence.Jco Clin Cancer Inform, vol. 4, Jan. 2020, pp. 35–49. Pubmed, doi:10.1200/CCI.19.00088.
Published In
Jco Clinical Cancer Informatics
Published Date
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A phase Ib study of capecitabine and ziv-aflibercept followed by a phase II single-arm expansion cohort in chemotherapy refractory metastatic colorectal cancer.

BACKGROUND: Patients with chemotherapy refractory metastatic colorectal cancer (CRC) have a poor prognosis and limited therapeutic options. In this phase Ib/II clinical trial, we established the maximum tolerated dose (MTD) and recommended phase II dose (RPTD) for the combination of capecitabine and ziv-aflibercept, and then we evaluated the efficacy of the combination in patients with chemotherapy refractory metastatic CRC. METHODS: All patients were required to have a Karnofsky Performance Status > 70% and adequate organ function. The phase Ib dose escalation cohort included patients with advanced solid tumors who had progressed on all standard therapies. Using a standard 3 + 3 design, we identified the MTD and RPTD for the combination. Fifty patients with metastatic CRC who had progressed on or were intolerant of a fluoropyrimidine, oxaliplatin, irinotecan, and bevacizumab were then enrolled in a single-arm phase II expansion cohort, and were treated at the RPTD. Prior EGFR antibody therapy was required for subjects with RAS wildtype tumors. The primary endpoint for the expansion cohort was progression-free survival (PFS) at two months. Secondary endpoints included objective response rate (ORR) and overall survival (OS). RESULTS: A total of 63 patients were enrolled and evaluable for toxicity (13 dose escalation; 50 expansion). The MTD and RPTD were: capecitabine 850 mg/m2, P.O. bid, days 1-14, and ziv-aflibercept 6 mg/kg I.V., day 1, of each 21-day cycle. In the expansion cohort, 72% of patients were progression-free at two months (95% confidence interval [CI], 60-84%). Median PFS and OS were 3.9 months (95% CI, 2.3-4.5) and 7.1 months (95% CI: 5.8-10.0), respectively. Among all patients evaluable for toxicity, the most common treatment related adverse events (all grade [%]; grade ≥ 3 [%]) included palmar-plantar erythrodysesthesia (41%; 6%), hypertension (33%; 22%), and mucositis (19%; 5%). RNA was isolated from archived tumor specimens and gene expression analyses revealed no association between angiogenic biomarkers and clinical outcomes. CONCLUSION: The combination of capecitabine and ziv-aflibercept at the RPTD demonstrated acceptable safety and tolerability. PFS at 2 months in patients with chemotherapy refractory metastatic CRC was significantly greater than that in historical controls, indicating that this combination warrants further study. TRIAL REGISTRATION: This clinical trial was registered in the system as NCT01661972 on July 31, 2012.
Strickler, JH; Rushing, CN; Niedzwiecki, D; McLeod, A; Altomare, I; Uronis, HE; Hsu, SD; Zafar, SY; Morse, MA; Chang, DZ; Wells, JL; Blackwell, KL; Marcom, PK; Arrowood, C; Bolch, E; Haley, S; Rangwala, FA; Hatch, AJ; Nixon, AB; Hurwitz, HI
MLA Citation
Strickler, John H., et al. “A phase Ib study of capecitabine and ziv-aflibercept followed by a phase II single-arm expansion cohort in chemotherapy refractory metastatic colorectal cancer.Bmc Cancer, vol. 19, no. 1, Nov. 2019, p. 1032. Pubmed, doi:10.1186/s12885-019-6234-8.
Published In
Bmc Cancer
Published Date
Start Page

Financial Costs and Burden Related to Decisions for Breast Cancer Surgery.

PURPOSE: Financial toxicity is a well-recognized adverse effect of cancer care, yet little is known about how women consider treatment costs when facing preference-sensitive decisions for breast cancer surgery or how surgical treatment choice affects financial harm. We sought to determine how financial costs and burden relate to decisions for breast cancer surgery. METHODS: Women (≥ 18 years old) with a history of breast cancer were recruited from the Army of Women and Sisters Network to complete an 88-item electronic survey. Descriptive statistics and regression analysis were used to evaluate the impact of costs on surgical decisions and financial harm after breast cancer surgery. RESULTS: A total of 607 women with stage 0 to III breast cancer were included. Most were white (90%), were insured privately (70%) or by Medicare (25%), were college educated (78%), and reported household incomes of more than $74,000 (56%). Forty-three percent underwent breast-conserving surgery, 25% underwent mastectomy, 32% underwent bilateral mastectomy, and 36% underwent breast reconstruction. Twenty-eight percent reported that costs of treatment influenced their surgical decisions, and at incomes of $45,000 per year, costs were prioritized over breast preservation or appearance. Overall, 35% reported financial burden as a result of their cancer treatment, and 78% never discussed costs with their cancer team. When compared with breast-conserving surgery, bilateral mastectomy with or without reconstruction was significantly associated with higher incurred debt, significant to catastrophic financial burden, treatment-related financial hardship, and altered employment. Among the highest incomes, 65% of women were fiscally unprepared, reporting higher-than-expected (26%) treatment costs. CONCLUSION: Cancer treatment costs influenced decisions for breast cancer surgery, and comparably effective surgical treatments differed significantly in their risk of patient-reported financial burden, debt, and impact on employment. Cost transparency may inform preference-sensitive surgical decisions and improve patient-centered care.
Greenup, RA; Rushing, C; Fish, L; Campbell, BM; Tolnitch, L; Hyslop, T; Peppercorn, J; Wheeler, SB; Zafar, SY; Myers, ER; Hwang, ES
MLA Citation
Greenup, Rachel A., et al. “Financial Costs and Burden Related to Decisions for Breast Cancer Surgery.J Oncol Pract, vol. 15, no. 8, Aug. 2019, pp. e666–76. Pubmed, doi:10.1200/JOP.18.00796.
Published In
J Oncol Pract
Published Date
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Research Areas:

Academic Medical Centers
Administration, Oral
Age Factors
Aged, 80 and over
Ambulatory Care
Ampulla of Vater
Angiogenesis Inhibitors
Antibodies, Monoclonal
Antibodies, Monoclonal, Humanized
Antineoplastic Agents
Antineoplastic Combined Chemotherapy Protocols
Attitude of Health Personnel
Carcinoma, Non-Small-Cell Lung
Carcinoma, Squamous Cell
Cardiovascular Diseases
Chemoradiotherapy, Adjuvant
Clinical Trials as Topic
Cognition Disorders
Cohort Studies
Colorectal Neoplasms
Common Bile Duct Neoplasms
Comparative Effectiveness Research
Comprehensive Health Care
Continental Population Groups
Cooperative Behavior
Cost Control
Cost of Illness
Cost-Benefit Analysis
DNA Methylation
Data Collection
Decision Making
Decision Support Techniques
Delivery of Health Care
Delivery of Health Care, Integrated
Delphi Technique
Disease-Free Survival
Drug Administration Schedule
Drug Approval
Early Detection of Cancer
Epidemiologic Research Design
Evidence-Based Medicine
Evidence-Based Practice
Fee-for-Service Plans
Financial Support
Financing, Personal
Follow-Up Studies
Gastrointestinal Diseases
Gastrointestinal Neoplasms
Guideline Adherence
Health Care Costs
Health Care Rationing
Health Expenditures
Health Priorities
Health Services Accessibility
Health Services Needs and Demand
Health Services Research
Health Status
Hospitals, Veterans
Hydroxamic Acids
Immunosuppressive Agents
Injections, Intravenous
Insurance Carriers
Internal-External Control
Kaplan-Meier Estimate
Leukocytes, Mononuclear
Logistic Models
Long-Term Care
Medical History Taking
Medical Oncology
Microsatellite Instability
Middle Aged
Neoplasm Grading
Neoplasm Metastasis
Neoplasm Proteins
Neoplasm Staging
Odds Ratio
Organizational Innovation
Pain Measurement
Palliative Care
Patient Preference
Patient Satisfaction
Patient-Centered Care
Personnel, Hospital
Physician's Practice Patterns
Pilot Projects
Practice Patterns, Physicians'
Program Development
Program Evaluation
Prospective Studies
Protein Kinase Inhibitors
Quality Assurance, Health Care
Quality Improvement
Quality Indicators, Health Care
Quality of Health Care
Quality of Life
Randomized Controlled Trials as Topic
Reference Standards
Regional Health Planning
Regression Analysis
Reproducibility of Results
Research Design
Retrospective Studies
Sarcoma, Kaposi
Self Concept
Social Stigma
Socioeconomic Factors
Stress, Psychological
Surveys and Questionnaires
Survival Rate
Terminology as Topic
Treatment Outcome
Tumor Markers, Biological
United States
United States Department of Veterans Affairs
Veterans Health
Withholding Treatment
Young Adult