Background: Therapeutic options for men with metastatic castrate-resistant prostate cancer (mCRPC) have expanded significantly over the past 5 years with several new agents demonstrating improved survival, including 2 oral agents. Abiraterone acetate (AA), a CYP-17 androgen synthesis inhibitor, obtained initial FDA approval in 2011 for post-docetaxel (DXT) use and gained expanded approval in 2012 for pre-DXT use. Enzalutamide (ENZ), an androgen receptor signaling inhibitor, also gained FDA approval in 2012 (post-DXT) and indication was expanded in 2014 (pre-DXT).

Purpose: The objective is to provide insight into the uptake of novel therapeutics and its impact on treatment for patients with mCRPC.

Methods: For this observational study, Veterans Affairs (VA) healthcare system data (including hospitalizations, outpatient visits, and pharmacy) were used to identify male veterans who received treatment for mCRPC between fiscal years 2008 and 2014. Sequencing patterns and treatment duration were assessed. Descriptive statistics were employed.

Results: During the study period, 8,774 patients initiated advanced lines of therapy associated with mCRPC. AA, DXT, and ketoconazole (KCZ) were the most commonly used firstlines of advanced therapies (24.6%, 24.8%, 47.0%, respectively). Between 2008 and 2013, the proportion of mCRPC patients treated with first-line DXT or KCZ dropped from 98% to 38% (P < .0001) while the proportion who received first-line AA increased to 58% (P < .0001). Furthermore, among the 4,169 patients treated with AA between 2011 and 2014, the proportion treated pre-DXT increased from 32% to 80% (P < .0001). AA was also the most common second-line treatment received. Between 2012 and 2013, ENZ use was low but increased dramatically. Among patients who initiated DXT, KCZ, or AA as first-line treatment in 2011/2012, median time on initial treatment was 5.9, 9.1, 11.5 months, respectively.

Conclusions: The FDA approval of AA and ENZ had a significant impact on treatment patterns for men with mCRPC within VA and was associated with decreased use of KCZ and delayed use of chemotherapy. Further information regarding patient and disease characteristics is needed. The rapid uptake of these novel agents has significant implications for disease-related outcomes.

Background: Therapeutic options for men with metastatic castrate-resistant prostate cancer (mCRPC) have expanded significantly over the past 5 years with several new agents demonstrating improved survival, including 2 oral agents. Abiraterone acetate (AA), a CYP-17 androgen synthesis inhibitor, obtained initial FDA approval in 2011 for post-docetaxel (DXT) use and gained expanded approval in 2012 for pre-DXT use. Enzalutamide (ENZ), an androgen receptor signaling inhibitor, also gained FDA approval in 2012 (post-DXT) and indication was expanded in 2014 (pre-DXT).

Purpose: The objective is to provide insight into the uptake of novel therapeutics and its impact on treatment for patients with mCRPC.

Methods: For this observational study, Veterans Affairs (VA) healthcare system data (including hospitalizations, outpatient visits, and pharmacy) were used to identify male veterans who received treatment for mCRPC between fiscal years 2008 and 2014. Sequencing patterns and treatment duration were assessed. Descriptive statistics were employed.

Results: During the study period, 8,774 patients initiated advanced lines of therapy associated with mCRPC. AA, DXT, and ketoconazole (KCZ) were the most commonly used firstlines of advanced therapies (24.6%, 24.8%, 47.0%, respectively). Between 2008 and 2013, the proportion of mCRPC patients treated with first-line DXT or KCZ dropped from 98% to 38% (P < .0001) while the proportion who received first-line AA increased to 58% (P < .0001). Furthermore, among the 4,169 patients treated with AA between 2011 and 2014, the proportion treated pre-DXT increased from 32% to 80% (P < .0001). AA was also the most common second-line treatment received. Between 2012 and 2013, ENZ use was low but increased dramatically. Among patients who initiated DXT, KCZ, or AA as first-line treatment in 2011/2012, median time on initial treatment was 5.9, 9.1, 11.5 months, respectively.

Conclusions: The FDA approval of AA and ENZ had a significant impact on treatment patterns for men with mCRPC within VA and was associated with decreased use of KCZ and delayed use of chemotherapy. Further information regarding patient and disease characteristics is needed. The rapid uptake of these novel agents has significant implications for disease-related outcomes.

Background: Therapeutic options for men with metastatic castrate-resistant prostate cancer (mCRPC) have expanded significantly over the past 5 years with several new agents demonstrating improved survival, including 2 oral agents. Abiraterone acetate (AA), a CYP-17 androgen synthesis inhibitor, obtained initial FDA approval in 2011 for post-docetaxel (DXT) use and gained expanded approval in 2012 for pre-DXT use. Enzalutamide (ENZ), an androgen receptor signaling inhibitor, also gained FDA approval in 2012 (post-DXT) and indication was expanded in 2014 (pre-DXT).

Purpose: The objective is to provide insight into the uptake of novel therapeutics and its impact on treatment for patients with mCRPC.

Methods: For this observational study, Veterans Affairs (VA) healthcare system data (including hospitalizations, outpatient visits, and pharmacy) were used to identify male veterans who received treatment for mCRPC between fiscal years 2008 and 2014. Sequencing patterns and treatment duration were assessed. Descriptive statistics were employed.

Results: During the study period, 8,774 patients initiated advanced lines of therapy associated with mCRPC. AA, DXT, and ketoconazole (KCZ) were the most commonly used firstlines of advanced therapies (24.6%, 24.8%, 47.0%, respectively). Between 2008 and 2013, the proportion of mCRPC patients treated with first-line DXT or KCZ dropped from 98% to 38% (P < .0001) while the proportion who received first-line AA increased to 58% (P < .0001). Furthermore, among the 4,169 patients treated with AA between 2011 and 2014, the proportion treated pre-DXT increased from 32% to 80% (P < .0001). AA was also the most common second-line treatment received. Between 2012 and 2013, ENZ use was low but increased dramatically. Among patients who initiated DXT, KCZ, or AA as first-line treatment in 2011/2012, median time on initial treatment was 5.9, 9.1, 11.5 months, respectively.

Conclusions: The FDA approval of AA and ENZ had a significant impact on treatment patterns for men with mCRPC within VA and was associated with decreased use of KCZ and delayed use of chemotherapy. Further information regarding patient and disease characteristics is needed. The rapid uptake of these novel agents has significant implications for disease-related outcomes.

Purpose/Objectives: Surgery and radiotherapy are the mainstays of treatment for stage I non-small cell lung cancer (NSCLC). While surgical resection is the treatment of choice, radiotherapy remains an option for high risk surgical candidates. We aim to analyze the use of selected primary treatment modalities at VA, community, and academic hospitals. To our knowledge, we are the largest study to compare the utilization of surgery and radiotherapy among hospital types for treatment of stage I NSCLC from 2003-2013.

Materials/Methods: This retrospective study employed the NCDB, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. 148,797 patients treated for stage I NSCLC at VA, community, or academic hospitals between 2003-2013 were identified. The Pearson’s chi-square test was used to determine significance.

Results: Of patients treated at the VA, community, and academic hospitals, 56.0%, 47.8%, and 42.2%, respectively, had one or more comorbid condition(s). Median distance traveled ranges (miles) were 25-49, 5-9, and 10-24, respectively. Median age ranges (years) were 60-69, 70-79, and 70-79, respectively. 96.9% were male at the VA, compared to 49.6% at community and 46.7% at academic hospitals. Slightly more patients were treated with surgery alone at the VA (60.2%) compared to community hospitals (51.5%; P < .0001); a smaller proportion of patients were treated with surgery at the VA compared to academic hospitals (64.4%; P < .0001). More patients were treated with radiation alone at the VA (16.8%) compared to academic (15.1%) and community (12.2%) hospitals (P < .0001). Patients received less combination therapy at VA hospitals (0.9%) compared to academic (1.8%) and community (1.8%) hospitals (P < .0001). The remaining patients (approximately 30%) received one of several permutations that combined 2 or more of the following treatment modalities: hormone therapy, chemotherapy, biological response modifier therapy, radiotherapy, and surgery.

Conclusion: Although there are minor differences in the proportion of patients receiving each treatment modality, use of radiotherapy and surgery to treat stage I NSCLC is relatively consistent among VA, community, and academic hospitals. Future studies should explore the treatment modalities excluded from this study, compare radiotherapy to stereotactic radiosurgery, and examine how treatment modality affects recurrence and survival.

Purpose/Objectives: Surgery and radiotherapy are the mainstays of treatment for stage I non-small cell lung cancer (NSCLC). While surgical resection is the treatment of choice, radiotherapy remains an option for high risk surgical candidates. We aim to analyze the use of selected primary treatment modalities at VA, community, and academic hospitals. To our knowledge, we are the largest study to compare the utilization of surgery and radiotherapy among hospital types for treatment of stage I NSCLC from 2003-2013.

Materials/Methods: This retrospective study employed the NCDB, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. 148,797 patients treated for stage I NSCLC at VA, community, or academic hospitals between 2003-2013 were identified. The Pearson’s chi-square test was used to determine significance.

Results: Of patients treated at the VA, community, and academic hospitals, 56.0%, 47.8%, and 42.2%, respectively, had one or more comorbid condition(s). Median distance traveled ranges (miles) were 25-49, 5-9, and 10-24, respectively. Median age ranges (years) were 60-69, 70-79, and 70-79, respectively. 96.9% were male at the VA, compared to 49.6% at community and 46.7% at academic hospitals. Slightly more patients were treated with surgery alone at the VA (60.2%) compared to community hospitals (51.5%; P < .0001); a smaller proportion of patients were treated with surgery at the VA compared to academic hospitals (64.4%; P < .0001). More patients were treated with radiation alone at the VA (16.8%) compared to academic (15.1%) and community (12.2%) hospitals (P < .0001). Patients received less combination therapy at VA hospitals (0.9%) compared to academic (1.8%) and community (1.8%) hospitals (P < .0001). The remaining patients (approximately 30%) received one of several permutations that combined 2 or more of the following treatment modalities: hormone therapy, chemotherapy, biological response modifier therapy, radiotherapy, and surgery.

Conclusion: Although there are minor differences in the proportion of patients receiving each treatment modality, use of radiotherapy and surgery to treat stage I NSCLC is relatively consistent among VA, community, and academic hospitals. Future studies should explore the treatment modalities excluded from this study, compare radiotherapy to stereotactic radiosurgery, and examine how treatment modality affects recurrence and survival.

Purpose/Objectives: Surgery and radiotherapy are the mainstays of treatment for stage I non-small cell lung cancer (NSCLC). While surgical resection is the treatment of choice, radiotherapy remains an option for high risk surgical candidates. We aim to analyze the use of selected primary treatment modalities at VA, community, and academic hospitals. To our knowledge, we are the largest study to compare the utilization of surgery and radiotherapy among hospital types for treatment of stage I NSCLC from 2003-2013.

Materials/Methods: This retrospective study employed the NCDB, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. 148,797 patients treated for stage I NSCLC at VA, community, or academic hospitals between 2003-2013 were identified. The Pearson’s chi-square test was used to determine significance.

Results: Of patients treated at the VA, community, and academic hospitals, 56.0%, 47.8%, and 42.2%, respectively, had one or more comorbid condition(s). Median distance traveled ranges (miles) were 25-49, 5-9, and 10-24, respectively. Median age ranges (years) were 60-69, 70-79, and 70-79, respectively. 96.9% were male at the VA, compared to 49.6% at community and 46.7% at academic hospitals. Slightly more patients were treated with surgery alone at the VA (60.2%) compared to community hospitals (51.5%; P < .0001); a smaller proportion of patients were treated with surgery at the VA compared to academic hospitals (64.4%; P < .0001). More patients were treated with radiation alone at the VA (16.8%) compared to academic (15.1%) and community (12.2%) hospitals (P < .0001). Patients received less combination therapy at VA hospitals (0.9%) compared to academic (1.8%) and community (1.8%) hospitals (P < .0001). The remaining patients (approximately 30%) received one of several permutations that combined 2 or more of the following treatment modalities: hormone therapy, chemotherapy, biological response modifier therapy, radiotherapy, and surgery.

Conclusion: Although there are minor differences in the proportion of patients receiving each treatment modality, use of radiotherapy and surgery to treat stage I NSCLC is relatively consistent among VA, community, and academic hospitals. Future studies should explore the treatment modalities excluded from this study, compare radiotherapy to stereotactic radiosurgery, and examine how treatment modality affects recurrence and survival.

Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.

Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.

Complex hematological tests aid in establishing hematologic diagnoses, but can be quite costly. We hypothesized that certain diagnostic tests (specifically JAK2 at $175/test, BCR-ABL at $163/test, and flow cytometry at $275/test) that were being ordered without input from a hematologist were generally not indicated and expensive. We reviewed all of these tests sent between September 2013 and September 2015. 20/55 or 36% of JAK2 mutations, 19/37 or 51% of BCR-ABL mutations, and 47/74 or 63% of flow cytometry were completed without hematology input, primarily via primary care (72/86 or 84%). Tests that were ordered or recommended by hematology were excluded from the subsequent cost analysis. In total $19,500 was spent (without hematology input). One hematologist then reviewed the charts on every test that had been ordered not by hematology to determine if the test was clinically appropriate. 12/20 or 60% of JAK2 mutations, 19/19 or 100% of BCR mutations, and 44/47 or 94% of flow cytometry evaluations were felt to be unnecessary. Thus $17,300 of the $19,500 could have been saved had there been hematology input at the outset. This would have amounted to 86 e-consults over 2 years, which would be 1.2 extra consults/week; these consults generally take under 10 minutes, so less than 2 minutes/day. This all translates to ~$1,075 over 2 years of a hematologist’s salary, clearly more cost-effective than permitting everyone to be able to order these tests. We should consider recommending hematology input prior to allowing these tests (and perhaps other costly unusual hematology investigations) to be sent out, perhaps via a pop-up suggestion for a hematology e-consult when ordered; the e-consult would also be a tool to educate other providers on the appropriate use of these tests and may ultimately lead to a decrease in the ordering of these e-consults.

Background: Recent evidence from the Government Performance Review Act Report on Oncology has shown an earlier detection of colorectal, lung, and prostate cancer in Veterans Administration Hospitals (VAHs) versus other SEER hospitals despite similar incidence rates.

Purpose: Assess melanoma screening by looking at incidence of stages at diagnosis. Earlier detection of melanoma compared to other hospitals may suggest better screening in VAHs.

Methods: Community Programs (CCP) receive 100-500 newly diagnosed cancer cases per year. Hospitals receiving 500+ patients are either Academic Comprehensive Programs (ACP) or Comprehensive Community Cancer Programs (CCCP). Using NCDB (2003-2013), which includes > 70% of newly diagnosed cancer patients, we utilized chi-square analysis and compared stage at diagnosis for patients with melanoma.

Results: VA hospitals consistently detect higher rates of early stage melanoma with 41% stage 0 and 73% stage 0/I versus the average of 27.75% stage 0 and 67.25% stage 0/I between all hospitals (P < .01). VA hospitals also consistently detect lower rates of late stage melanoma stage IV between all hospitals (P < .01).

Implications: This is the first study showing higher rates of early diagnosis of melanoma in VAH versus other hospital types in NCDB by looking at staging. Early stage melanoma was detected at greater frequencies and late stage melanoma at lower frequencies in VA hospitals. This may suggest better screening, resulting in better prognosis, for patients treated in VAH. 27.5% less patients were stage IV in VAH than the calculated average. If we apply the percentage of VAH stage IV melanoma to all other hospitals, good screening in VAH may have prevented 5,138 patients from becoming stage IV.

Background: Recent evidence from the Government Performance Review Act Report on Oncology has shown an earlier detection of colorectal, lung, and prostate cancer in Veterans Administration Hospitals (VAHs) versus other SEER hospitals despite similar incidence rates.

Purpose: Assess melanoma screening by looking at incidence of stages at diagnosis. Earlier detection of melanoma compared to other hospitals may suggest better screening in VAHs.

Methods: Community Programs (CCP) receive 100-500 newly diagnosed cancer cases per year. Hospitals receiving 500+ patients are either Academic Comprehensive Programs (ACP) or Comprehensive Community Cancer Programs (CCCP). Using NCDB (2003-2013), which includes > 70% of newly diagnosed cancer patients, we utilized chi-square analysis and compared stage at diagnosis for patients with melanoma.

Results: VA hospitals consistently detect higher rates of early stage melanoma with 41% stage 0 and 73% stage 0/I versus the average of 27.75% stage 0 and 67.25% stage 0/I between all hospitals (P < .01). VA hospitals also consistently detect lower rates of late stage melanoma stage IV between all hospitals (P < .01).

Implications: This is the first study showing higher rates of early diagnosis of melanoma in VAH versus other hospital types in NCDB by looking at staging. Early stage melanoma was detected at greater frequencies and late stage melanoma at lower frequencies in VA hospitals. This may suggest better screening, resulting in better prognosis, for patients treated in VAH. 27.5% less patients were stage IV in VAH than the calculated average. If we apply the percentage of VAH stage IV melanoma to all other hospitals, good screening in VAH may have prevented 5,138 patients from becoming stage IV.

Background: Recent evidence from the Government Performance Review Act Report on Oncology has shown an earlier detection of colorectal, lung, and prostate cancer in Veterans Administration Hospitals (VAHs) versus other SEER hospitals despite similar incidence rates.

Purpose: Assess melanoma screening by looking at incidence of stages at diagnosis. Earlier detection of melanoma compared to other hospitals may suggest better screening in VAHs.

Methods: Community Programs (CCP) receive 100-500 newly diagnosed cancer cases per year. Hospitals receiving 500+ patients are either Academic Comprehensive Programs (ACP) or Comprehensive Community Cancer Programs (CCCP). Using NCDB (2003-2013), which includes > 70% of newly diagnosed cancer patients, we utilized chi-square analysis and compared stage at diagnosis for patients with melanoma.

Results: VA hospitals consistently detect higher rates of early stage melanoma with 41% stage 0 and 73% stage 0/I versus the average of 27.75% stage 0 and 67.25% stage 0/I between all hospitals (P < .01). VA hospitals also consistently detect lower rates of late stage melanoma stage IV between all hospitals (P < .01).

Implications: This is the first study showing higher rates of early diagnosis of melanoma in VAH versus other hospital types in NCDB by looking at staging. Early stage melanoma was detected at greater frequencies and late stage melanoma at lower frequencies in VA hospitals. This may suggest better screening, resulting in better prognosis, for patients treated in VAH. 27.5% less patients were stage IV in VAH than the calculated average. If we apply the percentage of VAH stage IV melanoma to all other hospitals, good screening in VAH may have prevented 5,138 patients from becoming stage IV.

Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.

Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.

Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.

Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.

Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.

Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.

Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.

Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.

Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.

Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.

Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.

Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.

Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.

Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.

Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.

Background: Winchester et al (1999) showed that 61% of stage 4 pancreatic cancer patients in the National Cancer Data Base (NCDB) from 1985-95 received no treatment.

Methods: NCDB was queried to evaluate treatment of stage 4 pancreatic cancer from years 2003-2013. The study included 1,525 hospitals and 61,063 patients, of which 47 hospitals and 1,528 patients were from VA hospitals. Chi-square tests were run to compare patients at all hospitals not receiving treatment to VA patients.

Results: More stage 4 pancreatic patients at the VA received no treatment compared to the average in 2003-2013 (58.5% vs 46.8%). However, the VA was still lower than the 61% Winchester found in the 1990s. The percentage of patients within each age group that did not
receive treatment was at least 10% greater at the VA compared to other hospitals. VA patients had lower incomes, greater distances traveled to hospitals, and lived in areas that had more people without a high school degree compared to patients at all hospitals. 19.5% of VA patients,
versus 6.5% of all hospital patients, traveled over 100 miles for care. 22.3% of VA patients, compared to 15.7% of all hospital patients, had an income of less than $36,000. 21.1% of VA patients, compared to 14.5% of all hospital patients had lower education as shown by living in areas where more than 23% of the population did not graduate high school. (all P < .05)

Implications: The majority of stage IV pancreatic patients at the VA are not treated. VA patients with stage 4 pancreatic cancer who did not receive treatment traveled greater distances for care, had less education, and had lower incomes compared to those at other hospitals. Further investigation must be done to determine ways to provide better care to veterans facing pancreatic cancer.

Background: Winchester et al (1999) showed that 61% of stage 4 pancreatic cancer patients in the National Cancer Data Base (NCDB) from 1985-95 received no treatment.

Methods: NCDB was queried to evaluate treatment of stage 4 pancreatic cancer from years 2003-2013. The study included 1,525 hospitals and 61,063 patients, of which 47 hospitals and 1,528 patients were from VA hospitals. Chi-square tests were run to compare patients at all hospitals not receiving treatment to VA patients.

Results: More stage 4 pancreatic patients at the VA received no treatment compared to the average in 2003-2013 (58.5% vs 46.8%). However, the VA was still lower than the 61% Winchester found in the 1990s. The percentage of patients within each age group that did not
receive treatment was at least 10% greater at the VA compared to other hospitals. VA patients had lower incomes, greater distances traveled to hospitals, and lived in areas that had more people without a high school degree compared to patients at all hospitals. 19.5% of VA patients,
versus 6.5% of all hospital patients, traveled over 100 miles for care. 22.3% of VA patients, compared to 15.7% of all hospital patients, had an income of less than $36,000. 21.1% of VA patients, compared to 14.5% of all hospital patients had lower education as shown by living in areas where more than 23% of the population did not graduate high school. (all P < .05)

Implications: The majority of stage IV pancreatic patients at the VA are not treated. VA patients with stage 4 pancreatic cancer who did not receive treatment traveled greater distances for care, had less education, and had lower incomes compared to those at other hospitals. Further investigation must be done to determine ways to provide better care to veterans facing pancreatic cancer.

Background: Winchester et al (1999) showed that 61% of stage 4 pancreatic cancer patients in the National Cancer Data Base (NCDB) from 1985-95 received no treatment.

Methods: NCDB was queried to evaluate treatment of stage 4 pancreatic cancer from years 2003-2013. The study included 1,525 hospitals and 61,063 patients, of which 47 hospitals and 1,528 patients were from VA hospitals. Chi-square tests were run to compare patients at all hospitals not receiving treatment to VA patients.

Results: More stage 4 pancreatic patients at the VA received no treatment compared to the average in 2003-2013 (58.5% vs 46.8%). However, the VA was still lower than the 61% Winchester found in the 1990s. The percentage of patients within each age group that did not
receive treatment was at least 10% greater at the VA compared to other hospitals. VA patients had lower incomes, greater distances traveled to hospitals, and lived in areas that had more people without a high school degree compared to patients at all hospitals. 19.5% of VA patients,
versus 6.5% of all hospital patients, traveled over 100 miles for care. 22.3% of VA patients, compared to 15.7% of all hospital patients, had an income of less than $36,000. 21.1% of VA patients, compared to 14.5% of all hospital patients had lower education as shown by living in areas where more than 23% of the population did not graduate high school. (all P < .05)

Implications: The majority of stage IV pancreatic patients at the VA are not treated. VA patients with stage 4 pancreatic cancer who did not receive treatment traveled greater distances for care, had less education, and had lower incomes compared to those at other hospitals. Further investigation must be done to determine ways to provide better care to veterans facing pancreatic cancer.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

(Reuters Health) - Older people who break a bone are often receiving medications that can increase the risk of a fracture - and even after a fracture, less than 10 percent of them stop taking those drugs, according to a new study.

"One would expect that a significant health event like a fracture would result in some change in the use of prescription drugs that might have contributed to that event," said lead author Dr. Jeffrey C. Munson of the Geisel School of Medicine at Dartmouth in Lebanon, New Hampshire. "In contrast to this expectation, we observed that for the overwhelming majority of patients we studied, a fragility fracture did not lead to any change in medications that have been linked to fracture risk."

The authors used data on 168,000 Medicare beneficiaries, more than 80 percent of whom were women, on average age 80, who had experienced a hip, shoulder or wrist fracture. They compared these records with retail pharmacy claims to identify which patients had been taking medicines that increase the risk of a fall, decrease bone density or are otherwise tied to an increased risk of fracture.

About 75 percent of fracture patients had been taking one of these medications. While seven percent of people stopped taking the medication after their fracture, a similar number started to take a new medication also tied to fracture risk, the authors reported in JAMA Internal Medicine, online August 22.

"Some drugs affect balance and memory, like the sleeping pills, which can lead to a fall," said Dr. Sarah D. Berry of the Institute for Aging Research at Hebrew SeniorLife in Boston, Massachusetts, who coauthored a linked editorial.

Blood pressure medications cause changes in blood pressure that could lead to a fall. Other drugs, like prednisone or medications for heartburn, increase bone loss which can lead to a fracture, Berry told Reuters Health by email.

"Fractures are the leading cause of death from injury and one of the main reasons for nursing home placement in persons over the age of 65," she said.

"When a patient has a hip, shoulder or wrist fracture, it is important for healthcare providers to examine all the prescription medications he or she is taking, and carefully assess whether there is an opportunity to eliminate those that might cause a future fracture," Munson told Reuters Health by email.

However, he said, "In many cases, the benefits of a drug may outweigh its risks, even when those risks are significant."

Which drugs can be stopped will vary from case to case, Munson noted.

"For many of the drugs we studied, there are alternative drugs that treat the same conditions but with a lower risk of fracture," he said. "In other cases, it may be possible to eliminate a drug altogether."

SOURCE: http://bit.ly/2bc6PIN

JAMA Intern Med 2016.

(c) Copyright Thomson Reuters 2016.

Vials of blinatumomab powder

and solution for infusion

Photo courtesy of Amgen

The US Food and Drug Administration (FDA) has granted accelerated approval for blinatumomab (Blincyto®) to treat pediatric patients with Philadelphia chromosome-negative (Ph-) relapsed or refractory B-cell precursor acute lymphoblastic leukemia (BCP-ALL).

The approval is based on results from a phase 1/2 study.

Continued approval of blinatumomab for this indication may be contingent upon verification of clinical benefit in subsequent trials.

Blinatumomab is a bispecific, CD19-directed, CD3 T-cell engager (BiTE®) antibody construct that binds specifically to CD19 expressed on the surface of cells of B-lineage origin and CD3 expressed on the surface of T cells.

In 2014, blinatumomab received accelerated approval from the FDA to treat adults with Ph- relapsed or refractory BCP-ALL. The FDA has also granted the drug priority review, breakthrough therapy designation, and orphan drug designation.

Blinatumomab is being developed by Amgen. Full prescribing information is available at www.blincyto.com.

‘205 trial

The latest accelerated approval of blinatumomab is based on results from the phase 1/2 ‘205 trial, in which researchers evaluated blinatumomab in 93 pediatric patients with relapsed or refractory BCP-ALL.

Amgen said treatment in this study has been completed, subjects are being monitored for long-term efficacy, and the data will be submitted for publication.

Initial results from this study were presented at ASH 2014. The abstract included data on 39 patients with relapsed/refractory BCP-ALL and a median age of 9 (range, 2-16).

The patients received blinatumomab at a dose of 5-15 µg/m²/day. Nineteen patients completed 1 cycle of blinatumomab, 4 completed 2 cycles, and 2 completed 3 cycles.

During the first 2 treatment cycles, 12 patients achieved a complete response, 5 of whom were negative for minimal residual disease.

Six of the complete responders went on to transplant. The median relapse-free survival for complete responders was 5.6 months.

At 6 months of follow-up, the median overall survival for all 39 patients was 4.3 months.

All of the patients experienced adverse events. The most common were pyrexia (74%), anemia (33%), nausea (31%), headache (28%), hypertension (26%), increased alanine aminotransferase (23%), and cough (21%).

The most common grade 3 or higher events were anemia (26%), pyrexia (21%), increased alanine aminotransferase (18%), increased aspartate aminotransferase (18%), and febrile neutropenia (15%).

Three patients developed cytokine release syndrome (2 grade 3).

Vials of blinatumomab powder

and solution for infusion

Photo courtesy of Amgen

The US Food and Drug Administration (FDA) has granted accelerated approval for blinatumomab (Blincyto®) to treat pediatric patients with Philadelphia chromosome-negative (Ph-) relapsed or refractory B-cell precursor acute lymphoblastic leukemia (BCP-ALL).

The approval is based on results from a phase 1/2 study.

Continued approval of blinatumomab for this indication may be contingent upon verification of clinical benefit in subsequent trials.

Blinatumomab is a bispecific, CD19-directed, CD3 T-cell engager (BiTE®) antibody construct that binds specifically to CD19 expressed on the surface of cells of B-lineage origin and CD3 expressed on the surface of T cells.

In 2014, blinatumomab received accelerated approval from the FDA to treat adults with Ph- relapsed or refractory BCP-ALL. The FDA has also granted the drug priority review, breakthrough therapy designation, and orphan drug designation.

Blinatumomab is being developed by Amgen. Full prescribing information is available at www.blincyto.com.

‘205 trial

The latest accelerated approval of blinatumomab is based on results from the phase 1/2 ‘205 trial, in which researchers evaluated blinatumomab in 93 pediatric patients with relapsed or refractory BCP-ALL.

Amgen said treatment in this study has been completed, subjects are being monitored for long-term efficacy, and the data will be submitted for publication.

Initial results from this study were presented at ASH 2014. The abstract included data on 39 patients with relapsed/refractory BCP-ALL and a median age of 9 (range, 2-16).

The patients received blinatumomab at a dose of 5-15 µg/m²/day. Nineteen patients completed 1 cycle of blinatumomab, 4 completed 2 cycles, and 2 completed 3 cycles.

During the first 2 treatment cycles, 12 patients achieved a complete response, 5 of whom were negative for minimal residual disease.

Six of the complete responders went on to transplant. The median relapse-free survival for complete responders was 5.6 months.

At 6 months of follow-up, the median overall survival for all 39 patients was 4.3 months.

All of the patients experienced adverse events. The most common were pyrexia (74%), anemia (33%), nausea (31%), headache (28%), hypertension (26%), increased alanine aminotransferase (23%), and cough (21%).

The most common grade 3 or higher events were anemia (26%), pyrexia (21%), increased alanine aminotransferase (18%), increased aspartate aminotransferase (18%), and febrile neutropenia (15%).

Three patients developed cytokine release syndrome (2 grade 3).

Vials of blinatumomab powder

and solution for infusion

Photo courtesy of Amgen

The US Food and Drug Administration (FDA) has granted accelerated approval for blinatumomab (Blincyto®) to treat pediatric patients with Philadelphia chromosome-negative (Ph-) relapsed or refractory B-cell precursor acute lymphoblastic leukemia (BCP-ALL).

The approval is based on results from a phase 1/2 study.

Continued approval of blinatumomab for this indication may be contingent upon verification of clinical benefit in subsequent trials.

Blinatumomab is a bispecific, CD19-directed, CD3 T-cell engager (BiTE®) antibody construct that binds specifically to CD19 expressed on the surface of cells of B-lineage origin and CD3 expressed on the surface of T cells.

In 2014, blinatumomab received accelerated approval from the FDA to treat adults with Ph- relapsed or refractory BCP-ALL. The FDA has also granted the drug priority review, breakthrough therapy designation, and orphan drug designation.

Blinatumomab is being developed by Amgen. Full prescribing information is available at www.blincyto.com.

‘205 trial

The latest accelerated approval of blinatumomab is based on results from the phase 1/2 ‘205 trial, in which researchers evaluated blinatumomab in 93 pediatric patients with relapsed or refractory BCP-ALL.

Amgen said treatment in this study has been completed, subjects are being monitored for long-term efficacy, and the data will be submitted for publication.

Initial results from this study were presented at ASH 2014. The abstract included data on 39 patients with relapsed/refractory BCP-ALL and a median age of 9 (range, 2-16).

The patients received blinatumomab at a dose of 5-15 µg/m²/day. Nineteen patients completed 1 cycle of blinatumomab, 4 completed 2 cycles, and 2 completed 3 cycles.

During the first 2 treatment cycles, 12 patients achieved a complete response, 5 of whom were negative for minimal residual disease.

Six of the complete responders went on to transplant. The median relapse-free survival for complete responders was 5.6 months.

At 6 months of follow-up, the median overall survival for all 39 patients was 4.3 months.

All of the patients experienced adverse events. The most common were pyrexia (74%), anemia (33%), nausea (31%), headache (28%), hypertension (26%), increased alanine aminotransferase (23%), and cough (21%).

The most common grade 3 or higher events were anemia (26%), pyrexia (21%), increased alanine aminotransferase (18%), increased aspartate aminotransferase (18%), and febrile neutropenia (15%).

Three patients developed cytokine release syndrome (2 grade 3).

Background: Head and neck (HAN) cancer is diagnosed in more than 50,000 Americans annually and is the third most common malignancy in the Veteran patient population. There are > 185,000 American HAN cancer survivors. The comprehensive nature of this disease causes challenges from diagnosis through survivorship. A lack of patient navigation program (PNP) for patients with HAN cancer often lead to fragmented care, delay in initiation of treatment, increased healthcare cost, poor cancer outcome, and a decrease in patient satisfaction.

Purpose: To improve care outcomes among patients with HAN cancer through the implementation of the PNP. Specifically, the program is targeted towards providing holistic patient-centered care, eliminating fragmented care and delays, and decreasing emotional distress and healthcare cost.

Method: In the First Phase, we conducted a need assessment for the PNP. In the Second Phase, we implemented the PNP in 2015 using current evidence and Deming’s (1993) Plan-Do-Study-Act (PDSA) model. During the Implementation Phase of the PNP, we developed a clinical algorithm and order set. We also strengthened our partnership with Non-VA Care Coordination
to expedite community care.

Outcomes: The PNP has served 140 Veterans with well over 500 clinical visits. Consistent with our expectation, the program has resulted in improved oncology infrastructure and timeliness of care. For instance, before the program, there was an average of 16 weeks from suspicion to initiation of treatment. After PNP implementation, the process now takes 4 to 6 weeks. The PNP has eliminated repeat computerized axial tomography, and thus, decreasing healthcare cost by $262,500 annually. Besides its economic impact, the PNP has also led to improved patient and provider satisfaction.

Clinical Implications: Overall, the PNP is a robust patientcentered care program which provides holistic care to patients from cancer suspicion to treatment initiation. Although the PNP continues to evolve, its implementation in BPVAHCS has had a significant impact in the care of HAN cancer patients. Due to the success of the current PNP, BPVAHCS is planning to include all cancer sites by 2020.

Background: Head and neck (HAN) cancer is diagnosed in more than 50,000 Americans annually and is the third most common malignancy in the Veteran patient population. There are > 185,000 American HAN cancer survivors. The comprehensive nature of this disease causes challenges from diagnosis through survivorship. A lack of patient navigation program (PNP) for patients with HAN cancer often lead to fragmented care, delay in initiation of treatment, increased healthcare cost, poor cancer outcome, and a decrease in patient satisfaction.

Purpose: To improve care outcomes among patients with HAN cancer through the implementation of the PNP. Specifically, the program is targeted towards providing holistic patient-centered care, eliminating fragmented care and delays, and decreasing emotional distress and healthcare cost.

Method: In the First Phase, we conducted a need assessment for the PNP. In the Second Phase, we implemented the PNP in 2015 using current evidence and Deming’s (1993) Plan-Do-Study-Act (PDSA) model. During the Implementation Phase of the PNP, we developed a clinical algorithm and order set. We also strengthened our partnership with Non-VA Care Coordination
to expedite community care.

Outcomes: The PNP has served 140 Veterans with well over 500 clinical visits. Consistent with our expectation, the program has resulted in improved oncology infrastructure and timeliness of care. For instance, before the program, there was an average of 16 weeks from suspicion to initiation of treatment. After PNP implementation, the process now takes 4 to 6 weeks. The PNP has eliminated repeat computerized axial tomography, and thus, decreasing healthcare cost by $262,500 annually. Besides its economic impact, the PNP has also led to improved patient and provider satisfaction.

Clinical Implications: Overall, the PNP is a robust patientcentered care program which provides holistic care to patients from cancer suspicion to treatment initiation. Although the PNP continues to evolve, its implementation in BPVAHCS has had a significant impact in the care of HAN cancer patients. Due to the success of the current PNP, BPVAHCS is planning to include all cancer sites by 2020.

Background: Head and neck (HAN) cancer is diagnosed in more than 50,000 Americans annually and is the third most common malignancy in the Veteran patient population. There are > 185,000 American HAN cancer survivors. The comprehensive nature of this disease causes challenges from diagnosis through survivorship. A lack of patient navigation program (PNP) for patients with HAN cancer often lead to fragmented care, delay in initiation of treatment, increased healthcare cost, poor cancer outcome, and a decrease in patient satisfaction.

Purpose: To improve care outcomes among patients with HAN cancer through the implementation of the PNP. Specifically, the program is targeted towards providing holistic patient-centered care, eliminating fragmented care and delays, and decreasing emotional distress and healthcare cost.

Method: In the First Phase, we conducted a need assessment for the PNP. In the Second Phase, we implemented the PNP in 2015 using current evidence and Deming’s (1993) Plan-Do-Study-Act (PDSA) model. During the Implementation Phase of the PNP, we developed a clinical algorithm and order set. We also strengthened our partnership with Non-VA Care Coordination
to expedite community care.

Outcomes: The PNP has served 140 Veterans with well over 500 clinical visits. Consistent with our expectation, the program has resulted in improved oncology infrastructure and timeliness of care. For instance, before the program, there was an average of 16 weeks from suspicion to initiation of treatment. After PNP implementation, the process now takes 4 to 6 weeks. The PNP has eliminated repeat computerized axial tomography, and thus, decreasing healthcare cost by $262,500 annually. Besides its economic impact, the PNP has also led to improved patient and provider satisfaction.

Clinical Implications: Overall, the PNP is a robust patientcentered care program which provides holistic care to patients from cancer suspicion to treatment initiation. Although the PNP continues to evolve, its implementation in BPVAHCS has had a significant impact in the care of HAN cancer patients. Due to the success of the current PNP, BPVAHCS is planning to include all cancer sites by 2020.

CTPA showing PE

Image courtesy of

Medical College of Georgia

ROME—A new study suggests the YEARS algorithm may provide a simple method for ruling out pulmonary embolism (PE) and therefore reduce the need for computed tomography pulmonary angiography (CTPA).

“[The YEARS algorithm] can replace current diagnostic algorithms, which, although safe and accurate, are often not used in busy emergency departments because they are too complex,” said study investigator Tom Van der Hulle, MD, of Leiden University Medical Center in the Netherlands.

“The advantage of the YEARS algorithm over existing algorithms is a 14% reduction in the need for CTPA imaging and, with that, reduced potential for radiation-induced harm and overdiagnosis.”

Dr Van der Hulle described his team’s results with the YEARS algorithm at ESC Congress 2016 (abstract 5727).

About the algorithm

The YEARS algorithm consists of a blood test and 3 items of the original Wells rule.

Patients presenting to the emergency department can be evaluated based on:

1. Clinical signs of deep vein thrombosis (eg, swelling, edema)
2. Hemoptysis
3. Whether the clinician considers PE to be “the most likely diagnosis.”

Using this information combined with results of a blood test measuring D-dimer, clinicians can either exclude PE or recommend CTPA for definitive diagnosis.

Based on the algorithm, PE can be excluded in patients who have either:

• None of the 3 YEARS items and a D-dimer level <1000 ng/mL
• One or more YEARS items and a D-dimer level <500 ng/mL.

Testing the algorithm

Dr Van der Hulle and his colleagues prospectively evaluated the YEARS algorithm in 3465 patients. They had a mean age of 53, and 88% were outpatients.

If patients did not have PE excluded via the algorithm, they went on to CTPA. If PE was confirmed, patients received anticoagulant therapy.

Most of the patients in whom PE was excluded (either by algorithm or CTPA) were left untreated and were followed for 3 months, although 60 patients who had PE excluded received anticoagulants anyway.

In all, 1651 patients had PE excluded with the YEARS algorithm, and 1633 of them did not receive anticoagulation.

A total of 1814 patients did not have PE excluded via the YEARS algorithm and went on to CTPA. Of these patients, 456 had PE, 42 had PE excluded via CTPA but received anticoagulation, and 1316 had PE excluded but did not receive anticoagulation.

Five patients were lost to follow-up—4 with PE excluded via the YEARS algorithm and 1 who went on to CTPA.

Patient outcomes

The primary outcome of this study was the 3-month incidence of symptomatic venous thromboembolism (VTE).

A total of 2944 patients were evaluable (because they had PE excluded, did not receive anticoagulation, and were not lost to follow-up)—1629 who had PE excluded via the YEARS algorithm and 1315 who had PE excluded via CTPA.

Symptomatic VTE occurred in 0.61% of all evaluable patients, 0.43% of patients who had PE excluded via YEARS, and 0.84% of patients who had PE excluded via CTPA.

Fatal PE occurred in 0.20% of all evaluable patients, 0.12% of patients who had PE excluded via YEARS, and 0.30% of patients who had PE excluded via CTPA.

“This is fully in line with that observed in studies using traditional, sequential algorithms such as the 2-level Wells score and a fixed cut-off level of D-dimer of 500 ng/mL,” Dr Van der Hulle said.

“Using the YEARS algorithm, CTPA was not indicated in 48% of our patients at baseline, but this would have been only 34% of patients using the traditional algorithm. This shows that the YEARS algorithm can safely exclude PE and resulted in an absolute reduction of required CTPA of 14%.”

“We expect that the YEARS algorithm can be easily implemented outside the participating study sites and that these safety and efficacy outcomes are representative of what could be expected in regular clinical settings.”

CTPA showing PE

Image courtesy of

Medical College of Georgia

ROME—A new study suggests the YEARS algorithm may provide a simple method for ruling out pulmonary embolism (PE) and therefore reduce the need for computed tomography pulmonary angiography (CTPA).

“[The YEARS algorithm] can replace current diagnostic algorithms, which, although safe and accurate, are often not used in busy emergency departments because they are too complex,” said study investigator Tom Van der Hulle, MD, of Leiden University Medical Center in the Netherlands.

“The advantage of the YEARS algorithm over existing algorithms is a 14% reduction in the need for CTPA imaging and, with that, reduced potential for radiation-induced harm and overdiagnosis.”

Dr Van der Hulle described his team’s results with the YEARS algorithm at ESC Congress 2016 (abstract 5727).

About the algorithm

The YEARS algorithm consists of a blood test and 3 items of the original Wells rule.

Patients presenting to the emergency department can be evaluated based on:

1. Clinical signs of deep vein thrombosis (eg, swelling, edema)
2. Hemoptysis
3. Whether the clinician considers PE to be “the most likely diagnosis.”

Using this information combined with results of a blood test measuring D-dimer, clinicians can either exclude PE or recommend CTPA for definitive diagnosis.

Based on the algorithm, PE can be excluded in patients who have either:

• None of the 3 YEARS items and a D-dimer level <1000 ng/mL
• One or more YEARS items and a D-dimer level <500 ng/mL.

Testing the algorithm

Dr Van der Hulle and his colleagues prospectively evaluated the YEARS algorithm in 3465 patients. They had a mean age of 53, and 88% were outpatients.

If patients did not have PE excluded via the algorithm, they went on to CTPA. If PE was confirmed, patients received anticoagulant therapy.

Most of the patients in whom PE was excluded (either by algorithm or CTPA) were left untreated and were followed for 3 months, although 60 patients who had PE excluded received anticoagulants anyway.

In all, 1651 patients had PE excluded with the YEARS algorithm, and 1633 of them did not receive anticoagulation.

A total of 1814 patients did not have PE excluded via the YEARS algorithm and went on to CTPA. Of these patients, 456 had PE, 42 had PE excluded via CTPA but received anticoagulation, and 1316 had PE excluded but did not receive anticoagulation.

Five patients were lost to follow-up—4 with PE excluded via the YEARS algorithm and 1 who went on to CTPA.

Patient outcomes

The primary outcome of this study was the 3-month incidence of symptomatic venous thromboembolism (VTE).

A total of 2944 patients were evaluable (because they had PE excluded, did not receive anticoagulation, and were not lost to follow-up)—1629 who had PE excluded via the YEARS algorithm and 1315 who had PE excluded via CTPA.

Symptomatic VTE occurred in 0.61% of all evaluable patients, 0.43% of patients who had PE excluded via YEARS, and 0.84% of patients who had PE excluded via CTPA.

Fatal PE occurred in 0.20% of all evaluable patients, 0.12% of patients who had PE excluded via YEARS, and 0.30% of patients who had PE excluded via CTPA.

“This is fully in line with that observed in studies using traditional, sequential algorithms such as the 2-level Wells score and a fixed cut-off level of D-dimer of 500 ng/mL,” Dr Van der Hulle said.

“Using the YEARS algorithm, CTPA was not indicated in 48% of our patients at baseline, but this would have been only 34% of patients using the traditional algorithm. This shows that the YEARS algorithm can safely exclude PE and resulted in an absolute reduction of required CTPA of 14%.”

“We expect that the YEARS algorithm can be easily implemented outside the participating study sites and that these safety and efficacy outcomes are representative of what could be expected in regular clinical settings.”

CTPA showing PE

Image courtesy of

Medical College of Georgia

ROME—A new study suggests the YEARS algorithm may provide a simple method for ruling out pulmonary embolism (PE) and therefore reduce the need for computed tomography pulmonary angiography (CTPA).

“[The YEARS algorithm] can replace current diagnostic algorithms, which, although safe and accurate, are often not used in busy emergency departments because they are too complex,” said study investigator Tom Van der Hulle, MD, of Leiden University Medical Center in the Netherlands.

“The advantage of the YEARS algorithm over existing algorithms is a 14% reduction in the need for CTPA imaging and, with that, reduced potential for radiation-induced harm and overdiagnosis.”

Dr Van der Hulle described his team’s results with the YEARS algorithm at ESC Congress 2016 (abstract 5727).

About the algorithm

The YEARS algorithm consists of a blood test and 3 items of the original Wells rule.

Patients presenting to the emergency department can be evaluated based on:

1. Clinical signs of deep vein thrombosis (eg, swelling, edema)
2. Hemoptysis
3. Whether the clinician considers PE to be “the most likely diagnosis.”

Using this information combined with results of a blood test measuring D-dimer, clinicians can either exclude PE or recommend CTPA for definitive diagnosis.

Based on the algorithm, PE can be excluded in patients who have either:

• None of the 3 YEARS items and a D-dimer level <1000 ng/mL
• One or more YEARS items and a D-dimer level <500 ng/mL.

Testing the algorithm

Dr Van der Hulle and his colleagues prospectively evaluated the YEARS algorithm in 3465 patients. They had a mean age of 53, and 88% were outpatients.

If patients did not have PE excluded via the algorithm, they went on to CTPA. If PE was confirmed, patients received anticoagulant therapy.

Most of the patients in whom PE was excluded (either by algorithm or CTPA) were left untreated and were followed for 3 months, although 60 patients who had PE excluded received anticoagulants anyway.

In all, 1651 patients had PE excluded with the YEARS algorithm, and 1633 of them did not receive anticoagulation.

A total of 1814 patients did not have PE excluded via the YEARS algorithm and went on to CTPA. Of these patients, 456 had PE, 42 had PE excluded via CTPA but received anticoagulation, and 1316 had PE excluded but did not receive anticoagulation.

Five patients were lost to follow-up—4 with PE excluded via the YEARS algorithm and 1 who went on to CTPA.

Patient outcomes

The primary outcome of this study was the 3-month incidence of symptomatic venous thromboembolism (VTE).

A total of 2944 patients were evaluable (because they had PE excluded, did not receive anticoagulation, and were not lost to follow-up)—1629 who had PE excluded via the YEARS algorithm and 1315 who had PE excluded via CTPA.

Symptomatic VTE occurred in 0.61% of all evaluable patients, 0.43% of patients who had PE excluded via YEARS, and 0.84% of patients who had PE excluded via CTPA.

Fatal PE occurred in 0.20% of all evaluable patients, 0.12% of patients who had PE excluded via YEARS, and 0.30% of patients who had PE excluded via CTPA.

“This is fully in line with that observed in studies using traditional, sequential algorithms such as the 2-level Wells score and a fixed cut-off level of D-dimer of 500 ng/mL,” Dr Van der Hulle said.

“Using the YEARS algorithm, CTPA was not indicated in 48% of our patients at baseline, but this would have been only 34% of patients using the traditional algorithm. This shows that the YEARS algorithm can safely exclude PE and resulted in an absolute reduction of required CTPA of 14%.”

“We expect that the YEARS algorithm can be easily implemented outside the participating study sites and that these safety and efficacy outcomes are representative of what could be expected in regular clinical settings.”