User login
The Effect of Adjuvant Therapy Type on Survival for Patients With Sage II Osteosarcoma
Background
Osteosarcoma is an aggressive bone malignancy often treated with surgery. On diagnosis, the majority of patients present with stage II disease. The objective of this study was to compare differences in survival between three commonly used adjuvant therapies: chemotherapy, radiation, and combined chemoradiation therapy in patients presenting with stage II disease.
Methods
The National Cancer Database (NCDB) was used to identify patients diagnosed with osteosarcoma from 2004 to 2018 using the ICD-O-3 histology codes 9180-9187. Patients with stage II disease and who had undergone a surgical procedure at the primary site were identified. Patients were grouped by the receipt of adjuvant chemotherapy, radiation, or chemoradiation. Descriptive statistics and Kaplan-Meier curves were used to measure survival in these patients. One way ANOVA and chi-square analyses were used to evaluate differences among treatment groups. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
Of 9955 patients in the NCDB diagnosed with osteosarcoma, 4378 (44%) presented with stage II disease. 710 (17.9%) of these surgical patients received additional adjuvant therapy. 66.0% received chemotherapy, 24.4% received radiation, and 9.57% received combined chemoradiation. Adjuvant chemotherapy had the longest median survival time of 91.7 months. Median survival for adjuvant radiotherapy was 48 months and combined chemoradiation was 50.5 months. On log-rank pairwise comparison, the difference in survival between adjuvant chemotherapy and adjuvant chemoradiation was found to be statistically significant. (P < .001). Patients receiving adjuvant chemotherapy were more likely to be younger and have private insurance. (P < .05) Conversely, patients receiving adjuvant radiation were more likely to be older and have Medicare. (P < .05). No significant differences were seen among patient race, sex, income, or Charleson-Deyo comorbidity score.
Conclusions
This study showed that patients with stage II osteosarcoma who receive adjuvant chemotherapy experience improved median survival in comparison to patients who receive adjuvant radiation. This is an important clinical finding, which should guide future treatment. However, further investigation is required to identify patient and treatment specific factors, which are contributing to mortality.
Background
Osteosarcoma is an aggressive bone malignancy often treated with surgery. On diagnosis, the majority of patients present with stage II disease. The objective of this study was to compare differences in survival between three commonly used adjuvant therapies: chemotherapy, radiation, and combined chemoradiation therapy in patients presenting with stage II disease.
Methods
The National Cancer Database (NCDB) was used to identify patients diagnosed with osteosarcoma from 2004 to 2018 using the ICD-O-3 histology codes 9180-9187. Patients with stage II disease and who had undergone a surgical procedure at the primary site were identified. Patients were grouped by the receipt of adjuvant chemotherapy, radiation, or chemoradiation. Descriptive statistics and Kaplan-Meier curves were used to measure survival in these patients. One way ANOVA and chi-square analyses were used to evaluate differences among treatment groups. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
Of 9955 patients in the NCDB diagnosed with osteosarcoma, 4378 (44%) presented with stage II disease. 710 (17.9%) of these surgical patients received additional adjuvant therapy. 66.0% received chemotherapy, 24.4% received radiation, and 9.57% received combined chemoradiation. Adjuvant chemotherapy had the longest median survival time of 91.7 months. Median survival for adjuvant radiotherapy was 48 months and combined chemoradiation was 50.5 months. On log-rank pairwise comparison, the difference in survival between adjuvant chemotherapy and adjuvant chemoradiation was found to be statistically significant. (P < .001). Patients receiving adjuvant chemotherapy were more likely to be younger and have private insurance. (P < .05) Conversely, patients receiving adjuvant radiation were more likely to be older and have Medicare. (P < .05). No significant differences were seen among patient race, sex, income, or Charleson-Deyo comorbidity score.
Conclusions
This study showed that patients with stage II osteosarcoma who receive adjuvant chemotherapy experience improved median survival in comparison to patients who receive adjuvant radiation. This is an important clinical finding, which should guide future treatment. However, further investigation is required to identify patient and treatment specific factors, which are contributing to mortality.
Background
Osteosarcoma is an aggressive bone malignancy often treated with surgery. On diagnosis, the majority of patients present with stage II disease. The objective of this study was to compare differences in survival between three commonly used adjuvant therapies: chemotherapy, radiation, and combined chemoradiation therapy in patients presenting with stage II disease.
Methods
The National Cancer Database (NCDB) was used to identify patients diagnosed with osteosarcoma from 2004 to 2018 using the ICD-O-3 histology codes 9180-9187. Patients with stage II disease and who had undergone a surgical procedure at the primary site were identified. Patients were grouped by the receipt of adjuvant chemotherapy, radiation, or chemoradiation. Descriptive statistics and Kaplan-Meier curves were used to measure survival in these patients. One way ANOVA and chi-square analyses were used to evaluate differences among treatment groups. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
Of 9955 patients in the NCDB diagnosed with osteosarcoma, 4378 (44%) presented with stage II disease. 710 (17.9%) of these surgical patients received additional adjuvant therapy. 66.0% received chemotherapy, 24.4% received radiation, and 9.57% received combined chemoradiation. Adjuvant chemotherapy had the longest median survival time of 91.7 months. Median survival for adjuvant radiotherapy was 48 months and combined chemoradiation was 50.5 months. On log-rank pairwise comparison, the difference in survival between adjuvant chemotherapy and adjuvant chemoradiation was found to be statistically significant. (P < .001). Patients receiving adjuvant chemotherapy were more likely to be younger and have private insurance. (P < .05) Conversely, patients receiving adjuvant radiation were more likely to be older and have Medicare. (P < .05). No significant differences were seen among patient race, sex, income, or Charleson-Deyo comorbidity score.
Conclusions
This study showed that patients with stage II osteosarcoma who receive adjuvant chemotherapy experience improved median survival in comparison to patients who receive adjuvant radiation. This is an important clinical finding, which should guide future treatment. However, further investigation is required to identify patient and treatment specific factors, which are contributing to mortality.
A Case Report of Palliative Pembrolizumab Monotherapy for a Poorly Differentiated Malignancy
Introduction
The critical role of palliative radiotherapy (RT) in the management of advanced cancer is evolving due to the advent of novel therapeuticapproaches. We report the case of a veteran with a soft tissue metastasis who had a robust response to pembrolizumab, allowing for the deferral of palliative RT.
Case Presentation
An 86-year-old male presented with a rapidly growing, painful, malodorous, fungating right inguinal soft tissue mass measuring 10×7×3 cm that had rendered the patient non-ambulatory, with subsequent imaging also demonstrating a left pleural-based lung mass. Biopsy was consistent with a poorly differentiated carcinoma, and molecular profiling revealed a KRAS G12C mutation, high tumor mutational burden (TMB 18 mutations/megabase), and high PD-L1 expression (TPS 100%). The patient’s poor functional status precluded the use of aggressive combination chemotherapy, but the molecular features were favorable for response to immune checkpoint inhibitor monotherapy, which is better tolerated. He was initiated on pembrolizumab with the goal of symptom palliation and potentially prolonging his life. However, as rapid responses to immunotherapy are uncommon, radiation oncology was consulted for palliative RT. Twenty days after starting pembrolizumab and 2 weeks after RT simulation, the inguinal mass had markedly regressed with an open tissue defect at the site. As the palliative goal had been achieved, RT was deferred to avoid the development of a non-healing wound.
Conclusions
Our case highlights palliative treatment modalities for soft tissue masses. Immunotherapy is now a component of first-line therapy in many cancer types, but rapid and robust responses to monotherapy are rare. There is the exciting potential to combine immunotherapy with RT, with small case series indicating synergy, although further research is needed. In cases with molecular characteristics favoring response to immunotherapy, an optimal sequencing approach may incorporate an initial run-in phase with immunotherapy to determine if symptom palliation can be achieved with unimodal therapy. The location of the mass in a non-radiation sensitive region allowed us to entertain the use of combination therapy for our patient, but ultimately was not needed. Palliative RT will remain an option at the time of cancer progression.
Introduction
The critical role of palliative radiotherapy (RT) in the management of advanced cancer is evolving due to the advent of novel therapeuticapproaches. We report the case of a veteran with a soft tissue metastasis who had a robust response to pembrolizumab, allowing for the deferral of palliative RT.
Case Presentation
An 86-year-old male presented with a rapidly growing, painful, malodorous, fungating right inguinal soft tissue mass measuring 10×7×3 cm that had rendered the patient non-ambulatory, with subsequent imaging also demonstrating a left pleural-based lung mass. Biopsy was consistent with a poorly differentiated carcinoma, and molecular profiling revealed a KRAS G12C mutation, high tumor mutational burden (TMB 18 mutations/megabase), and high PD-L1 expression (TPS 100%). The patient’s poor functional status precluded the use of aggressive combination chemotherapy, but the molecular features were favorable for response to immune checkpoint inhibitor monotherapy, which is better tolerated. He was initiated on pembrolizumab with the goal of symptom palliation and potentially prolonging his life. However, as rapid responses to immunotherapy are uncommon, radiation oncology was consulted for palliative RT. Twenty days after starting pembrolizumab and 2 weeks after RT simulation, the inguinal mass had markedly regressed with an open tissue defect at the site. As the palliative goal had been achieved, RT was deferred to avoid the development of a non-healing wound.
Conclusions
Our case highlights palliative treatment modalities for soft tissue masses. Immunotherapy is now a component of first-line therapy in many cancer types, but rapid and robust responses to monotherapy are rare. There is the exciting potential to combine immunotherapy with RT, with small case series indicating synergy, although further research is needed. In cases with molecular characteristics favoring response to immunotherapy, an optimal sequencing approach may incorporate an initial run-in phase with immunotherapy to determine if symptom palliation can be achieved with unimodal therapy. The location of the mass in a non-radiation sensitive region allowed us to entertain the use of combination therapy for our patient, but ultimately was not needed. Palliative RT will remain an option at the time of cancer progression.
Introduction
The critical role of palliative radiotherapy (RT) in the management of advanced cancer is evolving due to the advent of novel therapeuticapproaches. We report the case of a veteran with a soft tissue metastasis who had a robust response to pembrolizumab, allowing for the deferral of palliative RT.
Case Presentation
An 86-year-old male presented with a rapidly growing, painful, malodorous, fungating right inguinal soft tissue mass measuring 10×7×3 cm that had rendered the patient non-ambulatory, with subsequent imaging also demonstrating a left pleural-based lung mass. Biopsy was consistent with a poorly differentiated carcinoma, and molecular profiling revealed a KRAS G12C mutation, high tumor mutational burden (TMB 18 mutations/megabase), and high PD-L1 expression (TPS 100%). The patient’s poor functional status precluded the use of aggressive combination chemotherapy, but the molecular features were favorable for response to immune checkpoint inhibitor monotherapy, which is better tolerated. He was initiated on pembrolizumab with the goal of symptom palliation and potentially prolonging his life. However, as rapid responses to immunotherapy are uncommon, radiation oncology was consulted for palliative RT. Twenty days after starting pembrolizumab and 2 weeks after RT simulation, the inguinal mass had markedly regressed with an open tissue defect at the site. As the palliative goal had been achieved, RT was deferred to avoid the development of a non-healing wound.
Conclusions
Our case highlights palliative treatment modalities for soft tissue masses. Immunotherapy is now a component of first-line therapy in many cancer types, but rapid and robust responses to monotherapy are rare. There is the exciting potential to combine immunotherapy with RT, with small case series indicating synergy, although further research is needed. In cases with molecular characteristics favoring response to immunotherapy, an optimal sequencing approach may incorporate an initial run-in phase with immunotherapy to determine if symptom palliation can be achieved with unimodal therapy. The location of the mass in a non-radiation sensitive region allowed us to entertain the use of combination therapy for our patient, but ultimately was not needed. Palliative RT will remain an option at the time of cancer progression.
Chimeric Antigen Receptor T-cell Therapy in the Veterans Affairs Network: the Tennessee Valley Healthcare System Experience
Purpose/Background
Chimeric antigen receptor T-cell (CART) therapy has emerged as a novel treatment for hematologic malignancies, with six FDA agents approved for commercial use. The Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) is the only VA facility authorized to administer CART therapy. As these therapies are changing the paradigm of treatment, the purpose of this review will report the TVHS experience thus far.
Methods
TVHS began coordination with pharmaceutical manufacturers of CART therapies upon first approval in 2017 and became an authorized treatment center for CART therapy in September 2019 with the first CART infusion performed in December of that year. This is a retrospective electronic chart review of all CART patients referred to TVHS from the program’s inception, December 1, 2019 through June 30, 2021. The primary objective of this analysis will be to evaluate the efficacy outcomes of veterans who received CART therapy at TVHS, including overall response rates (ORR), progression free survival (PFS), and overall survival (OS). Secondary objectives include assessment of toxicities, including rates and maximum grades of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).
Results
A total of 28 patients have received CART infusion at TVHS to date. Fifteen of these patients have reached one year post-CART infusion and are included in this analysis. The majority of patients were White (67%) and were treated for diffuse large B-cell lymphoma (87%). All patients were male and ten (67%) were over the age of 65. ORR was 93% (73% achieved complete response [CR]). One-year PFS and OS were both 60%. Of patients who achieved CR by day 100, 89% remain in CR to date. CRS toxicity was observed in 73% of patients (no Grade 3 or higher). ICANS was observed in 26.7% of patients (20% Grade 3 or higher).
Conclusions
CART therapy within the VA has become a well-established practice at TVHS and appears to be a safe and effective therapeutic option for veterans with aggressive lymphoid malignancies.
Purpose/Background
Chimeric antigen receptor T-cell (CART) therapy has emerged as a novel treatment for hematologic malignancies, with six FDA agents approved for commercial use. The Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) is the only VA facility authorized to administer CART therapy. As these therapies are changing the paradigm of treatment, the purpose of this review will report the TVHS experience thus far.
Methods
TVHS began coordination with pharmaceutical manufacturers of CART therapies upon first approval in 2017 and became an authorized treatment center for CART therapy in September 2019 with the first CART infusion performed in December of that year. This is a retrospective electronic chart review of all CART patients referred to TVHS from the program’s inception, December 1, 2019 through June 30, 2021. The primary objective of this analysis will be to evaluate the efficacy outcomes of veterans who received CART therapy at TVHS, including overall response rates (ORR), progression free survival (PFS), and overall survival (OS). Secondary objectives include assessment of toxicities, including rates and maximum grades of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).
Results
A total of 28 patients have received CART infusion at TVHS to date. Fifteen of these patients have reached one year post-CART infusion and are included in this analysis. The majority of patients were White (67%) and were treated for diffuse large B-cell lymphoma (87%). All patients were male and ten (67%) were over the age of 65. ORR was 93% (73% achieved complete response [CR]). One-year PFS and OS were both 60%. Of patients who achieved CR by day 100, 89% remain in CR to date. CRS toxicity was observed in 73% of patients (no Grade 3 or higher). ICANS was observed in 26.7% of patients (20% Grade 3 or higher).
Conclusions
CART therapy within the VA has become a well-established practice at TVHS and appears to be a safe and effective therapeutic option for veterans with aggressive lymphoid malignancies.
Purpose/Background
Chimeric antigen receptor T-cell (CART) therapy has emerged as a novel treatment for hematologic malignancies, with six FDA agents approved for commercial use. The Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) is the only VA facility authorized to administer CART therapy. As these therapies are changing the paradigm of treatment, the purpose of this review will report the TVHS experience thus far.
Methods
TVHS began coordination with pharmaceutical manufacturers of CART therapies upon first approval in 2017 and became an authorized treatment center for CART therapy in September 2019 with the first CART infusion performed in December of that year. This is a retrospective electronic chart review of all CART patients referred to TVHS from the program’s inception, December 1, 2019 through June 30, 2021. The primary objective of this analysis will be to evaluate the efficacy outcomes of veterans who received CART therapy at TVHS, including overall response rates (ORR), progression free survival (PFS), and overall survival (OS). Secondary objectives include assessment of toxicities, including rates and maximum grades of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).
Results
A total of 28 patients have received CART infusion at TVHS to date. Fifteen of these patients have reached one year post-CART infusion and are included in this analysis. The majority of patients were White (67%) and were treated for diffuse large B-cell lymphoma (87%). All patients were male and ten (67%) were over the age of 65. ORR was 93% (73% achieved complete response [CR]). One-year PFS and OS were both 60%. Of patients who achieved CR by day 100, 89% remain in CR to date. CRS toxicity was observed in 73% of patients (no Grade 3 or higher). ICANS was observed in 26.7% of patients (20% Grade 3 or higher).
Conclusions
CART therapy within the VA has become a well-established practice at TVHS and appears to be a safe and effective therapeutic option for veterans with aggressive lymphoid malignancies.
Impact of Pharmacist-Driven Telemedicine Services in Hematopoietic Stem Cell Transplant (HSCT) Long-term Care Clinic in a Veteran Population
Background
Patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) are high-risk patients with complex medication regimens, including anti-rejection medications, infection prophylaxis, other post-transplant complication prophylaxis in addition to their chronic medications for co-morbid conditions. At the VA Tennessee Valley Healthcare System (TVHS), there are 3 stages of care once a patient receives an allogeneic transplant: inpatient transplant (through engraftment), outpatient posttransplant (through day +100), and long-term care (LTC) transplant (post-departure from the transplant facility). Currently, TVHS has 2 Clinical Pharmacist Practitioners (CPP) involved in the inpatient and outpatient settings. The purpose of this quality improvement initiative was to evaluate the impact of pharmacist services on continuity of care for longterm HSCT patients, vaccine completion rates, and immunosuppression/chemotherapy monitoring.
Methods
Patients were identified for enrollment based on a referral from a CPP, nurse practitioner (NP), or physician (MD). Patients with a history of allogeneic transplant were automatically referred from the CPP at departure and scheduled for a 2-week and 6-week post-departure visit. During these visits, the pharmacist conducted a medication reconciliation, assessed for medication errors or lapses in therapy, and provided medication counseling deemed necessary by clinical judgement. In addition to these 2 medication reconciliation visits, patients were also automatically scheduled for a vaccine assessment 6-months post-transplant. Pharmacy interventions from these visits were recorded in pre-specified categories. In addition to these predetermined visits, patients with complex medication regimens or undergoing significant changes could also be referred by either the NP or MD.
Results
A total of 18 patients were enrolled in the CPP clinic from October 2021 through May 2022. During this period, 42 visits were completed as each patient was seen multiple times (mean number of visits 1.8). A total of 16 medication errors/lapses were identified and addressed. The most common types of interventions included medication reconciliation (42), adherence counseling (39), general medication interventions (26), and vaccine interventions (20).
Conclusions
This pharmacist-driven telemedicine service incorporated into the long-term care HSCT clinic demonstrated benefit in identifying and addressing medication errors/lapses. Further study including the impact on patient outcomes such as hospital readmissions post-transplant, could strengthen the importance of pharmacy involvement in this setting.
Background
Patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) are high-risk patients with complex medication regimens, including anti-rejection medications, infection prophylaxis, other post-transplant complication prophylaxis in addition to their chronic medications for co-morbid conditions. At the VA Tennessee Valley Healthcare System (TVHS), there are 3 stages of care once a patient receives an allogeneic transplant: inpatient transplant (through engraftment), outpatient posttransplant (through day +100), and long-term care (LTC) transplant (post-departure from the transplant facility). Currently, TVHS has 2 Clinical Pharmacist Practitioners (CPP) involved in the inpatient and outpatient settings. The purpose of this quality improvement initiative was to evaluate the impact of pharmacist services on continuity of care for longterm HSCT patients, vaccine completion rates, and immunosuppression/chemotherapy monitoring.
Methods
Patients were identified for enrollment based on a referral from a CPP, nurse practitioner (NP), or physician (MD). Patients with a history of allogeneic transplant were automatically referred from the CPP at departure and scheduled for a 2-week and 6-week post-departure visit. During these visits, the pharmacist conducted a medication reconciliation, assessed for medication errors or lapses in therapy, and provided medication counseling deemed necessary by clinical judgement. In addition to these 2 medication reconciliation visits, patients were also automatically scheduled for a vaccine assessment 6-months post-transplant. Pharmacy interventions from these visits were recorded in pre-specified categories. In addition to these predetermined visits, patients with complex medication regimens or undergoing significant changes could also be referred by either the NP or MD.
Results
A total of 18 patients were enrolled in the CPP clinic from October 2021 through May 2022. During this period, 42 visits were completed as each patient was seen multiple times (mean number of visits 1.8). A total of 16 medication errors/lapses were identified and addressed. The most common types of interventions included medication reconciliation (42), adherence counseling (39), general medication interventions (26), and vaccine interventions (20).
Conclusions
This pharmacist-driven telemedicine service incorporated into the long-term care HSCT clinic demonstrated benefit in identifying and addressing medication errors/lapses. Further study including the impact on patient outcomes such as hospital readmissions post-transplant, could strengthen the importance of pharmacy involvement in this setting.
Background
Patients undergoing allogeneic hematopoietic stem cell transplant (HSCT) are high-risk patients with complex medication regimens, including anti-rejection medications, infection prophylaxis, other post-transplant complication prophylaxis in addition to their chronic medications for co-morbid conditions. At the VA Tennessee Valley Healthcare System (TVHS), there are 3 stages of care once a patient receives an allogeneic transplant: inpatient transplant (through engraftment), outpatient posttransplant (through day +100), and long-term care (LTC) transplant (post-departure from the transplant facility). Currently, TVHS has 2 Clinical Pharmacist Practitioners (CPP) involved in the inpatient and outpatient settings. The purpose of this quality improvement initiative was to evaluate the impact of pharmacist services on continuity of care for longterm HSCT patients, vaccine completion rates, and immunosuppression/chemotherapy monitoring.
Methods
Patients were identified for enrollment based on a referral from a CPP, nurse practitioner (NP), or physician (MD). Patients with a history of allogeneic transplant were automatically referred from the CPP at departure and scheduled for a 2-week and 6-week post-departure visit. During these visits, the pharmacist conducted a medication reconciliation, assessed for medication errors or lapses in therapy, and provided medication counseling deemed necessary by clinical judgement. In addition to these 2 medication reconciliation visits, patients were also automatically scheduled for a vaccine assessment 6-months post-transplant. Pharmacy interventions from these visits were recorded in pre-specified categories. In addition to these predetermined visits, patients with complex medication regimens or undergoing significant changes could also be referred by either the NP or MD.
Results
A total of 18 patients were enrolled in the CPP clinic from October 2021 through May 2022. During this period, 42 visits were completed as each patient was seen multiple times (mean number of visits 1.8). A total of 16 medication errors/lapses were identified and addressed. The most common types of interventions included medication reconciliation (42), adherence counseling (39), general medication interventions (26), and vaccine interventions (20).
Conclusions
This pharmacist-driven telemedicine service incorporated into the long-term care HSCT clinic demonstrated benefit in identifying and addressing medication errors/lapses. Further study including the impact on patient outcomes such as hospital readmissions post-transplant, could strengthen the importance of pharmacy involvement in this setting.
Discontinuation of Allopurinol for Tumor Lysis Syndrome Report
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Background/Purpose
Tumor lysis syndrome (TLS) is caused by the release of intracellular products into the blood following rapid lysis of malignant cells resulting in hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Complications of TLS include acute renal failure, cardiac arrhythmias, seizure, and sudden death. Allopurinol is commonly initiated as prophylaxis for patients at risk for TLS to prevent buildup of uric acid and decrease the incidence of obstructive uropathy caused by uric acid precipitation. Allopurinol takes several days to reduce uric acid levels, therefore it is recommended to initiate allopurinol 1 to 2 days prior to the start of chemotherapy and continue until the risk of TLS has ceased, usually within 7 days of chemotherapy initiation. Unnecessarily continuing allopurinol beyond 10 days increases the risk of adverse events, including allergic skin rashes and myelosuppression. A report of allopurinol orders for TLS from March 1, 2020, to March 31, 2021 was generated. Of these orders, there were 44 unique patients and 56 total allopurinol courses. The median duration of allopurinol for TLS was 39 days, with a duration of allopurinol of 10 days or less in 10 (18.2%) cases.
Methods
On September 16, 2021, inpatient prescribing of new allopurinol orders was restricted to an inpatient order menu with quick orders designating an indication of gout or TLS in the comment section. The TLS quick order was defaulted to a dose of 300 mg for 10 days. Education was also provided to the medical staff. Descriptive statistics were used.
Results
Since implementation of the allopurinol order menu, 17 patients with cancer have initiated allopurinol for TLS. The menu was used in 14 (82.4%) patients. The median duration of allopurinol was 8 days and 11 (64.7%) allopurinol courses were 10 days or less. The main reasons for not using the allopurinol menu were due to dose reduction of allopurinol due to renal dysfunction or the primary hematologist/oncologist ordering outpatient allopurinol prior to admission for chemotherapy.
Implications
The introduction of an inpatient allopurinol order menu has decreased excessive allopurinol therapy when utilized for TLS. This has resulted in decreased pill burden, adverse events, and cost.
Blood type linked to higher risk for early onset stroke
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
Conversely, results from a meta-analysis of nearly 17,000 cases of ischemic stroke in adults younger than 60 years showed that having type O blood reduced the risk for EOS by 12%.
In addition, the associations with risk were significantly stronger in EOS than in those with late-onset stroke (LOS), pointing to a stronger role for prothrombotic factors in younger patients, the researchers noted.
“What this is telling us is that maybe what makes you susceptible to stroke as a young adult is the blood type, which is really giving you a much higher risk of clotting and stroke compared to later onset,” coinvestigator Braxton Mitchell, PhD, professor of medicine and epidemiology and public health at the University of Maryland, Baltimore, said in an interview.
The findings were published online in Neurology.
Strong association
The genome-wide association study (GWAS) was done as part of the Genetics of Early Onset Ischemic Stroke Consortium, a collaboration of 48 different studies across North America, Europe, Japan, Pakistan, and Australia. It assessed early onset ischemic stroke in patients aged 18-59 years.
Researchers included data from 16,927 patients with stroke. Of these, 5,825 had a stroke before age 60, defined as early onset. GWAS results were also examined for nearly 600,000 individuals without stroke.
Results showed two genetic variants tied to blood types A and O emerged as highly associated with risk for early stroke.
Researchers found that the protective effects of type O were significantly stronger with EOS vs. LOS (odds ratio [OR], 0.88 vs. 0.96, respectively; P = .001). Likewise, the association between type A and increased EOS risk was significantly stronger than that found in LOS (OR, 1.16 vs. 1.05; P = .005).
Using polygenic risk scores, the investigators also found that the greater genetic risk for venous thromboembolism, another prothrombotic condition, was more strongly associated with EOS compared with LOS (P = .008).
Previous studies have shown a link between stroke risk and variants of the ABO gene, which determines blood type. The new analysis suggests that type A and O gene variants represent nearly all of those genetically linked with early stroke, the researchers noted.
While the findings point to blood type as a risk factor for stroke in younger people, Dr. Mitchell cautions that “at the moment, blood group does not have implications for preventive care.”
“The risk of stroke due to blood type is smaller than other risk factors that we know about, like smoking and hypertension,” he said. “I would be much more worried about these other risk factors, especially because those may be modifiable.”
He noted the next step in the study is to assess how blood type interacts with other known risk factors to raise stroke risk.
“There may be a subset of people where, if you have blood type A and you have some of these other risk factors, it’s possible that you may be at particularly high risk,” Dr. Mitchell said.
More research needed on younger patients
In an accompanying editorial, Jennifer Juhl Majersik, MD, associate professor of neurology at the University of Utah, Salt Lake City, and Paul Lacaze, PhD, associate professor and head of the public health genomics program at Monash University, Australia, noted that the study fills a gap in stroke research, which often focuses mostly on older individuals.
“In approximately 40% of people with EOS, the stroke is cryptogenic, and there is scant data from clinical trials to guide the selection of preventative strategies in this population, as people with EOS are often excluded from trials,” Dr. Majersik and Dr. Lacaze wrote.
“This work has deepened our understanding of EOS pathophysiology,” they added.
The editorialists noted that future research can build on the results from this analysis, “with the goal of a more precise understanding of stroke pathophysiology, leading to targeted preventative treatments for EOS and a reduction in disability in patients’ most productive years.”
Dr. Mitchell echoed the call for greater inclusion of young patients with stroke in clinical trials.
“As we’re learning, stroke in older folks isn’t the same as stroke in younger people,” he said. “There are many shared risk factors but there are also some that are different ... so there really is a need to include younger people.”
A version of this article first appeared on Medscape.com.
FROM NEUROLOGY
Impact of Insurance Status on Survival in Hurthle Cell Carcinoma: A National Cancer Database (NCDB) Analysis
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Background
Hurthle cell carcinoma (HCC), also known as oxyphilic adenocarcinoma, is a rare malignancy characterized by the presence of mitochondrion-rich, eosinophilic epithelial cells known as Hurthle cells. HCC is a variant of follicular thyroid cancer and can metastasize more aggressively than other thyroid malignancies. The purpose of this study is to identify how insurance status impacts median survival time in patients with HCC.
Methods
Using the NCDB, we identified 10,378 patients diagnosed with HCC between 2004 and 2016 using ICD-O-3 histology code 8290. The cohort was analyzed to identify differences in survival outcomes based on the insurance status of the patient during treatment. The 4 categories of insurance identified were uninsured, private insurance, Medicaid, and Medicare. Univariate analysis was performed assessing patient length of survival for each insurance subtype. Data were analyzed using SPSS and statistical significance was set at P = .05.
Results
We identified statistically significant differences (P < .001) in survival outcomes between privately insured patients and patients with Medicaid or Medicare. Privately insured patients had the highest rates of median survival with 150.9 months, while patients on Medicare had the lowest rates of median survival with 108.1 months. Medicaid and uninsured patients had a median survival rates of 134.5 months and 141.9 months, respectively. 40.8% of privately insured patients presented at stage I, while 20.8% of Medicare patients presented at stage I. Patients with private insurance had the lowest rate of presenting with stage IV disease at 5.0%, which was dramatically different from patients with Medicare that presented with stage IV HCC at a rate of 13.0%.
Conclusions
This study shows the discrepancies of survival in patients with HCC based on insurance coverage. HCC patients with private insurance have significantly longer survival outcomes than patients on Medicaid and Medicare. We hypothesize that privately insured patients are more likely to seek treatment earlier and receive a higher level of care. Privately insured patients were also less likely to present with Stage IV HCC than patients with other insurance statuses. Future directions should analyze how treatment type affects survival outcomes.
Demographics in Early vs Late-Stage Laryngeal Squamous Cell Carcinoma: A NCDB Review
Purpose
To evaluate how various demographic factors impact the stage of cancer at diagnosis.
Background
Laryngeal squamous cell carcinoma (SCC) is a common cancer with variable clinical presentation. While the probability of cure is high, more advanced tumors are less likely to be cured and more likely to have functional deficits from surgical treatment. Given the worsened prognosis of a later-stage diagnosis, it is important to understand what may contribute to a late presentation.
Method/Analysis
Using the National Cancer Database (NCDB), 73,330 patients were identified between 2004 and 2016 with laryngeal SCC. Early (stage 0 or I) vs late-stage (stage IV) cancers were compared based on demographic variables utilizing descriptive statistics, multivariate, and chi-square analyses on SPSS version 28 with a significance of P < .05.
Results
Women were 27% more likely to have late-stage SCC than men. Black patients were 44% more likely to have late-stage SCC than White patients. No significant difference was found between Hispanic and non-Hispanic patients. Patients with private insurance, Medicare, or other government insurance were less likely (73%, 74%, and 62%, respectively) to have late-stage SCC compared to patients without insurance. Patients with Medicaid were 12% more likely to present later than the uninsured. Patients making $63,000 or greater were 23% less likely to have late-stage SCC than those making less than $38,000. Patients living in more educated areas (< 7% of adults had no high school degree) were 32% less likely to have late-stage SCC compared to less educated areas (> 21% of adults had no high school degree).
Conclusions/Implications
Patients who are Black, uninsured or on Medicaid, have low-socioeconomic status, and live in less educated areas have less favorable diagnoses than their counterparts. These data demonstrates inequities in health care and may lead to a better understanding of social determinants of health that can be used to advocate for improved access and quality of care.
Purpose
To evaluate how various demographic factors impact the stage of cancer at diagnosis.
Background
Laryngeal squamous cell carcinoma (SCC) is a common cancer with variable clinical presentation. While the probability of cure is high, more advanced tumors are less likely to be cured and more likely to have functional deficits from surgical treatment. Given the worsened prognosis of a later-stage diagnosis, it is important to understand what may contribute to a late presentation.
Method/Analysis
Using the National Cancer Database (NCDB), 73,330 patients were identified between 2004 and 2016 with laryngeal SCC. Early (stage 0 or I) vs late-stage (stage IV) cancers were compared based on demographic variables utilizing descriptive statistics, multivariate, and chi-square analyses on SPSS version 28 with a significance of P < .05.
Results
Women were 27% more likely to have late-stage SCC than men. Black patients were 44% more likely to have late-stage SCC than White patients. No significant difference was found between Hispanic and non-Hispanic patients. Patients with private insurance, Medicare, or other government insurance were less likely (73%, 74%, and 62%, respectively) to have late-stage SCC compared to patients without insurance. Patients with Medicaid were 12% more likely to present later than the uninsured. Patients making $63,000 or greater were 23% less likely to have late-stage SCC than those making less than $38,000. Patients living in more educated areas (< 7% of adults had no high school degree) were 32% less likely to have late-stage SCC compared to less educated areas (> 21% of adults had no high school degree).
Conclusions/Implications
Patients who are Black, uninsured or on Medicaid, have low-socioeconomic status, and live in less educated areas have less favorable diagnoses than their counterparts. These data demonstrates inequities in health care and may lead to a better understanding of social determinants of health that can be used to advocate for improved access and quality of care.
Purpose
To evaluate how various demographic factors impact the stage of cancer at diagnosis.
Background
Laryngeal squamous cell carcinoma (SCC) is a common cancer with variable clinical presentation. While the probability of cure is high, more advanced tumors are less likely to be cured and more likely to have functional deficits from surgical treatment. Given the worsened prognosis of a later-stage diagnosis, it is important to understand what may contribute to a late presentation.
Method/Analysis
Using the National Cancer Database (NCDB), 73,330 patients were identified between 2004 and 2016 with laryngeal SCC. Early (stage 0 or I) vs late-stage (stage IV) cancers were compared based on demographic variables utilizing descriptive statistics, multivariate, and chi-square analyses on SPSS version 28 with a significance of P < .05.
Results
Women were 27% more likely to have late-stage SCC than men. Black patients were 44% more likely to have late-stage SCC than White patients. No significant difference was found between Hispanic and non-Hispanic patients. Patients with private insurance, Medicare, or other government insurance were less likely (73%, 74%, and 62%, respectively) to have late-stage SCC compared to patients without insurance. Patients with Medicaid were 12% more likely to present later than the uninsured. Patients making $63,000 or greater were 23% less likely to have late-stage SCC than those making less than $38,000. Patients living in more educated areas (< 7% of adults had no high school degree) were 32% less likely to have late-stage SCC compared to less educated areas (> 21% of adults had no high school degree).
Conclusions/Implications
Patients who are Black, uninsured or on Medicaid, have low-socioeconomic status, and live in less educated areas have less favorable diagnoses than their counterparts. These data demonstrates inequities in health care and may lead to a better understanding of social determinants of health that can be used to advocate for improved access and quality of care.
Disparities in Palliative Care Utilization in Malignant Mixed Mullerian Tumor: A National Cancer Database (NCDB) Study
Study Purpose/Background
Malignant mixed Mullerian tumor (MMMT), known as carcinosarcoma of the uterus, is a rare tumor consisting of malignant epithelial and mesenchymal components. Palliative care (PC) has been shown to enhance quality of life and improve outcomes in patients with advanced or incurable cancer. Patients with MMMT may benefit from PC. The project’s objective is to describe disparities in PC utilization among MMMT patients using the National Cancer Database (NCDB).
Methods/Design
A total of 14,085 patients, diagnosed with MMMT, were identified utilizing the NCDB ICD-O-3 histology code 8950. Demographic factors (race, income, facility type, insurance, geographic location, grade, and Charlson-Deyo comorbidity score) were studied in relation to the receipt of PC using multivariate logistic regression.
Results
3.10% of the study cohort received PC (437/14085). Participants with a median income of ≥ $63,000 (2.74%) were less likely to receive PC than participants making < $38,000 (3.93%), P = .049. Participants treated at an academic/research program (2.48%) were less likely to receive PC compared to patients treated at a community cancer program (4.44%), P = .023. Those with private insurance (2.50%), were less likely to receive PC than those with no insurance (3.56%), P = .032. Participants who received treatment at a facility located in the South Atlantic (2.25%), East North Central (3.11%), West South Central (2.73%) or Pacific (1.36%), were less likely to receive PC than patients who received treatment at a New England facility (4.42%), P < .001, P = .031, P = .017, and P < .001, respectively. Those with tumors that were undifferentiated, anaplastic (3.52%) were more likely to receive PC than those with well-differentiated tumors (1.01%), P = .040.
Conclusions/Implications
PC is underutilized in patients with private insurance, received treatment at an academic/research program, had well-differentiated tumors, and were in the South Atlantic, East North Central, West South Central, and Pacific regions. By highlighting disparities that exist, our study can aid clinicians in addressing PC underutilization to help provide more comprehensive care for patients.
Study Purpose/Background
Malignant mixed Mullerian tumor (MMMT), known as carcinosarcoma of the uterus, is a rare tumor consisting of malignant epithelial and mesenchymal components. Palliative care (PC) has been shown to enhance quality of life and improve outcomes in patients with advanced or incurable cancer. Patients with MMMT may benefit from PC. The project’s objective is to describe disparities in PC utilization among MMMT patients using the National Cancer Database (NCDB).
Methods/Design
A total of 14,085 patients, diagnosed with MMMT, were identified utilizing the NCDB ICD-O-3 histology code 8950. Demographic factors (race, income, facility type, insurance, geographic location, grade, and Charlson-Deyo comorbidity score) were studied in relation to the receipt of PC using multivariate logistic regression.
Results
3.10% of the study cohort received PC (437/14085). Participants with a median income of ≥ $63,000 (2.74%) were less likely to receive PC than participants making < $38,000 (3.93%), P = .049. Participants treated at an academic/research program (2.48%) were less likely to receive PC compared to patients treated at a community cancer program (4.44%), P = .023. Those with private insurance (2.50%), were less likely to receive PC than those with no insurance (3.56%), P = .032. Participants who received treatment at a facility located in the South Atlantic (2.25%), East North Central (3.11%), West South Central (2.73%) or Pacific (1.36%), were less likely to receive PC than patients who received treatment at a New England facility (4.42%), P < .001, P = .031, P = .017, and P < .001, respectively. Those with tumors that were undifferentiated, anaplastic (3.52%) were more likely to receive PC than those with well-differentiated tumors (1.01%), P = .040.
Conclusions/Implications
PC is underutilized in patients with private insurance, received treatment at an academic/research program, had well-differentiated tumors, and were in the South Atlantic, East North Central, West South Central, and Pacific regions. By highlighting disparities that exist, our study can aid clinicians in addressing PC underutilization to help provide more comprehensive care for patients.
Study Purpose/Background
Malignant mixed Mullerian tumor (MMMT), known as carcinosarcoma of the uterus, is a rare tumor consisting of malignant epithelial and mesenchymal components. Palliative care (PC) has been shown to enhance quality of life and improve outcomes in patients with advanced or incurable cancer. Patients with MMMT may benefit from PC. The project’s objective is to describe disparities in PC utilization among MMMT patients using the National Cancer Database (NCDB).
Methods/Design
A total of 14,085 patients, diagnosed with MMMT, were identified utilizing the NCDB ICD-O-3 histology code 8950. Demographic factors (race, income, facility type, insurance, geographic location, grade, and Charlson-Deyo comorbidity score) were studied in relation to the receipt of PC using multivariate logistic regression.
Results
3.10% of the study cohort received PC (437/14085). Participants with a median income of ≥ $63,000 (2.74%) were less likely to receive PC than participants making < $38,000 (3.93%), P = .049. Participants treated at an academic/research program (2.48%) were less likely to receive PC compared to patients treated at a community cancer program (4.44%), P = .023. Those with private insurance (2.50%), were less likely to receive PC than those with no insurance (3.56%), P = .032. Participants who received treatment at a facility located in the South Atlantic (2.25%), East North Central (3.11%), West South Central (2.73%) or Pacific (1.36%), were less likely to receive PC than patients who received treatment at a New England facility (4.42%), P < .001, P = .031, P = .017, and P < .001, respectively. Those with tumors that were undifferentiated, anaplastic (3.52%) were more likely to receive PC than those with well-differentiated tumors (1.01%), P = .040.
Conclusions/Implications
PC is underutilized in patients with private insurance, received treatment at an academic/research program, had well-differentiated tumors, and were in the South Atlantic, East North Central, West South Central, and Pacific regions. By highlighting disparities that exist, our study can aid clinicians in addressing PC underutilization to help provide more comprehensive care for patients.
Creation of a National Virtual Tumor Board Through the National TeleOncology Service
Background
There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.
Observations
Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.
Results
A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).
Conclusions
The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.
Background
There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.
Observations
Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.
Results
A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).
Conclusions
The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.
Background
There is unequal access to subspecialty oncology expertise across the Veterans Affairs (VA) network. To address this need, the VA established National TeleOncology (NTO), which provides multiple virtual services (asynchronous [electronic consult] and synchronous [phone, video to home, video to facility]) to over 20 VA sites. Beyond these care modalities, a virtual tumor board was conceived to provide a forum for multidisciplinary review of patient cases. We describe the creation of the first NTO virtual tumor board, encompassing malignant hematology diagnoses.
Observations
Tumor boards are considered a standard of care. While challenging to quantify nationally, multiple single institution experiences have established the importance of tumor boards across different measures. A panel of stakeholders were convened to discuss the creation of a virtual tumor board. Best practices and standard operating procedures were created based on guidance from relevant literature and internal VA experience. Participants from specialties including medical oncology, surgical oncology, radiology, pathology, transplant, and palliative care were engaged from eight different VA medical centers across the nation. On March 2, 2022, the initial tumor board was held allowing for synchronous virtual review of patient pathology and imaging. Thus far 6 tumor boards have been convened, reviewing 11 patients originating from 6 different VA sites.
Results
A participant survey was conducted after 4 sessions, which indicated that all who completed the survey (n = 9) found the sessions beneficial or somewhat beneficial, and 55% found the sessions highly applicable to their practice. The most recent tumor board had 33 participants (physicians, nurses, advanced practice practitioners, and pharmacists).
Conclusions
The establishment of a national VA tumor board represents a novel approach to the review of oncology cases across the VA network. The goal of this tumor board is to leverage the diverse knowledge base that exists within the VA to deliver equitable care regardless of veteran location. Along with improving our general understanding of tumor board application, we believe that the NTO tumor board establishes a unique forum for additional tumor types, continued medical education opportunities, and the review of VA clinical trial opportunities.