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Update on the VA Precision Oncology Program
Purpose: To inform VA stakeholders of the availability of precision oncology (PO) services for Veterans with advanced cancer.
Background: PO offers the promise of effective, low-toxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A systemwide PO program (POP), including patients in rural areas, launched in July 2016.
Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from POP records and cancer characteristics were extracted from POP and medical records. Drug use data were obtained from the VA Corporate Data Warehouse. NGS testing results, and annotations were extracted from POP records.
Results: 1,442 tumor samples were sent for NGS testing as of 5/21/17 from 61 facilities. Rural patient testing (35%) was similar to VHA rurality (33%) and more than twice the US rate (14%). Most common diagnoses: lung (688: adeno 482, squamous 134), unknown (114), colorectal (103), skin (96), prostate (76), and H&N (66). Sample test requests increased rapidly after national implementation in July 2016 (23 samples/month prior to implementation to mean 126 samples/month 3 months later) as did the number of participating facilities (10/quarter to 39/month). Sequencing success rate increased from 68% to 71% over the same interval, while mean turn around time remained similar at 19.7 and 19.1 days, respectively. To date, 26 patients received a recommended drug outside a clinical trial, some more than 9 months after NGS. 5 additional patients had received an NGS-recommended drug prior to testing. NGS results are available for a cohort of 344 patients including: lung 200 (adeno 138, squamous 51), skin 28, LN 20, liver 19, GI 16. 979 variants were found most commonly in TP53, KRAS, STK11, APC, PIK3CA, and CDKN2A. 228 patients (66%) had actionable results (on-label drug 24, off-label drug 165, clinical trial 213). A PO consultation service (available by IFC) and a liquid biopsy are now available nationally.
Conclusions: Implementation of tumor NGS testing in VHA has been successful. Further program expansion, addition of hematological malignancies, deployment of informatics tools and efforts to expand access to appropriate drugs are ongoing.
Purpose: To inform VA stakeholders of the availability of precision oncology (PO) services for Veterans with advanced cancer.
Background: PO offers the promise of effective, low-toxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A systemwide PO program (POP), including patients in rural areas, launched in July 2016.
Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from POP records and cancer characteristics were extracted from POP and medical records. Drug use data were obtained from the VA Corporate Data Warehouse. NGS testing results, and annotations were extracted from POP records.
Results: 1,442 tumor samples were sent for NGS testing as of 5/21/17 from 61 facilities. Rural patient testing (35%) was similar to VHA rurality (33%) and more than twice the US rate (14%). Most common diagnoses: lung (688: adeno 482, squamous 134), unknown (114), colorectal (103), skin (96), prostate (76), and H&N (66). Sample test requests increased rapidly after national implementation in July 2016 (23 samples/month prior to implementation to mean 126 samples/month 3 months later) as did the number of participating facilities (10/quarter to 39/month). Sequencing success rate increased from 68% to 71% over the same interval, while mean turn around time remained similar at 19.7 and 19.1 days, respectively. To date, 26 patients received a recommended drug outside a clinical trial, some more than 9 months after NGS. 5 additional patients had received an NGS-recommended drug prior to testing. NGS results are available for a cohort of 344 patients including: lung 200 (adeno 138, squamous 51), skin 28, LN 20, liver 19, GI 16. 979 variants were found most commonly in TP53, KRAS, STK11, APC, PIK3CA, and CDKN2A. 228 patients (66%) had actionable results (on-label drug 24, off-label drug 165, clinical trial 213). A PO consultation service (available by IFC) and a liquid biopsy are now available nationally.
Conclusions: Implementation of tumor NGS testing in VHA has been successful. Further program expansion, addition of hematological malignancies, deployment of informatics tools and efforts to expand access to appropriate drugs are ongoing.
Purpose: To inform VA stakeholders of the availability of precision oncology (PO) services for Veterans with advanced cancer.
Background: PO offers the promise of effective, low-toxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A systemwide PO program (POP), including patients in rural areas, launched in July 2016.
Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from POP records and cancer characteristics were extracted from POP and medical records. Drug use data were obtained from the VA Corporate Data Warehouse. NGS testing results, and annotations were extracted from POP records.
Results: 1,442 tumor samples were sent for NGS testing as of 5/21/17 from 61 facilities. Rural patient testing (35%) was similar to VHA rurality (33%) and more than twice the US rate (14%). Most common diagnoses: lung (688: adeno 482, squamous 134), unknown (114), colorectal (103), skin (96), prostate (76), and H&N (66). Sample test requests increased rapidly after national implementation in July 2016 (23 samples/month prior to implementation to mean 126 samples/month 3 months later) as did the number of participating facilities (10/quarter to 39/month). Sequencing success rate increased from 68% to 71% over the same interval, while mean turn around time remained similar at 19.7 and 19.1 days, respectively. To date, 26 patients received a recommended drug outside a clinical trial, some more than 9 months after NGS. 5 additional patients had received an NGS-recommended drug prior to testing. NGS results are available for a cohort of 344 patients including: lung 200 (adeno 138, squamous 51), skin 28, LN 20, liver 19, GI 16. 979 variants were found most commonly in TP53, KRAS, STK11, APC, PIK3CA, and CDKN2A. 228 patients (66%) had actionable results (on-label drug 24, off-label drug 165, clinical trial 213). A PO consultation service (available by IFC) and a liquid biopsy are now available nationally.
Conclusions: Implementation of tumor NGS testing in VHA has been successful. Further program expansion, addition of hematological malignancies, deployment of informatics tools and efforts to expand access to appropriate drugs are ongoing.
Anti-CD20 Antibody Order Checks and Medication Use Evaluation Tracker Increase Hepatitis B Testing and Antiviral Treatment in VHA
Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
Purpose: In patients initiating treatment with anti-CD20 antibodies (Ab), 20-60% with prior hepatitis B (HBV) infection not receiving HBV antiviral prophylaxis experience HBV reactivation—with hepatitis (33%), liver failure (13%), and death (5%). HBV reactivation is prevented with HBV antiviral therapy during and 12 months after anti-CD20 Ab therapy in patients with positive HBV surface antigen (HBsAg+) or HBV core antibody (HBcAb+). Our goal is to widely use anti-CD20 Ab order checks to increase testing and antiviral treatment to prevent HBV reactivation.
Background: Without HBV treatment in those at risk, fatal HBV reactivation affects 1 in 1,000 receiving rituximab. In a VHA analysis of 19,304 patients initiating anti-CD20 Ab (2002-14), > 60% of patients had HBV testing by 2014; 1 in 9 Veterans had either chronic (1-2% HBsAg+) or prior (9% HBcAb+) HBV, yet < 18% received HBV antiviral therapy. While information modestly affects behaviors, order checks with treatment algorithms can be > 95% effective.
Methods: Since 2015, our team has shared information widely, updated pharmacy criteria for use, and enabled HBV antiviral prescribing by all providers. To identify HBV testing or treatment omissions, we launched a Medication Use Evaluation Tracker (MUET), and programmed an anti- CD20 Ab order check that displays only if either HBV testing or treatment has not been done.
Results: Since 2014, HBV testing in patients initiating anti-CD20 Ab increased to 64-78% and HBV antiviral prophylaxis from < 18% to 44%. In November 2016, an anti-CD20 Ab order check was piloted at 3 sites and functional in CPRS with additional sites reporting favorable use. Additionally, a MUET was released for anti-CD20 Ab therapies providing an additional safety check.
Conclusions: VHA has increased HBV testing and antiviral treatment with anti-CD20 antibody initiation—yet more than half of patients remain at risk of HBV reactivation. Successfully used in up to 15 sites, programmed anti-CD20 Ab order checks highlight to providers when HBV testing
or antiviral prophylaxis is needed. Achieving broad use of this order check will increase HBV prophylaxis prescribing and decrease subsequent HBV reactivation. An anti-CD20 Ab MUET provides an additional safety check option for identifying at risk patient.
Hypertension Among Veterans Affairs Colorectal Cancer Survivors: A Matched Case-Control Analysis
Purpose: We sought to: (1) determine the odds of colorectal cancer (CRC) survivors being diagnosed with hypertension 2 years post-CRC diagnosis; (2) assess differences in blood pressure (BP) control one year post-CRC diagnosis; and (3) assess differences in antihypertensive medication adherence one year post-CRC diagnosis, all relative to matched non-cancer controls.
Background: CRC and hypertension share common risk factors. Because CRC survivors often transition from oncology-led care to primary care, it is important to know whether they have differential prevalence of hypertension for chronic disease management.
Methods: We used the national VA Central Cancer Registry to identify patients diagnosed with non-metastatic CRC from 10/1/2008 to 12/31/2012 who had ≥ 1 primary care or oncology visit in the previous year. Up to 3 non-cancer controls were identified for each CRC survivor through electronic health records matched on age, race, sex, copayment status, geographic region, distance to VA healthcare, body mass index, number of outpatient visits (≥ 3 vs. fewer), and pre-existing hypertension, hyperlipidemia, and diabetes. We used logistic regression to calculate odds ratios (OR) and confidence intervals (CI) for being diagnosed with, and control of, hypertension between CRC survivors and controls. We calculated Medication Possession Ratio (MPR), a pharmacy refill-based adherence measure, for patients prescribed metoprolol tartrate.
Results: 9,758 patients with CRC were matched to 29,066 controls. The cohort was predominantly white (79.5%) men (97.8%), mean age of 66.8 years. Compared to matched controls, CRC survivors had 60% higher odds of being diagnosed with hypertension (OR = 1.59, 95% CI, = 1.51-1.67) one year post-diagnosis (69.4% CRC survivors have hypertension). CRC survivors experienced lower odds of BP control (OR = 0.89, 95% CI, 0.85-0.94); antihypertensive medication adherence was lower (relative MPR difference 7%) compared with matched non-cancer controls.
Implications: Compared to patients without a history of cancer, CRC survivors have higher odds of being diagnosed with hypertension, worse BP control, and worse antihypertension medication adherence. A critical component of survivorship care for CRC patients is management of hypertension to reduce CVD risk.
Purpose: We sought to: (1) determine the odds of colorectal cancer (CRC) survivors being diagnosed with hypertension 2 years post-CRC diagnosis; (2) assess differences in blood pressure (BP) control one year post-CRC diagnosis; and (3) assess differences in antihypertensive medication adherence one year post-CRC diagnosis, all relative to matched non-cancer controls.
Background: CRC and hypertension share common risk factors. Because CRC survivors often transition from oncology-led care to primary care, it is important to know whether they have differential prevalence of hypertension for chronic disease management.
Methods: We used the national VA Central Cancer Registry to identify patients diagnosed with non-metastatic CRC from 10/1/2008 to 12/31/2012 who had ≥ 1 primary care or oncology visit in the previous year. Up to 3 non-cancer controls were identified for each CRC survivor through electronic health records matched on age, race, sex, copayment status, geographic region, distance to VA healthcare, body mass index, number of outpatient visits (≥ 3 vs. fewer), and pre-existing hypertension, hyperlipidemia, and diabetes. We used logistic regression to calculate odds ratios (OR) and confidence intervals (CI) for being diagnosed with, and control of, hypertension between CRC survivors and controls. We calculated Medication Possession Ratio (MPR), a pharmacy refill-based adherence measure, for patients prescribed metoprolol tartrate.
Results: 9,758 patients with CRC were matched to 29,066 controls. The cohort was predominantly white (79.5%) men (97.8%), mean age of 66.8 years. Compared to matched controls, CRC survivors had 60% higher odds of being diagnosed with hypertension (OR = 1.59, 95% CI, = 1.51-1.67) one year post-diagnosis (69.4% CRC survivors have hypertension). CRC survivors experienced lower odds of BP control (OR = 0.89, 95% CI, 0.85-0.94); antihypertensive medication adherence was lower (relative MPR difference 7%) compared with matched non-cancer controls.
Implications: Compared to patients without a history of cancer, CRC survivors have higher odds of being diagnosed with hypertension, worse BP control, and worse antihypertension medication adherence. A critical component of survivorship care for CRC patients is management of hypertension to reduce CVD risk.
Purpose: We sought to: (1) determine the odds of colorectal cancer (CRC) survivors being diagnosed with hypertension 2 years post-CRC diagnosis; (2) assess differences in blood pressure (BP) control one year post-CRC diagnosis; and (3) assess differences in antihypertensive medication adherence one year post-CRC diagnosis, all relative to matched non-cancer controls.
Background: CRC and hypertension share common risk factors. Because CRC survivors often transition from oncology-led care to primary care, it is important to know whether they have differential prevalence of hypertension for chronic disease management.
Methods: We used the national VA Central Cancer Registry to identify patients diagnosed with non-metastatic CRC from 10/1/2008 to 12/31/2012 who had ≥ 1 primary care or oncology visit in the previous year. Up to 3 non-cancer controls were identified for each CRC survivor through electronic health records matched on age, race, sex, copayment status, geographic region, distance to VA healthcare, body mass index, number of outpatient visits (≥ 3 vs. fewer), and pre-existing hypertension, hyperlipidemia, and diabetes. We used logistic regression to calculate odds ratios (OR) and confidence intervals (CI) for being diagnosed with, and control of, hypertension between CRC survivors and controls. We calculated Medication Possession Ratio (MPR), a pharmacy refill-based adherence measure, for patients prescribed metoprolol tartrate.
Results: 9,758 patients with CRC were matched to 29,066 controls. The cohort was predominantly white (79.5%) men (97.8%), mean age of 66.8 years. Compared to matched controls, CRC survivors had 60% higher odds of being diagnosed with hypertension (OR = 1.59, 95% CI, = 1.51-1.67) one year post-diagnosis (69.4% CRC survivors have hypertension). CRC survivors experienced lower odds of BP control (OR = 0.89, 95% CI, 0.85-0.94); antihypertensive medication adherence was lower (relative MPR difference 7%) compared with matched non-cancer controls.
Implications: Compared to patients without a history of cancer, CRC survivors have higher odds of being diagnosed with hypertension, worse BP control, and worse antihypertension medication adherence. A critical component of survivorship care for CRC patients is management of hypertension to reduce CVD risk.
Development of Templates to Standardize Oncology Documentation and Automate Measurement of Quality of Cancer Care
Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.
Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status, chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.
To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.
Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.
Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.
Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.
Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.
Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status, chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.
To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.
Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.
Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.
Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.
Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.
Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status, chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.
To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.
Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.
Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.
Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.
Implementation and Utility of the VA Symptom Management Tool (VAST)
Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.
Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.
Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).
Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.
Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.
Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.
Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).
Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.
Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.
Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.
Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).
Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.
VA Precision Oncology Program
Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.
Methods: Standard project management techniques and descriptive statistics were used.
Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.
Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.
Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.
Methods: Standard project management techniques and descriptive statistics were used.
Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.
Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.
Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.
Methods: Standard project management techniques and descriptive statistics were used.
Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.
Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.
Big Data, Precision Oncology, and Virtual Cancer Centers: The VA’s Initiatives Transforming Cancer Care
The VA’s National Oncology Program Office is an active participant in the White House’s Cancer Moonshot Initiative. This presentation will summarize efforts underway to provide Veterans with state of the art cancer care in a learning healthcare system. To achieve the goals of the Cancer Moonshot Initiative and Precision Oncology, the VA needs to: Provide all Veterans with timely access to coordinated, interdisciplinary, disease-specific cancer care; identify and facilitate VA medical center participation in compelling clinical trials that are designed to test novel therapeutics targeted at mutations with a high prevalence among Veterans; and, improve the infrastructure and capability for VA clinicians to practice in a learning healthcare system through decision support tool and robust data analytics.
The VA National Program Office has partnered with the National Cancer Institute (NCI) and the White House to implement innovations designed to achieve these objectives. It has received funding to provide Veterans access to next generation sequencing of tumor tissue. Data generated from analysis of the cancer genome will be analyzed by IBM’s Watson computers.
We are also developing a governance structure for national, multisite clinical trials. It will be similar in formatto NCI’s cooperative groups with oncologists leading diseases committees to evaluate which treatment clinical trials should be conducted nationally within the VA. We have developed national contract research agreements with the large pharmaceutical companies to facilitate national clinical trials. We have also developed agreements with VA Central Office and NCI that will allow industry funded studies to be submitted to the VA Centralized Institutional Review Boards (C-IRB) and VAMCs will be able to accept studies that have been approved by NCI’s centralized IRB. We are leveraging Connected/Tele-health technologies to develop Virtual Tumors Boards and Virtual Cancer Centers. These Virtual Cancer Centers are designed to provide access to expedited workup by specialized clinicians using evidence-based guidelines and clinical care pathways.
The VA’s National Oncology Program Office is an active participant in the White House’s Cancer Moonshot Initiative. This presentation will summarize efforts underway to provide Veterans with state of the art cancer care in a learning healthcare system. To achieve the goals of the Cancer Moonshot Initiative and Precision Oncology, the VA needs to: Provide all Veterans with timely access to coordinated, interdisciplinary, disease-specific cancer care; identify and facilitate VA medical center participation in compelling clinical trials that are designed to test novel therapeutics targeted at mutations with a high prevalence among Veterans; and, improve the infrastructure and capability for VA clinicians to practice in a learning healthcare system through decision support tool and robust data analytics.
The VA National Program Office has partnered with the National Cancer Institute (NCI) and the White House to implement innovations designed to achieve these objectives. It has received funding to provide Veterans access to next generation sequencing of tumor tissue. Data generated from analysis of the cancer genome will be analyzed by IBM’s Watson computers.
We are also developing a governance structure for national, multisite clinical trials. It will be similar in formatto NCI’s cooperative groups with oncologists leading diseases committees to evaluate which treatment clinical trials should be conducted nationally within the VA. We have developed national contract research agreements with the large pharmaceutical companies to facilitate national clinical trials. We have also developed agreements with VA Central Office and NCI that will allow industry funded studies to be submitted to the VA Centralized Institutional Review Boards (C-IRB) and VAMCs will be able to accept studies that have been approved by NCI’s centralized IRB. We are leveraging Connected/Tele-health technologies to develop Virtual Tumors Boards and Virtual Cancer Centers. These Virtual Cancer Centers are designed to provide access to expedited workup by specialized clinicians using evidence-based guidelines and clinical care pathways.
The VA’s National Oncology Program Office is an active participant in the White House’s Cancer Moonshot Initiative. This presentation will summarize efforts underway to provide Veterans with state of the art cancer care in a learning healthcare system. To achieve the goals of the Cancer Moonshot Initiative and Precision Oncology, the VA needs to: Provide all Veterans with timely access to coordinated, interdisciplinary, disease-specific cancer care; identify and facilitate VA medical center participation in compelling clinical trials that are designed to test novel therapeutics targeted at mutations with a high prevalence among Veterans; and, improve the infrastructure and capability for VA clinicians to practice in a learning healthcare system through decision support tool and robust data analytics.
The VA National Program Office has partnered with the National Cancer Institute (NCI) and the White House to implement innovations designed to achieve these objectives. It has received funding to provide Veterans access to next generation sequencing of tumor tissue. Data generated from analysis of the cancer genome will be analyzed by IBM’s Watson computers.
We are also developing a governance structure for national, multisite clinical trials. It will be similar in formatto NCI’s cooperative groups with oncologists leading diseases committees to evaluate which treatment clinical trials should be conducted nationally within the VA. We have developed national contract research agreements with the large pharmaceutical companies to facilitate national clinical trials. We have also developed agreements with VA Central Office and NCI that will allow industry funded studies to be submitted to the VA Centralized Institutional Review Boards (C-IRB) and VAMCs will be able to accept studies that have been approved by NCI’s centralized IRB. We are leveraging Connected/Tele-health technologies to develop Virtual Tumors Boards and Virtual Cancer Centers. These Virtual Cancer Centers are designed to provide access to expedited workup by specialized clinicians using evidence-based guidelines and clinical care pathways.
Cancer Incidence in the Veterans Affairs Healthcare System: A Veterans Affairs Central Cancer Registry Analysis
Purpose: Our objective is to comprehensively describe cancer incidence as reported in the VA Central Cancer Registry (VACCR).
Background: Approximately 3% of US cancer cases are diagnosed and treated in the VA healthcare system each year. These cancer cases are reported in the VACCR. In 2012, we published the first comprehensive description of cancer incidence as reported in the VACCR for patients diagnosed in 2007. In our current analysis, we provide an updated description of cancer incidence as reported in the VACCR for patients diagnosed in 2010.
Methods: This was a retrospective, cross-sectional study. We obtained data from 2 sources: (1) VACCR for incident cancer cases; (2) VHA Support Service Center (VSSC) for underlying population of VA healthcare system users.
Data Analysis: Analyses focused on diagnoses in 2010. Noninvasive cancers and those missing TNM stage were excluded from analyses. Cancer incidence among VA patients was descriptively
compared to the general US cancer population.
Results: In 2010, 49,857 cases were reported in VACCR. We excluded non-invasive cases (n = 3,687) and those with missing/unknown stage (n = 8,645). There were 37,525 reported invasive, incident cancers, and 97% (n = 36,454) of those were diagnosed among men. Almost 80% (n = 29,364) of newly diagnosed patients were white, 20% (n = 7,293) were black, and less than 2% (n = 450) were another race. The median age at diagnosis was 64 years. The six most frequently diagnosed cancers were prostate (33%, n = 12,431), lung/bronchus (19%, n = 7,159), colon/rectum (9%, n = 3,419), kidney/renal pelvis (4%, n = 1,657), and urinary bladder (4%, n = 1,427) and skin melanomas (4%, n = 1,421). The most common cancers reported in VACCR have remained stable from 2007 to 2010. Approximately 87% (n = 10,845) of prostate, 33% (n = 2,391) of lung/bronchus, and 59% (n = 2,013) of colon/rectum cancers were diagnosed with early stage (stage I or II) disease. Compared to SEER, cases reported in the VACCR tend to be diagnosed at earlier stages. The overall cancer incidence rate among VA users was 414.8 per 100,000 person-years.
Implications: The VA continues to be a large provider of cancer care in the US. VACCR data indicate that incident cancers in VA in 2010 approximately mirrored those observed among US men.
Purpose: Our objective is to comprehensively describe cancer incidence as reported in the VA Central Cancer Registry (VACCR).
Background: Approximately 3% of US cancer cases are diagnosed and treated in the VA healthcare system each year. These cancer cases are reported in the VACCR. In 2012, we published the first comprehensive description of cancer incidence as reported in the VACCR for patients diagnosed in 2007. In our current analysis, we provide an updated description of cancer incidence as reported in the VACCR for patients diagnosed in 2010.
Methods: This was a retrospective, cross-sectional study. We obtained data from 2 sources: (1) VACCR for incident cancer cases; (2) VHA Support Service Center (VSSC) for underlying population of VA healthcare system users.
Data Analysis: Analyses focused on diagnoses in 2010. Noninvasive cancers and those missing TNM stage were excluded from analyses. Cancer incidence among VA patients was descriptively
compared to the general US cancer population.
Results: In 2010, 49,857 cases were reported in VACCR. We excluded non-invasive cases (n = 3,687) and those with missing/unknown stage (n = 8,645). There were 37,525 reported invasive, incident cancers, and 97% (n = 36,454) of those were diagnosed among men. Almost 80% (n = 29,364) of newly diagnosed patients were white, 20% (n = 7,293) were black, and less than 2% (n = 450) were another race. The median age at diagnosis was 64 years. The six most frequently diagnosed cancers were prostate (33%, n = 12,431), lung/bronchus (19%, n = 7,159), colon/rectum (9%, n = 3,419), kidney/renal pelvis (4%, n = 1,657), and urinary bladder (4%, n = 1,427) and skin melanomas (4%, n = 1,421). The most common cancers reported in VACCR have remained stable from 2007 to 2010. Approximately 87% (n = 10,845) of prostate, 33% (n = 2,391) of lung/bronchus, and 59% (n = 2,013) of colon/rectum cancers were diagnosed with early stage (stage I or II) disease. Compared to SEER, cases reported in the VACCR tend to be diagnosed at earlier stages. The overall cancer incidence rate among VA users was 414.8 per 100,000 person-years.
Implications: The VA continues to be a large provider of cancer care in the US. VACCR data indicate that incident cancers in VA in 2010 approximately mirrored those observed among US men.
Purpose: Our objective is to comprehensively describe cancer incidence as reported in the VA Central Cancer Registry (VACCR).
Background: Approximately 3% of US cancer cases are diagnosed and treated in the VA healthcare system each year. These cancer cases are reported in the VACCR. In 2012, we published the first comprehensive description of cancer incidence as reported in the VACCR for patients diagnosed in 2007. In our current analysis, we provide an updated description of cancer incidence as reported in the VACCR for patients diagnosed in 2010.
Methods: This was a retrospective, cross-sectional study. We obtained data from 2 sources: (1) VACCR for incident cancer cases; (2) VHA Support Service Center (VSSC) for underlying population of VA healthcare system users.
Data Analysis: Analyses focused on diagnoses in 2010. Noninvasive cancers and those missing TNM stage were excluded from analyses. Cancer incidence among VA patients was descriptively
compared to the general US cancer population.
Results: In 2010, 49,857 cases were reported in VACCR. We excluded non-invasive cases (n = 3,687) and those with missing/unknown stage (n = 8,645). There were 37,525 reported invasive, incident cancers, and 97% (n = 36,454) of those were diagnosed among men. Almost 80% (n = 29,364) of newly diagnosed patients were white, 20% (n = 7,293) were black, and less than 2% (n = 450) were another race. The median age at diagnosis was 64 years. The six most frequently diagnosed cancers were prostate (33%, n = 12,431), lung/bronchus (19%, n = 7,159), colon/rectum (9%, n = 3,419), kidney/renal pelvis (4%, n = 1,657), and urinary bladder (4%, n = 1,427) and skin melanomas (4%, n = 1,421). The most common cancers reported in VACCR have remained stable from 2007 to 2010. Approximately 87% (n = 10,845) of prostate, 33% (n = 2,391) of lung/bronchus, and 59% (n = 2,013) of colon/rectum cancers were diagnosed with early stage (stage I or II) disease. Compared to SEER, cases reported in the VACCR tend to be diagnosed at earlier stages. The overall cancer incidence rate among VA users was 414.8 per 100,000 person-years.
Implications: The VA continues to be a large provider of cancer care in the US. VACCR data indicate that incident cancers in VA in 2010 approximately mirrored those observed among US men.