B-Cell Lymphoma ICYMI

Clinical Situation

Delays in diagnosis affect outcomes in veterans with cancer. Veterans sent into the community for suspected cancer frequently experience delays in diagnosis and treatment. This is further complicated by inappropriate workup, resulting in additional delays. Retaining veterans within the VA system for care and providing guidance to primary care providers (PCPs) to assist with expedited workup was an identified need. The Suspicion of Cancer Clinic (SOCC) was developed to address barriers to timely cancer diagnosis and care.

Literature

Researched private sector models of rapid cancer diagnostic and suspicion clinics. Literature analyzed showed improved outcomes through reduction of diagnostic delay. Nurse practitioner (NP)-led clinics were determined to be effective in expediting diagnosis and reducing cancer care delays.

Intervention

The Suspicion of Cancer Clinic is a tele-clinic, staffed with a NP. Diagnostic consult for the NP to assume the workup upon discovery of high suspicion of cancer, or via non-visit consult (NVC) to provide diagnostic guidance are available to PCPs. Outreach and education were performed prior initial clinic launch and post-launch, when need for further clarification of role and scope of the clinic was identified, based on consult trends.

Outcomes/Implications

The SOCC received 133 consults between 9/1/2021 and 6/6/2022 for veterans ranging age 29-94 years. Of these consults, 25 were expedited, diagnostic workups, 47 were NVCs, eliminating unnecessary or incomplete workups, yielding 23 veterans diagnosed with one of 8 types cancer. An additional 34 consults were forwarded to other appropriate service, and 27 were not appropriate for clinic and cancelled. Further outreach and education resulted in a 55% decrease in inappropriate consults. The NP retained 10 veterans (50%) within the VA for diagnostics, who had planned to receive community workup, which is an average four-week delay to schedule in the community. The SOCC was developed utilizing existing staff. The tele-clinic relieves workspace burden. Veterans received timely and appropriate cancer workups, reducing diagnostic delays. PCPs received additional support and guidance. Veterans retained within the VA system is more cost-effective and avoids community care delays. NP-led suspicion/rapid diagnostic clinic effectively reduced care delays by immediate initiation of further diagnostics and appropriate utilization of resources.

References

Campbell C, Nowell A, Karagheusian K, Giroux J, Kiteley C, Martelli L, McQuestion M, Quinn M, Rowe Samadhin YP, Touw M, Moody L. Practical innovation: Advanced practice nurses in cancer care. Can Oncol Nurs J. 2020 Jan 1;30(1):9-15. doi:10.5737/23688076301915. PMID: 33119001; PMCID: PMC7585714.

Drudge-Coates L, Khati V, Ballesteros R, Martyn-Hemphill C, Brown C, Green J, Challacombe B, Muir G. A nurse practitioner model for the assessment of suspected prostate cancer referrals is safe, cost and time efficient. Ecancermedicalscience. 2019 Dec 18;13:994. doi:10.3332/ecancer.2019.994. PMID: 32010218; PMCID: PMC6974368.

Nixon S, Bezverbnaya K, Maganti M, Gullane P, Reedijk M, Kuruvilla J, Prica A, Kridel R, Kukreti V, Bennett S, Rogalla P, Delabie J, Pintilie M, Crump M. Evaluation of Lymphadenopathy and Suspected Lymphoma in a Lymphoma Rapid Diagnosis Clinic. JCO Oncol Pract. 2020 Jan;16(1):e29-e36. doi:10.1200/JOP.19.00202. Epub 2019 Oct 1. PMID: 31573831.

Vasilakis C, Forte P. Setting up a rapid diagnostic clinic for patients with vague symptoms of cancer: a mixed method process evaluation study. BMC Health Serv Res. 2021 Apr 17;21(1):357. doi: 10.1186/s12913-021-06360-0. PMID: 33865373; PMCID: PMC8052708.

Clinical Situation

Delays in diagnosis affect outcomes in veterans with cancer. Veterans sent into the community for suspected cancer frequently experience delays in diagnosis and treatment. This is further complicated by inappropriate workup, resulting in additional delays. Retaining veterans within the VA system for care and providing guidance to primary care providers (PCPs) to assist with expedited workup was an identified need. The Suspicion of Cancer Clinic (SOCC) was developed to address barriers to timely cancer diagnosis and care.

Literature

Researched private sector models of rapid cancer diagnostic and suspicion clinics. Literature analyzed showed improved outcomes through reduction of diagnostic delay. Nurse practitioner (NP)-led clinics were determined to be effective in expediting diagnosis and reducing cancer care delays.

Intervention

The Suspicion of Cancer Clinic is a tele-clinic, staffed with a NP. Diagnostic consult for the NP to assume the workup upon discovery of high suspicion of cancer, or via non-visit consult (NVC) to provide diagnostic guidance are available to PCPs. Outreach and education were performed prior initial clinic launch and post-launch, when need for further clarification of role and scope of the clinic was identified, based on consult trends.

Outcomes/Implications

The SOCC received 133 consults between 9/1/2021 and 6/6/2022 for veterans ranging age 29-94 years. Of these consults, 25 were expedited, diagnostic workups, 47 were NVCs, eliminating unnecessary or incomplete workups, yielding 23 veterans diagnosed with one of 8 types cancer. An additional 34 consults were forwarded to other appropriate service, and 27 were not appropriate for clinic and cancelled. Further outreach and education resulted in a 55% decrease in inappropriate consults. The NP retained 10 veterans (50%) within the VA for diagnostics, who had planned to receive community workup, which is an average four-week delay to schedule in the community. The SOCC was developed utilizing existing staff. The tele-clinic relieves workspace burden. Veterans received timely and appropriate cancer workups, reducing diagnostic delays. PCPs received additional support and guidance. Veterans retained within the VA system is more cost-effective and avoids community care delays. NP-led suspicion/rapid diagnostic clinic effectively reduced care delays by immediate initiation of further diagnostics and appropriate utilization of resources.

References

Campbell C, Nowell A, Karagheusian K, Giroux J, Kiteley C, Martelli L, McQuestion M, Quinn M, Rowe Samadhin YP, Touw M, Moody L. Practical innovation: Advanced practice nurses in cancer care. Can Oncol Nurs J. 2020 Jan 1;30(1):9-15. doi:10.5737/23688076301915. PMID: 33119001; PMCID: PMC7585714.

Drudge-Coates L, Khati V, Ballesteros R, Martyn-Hemphill C, Brown C, Green J, Challacombe B, Muir G. A nurse practitioner model for the assessment of suspected prostate cancer referrals is safe, cost and time efficient. Ecancermedicalscience. 2019 Dec 18;13:994. doi:10.3332/ecancer.2019.994. PMID: 32010218; PMCID: PMC6974368.

Nixon S, Bezverbnaya K, Maganti M, Gullane P, Reedijk M, Kuruvilla J, Prica A, Kridel R, Kukreti V, Bennett S, Rogalla P, Delabie J, Pintilie M, Crump M. Evaluation of Lymphadenopathy and Suspected Lymphoma in a Lymphoma Rapid Diagnosis Clinic. JCO Oncol Pract. 2020 Jan;16(1):e29-e36. doi:10.1200/JOP.19.00202. Epub 2019 Oct 1. PMID: 31573831.

Vasilakis C, Forte P. Setting up a rapid diagnostic clinic for patients with vague symptoms of cancer: a mixed method process evaluation study. BMC Health Serv Res. 2021 Apr 17;21(1):357. doi: 10.1186/s12913-021-06360-0. PMID: 33865373; PMCID: PMC8052708.

Clinical Situation

Delays in diagnosis affect outcomes in veterans with cancer. Veterans sent into the community for suspected cancer frequently experience delays in diagnosis and treatment. This is further complicated by inappropriate workup, resulting in additional delays. Retaining veterans within the VA system for care and providing guidance to primary care providers (PCPs) to assist with expedited workup was an identified need. The Suspicion of Cancer Clinic (SOCC) was developed to address barriers to timely cancer diagnosis and care.

Literature

Researched private sector models of rapid cancer diagnostic and suspicion clinics. Literature analyzed showed improved outcomes through reduction of diagnostic delay. Nurse practitioner (NP)-led clinics were determined to be effective in expediting diagnosis and reducing cancer care delays.

Intervention

The Suspicion of Cancer Clinic is a tele-clinic, staffed with a NP. Diagnostic consult for the NP to assume the workup upon discovery of high suspicion of cancer, or via non-visit consult (NVC) to provide diagnostic guidance are available to PCPs. Outreach and education were performed prior initial clinic launch and post-launch, when need for further clarification of role and scope of the clinic was identified, based on consult trends.

Outcomes/Implications

The SOCC received 133 consults between 9/1/2021 and 6/6/2022 for veterans ranging age 29-94 years. Of these consults, 25 were expedited, diagnostic workups, 47 were NVCs, eliminating unnecessary or incomplete workups, yielding 23 veterans diagnosed with one of 8 types cancer. An additional 34 consults were forwarded to other appropriate service, and 27 were not appropriate for clinic and cancelled. Further outreach and education resulted in a 55% decrease in inappropriate consults. The NP retained 10 veterans (50%) within the VA for diagnostics, who had planned to receive community workup, which is an average four-week delay to schedule in the community. The SOCC was developed utilizing existing staff. The tele-clinic relieves workspace burden. Veterans received timely and appropriate cancer workups, reducing diagnostic delays. PCPs received additional support and guidance. Veterans retained within the VA system is more cost-effective and avoids community care delays. NP-led suspicion/rapid diagnostic clinic effectively reduced care delays by immediate initiation of further diagnostics and appropriate utilization of resources.

References

Campbell C, Nowell A, Karagheusian K, Giroux J, Kiteley C, Martelli L, McQuestion M, Quinn M, Rowe Samadhin YP, Touw M, Moody L. Practical innovation: Advanced practice nurses in cancer care. Can Oncol Nurs J. 2020 Jan 1;30(1):9-15. doi:10.5737/23688076301915. PMID: 33119001; PMCID: PMC7585714.

Drudge-Coates L, Khati V, Ballesteros R, Martyn-Hemphill C, Brown C, Green J, Challacombe B, Muir G. A nurse practitioner model for the assessment of suspected prostate cancer referrals is safe, cost and time efficient. Ecancermedicalscience. 2019 Dec 18;13:994. doi:10.3332/ecancer.2019.994. PMID: 32010218; PMCID: PMC6974368.

Nixon S, Bezverbnaya K, Maganti M, Gullane P, Reedijk M, Kuruvilla J, Prica A, Kridel R, Kukreti V, Bennett S, Rogalla P, Delabie J, Pintilie M, Crump M. Evaluation of Lymphadenopathy and Suspected Lymphoma in a Lymphoma Rapid Diagnosis Clinic. JCO Oncol Pract. 2020 Jan;16(1):e29-e36. doi:10.1200/JOP.19.00202. Epub 2019 Oct 1. PMID: 31573831.

Vasilakis C, Forte P. Setting up a rapid diagnostic clinic for patients with vague symptoms of cancer: a mixed method process evaluation study. BMC Health Serv Res. 2021 Apr 17;21(1):357. doi: 10.1186/s12913-021-06360-0. PMID: 33865373; PMCID: PMC8052708.

Purpose

This was an open label trial to determine feasibility and acceptability of 2 complementary and integrative interventions (self-hypnosis [HYP] and mindfulness meditation [MM]) for pain in veterans undergoing treatment for head and neck cancer (HNC) at VA Puget Sound.

Background

HNC is associated with pain prior to and during treatment. HYP and MM have shown promise for procedural, acute, and chronic pain and may be a helpful addition to cancer treatment.

Methods

All veterans initiating treatment during the study window (2018-2020) were offered study treatment in addition to usual care. After providing informed consent and hearing a brief description of the interventions, participants selected either the HYP or MM intervention or a control condition (ie, complete assessments but no intervention). Participants met with a study clinician who introduced the intervention and provided audio recordings and a workbook and instructed them to listen to the recordings as often as they deemed helpful. Participants completed survey assessments at baseline, week 4, and at study completion (8 weeks). Measures included patient-reported satisfaction and perceived treatment helpfulness, frequency of practice, and likeliness of using skills going forward.

Data Analysis

Descriptive statistics were computed for all measures collected. No statistical tests were conducted due to small sample size.

Results

Of the 15 veterans who enrolled, 7 selected HYP, 7 selected MM, none selected the control condition, and 1 withdrew prior to treatment selection. Of the 14 completers, 79% reported that their chosen treatment was helpful and that they practiced at least once a week; 71% reported that they are likely to use these skills going forward. No adverse events were reported.

Conclusions/Implications

Self-guided HYP and MM interventions can be administered feasibly and are highly acceptable to veterans undergoing HNC treatment in a VA setting. HYP or MM interventions are feasible to implement with little demand on resources, and that listening to recordings is acceptable and helpful for veterans with pain related to cancer and cancer treatment. Further research is warranted to formally evaluate the efficacy of these interventions in this population in a well-powered study.

Purpose

This was an open label trial to determine feasibility and acceptability of 2 complementary and integrative interventions (self-hypnosis [HYP] and mindfulness meditation [MM]) for pain in veterans undergoing treatment for head and neck cancer (HNC) at VA Puget Sound.

Background

HNC is associated with pain prior to and during treatment. HYP and MM have shown promise for procedural, acute, and chronic pain and may be a helpful addition to cancer treatment.

Methods

All veterans initiating treatment during the study window (2018-2020) were offered study treatment in addition to usual care. After providing informed consent and hearing a brief description of the interventions, participants selected either the HYP or MM intervention or a control condition (ie, complete assessments but no intervention). Participants met with a study clinician who introduced the intervention and provided audio recordings and a workbook and instructed them to listen to the recordings as often as they deemed helpful. Participants completed survey assessments at baseline, week 4, and at study completion (8 weeks). Measures included patient-reported satisfaction and perceived treatment helpfulness, frequency of practice, and likeliness of using skills going forward.

Data Analysis

Descriptive statistics were computed for all measures collected. No statistical tests were conducted due to small sample size.

Results

Of the 15 veterans who enrolled, 7 selected HYP, 7 selected MM, none selected the control condition, and 1 withdrew prior to treatment selection. Of the 14 completers, 79% reported that their chosen treatment was helpful and that they practiced at least once a week; 71% reported that they are likely to use these skills going forward. No adverse events were reported.

Conclusions/Implications

Self-guided HYP and MM interventions can be administered feasibly and are highly acceptable to veterans undergoing HNC treatment in a VA setting. HYP or MM interventions are feasible to implement with little demand on resources, and that listening to recordings is acceptable and helpful for veterans with pain related to cancer and cancer treatment. Further research is warranted to formally evaluate the efficacy of these interventions in this population in a well-powered study.

Purpose

This was an open label trial to determine feasibility and acceptability of 2 complementary and integrative interventions (self-hypnosis [HYP] and mindfulness meditation [MM]) for pain in veterans undergoing treatment for head and neck cancer (HNC) at VA Puget Sound.

Background

HNC is associated with pain prior to and during treatment. HYP and MM have shown promise for procedural, acute, and chronic pain and may be a helpful addition to cancer treatment.

Methods

All veterans initiating treatment during the study window (2018-2020) were offered study treatment in addition to usual care. After providing informed consent and hearing a brief description of the interventions, participants selected either the HYP or MM intervention or a control condition (ie, complete assessments but no intervention). Participants met with a study clinician who introduced the intervention and provided audio recordings and a workbook and instructed them to listen to the recordings as often as they deemed helpful. Participants completed survey assessments at baseline, week 4, and at study completion (8 weeks). Measures included patient-reported satisfaction and perceived treatment helpfulness, frequency of practice, and likeliness of using skills going forward.

Data Analysis

Descriptive statistics were computed for all measures collected. No statistical tests were conducted due to small sample size.

Results

Of the 15 veterans who enrolled, 7 selected HYP, 7 selected MM, none selected the control condition, and 1 withdrew prior to treatment selection. Of the 14 completers, 79% reported that their chosen treatment was helpful and that they practiced at least once a week; 71% reported that they are likely to use these skills going forward. No adverse events were reported.

Conclusions/Implications

Self-guided HYP and MM interventions can be administered feasibly and are highly acceptable to veterans undergoing HNC treatment in a VA setting. HYP or MM interventions are feasible to implement with little demand on resources, and that listening to recordings is acceptable and helpful for veterans with pain related to cancer and cancer treatment. Further research is warranted to formally evaluate the efficacy of these interventions in this population in a well-powered study.

Purpose

To identify the effectiveness of aromatherapy as an adjunct in improving pain and overall sense of well-being among patients with cancer receiving hospice care.

Background

There is limited data available on the use of aromatherapy for pain management among patients with cancer receiving end-of-life care. This project identifies the benefits of aromatherapy in a population where it was not previously evaluated.

Methods

Patients with cancer who were admitted to the hospice unit of a local hospital within a large healthcare system for at least 24 hours and taking opioids for neoplasm related pain at least once a day were included in the study. Patients with allergy to essential oils, and those suffering from allergic rhinitis and common cold, and a history of asthma were excluded. Patients who were unable to consent for study participation were also excluded.

Data Analysis

Retrospective chart analysis and surveys were used to collect the data. Univariate descriptive statistics were used for patient characteristics. A Wilcoxon Signed Rank Test was used to determine opioid use before and after aromatherapy. The t test was used to compare pain scores before and after aromatherapy. A 5-point Likert scale was used to evaluate how soothing the participants found the treatment to be. The Numeric Pain Intensity Scale was used for pain scores.

Results

There was a total of 40 participants, all of whom were male with an average age of 69 years. Pain scores before and after treatment were found to be statistically significant at an average of 5.15/10 vs 3.68/10, respectively. On a scale from 1-5 with 5 being the most soothing, there was an average rating of 3.87 among participants. There was not a statistically significant decline in opioid use from pre-treatment to post-treatment. Higher pain scores before intervention were associated with rating the lotion as more soothing.

Conclusions

The use of aromatherapy as a complement to opioids for cancer-related pain in the end-of-life was associated with an increase sense of well-being, resulted in lower pain scores and seems to have subjective comfort merit.

Implications

This study shows the potential benefits of using aromatherapy in end-of-life care among patients with cancer.

Purpose

To identify the effectiveness of aromatherapy as an adjunct in improving pain and overall sense of well-being among patients with cancer receiving hospice care.

Background

There is limited data available on the use of aromatherapy for pain management among patients with cancer receiving end-of-life care. This project identifies the benefits of aromatherapy in a population where it was not previously evaluated.

Methods

Patients with cancer who were admitted to the hospice unit of a local hospital within a large healthcare system for at least 24 hours and taking opioids for neoplasm related pain at least once a day were included in the study. Patients with allergy to essential oils, and those suffering from allergic rhinitis and common cold, and a history of asthma were excluded. Patients who were unable to consent for study participation were also excluded.

Data Analysis

Retrospective chart analysis and surveys were used to collect the data. Univariate descriptive statistics were used for patient characteristics. A Wilcoxon Signed Rank Test was used to determine opioid use before and after aromatherapy. The t test was used to compare pain scores before and after aromatherapy. A 5-point Likert scale was used to evaluate how soothing the participants found the treatment to be. The Numeric Pain Intensity Scale was used for pain scores.

Results

There was a total of 40 participants, all of whom were male with an average age of 69 years. Pain scores before and after treatment were found to be statistically significant at an average of 5.15/10 vs 3.68/10, respectively. On a scale from 1-5 with 5 being the most soothing, there was an average rating of 3.87 among participants. There was not a statistically significant decline in opioid use from pre-treatment to post-treatment. Higher pain scores before intervention were associated with rating the lotion as more soothing.

Conclusions

The use of aromatherapy as a complement to opioids for cancer-related pain in the end-of-life was associated with an increase sense of well-being, resulted in lower pain scores and seems to have subjective comfort merit.

Implications

This study shows the potential benefits of using aromatherapy in end-of-life care among patients with cancer.

Purpose

To identify the effectiveness of aromatherapy as an adjunct in improving pain and overall sense of well-being among patients with cancer receiving hospice care.

Background

There is limited data available on the use of aromatherapy for pain management among patients with cancer receiving end-of-life care. This project identifies the benefits of aromatherapy in a population where it was not previously evaluated.

Methods

Patients with cancer who were admitted to the hospice unit of a local hospital within a large healthcare system for at least 24 hours and taking opioids for neoplasm related pain at least once a day were included in the study. Patients with allergy to essential oils, and those suffering from allergic rhinitis and common cold, and a history of asthma were excluded. Patients who were unable to consent for study participation were also excluded.

Data Analysis

Retrospective chart analysis and surveys were used to collect the data. Univariate descriptive statistics were used for patient characteristics. A Wilcoxon Signed Rank Test was used to determine opioid use before and after aromatherapy. The t test was used to compare pain scores before and after aromatherapy. A 5-point Likert scale was used to evaluate how soothing the participants found the treatment to be. The Numeric Pain Intensity Scale was used for pain scores.

Results

There was a total of 40 participants, all of whom were male with an average age of 69 years. Pain scores before and after treatment were found to be statistically significant at an average of 5.15/10 vs 3.68/10, respectively. On a scale from 1-5 with 5 being the most soothing, there was an average rating of 3.87 among participants. There was not a statistically significant decline in opioid use from pre-treatment to post-treatment. Higher pain scores before intervention were associated with rating the lotion as more soothing.

Conclusions

The use of aromatherapy as a complement to opioids for cancer-related pain in the end-of-life was associated with an increase sense of well-being, resulted in lower pain scores and seems to have subjective comfort merit.

Implications

This study shows the potential benefits of using aromatherapy in end-of-life care among patients with cancer.

Purpose

This study addresses a gap in knowledge regarding palliative care utilization patterns in smallcell carcinoma of the prostate.

Background

Prostate cancer is the most common cancer affecting males. One of the most aggressive malignancies of the prostate is small cell carcinoma (SCC) of the prostate. Almost 70% of patients diagnosed with SCC present with the disseminated disease with a low 5-year survival rate of less than 2%. The role of palliative care can be beneficial in metastatic prostate cancer given its largely incurable course. Despite evidence favoring palliative care for prostate cancer in several patient populations, it remains under-utilized. Palliative care utilization patterns in SCC of the prostate have not yet been studied.

Methods

This is a retrospective study of patients diagnosed with all subtypes of AJCC staged metastatic SCC of the prostate between 2004 and 2017 in the National Cancer Database (NCDB) to determine palliative care usage (n = 615). Exclusion criteria included missing data.

Data Analysis

 Variables were evaluated for significance (P < .05) in relation to the receipt of palliative care using Pearson Chi-Square, ANOVA, and Kaplan- Meier tests. Multivariate analysis was performed via binary logistics regression.

Results

Among the 961 patients diagnosed with SCC of the prostate, 64% had metastatic disease (n = 615). The metastatic cohort was more likely to receive palliative care than those that did not have distant metastasis (24.2% vs 5.7%, P < .001). Palliative care use has grown between 2004 (n = 6) and 2017 (n = 20). Patients that were uninsured were more likely than insured patients to receive palliative care (50% vs 23.5%, P = .003; 95% CI, 0.051- 0.546). Non-Hispanic patients were also more likely than Hispanic patients to receive palliative care (P = .033; 95% CI, 1.154-28.140). New England locations had the highest utilization of palliative care (43.%, P = .009). Factors that impacted palliative care use included facility region, insurance status, and Hispanic status. As palliative care continues to be utilized more frequently, we hope that this study can provide a starting point in studying and preventing palliative treatment disparities.

Purpose

This study addresses a gap in knowledge regarding palliative care utilization patterns in smallcell carcinoma of the prostate.

Background

Prostate cancer is the most common cancer affecting males. One of the most aggressive malignancies of the prostate is small cell carcinoma (SCC) of the prostate. Almost 70% of patients diagnosed with SCC present with the disseminated disease with a low 5-year survival rate of less than 2%. The role of palliative care can be beneficial in metastatic prostate cancer given its largely incurable course. Despite evidence favoring palliative care for prostate cancer in several patient populations, it remains under-utilized. Palliative care utilization patterns in SCC of the prostate have not yet been studied.

Methods

This is a retrospective study of patients diagnosed with all subtypes of AJCC staged metastatic SCC of the prostate between 2004 and 2017 in the National Cancer Database (NCDB) to determine palliative care usage (n = 615). Exclusion criteria included missing data.

Data Analysis

 Variables were evaluated for significance (P < .05) in relation to the receipt of palliative care using Pearson Chi-Square, ANOVA, and Kaplan- Meier tests. Multivariate analysis was performed via binary logistics regression.

Results

Among the 961 patients diagnosed with SCC of the prostate, 64% had metastatic disease (n = 615). The metastatic cohort was more likely to receive palliative care than those that did not have distant metastasis (24.2% vs 5.7%, P < .001). Palliative care use has grown between 2004 (n = 6) and 2017 (n = 20). Patients that were uninsured were more likely than insured patients to receive palliative care (50% vs 23.5%, P = .003; 95% CI, 0.051- 0.546). Non-Hispanic patients were also more likely than Hispanic patients to receive palliative care (P = .033; 95% CI, 1.154-28.140). New England locations had the highest utilization of palliative care (43.%, P = .009). Factors that impacted palliative care use included facility region, insurance status, and Hispanic status. As palliative care continues to be utilized more frequently, we hope that this study can provide a starting point in studying and preventing palliative treatment disparities.

Purpose

This study addresses a gap in knowledge regarding palliative care utilization patterns in smallcell carcinoma of the prostate.

Background

Prostate cancer is the most common cancer affecting males. One of the most aggressive malignancies of the prostate is small cell carcinoma (SCC) of the prostate. Almost 70% of patients diagnosed with SCC present with the disseminated disease with a low 5-year survival rate of less than 2%. The role of palliative care can be beneficial in metastatic prostate cancer given its largely incurable course. Despite evidence favoring palliative care for prostate cancer in several patient populations, it remains under-utilized. Palliative care utilization patterns in SCC of the prostate have not yet been studied.

Methods

This is a retrospective study of patients diagnosed with all subtypes of AJCC staged metastatic SCC of the prostate between 2004 and 2017 in the National Cancer Database (NCDB) to determine palliative care usage (n = 615). Exclusion criteria included missing data.

Data Analysis

 Variables were evaluated for significance (P < .05) in relation to the receipt of palliative care using Pearson Chi-Square, ANOVA, and Kaplan- Meier tests. Multivariate analysis was performed via binary logistics regression.

Results

Among the 961 patients diagnosed with SCC of the prostate, 64% had metastatic disease (n = 615). The metastatic cohort was more likely to receive palliative care than those that did not have distant metastasis (24.2% vs 5.7%, P < .001). Palliative care use has grown between 2004 (n = 6) and 2017 (n = 20). Patients that were uninsured were more likely than insured patients to receive palliative care (50% vs 23.5%, P = .003; 95% CI, 0.051- 0.546). Non-Hispanic patients were also more likely than Hispanic patients to receive palliative care (P = .033; 95% CI, 1.154-28.140). New England locations had the highest utilization of palliative care (43.%, P = .009). Factors that impacted palliative care use included facility region, insurance status, and Hispanic status. As palliative care continues to be utilized more frequently, we hope that this study can provide a starting point in studying and preventing palliative treatment disparities.

Purpose

Hospitalized patients with advanced malignancies often have high symptom burden and poor quality of life, which are frequently under-recognized or under-treated. Accordingly, the integration of specialty palliative care (PC) in this population is imperative. Unfortunately, a sustainable referral model to capture patients for timely PC involvement is lacking. This quality improvement study evaluated the implementation of a clinical trigger-based referral process to PC for inpatients on the Hematology/Oncology (HO) service at Hines VA Hospital. Clinical outcomes studied included: Life-Sustaining Treatment (LST) note completion rates; measurement of overall survival at 3, 6, and 12 months; rate of re-hospitalization within 30 days; and venue of death and treating specialty of deceased patients.

Methods

House staff received a weekly email that included the clinical PC triggers. Admitted patients who met trigger criteria would prompt consultation to PC. Clinical triggers included: metastatic oncologic disease or relapsed hematologic disease; uncontrolled symptoms; > 2 unscheduled hospitalizations in the prior 30 days; and unscheduled hospitalizations lasting > 7 days.

Results

A total of 63 patients were admitted to the HO service between December 2020 through February 2021. Of those, 53 (84.1%) met at least 1 trigger and 36 (68%) received PC consultation. Of the patients that met trigger criteria and received a PC consult, 85.7% died with hospice compared to 44.4% in the group who did not receive a PC consult (P < .01). Nineteen (51.3%) died within 6 months of discharge compared to 7 (26.9%) who did not receive a PC consult (P = .08). Twelve (33.3%) had recurrent hospitalizations compared to 5 (29%) who did not receive a PC consult (P = .38), and 20 (55.6%) had a new or updated LST note compared to 2 (11.8%) who did not receive PC consultation (P < .01).

Conculsions

This study demonstrated the feasibility of implementing a trigger-based system for PC consultation in a veteran inpatient HO population. Notably, a large majority of HO inpatients met criteria for at least 1 PC trigger. No significant difference was found in overall survival at 6 months; however, patients who received PC consultation were more likely to receive hospice services at the end of life.

Purpose

Hospitalized patients with advanced malignancies often have high symptom burden and poor quality of life, which are frequently under-recognized or under-treated. Accordingly, the integration of specialty palliative care (PC) in this population is imperative. Unfortunately, a sustainable referral model to capture patients for timely PC involvement is lacking. This quality improvement study evaluated the implementation of a clinical trigger-based referral process to PC for inpatients on the Hematology/Oncology (HO) service at Hines VA Hospital. Clinical outcomes studied included: Life-Sustaining Treatment (LST) note completion rates; measurement of overall survival at 3, 6, and 12 months; rate of re-hospitalization within 30 days; and venue of death and treating specialty of deceased patients.

Methods

House staff received a weekly email that included the clinical PC triggers. Admitted patients who met trigger criteria would prompt consultation to PC. Clinical triggers included: metastatic oncologic disease or relapsed hematologic disease; uncontrolled symptoms; > 2 unscheduled hospitalizations in the prior 30 days; and unscheduled hospitalizations lasting > 7 days.

Results

A total of 63 patients were admitted to the HO service between December 2020 through February 2021. Of those, 53 (84.1%) met at least 1 trigger and 36 (68%) received PC consultation. Of the patients that met trigger criteria and received a PC consult, 85.7% died with hospice compared to 44.4% in the group who did not receive a PC consult (P < .01). Nineteen (51.3%) died within 6 months of discharge compared to 7 (26.9%) who did not receive a PC consult (P = .08). Twelve (33.3%) had recurrent hospitalizations compared to 5 (29%) who did not receive a PC consult (P = .38), and 20 (55.6%) had a new or updated LST note compared to 2 (11.8%) who did not receive PC consultation (P < .01).

Conculsions

This study demonstrated the feasibility of implementing a trigger-based system for PC consultation in a veteran inpatient HO population. Notably, a large majority of HO inpatients met criteria for at least 1 PC trigger. No significant difference was found in overall survival at 6 months; however, patients who received PC consultation were more likely to receive hospice services at the end of life.

Purpose

Hospitalized patients with advanced malignancies often have high symptom burden and poor quality of life, which are frequently under-recognized or under-treated. Accordingly, the integration of specialty palliative care (PC) in this population is imperative. Unfortunately, a sustainable referral model to capture patients for timely PC involvement is lacking. This quality improvement study evaluated the implementation of a clinical trigger-based referral process to PC for inpatients on the Hematology/Oncology (HO) service at Hines VA Hospital. Clinical outcomes studied included: Life-Sustaining Treatment (LST) note completion rates; measurement of overall survival at 3, 6, and 12 months; rate of re-hospitalization within 30 days; and venue of death and treating specialty of deceased patients.

Methods

House staff received a weekly email that included the clinical PC triggers. Admitted patients who met trigger criteria would prompt consultation to PC. Clinical triggers included: metastatic oncologic disease or relapsed hematologic disease; uncontrolled symptoms; > 2 unscheduled hospitalizations in the prior 30 days; and unscheduled hospitalizations lasting > 7 days.

Results

A total of 63 patients were admitted to the HO service between December 2020 through February 2021. Of those, 53 (84.1%) met at least 1 trigger and 36 (68%) received PC consultation. Of the patients that met trigger criteria and received a PC consult, 85.7% died with hospice compared to 44.4% in the group who did not receive a PC consult (P < .01). Nineteen (51.3%) died within 6 months of discharge compared to 7 (26.9%) who did not receive a PC consult (P = .08). Twelve (33.3%) had recurrent hospitalizations compared to 5 (29%) who did not receive a PC consult (P = .38), and 20 (55.6%) had a new or updated LST note compared to 2 (11.8%) who did not receive PC consultation (P < .01).

Conculsions

This study demonstrated the feasibility of implementing a trigger-based system for PC consultation in a veteran inpatient HO population. Notably, a large majority of HO inpatients met criteria for at least 1 PC trigger. No significant difference was found in overall survival at 6 months; however, patients who received PC consultation were more likely to receive hospice services at the end of life.

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.

Inroduction

Romiplostim is an agonist of the thrombopoietin receptor that stimulates platelet production. Several studies have evaluated the role of romiplostim in the prevention of chemotherapy-induced thrombocytopenia (CIT). Romiplostim may reduce dose reductions, treatment delays, bleeding events, and transfusions.

Less is known about treatment of CIT in patients with pre-existing thrombocytopenia (TCP), such as those with myelodysplastic syndrome (MDS). Here we present a case of a patient with TCP secondary to MDS who was given romiplostim during the treatment of pancreatic adenocarcinoma with FOLFIRINOX.

Case Report

The patient is a 76-year-old male with history of chronic TCP (baseline platelets 50-90 K/μL) presumed secondary to myelodysplastic syndrome, although a bone marrow biopsy was inconclusive. He had not had any major bleeding events or transfusions, aside from one unit of platelets given after a cervical spine fusion.

He was later diagnosed with borderline-resectable pancreatic adenocarcinoma, Stage IbT2N0. Plan made to administer neoadjuvant FOLFIRNOX chemotherapy, followed by Whipple.

The patient was started on romiplostim with a dose range of 1-10 mcg/kg weekly to maintain platelets between 60-200. We initially planned to give all 12 cycles neoadjuvantly but found that we could not maintain a platelet count over 50 K/μL despite maximal uptitration of romiplostim so the Whipple was performed after Cycle 9. Three additional cycles were given post-operatively. There were no dose-reductions, although oxaliplatin was held after cycle 9 due to neuropathy. He developed a jejunal bleed post-Whipple that required embolization but did not require transfusion.

Summary

This was a case in which romiplostim was successfully used during FOLFIRINOX to support platelets in a patient with baseline TCP from MDS. Despite a jejunal bleed after Whipple, the patient tolerated the treatment well and was able to complete all 12 cycles of peri-operative FOLFIRINOX. This approach may be beneficial in other patients with pre-existing TCP receiving chemotherapy.

Inroduction

Romiplostim is an agonist of the thrombopoietin receptor that stimulates platelet production. Several studies have evaluated the role of romiplostim in the prevention of chemotherapy-induced thrombocytopenia (CIT). Romiplostim may reduce dose reductions, treatment delays, bleeding events, and transfusions.

Less is known about treatment of CIT in patients with pre-existing thrombocytopenia (TCP), such as those with myelodysplastic syndrome (MDS). Here we present a case of a patient with TCP secondary to MDS who was given romiplostim during the treatment of pancreatic adenocarcinoma with FOLFIRINOX.

Case Report

The patient is a 76-year-old male with history of chronic TCP (baseline platelets 50-90 K/μL) presumed secondary to myelodysplastic syndrome, although a bone marrow biopsy was inconclusive. He had not had any major bleeding events or transfusions, aside from one unit of platelets given after a cervical spine fusion.

He was later diagnosed with borderline-resectable pancreatic adenocarcinoma, Stage IbT2N0. Plan made to administer neoadjuvant FOLFIRNOX chemotherapy, followed by Whipple.

The patient was started on romiplostim with a dose range of 1-10 mcg/kg weekly to maintain platelets between 60-200. We initially planned to give all 12 cycles neoadjuvantly but found that we could not maintain a platelet count over 50 K/μL despite maximal uptitration of romiplostim so the Whipple was performed after Cycle 9. Three additional cycles were given post-operatively. There were no dose-reductions, although oxaliplatin was held after cycle 9 due to neuropathy. He developed a jejunal bleed post-Whipple that required embolization but did not require transfusion.

Summary

This was a case in which romiplostim was successfully used during FOLFIRINOX to support platelets in a patient with baseline TCP from MDS. Despite a jejunal bleed after Whipple, the patient tolerated the treatment well and was able to complete all 12 cycles of peri-operative FOLFIRINOX. This approach may be beneficial in other patients with pre-existing TCP receiving chemotherapy.

Inroduction

Romiplostim is an agonist of the thrombopoietin receptor that stimulates platelet production. Several studies have evaluated the role of romiplostim in the prevention of chemotherapy-induced thrombocytopenia (CIT). Romiplostim may reduce dose reductions, treatment delays, bleeding events, and transfusions.

Less is known about treatment of CIT in patients with pre-existing thrombocytopenia (TCP), such as those with myelodysplastic syndrome (MDS). Here we present a case of a patient with TCP secondary to MDS who was given romiplostim during the treatment of pancreatic adenocarcinoma with FOLFIRINOX.

Case Report

The patient is a 76-year-old male with history of chronic TCP (baseline platelets 50-90 K/μL) presumed secondary to myelodysplastic syndrome, although a bone marrow biopsy was inconclusive. He had not had any major bleeding events or transfusions, aside from one unit of platelets given after a cervical spine fusion.

He was later diagnosed with borderline-resectable pancreatic adenocarcinoma, Stage IbT2N0. Plan made to administer neoadjuvant FOLFIRNOX chemotherapy, followed by Whipple.

The patient was started on romiplostim with a dose range of 1-10 mcg/kg weekly to maintain platelets between 60-200. We initially planned to give all 12 cycles neoadjuvantly but found that we could not maintain a platelet count over 50 K/μL despite maximal uptitration of romiplostim so the Whipple was performed after Cycle 9. Three additional cycles were given post-operatively. There were no dose-reductions, although oxaliplatin was held after cycle 9 due to neuropathy. He developed a jejunal bleed post-Whipple that required embolization but did not require transfusion.

Summary

This was a case in which romiplostim was successfully used during FOLFIRINOX to support platelets in a patient with baseline TCP from MDS. Despite a jejunal bleed after Whipple, the patient tolerated the treatment well and was able to complete all 12 cycles of peri-operative FOLFIRINOX. This approach may be beneficial in other patients with pre-existing TCP receiving chemotherapy.

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.

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.