AVAHO

INTRODUCTION

Fragmentation of medical services is a significant barrier in modern patient care with contributing factors including patient and system level details. The Veterans Affairs (VA) department is the largest integrated health care organization in the US. Given the complex challenges of such a system, the VA has developed resources to lessen the impact of care fragmentation, potentially widening services and diminishing traditional barriers to care. We present a patient case as an example of how VA programs are impacting current veteran oncologic care.

CASE PRESENTATION

An 86-year-old veteran with shortness of breath and fatigue was found to have macrocytic anemia. Located nearly 200 miles from the closest VA with hematology services he was referred through the National TeleOncology (NTO) service to see hematology using clinical video telehealth (CVT) technology stationed at a VA approximately 100 miles from his home. Consultation led to lab work revealing no viral, nutritional, or rheumatologic explanation. A bone marrow biopsy was completed without clear diagnosis though molecular alterations demonstrated ASXL1, TET2 and CBL mutations. Hematopathology services were sought, and the patient’s case was presented at the NTO virtual hematologic tumor board where expert VA hematopathology, radiology and medical hematology opinions were available. A diagnosis of myelodysplastic syndrome was rendered with care recommendations including the novel agent luspatercept. Given patient age and comorbidities, transportation remained a barrier. The patient was set up to receive services through home based primary care (HBPC) with weekly lab draws and medication administration. Ultimately, the patient was able to receive the first dose of luspatercept through the NTO affiliated VA with subsequent administrations to be given by HBPC. Additional visits planned using at home VA video Connect (VVC) service and CVT visits with NTO hematology at his local community based outpatient center (CBOC) located 30 miles from his home.

DISCUSSION

Located over 3 hours from the closest in-person VA hematologist, this patient was able to receive complex care thanks to a marriage of in-person and virtual services involving specialty nurses, pharmacists, and physicians from across VA. Services such as the NTO hub-spoke model, virtual tumor boards and HBPC, reveal a care framework unique to the VA.

INTRODUCTION

Fragmentation of medical services is a significant barrier in modern patient care with contributing factors including patient and system level details. The Veterans Affairs (VA) department is the largest integrated health care organization in the US. Given the complex challenges of such a system, the VA has developed resources to lessen the impact of care fragmentation, potentially widening services and diminishing traditional barriers to care. We present a patient case as an example of how VA programs are impacting current veteran oncologic care.

CASE PRESENTATION

An 86-year-old veteran with shortness of breath and fatigue was found to have macrocytic anemia. Located nearly 200 miles from the closest VA with hematology services he was referred through the National TeleOncology (NTO) service to see hematology using clinical video telehealth (CVT) technology stationed at a VA approximately 100 miles from his home. Consultation led to lab work revealing no viral, nutritional, or rheumatologic explanation. A bone marrow biopsy was completed without clear diagnosis though molecular alterations demonstrated ASXL1, TET2 and CBL mutations. Hematopathology services were sought, and the patient’s case was presented at the NTO virtual hematologic tumor board where expert VA hematopathology, radiology and medical hematology opinions were available. A diagnosis of myelodysplastic syndrome was rendered with care recommendations including the novel agent luspatercept. Given patient age and comorbidities, transportation remained a barrier. The patient was set up to receive services through home based primary care (HBPC) with weekly lab draws and medication administration. Ultimately, the patient was able to receive the first dose of luspatercept through the NTO affiliated VA with subsequent administrations to be given by HBPC. Additional visits planned using at home VA video Connect (VVC) service and CVT visits with NTO hematology at his local community based outpatient center (CBOC) located 30 miles from his home.

DISCUSSION

Located over 3 hours from the closest in-person VA hematologist, this patient was able to receive complex care thanks to a marriage of in-person and virtual services involving specialty nurses, pharmacists, and physicians from across VA. Services such as the NTO hub-spoke model, virtual tumor boards and HBPC, reveal a care framework unique to the VA.

INTRODUCTION

Fragmentation of medical services is a significant barrier in modern patient care with contributing factors including patient and system level details. The Veterans Affairs (VA) department is the largest integrated health care organization in the US. Given the complex challenges of such a system, the VA has developed resources to lessen the impact of care fragmentation, potentially widening services and diminishing traditional barriers to care. We present a patient case as an example of how VA programs are impacting current veteran oncologic care.

CASE PRESENTATION

An 86-year-old veteran with shortness of breath and fatigue was found to have macrocytic anemia. Located nearly 200 miles from the closest VA with hematology services he was referred through the National TeleOncology (NTO) service to see hematology using clinical video telehealth (CVT) technology stationed at a VA approximately 100 miles from his home. Consultation led to lab work revealing no viral, nutritional, or rheumatologic explanation. A bone marrow biopsy was completed without clear diagnosis though molecular alterations demonstrated ASXL1, TET2 and CBL mutations. Hematopathology services were sought, and the patient’s case was presented at the NTO virtual hematologic tumor board where expert VA hematopathology, radiology and medical hematology opinions were available. A diagnosis of myelodysplastic syndrome was rendered with care recommendations including the novel agent luspatercept. Given patient age and comorbidities, transportation remained a barrier. The patient was set up to receive services through home based primary care (HBPC) with weekly lab draws and medication administration. Ultimately, the patient was able to receive the first dose of luspatercept through the NTO affiliated VA with subsequent administrations to be given by HBPC. Additional visits planned using at home VA video Connect (VVC) service and CVT visits with NTO hematology at his local community based outpatient center (CBOC) located 30 miles from his home.

DISCUSSION

Located over 3 hours from the closest in-person VA hematologist, this patient was able to receive complex care thanks to a marriage of in-person and virtual services involving specialty nurses, pharmacists, and physicians from across VA. Services such as the NTO hub-spoke model, virtual tumor boards and HBPC, reveal a care framework unique to the VA.

BACKGROUND

Implementation of lung cancer screening (LCS) in high-risk individuals reduces the risk of dying from lung cancer. The mortality benefit of LCS, however, can only be fully actualized in patients who adhere to follow-up screening examinations. Question: Does a centralized program offer better adherence to lung cancer screening compared with a decentralized approach?

METHODS

A retrospective analysis of a large Veterans Affairs medical center LCS program was conducted to compare adherence to follow-up screening in veterans established through the consult-based (centralized) program with those screened by primary care providers (decentralized). In addition, imaging referral rates from the centralized program were longitudinally reviewed and compared. The cohort included patients completing an LCS imaging examination between 10/2020 and 1/2022. Annual adherence was assessed in patients with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2 and was defined as returning for follow-up imaging within 15 months. Outcomes among patients undergoing screening using a centralized and decentralized approach were compared using a two-proportion z-test.

RESULTS

A total of 1,114 patients with a baseline Lung-RADS score of 1 or 2 were included. The amount of low-dose CT (LDCT) imaging ordered for LCS increased exponentially from 2021 to 2023; however, a higher percentage of LDCT examinations were ordered via the decentralized approach, with no significant change observed over time (76%, 71%, and 74% in 2021, 2022, and 2023, respectively). Overall adherence was 42%. Within the centralized program, adherence was 74% compared to 34% using a decentralized approach (p <0.001).

IMPLICATIONS

Adherence to annual screening among eligible veterans is greater within a centralized program. Future research aimed at identifying barriers and maximizing adherence to LCS is needed.

BACKGROUND

Implementation of lung cancer screening (LCS) in high-risk individuals reduces the risk of dying from lung cancer. The mortality benefit of LCS, however, can only be fully actualized in patients who adhere to follow-up screening examinations. Question: Does a centralized program offer better adherence to lung cancer screening compared with a decentralized approach?

METHODS

A retrospective analysis of a large Veterans Affairs medical center LCS program was conducted to compare adherence to follow-up screening in veterans established through the consult-based (centralized) program with those screened by primary care providers (decentralized). In addition, imaging referral rates from the centralized program were longitudinally reviewed and compared. The cohort included patients completing an LCS imaging examination between 10/2020 and 1/2022. Annual adherence was assessed in patients with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2 and was defined as returning for follow-up imaging within 15 months. Outcomes among patients undergoing screening using a centralized and decentralized approach were compared using a two-proportion z-test.

RESULTS

A total of 1,114 patients with a baseline Lung-RADS score of 1 or 2 were included. The amount of low-dose CT (LDCT) imaging ordered for LCS increased exponentially from 2021 to 2023; however, a higher percentage of LDCT examinations were ordered via the decentralized approach, with no significant change observed over time (76%, 71%, and 74% in 2021, 2022, and 2023, respectively). Overall adherence was 42%. Within the centralized program, adherence was 74% compared to 34% using a decentralized approach (p <0.001).

IMPLICATIONS

Adherence to annual screening among eligible veterans is greater within a centralized program. Future research aimed at identifying barriers and maximizing adherence to LCS is needed.

BACKGROUND

Implementation of lung cancer screening (LCS) in high-risk individuals reduces the risk of dying from lung cancer. The mortality benefit of LCS, however, can only be fully actualized in patients who adhere to follow-up screening examinations. Question: Does a centralized program offer better adherence to lung cancer screening compared with a decentralized approach?

METHODS

A retrospective analysis of a large Veterans Affairs medical center LCS program was conducted to compare adherence to follow-up screening in veterans established through the consult-based (centralized) program with those screened by primary care providers (decentralized). In addition, imaging referral rates from the centralized program were longitudinally reviewed and compared. The cohort included patients completing an LCS imaging examination between 10/2020 and 1/2022. Annual adherence was assessed in patients with a baseline Lung CT Screening Reporting and Data System (Lung-RADS) score of 1 or 2 and was defined as returning for follow-up imaging within 15 months. Outcomes among patients undergoing screening using a centralized and decentralized approach were compared using a two-proportion z-test.

RESULTS

A total of 1,114 patients with a baseline Lung-RADS score of 1 or 2 were included. The amount of low-dose CT (LDCT) imaging ordered for LCS increased exponentially from 2021 to 2023; however, a higher percentage of LDCT examinations were ordered via the decentralized approach, with no significant change observed over time (76%, 71%, and 74% in 2021, 2022, and 2023, respectively). Overall adherence was 42%. Within the centralized program, adherence was 74% compared to 34% using a decentralized approach (p <0.001).

IMPLICATIONS

Adherence to annual screening among eligible veterans is greater within a centralized program. Future research aimed at identifying barriers and maximizing adherence to LCS is needed.

INTRODUCTION

The development of imatinib and now newer tyrosine kinase inhibitors (TKIs) has revolutionized the overall survival of patients with CML. However, toxicity and treatment-resistance can result in premature discontinuation of therapy. Asciminib, a novel TKI, may have fewer off-target effects. It also bypasses the mechanism of resistance to first-line TKIs by binding to a different site on the BCR-ABL fusion protein. In our institution, three patients have been initiated on asciminib thus far. We present their cases, with a focus on quality of life.

CASE PRESENTATIONS

(1) A 76-year-old male with a history of diffuse vascular disease experienced off-target effects on multiple TKIs (i.e. intolerable nausea on imatinib, pleural effusion on dasatinib, complete heart block on nilotinib), so he was switched to asciminib. He has been tolerating asciminib well over five months and continues to see significant log reduction in BCR-ABL transcripts. (2) A 71-year-old male with a history of multiple complicated gastrointestinal infections never achieved major molecular remission on imatinib and was unable to tolerate dasatinib or bosutinib due to severe nausea and vomiting. He was switched to asciminib, which he has been tolerating well for one year, and has achieved complete hematologic response. (3) A 73-year-old male with a history of chronic kidney disease experienced kidney injury thought to be due to imatinib and was switched to bosutinib. His BCRABL transcripts rose on bosutinib, so patient was started on asciminib, which he has been tolerating well.

DISCUSSION

In this series of patients in their 70s with multiple underlying comorbidities, the unifying theme is that of intolerance to first-line TKIs due to toxicity (cardiac, pulmonary, gastrointestinal, and renal). Existing data suggests that asciminib results in less toxicity than other first-line TKIs, and this is evident in our patients. More importantly, the combination of efficacy and tolerability gives these patients the opportunity to proceed with life-prolonging therapy, even for those who face treatment resistance with other agents.

CONCLUSIONS

For CML patients who have failed at least two lines of treatment, whether it is due to disease progression or intolerable toxicity, asciminib is an effective alternative. Further study may result in its promotion to first-line therapy for this disease.

INTRODUCTION

The development of imatinib and now newer tyrosine kinase inhibitors (TKIs) has revolutionized the overall survival of patients with CML. However, toxicity and treatment-resistance can result in premature discontinuation of therapy. Asciminib, a novel TKI, may have fewer off-target effects. It also bypasses the mechanism of resistance to first-line TKIs by binding to a different site on the BCR-ABL fusion protein. In our institution, three patients have been initiated on asciminib thus far. We present their cases, with a focus on quality of life.

CASE PRESENTATIONS

(1) A 76-year-old male with a history of diffuse vascular disease experienced off-target effects on multiple TKIs (i.e. intolerable nausea on imatinib, pleural effusion on dasatinib, complete heart block on nilotinib), so he was switched to asciminib. He has been tolerating asciminib well over five months and continues to see significant log reduction in BCR-ABL transcripts. (2) A 71-year-old male with a history of multiple complicated gastrointestinal infections never achieved major molecular remission on imatinib and was unable to tolerate dasatinib or bosutinib due to severe nausea and vomiting. He was switched to asciminib, which he has been tolerating well for one year, and has achieved complete hematologic response. (3) A 73-year-old male with a history of chronic kidney disease experienced kidney injury thought to be due to imatinib and was switched to bosutinib. His BCRABL transcripts rose on bosutinib, so patient was started on asciminib, which he has been tolerating well.

DISCUSSION

In this series of patients in their 70s with multiple underlying comorbidities, the unifying theme is that of intolerance to first-line TKIs due to toxicity (cardiac, pulmonary, gastrointestinal, and renal). Existing data suggests that asciminib results in less toxicity than other first-line TKIs, and this is evident in our patients. More importantly, the combination of efficacy and tolerability gives these patients the opportunity to proceed with life-prolonging therapy, even for those who face treatment resistance with other agents.

CONCLUSIONS

For CML patients who have failed at least two lines of treatment, whether it is due to disease progression or intolerable toxicity, asciminib is an effective alternative. Further study may result in its promotion to first-line therapy for this disease.

INTRODUCTION

The development of imatinib and now newer tyrosine kinase inhibitors (TKIs) has revolutionized the overall survival of patients with CML. However, toxicity and treatment-resistance can result in premature discontinuation of therapy. Asciminib, a novel TKI, may have fewer off-target effects. It also bypasses the mechanism of resistance to first-line TKIs by binding to a different site on the BCR-ABL fusion protein. In our institution, three patients have been initiated on asciminib thus far. We present their cases, with a focus on quality of life.

CASE PRESENTATIONS

(1) A 76-year-old male with a history of diffuse vascular disease experienced off-target effects on multiple TKIs (i.e. intolerable nausea on imatinib, pleural effusion on dasatinib, complete heart block on nilotinib), so he was switched to asciminib. He has been tolerating asciminib well over five months and continues to see significant log reduction in BCR-ABL transcripts. (2) A 71-year-old male with a history of multiple complicated gastrointestinal infections never achieved major molecular remission on imatinib and was unable to tolerate dasatinib or bosutinib due to severe nausea and vomiting. He was switched to asciminib, which he has been tolerating well for one year, and has achieved complete hematologic response. (3) A 73-year-old male with a history of chronic kidney disease experienced kidney injury thought to be due to imatinib and was switched to bosutinib. His BCRABL transcripts rose on bosutinib, so patient was started on asciminib, which he has been tolerating well.

DISCUSSION

In this series of patients in their 70s with multiple underlying comorbidities, the unifying theme is that of intolerance to first-line TKIs due to toxicity (cardiac, pulmonary, gastrointestinal, and renal). Existing data suggests that asciminib results in less toxicity than other first-line TKIs, and this is evident in our patients. More importantly, the combination of efficacy and tolerability gives these patients the opportunity to proceed with life-prolonging therapy, even for those who face treatment resistance with other agents.

CONCLUSIONS

For CML patients who have failed at least two lines of treatment, whether it is due to disease progression or intolerable toxicity, asciminib is an effective alternative. Further study may result in its promotion to first-line therapy for this disease.

PURPOSE

This quality improvement project aimed at addressing the issue of long waiting times in the hematology/ oncology clinic at Stratton VA Medical Center, aiming to improve the delivery time of infusion drugs and enhance patient care.

BACKGROUND

Patient feedback indicated that long waiting times were a significant barrier to care, with 32% of patients identifying this as an issue. Prolonged wait times in the healthcare setting can have various negative consequences, including increased patient dissatisfaction, reduced patient engagement, compromised patient safety, and increased healthcare costs.

METHODS

An interdisciplinary team comprising physicians, nurses, and pharmacists conducted a study to identify the primary contributors to extended wait times. Inadequate preparation for patients with complex infusion needs and delays in administering premedications were identified as the key factors. Wait times were measured using two variables: Go To Label Print (GTLP) and Go To First Bag Scanned (GTFS). Baseline data were collected showing a median GTLP of 8 minutes and a median GTFS of 67 minutes.

DATA ANALYSIS

The team analyzed real-time data related to wait times and the impact of interventions.

RESULTS

Two interventions were implemented: 1) redistributing patients with complex needs across the schedule and 2) adding premedications to the automated medication dispensing system. Postintervention analysis revealed a significant improvement in wait times. The median GTLP decreased to 2 minutes, and the median GTFS reduced to 53 minutes, representing a 75% improvement in GTLP and a 21% improvement in GTFS. These changes are estimated to save 303 patient hours annually.

IMPLICATIONS

This quality improvement project highlighted the significance of addressing long wait times, as they can significantly impact patient care. The team’s efforts, including the analysis of real-time data, interprofessional collaboration, and the implementation of sustainable changes through Plan-Do- Study-Act cycles, successfully improved infusion drug delivery time. These findings and interventions can serve as a model for other healthcare facilities seeking to streamline workflow in infusion centers and enhance patient care.

PURPOSE

This quality improvement project aimed at addressing the issue of long waiting times in the hematology/ oncology clinic at Stratton VA Medical Center, aiming to improve the delivery time of infusion drugs and enhance patient care.

BACKGROUND

Patient feedback indicated that long waiting times were a significant barrier to care, with 32% of patients identifying this as an issue. Prolonged wait times in the healthcare setting can have various negative consequences, including increased patient dissatisfaction, reduced patient engagement, compromised patient safety, and increased healthcare costs.

METHODS

An interdisciplinary team comprising physicians, nurses, and pharmacists conducted a study to identify the primary contributors to extended wait times. Inadequate preparation for patients with complex infusion needs and delays in administering premedications were identified as the key factors. Wait times were measured using two variables: Go To Label Print (GTLP) and Go To First Bag Scanned (GTFS). Baseline data were collected showing a median GTLP of 8 minutes and a median GTFS of 67 minutes.

DATA ANALYSIS

The team analyzed real-time data related to wait times and the impact of interventions.

RESULTS

Two interventions were implemented: 1) redistributing patients with complex needs across the schedule and 2) adding premedications to the automated medication dispensing system. Postintervention analysis revealed a significant improvement in wait times. The median GTLP decreased to 2 minutes, and the median GTFS reduced to 53 minutes, representing a 75% improvement in GTLP and a 21% improvement in GTFS. These changes are estimated to save 303 patient hours annually.

IMPLICATIONS

This quality improvement project highlighted the significance of addressing long wait times, as they can significantly impact patient care. The team’s efforts, including the analysis of real-time data, interprofessional collaboration, and the implementation of sustainable changes through Plan-Do- Study-Act cycles, successfully improved infusion drug delivery time. These findings and interventions can serve as a model for other healthcare facilities seeking to streamline workflow in infusion centers and enhance patient care.

PURPOSE

This quality improvement project aimed at addressing the issue of long waiting times in the hematology/ oncology clinic at Stratton VA Medical Center, aiming to improve the delivery time of infusion drugs and enhance patient care.

BACKGROUND

Patient feedback indicated that long waiting times were a significant barrier to care, with 32% of patients identifying this as an issue. Prolonged wait times in the healthcare setting can have various negative consequences, including increased patient dissatisfaction, reduced patient engagement, compromised patient safety, and increased healthcare costs.

METHODS

An interdisciplinary team comprising physicians, nurses, and pharmacists conducted a study to identify the primary contributors to extended wait times. Inadequate preparation for patients with complex infusion needs and delays in administering premedications were identified as the key factors. Wait times were measured using two variables: Go To Label Print (GTLP) and Go To First Bag Scanned (GTFS). Baseline data were collected showing a median GTLP of 8 minutes and a median GTFS of 67 minutes.

DATA ANALYSIS

The team analyzed real-time data related to wait times and the impact of interventions.

RESULTS

Two interventions were implemented: 1) redistributing patients with complex needs across the schedule and 2) adding premedications to the automated medication dispensing system. Postintervention analysis revealed a significant improvement in wait times. The median GTLP decreased to 2 minutes, and the median GTFS reduced to 53 minutes, representing a 75% improvement in GTLP and a 21% improvement in GTFS. These changes are estimated to save 303 patient hours annually.

IMPLICATIONS

This quality improvement project highlighted the significance of addressing long wait times, as they can significantly impact patient care. The team’s efforts, including the analysis of real-time data, interprofessional collaboration, and the implementation of sustainable changes through Plan-Do- Study-Act cycles, successfully improved infusion drug delivery time. These findings and interventions can serve as a model for other healthcare facilities seeking to streamline workflow in infusion centers and enhance patient care.

BACKGROUND

Leiomyosarcoma is a rare neoplasm of smooth muscle that can originate from various organ systems. Of the gastrointestinal tract, the rarity and the difficulty of diagnosing small intestine leiomyosarcoma affect its poor prognosis. With an average age of diagnosis of 64 years and a median life expectancy of 45 months, there exists a lack of information on the disparities that exist in these patients and how patient demographics contribute to differences in survival outcomes.

METHODS

We used the National Cancer Database to identify patients diagnosed with small intestine leiomyosarcoma (ICD-O-3 histology code 8890) between 2004-2019 (N=406). General patient characteristics were assessed using descriptive statistics. Survival was evaluated using Kaplan-Meier curves and log-rank tests. Significance was set at p<0.05.

RESULTS

When analyzing race, patients diagnosed with small intestine leiomyosarcoma were predominantly White (81.8%) and African American (14.3%); however, White patients had statistically worse survival outcomes than African Americans (67 vs 97 months) (p=0.004). Patients with private insurance had statistically better outcomes when compared to Medicare (p<0.001). When compared to White patients, African Americans had a higher proportion of private insurance (53.4% vs 37.2%) and lower proportion of Medicare coverage (5.2% and 48.2%), a lower average age of diagnosis (60.5 vs 64.7 years), shorter travel distances (14.7 vs 31.1 miles) and fewer days between staging procedure and surgical diagnostics from initial diagnosis (4.54 vs 12.5 days). Patients who received surgical intervention had a statistically significant improved survival outcome than those who did not (78 vs 15 months) (p<0.001) with the majority of these procedures being partial gastrectomies (53.6%). More patients of the cohort were treated at comprehensive community cancer programs (36.2%), followed by academic research programs (32.0%), integrated network cancer programs (18.5%) and community cancer programs (8.6%).

CONCLUSIONS

Factors associated with increased survival outcomes include race, average age of diagnosis, travel distance, fewer days between diagnostic procedure and initial diagnosis, insurance status and surgical treatment. These findings make a valuable contribution to the ongoing research on disparities affecting survival in patients with small intestine leiomyosarcoma.

BACKGROUND

Leiomyosarcoma is a rare neoplasm of smooth muscle that can originate from various organ systems. Of the gastrointestinal tract, the rarity and the difficulty of diagnosing small intestine leiomyosarcoma affect its poor prognosis. With an average age of diagnosis of 64 years and a median life expectancy of 45 months, there exists a lack of information on the disparities that exist in these patients and how patient demographics contribute to differences in survival outcomes.

METHODS

We used the National Cancer Database to identify patients diagnosed with small intestine leiomyosarcoma (ICD-O-3 histology code 8890) between 2004-2019 (N=406). General patient characteristics were assessed using descriptive statistics. Survival was evaluated using Kaplan-Meier curves and log-rank tests. Significance was set at p<0.05.

RESULTS

When analyzing race, patients diagnosed with small intestine leiomyosarcoma were predominantly White (81.8%) and African American (14.3%); however, White patients had statistically worse survival outcomes than African Americans (67 vs 97 months) (p=0.004). Patients with private insurance had statistically better outcomes when compared to Medicare (p<0.001). When compared to White patients, African Americans had a higher proportion of private insurance (53.4% vs 37.2%) and lower proportion of Medicare coverage (5.2% and 48.2%), a lower average age of diagnosis (60.5 vs 64.7 years), shorter travel distances (14.7 vs 31.1 miles) and fewer days between staging procedure and surgical diagnostics from initial diagnosis (4.54 vs 12.5 days). Patients who received surgical intervention had a statistically significant improved survival outcome than those who did not (78 vs 15 months) (p<0.001) with the majority of these procedures being partial gastrectomies (53.6%). More patients of the cohort were treated at comprehensive community cancer programs (36.2%), followed by academic research programs (32.0%), integrated network cancer programs (18.5%) and community cancer programs (8.6%).

CONCLUSIONS

Factors associated with increased survival outcomes include race, average age of diagnosis, travel distance, fewer days between diagnostic procedure and initial diagnosis, insurance status and surgical treatment. These findings make a valuable contribution to the ongoing research on disparities affecting survival in patients with small intestine leiomyosarcoma.

BACKGROUND

Leiomyosarcoma is a rare neoplasm of smooth muscle that can originate from various organ systems. Of the gastrointestinal tract, the rarity and the difficulty of diagnosing small intestine leiomyosarcoma affect its poor prognosis. With an average age of diagnosis of 64 years and a median life expectancy of 45 months, there exists a lack of information on the disparities that exist in these patients and how patient demographics contribute to differences in survival outcomes.

METHODS

We used the National Cancer Database to identify patients diagnosed with small intestine leiomyosarcoma (ICD-O-3 histology code 8890) between 2004-2019 (N=406). General patient characteristics were assessed using descriptive statistics. Survival was evaluated using Kaplan-Meier curves and log-rank tests. Significance was set at p<0.05.

RESULTS

When analyzing race, patients diagnosed with small intestine leiomyosarcoma were predominantly White (81.8%) and African American (14.3%); however, White patients had statistically worse survival outcomes than African Americans (67 vs 97 months) (p=0.004). Patients with private insurance had statistically better outcomes when compared to Medicare (p<0.001). When compared to White patients, African Americans had a higher proportion of private insurance (53.4% vs 37.2%) and lower proportion of Medicare coverage (5.2% and 48.2%), a lower average age of diagnosis (60.5 vs 64.7 years), shorter travel distances (14.7 vs 31.1 miles) and fewer days between staging procedure and surgical diagnostics from initial diagnosis (4.54 vs 12.5 days). Patients who received surgical intervention had a statistically significant improved survival outcome than those who did not (78 vs 15 months) (p<0.001) with the majority of these procedures being partial gastrectomies (53.6%). More patients of the cohort were treated at comprehensive community cancer programs (36.2%), followed by academic research programs (32.0%), integrated network cancer programs (18.5%) and community cancer programs (8.6%).

CONCLUSIONS

Factors associated with increased survival outcomes include race, average age of diagnosis, travel distance, fewer days between diagnostic procedure and initial diagnosis, insurance status and surgical treatment. These findings make a valuable contribution to the ongoing research on disparities affecting survival in patients with small intestine leiomyosarcoma.

BACKGROUND

While the MISSION Act for community care has increased Veteran access to specialty services, this has caused considerable fragmentation of care and financial cost to U.S. taxpayers. The VA Salt Lake City Health Care System (VA SLCHCS) referral area spans 125,000 square miles, one of the largest geographic regions in the VA health care system. Numerous VA Community- Based Outpatient Clinics (CBOCs) have been established in central and southern Utah, eastern Nevada, and southern Idaho; however, these clinics do not currently provide specialty services.

DISCUSSION

In conjunction with the National Oncology Program’s Close to Me project team, we conducted a cost analysis to determine financial feasibility of providing low-risk oncology parenteral therapies at rural CBOCs. Based on FY22 DO Paid Claim PowerBI and Pyramid Analytics Reports, VA SLCHCS paid claims for Community Care Hematology/Oncology community services in excess of $5.7 million for 380 unique Veterans (approximately $15,060 per unique Veteran). Comparatively, Veterans received high quality oncology care through VA SLCHCS with an estimated average cost of care of $5,424 per unique Veteran. Cost of parenteral therapies was estimated via review of Community Care Paid Claims Reports for individual drug claim costs (based on Jcode), VA drug pricing data from the VA National Acquisition Center Catalog, and drug unit claims data. The unit price of VA-care and community care costs were calculated and drug cost at the VA versus non- VA was compared. By retaining or re-establishing Hematology/Oncology Veteran care within VA, we estimate cost savings of approximately $9,636 per unique Veteran.

CONCLUSIONS

By re-establishing oncology care within VA SLCHCS the facility could net a substantial cost savings while simultaneously making Veterans lives easier, reduce need for transportation to/from the main SLC VA site, decrease costs due to VA pricing contracts, lessen Veteran out-of-pocket costs, improve care coordination through use of one electronic medical record, and maintain Veteran care within VA SLCHCS. Additionally, VA SLCHCS oncology will help lead the effort to launch a system within the CBOC’s to deliver high-cost parental therapies that could benefit other medical specialties such as gastroenterology, dermatology, and rheumatology.

BACKGROUND

While the MISSION Act for community care has increased Veteran access to specialty services, this has caused considerable fragmentation of care and financial cost to U.S. taxpayers. The VA Salt Lake City Health Care System (VA SLCHCS) referral area spans 125,000 square miles, one of the largest geographic regions in the VA health care system. Numerous VA Community- Based Outpatient Clinics (CBOCs) have been established in central and southern Utah, eastern Nevada, and southern Idaho; however, these clinics do not currently provide specialty services.

DISCUSSION

In conjunction with the National Oncology Program’s Close to Me project team, we conducted a cost analysis to determine financial feasibility of providing low-risk oncology parenteral therapies at rural CBOCs. Based on FY22 DO Paid Claim PowerBI and Pyramid Analytics Reports, VA SLCHCS paid claims for Community Care Hematology/Oncology community services in excess of $5.7 million for 380 unique Veterans (approximately $15,060 per unique Veteran). Comparatively, Veterans received high quality oncology care through VA SLCHCS with an estimated average cost of care of $5,424 per unique Veteran. Cost of parenteral therapies was estimated via review of Community Care Paid Claims Reports for individual drug claim costs (based on Jcode), VA drug pricing data from the VA National Acquisition Center Catalog, and drug unit claims data. The unit price of VA-care and community care costs were calculated and drug cost at the VA versus non- VA was compared. By retaining or re-establishing Hematology/Oncology Veteran care within VA, we estimate cost savings of approximately $9,636 per unique Veteran.

CONCLUSIONS

By re-establishing oncology care within VA SLCHCS the facility could net a substantial cost savings while simultaneously making Veterans lives easier, reduce need for transportation to/from the main SLC VA site, decrease costs due to VA pricing contracts, lessen Veteran out-of-pocket costs, improve care coordination through use of one electronic medical record, and maintain Veteran care within VA SLCHCS. Additionally, VA SLCHCS oncology will help lead the effort to launch a system within the CBOC’s to deliver high-cost parental therapies that could benefit other medical specialties such as gastroenterology, dermatology, and rheumatology.

BACKGROUND

While the MISSION Act for community care has increased Veteran access to specialty services, this has caused considerable fragmentation of care and financial cost to U.S. taxpayers. The VA Salt Lake City Health Care System (VA SLCHCS) referral area spans 125,000 square miles, one of the largest geographic regions in the VA health care system. Numerous VA Community- Based Outpatient Clinics (CBOCs) have been established in central and southern Utah, eastern Nevada, and southern Idaho; however, these clinics do not currently provide specialty services.

DISCUSSION

In conjunction with the National Oncology Program’s Close to Me project team, we conducted a cost analysis to determine financial feasibility of providing low-risk oncology parenteral therapies at rural CBOCs. Based on FY22 DO Paid Claim PowerBI and Pyramid Analytics Reports, VA SLCHCS paid claims for Community Care Hematology/Oncology community services in excess of $5.7 million for 380 unique Veterans (approximately $15,060 per unique Veteran). Comparatively, Veterans received high quality oncology care through VA SLCHCS with an estimated average cost of care of $5,424 per unique Veteran. Cost of parenteral therapies was estimated via review of Community Care Paid Claims Reports for individual drug claim costs (based on Jcode), VA drug pricing data from the VA National Acquisition Center Catalog, and drug unit claims data. The unit price of VA-care and community care costs were calculated and drug cost at the VA versus non- VA was compared. By retaining or re-establishing Hematology/Oncology Veteran care within VA, we estimate cost savings of approximately $9,636 per unique Veteran.

CONCLUSIONS

By re-establishing oncology care within VA SLCHCS the facility could net a substantial cost savings while simultaneously making Veterans lives easier, reduce need for transportation to/from the main SLC VA site, decrease costs due to VA pricing contracts, lessen Veteran out-of-pocket costs, improve care coordination through use of one electronic medical record, and maintain Veteran care within VA SLCHCS. Additionally, VA SLCHCS oncology will help lead the effort to launch a system within the CBOC’s to deliver high-cost parental therapies that could benefit other medical specialties such as gastroenterology, dermatology, and rheumatology.

PURPOSE

To evaluate if low molecular weight iron dextran (LMWID) is a safe and effective alternative to iron sucrose for intravenous iron administration.

BACKGROUND

In recent years, intravenous iron administration has increased due to clinical indications and rapid iron repletion. Early IV iron formulations had safety concerns that precluded widespread use. High molecular weight iron dextran was removed from the US market in 2009 due to safety concerns. Since then, several new IV formulations including LMWID and iron sucrose have been approved with a favorable benefit risk profile. While recent evidence and guidelines indicate that LMWID and other iron formulations have comparable safety profiles, no head-to-head comparisons exist. Both iron sucrose and LMWID are used for the treatment of IDA in Veterans Affairs hospitals. Iron sucrose is given 200 mg weekly for 5 weeks, while LMWID is given as a single 1-gram dose over 3 hours. We conducted a retrospective crosssectional analysis to compare the safety and efficacy of IV LMWID to IV iron sucrose.

METHODS

We identified 129 patients (LMWID: n=29, iron sucrose: n=100) who received intravenous iron from 01/01/2022 to 03/03/2023. To match the sample size, we selected every 3rd patient from the iron sucrose group (n=33). We captured data on infusion-related reactions, history of asthma/inflammatory bowel disease/> 2 drug allergies, overall and ≥ 2 g/dL hemoglobin increase, and treatment cost. Descriptive statistics were used to describe the safety and efficacy parameters. An unpaired t-test was used to calculate statistical significance of the cost.

RESULTS

We found that 82.7% of the patients who received LMWID had an increase in hemoglobin vs. 60.6% in the iron sucrose group. 48.3% of patients in LMWID had ≥ 2 hemoglobin increases vs. 27.3% in the iron sucrose group. The cost for LMWID administration was $2016.10, compared to $2315.40 for administration of IV iron sucrose cost. Two-tailed p value < 0.0001 indicating the observed difference to be statistically significant. No infusion reactions were observed in both groups.

CONCLUSIONS

In this single center analysis, IV LMWID administered provided comparable safety, and improved effectiveness, and cost-effectiveness to iron sucrose.

PURPOSE

To evaluate if low molecular weight iron dextran (LMWID) is a safe and effective alternative to iron sucrose for intravenous iron administration.

BACKGROUND

In recent years, intravenous iron administration has increased due to clinical indications and rapid iron repletion. Early IV iron formulations had safety concerns that precluded widespread use. High molecular weight iron dextran was removed from the US market in 2009 due to safety concerns. Since then, several new IV formulations including LMWID and iron sucrose have been approved with a favorable benefit risk profile. While recent evidence and guidelines indicate that LMWID and other iron formulations have comparable safety profiles, no head-to-head comparisons exist. Both iron sucrose and LMWID are used for the treatment of IDA in Veterans Affairs hospitals. Iron sucrose is given 200 mg weekly for 5 weeks, while LMWID is given as a single 1-gram dose over 3 hours. We conducted a retrospective crosssectional analysis to compare the safety and efficacy of IV LMWID to IV iron sucrose.

METHODS

We identified 129 patients (LMWID: n=29, iron sucrose: n=100) who received intravenous iron from 01/01/2022 to 03/03/2023. To match the sample size, we selected every 3rd patient from the iron sucrose group (n=33). We captured data on infusion-related reactions, history of asthma/inflammatory bowel disease/> 2 drug allergies, overall and ≥ 2 g/dL hemoglobin increase, and treatment cost. Descriptive statistics were used to describe the safety and efficacy parameters. An unpaired t-test was used to calculate statistical significance of the cost.

RESULTS

We found that 82.7% of the patients who received LMWID had an increase in hemoglobin vs. 60.6% in the iron sucrose group. 48.3% of patients in LMWID had ≥ 2 hemoglobin increases vs. 27.3% in the iron sucrose group. The cost for LMWID administration was $2016.10, compared to $2315.40 for administration of IV iron sucrose cost. Two-tailed p value < 0.0001 indicating the observed difference to be statistically significant. No infusion reactions were observed in both groups.

CONCLUSIONS

In this single center analysis, IV LMWID administered provided comparable safety, and improved effectiveness, and cost-effectiveness to iron sucrose.

PURPOSE

To evaluate if low molecular weight iron dextran (LMWID) is a safe and effective alternative to iron sucrose for intravenous iron administration.

BACKGROUND

In recent years, intravenous iron administration has increased due to clinical indications and rapid iron repletion. Early IV iron formulations had safety concerns that precluded widespread use. High molecular weight iron dextran was removed from the US market in 2009 due to safety concerns. Since then, several new IV formulations including LMWID and iron sucrose have been approved with a favorable benefit risk profile. While recent evidence and guidelines indicate that LMWID and other iron formulations have comparable safety profiles, no head-to-head comparisons exist. Both iron sucrose and LMWID are used for the treatment of IDA in Veterans Affairs hospitals. Iron sucrose is given 200 mg weekly for 5 weeks, while LMWID is given as a single 1-gram dose over 3 hours. We conducted a retrospective crosssectional analysis to compare the safety and efficacy of IV LMWID to IV iron sucrose.

METHODS

We identified 129 patients (LMWID: n=29, iron sucrose: n=100) who received intravenous iron from 01/01/2022 to 03/03/2023. To match the sample size, we selected every 3rd patient from the iron sucrose group (n=33). We captured data on infusion-related reactions, history of asthma/inflammatory bowel disease/> 2 drug allergies, overall and ≥ 2 g/dL hemoglobin increase, and treatment cost. Descriptive statistics were used to describe the safety and efficacy parameters. An unpaired t-test was used to calculate statistical significance of the cost.

RESULTS

We found that 82.7% of the patients who received LMWID had an increase in hemoglobin vs. 60.6% in the iron sucrose group. 48.3% of patients in LMWID had ≥ 2 hemoglobin increases vs. 27.3% in the iron sucrose group. The cost for LMWID administration was $2016.10, compared to $2315.40 for administration of IV iron sucrose cost. Two-tailed p value < 0.0001 indicating the observed difference to be statistically significant. No infusion reactions were observed in both groups.

CONCLUSIONS

In this single center analysis, IV LMWID administered provided comparable safety, and improved effectiveness, and cost-effectiveness to iron sucrose.

PURPOSE

To construct a composite score representing modifiable lifestyle and environmental risk (e-score) and test for associations with colonoscopy findings among US Veteran participants of CSP #380.

BACKGROUND

Understanding environmental and genetic risks beyond self-reported family history is a way to develop personalized colorectal cancer (CRC) screening. The Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO) study examined CRC risk stratified by sex and included an e-score along with genetic risk scores, where higher scores indicated higher risk. Both e-scores and genetic risk scores were significantly associated with CRC risk and models that included these were more robust than models that only included family history.

METHODS

CSP #380 is a prospective study of outcomes during colonoscopy screening (1994-97) and follow- up (1994-2009) for 3,121 asymptomatic Veterans aged 50-75. The dichotomous outcome of interest was most significant colonoscopy findings (MSCF) of i) advanced neoplasia (AN: ≥10mm adenomas or advanced histology, or invasive CRC) vs. ii) non-advanced adenomas (<10mm with tubular histology) or no neoplasia. The independent variable, e-score, was weighted according to the GECCO male sample and comprised BMI, height, diabetes, NSAID use, education, alcohol intake, smoking, exercise, and diet.

DATA ANALYSIS

Logistic regression was used to test associations between MSCF and e-scores, controlling for age, family history and number of colonoscopies.

RESULTS

Among 2,846 participants with complete data, 33.3% were aged 50-59 at baseline, 97% were male, and 83.8% were White. Those with AN (n=405, 14.2%) compared to those without AN (n=2,441, 85.8%) had higher median e-scores (29.5, range:0-99.8 vs. 29.0, range:5.2-100), suggesting a difference. The logistic regression models showed older participants (aOR: 1.04, 95% CI: 1.03-1.06) and those with more colonoscopies (aOR: 1.19, 95% CI: 1.06-1.33) had higher odds for AN. However, e-scores and family history were not significantly associated with MCSF.

IMPLICATIONS

E-scores were not significantly associated with MSCF in this preliminary study. Developing escores among a larger, diverse sample (N~381,695) of US veterans in the Million Veterans Program study will allow for stratified models in investigations of environmental and genetic risk for CRC. Outcomes from those analyses will support advances in screening guidelines with tailored programs for long-term CRC prevention.

PURPOSE

To construct a composite score representing modifiable lifestyle and environmental risk (e-score) and test for associations with colonoscopy findings among US Veteran participants of CSP #380.

BACKGROUND

Understanding environmental and genetic risks beyond self-reported family history is a way to develop personalized colorectal cancer (CRC) screening. The Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO) study examined CRC risk stratified by sex and included an e-score along with genetic risk scores, where higher scores indicated higher risk. Both e-scores and genetic risk scores were significantly associated with CRC risk and models that included these were more robust than models that only included family history.

METHODS

CSP #380 is a prospective study of outcomes during colonoscopy screening (1994-97) and follow- up (1994-2009) for 3,121 asymptomatic Veterans aged 50-75. The dichotomous outcome of interest was most significant colonoscopy findings (MSCF) of i) advanced neoplasia (AN: ≥10mm adenomas or advanced histology, or invasive CRC) vs. ii) non-advanced adenomas (<10mm with tubular histology) or no neoplasia. The independent variable, e-score, was weighted according to the GECCO male sample and comprised BMI, height, diabetes, NSAID use, education, alcohol intake, smoking, exercise, and diet.

DATA ANALYSIS

Logistic regression was used to test associations between MSCF and e-scores, controlling for age, family history and number of colonoscopies.

RESULTS

Among 2,846 participants with complete data, 33.3% were aged 50-59 at baseline, 97% were male, and 83.8% were White. Those with AN (n=405, 14.2%) compared to those without AN (n=2,441, 85.8%) had higher median e-scores (29.5, range:0-99.8 vs. 29.0, range:5.2-100), suggesting a difference. The logistic regression models showed older participants (aOR: 1.04, 95% CI: 1.03-1.06) and those with more colonoscopies (aOR: 1.19, 95% CI: 1.06-1.33) had higher odds for AN. However, e-scores and family history were not significantly associated with MCSF.

IMPLICATIONS

E-scores were not significantly associated with MSCF in this preliminary study. Developing escores among a larger, diverse sample (N~381,695) of US veterans in the Million Veterans Program study will allow for stratified models in investigations of environmental and genetic risk for CRC. Outcomes from those analyses will support advances in screening guidelines with tailored programs for long-term CRC prevention.

PURPOSE

To construct a composite score representing modifiable lifestyle and environmental risk (e-score) and test for associations with colonoscopy findings among US Veteran participants of CSP #380.

BACKGROUND

Understanding environmental and genetic risks beyond self-reported family history is a way to develop personalized colorectal cancer (CRC) screening. The Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO) study examined CRC risk stratified by sex and included an e-score along with genetic risk scores, where higher scores indicated higher risk. Both e-scores and genetic risk scores were significantly associated with CRC risk and models that included these were more robust than models that only included family history.

METHODS

CSP #380 is a prospective study of outcomes during colonoscopy screening (1994-97) and follow- up (1994-2009) for 3,121 asymptomatic Veterans aged 50-75. The dichotomous outcome of interest was most significant colonoscopy findings (MSCF) of i) advanced neoplasia (AN: ≥10mm adenomas or advanced histology, or invasive CRC) vs. ii) non-advanced adenomas (<10mm with tubular histology) or no neoplasia. The independent variable, e-score, was weighted according to the GECCO male sample and comprised BMI, height, diabetes, NSAID use, education, alcohol intake, smoking, exercise, and diet.

DATA ANALYSIS

Logistic regression was used to test associations between MSCF and e-scores, controlling for age, family history and number of colonoscopies.

RESULTS

Among 2,846 participants with complete data, 33.3% were aged 50-59 at baseline, 97% were male, and 83.8% were White. Those with AN (n=405, 14.2%) compared to those without AN (n=2,441, 85.8%) had higher median e-scores (29.5, range:0-99.8 vs. 29.0, range:5.2-100), suggesting a difference. The logistic regression models showed older participants (aOR: 1.04, 95% CI: 1.03-1.06) and those with more colonoscopies (aOR: 1.19, 95% CI: 1.06-1.33) had higher odds for AN. However, e-scores and family history were not significantly associated with MCSF.

IMPLICATIONS

E-scores were not significantly associated with MSCF in this preliminary study. Developing escores among a larger, diverse sample (N~381,695) of US veterans in the Million Veterans Program study will allow for stratified models in investigations of environmental and genetic risk for CRC. Outcomes from those analyses will support advances in screening guidelines with tailored programs for long-term CRC prevention.

BACKGROUND

Tobacco use is a known factor in oncologic outcomes in Veterans. Lung cancer is not only the leading cause of cancer death in the U.S., but it is also more prevalent among Veterans. Tobacco use is underassessed and undertreated in healthcare settings. Newly diagnosed cancer patients seen at the Day-Treatment Center of Edward Hines Jr. VA Hospital were not consistently screened for tobacco use or appropriately referred to the hospital-based Tobacco Cessation Program.

PURPOSE

This quality improvement project was created to use existing resources to increase the percentage of newly diagnosed cancer patients screened for tobacco use based off the CoC Just ASK Quality Improvement Project and Clinical Study.

METHODS/DATA ANALYSIS

Using Plan-Do-Study- Act (PDSA) quality improvement methodology, a multidisciplinary team led by Oncology Nursing, Oncologists, Pharmacy, Social Work and Behavioral Health, to standardize processes to increase the percentage of tobacco use screening. The primary intervention was designating nurse educators to standardize the cancer treatment education process to include an assessment for tobacco by using the Just ASK criteria. The primary study goal was to increase tobacco use screening from 54.8% (Baseline Data) to 85% (Target State Goal).

RESULTS

Baseline number of tobacco screening in 2021 was 54.8%. From 1/1/22-6/30/22, 52.8% were screened using the Just ASK criteria. After the first PDSA cycle, from 7/1/22-12/31/22, tobacco screenings increased to 95.1%. PDSA cycle two revealed a 25% increase in Q1 accepting referrals. 62.5% of positive tobacco users agreed to accept care compared to 25% in PDSA cycle one.

CONCLUSIONS/IMPLICATIONS

The quality study met the primary goal of screening newly diagnosed cancer patients. The success of this project supported the use of existing VA hospital-based program resources such as educational materials, supportive medication, and behavioral counseling. Interventions directed at standardization of clinical workflow processes through nursing education and linkage to resources increased tobacco screening among newly diagnosed Veterans with cancer. Planned PDSA cycle two will spread standardized processes in the Rad/Onc Department and build capacity to offer smoking cessation assistance to newly diagnosed cancer patients who report as a current smoker. Annual VHA clinical reminders will be built in and satisfied by using an EMR tobacco screen template.

BACKGROUND

Tobacco use is a known factor in oncologic outcomes in Veterans. Lung cancer is not only the leading cause of cancer death in the U.S., but it is also more prevalent among Veterans. Tobacco use is underassessed and undertreated in healthcare settings. Newly diagnosed cancer patients seen at the Day-Treatment Center of Edward Hines Jr. VA Hospital were not consistently screened for tobacco use or appropriately referred to the hospital-based Tobacco Cessation Program.

PURPOSE

This quality improvement project was created to use existing resources to increase the percentage of newly diagnosed cancer patients screened for tobacco use based off the CoC Just ASK Quality Improvement Project and Clinical Study.

METHODS/DATA ANALYSIS

Using Plan-Do-Study- Act (PDSA) quality improvement methodology, a multidisciplinary team led by Oncology Nursing, Oncologists, Pharmacy, Social Work and Behavioral Health, to standardize processes to increase the percentage of tobacco use screening. The primary intervention was designating nurse educators to standardize the cancer treatment education process to include an assessment for tobacco by using the Just ASK criteria. The primary study goal was to increase tobacco use screening from 54.8% (Baseline Data) to 85% (Target State Goal).

RESULTS

Baseline number of tobacco screening in 2021 was 54.8%. From 1/1/22-6/30/22, 52.8% were screened using the Just ASK criteria. After the first PDSA cycle, from 7/1/22-12/31/22, tobacco screenings increased to 95.1%. PDSA cycle two revealed a 25% increase in Q1 accepting referrals. 62.5% of positive tobacco users agreed to accept care compared to 25% in PDSA cycle one.

CONCLUSIONS/IMPLICATIONS

The quality study met the primary goal of screening newly diagnosed cancer patients. The success of this project supported the use of existing VA hospital-based program resources such as educational materials, supportive medication, and behavioral counseling. Interventions directed at standardization of clinical workflow processes through nursing education and linkage to resources increased tobacco screening among newly diagnosed Veterans with cancer. Planned PDSA cycle two will spread standardized processes in the Rad/Onc Department and build capacity to offer smoking cessation assistance to newly diagnosed cancer patients who report as a current smoker. Annual VHA clinical reminders will be built in and satisfied by using an EMR tobacco screen template.

BACKGROUND

Tobacco use is a known factor in oncologic outcomes in Veterans. Lung cancer is not only the leading cause of cancer death in the U.S., but it is also more prevalent among Veterans. Tobacco use is underassessed and undertreated in healthcare settings. Newly diagnosed cancer patients seen at the Day-Treatment Center of Edward Hines Jr. VA Hospital were not consistently screened for tobacco use or appropriately referred to the hospital-based Tobacco Cessation Program.

PURPOSE

This quality improvement project was created to use existing resources to increase the percentage of newly diagnosed cancer patients screened for tobacco use based off the CoC Just ASK Quality Improvement Project and Clinical Study.

METHODS/DATA ANALYSIS

Using Plan-Do-Study- Act (PDSA) quality improvement methodology, a multidisciplinary team led by Oncology Nursing, Oncologists, Pharmacy, Social Work and Behavioral Health, to standardize processes to increase the percentage of tobacco use screening. The primary intervention was designating nurse educators to standardize the cancer treatment education process to include an assessment for tobacco by using the Just ASK criteria. The primary study goal was to increase tobacco use screening from 54.8% (Baseline Data) to 85% (Target State Goal).

RESULTS

Baseline number of tobacco screening in 2021 was 54.8%. From 1/1/22-6/30/22, 52.8% were screened using the Just ASK criteria. After the first PDSA cycle, from 7/1/22-12/31/22, tobacco screenings increased to 95.1%. PDSA cycle two revealed a 25% increase in Q1 accepting referrals. 62.5% of positive tobacco users agreed to accept care compared to 25% in PDSA cycle one.

CONCLUSIONS/IMPLICATIONS

The quality study met the primary goal of screening newly diagnosed cancer patients. The success of this project supported the use of existing VA hospital-based program resources such as educational materials, supportive medication, and behavioral counseling. Interventions directed at standardization of clinical workflow processes through nursing education and linkage to resources increased tobacco screening among newly diagnosed Veterans with cancer. Planned PDSA cycle two will spread standardized processes in the Rad/Onc Department and build capacity to offer smoking cessation assistance to newly diagnosed cancer patients who report as a current smoker. Annual VHA clinical reminders will be built in and satisfied by using an EMR tobacco screen template.

INTRODUCTION

Medulloblastoma (MB) is rarely seen in adulthood. Treatment guidelines are derived from studies of the pediatric population, results favoring the Packer regimen (cisplatin plus cyclophosphamide or lomustine plus vincristine). MB rarely has extraneural metastases, especially the bone marrow.

CASE PRESENTATION

A 32-year-old female with a past medical history of cerebellar MB confirmed on surgical pathology status post resection, weekly radiation and vincristine treatment presented to us in clinic to re-establish care. She was lost to follow-up 9 months after initial diagnosis and wished to continue treatment. She was started on Lomustine, Cisplatin and Vincristine after discussion with our colleagues at MSKCC, where she had received her initial treatment. After cycle three, she developed intractable bone pain and pancytopenia. Bone marrow biopsy revealed metastasis of Sonic Hedgehog Desmoplastic/nodular variant MB. PET and CT imaging confirmed metastatic disease in the bone marrow and repeat MRI brain showed abnormal nodular enhancement. CSF analysis to assess for spinal metastasis was negative. The patient was started on Temozolomide, Irinotecan and Bevacizumab with significant improvement in bone pain and radiological improvement noted on PET and CT scans. After cycle six, the patient had increased bone pain and repeat FDG-PET showed increased uptake, however, she continued to receive treatment and her pain has improved off narcotics.

DISCUSSION

We highlight a case of adult MB in the bone marrow responsive to temozolomide, irinotecan and bevacizumab. We conducted a literature search using PubMed, Medline and Web of Science between 1990 to 2022. In 2021, COG Phase 2 screening trial showed bevacizumab, temozolamide/irinotecan therapy significantly reduced the risk of death with recurrent MBs, two studies included patients up to 21 and 23 years of age. Other modalities showing some response include Vincristine plus cyclophosphamide as well as high dose carboplatin, thiotepa and etoposide alongside autologous SCT. Vismodegib has also shown varied response of 15 months in two adults with extraneural MB metastasis. Given the unique entity of adult MB and extraneural metastasis, limitations include small sample and lack of generalizability.

CONCLUSIONS

Extraneural metastasis of MB yields a poor prognosis. Future considerations include randomized trials to establish efficacy of Temozolomide, Irinotecan plus Bevacizumab in this population.

INTRODUCTION

Medulloblastoma (MB) is rarely seen in adulthood. Treatment guidelines are derived from studies of the pediatric population, results favoring the Packer regimen (cisplatin plus cyclophosphamide or lomustine plus vincristine). MB rarely has extraneural metastases, especially the bone marrow.

CASE PRESENTATION

A 32-year-old female with a past medical history of cerebellar MB confirmed on surgical pathology status post resection, weekly radiation and vincristine treatment presented to us in clinic to re-establish care. She was lost to follow-up 9 months after initial diagnosis and wished to continue treatment. She was started on Lomustine, Cisplatin and Vincristine after discussion with our colleagues at MSKCC, where she had received her initial treatment. After cycle three, she developed intractable bone pain and pancytopenia. Bone marrow biopsy revealed metastasis of Sonic Hedgehog Desmoplastic/nodular variant MB. PET and CT imaging confirmed metastatic disease in the bone marrow and repeat MRI brain showed abnormal nodular enhancement. CSF analysis to assess for spinal metastasis was negative. The patient was started on Temozolomide, Irinotecan and Bevacizumab with significant improvement in bone pain and radiological improvement noted on PET and CT scans. After cycle six, the patient had increased bone pain and repeat FDG-PET showed increased uptake, however, she continued to receive treatment and her pain has improved off narcotics.

DISCUSSION

We highlight a case of adult MB in the bone marrow responsive to temozolomide, irinotecan and bevacizumab. We conducted a literature search using PubMed, Medline and Web of Science between 1990 to 2022. In 2021, COG Phase 2 screening trial showed bevacizumab, temozolamide/irinotecan therapy significantly reduced the risk of death with recurrent MBs, two studies included patients up to 21 and 23 years of age. Other modalities showing some response include Vincristine plus cyclophosphamide as well as high dose carboplatin, thiotepa and etoposide alongside autologous SCT. Vismodegib has also shown varied response of 15 months in two adults with extraneural MB metastasis. Given the unique entity of adult MB and extraneural metastasis, limitations include small sample and lack of generalizability.

CONCLUSIONS

Extraneural metastasis of MB yields a poor prognosis. Future considerations include randomized trials to establish efficacy of Temozolomide, Irinotecan plus Bevacizumab in this population.

INTRODUCTION

Medulloblastoma (MB) is rarely seen in adulthood. Treatment guidelines are derived from studies of the pediatric population, results favoring the Packer regimen (cisplatin plus cyclophosphamide or lomustine plus vincristine). MB rarely has extraneural metastases, especially the bone marrow.

CASE PRESENTATION

A 32-year-old female with a past medical history of cerebellar MB confirmed on surgical pathology status post resection, weekly radiation and vincristine treatment presented to us in clinic to re-establish care. She was lost to follow-up 9 months after initial diagnosis and wished to continue treatment. She was started on Lomustine, Cisplatin and Vincristine after discussion with our colleagues at MSKCC, where she had received her initial treatment. After cycle three, she developed intractable bone pain and pancytopenia. Bone marrow biopsy revealed metastasis of Sonic Hedgehog Desmoplastic/nodular variant MB. PET and CT imaging confirmed metastatic disease in the bone marrow and repeat MRI brain showed abnormal nodular enhancement. CSF analysis to assess for spinal metastasis was negative. The patient was started on Temozolomide, Irinotecan and Bevacizumab with significant improvement in bone pain and radiological improvement noted on PET and CT scans. After cycle six, the patient had increased bone pain and repeat FDG-PET showed increased uptake, however, she continued to receive treatment and her pain has improved off narcotics.

DISCUSSION

We highlight a case of adult MB in the bone marrow responsive to temozolomide, irinotecan and bevacizumab. We conducted a literature search using PubMed, Medline and Web of Science between 1990 to 2022. In 2021, COG Phase 2 screening trial showed bevacizumab, temozolamide/irinotecan therapy significantly reduced the risk of death with recurrent MBs, two studies included patients up to 21 and 23 years of age. Other modalities showing some response include Vincristine plus cyclophosphamide as well as high dose carboplatin, thiotepa and etoposide alongside autologous SCT. Vismodegib has also shown varied response of 15 months in two adults with extraneural MB metastasis. Given the unique entity of adult MB and extraneural metastasis, limitations include small sample and lack of generalizability.

CONCLUSIONS

Extraneural metastasis of MB yields a poor prognosis. Future considerations include randomized trials to establish efficacy of Temozolomide, Irinotecan plus Bevacizumab in this population.