Original Research

BACKGROUND

Minimal residual disease (MRD) testing in myeloma has been shown to be a strong prognostic marker for progression-free and overall survival. Limited data suggest MRD results may also be useful for therapy discontinuation decisions. The clonoSEQ Assay utilizes next generation sequencing involving a bone marrow sample, obtained at the time of diagnosis, to identify patient-specific sequence(s).

DISCUSSION

The same methodology is then applied later to assess for MRD. Although widely adopted at most US academic centers, there has been limited use of MRD across VA centers. In 2022 the Cleveland Louis Stokes VAMC partnered with Adaptive Biotechnologies to develop a process for MRD/clonoSEQ testing in myeloma pts. Hematology, Pathology, Medicine, Administration and Adaptive Biotechnologies representatives met to develop a streamlined process for ordering, sample procurement, billing and result documentation. In 5/2022 the 1st specimen was sent. EQUATE is a national cooperative group trial requiring baseline clono- SEQ testing with a positive sequence ID. Daratumumab hyaluronidase (part of standard treatment) is provided to the institution at no cost on the trial but otherwise would cost the VA $5,797.38/dose. clonoSEQ costs VA $1950/test. There have been 14 specimens sent involving 12 pts: 12 baseline marrow and 2 for MRD (posttransplant). All of the baseline specimens were found to have an identifiable sequence. Both of the MRD tracking specimens were positive. The average turnaround time for clonoSEQ results was 13.2 days (range 7 to 18 days). 4 of the 12 pts with a positive initial clonoSEQ ID qualified for the EQUATE trial but would not have been deemed eligible without the baseline clonoSEQ results. 2 of these pts have enrolled on the trial and started treatment. Costs for 14 clonoSEQ tests: $27,300. Estimated cost savings for the 2 pts enrolled onto EQUATE: $127, 542.36/pt/year= $255,084.72/year. Overall cost savings: $227,784.72.

CONCLUSIONS

An efficient process for baseline and post-treatment (MRD) clonoSEQ testing in myeloma pts was developed. Although expensive, use of this test resulted in significant overall cost savings by allowing enrollment onto a clinical trial. In addition, if studies determine that negative MRD results can guide therapeutic decisions, use of clonoSEQ testing may result in further benefits.

BACKGROUND

Minimal residual disease (MRD) testing in myeloma has been shown to be a strong prognostic marker for progression-free and overall survival. Limited data suggest MRD results may also be useful for therapy discontinuation decisions. The clonoSEQ Assay utilizes next generation sequencing involving a bone marrow sample, obtained at the time of diagnosis, to identify patient-specific sequence(s).

DISCUSSION

The same methodology is then applied later to assess for MRD. Although widely adopted at most US academic centers, there has been limited use of MRD across VA centers. In 2022 the Cleveland Louis Stokes VAMC partnered with Adaptive Biotechnologies to develop a process for MRD/clonoSEQ testing in myeloma pts. Hematology, Pathology, Medicine, Administration and Adaptive Biotechnologies representatives met to develop a streamlined process for ordering, sample procurement, billing and result documentation. In 5/2022 the 1st specimen was sent. EQUATE is a national cooperative group trial requiring baseline clono- SEQ testing with a positive sequence ID. Daratumumab hyaluronidase (part of standard treatment) is provided to the institution at no cost on the trial but otherwise would cost the VA $5,797.38/dose. clonoSEQ costs VA $1950/test. There have been 14 specimens sent involving 12 pts: 12 baseline marrow and 2 for MRD (posttransplant). All of the baseline specimens were found to have an identifiable sequence. Both of the MRD tracking specimens were positive. The average turnaround time for clonoSEQ results was 13.2 days (range 7 to 18 days). 4 of the 12 pts with a positive initial clonoSEQ ID qualified for the EQUATE trial but would not have been deemed eligible without the baseline clonoSEQ results. 2 of these pts have enrolled on the trial and started treatment. Costs for 14 clonoSEQ tests: $27,300. Estimated cost savings for the 2 pts enrolled onto EQUATE: $127, 542.36/pt/year= $255,084.72/year. Overall cost savings: $227,784.72.

CONCLUSIONS

An efficient process for baseline and post-treatment (MRD) clonoSEQ testing in myeloma pts was developed. Although expensive, use of this test resulted in significant overall cost savings by allowing enrollment onto a clinical trial. In addition, if studies determine that negative MRD results can guide therapeutic decisions, use of clonoSEQ testing may result in further benefits.

BACKGROUND

Minimal residual disease (MRD) testing in myeloma has been shown to be a strong prognostic marker for progression-free and overall survival. Limited data suggest MRD results may also be useful for therapy discontinuation decisions. The clonoSEQ Assay utilizes next generation sequencing involving a bone marrow sample, obtained at the time of diagnosis, to identify patient-specific sequence(s).

DISCUSSION

The same methodology is then applied later to assess for MRD. Although widely adopted at most US academic centers, there has been limited use of MRD across VA centers. In 2022 the Cleveland Louis Stokes VAMC partnered with Adaptive Biotechnologies to develop a process for MRD/clonoSEQ testing in myeloma pts. Hematology, Pathology, Medicine, Administration and Adaptive Biotechnologies representatives met to develop a streamlined process for ordering, sample procurement, billing and result documentation. In 5/2022 the 1st specimen was sent. EQUATE is a national cooperative group trial requiring baseline clono- SEQ testing with a positive sequence ID. Daratumumab hyaluronidase (part of standard treatment) is provided to the institution at no cost on the trial but otherwise would cost the VA $5,797.38/dose. clonoSEQ costs VA $1950/test. There have been 14 specimens sent involving 12 pts: 12 baseline marrow and 2 for MRD (posttransplant). All of the baseline specimens were found to have an identifiable sequence. Both of the MRD tracking specimens were positive. The average turnaround time for clonoSEQ results was 13.2 days (range 7 to 18 days). 4 of the 12 pts with a positive initial clonoSEQ ID qualified for the EQUATE trial but would not have been deemed eligible without the baseline clonoSEQ results. 2 of these pts have enrolled on the trial and started treatment. Costs for 14 clonoSEQ tests: $27,300. Estimated cost savings for the 2 pts enrolled onto EQUATE: $127, 542.36/pt/year= $255,084.72/year. Overall cost savings: $227,784.72.

CONCLUSIONS

An efficient process for baseline and post-treatment (MRD) clonoSEQ testing in myeloma pts was developed. Although expensive, use of this test resulted in significant overall cost savings by allowing enrollment onto a clinical trial. In addition, if studies determine that negative MRD results can guide therapeutic decisions, use of clonoSEQ testing may result in further benefits.

PURPOSE

To analyze associations between colorectal cancer progression and diet scores calculated using published scoring approaches for three dietary patterns: Healthy Eating Index (HEI), Mediterranean Diet (Mediterranean), and Dietary Approaches to Stop Hypertension Diet (DASH).

BACKGROUND

Little is known about whether longterm risk for progression to colorectal cancer is associated with recommended healthy dietary patterns among US veterans. Previous studies of veterans have shown higher intake of fiber and vitamin D reduced risk, and red meat increased risk for finding colorectal cancer precursors during colonoscopy. However, studying dietary patterns in aggregate may be more clinically relevant for longitudinal studies of colorectal cancer prevention.

METHODS

3,121 asymptomatic US veterans aged 50-75 received colonoscopy between 1994-97 and were followed through 2009. Most significant colonoscopy findings (MSCF) across the study period were: (i) no neoplasia (NN), (ii) non-advanced adenomas (NAAs) or (iii) advanced neoplasia (AN). Baseline dietary questionnaire data were used to calculate three dietary pattern (HEI, Mediterranean, and DASH) scores.

DATA ANALYSIS

Multinomial logistic regression models were used in a cross-sectional analysis to test for associations represented by adjusted odds ratios (aOR) between MSCF and dietary pattern scores, controlling for demographics and clinical risk factors.

RESULTS

Among 3,023 participants with complete data, 97% were male, and 83.8% were White. Increasing scores, representing healthier diets, for each dietary pattern had similar or lower odds for NAAs and AN, respectively, versus NN. They were HEI: aOR: 1.00, 95% CI: 0.99-1.01 and aOR 0.97, 95% CI: 0.99-1.01; Mediterranean: aOR: 0.98, 95% CI: 0.95-1.02 and aOR 0.95, 95% CI: 0.90-0.999; DASH: aOR: 0.99, 95% CI: 0.99- 1.00 and aOR 0.99, 95% CI: 0.98-0.999. Across each dietary pattern, higher whole grain and fiber category scores generally had lower odds for NAAs and AN.

CONCLUSIONS

Study results revealed that overall higher dietary quality and specific dietary components of whole grain or fiber intake, based on three different dietary patterns suggest lower odds for CRC precursors. Findings indicate potential differences in dietary intake patterns and more research is needed to determine the benefit of developing tailored CRC screening and surveillance clinical guidelines.

PURPOSE

To analyze associations between colorectal cancer progression and diet scores calculated using published scoring approaches for three dietary patterns: Healthy Eating Index (HEI), Mediterranean Diet (Mediterranean), and Dietary Approaches to Stop Hypertension Diet (DASH).

BACKGROUND

Little is known about whether longterm risk for progression to colorectal cancer is associated with recommended healthy dietary patterns among US veterans. Previous studies of veterans have shown higher intake of fiber and vitamin D reduced risk, and red meat increased risk for finding colorectal cancer precursors during colonoscopy. However, studying dietary patterns in aggregate may be more clinically relevant for longitudinal studies of colorectal cancer prevention.

METHODS

3,121 asymptomatic US veterans aged 50-75 received colonoscopy between 1994-97 and were followed through 2009. Most significant colonoscopy findings (MSCF) across the study period were: (i) no neoplasia (NN), (ii) non-advanced adenomas (NAAs) or (iii) advanced neoplasia (AN). Baseline dietary questionnaire data were used to calculate three dietary pattern (HEI, Mediterranean, and DASH) scores.

DATA ANALYSIS

Multinomial logistic regression models were used in a cross-sectional analysis to test for associations represented by adjusted odds ratios (aOR) between MSCF and dietary pattern scores, controlling for demographics and clinical risk factors.

RESULTS

Among 3,023 participants with complete data, 97% were male, and 83.8% were White. Increasing scores, representing healthier diets, for each dietary pattern had similar or lower odds for NAAs and AN, respectively, versus NN. They were HEI: aOR: 1.00, 95% CI: 0.99-1.01 and aOR 0.97, 95% CI: 0.99-1.01; Mediterranean: aOR: 0.98, 95% CI: 0.95-1.02 and aOR 0.95, 95% CI: 0.90-0.999; DASH: aOR: 0.99, 95% CI: 0.99- 1.00 and aOR 0.99, 95% CI: 0.98-0.999. Across each dietary pattern, higher whole grain and fiber category scores generally had lower odds for NAAs and AN.

CONCLUSIONS

Study results revealed that overall higher dietary quality and specific dietary components of whole grain or fiber intake, based on three different dietary patterns suggest lower odds for CRC precursors. Findings indicate potential differences in dietary intake patterns and more research is needed to determine the benefit of developing tailored CRC screening and surveillance clinical guidelines.

PURPOSE

To analyze associations between colorectal cancer progression and diet scores calculated using published scoring approaches for three dietary patterns: Healthy Eating Index (HEI), Mediterranean Diet (Mediterranean), and Dietary Approaches to Stop Hypertension Diet (DASH).

BACKGROUND

Little is known about whether longterm risk for progression to colorectal cancer is associated with recommended healthy dietary patterns among US veterans. Previous studies of veterans have shown higher intake of fiber and vitamin D reduced risk, and red meat increased risk for finding colorectal cancer precursors during colonoscopy. However, studying dietary patterns in aggregate may be more clinically relevant for longitudinal studies of colorectal cancer prevention.

METHODS

3,121 asymptomatic US veterans aged 50-75 received colonoscopy between 1994-97 and were followed through 2009. Most significant colonoscopy findings (MSCF) across the study period were: (i) no neoplasia (NN), (ii) non-advanced adenomas (NAAs) or (iii) advanced neoplasia (AN). Baseline dietary questionnaire data were used to calculate three dietary pattern (HEI, Mediterranean, and DASH) scores.

DATA ANALYSIS

Multinomial logistic regression models were used in a cross-sectional analysis to test for associations represented by adjusted odds ratios (aOR) between MSCF and dietary pattern scores, controlling for demographics and clinical risk factors.

RESULTS

Among 3,023 participants with complete data, 97% were male, and 83.8% were White. Increasing scores, representing healthier diets, for each dietary pattern had similar or lower odds for NAAs and AN, respectively, versus NN. They were HEI: aOR: 1.00, 95% CI: 0.99-1.01 and aOR 0.97, 95% CI: 0.99-1.01; Mediterranean: aOR: 0.98, 95% CI: 0.95-1.02 and aOR 0.95, 95% CI: 0.90-0.999; DASH: aOR: 0.99, 95% CI: 0.99- 1.00 and aOR 0.99, 95% CI: 0.98-0.999. Across each dietary pattern, higher whole grain and fiber category scores generally had lower odds for NAAs and AN.

CONCLUSIONS

Study results revealed that overall higher dietary quality and specific dietary components of whole grain or fiber intake, based on three different dietary patterns suggest lower odds for CRC precursors. Findings indicate potential differences in dietary intake patterns and more research is needed to determine the benefit of developing tailored CRC screening and surveillance clinical guidelines.

PURPOSE

Assess the clinical impact (CI) of UV-related DNA damage signatures (UVsig) in Veterans with cancer of unknown primary (CUP) and cancer of extracutaneous origin (CEO).

BACKGROUND

UVsig have been reported in CUP and CEO (i.e. head and neck cancer and lung cancer). The presence of UVsig suggests a cutaneous origin and potential misclassification of CEO using conventional histopathologic evaluation. Literature on the association of UVsig in pan-cancer genomics is limited.

METHODS

This is a retrospective study of Veterans who underwent comprehensive genomic profiling with FoundationOne CDx during 2/1/2019 to 9/30/2022 through the VA National Precision Oncology Program. The outcome was the CI of UVsig (high, medium, and low) determined by blinded chart reviews: (1) high: UVsig leading to change in diagnoses (CID) and a different first-line therapy (FLT) would have been offered; (2) medium: UVsig leading to CID, but appropriate FLT offered; (3) low: diagnoses modified by clinicians and treated as cutaneous cancers. NCCN Guidelines were referenced for FLT.

DATA ANALYSIS

Descriptive statistics and chi-square tests were utilized to evaluate the UVsig CI.

RESULTS

Among 5,565 cases with 10 or more assessable alterations for UVsig analysis, 650 (11.7%) were positive for UVsig. CUP and CEO cohorts each had 41 cases analyzed. In the CUP cases, 20 (48.8%), 9 (21.9%), and 12 (29.3%) were categorized as having high, medium, and low CI, respectively; and in the CEO cases, it was 22 (53.7%), 15 (36.6%), and 4 (9.8%). There was no difference statistically between the CUP and CEO groups on the percentage distribution of CI (p=0.06). Among the 42 out of 82 cases having high CI, 37 (88.1%) received cytotoxic chemotherapy without any indication, and 5 (11.9%) were not offered immunotherapy (IO) as FLT. More than half of the 82 cases had high CI; more than 90% of the CEO cases had high and medium CI.

IMPLICATIONS

UVsig serves as a useful biomarker for cancers with cutaneous origin. About 1% of the 5,565 cases analyzed had high UVsig CI. Knowledge of UVsig could lead to omission of chemotherapy (hence avoiding toxicities) or addition of IO (for potential benefits).

PURPOSE

Assess the clinical impact (CI) of UV-related DNA damage signatures (UVsig) in Veterans with cancer of unknown primary (CUP) and cancer of extracutaneous origin (CEO).

BACKGROUND

UVsig have been reported in CUP and CEO (i.e. head and neck cancer and lung cancer). The presence of UVsig suggests a cutaneous origin and potential misclassification of CEO using conventional histopathologic evaluation. Literature on the association of UVsig in pan-cancer genomics is limited.

METHODS

This is a retrospective study of Veterans who underwent comprehensive genomic profiling with FoundationOne CDx during 2/1/2019 to 9/30/2022 through the VA National Precision Oncology Program. The outcome was the CI of UVsig (high, medium, and low) determined by blinded chart reviews: (1) high: UVsig leading to change in diagnoses (CID) and a different first-line therapy (FLT) would have been offered; (2) medium: UVsig leading to CID, but appropriate FLT offered; (3) low: diagnoses modified by clinicians and treated as cutaneous cancers. NCCN Guidelines were referenced for FLT.

DATA ANALYSIS

Descriptive statistics and chi-square tests were utilized to evaluate the UVsig CI.

RESULTS

Among 5,565 cases with 10 or more assessable alterations for UVsig analysis, 650 (11.7%) were positive for UVsig. CUP and CEO cohorts each had 41 cases analyzed. In the CUP cases, 20 (48.8%), 9 (21.9%), and 12 (29.3%) were categorized as having high, medium, and low CI, respectively; and in the CEO cases, it was 22 (53.7%), 15 (36.6%), and 4 (9.8%). There was no difference statistically between the CUP and CEO groups on the percentage distribution of CI (p=0.06). Among the 42 out of 82 cases having high CI, 37 (88.1%) received cytotoxic chemotherapy without any indication, and 5 (11.9%) were not offered immunotherapy (IO) as FLT. More than half of the 82 cases had high CI; more than 90% of the CEO cases had high and medium CI.

IMPLICATIONS

UVsig serves as a useful biomarker for cancers with cutaneous origin. About 1% of the 5,565 cases analyzed had high UVsig CI. Knowledge of UVsig could lead to omission of chemotherapy (hence avoiding toxicities) or addition of IO (for potential benefits).

PURPOSE

Assess the clinical impact (CI) of UV-related DNA damage signatures (UVsig) in Veterans with cancer of unknown primary (CUP) and cancer of extracutaneous origin (CEO).

BACKGROUND

UVsig have been reported in CUP and CEO (i.e. head and neck cancer and lung cancer). The presence of UVsig suggests a cutaneous origin and potential misclassification of CEO using conventional histopathologic evaluation. Literature on the association of UVsig in pan-cancer genomics is limited.

METHODS

This is a retrospective study of Veterans who underwent comprehensive genomic profiling with FoundationOne CDx during 2/1/2019 to 9/30/2022 through the VA National Precision Oncology Program. The outcome was the CI of UVsig (high, medium, and low) determined by blinded chart reviews: (1) high: UVsig leading to change in diagnoses (CID) and a different first-line therapy (FLT) would have been offered; (2) medium: UVsig leading to CID, but appropriate FLT offered; (3) low: diagnoses modified by clinicians and treated as cutaneous cancers. NCCN Guidelines were referenced for FLT.

DATA ANALYSIS

Descriptive statistics and chi-square tests were utilized to evaluate the UVsig CI.

RESULTS

Among 5,565 cases with 10 or more assessable alterations for UVsig analysis, 650 (11.7%) were positive for UVsig. CUP and CEO cohorts each had 41 cases analyzed. In the CUP cases, 20 (48.8%), 9 (21.9%), and 12 (29.3%) were categorized as having high, medium, and low CI, respectively; and in the CEO cases, it was 22 (53.7%), 15 (36.6%), and 4 (9.8%). There was no difference statistically between the CUP and CEO groups on the percentage distribution of CI (p=0.06). Among the 42 out of 82 cases having high CI, 37 (88.1%) received cytotoxic chemotherapy without any indication, and 5 (11.9%) were not offered immunotherapy (IO) as FLT. More than half of the 82 cases had high CI; more than 90% of the CEO cases had high and medium CI.

IMPLICATIONS

UVsig serves as a useful biomarker for cancers with cutaneous origin. About 1% of the 5,565 cases analyzed had high UVsig CI. Knowledge of UVsig could lead to omission of chemotherapy (hence avoiding toxicities) or addition of IO (for potential benefits).

BACKGROUND/PURPOSE

Febrile neutropenia (FN) is considered a life-threatening oncologic emergency that requires prompt recognition of the condition and expeditious administration of antibiotics. In 2021, a neutropenic workgroup in the VA Northeast Ohio Healthcare System (VANEOHS) began working on updating the neutropenic policy to match current neutropenic guidelines. In 2022, the policy was approved, and the following changes were implemented (1) timing of antibiotic administration changed from two hours to one hour of fever presentation (2) absolute neutrophil count (ANC) criteria changed from an ANC of ≤ 1.0 K/cmm to an ANC of ≤ 0.5 K/cmm or an ANC that is expected to decrease to ≤ 0.5 K/cmm during the next 48 hours.

SYNTHESIS OF LITERATURE

Each hour that antibiotics are delayed is associated with a decrease in survival and an increase in mortality of 7.6% (Koenig et al, 2019).

INTERVENTIONS

The existing neutropenic policy, order sets, and antibiogram were updated. The physicians, pharmacists, and nurses from the neutropenic workgroup conducted educational in-services with their respective groups. Badge backers were created for inpatient nursing staff to wear as a quick reference. Posters were hung in the medicine team workrooms. A protected health information (PHI) Outlook email was set up to automatically generate, notifying workgroup members when initial antibiotics are administered to a patient with neutropenic fever. This email allows “real time” tracking of initial antibiotic administration. A certificate of recognition was created to email to nurses who administer antibiotics within the 1-hour timeframe.

RESULTS

Monthly chart audits of timing from fever presentation to antibiotic administration are conducted. Data is reported monthly at the neutropenic workgroup meetings. The following data was gathered after implementation and shows gram negative antibiotic administration within one hour of fever presentation: September 2022, 100% (n = 1), October 2022, 100% (n = 1), November 2022, N/A (n = 0), December 2022, N/A (n = 0), January 2023, N/A (n = 0), February 2023, 100% (n = 1), March 2023, 100% (n = 1), and April 2023, N/A (n = 0).

IMPLICATIONS

Continue to monitor data to ensure targets are met and reevaluate process as needed.

BACKGROUND/PURPOSE

Febrile neutropenia (FN) is considered a life-threatening oncologic emergency that requires prompt recognition of the condition and expeditious administration of antibiotics. In 2021, a neutropenic workgroup in the VA Northeast Ohio Healthcare System (VANEOHS) began working on updating the neutropenic policy to match current neutropenic guidelines. In 2022, the policy was approved, and the following changes were implemented (1) timing of antibiotic administration changed from two hours to one hour of fever presentation (2) absolute neutrophil count (ANC) criteria changed from an ANC of ≤ 1.0 K/cmm to an ANC of ≤ 0.5 K/cmm or an ANC that is expected to decrease to ≤ 0.5 K/cmm during the next 48 hours.

SYNTHESIS OF LITERATURE

Each hour that antibiotics are delayed is associated with a decrease in survival and an increase in mortality of 7.6% (Koenig et al, 2019).

INTERVENTIONS

The existing neutropenic policy, order sets, and antibiogram were updated. The physicians, pharmacists, and nurses from the neutropenic workgroup conducted educational in-services with their respective groups. Badge backers were created for inpatient nursing staff to wear as a quick reference. Posters were hung in the medicine team workrooms. A protected health information (PHI) Outlook email was set up to automatically generate, notifying workgroup members when initial antibiotics are administered to a patient with neutropenic fever. This email allows “real time” tracking of initial antibiotic administration. A certificate of recognition was created to email to nurses who administer antibiotics within the 1-hour timeframe.

RESULTS

Monthly chart audits of timing from fever presentation to antibiotic administration are conducted. Data is reported monthly at the neutropenic workgroup meetings. The following data was gathered after implementation and shows gram negative antibiotic administration within one hour of fever presentation: September 2022, 100% (n = 1), October 2022, 100% (n = 1), November 2022, N/A (n = 0), December 2022, N/A (n = 0), January 2023, N/A (n = 0), February 2023, 100% (n = 1), March 2023, 100% (n = 1), and April 2023, N/A (n = 0).

IMPLICATIONS

Continue to monitor data to ensure targets are met and reevaluate process as needed.

BACKGROUND/PURPOSE

Febrile neutropenia (FN) is considered a life-threatening oncologic emergency that requires prompt recognition of the condition and expeditious administration of antibiotics. In 2021, a neutropenic workgroup in the VA Northeast Ohio Healthcare System (VANEOHS) began working on updating the neutropenic policy to match current neutropenic guidelines. In 2022, the policy was approved, and the following changes were implemented (1) timing of antibiotic administration changed from two hours to one hour of fever presentation (2) absolute neutrophil count (ANC) criteria changed from an ANC of ≤ 1.0 K/cmm to an ANC of ≤ 0.5 K/cmm or an ANC that is expected to decrease to ≤ 0.5 K/cmm during the next 48 hours.

SYNTHESIS OF LITERATURE

Each hour that antibiotics are delayed is associated with a decrease in survival and an increase in mortality of 7.6% (Koenig et al, 2019).

INTERVENTIONS

The existing neutropenic policy, order sets, and antibiogram were updated. The physicians, pharmacists, and nurses from the neutropenic workgroup conducted educational in-services with their respective groups. Badge backers were created for inpatient nursing staff to wear as a quick reference. Posters were hung in the medicine team workrooms. A protected health information (PHI) Outlook email was set up to automatically generate, notifying workgroup members when initial antibiotics are administered to a patient with neutropenic fever. This email allows “real time” tracking of initial antibiotic administration. A certificate of recognition was created to email to nurses who administer antibiotics within the 1-hour timeframe.

RESULTS

Monthly chart audits of timing from fever presentation to antibiotic administration are conducted. Data is reported monthly at the neutropenic workgroup meetings. The following data was gathered after implementation and shows gram negative antibiotic administration within one hour of fever presentation: September 2022, 100% (n = 1), October 2022, 100% (n = 1), November 2022, N/A (n = 0), December 2022, N/A (n = 0), January 2023, N/A (n = 0), February 2023, 100% (n = 1), March 2023, 100% (n = 1), and April 2023, N/A (n = 0).

IMPLICATIONS

Continue to monitor data to ensure targets are met and reevaluate process as needed.

PURPOSE

Study clinical characteristics of Rectal Mucinous Adenocarcinoma (RMA).

BACKGROUND

RMA is a rare histological subtype with an impaired response to chemoradiotherapy and an overall poor prognosis. High-grade tumors are associated with older age. Previous studies have shown conflicting results on prognosis.

METHODS

Retrospective analysis of National Cancer Database was conducted from 2004-2020 for subjects with histology code 8480 in primary sites C19 and C20 (rectosigmoid-junction and rectum, n = 14,044), using multivariate analysis with Cox regression.

RESULTS

Median age of diagnosis was 65 years with 69.5% were in the 45-75 years age range. 59.2% were male while 40.8% were female. 84.7% were White, 9.7% were Black, 0.4% were American Indian and 3.4% were Asian. 6.9% were Hispanic. 33.9% were in the upper-income quartile. 40.6% were seen at community cancer programs while 33% went to academic programs. 36.5% had stage III RMA. Out of the 14,044 patients with RMA, 10,546 received surgery, 5,179 received chemotherapy, 233 received immunotherapy and 55 received hormone therapy. Patients >75 years had significantly lower overall survival (OS) compared to those <45 years (HR 0.67). Female patients had significantly higher OS than male (HR - 0.07). Black patients had significantly lower OS than White (HR 0.08). Hispanic patients had significantly higher OS than non- Hispanic (HR - 0.14). Patients with private and government insurance had significantly higher OS than noninsured patients (HR - 0.35 and - 0.26 respectively). Patients with median higher-income quartiles had significantly higher OS than lower quartiles (HR - 0.13). Academic facilities had significantly higher OS than community programs (HR - 0.13). Patients who received surgery had significantly higher OS than those that did not (HR - 0.67); median survival for patients who received surgery was 71 months vs 28 months for non-surgical candidates.

CONCLUSIONS

Surgery is the most important treatment modality in RMA. Uninsured, older Black male patients from lower-income quartiles had significantly lower OS. Access to academic centers also contributed to differences in OS outcomes which throws light on healthcare disparities.

IMPLICATIONS

Additional studies need to be conducted for viable solutions to assist with social determinants of healthcare in RMA.

PURPOSE

Study clinical characteristics of Rectal Mucinous Adenocarcinoma (RMA).

BACKGROUND

RMA is a rare histological subtype with an impaired response to chemoradiotherapy and an overall poor prognosis. High-grade tumors are associated with older age. Previous studies have shown conflicting results on prognosis.

METHODS

Retrospective analysis of National Cancer Database was conducted from 2004-2020 for subjects with histology code 8480 in primary sites C19 and C20 (rectosigmoid-junction and rectum, n = 14,044), using multivariate analysis with Cox regression.

RESULTS

Median age of diagnosis was 65 years with 69.5% were in the 45-75 years age range. 59.2% were male while 40.8% were female. 84.7% were White, 9.7% were Black, 0.4% were American Indian and 3.4% were Asian. 6.9% were Hispanic. 33.9% were in the upper-income quartile. 40.6% were seen at community cancer programs while 33% went to academic programs. 36.5% had stage III RMA. Out of the 14,044 patients with RMA, 10,546 received surgery, 5,179 received chemotherapy, 233 received immunotherapy and 55 received hormone therapy. Patients >75 years had significantly lower overall survival (OS) compared to those <45 years (HR 0.67). Female patients had significantly higher OS than male (HR - 0.07). Black patients had significantly lower OS than White (HR 0.08). Hispanic patients had significantly higher OS than non- Hispanic (HR - 0.14). Patients with private and government insurance had significantly higher OS than noninsured patients (HR - 0.35 and - 0.26 respectively). Patients with median higher-income quartiles had significantly higher OS than lower quartiles (HR - 0.13). Academic facilities had significantly higher OS than community programs (HR - 0.13). Patients who received surgery had significantly higher OS than those that did not (HR - 0.67); median survival for patients who received surgery was 71 months vs 28 months for non-surgical candidates.

CONCLUSIONS

Surgery is the most important treatment modality in RMA. Uninsured, older Black male patients from lower-income quartiles had significantly lower OS. Access to academic centers also contributed to differences in OS outcomes which throws light on healthcare disparities.

IMPLICATIONS

Additional studies need to be conducted for viable solutions to assist with social determinants of healthcare in RMA.

PURPOSE

Study clinical characteristics of Rectal Mucinous Adenocarcinoma (RMA).

BACKGROUND

RMA is a rare histological subtype with an impaired response to chemoradiotherapy and an overall poor prognosis. High-grade tumors are associated with older age. Previous studies have shown conflicting results on prognosis.

METHODS

Retrospective analysis of National Cancer Database was conducted from 2004-2020 for subjects with histology code 8480 in primary sites C19 and C20 (rectosigmoid-junction and rectum, n = 14,044), using multivariate analysis with Cox regression.

RESULTS

Median age of diagnosis was 65 years with 69.5% were in the 45-75 years age range. 59.2% were male while 40.8% were female. 84.7% were White, 9.7% were Black, 0.4% were American Indian and 3.4% were Asian. 6.9% were Hispanic. 33.9% were in the upper-income quartile. 40.6% were seen at community cancer programs while 33% went to academic programs. 36.5% had stage III RMA. Out of the 14,044 patients with RMA, 10,546 received surgery, 5,179 received chemotherapy, 233 received immunotherapy and 55 received hormone therapy. Patients >75 years had significantly lower overall survival (OS) compared to those <45 years (HR 0.67). Female patients had significantly higher OS than male (HR - 0.07). Black patients had significantly lower OS than White (HR 0.08). Hispanic patients had significantly higher OS than non- Hispanic (HR - 0.14). Patients with private and government insurance had significantly higher OS than noninsured patients (HR - 0.35 and - 0.26 respectively). Patients with median higher-income quartiles had significantly higher OS than lower quartiles (HR - 0.13). Academic facilities had significantly higher OS than community programs (HR - 0.13). Patients who received surgery had significantly higher OS than those that did not (HR - 0.67); median survival for patients who received surgery was 71 months vs 28 months for non-surgical candidates.

CONCLUSIONS

Surgery is the most important treatment modality in RMA. Uninsured, older Black male patients from lower-income quartiles had significantly lower OS. Access to academic centers also contributed to differences in OS outcomes which throws light on healthcare disparities.

IMPLICATIONS

Additional studies need to be conducted for viable solutions to assist with social determinants of healthcare in RMA.

BACKGROUND

The National Precision Oncology Program (NPOP) provides comprehensive genomic profiling (CGP) through external vendors to patients within the Veterans Affairs Healthcare System who meet testing guidelines. We sought to assess the concordance of cancer therapy recommendations between Foundation Medicine (FM), one of the NPOP vendors, and OncoKB, an FDA-recognized public precision oncology knowledge database, which annotates human genetic variants associated with therapies guidance at varying levels of evidence.

METHODS

We selected FM CGP test reports with at least one therapy recommendation regardless of FDA approval or level of evidence were selected to compare FM and OncoKB therapy annotations of different mutation types, including short variants (SVs), rearrangements, and copy number alterations (CNAs) between 02/01/2019-03/13/2023. Therapy recommendations of annotations for unique combinations of gene, variant, and cancer type from FM and OncoKB were compared. Comparisons were scored as an Exact Match (EM) if FM and OncoKB therapy annotation was the same or a Partial Match (PM) if the FM therapy annotation was a subset of OncoKB’s or vice versa.

RESULTS

For annotations involving FDA-approved therapies, a total of 10,435 cases were compared for SVs, 546 for rearrangements, and 732 for CNAs. Among SVs annotations, 7,029 (67.4%) were EM and 787 (7.5%) were PM. Of rearrangement annotations, 328 (60.1%) were EM and 95 (17.4%) were PM. Of CNA annotations, 469 (64.1%) were EM and 28 (3.8%) were PM. For off-label therapies, agreement between annotation sources was much lower in all above scenarios. Examples included 3022 (29%) cases were identified as EM plus PM for SVs, 324 (59.3%) for rearrangements, and 42 (5.7%) for CNAs.

CONCLUSIONS

Therapy recommendations were inconsistent between FM and OncoKB annotation services, with a substantial disagreement among both FDA-approved and off-label therapy annotations. The limitation of time difference of annotations performed between FM and OncoKB therapy annotations accounted for some disagreement. Establishing accuracy and improving concordance between different annotation services is needed to better match treatments to patients and improve provider trust and reliability of annotation service.

BACKGROUND

The National Precision Oncology Program (NPOP) provides comprehensive genomic profiling (CGP) through external vendors to patients within the Veterans Affairs Healthcare System who meet testing guidelines. We sought to assess the concordance of cancer therapy recommendations between Foundation Medicine (FM), one of the NPOP vendors, and OncoKB, an FDA-recognized public precision oncology knowledge database, which annotates human genetic variants associated with therapies guidance at varying levels of evidence.

METHODS

We selected FM CGP test reports with at least one therapy recommendation regardless of FDA approval or level of evidence were selected to compare FM and OncoKB therapy annotations of different mutation types, including short variants (SVs), rearrangements, and copy number alterations (CNAs) between 02/01/2019-03/13/2023. Therapy recommendations of annotations for unique combinations of gene, variant, and cancer type from FM and OncoKB were compared. Comparisons were scored as an Exact Match (EM) if FM and OncoKB therapy annotation was the same or a Partial Match (PM) if the FM therapy annotation was a subset of OncoKB’s or vice versa.

RESULTS

For annotations involving FDA-approved therapies, a total of 10,435 cases were compared for SVs, 546 for rearrangements, and 732 for CNAs. Among SVs annotations, 7,029 (67.4%) were EM and 787 (7.5%) were PM. Of rearrangement annotations, 328 (60.1%) were EM and 95 (17.4%) were PM. Of CNA annotations, 469 (64.1%) were EM and 28 (3.8%) were PM. For off-label therapies, agreement between annotation sources was much lower in all above scenarios. Examples included 3022 (29%) cases were identified as EM plus PM for SVs, 324 (59.3%) for rearrangements, and 42 (5.7%) for CNAs.

CONCLUSIONS

Therapy recommendations were inconsistent between FM and OncoKB annotation services, with a substantial disagreement among both FDA-approved and off-label therapy annotations. The limitation of time difference of annotations performed between FM and OncoKB therapy annotations accounted for some disagreement. Establishing accuracy and improving concordance between different annotation services is needed to better match treatments to patients and improve provider trust and reliability of annotation service.

BACKGROUND

The National Precision Oncology Program (NPOP) provides comprehensive genomic profiling (CGP) through external vendors to patients within the Veterans Affairs Healthcare System who meet testing guidelines. We sought to assess the concordance of cancer therapy recommendations between Foundation Medicine (FM), one of the NPOP vendors, and OncoKB, an FDA-recognized public precision oncology knowledge database, which annotates human genetic variants associated with therapies guidance at varying levels of evidence.

METHODS

We selected FM CGP test reports with at least one therapy recommendation regardless of FDA approval or level of evidence were selected to compare FM and OncoKB therapy annotations of different mutation types, including short variants (SVs), rearrangements, and copy number alterations (CNAs) between 02/01/2019-03/13/2023. Therapy recommendations of annotations for unique combinations of gene, variant, and cancer type from FM and OncoKB were compared. Comparisons were scored as an Exact Match (EM) if FM and OncoKB therapy annotation was the same or a Partial Match (PM) if the FM therapy annotation was a subset of OncoKB’s or vice versa.

RESULTS

For annotations involving FDA-approved therapies, a total of 10,435 cases were compared for SVs, 546 for rearrangements, and 732 for CNAs. Among SVs annotations, 7,029 (67.4%) were EM and 787 (7.5%) were PM. Of rearrangement annotations, 328 (60.1%) were EM and 95 (17.4%) were PM. Of CNA annotations, 469 (64.1%) were EM and 28 (3.8%) were PM. For off-label therapies, agreement between annotation sources was much lower in all above scenarios. Examples included 3022 (29%) cases were identified as EM plus PM for SVs, 324 (59.3%) for rearrangements, and 42 (5.7%) for CNAs.

CONCLUSIONS

Therapy recommendations were inconsistent between FM and OncoKB annotation services, with a substantial disagreement among both FDA-approved and off-label therapy annotations. The limitation of time difference of annotations performed between FM and OncoKB therapy annotations accounted for some disagreement. Establishing accuracy and improving concordance between different annotation services is needed to better match treatments to patients and improve provider trust and reliability of annotation service.

BACKGROUND

Multiple myeloma, an incurable plasma cell malignancy, has an average age of diagnosis over 65 years. For transplant-eligible patients, high-dose melphalan 200 mg/m2 (MEL200), followed by autologous stem cell rescue (ASCR) is the standard in consolidation therapy. Most clinical trials evaluating MEL200 with ASCR excluded patients over 65 due to concerns for toxicity and treatment-related mortality, leading to use of reduced dose melphalan 140 mg/m2 (MEL140) in clinical practice for older patients. As this dose has limited studies surrounding its reduction, the purpose of this study was to compare outcomes and toxicities of MEL140 in patients over the age of 65 to MEL200 in patients 65 and under.

METHODS

This single-center institutional review board approved retrospective study was conducted at VA Tennessee Valley Healthcare System. All multiple myeloma patients greater than 18 years of age who received melphalan with ASCR from January 1, 2018, to December 31, 2021, were included. Patients were divided into two arms: age < 65 treated with MEL200 and age >65 treated with MEL140. The primary endpoint was oneyear progression-free survival (PFS). The secondary endpoints were one-year overall survival (OS), treatment related mortality, time to neutrophil engraftment, and toxicities including febrile neutropenia, diarrhea, mucositis, infection, and intensive care unit transfers.

RESULTS

A total of 222 patients were included, 114 patients in the MEL200 arm and 108 patients in the MEL140 arm. The primary endpoint of one-year PFS had no significant difference, with 103 (90.4%) patients in the MEL200 group compared to 99 (91.7%) patients in the MEL140 group (p=0.732). Similarly, there was no statistically significant difference in the secondary endpoint of one-year OS with 112 (98.3%) patients in the MEL200 group compared to 106 (98.2%) in the MEL140 group (p=0.956). Toxicities were similar; however, grade 3 mucositis was higher in the MEL200 arm.

CONCLUSIONS

Our study found no difference in oneyear PFS or one-year OS when comparing MEL140 to MEL200 with minimal differences in regimen-related toxicities. Although not powered to detect statistical difference, results suggests that dose reduction with MEL140 in patients >65 years does not impact one-year PFS when compared to patients <65 receiving standard MEL200.

BACKGROUND

Multiple myeloma, an incurable plasma cell malignancy, has an average age of diagnosis over 65 years. For transplant-eligible patients, high-dose melphalan 200 mg/m2 (MEL200), followed by autologous stem cell rescue (ASCR) is the standard in consolidation therapy. Most clinical trials evaluating MEL200 with ASCR excluded patients over 65 due to concerns for toxicity and treatment-related mortality, leading to use of reduced dose melphalan 140 mg/m2 (MEL140) in clinical practice for older patients. As this dose has limited studies surrounding its reduction, the purpose of this study was to compare outcomes and toxicities of MEL140 in patients over the age of 65 to MEL200 in patients 65 and under.

METHODS

This single-center institutional review board approved retrospective study was conducted at VA Tennessee Valley Healthcare System. All multiple myeloma patients greater than 18 years of age who received melphalan with ASCR from January 1, 2018, to December 31, 2021, were included. Patients were divided into two arms: age < 65 treated with MEL200 and age >65 treated with MEL140. The primary endpoint was oneyear progression-free survival (PFS). The secondary endpoints were one-year overall survival (OS), treatment related mortality, time to neutrophil engraftment, and toxicities including febrile neutropenia, diarrhea, mucositis, infection, and intensive care unit transfers.

RESULTS

A total of 222 patients were included, 114 patients in the MEL200 arm and 108 patients in the MEL140 arm. The primary endpoint of one-year PFS had no significant difference, with 103 (90.4%) patients in the MEL200 group compared to 99 (91.7%) patients in the MEL140 group (p=0.732). Similarly, there was no statistically significant difference in the secondary endpoint of one-year OS with 112 (98.3%) patients in the MEL200 group compared to 106 (98.2%) in the MEL140 group (p=0.956). Toxicities were similar; however, grade 3 mucositis was higher in the MEL200 arm.

CONCLUSIONS

Our study found no difference in oneyear PFS or one-year OS when comparing MEL140 to MEL200 with minimal differences in regimen-related toxicities. Although not powered to detect statistical difference, results suggests that dose reduction with MEL140 in patients >65 years does not impact one-year PFS when compared to patients <65 receiving standard MEL200.

BACKGROUND

Multiple myeloma, an incurable plasma cell malignancy, has an average age of diagnosis over 65 years. For transplant-eligible patients, high-dose melphalan 200 mg/m2 (MEL200), followed by autologous stem cell rescue (ASCR) is the standard in consolidation therapy. Most clinical trials evaluating MEL200 with ASCR excluded patients over 65 due to concerns for toxicity and treatment-related mortality, leading to use of reduced dose melphalan 140 mg/m2 (MEL140) in clinical practice for older patients. As this dose has limited studies surrounding its reduction, the purpose of this study was to compare outcomes and toxicities of MEL140 in patients over the age of 65 to MEL200 in patients 65 and under.

METHODS

This single-center institutional review board approved retrospective study was conducted at VA Tennessee Valley Healthcare System. All multiple myeloma patients greater than 18 years of age who received melphalan with ASCR from January 1, 2018, to December 31, 2021, were included. Patients were divided into two arms: age < 65 treated with MEL200 and age >65 treated with MEL140. The primary endpoint was oneyear progression-free survival (PFS). The secondary endpoints were one-year overall survival (OS), treatment related mortality, time to neutrophil engraftment, and toxicities including febrile neutropenia, diarrhea, mucositis, infection, and intensive care unit transfers.

RESULTS

A total of 222 patients were included, 114 patients in the MEL200 arm and 108 patients in the MEL140 arm. The primary endpoint of one-year PFS had no significant difference, with 103 (90.4%) patients in the MEL200 group compared to 99 (91.7%) patients in the MEL140 group (p=0.732). Similarly, there was no statistically significant difference in the secondary endpoint of one-year OS with 112 (98.3%) patients in the MEL200 group compared to 106 (98.2%) in the MEL140 group (p=0.956). Toxicities were similar; however, grade 3 mucositis was higher in the MEL200 arm.

CONCLUSIONS

Our study found no difference in oneyear PFS or one-year OS when comparing MEL140 to MEL200 with minimal differences in regimen-related toxicities. Although not powered to detect statistical difference, results suggests that dose reduction with MEL140 in patients >65 years does not impact one-year PFS when compared to patients <65 receiving standard MEL200.

BACKGROUND

In 2017, the Thoracic Tumor Board realized that there were patients whose lung resections had critical review of the slides and reports prior to presentation. Errors were found which resulted in a change of the pathology Tumor Nodal Metastases (pTNM) staging for the patient. The impacts were important for determining appropriate therapy. It was decided to systematically review all lung cancer resections for accuracy before determining definitive therapy recommendations.

METHODS

All lung resections for malignancy were examined prior and up to 2 days of completion for accuracy of tumor type, tumor size, tumor grade, lymph node metastases and pathologic stage (pTNM). Any errors found were given to the original pathologist for a change in the report before release or for a modified report to be issued.

RESULTS

From June 2017 to December 2020, there were 91 lung resections with 28 (30.77%) errors. Errors included: 16 incorrect pathologic staging, 5 missed tumors in lung and lymph nodes, 2 unexamined stapled surgical margins, 1 wrong site, 1 incorrect lymph node number and 2 missed tumor vascular invasion.

IMPLICATIONS

Quality improvement (QI) review of lung resections by a second pathologist is important and may clearly improve pathologic staging for lung cancer patients. It can be added to QI programs currently used in Surgical Pathology. It is important in directing appropriate postsurgical therapies.

BACKGROUND

In 2017, the Thoracic Tumor Board realized that there were patients whose lung resections had critical review of the slides and reports prior to presentation. Errors were found which resulted in a change of the pathology Tumor Nodal Metastases (pTNM) staging for the patient. The impacts were important for determining appropriate therapy. It was decided to systematically review all lung cancer resections for accuracy before determining definitive therapy recommendations.

METHODS

All lung resections for malignancy were examined prior and up to 2 days of completion for accuracy of tumor type, tumor size, tumor grade, lymph node metastases and pathologic stage (pTNM). Any errors found were given to the original pathologist for a change in the report before release or for a modified report to be issued.

RESULTS

From June 2017 to December 2020, there were 91 lung resections with 28 (30.77%) errors. Errors included: 16 incorrect pathologic staging, 5 missed tumors in lung and lymph nodes, 2 unexamined stapled surgical margins, 1 wrong site, 1 incorrect lymph node number and 2 missed tumor vascular invasion.

IMPLICATIONS

Quality improvement (QI) review of lung resections by a second pathologist is important and may clearly improve pathologic staging for lung cancer patients. It can be added to QI programs currently used in Surgical Pathology. It is important in directing appropriate postsurgical therapies.

BACKGROUND

In 2017, the Thoracic Tumor Board realized that there were patients whose lung resections had critical review of the slides and reports prior to presentation. Errors were found which resulted in a change of the pathology Tumor Nodal Metastases (pTNM) staging for the patient. The impacts were important for determining appropriate therapy. It was decided to systematically review all lung cancer resections for accuracy before determining definitive therapy recommendations.

METHODS

All lung resections for malignancy were examined prior and up to 2 days of completion for accuracy of tumor type, tumor size, tumor grade, lymph node metastases and pathologic stage (pTNM). Any errors found were given to the original pathologist for a change in the report before release or for a modified report to be issued.

RESULTS

From June 2017 to December 2020, there were 91 lung resections with 28 (30.77%) errors. Errors included: 16 incorrect pathologic staging, 5 missed tumors in lung and lymph nodes, 2 unexamined stapled surgical margins, 1 wrong site, 1 incorrect lymph node number and 2 missed tumor vascular invasion.

IMPLICATIONS

Quality improvement (QI) review of lung resections by a second pathologist is important and may clearly improve pathologic staging for lung cancer patients. It can be added to QI programs currently used in Surgical Pathology. It is important in directing appropriate postsurgical therapies.

PURPOSE

This quality improvement project aims to enhance the rate of germline genetic testing for prostate cancer at the Stratton VA Medical Center, improving risk reduction strategies and therapeutic options for patients.

BACKGROUND

Prostate cancer is prevalent at the Stratton VA Medical Center, yet the rate of genetic evaluation for prostate cancer remains suboptimal. National guidelines recommend genetic counseling and testing in specific patient populations. To address this gap, an interdisciplinary working group conducted gap analysis and root cause analysis, identifying four significant barriers.

METHODS 

The working group comprised medical oncologists, urologists, primary care physicians, genetics counselors, data experts, and a LEAN coach. Interventions included implementing a prostate cancer pathway to educate staff on genetic testing indications and integrating genetic testing screening into clinic visits. After the interventions were implemented in January 2022, patient charts were reviewed for all genetic referrals and new prostate cancer diagnoses from January to December 2022.

DATA ANALYSIS

Descriptive analysis was conducted on referral rates, evaluation visit completion rates, and genetic testing outcomes among prostate cancer patients.

RESULTS

During the study period, 59 prostate cancer patients were referred for genetic evaluation. Notably, this was a large increase from no genetic referrals for prostate cancer in the previous year. Among them, 43 completed the evaluation visit, and 34 underwent genetic testing. Noteworthy findings were observed in 5 patients, including 3 variants of unknown significance and 2 pathogenic germline variants: HOXB13 and BRCA2 mutations.

IMPLICATIONS

This project highlights the power of a collaborative, multidisciplinary approach to overcome barriers and enhance the quality of care for prostate cancer patients. The team’s use of gap analysis and root cause analysis successfully identified barriers and proposed solutions, leading to increased referrals and the identification of significant genetic findings. Continued efforts to improve access to germline genetic testing are crucial for enhanced patient care and improved outcomes.

PURPOSE

This quality improvement project aims to enhance the rate of germline genetic testing for prostate cancer at the Stratton VA Medical Center, improving risk reduction strategies and therapeutic options for patients.

BACKGROUND

Prostate cancer is prevalent at the Stratton VA Medical Center, yet the rate of genetic evaluation for prostate cancer remains suboptimal. National guidelines recommend genetic counseling and testing in specific patient populations. To address this gap, an interdisciplinary working group conducted gap analysis and root cause analysis, identifying four significant barriers.

METHODS 

The working group comprised medical oncologists, urologists, primary care physicians, genetics counselors, data experts, and a LEAN coach. Interventions included implementing a prostate cancer pathway to educate staff on genetic testing indications and integrating genetic testing screening into clinic visits. After the interventions were implemented in January 2022, patient charts were reviewed for all genetic referrals and new prostate cancer diagnoses from January to December 2022.

DATA ANALYSIS

Descriptive analysis was conducted on referral rates, evaluation visit completion rates, and genetic testing outcomes among prostate cancer patients.

RESULTS

During the study period, 59 prostate cancer patients were referred for genetic evaluation. Notably, this was a large increase from no genetic referrals for prostate cancer in the previous year. Among them, 43 completed the evaluation visit, and 34 underwent genetic testing. Noteworthy findings were observed in 5 patients, including 3 variants of unknown significance and 2 pathogenic germline variants: HOXB13 and BRCA2 mutations.

IMPLICATIONS

This project highlights the power of a collaborative, multidisciplinary approach to overcome barriers and enhance the quality of care for prostate cancer patients. The team’s use of gap analysis and root cause analysis successfully identified barriers and proposed solutions, leading to increased referrals and the identification of significant genetic findings. Continued efforts to improve access to germline genetic testing are crucial for enhanced patient care and improved outcomes.

PURPOSE

This quality improvement project aims to enhance the rate of germline genetic testing for prostate cancer at the Stratton VA Medical Center, improving risk reduction strategies and therapeutic options for patients.

BACKGROUND

Prostate cancer is prevalent at the Stratton VA Medical Center, yet the rate of genetic evaluation for prostate cancer remains suboptimal. National guidelines recommend genetic counseling and testing in specific patient populations. To address this gap, an interdisciplinary working group conducted gap analysis and root cause analysis, identifying four significant barriers.

METHODS 

The working group comprised medical oncologists, urologists, primary care physicians, genetics counselors, data experts, and a LEAN coach. Interventions included implementing a prostate cancer pathway to educate staff on genetic testing indications and integrating genetic testing screening into clinic visits. After the interventions were implemented in January 2022, patient charts were reviewed for all genetic referrals and new prostate cancer diagnoses from January to December 2022.

DATA ANALYSIS

Descriptive analysis was conducted on referral rates, evaluation visit completion rates, and genetic testing outcomes among prostate cancer patients.

RESULTS

During the study period, 59 prostate cancer patients were referred for genetic evaluation. Notably, this was a large increase from no genetic referrals for prostate cancer in the previous year. Among them, 43 completed the evaluation visit, and 34 underwent genetic testing. Noteworthy findings were observed in 5 patients, including 3 variants of unknown significance and 2 pathogenic germline variants: HOXB13 and BRCA2 mutations.

IMPLICATIONS

This project highlights the power of a collaborative, multidisciplinary approach to overcome barriers and enhance the quality of care for prostate cancer patients. The team’s use of gap analysis and root cause analysis successfully identified barriers and proposed solutions, leading to increased referrals and the identification of significant genetic findings. Continued efforts to improve access to germline genetic testing are crucial for enhanced patient care and improved outcomes.

Educational organizations across several specialties, including internal medicine and obstetrics and gynecology, have formal surveys¹; however, the field of dermatology has been without one. This study aimed to establish a formal survey for dermatology program directors (PDs) and clinician-educators. Because the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Dermatology surveys do not capture all metrics relevant to dermatology residency educators, an annual survey for our specialty may be helpful to compare dermatology-specific data among programs. Responses could provide context and perspective to faculty and residents who respond to the ACGME annual survey, as our Association of Professors of Dermatology (APD) survey asks more in-depth questions, such as how often didactics occur and who leads them. Resident commute time and faculty demographics and training also are covered. Current ad hoc surveys disseminated through listserves of various medical associations contain overlapping questions and reflect relatively low response rates; dermatology PDs may benefit from a survey with a high response rate to which they can contribute future questions and topics that reflect recent trends and current needs in graduate medical education. As future surveys are administered, the results can be captured in a centralized database accessible by dermatology PDs.

Methods

A survey of PDs from 141 ACGME-accredited dermatology residency programs was conducted by the Residency Program Director Steering Committee of the APD from November 2022 to January 2023 using a prevalidated questionnaire. Personalized survey links were created and sent individually to each PD’s email listed in the ACGME accreditation data system. All survey responses were captured anonymously, with a number assigned to keep de-identified responses separate and organized. The survey consisted of 137 survey questions addressing topics that included program characteristics, PD demographics, the impact of the COVID-19 pandemic on clinical rotation and educational conferences, available resident resources, quality improvement, clinical and didactic instruction, research content, diversity and inclusion, wellness, professionalism, evaluation systems, and graduate outcomes.

Data were collected using Qualtrics survey tools. After removing duplicate and incomplete surveys, data were analyzed using Qualtrics reports and Microsoft Excel for data plotting, averages, and range calculations.

Results

One hundred forty-one personalized survey links were created and sent individually to each program’s filed email obtained from the APD listserv. Fifty-three responses were recorded after removing duplicate or incomplete surveys (38% [53/141] response rate). As of May 2023, there were 144 ACGME-accredited dermatology residency programs due to 3 newly accredited programs in 2022-2023 academic year, which were not included in our survey population.

Program Characteristics—Forty-four respondents (83%) were from a university-based program. Fifty respondents (94%) were from programs that were ACGME accredited prior to 2020, while 3 programs (6%) were American Osteopathic Association accredited prior to singular accreditation. Seventy-one percent (38/53) of respondents had 1 or more associate PDs.

PD Demographics—Eighty-seven percent (45/52) of PDs who responded to the survey graduated from a US allopathic medical school (MD), 10% (5/52) graduated from a US osteopathic medical school (DO), and 4% (2/52) graduated from an international medical school. Seventy-four percent (35/47) of respondents were White, 17% (8/47) were Asian, and 2% (1/47) were Black or African American; this data was not provided for 4 respondents. Forty-eight percent (23/48) of PDs identified as cisgender man, 48% (23/48) identified as cisgender woman, and 4% (2/48) preferred not to answer. Eighty-one percent (38/47) of PDs identified as heterosexual or straight, 15% (7/47) identified as gay or lesbian, and 4% (2/47) preferred not to answer.

Impact of COVID-19 Pandemic on Residency Training—Due to the COVID-19 pandemic, 88% (45/51) of respondents incorporated telemedicine into the resident clinical rotation schedule. Moving forward, 75% (38/51) of respondents indicated that their programs plan to continue to incorporate telemedicine into the rotation schedule. Based on 50 responses, the average of educational conferences that became virtual at the start of the COVID-19 pandemic was 87%; based on 46 responses, the percentage of educational conferences that will remain virtual moving forward is 46%, while 90% (46/51) of respondents indicated that their programs plan to use virtual conferences in some capacity moving forward. Seventy-three percent (37/51) of respondents indicated that they plan to use virtual interviews as part of residency recruitment moving forward.

Available Resources—Twenty-four percent (11/46) of respondents indicated that residents in their program do not get protected time or time off for CORE examinations. Seventy-five percent (33/44) of PDs said their program provides funding for residents to participate in board review courses. The chief residents at 63% (31/49) of programs receive additional compensation, and 69% (34/49) provide additional administrative time to chief residents. Seventy-one percent (24/34) of PDs reported their programs have scribes for attendings, and 12% (4/34) have scribes for residents. Support staff help residents with callbacks and in-basket messages according to 76% (35/46) of respondents. The majority (98% [45/46]) of PDs indicated that residents follow-up on results and messages from patients seen in resident clinics, and 43% (20/46) of programs have residents follow-up with patients seen in faculty clinics. Only 15% (7/46) of PDs responded they have schedules with residents dedicated to handle these tasks. According to respondents, 33% (17/52) have residents who are required to travel more than 25 miles to distant clinical sites. Of them, 35% (6/17) provide accommodations.

Quality Improvement—Seventy-one percent (35/49) of respondents indicated their department has a quality improvement/patient safety team or committee, and 94% (33/35) of these teams include residents. A lecture series on quality improvement and patient safety is offered at 67% (33/49) of the respondents’ programs, while morbidity and mortality conferences are offered in 73% (36/49).

Clinical Instruction—Our survey asked PDs how many months each residency year spends on a certain rotational service. Based on 46 respondents, the average number of months dedicated to medical dermatology is 7, 5, and 6 months for postgraduate year (PGY) 2, PGY3, and PGY4, respectively. The average number of months spent in other subspecialties is provided in the Table. On average, PGY2 residents spend 8 half-days per week seeing patients in clinic, while PGY3 and PGY4 residents see patients for 7 half-days. The median and mean number of patients staffed by a single attending per hour in teaching clinics are 6 and 5.88, respectively. Respondents indicated that residents participate in the following specialty clinics: pediatric dermatology (96% [44/46]), laser/cosmetic (87% [40/44]), high-risk skin cancer (ie, immunosuppressed/transplant patient)(65% [30/44]), pigmented lesion/melanoma (52% [24/44]), connective tissue disease (52% [24/44]), teledermatology (50% [23/44]), free clinic for homeless and/or indigent populations (48% [22/44]), contact dermatitis (43% [20/44]), skin of color (43% [20/44]), oncodermatology (41% [19/44]), and bullous disease (33% [15/44]).

Additionally, in 87% (40/46) of programs, residents participate in a dedicated inpatient consultation service. Most respondents (98% [45/46]) responded that they utilize in-person consultations with a teledermatology supplement. Fifteen percent (7/46) utilize virtual teledermatology (live video-based consultations), and 57% (26/46) utilize asynchronous teledermatology (picture-based consultations). All respondents (n=46) indicated that 0% to 25% of patient encounters involving residents are teledermatology visits. Thirty-three percent (6/18) of programs have a global health special training track, 56% (10/18) have a Specialty Training and Advanced Research/Physician-Scientist Research Training track, 28% (5/18) have a diversity training track, and 50% (9/18) have a clinician educator training track.

Didactic Instruction—Five programs have a full day per week dedicated to didactics, while 36 programs have at least one half-day per week for didactics. On average, didactics in 57% (26/46) of programs are led by faculty alone, while 43% (20/46) are led at least in part by residents or fellows.

Research Content—Fifty percent (23/46) of programs have a specific research requirement for residents beyond general ACGME requirements, and 35% (16/46) require residents to participate in a longitudinal research project over the course of residency. There is a dedicated research coordinator for resident support at 63% (29/46) of programs. Dedicated biostatistics research support is available for resident projects at 42% (19/45) of programs. Additionally, at 42% (19/45) of programs, there is a dedicated faculty member for oversight of resident research.

Diversity, Equity, and Inclusion—Seventy-three percent (29/40) of programs have special diversity, equity, and inclusion programs or meetings specific to residency, 60% (24/40) have residency initiatives, and 55% (22/40) have a residency diversity committee. Eighty-six percent (42/49) of respondents strongly agreed that their current residents represent diverse ethnic and racial backgrounds (ie, >15% are not White). eTable 1 shows PD responses to this statement, which were stratified based on self-identified race. eTable 2 shows PD responses to the statement, “Our current residents represent an inclusion of gender/sexual orientation,” which were stratified based on self-identified gender identity/sexual orientation. Lastly, eTable 3 highlights the percentage of residents with an MD and DO degree, stratified based on PD degree.

Wellness—Forty-eight percent (20/42) of respondents indicated they are under stress and do not always have as much energy as before becoming a PD but do not feel burned out. Thirty-one percent (13/42) indicated they have 1 or more symptoms of burnout, such as emotional exhaustion. Eighty-six percent (36/42) are satisfied with their jobs overall (43% agree and 43% strongly agree [18/42 each]).

Evaluation System—Seventy-five percent (33/44) of programs deliver evaluations of residents by faculty online, 86% (38/44) of programs have PDs discuss evaluations in-person, and 20% (9/44) of programs have faculty evaluators discuss evaluations in-person. Seventy-seven percent (34/44) of programs have formal faculty-resident mentor-mentee programs. Clinical competency committee chair positions are filled by PDs, assistant PDs, or core faculty members 47%, 38%, and 16% of the time, respectively.

Graduation Outcomes of PGY4 Residents—About 28% (55/199) of graduating residents applied to a fellowship position, with the majority (15% [29/55]) matching into Mohs micrographic surgery and dermatologic oncology (MSDO) fellowships. Approximately 5% (9/199) and 4% (7/199) of graduates matched into dermatopathology and pediatric dermatology, respectively. The remaining 5% (10/199) of graduating residents applied to a fellowship but did not match. The majority (45% [91/199]) of residency graduates entered private practice after graduation. Approximately 21% (42/199) of graduating residents chose an academic practice with 17% (33/199), 2% (4/199), and 2% (3/199) of those positions being full-time, part-time, and adjunct, respectively.

Comment

The first annual APD survey is a novel data source and provides opportunities for areas of discussion and investigation. Evaluating the similarities and differences among dermatology residency programs across the United States can strengthen individual programs through collaboration and provide areas of cohesion among programs.

Diversity of PDs—An important area of discussion is diversity and PD demographics. Although DO students make up 1 in 4 US graduating medical students, they are not interviewed or ranked as often as MD students.² Diversity in PD race and ethnicity may be worthy of investigation in future studies, as match rates and recruitment of diverse medical school applicants may be impacted by these demographics.

Continued Use of Telemedicine in Training—Since 2020, the benefits of virtual residency recruitment have been debated among PDs across all medical specialties. Points in favor of virtual interviews include cost savings for programs and especially for applicants, as well as time efficiency, reduced burden of travel, and reduced carbon footprint. A problem posed by virtual interviews is that candidates are unable to fully learn institutional cultures and social environments of the programs.³ Likewise, telehealth was an important means of clinical teaching for residents during the height of the COVID-19 pandemic, with benefits that included cost-effectiveness and reduction of disparities in access to dermatologic care.⁴ Seventy-five percent (38/51) of PDs indicated that their program plans to include telemedicine in resident clinical rotation moving forward.

Resources Available—Our survey showed that resources available for residents, delivery of lectures and program time allocated to didactics, protected academic or study time for residents, and allocation of program time for CORE examinations are highly variable across programs. This could inspire future studies to be done to determine the differences in success of the resident on CORE examinations and in digesting material.

Postgraduate Career Plans and Fellowship Matches—Residents of programs that have a home MSDO fellowship are more likely to successfully match into a MSDO fellowship.⁵ Based on this survey, approximately 28% of graduating residents applied to a fellowship position, with 15%, 5%, and 3% matching into desired MSDO, dermatopathology, and pediatric dermatology fellowships, respectively. Additional studies are needed to determine advantages and disadvantages that lead to residents reaching their career goals.

Limitations—Limitations of this study include a small sample size that may not adequately represent all ACGME-accredited dermatology residency programs and selection bias toward respondents who are more likely to participate in survey-based research.

Conclusion

The APD plans to continue to administer this survey on an annual basis, with updates to the content and questions based on input from PDs. This survey will continue to provide valuable information to drive collaboration among residency programs and optimize the learning experience for residents. Our hope is that the response rate will increase in coming years, allowing us to draw more generalizable conclusions. Nonetheless, the survey data allow individual dermatology residency programs to compare their specific characteristics to other programs.

Educational organizations across several specialties, including internal medicine and obstetrics and gynecology, have formal surveys¹; however, the field of dermatology has been without one. This study aimed to establish a formal survey for dermatology program directors (PDs) and clinician-educators. Because the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Dermatology surveys do not capture all metrics relevant to dermatology residency educators, an annual survey for our specialty may be helpful to compare dermatology-specific data among programs. Responses could provide context and perspective to faculty and residents who respond to the ACGME annual survey, as our Association of Professors of Dermatology (APD) survey asks more in-depth questions, such as how often didactics occur and who leads them. Resident commute time and faculty demographics and training also are covered. Current ad hoc surveys disseminated through listserves of various medical associations contain overlapping questions and reflect relatively low response rates; dermatology PDs may benefit from a survey with a high response rate to which they can contribute future questions and topics that reflect recent trends and current needs in graduate medical education. As future surveys are administered, the results can be captured in a centralized database accessible by dermatology PDs.

Methods

A survey of PDs from 141 ACGME-accredited dermatology residency programs was conducted by the Residency Program Director Steering Committee of the APD from November 2022 to January 2023 using a prevalidated questionnaire. Personalized survey links were created and sent individually to each PD’s email listed in the ACGME accreditation data system. All survey responses were captured anonymously, with a number assigned to keep de-identified responses separate and organized. The survey consisted of 137 survey questions addressing topics that included program characteristics, PD demographics, the impact of the COVID-19 pandemic on clinical rotation and educational conferences, available resident resources, quality improvement, clinical and didactic instruction, research content, diversity and inclusion, wellness, professionalism, evaluation systems, and graduate outcomes.

Data were collected using Qualtrics survey tools. After removing duplicate and incomplete surveys, data were analyzed using Qualtrics reports and Microsoft Excel for data plotting, averages, and range calculations.

Results

One hundred forty-one personalized survey links were created and sent individually to each program’s filed email obtained from the APD listserv. Fifty-three responses were recorded after removing duplicate or incomplete surveys (38% [53/141] response rate). As of May 2023, there were 144 ACGME-accredited dermatology residency programs due to 3 newly accredited programs in 2022-2023 academic year, which were not included in our survey population.

Program Characteristics—Forty-four respondents (83%) were from a university-based program. Fifty respondents (94%) were from programs that were ACGME accredited prior to 2020, while 3 programs (6%) were American Osteopathic Association accredited prior to singular accreditation. Seventy-one percent (38/53) of respondents had 1 or more associate PDs.

PD Demographics—Eighty-seven percent (45/52) of PDs who responded to the survey graduated from a US allopathic medical school (MD), 10% (5/52) graduated from a US osteopathic medical school (DO), and 4% (2/52) graduated from an international medical school. Seventy-four percent (35/47) of respondents were White, 17% (8/47) were Asian, and 2% (1/47) were Black or African American; this data was not provided for 4 respondents. Forty-eight percent (23/48) of PDs identified as cisgender man, 48% (23/48) identified as cisgender woman, and 4% (2/48) preferred not to answer. Eighty-one percent (38/47) of PDs identified as heterosexual or straight, 15% (7/47) identified as gay or lesbian, and 4% (2/47) preferred not to answer.

Impact of COVID-19 Pandemic on Residency Training—Due to the COVID-19 pandemic, 88% (45/51) of respondents incorporated telemedicine into the resident clinical rotation schedule. Moving forward, 75% (38/51) of respondents indicated that their programs plan to continue to incorporate telemedicine into the rotation schedule. Based on 50 responses, the average of educational conferences that became virtual at the start of the COVID-19 pandemic was 87%; based on 46 responses, the percentage of educational conferences that will remain virtual moving forward is 46%, while 90% (46/51) of respondents indicated that their programs plan to use virtual conferences in some capacity moving forward. Seventy-three percent (37/51) of respondents indicated that they plan to use virtual interviews as part of residency recruitment moving forward.

Available Resources—Twenty-four percent (11/46) of respondents indicated that residents in their program do not get protected time or time off for CORE examinations. Seventy-five percent (33/44) of PDs said their program provides funding for residents to participate in board review courses. The chief residents at 63% (31/49) of programs receive additional compensation, and 69% (34/49) provide additional administrative time to chief residents. Seventy-one percent (24/34) of PDs reported their programs have scribes for attendings, and 12% (4/34) have scribes for residents. Support staff help residents with callbacks and in-basket messages according to 76% (35/46) of respondents. The majority (98% [45/46]) of PDs indicated that residents follow-up on results and messages from patients seen in resident clinics, and 43% (20/46) of programs have residents follow-up with patients seen in faculty clinics. Only 15% (7/46) of PDs responded they have schedules with residents dedicated to handle these tasks. According to respondents, 33% (17/52) have residents who are required to travel more than 25 miles to distant clinical sites. Of them, 35% (6/17) provide accommodations.

Quality Improvement—Seventy-one percent (35/49) of respondents indicated their department has a quality improvement/patient safety team or committee, and 94% (33/35) of these teams include residents. A lecture series on quality improvement and patient safety is offered at 67% (33/49) of the respondents’ programs, while morbidity and mortality conferences are offered in 73% (36/49).

Clinical Instruction—Our survey asked PDs how many months each residency year spends on a certain rotational service. Based on 46 respondents, the average number of months dedicated to medical dermatology is 7, 5, and 6 months for postgraduate year (PGY) 2, PGY3, and PGY4, respectively. The average number of months spent in other subspecialties is provided in the Table. On average, PGY2 residents spend 8 half-days per week seeing patients in clinic, while PGY3 and PGY4 residents see patients for 7 half-days. The median and mean number of patients staffed by a single attending per hour in teaching clinics are 6 and 5.88, respectively. Respondents indicated that residents participate in the following specialty clinics: pediatric dermatology (96% [44/46]), laser/cosmetic (87% [40/44]), high-risk skin cancer (ie, immunosuppressed/transplant patient)(65% [30/44]), pigmented lesion/melanoma (52% [24/44]), connective tissue disease (52% [24/44]), teledermatology (50% [23/44]), free clinic for homeless and/or indigent populations (48% [22/44]), contact dermatitis (43% [20/44]), skin of color (43% [20/44]), oncodermatology (41% [19/44]), and bullous disease (33% [15/44]).

Additionally, in 87% (40/46) of programs, residents participate in a dedicated inpatient consultation service. Most respondents (98% [45/46]) responded that they utilize in-person consultations with a teledermatology supplement. Fifteen percent (7/46) utilize virtual teledermatology (live video-based consultations), and 57% (26/46) utilize asynchronous teledermatology (picture-based consultations). All respondents (n=46) indicated that 0% to 25% of patient encounters involving residents are teledermatology visits. Thirty-three percent (6/18) of programs have a global health special training track, 56% (10/18) have a Specialty Training and Advanced Research/Physician-Scientist Research Training track, 28% (5/18) have a diversity training track, and 50% (9/18) have a clinician educator training track.

Didactic Instruction—Five programs have a full day per week dedicated to didactics, while 36 programs have at least one half-day per week for didactics. On average, didactics in 57% (26/46) of programs are led by faculty alone, while 43% (20/46) are led at least in part by residents or fellows.

Research Content—Fifty percent (23/46) of programs have a specific research requirement for residents beyond general ACGME requirements, and 35% (16/46) require residents to participate in a longitudinal research project over the course of residency. There is a dedicated research coordinator for resident support at 63% (29/46) of programs. Dedicated biostatistics research support is available for resident projects at 42% (19/45) of programs. Additionally, at 42% (19/45) of programs, there is a dedicated faculty member for oversight of resident research.

Diversity, Equity, and Inclusion—Seventy-three percent (29/40) of programs have special diversity, equity, and inclusion programs or meetings specific to residency, 60% (24/40) have residency initiatives, and 55% (22/40) have a residency diversity committee. Eighty-six percent (42/49) of respondents strongly agreed that their current residents represent diverse ethnic and racial backgrounds (ie, >15% are not White). eTable 1 shows PD responses to this statement, which were stratified based on self-identified race. eTable 2 shows PD responses to the statement, “Our current residents represent an inclusion of gender/sexual orientation,” which were stratified based on self-identified gender identity/sexual orientation. Lastly, eTable 3 highlights the percentage of residents with an MD and DO degree, stratified based on PD degree.

Wellness—Forty-eight percent (20/42) of respondents indicated they are under stress and do not always have as much energy as before becoming a PD but do not feel burned out. Thirty-one percent (13/42) indicated they have 1 or more symptoms of burnout, such as emotional exhaustion. Eighty-six percent (36/42) are satisfied with their jobs overall (43% agree and 43% strongly agree [18/42 each]).

Evaluation System—Seventy-five percent (33/44) of programs deliver evaluations of residents by faculty online, 86% (38/44) of programs have PDs discuss evaluations in-person, and 20% (9/44) of programs have faculty evaluators discuss evaluations in-person. Seventy-seven percent (34/44) of programs have formal faculty-resident mentor-mentee programs. Clinical competency committee chair positions are filled by PDs, assistant PDs, or core faculty members 47%, 38%, and 16% of the time, respectively.

Graduation Outcomes of PGY4 Residents—About 28% (55/199) of graduating residents applied to a fellowship position, with the majority (15% [29/55]) matching into Mohs micrographic surgery and dermatologic oncology (MSDO) fellowships. Approximately 5% (9/199) and 4% (7/199) of graduates matched into dermatopathology and pediatric dermatology, respectively. The remaining 5% (10/199) of graduating residents applied to a fellowship but did not match. The majority (45% [91/199]) of residency graduates entered private practice after graduation. Approximately 21% (42/199) of graduating residents chose an academic practice with 17% (33/199), 2% (4/199), and 2% (3/199) of those positions being full-time, part-time, and adjunct, respectively.

Comment

The first annual APD survey is a novel data source and provides opportunities for areas of discussion and investigation. Evaluating the similarities and differences among dermatology residency programs across the United States can strengthen individual programs through collaboration and provide areas of cohesion among programs.

Diversity of PDs—An important area of discussion is diversity and PD demographics. Although DO students make up 1 in 4 US graduating medical students, they are not interviewed or ranked as often as MD students.² Diversity in PD race and ethnicity may be worthy of investigation in future studies, as match rates and recruitment of diverse medical school applicants may be impacted by these demographics.

Continued Use of Telemedicine in Training—Since 2020, the benefits of virtual residency recruitment have been debated among PDs across all medical specialties. Points in favor of virtual interviews include cost savings for programs and especially for applicants, as well as time efficiency, reduced burden of travel, and reduced carbon footprint. A problem posed by virtual interviews is that candidates are unable to fully learn institutional cultures and social environments of the programs.³ Likewise, telehealth was an important means of clinical teaching for residents during the height of the COVID-19 pandemic, with benefits that included cost-effectiveness and reduction of disparities in access to dermatologic care.⁴ Seventy-five percent (38/51) of PDs indicated that their program plans to include telemedicine in resident clinical rotation moving forward.

Resources Available—Our survey showed that resources available for residents, delivery of lectures and program time allocated to didactics, protected academic or study time for residents, and allocation of program time for CORE examinations are highly variable across programs. This could inspire future studies to be done to determine the differences in success of the resident on CORE examinations and in digesting material.

Postgraduate Career Plans and Fellowship Matches—Residents of programs that have a home MSDO fellowship are more likely to successfully match into a MSDO fellowship.⁵ Based on this survey, approximately 28% of graduating residents applied to a fellowship position, with 15%, 5%, and 3% matching into desired MSDO, dermatopathology, and pediatric dermatology fellowships, respectively. Additional studies are needed to determine advantages and disadvantages that lead to residents reaching their career goals.

Limitations—Limitations of this study include a small sample size that may not adequately represent all ACGME-accredited dermatology residency programs and selection bias toward respondents who are more likely to participate in survey-based research.

Conclusion

The APD plans to continue to administer this survey on an annual basis, with updates to the content and questions based on input from PDs. This survey will continue to provide valuable information to drive collaboration among residency programs and optimize the learning experience for residents. Our hope is that the response rate will increase in coming years, allowing us to draw more generalizable conclusions. Nonetheless, the survey data allow individual dermatology residency programs to compare their specific characteristics to other programs.

Educational organizations across several specialties, including internal medicine and obstetrics and gynecology, have formal surveys¹; however, the field of dermatology has been without one. This study aimed to establish a formal survey for dermatology program directors (PDs) and clinician-educators. Because the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Dermatology surveys do not capture all metrics relevant to dermatology residency educators, an annual survey for our specialty may be helpful to compare dermatology-specific data among programs. Responses could provide context and perspective to faculty and residents who respond to the ACGME annual survey, as our Association of Professors of Dermatology (APD) survey asks more in-depth questions, such as how often didactics occur and who leads them. Resident commute time and faculty demographics and training also are covered. Current ad hoc surveys disseminated through listserves of various medical associations contain overlapping questions and reflect relatively low response rates; dermatology PDs may benefit from a survey with a high response rate to which they can contribute future questions and topics that reflect recent trends and current needs in graduate medical education. As future surveys are administered, the results can be captured in a centralized database accessible by dermatology PDs.

Methods

A survey of PDs from 141 ACGME-accredited dermatology residency programs was conducted by the Residency Program Director Steering Committee of the APD from November 2022 to January 2023 using a prevalidated questionnaire. Personalized survey links were created and sent individually to each PD’s email listed in the ACGME accreditation data system. All survey responses were captured anonymously, with a number assigned to keep de-identified responses separate and organized. The survey consisted of 137 survey questions addressing topics that included program characteristics, PD demographics, the impact of the COVID-19 pandemic on clinical rotation and educational conferences, available resident resources, quality improvement, clinical and didactic instruction, research content, diversity and inclusion, wellness, professionalism, evaluation systems, and graduate outcomes.

Data were collected using Qualtrics survey tools. After removing duplicate and incomplete surveys, data were analyzed using Qualtrics reports and Microsoft Excel for data plotting, averages, and range calculations.

Results

One hundred forty-one personalized survey links were created and sent individually to each program’s filed email obtained from the APD listserv. Fifty-three responses were recorded after removing duplicate or incomplete surveys (38% [53/141] response rate). As of May 2023, there were 144 ACGME-accredited dermatology residency programs due to 3 newly accredited programs in 2022-2023 academic year, which were not included in our survey population.

Program Characteristics—Forty-four respondents (83%) were from a university-based program. Fifty respondents (94%) were from programs that were ACGME accredited prior to 2020, while 3 programs (6%) were American Osteopathic Association accredited prior to singular accreditation. Seventy-one percent (38/53) of respondents had 1 or more associate PDs.

PD Demographics—Eighty-seven percent (45/52) of PDs who responded to the survey graduated from a US allopathic medical school (MD), 10% (5/52) graduated from a US osteopathic medical school (DO), and 4% (2/52) graduated from an international medical school. Seventy-four percent (35/47) of respondents were White, 17% (8/47) were Asian, and 2% (1/47) were Black or African American; this data was not provided for 4 respondents. Forty-eight percent (23/48) of PDs identified as cisgender man, 48% (23/48) identified as cisgender woman, and 4% (2/48) preferred not to answer. Eighty-one percent (38/47) of PDs identified as heterosexual or straight, 15% (7/47) identified as gay or lesbian, and 4% (2/47) preferred not to answer.

Impact of COVID-19 Pandemic on Residency Training—Due to the COVID-19 pandemic, 88% (45/51) of respondents incorporated telemedicine into the resident clinical rotation schedule. Moving forward, 75% (38/51) of respondents indicated that their programs plan to continue to incorporate telemedicine into the rotation schedule. Based on 50 responses, the average of educational conferences that became virtual at the start of the COVID-19 pandemic was 87%; based on 46 responses, the percentage of educational conferences that will remain virtual moving forward is 46%, while 90% (46/51) of respondents indicated that their programs plan to use virtual conferences in some capacity moving forward. Seventy-three percent (37/51) of respondents indicated that they plan to use virtual interviews as part of residency recruitment moving forward.

Available Resources—Twenty-four percent (11/46) of respondents indicated that residents in their program do not get protected time or time off for CORE examinations. Seventy-five percent (33/44) of PDs said their program provides funding for residents to participate in board review courses. The chief residents at 63% (31/49) of programs receive additional compensation, and 69% (34/49) provide additional administrative time to chief residents. Seventy-one percent (24/34) of PDs reported their programs have scribes for attendings, and 12% (4/34) have scribes for residents. Support staff help residents with callbacks and in-basket messages according to 76% (35/46) of respondents. The majority (98% [45/46]) of PDs indicated that residents follow-up on results and messages from patients seen in resident clinics, and 43% (20/46) of programs have residents follow-up with patients seen in faculty clinics. Only 15% (7/46) of PDs responded they have schedules with residents dedicated to handle these tasks. According to respondents, 33% (17/52) have residents who are required to travel more than 25 miles to distant clinical sites. Of them, 35% (6/17) provide accommodations.

Quality Improvement—Seventy-one percent (35/49) of respondents indicated their department has a quality improvement/patient safety team or committee, and 94% (33/35) of these teams include residents. A lecture series on quality improvement and patient safety is offered at 67% (33/49) of the respondents’ programs, while morbidity and mortality conferences are offered in 73% (36/49).

Clinical Instruction—Our survey asked PDs how many months each residency year spends on a certain rotational service. Based on 46 respondents, the average number of months dedicated to medical dermatology is 7, 5, and 6 months for postgraduate year (PGY) 2, PGY3, and PGY4, respectively. The average number of months spent in other subspecialties is provided in the Table. On average, PGY2 residents spend 8 half-days per week seeing patients in clinic, while PGY3 and PGY4 residents see patients for 7 half-days. The median and mean number of patients staffed by a single attending per hour in teaching clinics are 6 and 5.88, respectively. Respondents indicated that residents participate in the following specialty clinics: pediatric dermatology (96% [44/46]), laser/cosmetic (87% [40/44]), high-risk skin cancer (ie, immunosuppressed/transplant patient)(65% [30/44]), pigmented lesion/melanoma (52% [24/44]), connective tissue disease (52% [24/44]), teledermatology (50% [23/44]), free clinic for homeless and/or indigent populations (48% [22/44]), contact dermatitis (43% [20/44]), skin of color (43% [20/44]), oncodermatology (41% [19/44]), and bullous disease (33% [15/44]).

Additionally, in 87% (40/46) of programs, residents participate in a dedicated inpatient consultation service. Most respondents (98% [45/46]) responded that they utilize in-person consultations with a teledermatology supplement. Fifteen percent (7/46) utilize virtual teledermatology (live video-based consultations), and 57% (26/46) utilize asynchronous teledermatology (picture-based consultations). All respondents (n=46) indicated that 0% to 25% of patient encounters involving residents are teledermatology visits. Thirty-three percent (6/18) of programs have a global health special training track, 56% (10/18) have a Specialty Training and Advanced Research/Physician-Scientist Research Training track, 28% (5/18) have a diversity training track, and 50% (9/18) have a clinician educator training track.

Didactic Instruction—Five programs have a full day per week dedicated to didactics, while 36 programs have at least one half-day per week for didactics. On average, didactics in 57% (26/46) of programs are led by faculty alone, while 43% (20/46) are led at least in part by residents or fellows.

Research Content—Fifty percent (23/46) of programs have a specific research requirement for residents beyond general ACGME requirements, and 35% (16/46) require residents to participate in a longitudinal research project over the course of residency. There is a dedicated research coordinator for resident support at 63% (29/46) of programs. Dedicated biostatistics research support is available for resident projects at 42% (19/45) of programs. Additionally, at 42% (19/45) of programs, there is a dedicated faculty member for oversight of resident research.

Diversity, Equity, and Inclusion—Seventy-three percent (29/40) of programs have special diversity, equity, and inclusion programs or meetings specific to residency, 60% (24/40) have residency initiatives, and 55% (22/40) have a residency diversity committee. Eighty-six percent (42/49) of respondents strongly agreed that their current residents represent diverse ethnic and racial backgrounds (ie, >15% are not White). eTable 1 shows PD responses to this statement, which were stratified based on self-identified race. eTable 2 shows PD responses to the statement, “Our current residents represent an inclusion of gender/sexual orientation,” which were stratified based on self-identified gender identity/sexual orientation. Lastly, eTable 3 highlights the percentage of residents with an MD and DO degree, stratified based on PD degree.

Wellness—Forty-eight percent (20/42) of respondents indicated they are under stress and do not always have as much energy as before becoming a PD but do not feel burned out. Thirty-one percent (13/42) indicated they have 1 or more symptoms of burnout, such as emotional exhaustion. Eighty-six percent (36/42) are satisfied with their jobs overall (43% agree and 43% strongly agree [18/42 each]).

Evaluation System—Seventy-five percent (33/44) of programs deliver evaluations of residents by faculty online, 86% (38/44) of programs have PDs discuss evaluations in-person, and 20% (9/44) of programs have faculty evaluators discuss evaluations in-person. Seventy-seven percent (34/44) of programs have formal faculty-resident mentor-mentee programs. Clinical competency committee chair positions are filled by PDs, assistant PDs, or core faculty members 47%, 38%, and 16% of the time, respectively.

Graduation Outcomes of PGY4 Residents—About 28% (55/199) of graduating residents applied to a fellowship position, with the majority (15% [29/55]) matching into Mohs micrographic surgery and dermatologic oncology (MSDO) fellowships. Approximately 5% (9/199) and 4% (7/199) of graduates matched into dermatopathology and pediatric dermatology, respectively. The remaining 5% (10/199) of graduating residents applied to a fellowship but did not match. The majority (45% [91/199]) of residency graduates entered private practice after graduation. Approximately 21% (42/199) of graduating residents chose an academic practice with 17% (33/199), 2% (4/199), and 2% (3/199) of those positions being full-time, part-time, and adjunct, respectively.

Comment

The first annual APD survey is a novel data source and provides opportunities for areas of discussion and investigation. Evaluating the similarities and differences among dermatology residency programs across the United States can strengthen individual programs through collaboration and provide areas of cohesion among programs.

Diversity of PDs—An important area of discussion is diversity and PD demographics. Although DO students make up 1 in 4 US graduating medical students, they are not interviewed or ranked as often as MD students.² Diversity in PD race and ethnicity may be worthy of investigation in future studies, as match rates and recruitment of diverse medical school applicants may be impacted by these demographics.

Continued Use of Telemedicine in Training—Since 2020, the benefits of virtual residency recruitment have been debated among PDs across all medical specialties. Points in favor of virtual interviews include cost savings for programs and especially for applicants, as well as time efficiency, reduced burden of travel, and reduced carbon footprint. A problem posed by virtual interviews is that candidates are unable to fully learn institutional cultures and social environments of the programs.³ Likewise, telehealth was an important means of clinical teaching for residents during the height of the COVID-19 pandemic, with benefits that included cost-effectiveness and reduction of disparities in access to dermatologic care.⁴ Seventy-five percent (38/51) of PDs indicated that their program plans to include telemedicine in resident clinical rotation moving forward.

Resources Available—Our survey showed that resources available for residents, delivery of lectures and program time allocated to didactics, protected academic or study time for residents, and allocation of program time for CORE examinations are highly variable across programs. This could inspire future studies to be done to determine the differences in success of the resident on CORE examinations and in digesting material.

Postgraduate Career Plans and Fellowship Matches—Residents of programs that have a home MSDO fellowship are more likely to successfully match into a MSDO fellowship.⁵ Based on this survey, approximately 28% of graduating residents applied to a fellowship position, with 15%, 5%, and 3% matching into desired MSDO, dermatopathology, and pediatric dermatology fellowships, respectively. Additional studies are needed to determine advantages and disadvantages that lead to residents reaching their career goals.

Limitations—Limitations of this study include a small sample size that may not adequately represent all ACGME-accredited dermatology residency programs and selection bias toward respondents who are more likely to participate in survey-based research.

Conclusion

The APD plans to continue to administer this survey on an annual basis, with updates to the content and questions based on input from PDs. This survey will continue to provide valuable information to drive collaboration among residency programs and optimize the learning experience for residents. Our hope is that the response rate will increase in coming years, allowing us to draw more generalizable conclusions. Nonetheless, the survey data allow individual dermatology residency programs to compare their specific characteristics to other programs.