|
|
2024 Annual Meeting Accepted Abstracts
*Indicates selected for podium presentation
Click on abstract title to view digital poster (if available).
Jump to first author last names beginning with: A-C ~ D-H ~ K-L ~ M-O ~ P-R ~ S ~ T-X
Vitamin C deficiency associated with acute aplastic crisis in a 32-year-old black woman admitted with acute pain crisis of sickle cell disease
N. Abdallah1, J. Van Allen2, S. Godin1, R. Vankina2, O. Cole2, U. Hegde2
1- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
2- Department of Hematology and Oncology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
Background
Sickle cell anemia (SCA) is characterized by red cell destruction and oxidative stress response in organs. We describe severe malnutrition in a 32-year-old black woman with SCA who developed aplastic crisis and discuss the underlying cause.Methods
A 32-year-old black woman with hemoglobin SS disease was admitted to the hospital for worsening leg pains and intermittent gum and vaginal bleeding of 3-4 months. History included iron overload, chronic anemia, thrombophilia, and gastroesophageal reflux disease. Baseline hemoglobin was 7 gm% with reticulocyte count of 15%. Patient reported new pain and swelling of ankles and right knee that was confirmed to be hemarthrosis. Test for gout, autoimmune disease and viral infections were negative. About a week later, patient developed purpuric rash on legs and thighs and bruises around swollen ankles.Results
Hemoglobin, reticulocyte, white blood cell and platelet counts dropped to 3.8gm%, 0.2%, 1100 and 8000/microliter, respectively, requiring blood products. Close visualization of cutaneous purpuric rash favored perifollicular hemorrhages and no petechiae. Clinical diagnosis of scurvy was confirmed by low blood level of dehydroascorbic acid levels of <5 micromoles/L. Vitamin C supplementation resulted in full bone marrow and arthritis recovery.Conclusions
Hematopoietic stem cell function is impaired due to oxidative stress response in SCA patients. Vitamin C is protective and its deficiency can result in bone marrow failure. Distinguishing perifollicular hemorrhages from petechial rash helped accurate diagnoses and successful management in our patient. Use of nutritional screening tools in patients with SCA will help identify nutritional deficiencies and improve patient outcomes.
C. Bhanushali1, V. Mukhtiar1, V. Majmundar1, V. Bhanushali2, K. Babu3, S. Rajarajan3, K. Seetharaman1
1- Saint Vincent Hospital, Worcester, Worcester, MA
2- King Edward Memorial Hospital and Seth GS Medical College, Mumbai, India.
3- Allegheny General Hospital, Pittsburgh, PA
Background
Biosimilars are biological products highly similar to existing FDA-approved reference drugs and are gaining significance due to their cost saving potential. Our study aims to analyze the cost and spending trends of Traztuzumab biosimilars (Ogivri, Herzuma, Ontruzant, Trazimera, Kanjinti, Hercessi) as compared to the reference drug (Herceptin) from 2020 to 2022.
Methods
Data from the Centers for Medicare & Medicaid Services (CMS) for Medicare Part D was used to extract total spending, spending per claim, number of beneficiaries, and spending per beneficiary for trastuzumab and its biosimilars. All costs were adjusted for inflation and represented in 2022 US dollars.
Results
From 2020 to 2022, total spending on Herceptin decreased from $13,633,376 to $5,953,812, while that on all biosimilars increased, with Trazimera showing the steepest growth. Herceptin claims dropped by 48%, whereas claims for all biosimilars rose. Kanjinti had the highest number of claims in 2022, and Herzuma had the lowest. The number of Herceptin beneficiaries decreased by 44.5%, while the number of biosimilar beneficiaries increased, particularly for Kanjinti and Trazimera. Herceptin had the highest average spending per claim and per beneficiary, although both metrics decreased from 2020 to 2022.
Conclusions
The shift from Herceptin to biosimilars reflect changing trends in HER2-positive breast cancer, likely driven by cost savings and increased biosimilar availability. The decrease in Herceptin average spending per claim and beneficiary indicates a favorable outcome as a result of market competition. Continuous monitoring and analysis will be crucial to understanding the long-term impacts on healthcare costs and patient outcomes.
C. Bhanushali1, V. Mukhtiar1, K. Babu2, S. Rajarajan2, S. Preetham Kasire3, J. Jayakumar4, and A. Mariam Roy5
1- Saint Vincent Hospital, Worcester, Worcester, MA
2- Allegheny General Hospital, Pittsburgh, PA
3- Department of Internal Medicine, North Central Bronx Hospital/Jacobi Medical Central, Bronx; 5Internal Medicine
4- The Brooklyn Hospital Center, Brooklyn, NY
5- Ohio State University/ The Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH
Background
Mantle cell lymphoma (MCL) is a rare aggressive subtype of Non-Hodgkin lymphoma (NHL). Patients with MCL are at an increased risk of developing second primary malignancies (SPMs). Given the advancements in treatment and survival outcomes, we aim to analyzes the incidence of SPMs among MCL patients in the U.S. from 2000 to 2021.
Methods
National Cancer Institute’s SEER database (version 8.4.3) was used to identify MCL patients (ICD-O-3 code 9673/3) diagnosed between 2000 and 2021. SPMs were identified using the site recode and multiple primary standardized incidence ratio (MP-SIR) was used to determine the standardized incidence ratio (SIR).
Results
MCL patients had a 41% increased risk of SPMs (95% CI 1.34–1.49, p < 0.05) compared to the general population. The mean interval from MCL diagnosis to the onset of SPM was 58 months. Notably increased SIR were identified for salivary gland (2.53), respiratory (1.53), skin (2.16), melanoma (1.87), renal (1.69), and thyroid cancers (3.68). Hematological malignancies showed higher SIRs for NHL (2.23), chronic lymphocytic leukemia (2.72), acute lymphocytic leukemia (4.88), and myeloid and monocytic leukemia (5.55). The risks for thyroid, renal, and respiratory cancers were elevated in the first year following MCL diagnosis, while that for esophageal, sigmoid colon, vulvar, testicular cancers, and HL increased significantly after five years
Conclusions
This study underscores the elevated risk of SPMs in MCL patients, emphasizing the need for ongoing monitoring and targeted strategies, especially considering the 5-year median time to SPM. Further research is needed to understand the mechanisms driving these risks to improve patient outcomes.
C. Bhanushali1, V. Mukhtiar1, M. Mehta1, V. Bhanushali2, C. Cabot 3, R. Fatoki4 and K. Seetharaman1.
1- Saint Vincent Hospital, Worcester, Worcester, MA.
2- King Edward Memorial Hospital and Seth GS Medical College, Mumbai, India.
3- UMass Chan Medical School, Worcester.
4- University of Miami- Slyvester Comprehensive Cancer Center, Miami, FL.
Background
Multiple myeloma (MM) accounts for about 2% of cancer-related deaths annually and significantly contributes to cancer related morbidity in the United States. Advances in targeted therapies have improved overall survival, but access to these vary. Our study analyzes trends in incidence, mortality, and disparities in MM from 1991 to 2021, focusing on national, state level and sex-based disparities.
Methods
The Global Burden of Disease database was used to extract age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), and disability-adjusted life years (DALYs) of MM from 1991 to 2021, across all states. Mortality-to-incidence indices (MIIs) were calculated, and data was analyzed using joinpoint regression.
Results
Between 1991 and 2021, the ASIR of MM in the U.S. decreased by 10.33%, with a more significant decline in females (15.95%) than males (8.18%). ASMR decreased by 14.61%, with greater reductions in females (18.52%) compared to males (13.5%). DALYs for both sexes combined declined by 23.03%, with a larger reduction in females (26.26%) than in males (21.79%). Notable state variations were observed, with changes in ASIR ranging from a 45.62% increase in Kansas to a 49.23% decrease in New Hampshire. Changes in ASMR varied from a decrease by 1.14% in Oklahoma to 32.37% in the District of Columbia.
Conclusions
These findings enhance our understanding of the gender and state level disparities of MM underscoring the importance of targeted studies to explore the reasons behind these epidemiological differences.
Exercise Improves Cancer Related Fatigue. Now What? Developing a Standardized Approach to Exercise for All Phases of Cancer Survivorship
A.Brown and C. Brown
EnduraFit Training and Rehab, LLC
Background
The benefits of exercise on cancer related fatigue (CRF) are well documented with extensive research. However, many medical professionals are unsure how to best prescribe. Exercise is considered an inexpensive and effective modality to improve overall quality of life amongst cancer patients in all phases of care. The use of exercise to aid in decreased fatigue levels appears to be underutilized. The authors sought to pilot an app based, standardized exercise prescription to aid in the reduction of CRF.
Methods
A review of the literature surrounding best practice in exercise, as well as clinical expertise was utilized to create the exercise program. An integrated literature review approach and individual case studies were explored to assess exercise as a method to improve endurance, strength and fatigue levels. The app was created and consists of strength, endurance and mobility training for three phases of care (acute, home-based, community-based), tracking fatigue status. The variety of phases offers instruction for all levels of immunocompromised to improve overall CRF.
Results
Small sample sizes within daily practice are using this app-based exercise program with positive feedback and reported two-fold mean reduction in CRF.
Conclusions
This small pilot study resulted in positive outcomes for participants. Creating this app specifically for cancer patients, using standardized and intentional phasing of exercises, has yielded positive outcomes in overall health, wellness and CRF. Implementation of this evidence-based app may provide affordable standardized care to more cancer patients with a potential to advance accessibility of this app globally.
Neoadjuvant ArOMatase Inhibitor therapy for ER+ Breast Cancer, the NAOMI trial*
M. Buteau1,S. Tau2, C. Leatheng1, J. Marotti1, T. Miller3, M. Chamberlin1
1- Dartmouth-Hitchock Medical Center
2- Dartmouth College
3- Medical College of Wisconsin, Milwaukee
Background
There is a knowledge gap regarding Neoadjuvant Endocrine Therapy (NET)’ s effect on residual cancer cells and fatty acid oxidation which is essential for survival of dormant ER+BC cells after estrogen withdrawal in vitro. NAOMI is a study testing the effects of letrozole on residual cancer cells as well as markers of mitochondrial and fatty acid metabolism.
Methods
Phase II single-arm open-label study with use of letrozole prior to surgical resection. Eligible patients were women over 18, post-menopausal, with stage I-III ER+, HER2- BC. Primary objective was to assess whether residual cancer cells exhibit upregulation of the fatty acid transporter CPT1A compared to baseline. Secondary objectives included the proportion of subjects who had clinical response and whether residual cancer cells exhibit markers of altered mitochondrial and fatty acid metabolism compared to baseline tumors. Protocol was amended to include adherence rates to adjuvant AI.
Results
77 women have consented to study participation since December 2022 with 57 evaluable patients. Molecular analyses were done on diagnostic and post-letrozole tumor specimens from the first 33 patients. IHC was done using antibodies against Ki67, CPT1A, FASN, perilipin, CD36, and MT-CO2. CPT1A histoscore between baseline and post letrozole specimens were similar. Markers of altered mitochondrial and fatty acid metabolism including MT-CO2, CD36, FASN, Perilipin were unchanged when comparing pre and post-AI tissues. Ki67+ cells were substantially decreased during neoadjuvant letrozole therapy. Patients enrolled in NAOMI had a rate of adherence to adjuvant ET of 82%, higher than historical averages.
Conclusions
NET is associated with a decrease in Ki67+ BC cells however it has minimal impact on fatty acid and mitochondrial metabolism. It is suggested to increase adherence to adjuvant ET.
A new take on treatment in a patient with Plasmablastic Lymphoma
J. Caprino, R. Thomas, M. Gergi, S. Jasra
University of Vermont Medical Center
Background
Plasmablastic lymphoma (PBL) is a rare type of high-grade large B cell lymphoma with diffuse proliferation of plasmablasts, typically found in patients with HIV or those who are immunocompromised. Due to the rare and aggressive nature of this disease there is no clear consensus on treatment. Many different chemotherapy regimens have been used, but the prognosis remains poor. There have been some promising results in case reports using bortezomib or daratumumab with chemotherapy.
Methods
We present a case of plasmablastic lymphoma treated with bortezomib-CHOP, followed by lenalidomide, bortezomib, and dexamethasone, who achieved a complete response (CR) and remains in CR 2 years post-discontinuation of maintenance treatment. We compiled a review of 21 cases to show the uniqueness of this approach and the overall responses to different treatments.
Results
We compared the treatment regimens, outcomes, and adverse effects to the treatment. 4 of the 21 cases had HIV associated PBL the rest were non-HIV PBL. 12 out of 21 were treated with more traditional lymphoma regimens. The other 9 cases were treated with myeloma-based regimens.
Conclusions
Plasmablastic lymphoma is a rare and aggressive subtype of lymphoma. There is limited data on treatment using myeloma-based regimens and its impact on overall survival. This literature review highlights the lack of consensus surrounding treatment, as well as the overall poor prognosis. Our case shows the utility of myeloma-based regimens and promising results in regimens that target plasma cells.
Solving a Mystery: Following Breadcrumbs Leads to an Unsuspected Culprit.
I. Chidobem1, J. Kim1, D. Herrera1, H. Tul-Rehman1
1- Division of Hematology and Oncology at The University of Vermont Medical Center
Background
A systemic inflammatory response (SIR) can arise from various triggers, including infections, trauma, or malignancies. It necessitates a thorough evaluation to evaluate for the underlying etiology. Inflammatory leiomyosarcoma (ILMS) is a rare malignant smooth muscle neoplasm, characterized by a prominent inflammatory infiltrate. We present a case of a patient with ILMS, and improvement in SIR after treatment.
Methods
N/A
Results
A 65-year-old man with history of relapsed refractory peripheral T-Cell lymphoma, treated with chemotherapy, autologous hematopoietic stem cell transplant (HSCT) at first relapse, and allogeneic HSCT at second relapse, with subsequent remission, but course complicated by acute graft versus host disease who was noted to have adenopathy on CT scan, two years after allogeneic HSCT. Workup showed severely elevated inflammatory markers, neutrophilic leukocytosis, thrombocytosis, and anemia. Bone marrow biopsy showed hypocellular marrow without evidence of malignancy, mutations, or cytogenetic abnormalities. PET-CT scan showed mildly metabolically active reactive lymph nodes, as well as markedly FDG avid transverse colon mass. Colonoscopy confirmed a mass with marked inflammatory changes, and the patient underwent partial colectomy. Pathology showed high grade ILMS. His inflammatory markers, neutrophilic leukocytosis, thrombocytosis, anemia, weight and energy improved after partial colectomy. He declined adjuvant chemotherapy and is on active surveillance.
Conclusions
Malignancy-associated systemic inflammatory response underscores the complex interplay between tumor biology and immune system activation. This requires a nuanced approach, integrating effective tumor management, and ongoing research holds promise for targeted therapies aimed at inflammatory pathways. To our knowledge, this is the first reported case of a systemic inflammatory response associated with ILMS.
Z.Cieslak4, D.Bergman1,2, A. Shah, D. Green3, R. Vyas3, J. Karrs3, G. Tsongalis3, L. Vaickus3, P. Shah3
1- Department of Radiation Oncology and Applied Sciences, Dartmouth Hitchcock-Medical Center
2- Newton-Wellesley Hospital, Mass General Brigham, Tufts University School of Medicine
3- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center
4- Geisel School of Medicine at Dartmouth
Background
Despite consensus guidelines for solid tumor diagnoses, tumors of unknown origin are common. Whole-transcriptome sequencing has the potential to predict tissue origin and guide clinical management. We describe a proof-of-principle solid tumor tissue of origin (TOO) classifier utilizing routine whole-transcriptome sequencing data.
Methods
We performed clinical whole-transcriptome sequencing as part of our CLIA-approved whole-exome/whole transcriptome workflow, DH-CancerSeq, on 193 solid tumor samples from 15 tissues using integrated bioinformatics analysis for data processing and alignment. The classifier was based on a neural network model and evaluated using standard stratified K-fold cross validation with a 75-25 train-test split. Performance was quantified using precision (P), recall (R), and F1 score.
Results
A classifier model trained on 145 tumor samples achieved an average accuracy of 0.88 (42/48) on a stratified test set (P=0.86, R=0.88, F1=0.87), and 0.89 when considering top three predictions. Training accuracy was 100%. When filtered to model predictions with greater than 95% probability, 34/35 sample predictions were correct (0.97). 16/17 (0.94) sample predictions from lymph nodal deposits or distant metastases matched the patient’s primary tumor. Samples were correctly predicted across estimated tumor fraction (0.1-0.9), and misclassified samples had adequate tumor fraction (0.4-0.9).
Conclusions
We demonstrated the feasibility of a solid tumor TOO classifier using whole-transcriptome sequencing data integrated into routine workflows at an academic cancer center. Our neural network model achieved high accuracy, precision, and recall across tumor origin and percentage. Validation in larger and more diverse cohorts is underway.
E. Crum1,J. Fischer2, L. Graham2, L. Kelley2, P. Helbig2, L. Gaitor2, S. Halverson2, J. Rueter2
1- Bowdoin College
2-The Jackson Laboratory, Maine Cancer Genomics Initiative
Background
HER2-targeted therapies have expanded significantly across multiple cancer types in recent years. The pan-tumor approval of Trastuzumab deruxtecan earlier this year extended HER2-targeted treatment beyond specific tumor types to all solid tumors, increasing the need for HER2 testing. The Maine Cancer Genomics Initiative (MCGI) 2.0 initiative aims to broadly implement precision oncology and to increase the actionability of genomic tumor testing in Maine. To assess the impact of evolving HER2-targeted treatment, we analyzed data from 194 patients enrolled in the MCGI 2.0 study since 2021.
Methods
We reviewed the data of 194 enrolled patients, screening for HER2 testing and treatment indications. Descriptive statistics were used to compare treatment considerations based on tumor type.
Results
In a retrospective analysis of 188 evaluable patients, 23.4% received HER2 IHC testing, and 98.9% had NGS testing for ERBB2 amplifications or mutations. 52 patients were eligible for HER2 testing under existing FDA approvals at the time of testing. With the new pan-tumor approval, an additional 136 patients (72.3%) would now be eligible for HER2 IHC testing.
Conclusions
Retrospectively, Maine patients received appropriate HER2 testing, limited to about one-quarter of the solid cancer population in Maine. With new approvals in HER2-targeted therapy, another 72.3% of patients now qualify for HER2 IHC testing, posing a substantial burden for the healthcare system in a rural state, especially considering that some solid tumors (e.g., pancreatic cancer) do not seem to respond to HER2-targeted therapy, and other tumors (e.g., lung cancer) responses are primarily driven by activating mutations.
Two Experts: Feasibility and Acceptability of Agenda-Setting Questions and Patient Reported Outcomes for Cell Therapy Patients
J. Doherty1, K. Caldon2, C. Hayes2, J. Hill2, K. Holt3, J. King1, R. Lizcano2, P. Shah2, S. PonnamReddy2, P. Mills4, K. Meehan2, A. Van Citters1
1- The Dartmouth
Background
Patient reported outcome measures (PROMs) and agenda-setting questions can offer valuable information for improving the delivery and quality of care. Our objective was to evaluate the feasibility and acceptability of using agenda-setting questions and PROMs to support clinic visits for people receiving transplant or cellular therapy at Dartmouth Hitchcock Medical Center.
Methods
We conducted a prospective observational study between April 2022 and June 2024. We assigned short electronic pre-visit questionnaires (PVQ) one week prior to clinic visits for 202 consecutive patients receiving stem cell transplantation or chimeric antigen receptor (CAR) T-cell therapy. Providers reviewed free-text responses and PROMs in a clinical decision support dashboard, alongside clinical information. Patients and providers completed surveys to evaluate their experiences using the PVQ and dashboard. We analyzed surveys and electronic health record extracts with descriptive statistics.
Results
60% of PVQs were completed prior to clinic visits. Most (82%) patients reported that the PVQ was easy to complete and 88% of clinicians reported adequate time to review responses prior to the clinical visit. Most patients (88%) and clinicians (100%) reported that the PVQ was useful during the visit, facilitated discussions about patient priorities (patients 77%, clinicians 100%), and aided in making healthcare decisions (patients 74%, clinicians 88%). Patients reported that shared decision-making increased from 76% to 100%.
Conclusions
Agenda setting questions and PROMs that are electronically gathered and captured in a visual dashboard are feasible, acceptable, and are a helpful tool to improve collaborations and perceptions of decision-making across patients and clinicians.
A Rare Presentation of a Common Problem: Hospitalization with Stage IV Cancer
K. Ezell, S. Godin, V. Osadchyi
University of Connecticut
Background
Hepatocellular carcinoma (HCC) ranks as the fifth most common cancer and third leading cause of cancer death worldwide. Overall prognosis is poor, with a 5-year survival rate under 20%. HCC with isolated right heart involvement carries an estimated survival of one to 4 months, and there is no standardized treatment.
Methods
N/A
Results
An 82-year-old Kwa language-speaking woman with a history of stage IV HCC with biliary differentiation on maintenance Durvalumab was found minimally responsive at home. On arrival at the hospital, she was hypotensive and bradycardic. Electrocardiogram revealed a complete heart block, and CT imaging revealed a mass occupying half of the right ventricle concerning thrombus versus malignancy. She was stabilized on an epinephrine infusion and transported to a tertiary care center, where echocardiogram differentiated the mass as vascularized and invading the interventricular septum. She underwent aggressive treatment with intubation, transcutaneous, and then transvenous pacing with subsequent resolution of her bradycardia. During hospitalization, surgical intervention and placement of a permanent pacemaker were deferred. Her course following this index hospitalization included recurrent hemodynamic instability and rehospitalizations. She eventually transitioned to hospice with her primary oncologist.
Conclusions
In the above case, goals of care discussions were complicated by language barriers, cultural barriers, and delayed communication with the patient’s primary oncologist. We advocate for the early involvement of palliative care in hospitalized late-stage cancer patients as a means to improve patient care and quality of life and prevent rehospitalization by providing comprehensive care that addresses cultural, social, and medical needs.
J. Feyisa, G. Zingeta1, Y. Worku1, M. Awol1 ; E. Woldetsadik1 , M. Assefa1, T. Chama1, J. Feyisa1,2, H. Bedada1,3, M. Adem1,3
1- Department of Radiation Oncology and Applied Sciences, Dartmouth Hitchcock-Medical Center
2- Newton-Wellesley Hospital, Mass General Brigham, Tufts University School of Medicine
3- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center
4- Geisel School of Medicine at Dartmouth
Background
Head and neck cancers (HNCs) are the third most treated cancer with radiation in Ethiopia. Most patients present with advanced stage and are not candidates for curative treatment. We assessed the outcome of hypofractionated palliative radiotherapy (RT) for advanced HNCs in a resource-limited setting.
Methods
Patients with histology proven advanced HNC candidates for hypofractionated palliative RT were enrolled. Three regimens were allowed: 44.4 Gy in 12 fractions, 30 Gy in 10 fractions, and 20 Gy in five fractions. Response to treatment was assessed at baseline and at 4 weeks after treatment completion.
Results
Between January 2022 and January 2023, 52 patients were enrolled, and 25 patients were eligible for outcome assessment. Index symptoms include pain, bleeding, dysphagia, respiratory distress, and others in 25, 13, 10, 6, and 17 patients, respectively. Complete relief of the top three symptoms include pain in 52% of patients, hemostasis in 84% of patients, and dysphagia in 30% of patients. Objectively, 64% of patients attained partial response. For 48% of patients, their quality of life (QoL) improved in one parameter of the physical scores. Moreover, 64% of patients showed improvement in three parameters. The global functional score improved in 80% of patients. One patient had grade 3 xerostomia. At the end of the study period, 44% of patients died. The median survival after radiation was 9 months (95% CI, 7.2 to 10.8).
Conclusions
All palliative hypofractionated regimens used were effective in terms of symptom control, tumor response rate, and QoL, and were well tolerated.
J. Feyisa1,2, Y. Berhane3, G. Zingeta1, K. Abegaz4, M. Woldegeorgis1
1- Department of Oncology, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
2- Department of Radiation Oncology and Applied Sciences, Dartmouth Cancer Center, Lebanon, NH
3- Professor of Epidemiology and Public Health, Director, Addis Continental Institute of Public Health
4- Madda Walabu University, Ethiopia., Addis Ababa, Ethiopia
Background
Non metastatic cervical cancer is curable and can be treated with radiotherapy. A delay in receiving treatment due to long waiting times results in upstaging of the disease stage and negatively affects the treatment outcomes. However, real world evidence that progression occurs while waiting for treatment is scarce in low-income countries. We evaluated the impact of long waiting times for radiotherapy in patients with cervical cancer at a referral center in Ethiopia.
Methods
A longitudinal study was conducted from January 5, 2019, to May 30, 2020 to address the objectives of this study. Pathologically diagnosed cervical cancer patients with stage IIB to stage IVA were included in the study. We used Kaplan–Meier analysis to assess overall survival with time. Multivariate Cox regression analysis, using the backward LR selection method, was used to fit the final model.
Results
The median waiting time for radical radiotherapy after diagnosis was 477 days. Waiting for more than 51 days for radiotherapy results in disease progression. Of the 115 patients included in this study, 59 (51.3%) died during the study. A delay in waiting (AHR=3, 95%CI:1.7-4.9) was significantly associated with disease progression and decreased survival.
Conclusions
Waiting time to receive radiotherapy is very long. Urgent action is required to significantly reduce waiting times and improve the survival of cervical cancer patients.
Incidence and Risk Factors for Fungal Infection after CD19-targeted Chimeric Antigen Receptor T cell Therapy for Non-Hodgkin Lymphoma
C. Gaulin1, R. Chemaly2, Y. Jiang2, J. Ramdial3, S. Ahmed1, G. Rondon3, E. Ariza-Heredia2, A. Spallone2, S. Iyer1, P. Kebriaei3, S. Srour3, E. Shpall3, L. Nastoupil1, F. Khawaja2
Affiliations: The University of Texas MD Anderson Cancer Center
1- Department of Lymphoma and Myeloma
2- Department of Infectious Diseases
3- Department of Stem Cell Transplantation and Cellular Therapy
Background
Chimeric antigen receptor T-cell therapy (CAR T) is highly effective for the treatment of non-Hodgkin lymphoma (NHL); however, recipients are at risk of infectious complications. Infections following CAR T are predominantly bacterial or viral; nevertheless, a subset of recipients develop invasive fungal disease (IFD). The evidence guiding antifungal prophylaxis (PPx) is limited.
Methods
Adults with NHL who received CAR T between January 2018 and February 2021 at MD Anderson Cancer Center were identified. Demographics, oncologic history, and complications were collected. Patients were observed for 1 year after CAR T or until death. Antifungal PPx was administered per institutional protocol.
Results
218 patients were identified (Table 1). Most patients had diffuse large B cell lymphoma (73.4%) and received axicabtagene ciloleucel (93.6%). Therapy-related toxicities (Table 2) included: cytokine release syndrome (CRS) (88.5%), immune effector cell-associated neurotoxicity syndrome (ICANS) (59.2%) and hemophagocytic lymphohistiocytosis-like syndrome (IEC-HS) (8.3%). Sixteen patients (7.3%) developed IFD (Table 3). In univariate analysis (Table 4a), IEC-HS, grade 4 CRS, grade 4 ICANS, and any infection within 30 days prior to CAR T (PreCARinf) were associated with IFD. In multivariate analysis (Table 4b), grade 4 CRS/ICANS, and PreCARinf were independent predictors for IFD. Factors associated with mold infections in univariate analysis (Table 4c) included IEC-HS, grade 4 CRS/ICANS, steroid use, prior hematopoietic cell transplantation (HCT), and PreCARinf.
Conclusions
IFD after CAR T for NHL is uncommon. Higher grade toxicities and their treatment, as well as prior HCT and infections, may identify those at highest risk. Additional studies are needed to individualize antifungal PPx.
Advanced Mycosis Fungoides and Hodgkin Lymphoma: A Case of Complex Palliative Management
S. Godin, A. Pillai, K. Ezell, D. D'Andrea
University of Connecticut
Background
Mycosis fungoides (MF) is an uncommon malignancy, with an annual incidence of 6 cases per million in the United States. Surveillance, Epidemiology, and End-Result data show that 7.5% of MF patients develop a second malignancy. Prognosis is generally favorable, with a 5-year survival rate of 72% to 100% and a median survival of up to 35 years. We present a case of advanced-stage MF with concurrent Hodgkin Lymphoma (HL), highlighting complexities in palliative management.
Methods
A 55-year-old male with classical HL and MF was evaluated for worsening skin lesions. Initially diagnosed with MF after developing axillary skin lesions, and then years later, inguinal lymphadenopathy with biopsy favoring HL. His International Prognostic Score indicated a favorable outcome with treatment. After chemotherapy, he achieved complete remission.
Results
Interval scans revealed new axillary abscesses and suspicious skin changes. Biopsy confirmed CD30+ large T-cell transformation of MF. Despite intralesional doxorubicin, he experienced progressive sarcopenia, deconditioning, lesion dissemination, bulky adenopathy, and bilateral adrenal masses. Brentuximab was discussed; however, advanced disease, multiorgan failure, and low Karnofsky performance precluded initiation. His proxies initially disregarded his desire for hospice; however, after days of multidisciplinary care team meetings, he transitioned. After days in a near-sedated state, he expressed relief.
Conclusions
Brentuximab is promising but generally used in advanced disease. While oncologic responses are observed, such agents can cause systemic adverse effects, leading to poor survival. Early identification of patients unlikely to benefit, combined with a multidisciplinary palliative care approach, enhances patient education and decision-making, aligning management with patient goals.
M. Gray, S. Akram, K. Gernander, L. Twitchell, S. Lidofsky, H. Rehman
Department of Hematology & Oncology, University of Vermont Medical Center
Background
Patients undergoing immunosuppressive therapy have significantly increased risk for reactivation of viral hepatitis B in either asymptomatic carriers or those with resolved infections. As a result, ASCO recommends HBV serologic testing prior to initiation of cancer treatment. Despite these recommendations, adequate rates of pre-treatment testing have not been achieved.
Methods
Education was provided to all nurses and hematology/oncology providers regarding the importance of screening for HBV. Ambulatory staff was instructed to pend orders for Hepatitis B antibodies and providers confirmed testing was complete. Patient population was identified as those initiating oncologic treatment at University of Vermont Medical Center outpatient infusion center between 8/1/2022-7/31/2024. Data was obtained using EPIC Slicer Dicer software. Patients were further stratified into those who had undergone HBV testing before or after the intervention was implemented.
Results
In total, 2321 patients underwent treatment for either solid tumor or hematologic malignancies at the outpatient infusion center. Of those, 1341 had not previously received immunosuppressive treatment for cancer therapy. In 2022, approximately 5-13% (mean 5.55 ± 4.66%) of newly treated patients received adequate pretreatment HBV testing. After January 2023, monthly testing rates increased to 27.4-70.2% (mean 52.5 ± 12.2%).
Conclusions
Rates of HBV exposure testing in patients preparing to undergo chemotherapy or immunotherapy can be improved with systemic provider and nursing staff education. While overall risk is low, improved rates of screening, as recommended by ASCO, are essential to prevent morbidity and mortality associated with HBV reactivation. Ambulatory nurse-driven testing model has high rates of success for improved patient safety.
Upstream Oncology Nurse Navigation Improves Timeliness to Treatment in Lung Cancer
K. Hall
Solinsky Center for Cancer at the Elliot
Original Research
UNH Nursing Program: MSN-CNL capstone/manuscript
Background
As a result of our complex and fragmented healthcare system, patients often experience delays in care. Oncology Nurse Navigators (ONN) serve as liaisons, playing a crucial role in facilitating seamless care transitions before, during, and following the completion of each phase and modality of treatment. According to the literature, time to treatment (TTT) is considered a quality indicator for cancer care; defined as the total number of days from the date of diagnosis to the first day of treatment.
Methods
Decrease the length of time from initial diagnosis to initiation of treatment by implementing a standardized thoracic oncology clinical pathway - integrating upstream nurse navigation at the time of diagnosis.
ONN metrics/data collection were utilized to benchmark TTT facilitated by the ONN (N =130 total patients navigated).
Results
Upstream ONN demonstrated:
5-day decrease in the average time to treatment when comparing thoracic referrals (N=52) to non-thoracic referrals (N=78)
Average length of time from biopsy to treatment initiation for all lung cancer patients navigated was 25 days (mean) when compared to the national benchmark to offer treatment within 42 days of initial diagnosis.
Conclusions
As the primary point of contact across the care continuum, ONNs aim to close communication gaps and facilitate comprehensive, patient-centered care while advocating informed-shared decisions with the care team. ONNs are uniquely positioned to provide emotional support and communicate anticipated next steps to ease the fear of the unknown. Implications for practice are paramount as the complexity of cancer care continues to evolve.
Notes
Manuscript published in JONS, Feb 2024 issue
L. Haynes1, B. Gomes1, H. McCarthy, O. Motahari, A. Santos1, P. Skeffington1
1- Southcoast Health
Background
In 2016 Journal of Oncology Practice (ASCO), Memorial Sloan Kettering published data that oxaliplatin can be safely infused at rapid-rate (1mg/m2/minute) rather than the standard rate (two hours), with no significant difference in rate of hypersensitivity reactions (HSR). Based on this, NCCN changed their guidelines to support rapid-rate infusion and many cancer centers adopted this. Southcoast Health (SH) adopted rapid-rate infusion due to savings in chair time that it provided.
In 2023 Journal of Oncology Pharmacy Practice, University of New Mexico Comprehensive Cancer Center published data evaluating safety outcomes comparing the two rates of infusion. Their data confirmed rapid-rate infusion was not associated with increased HSR, but was associated with increased permanent oxaliplatin discontinuation and showed a significant increase in occurrence of peripheral neuropathy (PN).
Methods
Retrospective chart review (two years) and data collection with Martha’s Vineyard Hospital (MVH) and Kent County Memorial Health (KCMH) for data on standard rate infusion
Retrospective chart review (two years) and data collection at SH for data on standard rate and rapid-rate infusion
All patients were de- identified.
Results
99 patients in the standard rate arm and 97 patients in the rapid-rate arm. Rate of oxaliplatin discontinuation was similar between both arms however development of PN in standard rate arm was 63% and in the rapid-rate arm was 49.5%.
Conclusions
At SH, rapid-rate infusion was not associated with any increased rate of discontinuation of oxaliplatin nor with an increase in PN. At the present time, SH will continue to use rapid-rate infusion.
X. Hu1,2, A. Gurinovich3, S. Pan2, Y. Salei4, J. Lin5, A. Rodday3, S. Parsons2,3
1- Division of Hematology-Oncology, Department of Medicine, Maine Medical Center, Portland, ME
2- Division of Hematology-Oncology, Department of Medicine, Tufts Medical Center, Boston, MA
3- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
4- Division of Hematology-Oncology, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA
5- Department of Medicine, Tufts Medical Center, Boston, MA
Background
Immune checkpoint inhibitors (ICIs) have changed the treatment of lung cancer (LC). Body mass index (BMI) is a body size measurement and obesity, a chronic inflammatory state may influence ICI safety and efficacy.
Methods
Patients with LC, newly started on ICIs 2018-2021 were retrospectively identified. Patient characteristics and immune-related adverse events (irAEs) occurring within 12 months after ICI initiation were extracted; BMI was categorized into high (>=25 kg/m2) and low (<25 kg/m2). Logistic regression was used to assess BMI’s impact on irAEs. Multivariable Cox regression was performed to determine the effects of BMI on progression-free survival (PFS) and overall survival (OS).
Results
125 patients (median age: 70 years) were included. Comparing the high (N=66) and low BMI (N=59) groups, more Whites (p=0.002) were in the high group. 50 irAEs occurred in 39 individuals. No significant associations were found between BMI and the occurrence of any irAE (Odd ratio [OR]: 0.942, p=0.885). High BMI was marginally associated with the development of endocrinopathies (OR: 2.920, p=0.096], but not with pneumonitis (p=0.862). In multivariable analysis, high BMI showed trends of a superior PFS (Hazard ratio [HR]: 0.689, p=0.123), but unfavorable OS (HR: 1.134, p=0.668), although not statistically significant.
Conclusions
Findings suggested in LC patients treated with ICIs, BMI was not significantly associated with the occurrence of irAEs, but overweight or obese patients were more likely to develop endocrinopathies. BMI was found to have no significant impact on the efficacy of ICIs in LC. Future studies are warranted to validate these findings.
A. Huang1, V. Forbes2, R. Vankina2
1- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT
2- Department of Hematology and Oncology, University of Connecticut School of Medicine
Background
Hemin infusion is the cornerstone of prevention and treatment for acute intermittent porphyria (AIP) attacks. There is limited literature and no clinical trials on the use of hemin transfusion in pregnancy.
Methods
We present a case of a 27-year-old woman with a history of beta thalassemia minor, type 1 Von Willebrand Disease, and polysubstance use disorder who followed up with our Hematology clinic monthly for hemin infusion during pregnancy as prophylaxis for recurrent symptoms from AIP.
Results
The patient was presumably diagnosed with AIP at age 11 based on recurrent neurological and gastrointestinal symptoms and a mutation in the Hydroxymethylbilane Synthase (HMBS) gene (IVS9-31A>G 31 bp upstream from exon 10; HG19 11:118962804). Her attacks were adequately controlled with hemin infusions. Interestingly, her urine delta-aminolevulinic acid and urine/plasma/feces porphobilinogen and total porphyrins were all within normal limits during the attacks, and erythrocyte porphobilinogen deaminase was borderline-mildly low. Several years later, her HMBS pathogenic gene mutation was re-classified as a single nucleotide polymorphism, so hemin infusions were discontinued, which resulted in up to 20 hospital visits per year for attacks of abdominal pain and seizure. Monthly hemin infusions were resumed with symptom remission. The patient later became pregnant twice, and monthly hemin infusion was continued throughout her pregnancies. Both pregnancies were successful without AIP attacks or significant complications for the babies.
Conclusions
Our case adds to the literature on the successful use of regular hemin infusions during pregnancy in a patient with a presumed diagnosis of AIP in the absence of a corresponding HMBS mutation.
Comparative Study: Demographic, Geographic, and Socioeconomic Analysis of Maine Cancer Genomic Initiative and Maine Cancer Registry Data
R. Kapadia1, J. Miller1, E. Anderson2, J. Dibiase2, L. Kelley3, L. Graham3, J. Rueter3
1- Colby College, Waterville, ME, USA
2- MaineHealth Research for Institute, Portland, ME, USA
3- The Jackson Laboratory, Maine Cancer Genomics Initiative (MCGI), Augusta, ME, USA
Background
This study compared two clinical collections of data: the Maine Cancer Genomics Initiative (MCGI) 1.0 Study and the Maine Cancer Registry (MCR). The MCGI 1.0 Study analyzed patient-reported outcomes. The Maine Cancer Registry (MCR) monitors newly diagnosed cancers in Maine residents. The goal included a comparison of the MCGI 1.0 study population to the Maine Cancer Registry population.
Methods
The project analyzed MCGI and MCR data from June 2017 to December 2019. We used R to analyze demographics and clinical data, investigating distribution of location using ZIP codes, determining rurality using Rural Roundtable. Standard statistical measures were used for demographic analysis.
Results
The average age of patients in MCGI 1.0 was 63 years, and 67 years in the MCR dataset. Lung and breast cancer emerged as the top cancer sites in both datasets, highlighting their prevalence in Maine. The MCGI dataset had a higher incidence of gynecological and brain cancers. The representation of rural patients in northern Maine was higher in the MCGI dataset.
Conclusions
Overall, the two datasets had many similarities that informed our understanding of the MCGI patient population and cancer demographics of patients. The cancer type and distribution differences may be because the MCGI study was utilized more by rural oncologists. Additionally, cancers that are complicated and historically difficult to treat were more likely to have molecular profiling and enroll in the MCGI study.
Steroids, a Double-Edged Sword
J. Kim, H. Xu, I. Chidobem, H. tul Rehman
Hematology and Oncology Department at University of Vermont Medical Center
Background
CLL increases the risk of secondary malignancies, and the prognosis is worse when both CLL and melanoma are present.
Methods
We present a case of simultaneous flare-up of melanoma and CLL, highlighting management complexities.
Results
A 69-year-old female with a PALB2 pathogenic variant, prior history of melanoma (s/p resection and adjuvant Nivolumab), triple-negative breast cancer, T-cell NHL and CLL, presented with pleural effusion and adenopathy. An inguinal lymph node biopsy confirmed metastatic melanoma, and flow cytometry from pleural fluid demonstrated CLL. Multiple brain metastases with vasogenic edema and hemorrhage were noted as well and her WBC tripled. Dexamethasone was initiated for vasogenic edema. Concerned that CLL might drive melanoma by suppressing the immune system, ibrutinib was started while awaiting steroid washout before initiating immunotherapy. She received SRS to the largest cerebellar lesion. A follow-up MRI after the first cycle of immunotherapy showed disease progression with rising lymphocytes. She opted for comfort care. Autopsy confirmed metastatic melanoma and CLL involving multiple organs.
Conclusions
A PALB2 mutation is known to increase the risk of certain cancers but has shown better responses to immunotherapy, which was not the case here, likely due to underlying CLL and negative priming of immune system from the use of steroids that needed to control vasogenic edema. This case emphasizes the importance of avoiding negative priming of immune system prior to initiation of immunotherapy. A trial from Yale is currently evaluating the role of Bevacizumab with Pembrolizumab in this setting to avoid steroids in patients with brain metastasis and vasogenic edema.
Complete remission with Pembrolizumab in advanced Merkel cell carcinoma
S. Kumar1, Brian J Byrne2, J. Arunachalam1
1- University of Connecticut
2- Medical oncology, Hartford Healthcare Cancer Institute
Background
Merkel cell carcinoma (MCC) is a rare but aggressive neuroendocrine skin cancer with frequent recurrences, metastasis, and a high mortality rate. For advanced MCC, cytotoxic chemotherapy offers a median progression-free survival of only 3 months, until the advent of clinical trials that demonstrated efficacy of immune-checkpoint inhibitors.
Methods
Our patient, a 70yo Caucasian male with a history of CAD, rheumatoid arthritis, former smoker was diagnosed with MCC with biopsy of a left leg lesion. MCPyV and ctDNA was detectable. Staging FDG PET showed multifocal lymph node hypermetabolism involving left inguinal region, right axilla, right supraclavicular and mediastinal lymph node. Biopsy of left inguinal lymph node showed evidence of metastatic MCC. He underwent resection of primary and was diagnosed with advanced MCC.
Results
He had disease progression with worsening lymphadenopathy, confirmed with FDG PET, subsequently started on pembrolizumab 200mg. After one dose he developed autoimmune encephalitis and retinitis leading to discontinuation of treatment. In 2 months, he achieved complete resolution on imaging, undetectable ctDNA and improving MCPyV titers. He has been following up with oncology for 2 years now with no recurrence of disease.
Conclusions
Our case emphasizes the immunogenic nature of MCC and the role of immunotherapy in treatment. Current NCCN guidelines recommend a combination of radiation, surgery and neoadjuvant immunotherapy for management of nodal-positive disease. Our patient achieved a complete remission with just one dose of immunotherapy for this aggressive malignancy which highlights the use of immunotherapy in the adjuvant setting or first line in metastatic disease for better outcomes.
H. Kuznia, C. Lapp, S. Haghollahi, M. Afzal
Dartmouth Hitchcock Medical Center
Background
Neoadjuvant chemotherapy therapy followed by surgery has been the mainstay of locally advanced triple-negative breast cancer (TNBC) treatment. Recently the KEYNOTE-522 phase III clinical trial showed that the addition of immune checkpoint inhibitors has improved complete pathological response rate (PCR) with acceptable toxicities and improves clinical outcomes (1,2). The objective of this study is to describe real-world experiences with neoadjuvant chemoimmunotherapy at our institute.
Methods
This IRB-approved retrospective chart review included 28 patients with early stage TNBC who are receiving or have received the Keynote-522 regimen at Dartmouth Cancer Center. Data was collected and analyzed by the authors.
Results
Most patients had stage 2 disease (71%), while 21% had stage 3 and 7% had stage 1. Regarding treatment tolerance, 68% of patients experienced a dose delay and/or interruption. In total, 39% discontinued treatment due to intolerance and 32% required hospitalization. PCR was seen in 56% of patients, with RCB categories distributed as follows: RCB-0 58%, RCB-I 4%, RCB-II 29%, and RCB-III 8%.
Conclusions
In the Keynote-522 trial, PCR increased to 64.8%, while our experience yielded a lower percentage (56%) (3). In our experience, 39% of patients ultimately discontinued the regimen due to intolerance, while only 23.3% discontinued in the trial. It is possible that these differences may relate to increased comorbidities in patients outside of a clinical trial’s stringent inclusion criteria, as a higher percentage of our patients discontinued treatment. While most patients treated with the Keynote regimen achieved PCR, treatment tolerance continues to be a limiting factor.
Notes
References:
1. Schmid P, Park YH, Muñoz-Couselo E, et al.: Pembrolizumab (pembro) + chemotherapy (chemo) as neoadjuvant treatment for triple negative breast cancer (TNBC): Preliminary results from KEYNOTE-173. JCO. 2017; 35: 556.
2. Schmid P, Park YH, Muñoz-Couselo E, et al.: Abstract PD5-01: KEYNOTE-173: Phase 1b multicohort study of pembrolizumab (Pembro) in combination with chemotherapy as neoadjuvant treatment for triple-negative breast cancer (TNBC). Cancer Res. 2019; 79(4 Supplement): PD5–01.
3. Schmid P, Cortes J, Dent R, McArthur H, Pusztai L, Kümmel S, Denkert C, Park YH, Hui R, Harbeck N, Takahashi M, Im SA, Untch M, Fasching PA, Mouret-Reynier MA, Foukakis T, Ferreira M, Cardoso F, Zhou X, Karantza V, Tryfonidis K, Aktan G, O'Shaughnessy J; KEYNOTE-522 Investigators. Overall Survival with Pembrolizumab in Early-Stage Triple-Negative Breast Cancer. N Engl J Med. 2024 Sep 15. doi: 10.1056/NEJMoa2409932. Epub ahead of print. PMID: 39282906.
Utilization of novel BiTE agent for treatment of SCLC in a rural academic center
H. Kuznia, K. Dragnev
Dartmouth Hitchcock Medical Center
Background
Tarlatamab, a bispecific T-cell engager (BiTE) molecule targeting CD3 on T-cells and DLL3 on small cell lung cancer (SCLC) cells, received accelerated FDA approval in May 2024 as a second-line treatment after progression on platinum-based chemotherapy. BiTE therapy carries risk of cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS).
Methods
We present a case of SCLC treated with tarlatamab as a fourth-line agent monitored for development of side effects in the inpatient setting.
Results
A 56 year-old male was diagnosed with metastatic SCLC involving the left lower lobe and multiple lymph nodes. He progressed on three different treatment lines, including carboplatin, etoposide, and checkpoint inhibitor; lurbinectedin; and irinotecan. He was then treated with inpatient tarlatamab, developing grade 2 CRS with his initial dose. This was managed with dexamethasone and tocilizumab. With both the second and third doses, he developed grade 1 ICANS, managed with acetaminophen and ibuprofen. He received his fourth dose as an outpatient without complication. Initial imaging is pending, updated results to be presented at meeting.
Conclusions
This is the first approval of BiTE therapy in solid malignancies. We must ensure adequate monitoring for side effects such as CRS and ICANS. As we become familiar with chronicity of symptom onset, we may be able to develop safe outpatient protocols, allowing for reduced burden on both the patient and healthcare system.
Undergraduate medical training in oncology: Insights from a unique multidisciplinary rotation
T. LaJoie1, Karin Cole2
1- Tufts University School of Medicine, Maine Track Program
2- Department of Surgery, Northern Light Mercy Hospital, Portland, ME
Background
Malignancy is a highly prevalent and morbid diagnosis, and a need has been identified for more clinical education opportunities in oncology for medical students in the U.S. This review highlights successes of offering a multidisciplinary rotation.
Methods
Multidisciplinary Oncology is an elective rotation offered through Northern Light Mercy Hospital’s cancer program. The rotation includes clinical experience in medical, radiation, and surgical oncology, palliative care, and genetics. Students attend multidisciplinary conferences and complete online assignments (Google Classroom code: ngcykon). The rotation requires a final project reflecting the student’s interest in oncology, followed by a survey assessing the overall quality of clinical teaching, conferences, references provided to students, teaching on social determinants of health, and the overall elective.
Results
Survey data from nine students completing the rotation between 2020 and 2023 was available. Instructors received high praise, with 78% rating teaching quality as “Excellent”. The overall rotation was unanimously rated “Excellent”. Students appreciated patient variety, opportunities to follow patients across subspecialties, operating room experiences, and the self-directed format of the rotation.
Conclusions
A multidisciplinary rotation proves promising for addressing the need for more comprehensive oncology education in medical school. Students identified high-quality teaching and self-directed learning as strengths of this rotation. From an educator’s perspective, teaching burden was reduced given the wider distribution of responsibility, and online assignments offered robust assessment of student progress. Challenges include instructor scheduling, maintaining an updated curriculum, uneven subspecialty exposure, and primarily observational patient interactions. Overall, the rotation offers valuable insights into addressing education gaps while acknowledging areas for improvement.
C. Lapp, J. O'Farrell, M. Afzal, MD
Dartmouth Health
Background
Tumor lysis syndrome (TLS) is a life-threatening condition seen most often in patients undergoing chemotherapy for hematologic malignancies. Spontaneous TLS can be observed in aggressive hematological malignancies but is rarely associated with solid tumors. Spontaneous TLS due to gastric adenocarcinoma is extremely rare. This report highlights a case of spontaneous TLS complicated by paraneoplastic leukemoid reaction due to metastatic gastric adenocarcinoma.
Methods
A 60-year-old male presented with three weeks of abdominal pain. CT abdomen/pelvis revealed a large gastric mass and extensive metastatic disease throughout the abdomen. EGD with biopsy of the gastric mass showed poorly differentiated gastric adenocarcinoma. Days later and prior to starting chemotherapy, he represented to the hospital with worsening abdominal pain. Labs revealed significant leukocytosis and a pattern concerning for TLS. CT scan showed diffuse mediastinal and supraclavicular lymphadenopathy. Due to high suspicion for concurrent hematologic malignancy, repeat flow cytometry and bone marrow biopsy were performed and were negative. Leukocytosis was attributed to leukemoid reaction. He developed multiorgan failure and DIC. He transitioned to comfort measures and passed away shortly thereafter.
Results
TLS is uncommon in solid tumors, particularly in the absence of treatment with chemotherapy. There are only four previously published cases of TLS in patients with gastric adenocarcinoma. Concurrent leukemoid reaction and massive lymphadenopathy complicated this case, leading to the initial suspicion of a concurrent hematologic malignancy.
Conclusions
Although often associated with hematologic malignancy, spontaneous TLS in the setting of solid-tumor malignancy should be considered when treating patients with characteristic electrolyte abnormalities and known solid malignancy.
Notes
References:
Abukhiran IA, Jasser J, Syrbu S. Paraneoplastic leukemoid reactions induced by cytokine-secreting tumours. Journal of Clinical Pathology, 2020; 73: 310-313.
Granger, J. M., & Kontoyiannis, D. P. (2009). Etiology and outcome of extreme leukocytosis in 758 nonhematologic cancer patients: a retrospective, single‐institution study. Cancer: Interdisciplinary International Journal of the American Cancer Society, 115(17), 3919-3923.
Lingamaneni P, Desai P et al. Tumor Lysis Syndrome in a Patient with Gastric Adenocarcinoma. Journal of Investigative Medicine High Impact Case Reports. 2020; 8.
Miller, J. I., Sarver, R. G., & Drach, G. W. (1994). Leukemoid reaction: a rare paraneoplastic syndrome associated with advanced bladder carcinoma. Urology, 44(3), 444-446.
Cherenkov Imaging with a Predicted Surface Dose Overlay for Treatment Verification
A. P. Lauder1, S. M. Decker2, P. Bruza3, D. J. Gladstone1,4, M. Jermyn3, and L. A. Jarvis1,4
1- Department of Radiation Oncology and Applied Sciences, Dartmouth Cancer Center, Dartmouth Health, Lebanon, NH
2- Thayer School of Engineering, Dartmouth College, Hanover, NH
3- DoseOptics, LLC, Lebanon, NH
4- Geisel School of Medicine, Dartmouth College, Hanover, NH
Background
Cherenkov imaging utilizes light emitted during radiation therapy, allowing for visualization of radiation treatments. Cherenkov emissions indicate the treated region and therefore can be used for positional verification; however, there is no method to confirm that the Cherenkov image matches the prediction from the treatment planning system (TPS). In this study, the potential of incorporating a predicted surface dose overlay (PSDO) with Cherenkov image review is examined.
Methods
PSDOs were generated using the TPS RTPlan and RTDose files for each beam, and CT scan. The PSDO was generated using a 14% isodose of the 5mm planned maximum surface dose and displayed on top of the Cherenkov images. The patient imaging was scored as congruent if the PSDO shape, size and position visually matched the Cherenkov emissions and non-congruent if not matching.
Results
604 treatment fractions for 39 consecutive patients receiving standard of care treatment and pre-treatment imaging were evaluated. Non-congruence of the PSDO with the Cherenkov emission image was detected in 2 treatment courses, totaling 33 of the 604 (5.4%) reviewed treatment fractions. One case was due to anatomy change that occurred during the treatment course. The second case was due to inaccuracy in patient setup and resulted in excess contralateral chest wall dose. This second case was not previously recognized by the treatment team and was not detected by pre-treatment weekly port films or daily SGRT.
Conclusions
PSDO incorporated into Cherenkov imaging systems is a useful tool for evaluating accuracy of treatment delivery and has potential for improving treatment quality.
C. Leatheng1, A. Ephraim1, G. Brooks2
1- Dartmouth-Hitchcock Medical Center
2- Department of Internal Medicine, Section of Hematology & Oncology, Dartmouth Cancer Center
Background
Fluoropyrimidine chemotherapy agents are commonly used to treat solid tumors. Fluoropyrimidines are degraded by the enzyme dihydropyridine dehydrogenase (DPD), encoded by the DPYD gene. Deleterious variants in DPYD leads to functional DPD deficiency and increased toxicity risk.
Methods
We conducted a retrospective study of patients with screen-detected deleterious DPYD variants who were treated with fluoropyrimidine chemotherapy between 01/1/15-04/15/23. Outcomes of interest were initial fluoropyrimidine dosing, dose adjustments (cycles 2-6), and early toxicities.
Results
We identified 11 patients with heterozygous DPYD variants, including *2A (n=5), c.2846A>T (3), c.1129-5923C>G (2) and *13 (1). Initial chemotherapy regimens included FOLFOX (7), mFOLFIRINOX (3) and CAPEOX (1). Of 10 patients receiving FOLFOX/mFOLFIRNOX, eight began treatment with a 50-60% reduction of the 5-FU infusion dose, one received a 25% reduction, and one received a standard dose (due to treatment initiation prior to return of the genotype result). Six patients tolerated the initial 5-FU infusion dose without further dose reductions, including 3 who tolerated limited dose-escalation. Four patients required further dose reduction from the cycle 1 dose, due to toxicity. The patient who received a standard 5-FU infusion dose in cycle 1 experienced grade 3 toxicity but tolerated subsequent treatment after 50% dose reduction. The patient treated with CAPEOX tolerated 4 planned cycles with a 50% capecitabine dose reduction.
Conclusions
Most patients who screened positive for deleterious DPYD gene variants tolerated fluoropyrimidine chemotherapy with a 50% dose reduction. However, 3 of 11 patients experienced toxicity requiring dose reduction of >50%, or treatment discontinuation.
Launch of an Opt Out Tobacco Cessation Referral Process Across a Cancer Care Network
A. Litterini1, D. Spaulding2, T. Robbins3
1- MaineHealth Cancer Care Network
2- MaineHealth Center for Tobacco Independence
3- MaineHealth Information Technology
Background
As the leading cause of preventable disease, disability and death in the US, tobacco use is also a well-established cause of up to 13 types of cancer, cancer-related death, and all-cause mortality. In the state of Maine, where lung cancer has the highest incidence and mortality, tobacco use is higher than the national average (Maine: 15.6%; US: 11.6%). Within the MaineHealth Cancer Care Network in 2024, 10.8% of our survivors are using some form of tobacco or vape at the time of a new cancer diagnosis, but only 25.1% of those individuals were referred for cessation support within 90 days of initial consult.
Methods
In collaboration with the Center for Tobacco Independence, the Epic Build team create a new best practice advisory (BPA) ‘opt out’ automatic referral process which launched in June, 2024. For patients positive for tobacco or vaping at the time of consult for a new cancer diagnosis, the new BPA fired for all staff and providers during multiple encounter types.
Results
The 90-day pilot was launched at seven sites across the network. Edits to the BPA during the pilot period included: 1) the elimination of the diagnosis of “nicotine dependence” to resolve the encounter; and 2) the elimination of the BPA trigger during phone encounters. Two additional sites were added at the end of the pilot period.
Conclusions
An opt out approach to tobacco cessation referrals is feasible for a large oncology network. The next steps include the roll out of the process across MaineHealth system-wide.
Haploidentical Transplantation for Hematological Malignancies – A Single-Center Experience
R. Lizcano, J. Hill, Jr, C. Hayes, P. Shah, S. PonnamReddy, K. Caldon, K. Meehan
Transplant and Cellular Therapy Program, Dartmouth Cancer Center, Dartmouth Hitchcock Clinics & Medical Center, Lebanon, NH
Background
Allogeneic hematopoietic stem cell transplantation using a HLA-haploidentical donor (Haplo-HSCT) expands access to a potentially curative treatment for transplant-eligible patients who may otherwise lack a donor.
Methods
We report 20 patients (Male = 13; Median age = 65 years) who received a Haplo-HSCT at Dartmouth Cancer Center. Indications for transplant included acute Leukemias (n = 11), high-risk myelodysplastic/myeloproliferative disorders (n = 5), or Lymphoma (n = 4). Most donors (n = 12) were biological adult offspring of recipients. Donors underwent peripheral blood stem cell collection and recipients received conditioning with fludarabine, cyclophosphamide, low dose total body irradiation, and immunosuppression with post-transplant cyclophosphamide, mycophenolate, and tacrolimus.
Results
Overall survival at 100 days and 1 year was 90% and 80%, respectively. Progression/relapse-free survival at 100 days and 1 year was 85% and 65 percent, respectively. The most commonly reported > grade 3 was anorexia (70%), as expected. Acute Graft versus Host Disease (GvHD) was seen in 3 patients (15%). Chronic GvHD was seen in 9 patients (45%). An interesting finding was that the discovery of mixed chimerism (less than 90% donor), obtained on average 50 days after transplant, was observed in 20% of patients (n = 4 pts) and this finding was universally predictive of relapse. The 4 patients suffered from Acute Leukemia (n = 2) and MDS (n = 2).
Conclusions
Haplo-HSCT is a safe, feasible, and potentially curative option for patients who previously would have been unable to receive a transplant. An unexpected discovery was that mixed chimerism (less than 90% donor) following a Haplo-HSCT is highly predictive of relapse.
A. Matous1, M. Clark2, Michael Jermyn3, Anna Fariss1, Shauna McVorran1, Lesley Jarvis1
1- Dartmouth Cancer Center at Dartmouth-Hitchcock Medical Center
2- Thayer School of Engineering at Dartmouth
3- DoseOptics
Background
Radiotherapy techniques for breast cancer are evolving, with many patients now receiving aPBI. Because this technique uses volumetric modulated arc therapy (VMAT), radiation dose to the contralateral breast (CB) and other areas outside the target volume may be greater than what is seen with classic tangent-based plans. Cherenkov imaging provides visualization of radiotherapy beams on patients and facilitates incident detection by allowing for visualization of dose to anatomical sites outside the treatment field. When combined with in vivo dosimetry, this unanticipated dose can be directly measured, providing important clinical information.
Methods
Cherenkov images from a subset of patients receiving aPBI were retrospectively reviewed and instances of dose to areas outside the treated breast were identified. For patients imaged with in vivo dosimetry, measured dose was compared with dose predicted in the treatment planning system (TPS) and accepted dose constraints.
Results
Images for 13 unique patients were reviewed. Instances of dose outside the treated breast were identified for 7 / 13 patients and included CB and bilateral axillae. In vivo dosimetry at sites of visualized CB dose was recorded during 1 fraction for 5 / 7 patients and ranged from 16.98 – 33.2 cGy per fraction. All were in accordance with dose per fraction predicted in the TPS to within 1.98 – 12.7 cGy and below the CB constraint of 200 cGy per treatment course.
Conclusions
In a small sample of patients receiving aPBI, CB dose as visualized with Cherenkov imaging and measured with in vivo dosimetry did not exceed pre-defined dose constraints.
Funded radiation oncology visiting medical student electives: a cross-sectional analysis
C. McNamara1, D. Bergman12, A. Gayne1, C. McNamara1, C. Thomas Jr.134, N. Kapadia1345
1- Dartmouth Geisel School of Medicine, Dartmouth College, Hanover, NH
2- Newton-Wellesley Hospital, Mass General Brigham, Tufts University School of Medicine, Newton, MA
3- Dartmouth Health, Department of Radiation Oncology and Applied Sciences, Lebanon, NH
4- Dartmouth Cancer Center, Lebanon, NH
5- The Dartmouth Institute of Clinical Practice and Health Policy, Hanover, NH
Background
Visiting electives increase medical student exposure to radiation oncology (RO) and may influence the match. Some institutions offer scholarships for visiting students in RO to offset the financial burden. Here, we provide the first characterization of funded RO electives.
Methods
RO departments hosting visiting electives were identified through the FREIDA and VSLO databases. Funding availability and departmental characteristics were identified via internet search by two independent reviewers. Discrepancies were identified and resolved. Fisher's Exact Test and Student’s t-test were used to examine elective geospatial distribution and departmental size.
Results
40 of 92 identified programs offer scholarships (43.5%). The median stipend was $2,000 (IQR $1500-$2500), range $1,000-$5,000. 92.6% (25/27) of funded programs offered >$1,500. 13 programs (32.5%) did not disclose stipend amount. The distribution of funding varied significantly by department size, with larger departments more likely to offer funding. Significant variability was seen by geographic region, with New England and Mountain Regions having the highest proportion of funded programs and West South Central and East South Central the lowest.
Conclusions
The equity gap presented by visiting electives is large in RO. As of 2024, fewer than half (43.5%) of RO electives offer support. Most scholarships exceed $1,500, aligning with 2015 expenditure adjusted for inflation. Unequal distribution of funding by department size and geography illustrates the necessity of addressing access disparities. Our study serves as a valuable resource for students and can help expand diversity in RO.
CAR-T Therapy versus Bispecific Antibodies in Relapsed Refractory Multiple Myeloma: systematic review and metanalysis of toxicity and response
M. Mehta1, D. Namjoshi2, V. Mukhtiar3, M. Ramanathan4
1,2,3- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA
4- Division of Hematology/Oncology, Department of Medicine, University of Massachusetts Memorial Medical Center, Worcester, MA
Background
Relapsed refractory multiple myeloma (RRMM) remains a challenging clinical condition characterized by poor prognosis and a scarcity of effective treatment options. Emerging therapies such as CAR-T cell therapy and bispecific antibodies (BsAbs) have demonstrated encouraging outcomes; however, their clinical utility is limited by toxicity profile. In this study, we aim to compare the efficacy and safety profiles of CAR-T therapy and BsAbs in RRMM.
Methods
We identified 710 records from different databases out of which 33 studies were included in the final analysis. Primary outcome was expressed as pooled proportion and pooled incidence for adverse events and overall response rate (ORR).
Results
The incidence of CRS was 0.84 (95% CI [0.77,0.90]) with CAR-T therapy, compared to 0.51 (95% CI [0.41, 0.61]) with BsAbs (p-value < 0.01). Mean CRS time of resolution was 9.8 days [6.85, 12.75] with CAR-T, 2.25 days (95% CI [2.06,2.44]) with BsAbs (p<0.01). Incidence of ICANS was 66.5% (95% CI [0.08, 0.45]) with CAR-T, compared to 33.5% (95% CI [0.03, 0.10]) with BsAbs (p=0.045).
Pooled proportion of overall response rate (ORR) was 0.84[0.77;0.91] with CAR-T, 0.59[0.50;0.67] with BsAbs (p< 0.01). The pooled proportion of mortality due to adverse events was 0.15[0.09,0.20] in CAR-T group and 0.14[0.06;0.22] in BsAbs.
(p=0.94).
Conclusions
BsAbs demonstrated a more favorable toxicity profile compared to CAR-T therapy. CAR-T therapy was more efficacious than BsAbs in terms of ORR. There was no difference in mortality rates due to disease progression or adverse events. Future studies should focus on mitigating these adverse events and mechanisms to enhance efficacy while decreasing the toxicity.
Navigating a Diagnostic Conundrum: A Unique Case of HLH with Severe Thrombocytopenia
M. Mehta1, V. Mukhtiar2, K. Seetharaman3
1,2- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA
3- Division of Hematology/Oncology, Saint Vincent Hospital, Worcester, MA
Background
Hemophagocytic Lymphohistiocytosis (HLH) is a life-threatening syndrome caused by dysregulated immune activation causing excessive cytokine release. It is a rare syndrome with variable clinical presentation which poses a diagnostic clinical challenge.
Methods
Consent was obtained for journal submission.
Results
A 58-year-old woman, presented with generalized weakness, upper respiratory symptoms, diarrhea, and myalgia. Physical examination revealed diffuse petechiae on the abdomen. Laboratory investigations revealed a platelet count of 11,000, anemia, ferritin 6226, D-dimer 3.13, fibrinogen 294, PT/INR 11.8/1.1, haptoglobin 334, LDH 356, triglycerides 443. Infectious workup including HIV, Hepatitis C, EBV, CMV, and H. Pylori was negative. She received 3U of platelets, methylprednisolone and IVIG. ITP was later ruled out by splenomegaly on CT Abdomen. She fulfilled 4 out of 8 criteria from the HLH-2004 trial. Bone marrow biopsy revealed hypercellular marrow with hemophagocytosis. IL-8 and IL2 Receptor were negative.
Her symptoms resolved and platelet count normalized. On follow-up, ferritin improved to 2802 on day 10, 1647 day 20, and 162 at 2 months. She did not require further treatment.
Conclusions
Patients with HLH are usually acutely ill with multiorgan failure requiring critical care. However, multiple case reports have been published with smoldering presentations of HLH. Furthermore, it can be associated with an infectious or malignant pathology contributing to the overall underdiagnosis of this condition. Our case highlights the importance of considering HLH in the differentials for unexplained cytopenias. Importantly, one should not await a definitive diagnosis to begin treatment.
Prevention of Sarcopenia in Non-Small Cell Lung Cancer (NSCLC)
A. Merker, J. Le, G. Davis, E. Chinn, R. Walsh, F. Khan, A. Anwar, S. Ades, K. Dittus, M. Toth, H. Rehman
University of Vermont Medical Center
Background
Exercise and increased muscle mass has been shown to improve outcomes in patients with certain solid tumors. In patients with lung cancer, studies have shown variable results in examining exercise’s benefits and particularly in patients who are undergoing active anticancer therapy. Our goal is to assess the feasibility of implementing a structured exercise program with patients who have NSCLC in a rural setting. This pilot program received funding through NNECOS research grant.
Methods
Our study, aimed to recruit 15 participants receiving systemic therapy for stage III and IV NSCLC and coach them through a 12-week exercise program (either in-person or remotely). In addition to assessing feasibility of this study design, differences in measurements pre and post program include 6-minute walk test, 30 second sit-and-stand test and grip strength, skeletal muscle index (SMI) as well as, to follow progression free survival (PFS), overall survival (OS) and response rate (RR).
Results
Of the 91 patients screened, 6 have been enrolled and 2 have fully completed the study. Of these 2, one showed improved measures. Of the 6 enrolled, 3 have shown an increase in SMI and 3 have shown a decline.
Conclusions
Incorporation of exercise (whether in person or remotely) is challenging in patients undergoing treatment for NSCLC and requires a multimodal enrollment plan (encouragement by physicians, availability of internet access vs gyms/rehab, family support etc). We will need to overcome several barriers to facilitate implementation of such programs and their successful utilization.
Obstructed: An unusual presentation of extramedullary AML
A. Merker, R. Thomas, D. Adrianzen
University of Vermont Medical Center
Background
Myeloid sarcoma, is an uncommon extramedullary complication of certain leukemias affecting less than 10% of patients with acute myeloid leukemia (AML). It most often presents in cutaneous or nodal locations, although it can be found in any organ. Depending on the location, treatment can include radiation therapy, but most often includes systemic chemotherapy.
Methods
33 year old with AML s/p 3 failed allogenic stem cell transplant (SCT), complicated by myeloid sarcoma of the larynx and chronic graft versus host disease, who is 89 days status post rescue SCT and preparing for induction chemotherapy with azacitidine and venetoclax. He presents to hematology clinic with 1 week of progressively worsening abdominal pain and emesis.
Results
Emergent CT was obtained showing a small bowel obstruction (SBO) with circumferential soft tissue thickening suspicious for underlying mass, presumed to be in the setting of his recently relapsed leukemia. Labs were remarkable for WBC 54,000, which was 85% blasts. He was urgently cytoreduced with hydroxyurea and cytarabine. SBO symptoms resolved and improvement seen on repeat imaging without plans for surgical intervention or radiation to the presumed myeloid sarcoma of the small bowel.
Conclusions
This is a rare case of a patient with relapsed AML after 3 allogenic SCT and has had 2 separate occurrences of myeloid sarcoma, an uncommon complication of the disease. Current plans for continued treatment of relapsed AML with aza/ven are underway, with hopes that the presumed myeloid sarcoma will respond as well.
Assessment of a novel, blood-based biomarker, NOHA, as a longitudinal measure of response to curative-intent neoadjuvant therapy among individuals with triple negative breast cancer: an interim analysis
S. Mohan1, J. Saunders2, R. Buchsbaum3, S. Monahan2, J. DiPalazzo2, C. Frankenfeld2, B Bertaux4, D. Van Pelt5, S. Miesfeldt5
1- University of New England, Por
Background
Oncologists lack tools to adapt/optimize curative-intent triple negative breast cancer (TNBC) neoadjuvant therapy (NT), limiting achievement of pathological complete response (pCR) and risking exposure to ineffective agents. Nw-hydroxy L-Arginine (NOHA) is a promising blood-based breast cancer biomarker reflecting stage, grade, and molecular phenotype (U.S. Utility Patent 10,073,099).
Aim: We performed an interim analysis of our ongoing study assessing correlation between longitudinal NOHA normalization and measures of clinical/pathologic response to TNBC NT.
Methods
Blood samples, collected at 5 timepoints: pre-NT, post cycle 2 and 4 of NT, pre-surgery, and post-surgery, underwent NOHA analysis by ELISA involving proprietary monoclonal antibody, and compared with LC-MS NOHA measurement for experimental validation (at p<0.05). NOHA normalization was correlated with measures of clinical and pathological treatment response.
Results
All 33 TNBC subjects were women, with 32 white/1 black; average age 57; >50% had at least 1 comorbidity; 85% had high-grade disease; and 82% were stage II-III. NT regimens varied; 14 included pembrolizumab. Seventeen subjects achieved pCR. NOHA levels increased towards healthy levels (≥8nM) from 1.8±0.1nM to 6.5±0.1nM across all 33 subjects. Current data is trending towards differences in post-surgical NOHA levels comparing those achieving pCR vs.<pCR.
Conclusions
NOHA levels normalize in TNBC patients over the course of NT. NOHA may be useful for distinguishing pCR vs.<pCR; however, more data is needed to establish this finding’s significance.
Notes
Keywords: TNBC, BRCA1, treatment outcome, NOHA, biomarker.
Racial, Ethnic, and Socioeconomic Disparities in Chronic Myeloid Leukemia Survival Outcomes
V. Mukhtiar, C. Bhanushali, O. Gandhi, M. Mehta
Saint Vincent Hospital
Background
Health disparities in the U.S. impact minority populations across various cancers, yet the effects of race on treatment access and survival for chronic myeloid leukemia (CML) remain unclear; this study investigates how racial, ethnic, and socioeconomic factors influence treatment access and survival.
Methods
We conducted a retrospective analysis of SEER data for CML patients diagnosed between 2000 and 2021. Demographic and treatment characteristics were compared among various racial and ethnic groups. Survival outcomes were assessed by considering factors like median household income, age, sex, ethnicity, race, and urbanicity. Chi-squared tests and odds ratios (ORs) were used to analyse the relationships between these variables and survival outcomes.
Results
Of 10,667 CML patents, majority were White (80.51%), followed by Black (10.84%), Asian/Pacific Islander (7.94%), and American Indian/Alaska Native (0.69%). Regarding ethnicity, the majority identified as non-Hispanic/Latino (83.68%, N=8,927). Highest incidence occurred in 50-69 years. Survival analysis revealed disparities, with patients over age 80 years with greater cancer-related death risk (OR: 3.12). Males had worse outcomes than females (OR: 1.15), and Black (OR: 1.55) and Asian patients (OR: 1.35) compared to the Whites. High-income patients had better survival, while low-income groups faced higher risk (OR: 2.05). Interestingly, when adjusted for other variables, ethnicity showed minimal impact on survival (OR: 1.05, 95% CI: 0.95-1.16, p=0.317).
Conclusions
The study highlights significant disparities in CML outcomes based on demographic and socioeconomic factors, suggesting that access to care and treatment adherence, rather than ethnicity alone, may play a more crucial role in survival outcomes.
Notes
This study shows significant disparities in CML outcomes based on demographic and socioeconomic factors, suggesting that access to care and treatment adherence are important factors affecting survival.
Hyperhemolysis in Sickle Cell Crisis: A Rare Diagnostic and Therapeutic Challenge
J. O'Farrell1, Y. Lee2, J. Hill3
1- Dartmouth-Hitchcock Medical Center
2- Department of Internal Medicine, Section of Hematology & Oncology, Dartmouth Cancer Center, Lebanon, NH
3- Department of Internal Medicine, Section of Hematology & Oncology, Dartmouth Cancer Center, Lebanon, NH
Background
Sickle cell anemia (SCA) is a challenging disease to treat, especially in rural areas with limited access to care. A rare and potentially life-threatening complication of sickle cell crisis (SCC) is hyperhemolysis, which involves transfusion-associated hemolysis from autologous and allogeneic red blood cell consumption, partially mediated by the complement system. Treatment primarily consists of immunosuppressive and immunomodulatory medications to mitigate immune-related hemolysis.
Methods
A 27-year-old female with SCA and remote history of acute chest syndrome on chronic hydroxyurea therapy presented with SCC triggered by COVID-19 infection. Despite receiving a two-unit transfusion of packed red blood cells, her hemoglobin dropped from 7.7 to 5.9, bilirubin increased from 8.1 to 21 (all indirect), and haptoglobin became undetectable, indicating hyperhemolytic syndrome. To prevent further hemolysis, additional transfusions were withheld, and the patient was treated with methylprednisolone, intravenous immunoglobulin, tocilizumab, and eculizumab, leading to gradual improvement in hemoglobin levels.
Results
Hyperhemolytic syndrome demands prompt diagnosis and early intervention with multiple agents to curb potentially fatal complement-mediated RBC destruction. In this case, the combination of immunosuppressive/immunomodulatory medications and supportive measures (eg, folate, erythropoietin) effectively managed the condition. The patient’s anemia progressively improved, demonstrating the efficacy of a comprehensive, multi-faceted therapeutic approach.
Conclusions
This case underscores the complexity of identifying and treating hyperhemolysis as a rare complication of SCA. Effective management includes multiple interventions with immunosuppressive, immunomodulatory and supportive modalities, though responses are generally delayed and protracted. Further studies are needed to optimize strategies for the prompt turnaround and resolution of this potentially devastating syndrome.
Community Cancer Program Integrated Team Approach to Oral Anticancer Therapy
S. Perkins, J. Charland, D. MacFarland
Mercy Cancer Care
Background
Oral oncolytic use is growing exponentially as the research evolves in treating all manner of diagnosis. Ensuring that a patient is educated, compliant with medication and executing early intervention/ management of toxicities is imperative.
Methods
Here are Mercy Cancer Care we developed a workflow between physician, nurse practitioner and nurse navigators to educate patient on drug administration, side effects and lab schedule.
Results
Prior to start of therapy an assessment encompassing dosing, schedule, and administration as well as barriers to compliancy is completed. Nurse navigators work closely with prior authorization specialist and financial advocate to ensure that patient receives approval of treatment and patient assistance for drug co-pays, if necessary, to ensure timely approvals and delivery of medications and to ensure no delays in treatment with renewal of assistance programs and insurance changes. We have incorporated the electronic medical record (EMAR) to aid with all aspects of the process, allowing for a streamlined process. A call is placed by the nurse navigators verifying start of treatment; followed by weekly telephone calls to assess adherence and side effects. Weekly calls moving to biweekly, then once stable cadence of calls alternating between return to clinic visits allowing for close observation of laboratory values and toxicities.
Conclusions
The program we have put into practice has allowed for us to have smooth system for initiating and managing patients on oral oncolytic medication, allowing for early interventions of potential toxicities and side effects, and maintain adherence compliancy.
Development of a Genomic Tumor testing process to expand access to Genomic Clinical Trials in Rural Maine
A. Peters, R. Zhang, C. Bailey, C. Mancini, S. Sinclair
Northern Light Cancer Center
Background
Genomic tumor testing (GTT) has become a cornerstone of cancer treatment. The molecular analysis of tumors using next generation sequencing (NGS) has led to the development of multiple clinical trials that utilize genomic testing results to inform treatment. The need was identified to standardize a process for GTT providing timely access of reports aiding in treatment decision and clinical trial/Maine Cancer Genomic Initiative (MCGI) 2.0 participation.
Methods
In June 2022, a Genomic Research Nurse (GRN) was hired to develop a process for facilitating GTT and review of results. Order sets were created in the EMR and directly routed to the GRN and Insurance authorization team for testing initiation and authorization. Status is tracked for specimen/insurance needs ensuring timely results. Results are reviewed and assessed for onsite clinical trial eligibility and reported to ordering physician.
Results
Since implementing this process, 8 additional GTT order sets were developed in the EMR. Analysis of the most ordered tissue based GTT, showed a 66.9% increase in orders and an average turnaround decrease of 4.2 business days. 100% (n=539) of NGS reports were reviewed for genomic based trials. 33 patients were enrolled to genomic based clinical trials. 113 patients were enrolled to MCGI 2.0. 232 (44.7%) patients are being followed for future trial eligibility.
Conclusions
Creating this process has increased the ordering of GTT, identified the need for new GTT order sets, decreased overall result turnaround time and opened opportunities for clinical trial participation.
FLT3 mutation as a mechanism of dasatinib resistance and blast transformation
S. Pettit, A. Rogers
MaineHealth Maine Medical Center Portland
Background
FMS-like tyrosine kinase 3 (FLT3) D835 mutations have been associated with Tyrosine kinase inhibitor (TKI) resistance. TKIs with activity against BCR-ABL1 are commonly used to treat chronic myeloid leukemia (CML). Two such TKIs, Dasatinib and Ponatinib, also have activity against FLT3, but only ponatinib has prior evidence of activity at the D835 residue. We suspect development of the FLT3 D835 mutation serves as a resistance factor against CML treated with dasatinib, contributing to disease transformation, and that such cases may be effectively treated with ponatinib.
Methods
We present a case of CML with transformation to B-cell acute lymphoblastic leukemia (ALL) and new FLT3 D835V mutation in the setting of dasatinib therapy, subsequently managed effectively with ponatinib.
Results
A 60-year-old female with CML initially negative for FLT3 mutations underwent transformation to B-cell ALL after achieving initial milestones and maintaining BCR-ABL1 p190 transcripts <1.4% for over 2 years with dasatinib therapy. At time of transformation, she had a new acquired FLT3 D835V mutation. Furthermore, evidence of lingering B-cell ALL abated with mini hyper-CVAD plus ponatinib therapy.
Conclusions
CML patients treated with Dasatinib may be at increased risk for developing resistant FLT3 D835 mutations. In such cases, Ponatinib may be effective in suppressing these activating mutations. These relationships should be further clarified and best practices updated accordingly.
K. Plummer, L. Kelley, S. Halverson, J. Fischer, L. Graham, P. Helbig, L. Gaitor, J. Rueter
The Jackson Laboratory, Maine Cancer Genomics Initiative
Background
The use of biomarker testing to identify targeted therapies for solid tumors has been rapidly increasing over the past decade and new technologies along with FDA approved treatments have followed suit. It can be challenging for community oncologists to stay updated on these new advancements and the constantly changing landscape of precision oncology. To address this, the Maine
Cancer Genomics Initiative (MCGI) has been offering Genomic Tumor Boards (GTBs) to oncologists in Maine since 2017. These GTBs have proven successful at increasing the use of precision oncology in the community setting, however, developing and delivering GTBs can be time-consuming and is difficult to scale. To expand the GTBs to additional rural oncologists, the process must be optimized, which can be remedied by new software solutions.
Methods
We developed a business process model (BPM) to represent the GTB process, and
implemented time tracking at each step in the process.
Results
There are four major areas of our current GTB process from gathering the patient information, preparing the GTB, holding the GTB, and returning the GTB minutes to the clinician. It takes an average 149 minutes to fully complete a GTB case. Minutes creation takes the most time (49 minutes per case) followed by evidence preparation (32 minutes per case).
Conclusions
Developing the BPM allowed us to assess the most complex and time-consuming areas of our GTB process. This highlighted two areas where we can explore software solutions for streamlining our process, which will allow us to scale our GTB offerings.
Does Patient’s Age and Sex Matter When it Comes to Invasive Melanoma in Rural Maine
T. Prokop1, M. Babcock1, M. Skacel1, D. Prokop2
1- Dahl-Chase Pathology, Bangor, Maine
2- Saint Joseph's Hospital, Bangor, Maine
Background
Invasive melanomas are heterogeneous groups, some with high mortality.Patient characteristics like age and sex may have different frequencies of high risk melanomas as determined by Gene Expression Profile stage and histologic features. We looked at 128 patients diagnosed with invasive melanoma in Maine between 2019-2023 and their GEP category and histologic features to see if there is any increase in frequency of high risk melanomas amongst different patient age and sex demographics. We also looked for any associations between mitotic rate, Breslow thickness and presence of ulceration.
Methods
Histologic and GEP characteristics were correlated with demographics in patients with invasive melanoma
Results
Mitotic rates increased with age. 18-40 age group (n=24) high mitotic rate (> 4 mitoses/mm2) 4.1%, 65+ age group( n=51) 9.8%. GEP stage frequency for 2A and 2B (highest risk stages) increased with age: 4.1% (≤ 40), 13.7% (≥65+). Breslow thickness (BT) average increased with age (18-40,65+): .59mm, and 1.32mm respectively. Ulceration presence increased with age; 0% ( 18-40) and 9.8% ( 65+). 2+ mitotic rate 9.6% ( females; n=8); 21.8% (males, n=12). GEP stage 2A or 2B 6.8% (females) and 10.9% (males). Average BT .82mm (females); 1.28mm (males).Ulceration presence 10.9% (males) 4.10% (females).
Conclusions
There was a different frequency of high risk melanomas as determined by histology and between different age and gender groups in our sample. Age and gender may be important in determining high risk melanoma occurrence.
Delayed-Onset Immune-Related Cholangitis Following Durvalumab Treatment
K. Reed1 and R. Holcombe1,2
1- Larner College of Medicine, University of Vermont
2- University of Vermont Cancer Center
Background
Checkpoint inhibitor (CKI) treatment carries the risk of a range of immune-related adverse events (irAEs). Immune-related cholangitis (IR-cholangitis) is a rare hepatic irAE occuring in only 0.05 - 0.7% of patients treated with CKIs. Formal criteria necessary to differentiate IR-cholangitis from the more common hepatic irAE, autoimmune hepatitis (AIH) have not yet been determined. There are only two reported cases of durvalumab-related IR-cholangitis, with just one resulting from durvalumab monotherapy. No cases of delayed-onset IR-cholangitis from durvalumab have been reported. Here, we describe a case of rare, delayed-onset IR-cholangitis from durvalumab.
Methods
A 65-year-old female treated with durvalumab for cholangiocarcinoma developed severe pruritus and dark urine 15 weeks and 5 days after the last dose of durvalumab. Elevated liver function tests (LFTs) revealed a cholestatic pattern of injury. Due to the presence of pruritus, serum bile acids were evaluated and found to be above the upper limit of normal. An MRI-cholangiogram revealed mild dilation of the intra and extrahepatic ducts. After excluding other potential etiologies, a diagnosis of delayed-onset immune-related cholangitis from durvalumab was determined.
Results
Treatment with prednisone and ursodeoxycholic acid normalized LFTs. IR-cholangitis relapsed after discontinuation of steroids. Measurement of serum bile acids was found to be a novel, sensitive method to monitor for response to treatment and potential relapse.
Conclusions
Durvalumab is an unrecognized cause of delayed-onset IR-cholangitis. Measuring serum bile acids may be useful in monitoring for response to treatment and potential relapse and may be of diagnostic significance in differentiating IR-cholangitis from AIH.
Clinical remission of recurrent respiratory papillomatosis after anti VEGF treatment
E. Rivera, D. Silverman, T. Lahiri, H. tul Rehman
University of Vermont Medical Center and the Larner College of Medicine at the University of Vermont
Background
Recurrent respiratory papillomatosis (RRP) is a rare condition whereby benign tumor growth is perpetuated by HPV 6 and 11. Patients with this condition are at increased risk of chronic cough, dysphonia, dysphagia, and airway compromise.3 Juvenile onset of disease is more aggressive and associated with higher rates of recurrence.1
Methods
Our case involves a 22-year-old male who underwent multiple lines of treatment and more than 65 surgeries for refractory RRP.
Results
A 22-year-old male was diagnosed with RRP at 18 months old. He had a high disease burden with bilateral pulmonary lesions and laryngeal lesions. Treatment with HPV vaccination, interferon alpha-2b, and intralesional cidofovir were unsuccessful. Interferon caused significant weight loss and cidofovir was discontinued following a concern for allergic reaction. He also required interval surgical excision of laryngeal papillomatosis every three months. Surgical pathology of laryngeal growth revealed squamous papillomatosis without high-grade dysplasia. Systemic bevacizumab was initiated due to progressive respiratory symptoms. He responded well to bevacizumab and did not require any surgical resection while on treatment. His insurance changed eventually, and he was not able to receive further therapy for a year, leading to relapse and need for surgery again. He was started on compassionate use program for bevacizumab and went into clinical remission again and has stayed in remission.
Conclusions
Bevacizumab can be effective in treatment of refractory recurrent respiratory papillomatosis with a better side effect profile and can potentially save patients from excessive surgical procedures.1,2,
Notes
References:
Best, SR, Mohr, M, Zur, KB. Systemic Bevacizumab for Recurrent Respiratory Papillomatosis: A National Survey (nih.gov) Laryngoscope. 2017 October ; 127(10): 2225–2229. doi:10.1002/lary.26662.
Derkay CS, Wikner EE, Pransky S, Best SR, Zur K, Sidell DR, Klein A, Rosen C, Dikkers FG, Johnson R. Systemic Use of Bevacizumab for Recurrent Respiratory Papillomatosis: Who, What, Where, When, and Why? Laryngoscope. 2023 Jan;133(1):2-3. doi: 10.1002/lary.30180. Epub 2022 May 11. PMID: 35543118; PMCID: PMC10084367.
Pogoda L, Ziylan F, Smeeing DPJ, Dikkers FG, Rinkel RNPM. Bevacizumab as treatment option for recurrent respiratory papillomatosis: a systematic review. Eur Arch Otorhinolaryngol. 2022 Sep;279(9):4229-4240. doi: 10.1007/s00405-022-07388-6. Epub 2022 Apr 24. PMID: 35462578; PMCID: PMC9363326.
Creating an escape room to teach neutropenic fever management
K. Rogers
University of Vermont Medical Center
Background
Neutropenic fever is a life-threatening complication of cancer care. Cancer patients may present with fevers in the inpatient or outpatient setting. Timely, appropriate treatment is essential and requires critical thinking and collaboration. Escape rooms, in which teams solve a series of puzzles and compete for the fastest time, have been documented as an educational tool in other nursing specialties but are relatively new to oncology.
Methods
Nurse leaders created an escape room as part of an annual competency assessment. Teams of 4-6 worked together to solve a series of puzzles that demonstrated the steps involved in the assessment and management a neutropenic fever. We built teams with a mix of inpatient, primary outpatient, and infusion nurses. Teams competed to complete the puzzles in the fastest time. Participants evaluated the escape room on a 10-point Likert scale and were invited to provide narrative feedback on their experience.
Results
56 nurses completed the escape room. Feedback was overwhelmingly positive with participants rating the experience an average 9.8/10. Participants reported it helped build teamwork while testing their knowledge. Observers noted participants working together and calling on the varied expertise of their colleagues
Conclusions
The escape room was a fun way to engage nurses and build a supportive team. Teams of four worked best. Scheduling time for nurses to leave their assignment during a scheduled shift was challenging. The positive feedback suggests that gamification with escape rooms increases nurses’ engagement with educational content.
Self-Reported Financial Toxicity among Rural Cancer Patients Treated with Radiotherapy
M.L. Rose1, R. Yen2, S.T. Sha3, A. Van Critters3, N.S. Kapadia2,1
1- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
2- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
3- Memorial Sloan Kettering, New York City, NY
Background
Financial toxicity (FT) represents the direct and indirect expenses that cause additional burden on patients within healthcare that affects their wellbeing. FT has not been studied in rural population, we therefore conducted a feasibility study and identify initial trends for targeted intervention.
Methods
We surveyed radiotherapy patients at a satellite clinic linked to a tertiary academic medical center. Surveys were provided at the time of simulation (baseline), weekly while on treatment, and during any scheduled follow-up visits for six months post-completion of RT.
Results
27 participants consented from 09/2022 to 02/2023. One participant withdrew after baseline. Overall, 93% of weekly surveys contained complete responses. Baseline demographics of the cohort consisted mostly of older (mean age 68 years) white (n=27/27) men (n= 26/27) with prostate cancer (n=18/27). The plurality of patients (44%) reported yearly income less than $48,000; 48% received a high-school education or less. COST scores remained largely stable during weekly treatment (median 9, IQR 3-21, range 0-42.9) and slightly decreased during follow-up (median 4, IQR 0-9, range 0-38. When asked what expenses were decreased, most respondents reported spending less on other transportation/gas (n=7), entertainment (n=7), and food (n=6). One participant sold assets to cover costs of cancer treatment.
Conclusions
FT surveys among a rural radiotherapy population is feasible with high fidelity of data collection. Though the mean COST scores in this pilot cohort did not appreciably change throughout treatment, patients reported significant hardship as evidenced by selling assets and forgoing essential expenses.
S. Rotenberg1, P. Barr1,2,7, C. Ganoe1,2, L.Oh1,2, N.Kapadia3, T. Grigsby6, P. Whitney6, L. Mistler4, S.Tarczewski2, L. Loeb5, M. Bruce4
1- Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Hanover NH
2- Center for Technology and Behavioral Health
3- Department of Oncology, Dartmouth Health, Lebanon, NH
4- Department of Psychiatry, Dartmouth Health, Lebanon NH
5- DALI Lab, Dartmouth College, Hanover NH
6- Patient Partner
7- The Dartmouth Institute for Health Policy Clinical Practice
Background
fDepression affects up to 20% of patients with cancer, yet most do not receive treatment. Key barriers include: low detection, low mental health literacy and limited accessibility (especially in rural communities). We developed an online pathway to treatment (iPath*D) that connects cancer patients who screen positive for depression to evidence-based treatments.
Methods
Two rounds of participatory design sessions with high fidelity interactive versions of iPath*D were completed. Participants were recruited from a rural cancer center who were either currently in treatment or had completed treatment in the past 12 months and had experienced symptoms of depression. Round one included one female and four males aged 49-85 years (median 74 years). Round two included one female and four males aged 29-76 years (median 66 years). Participants completed typical tasks in iPath*D, followed by the System Usability Scale (SUS) survey (targeted ≥68/100) and debrief interview.
Results
Median SUS scores for round one were 65 (range 40-75), and 67 (range 45-73) for round two. Participants were positive about the possibility of an app which introduces patients with cancer to the topic of depression and links them to evidence-based treatment. Participants noted the importance of communicating decisions with family and care providers. Participants also suggested content for the app: information on support groups (both local and national), and other well-being support (e.g., nutrition, exercise, etc.).
Conclusions
Patient feedback suggests that an app such as iPath*D can be helpful to connect patients with cancer and depression to evidence-based treatment. Pilot trial is underway.
Retrospective Analysis of Clinical Presentation and Treatment of Patients with Glioblastoma in Rural and Urban Counties
G. Sarriera Valentin1, E. D’Agostino2, A. Thomas2
1- Larner College of Medicine at the University of Vermont
2- Department of Neurology, University of Vermont Medical Center
Background
US residents of rural counties have a higher cancer-associated mortality than their urban counterparts. This trend has been shown in multiple cancer types, but the impact of rurality is under-studied in glioblastoma.
Methods
IRB-approved retrospective cohort study of patients with newly diagnosed glioblastoma treated at the University of Vermont Medical Center (UVMMC) (01/2017-12/2021), urban vs rural was determined by US Department of Agriculture Rural-Urban Continuum Codes (1-3=urban; 4-9=rural) for county of residence. Correlates were assessed using Chi-Square test on SPSS (p-value <0.05).
Results
Our study included 119 patients, 68 rural and 51 urban. Urban and rural patients were of similar age (median 63 vs 64.5), KPS (70 for each), gender, ethnicity, and sex. Time between symptom onset and neurosurgery was insignificantly different: 49 days for rural patients and 82 for urban patients. Percent receiving gross total resection was similar (44% rural vs 47% urban), with no difference in MGMT methylation (43% rural, 47% urban) or IDH mutation (6% rural, 4% urban. 80% of rural patients vs 78% urban received radiation (median 60Gy vs 58Gy), and 78% in each group received adjuvant temozolomide (median 3 vs 1.5 cycles, rural/urban). Median progression free survival was 5.9 months for rural vs 3.6 months for urban (p>0.05), and overall survival was 11.9 vs 8.7 months, respectively, (p>0.05).
Conclusions
Urban and rural patients with glioblastoma at UVMMC had similar presentation, treatment, and outcomes. Access to a tertiary hospital centrally located in a rural catchment area for neuro-oncologic management may help mitigate the disparities rural patients face when accessing cancer care.
The effect of touch on pain and anxiety during bone marrow biopsy procedure
A. Schaal, N. Dhawan, J. Pushee, K. Broglio
Dartmouth Health
Background
Bone marrow biopsies (BMBx) can be a painful procedure and are often associated with anxiety. No data exists regarding touch to the feet during the BMBx procedure as an intervention to minimize both pain and anxiety
Methods
Forty-six patients were randomized to receive either simple touch to the feet during the BMBx procedure or standard of care of no touch. Patients completed a visual analog scale (0-10) for pain before, during, and after the procedure and also completed the six item State Anxiety scale before and after the procedure. Three open ended questions were asked at the completion of the biopsy to explore the patient’s overall experience
Results
No statistically significant differences in pain or anxiety were identified between the two groups. Participants in the treatment group reported more positive feedback and provided less suggestions for how to improve the patient experience as compared to the control group
Conclusions
Although there was no statistical significance improvement in pain or anxiety with the touch intervention, the patients reported an improved overall experience. Adding touch as an intervention can be safely used to improve the patients experience during BMBx as it does not incur an additional cost or time and has no reported side effects
Easing Cancer Burden: short versus long course adjuvant radiation therapy for cutaneous squamous cell carcinoma
A. Schrager1, C. Weinberger2, P. Callas3, C. Anker4
1- The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, Vermont
2- Division of Dermatology, University of Vermont Medical Center, Burlington, Vermont
3- Department of Mathematics & Statistics, University of Vermont, Burlington, Vermont
4- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, Vermont
Background
Standard indications for adjuvant radiation therapy (RT) after surgery for cutaneous squamous cell carcinoma (cSCC) typically involve 2-3 (Brigham and Women’s Hospital (BWH) T2b) or 4 (BWH T3) of the following risk factors: poor differentiation, perineural invasion, tumor >2 cm, and deep invasion. To our knowledge, short-course RT (SCRT; 30 Gy in 5 fractions given twice weekly), which has been established as safe and effective for cutaneous melanoma, has not been studied in cSCC. In this study, we compared the safety and efficacy of SCRT vs long-course RT (>=4 weeks daily RT of fraction size <=2.5 Gy).
Methods
We assessed BWH stage T2b/T3 cSCC patients undergoing Mohs followed by LCRT or SCRT for toxicity and oncologic outcomes.
Results
For the LCRT group (n=9, BWH:T2b 78% & T3 22%), median follow-up was 40 months; median (range) dose and # fractions were 6000 (5250-6600 Gy) and 30 (20-33), respectively, with regional nodes treated in 44% of patients. For the SCRT group (n=6, BWH T2b 66% & T3 33%), median follow-up was 17 months, with regional nodes treated in 17%. Neither group experienced recurrent cSCC.
Grade 2+ toxicities were similar (30% LCRT vs. 50% SCRT). They included dermatitis (3 SCRT vs. 2 LCRT), muscle necrosis (1 SCRT), parotiditis (1 SCRT), dysgeusia (1 LCRT) and mucositis (1 LCRT).
Conclusions
Patients undergoing SCRT vs. LCRT had similar outcomes, although conclusions are limited by small patient numbers and short follow-up time. As SCRT is significantly more appealing to patients due to its relative convenience, further investigations are warranted.
Aleukemic Mast Cell Leukemia with Genomic Instability: A Case Report
A. Sharma1, R. Vankina2
1- Department of Internal Medicine, University of Connecticut
2- Department of Hematology Oncology, University of Connecticut
Background
Mast cell leukemia (MCL) is a rare and aggressive mast cell neoplasm, often associated with multiple genetic mutations. Aleukemic variants, where mast cells are not elevated in peripheral blood, present significant diagnostic challenges. This case report describes an 86-year-old male with a history of diffuse large B-cell lymphoma (DLBCL) and prostate adenocarcinoma, who was diagnosed with aleukemic MCL.
Methods
The patient presented with acute pancytopenia. Comprehensive workup included peripheral smear, imaging studies, bone marrow biopsy, and next-generation sequencing (NGS) to evaluate the genetic profile of the disease. Immunohistochemistry was used to characterize the mast cells.
Results
Bone marrow biopsy revealed ≥20% pleomorphic mast cells positive for CD117, CD33, and partially positive for CD25, but negative for CD2 and CD34. NGS identified several mutations: TP53 (VAF 50%), RB1 (VAF 40%), and others. Tryptase levels exceeded 11,999 ng/mL. Despite the offer of treatment with midostaurin, the patient’s condition deteriorated rapidly, resulting in death. The findings suggest a potential association with chronic myelomonocytic leukemia (CMML) or myelodysplastic syndromes (MDS).
Conclusions
This case highlights the complexity of diagnosing and managing aleukemic MCL, especially in the presence of multiple high-risk genetic mutations. The rapid progression observed underscores the need for early recognition and aggressive treatment strategies tailored to the patient’s genomic profile. Further research is essential to establish more effective surveillance and treatment protocols for this rare condition.
A. Sharma1, N. Dhawan2, I. Monsalve1, M. Pomeroy1, C. Hayes1, K. Silvius1, M. Dowling-Schmitt1, R. Johnson1, K. Field1, A. Park1, C. Rodriguez1, R. Montano1, P. Benoit1, S. Haghollahi3, F. Lansigan1
1- Division of Hematology/Oncology, Dartmouth Cancer Center, Dartmouth Health, Lebanon, NH
2- Division of Hematology/Oncology, Department of Medicine, Western Michigan University, Kalamazoo, MI
3- Department of Medicine, Dartmouth Health, Lebanon, NH
Background
Morbidity and mortality (M&M) conferences are a key tenet of improving patient safety and spurring quality improvement. They additionally serve an educational role and are required by ACGME-accredited training programs. The traditional format primarily includes an audience of clinicians. We sought to develop an interactive, interprofessional M&M (i-MM) to gain perspective of all team members while meeting the ACGME core competencies for patient safety and quality improvement.
Methods
A planning committee led by our fellowship program director was created. This committee established conference design. We implemented Plan-Do-Study-Act (PDSA) cycles following each conference to spark quality improvement. The objectives of this conference were mapped to ACGME core competencies for patient safety and quality improvement for hematology/oncology fellowships. The effectiveness of this conference was gauged via an anonymous post-session survey using a 4-point Likert scale.
Results
We had representation from quality and safety leaders, faculty, fellows, residents, pharmacy, social work, and nursing in attendance. Through our first 3 sessions, our post-session survey had an average of 3.7/4 for all interprofessional goals. It was reported from several nurses that the moderated session was “inclusive and empowering”. PDSA cycle 1 led to cycling of presenting profession along with change to sepsis identification tools.
Conclusions
The i-MM was an effective approach to meeting ACGME requirements for safety and quality while creating an inclusive environment for all team members. It furthered the culture of safety and collaboration at Dartmouth Cancer Center while leading to quality improvement and creating innovative solutions to provide equitable care for all patients with cancer.
KRAS G12C and PD-L1 Status in Lung Cancer Patients in Rural Maine
E. Shum, M. Babcock
Dahl-Chase Diagnostic Services
Background
Lung cancer is the second most common cancer in men and women, and the leading cause of cancer death in the United States. KRAS serves as a regulating molecule in the cell growth cycle. When it becomes mutated, KRAS can allow tumor cells to grow uncontrollably. Immune checkpoint inhibitors target CTLA-4, PD-1, and PD-L1, and there is evidence of ICI treatment restoring cell activity. Lung cancer patients with KRAS mutations show improved survival but not all patients respond. What is the distribution and frequency of KRAS mutated lung cancer in rural Maine in patients eligible for immunotherapy?
Methods
Retrospective review of pathology and molecular profiling results of cancer patients (n=2087) from the Northern Light Eastern Maine Medical Center system between January 1, 2020 and August 10, 2024, were deidentified. Patient tumors tested (n=1293) by next generation sequencing with PD-L1 immunohistochemistry results were subject to data review to determine if KRAS codon and amino acid substitutions are associated with PD-L1 status.
Results
30.1 % of lung tumors contained a KRAS mutation (n=389/1293) at position G12C (45.5%; n=177/389). KRAS positive tumors categorized by PD-L1 status were 39.8% high (n=155/389), 24.4% low (n=95/389), 33.7% no expression (n=131/389). KRAS G12C represents 41.8%, 26.6%, and 31.6%, of high, low, and no PD-L1 expression, respectively.
Conclusions
Our findings show that lung cancer patient PD-L1 status was distributed similarly among KRAS mutated tumors.
Is it ever Hemophagocytic Lymphohistiocytosis (HLH)?
S. Sidhu1, A. Sharma1, J. Castillo2
1- University of Connecticut Internal Medicine Residency
2- Department of Internal Medicine, Hartford Hospital
Background
HLH is a highly aggressive immune dysregulation syndrome resulting in tissue destruction. It can be associated with genetic predisposition but can occur in the setting of other etiologies causing immune hyperactivity. Varied presentation can delay early diagnosis and prompt management, especially in the absence of a known trigger.
Methods
66 y/o male who was treated for presumed HLH with HLH-94 protocol with good response a few months prior presented with 3 weeks of fatigue, progressive altered mental status and fevers. Was initially treated for suspected pneumonia and meningoencephalitis without improvement. Extensive infectious work up including blood cultures, CSF analysis and also rheumatologic panel were negative. Found to have ferritin level of 1864, triglycerides of 555, calcium 12.0. Due to lack of clinical improvement and history of HLH, BM biopsy was recommended.
Results
BM biopsy revealed hemophagocytes and megakaryocytic hyperplasia, rare atypical CD20+ large B-cell with minute kappa monoclonal CD5+ B-cell population. Due to concerns for aggressive B-cell lymphoma, PET scan was obtained only revealing hepatosplenomegaly and diffuse BM uptake. Skin biopsies from three sites showed focal dense proliferation of abnormal CD20+ B cells, consistent with intravascular large B-cell lymphoma.
Conclusions
HLH associated with lymphomas carries a worse prognosis. HLH could result after direct disease treatment with immunotherapy or from immunosuppression from the disease process itself. However, HLH preceding lymphoma diagnosis is rare. The case highlights the importance of prompt recognition and workup of potential triggers to ensure timely management.
A. Sinclair-Steele, M. Babcock, B. King, M. Skacel
Graduate School of Biomedical Sciences and Engineering (GSBSE), University of Maine, Orono, Maine.
Dahl-Chase Pathology Associates, Bangor, Maine
Background
Pre-analytical tumor tissue prioritization is critical for diagnosing and treating cancer. Molecular profiling is performed after patient tumor tissue processing for a diagnosis. Due to insufficient FFPE tumor material for analysis, 30% of advanced lung cancer tumor biopsies lack the tissue required for molecular subtyping (30% tumor material required). Unused FFPE tissue was used for molecular profiling since there is a critical need for maximizing tissue for molecular profiling so patients have access to precision medicines.
Methods
Retrospective review of pathology and molecular profiling results from deidentified cancer patients (n=2087) from the Northern Light, Eastern Maine Medical Center system between January 1, 2020 and Aug 10, 2024; when unused, level 2-3 unstained tissue sections from tissue processing were used as a specimen source. Data review included tumor %, tumor areas (mm2), mutational findings, and extended molecular profiling send out logs.
Results
Cohort case review (n=2087) of solid tumor cases (46.6%) with next-generation sequencing results (n=972/2087) demonstrates 70.1% were lung cancers (n=681/972). 28.9% of tested lung cancers (n=197/681) were < 30% tumor content, and 41.6% had at least one actionable finding. 49% of all tumors (n=1038/2087) had at least one actionable finding, and 565 were lung cancers. Of these lung cancers, 182 had either a tier I or II mutation and were <30% tumor tissue.
Conclusions
Our findings support the use of previously discarded FFPE tissue sections for molecular profiling improves rural cancer patient access to precision oncology.
Bone metastasis and incidence of hypocalcemia, is denosumab the drug of choice?
P. Skeffington, J. DallaCosta, T. Caron
Southcoast Health Center for Cancer Care
Background
Recent update from Amgen on Prolia© for patients with renal dysfunction: “Increased risk of hypocalcemia in patients with advanced chronic kidney disease.” Many cancer patients present with diminished renal function, which makes this information pertinent to these patients. Studies have been published that highlight the incidence and risk of denosumab-related hypocalcemia in cancer patients.
Method
A one-year retrospective chart review was completed looking at patients with bone metastases from solid tumors that were treated with denosumab. Evaluation of calcium, albumin and calculations for Corrected Calcium was undertaken.
Results
Incidence of all-grade hypocalcemia (defined as equal to 8.7 mg/dL or less) occurred in 7% of cancer patients at Southcoast Health. This is within range of other studies that showed a rate of 0.1 to 12.8%. Pooled analysis of randomized controlled studies (Wei-Xiang et al) showed an overall incidence of 5.2% Use of concurrent calcium and vitamin D supplementation in patients on denosumab/Zoledronic acid therapy is recommended by NCCN (guidelines in progress), also recommended in the British Columbia Cancer Agency guidelines. Southcoast did not have this built into its Epic Protocols
Conclusions
To better care for patients at Southcoast: baseline creatinine, calcium, phosphorus and albumin added to order sets, stat creatinine will be drawn prior to each dose of denosumab and oral calcium and vitamin D to be part of the protocol unless contraindicated.
Marjolin Ulcer Disguised as Osteomyelitis in Locally Advanced Basal Cell Carcinoma
A. Strumilowska1, H. Rehman2
1- University of Vermont Department of Medicine,
2- University of Vermont Department of Hematology and Oncology
Background
Marjolin ulcers are cutaneous neoplasms that arise in previously injured skin, burns and chronic wounds. Squamous cell carcinoma (SCC) is a common etiology of Marjolin ulcers; however, cases involving basal cell carcinoma (BCC) can rarely be seen.
Methods
We present a case of a 65-year-old male with limited prior healthcare exposure who presented with fevers in the setting of left-sided facial wound from prior trauma reported 10-years ago. The patient was noted to have complete obliteration of his left ear with initial presentation concerning for sepsis secondary to underlying osteomyelitis. Further work-up revealed osteomyelitis of the skull with surgical pathology demonstrating underlying basal cell carcinoma of the skin. Bone biopsy results did not show invasion of the skull, however, further imaging was nonconclusive with some concern for osseous involvement. There was no evidence of metastatic disease on further imaging.
Results
Following multidisciplinary discussions with oncology, dermatology, otolaryngology and radiology, patient was started on vismodegib. Follow up dermatology appointments demonstrated granulation tissue at the base with decrease in wound size.
Conclusions
This clinical presentation highlights the importance of maintaining a broad differential in wound diagnosis as rare pathologies like Marjolin ulcers may be missed in the setting of suspected infections. This case further demonstrates the unique finding of basal cell carcinoma-associated Marjolin ulcer, a rare presentation compared to the more common SCC. Additionally, the 10-year latency between trauma and development of locally advanced obliteration of the left ear is unusual given the typical latency of 30 years.
Cannabis habits and perceptions among GI oncology patients at Dartmouth Cancer Center
R. Symmes1, E. McGrath2, M. Stannard3
1- Rivier University
2,3- Gastrointestinal Oncology Program, Dartmouth Cancer Center
Background
38 states have legalized cannabis for either medical or recreational use. Many cancer patients use cannabis for perceived relief from symptoms or to treat their disease. Despite this, clinicians are often unaware. A chart review at our clinic revealed that only 4% of charts recorded cannabis use. Stigma surrounding cannabis may impede clear communication between clinicians and patients. Little is known about the interactions with chemotherapy and disease progression.The purpose of this study was to explore GI oncology patients’ patterns of cannabis use and acquisition. A secondary purpose was to recognize if any patients had been counseled about the potential risks, benefits, and interactions that accompany cannabis usage.
Methods
A 25-question survey was developed to capture patient demographics, cancer characteristics, and details regarding cannabis use. Patients also revealed whether they had been counseled on the potential benefits, risks, or interactions that may be associated with cannabis use.
Results
210 patients were invited to participate in this study with 57 responses. Prior to cancer diagnosis, 49.1% of patients reported having used cannabis. Since their diagnosis, 43.8% of respondents reported having used cannabis. An overwhelming majority reported never receiving counseling on potential drug or disease interactions (86.4% and 95.0% respectively).
Conclusions
Expanding education amongst healthcare providers regarding the effects and interactions of cannabis will allow for more effective counseling to patients.
An Uncommon Encounter with Tumor Lysis Syndrome in Colorectal Cancer
W. Tan1,2, U. de Matos3, Q. Wu4, F. Forouhar4, R. Vankina1, P. Kapadia1, V. Forbes1
1- Department of Hematology and Oncology, Carole and Ray Neag Comprehensive Cancer Center, University of Connecticut Health Center, F
Background
Tumor lysis syndrome (TLS) is an oncologic emergency caused by massive release of potassium, phosphorus, and nucleic acid from tumor cells. TLS is rarely reported in colorectal cancer, but carries a high mortality. We present TLS in a patient with metastatic colon cancer after receiving 5-fluorouracil (5-FU), Leucovorin, and Oxaliplatin (FOLFOX).
Methods
61-year-old male with history of renal cell carcinoma status post left nephrectomy presented with persistent cough. Chest X-ray showed questionable pulmonary nodule and follow-up CT chest/abdomen/pelvis showed hepatic lesions. He underwent colonoscopy which revealed a large cecal mass. Biopsy of the mass and hepatic lesions confirmed stage IV colon adenocarcinoma with liver metastasis. He was started on FOLFOX with a 48 hour 5-FU infusion pump. Approximately 24 hours into infusion, the pump disconnected by accident, and no additional 5-FU was infused. 5-FU was resumed. After completing the infusion, he became hypotensive and tachycardic.
Results
In the emergency department, he met criteria for clinical TLS with phosphorus 6.1 mg/dL, uric acid 18.7 mg/dL, and creatinine 2.5 mg/dL. Two doses of Rasburicase 3 mg were administered and he was started on Febuxostat 40 mg daily. His TLS resolved with clinical improvement, but he remained too weak to undergo additional treatment. Unfortunately, he developed multiorgan failure and passed away.
Conclusions
Although TLS in colon cancer is rare, it is important to recognize that it may occur in patients with high tumor burden on chemotherapy and lead to poor outcomes.
T. Khodadad, A. Thomas
University of Vermont
Background
The recursive partitioning analysis (RPA) is a widely used prognostic tool for solid tumor brain metastases (BMETS), developed in 1997. The updated RPA (U-RPA) classification offers a more contemporary approach based on multi-institutional data in a modern patient cohort, which we applied to better understand our institutional quality outcomes.
Methods
This retrospective study analyzed patients diagnosed with BMETS from solid tumors between 2020 and 2022. Kaplan-Meier survival analysis and Cox proportional hazards modeling were employed to assess the impact of U-RPA classifications, treatment modalities, and KPS.
Results
222 patients with BMETS were analyzed (102 non-small cell lung cancer, 30 breast, 30 melanoma, 61 other), including 23 in U-RPA Class 1, 51 U-RPA-2A, 71 U-RPA-2B, and 78 U-RPA-3. Median overall survival (OS) was 192 days, with 49 patients (22%) alive at the time of analysis (censored on last follow-up). Mean survival directly correlated with U-RPA class (1=521 days, 2A=476 days, 2B=406 days, 3=209 days), while median survival was shortest for U-RPA Class 3 (90 days). Median survival did not follow U-RPA class for Classes 1, 2A and 2B, likely due to the large percent of patients still alive (48% for class 1) and small sample size. While 91% of patients received cancer-treatment for BMETS, only 18% of patients in U-RPA 3 received treatment beyond supportive care.
Conclusions
The U-RPA classification may help predict prognosis in a modern cohort of patients diagnosed and treated with BMETS in our institution and may help aid physicians in discussions about prognosis and expected outcomes.
Assessing Prognostic Uncertainty in Cancer Survivors Presenting for Surveillance Visits
C.A. Thomas1, A. Franklin1, M. Glantz2, P.K.J. Han3, P. Bogden4
1- New England Cancer Specialists, Department of Clinical Research, Scarborough, ME.
2- Penn State Cancer Institute, Hershey, PA.
3- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD.
4- The Roux Institute Northeastern University, Department of Computer Science, Portland, ME.
Background
Cancer survivors face uncertainty about their future because of the possibility of cancer recurrence. Evidence suggests that prognostic uncertainty might not only be negative because it may give patients a chance to hope for a more favorable outcome. We evaluated uncertainty and emotional well-being by assessing uncertainty levels in cancer survivors.
Methods
Adult cancer survivors presenting for follow-up appointments to discuss surveillance test results such as imaging studies at New England Cancer Specialists and Penn State Cancer Institute were asked to fill out a survey to self-evaluate their attitudes regarding cancer recurrence. Patients were also asked how they cope with cancer related stress. Questions used a 4- or 5-point Likert scale. Survey results were entered into REDCap, along with demographic and social information, cancer stage and status, and instruments measuring patients’ overall quality of life and self-reported outcomes.
Results
Surveys from 222 patients at NECS and Penn State are available. Preliminary results suggest a significant correlation between ECOG and self-reported hope. Based on the Herth Hope Index, patients with a higher ECOG score reported decreased hope. Other correlative interactions will be presented at the conference.
Conclusions
Evaluating cancer survivors’ attitudes towards cancer recurrence is feasible in a high-volume cancer clinic. Initial results suggest a correlation between patients’ ECOG and Herth Hope Index score. The study is ongoing and will serve as a platform for future investigations to support cancer survivors.
Notes
This work was supported by a grant from the Department of Clinical Research at New England Cancer Specialists to AF.
The Impact of Extended Panel Molecular Testing on Treatment Decisions for Patients with Stage IV Lung, Breast, Colon, and Prostate Cancer
C.A. Thomas2, C. Edwards1
1- University of Maine, College of Biology and Ecology, Orono, Maine
2- New England Cancer Specialists, Department of Clinical Research, Scarborough, Maine
Background
The use of Extended Panel Molecular Testing (EPMT) to evaluate patients with advanced malignancies is increasing. This study aimed to determine the impact of EPMT on treatment plans for stage IV breast, colon, lung and prostate cancer patients. This was achieved by assessing the frequency, actionability and the treatment decisions of patients who received EPMT.
Methods
Between 2016 and 2024, 2,880 patients with stage IV lung, breast, colon, and prostate cancer at NECS were evaluated to determine EPMT frequency. The results and treatment plans for patients receiving EPMT were recorded and categorized.
Results
Between 2016 and 2024, 1,369 patients received EPMT, (627 lung, 201 breast, 156 colon, 385 prostate). Actionable mutations: breast 61.7% (n=124), lung 62% (n=389), colon 62.2% (n=97), prostate 22.6% (n=87). Targeted therapy received: 126 lung (32.4%), 37 breast (29.8%), 8 colon (8.2%), 24 prostate (27.6%). Reasons for patients to not receive EPMT informed therapy: standard of care (51.7%), performance status inadequate (17.8%), discovered but not discussed (15.6%), clinical trial (10.9%), patient declined (2%), not on treatment (2%).
Conclusions
Increased EPMT usage is beneficial as it often allows for a broader view of treatment options. A greater understanding of the impact EPMT has on treatment can be obtained by analyzing reasons why patients with actionable results did not receive targeted therapy. We hypothesize that EPMT usage will continue to increase, thus allowing for effective treatment options to be utilized more frequently.
Notes
This work was supported by a grant to CE from the Department of Clinical Research, New England Cancer Specialists
R. Thomas, A. Sparks3, K. Wilkinson1, M. Gergi1,2, A. Repp1,2, N. Roetker4, N. Smith5,6,7, P. Muthukrishnan1,2, K. Martin1,2, and N. Zakai1,2,8
1- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
2- University of Vermont Medical Center, Burlington, Vermont, USA
3- Biomedical Statistics Research Core, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
4- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
5- Department of Epidemiology, University of Washington, Seattle, Washington, USA
6- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle Washington, USA
7- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle Washington, USA
8- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
Background
Most studies of hospital-associated venous thromboembolism (VTE) either do not specifically assess post-discharge events or only assess risk factors at hospital admission rather than discharge.
Methods
Patients discharged from the University of Vermont Medical Center between January 2010 and September 2019 were followed for inpatient and outpatient VTE events for up to 90 days. Age-, sex-, race-, and length of stay-adjusted Cox models estimated the hazard ratios (HR) and 95% confidence intervals (CI) for potential risk factors for PD-VTE.
Results
Among 22,617 admissions, there were 180 PD-VTE events (90-day cumulative incidence of 0.8%). The median time from discharge to PD-VTE was 29 days. Prior history of VTE (3.34 HR; 2.26-4.93 95% CI) and active cancer (3.13 HR; 2.31-4.23 95% CI) were associated with increased risk of PD-VTE. Longer hospital stays (1.84 HR; 1.23-2.75 95% CI for 6-10 days and 1.64 HR; 0.93, 2.90 for 11+ days 95% CI), were associated with increased risk of post-discharge VTE. Both the mortality (1.22 HR 1.06-1.41 95% CI) and readmission (1.30 HR; 1.13-1.50 95% CI) Elixhauser Comorbidity Indices were associated with increased risk of PD-VTE.
Conclusions
Risk factors for VTE after discharge include characteristics related to hospitalization as well as patient specific risk factors and differ from those for VTE diagnosed during hospitalization. Age, length of hospital stay, discharge diagnoses, history of VTE, active cancer, and comorbidity indices increased the risk of PD-VTE. These data support that characteristics of the hospitalization influence PD-VTE risk and that risk assessment should be done at discharge.
G. Wasp1,2,3,4, A. Martinez-Pereira4, P. Bagley5, E. Vitale5, A. Barnato4,6, E. Murnane7, J. O’Farrell1, J. Mitra7, C.Saunders4,6, P. Barr4
1- Department of Medicine, Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, NH
2- Dartmouth Cancer Center, DHMC, Lebanon, NH
3- Geisel School of Medicine at Dartmouth, Hanover, NH
4- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
5- Biomedical Libraries, Dartmouth College, Hanover, NH
6- Section of Palliative Care, Department of Medicine, DHMC, Lebanon, NH
7- Thayer School of Engineering, Dartmouth College, Hanover, NH
Background
The aim of this study was to review the literature on intrapersonal (i.e., self) clinician emotion regulation and its impact on serious illness communication involving patients with advanced cancer.
Methods
We searched Medline, PsycInfo, CINAHL, Cochrane, and Scopus were searched for studies investigating clinician emotion regulation in the context of serious illness communication and medical decision-making involving patients with advanced cancer. Following PRISMA Statement guidance, we screened search results, extracted data, and assessed quality from included studies.
Results
Out of 2,556 articles identified by the search strategy, 28 met the inclusion criteria. The median number of clinician participants in each study was 40 (range 11-416). Out of 28 studies, 25 (89%) involved only physicians or physicians-in-training, 0 included nurse practitioners, and 5 (18%) studies included patients. Most studies (79%) used qualitative methods (6 qualitative only, 14 mixed methods), and 8 (36%) studies used quantitative methods only. The data collection strategies used to assess clinician emotion regulation included: survey (79%, 22/28), observation (50%, 14/22), interview (32%, 7/22), and biometric (21%, 6/28). Most (64%) examined intrapersonal clinician emotion regulation exclusively, though 10 (35%) also examined interpersonal emotion regulation (clinician regulating patient emotion). For our quality assessment, 19 (68%) articles were rated good/high, 2 (7%) fair, and 7 (25%) poor/low quality.
Conclusions
The assessment of this complex psychological process in clinicians is heterogeneous. Most studies rely on self-report surveys, but many studies use additional methods. Since serious illness communication encapsulates many communication tasks there is no uniform assessment strategy.
Employing a Clinical-Administrative Dyad to Build a Quality Enterprise
J. Willyard1, N. Kapadia2
1- Dartmouth-Hitchcock
2- Dartmouth Cancer Center
Background
One of the challenges we experience within healthcare is the ability to build a meaningful quality enterprise that addresses both clinical and operational opportunities. This presentation describes the methodology and results of a clinician-administrator dyad engaged as the chairs of a Quality Council (QC) that is charged with coordination of existing work, launching new initiatives, and timely, transparent communication to all relevant shareholders.
Methods
The methodology of the QC is to deploy a committee-subcommittee structure, supported by automated tools and dedicated operational quality staff, to maintain visibility of a host of clinical and operational quality initiatives through quarterly departmental meetings. An overview of deployed, including an Idea board, Kanban boards, and automation software will be provided. The structures, people and tools utilized by the QC operationalize quality improvement as a system-wide expectation, versus a set of tasks that are "owned" by a single person or role.
Results
Results of the QC include resolution of 200+ issues submitted through the incident reporting system in the last 16 months, development and operationalization of several department-wide policies, adoption of standard work related to documentation changes, and response to more than 25 submissions to the Idea board.
Conclusions
Balancing clinical and operational needs is always a challenge, but the dyad leadership approach to a QC promotes robust stakeholder representation and broad discussion, while the QC itself offers a consistent forum for ongoing quality discussions. Representation from “both sides of the house” allows a quality enterprise to flourish.
Therapeutic Response to AIM Chemotherapy in High-Grade Myxoid Pleomorphic Liposarcoma
A. Wood, A. Merker, H. tul Rehman
University of Vermont Medical Center
Background
High-Grade Myxoid Pleomorphic Liposarcoma (HGMPL), first classified in the 2020 WHO classification of tumors, is a newly recognized subtype of liposarcoma. It is characterized by loss of heterozygosity, a predilection for the mediastinum, and poorer outcomes. Due to its recent classification, there are no consensus-based treatment protocols.
Methods
A 47-year-old female presented with chest pain and dyspnea and was found to have a 4.3 x 2.6 cm right hilar mass on CTPE. Upon referral for chemotherapy, a follow-up CT scan revealed an enlarging mass measuring 10.5 x 6.5 x 6.0 cm with associated Superior Vena Cava Syndrome (SVCS). Endobronchial biopsy confirmed HGMPL with widespread loss of heterozygosity. The patient began Ifosfamide, Doxorubicin, and Mesna chemotherapy (AIM). After three cycles, an 8-week follow-up CT scan showed a reduction in tumor size to 7.5 x 6.7 x 7.2 cm.
Results
Due to the rarity and recent classification of HGMPL, standardized treatment protocols have yet to be established. Therapeutic strategies are often extrapolated from regimens employed for other soft tissue sarcomas. In this context, AIM chemotherapy has demonstrated potential efficacy, as evidenced by the reduction in tumor volume from approximately 221 cm³ to 168 cm³, opening the door to adjunctive radiotherapy and surgery.
Conclusions
In this case, AIM chemotherapy resulted in tumor shrinkage and symptomatic improvement in SVCS. While this outcome suggests AIM may be an effective treatment for HGMPL, further research is needed to confirm its broader applicability.
Obesity paradox in breast cancer patients receiving pembrolizumab
H. Xu, X. Xu1, C. Chiang2, J. Song3, N. Xanthavanij1, K. Chi3, Y. Chang4, Y. Chang5, C. Chiang6, Shuwen Lin7
1- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
2- Division of Hematology and Oncology, Department of Medicine, University of Vermont Medical Center, Burlington, VT, USA
3- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
4- Department of Medicine, Danbury Hospital, Danbury, CT, USA
5- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
6- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
7- Department of Oncology, Montefiore Medical Center, Montefiore Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA
Background
ICIs have improved the survival outcomes in patients with breast cancer. Studies have showed that patients with a higher BMI may have a better response to ICIs. To date, the association between BMI and survival outcomes of patients with breast cancer who has received ICIs is unclear.
Methods
We conducted a retrospective, propensity score-matched cohort study using the TriNetX Analytics Network database. Patients were classified into overweight (BMI≥25 kg/m2) or non-overweight (BMI<25 kg/m2). The primary outcome was all-cause mortality within 1 year of the index date. We also performed a sensitivity analysis comprising patients who received chemotherapy only.
Results
We identified 1628 eligible patients, of whom 1163 had BMI≥25 kg/m2 and 465 had BMI<25 kg/m2. After propensity score matching, 410 patients in each cohort were well balanced for demographics, breast cancer-directed therapy, and underlying comorbidities. Over a median follow-up of 1 year, 28 and 53 patients died in the BMI≥25 kg/m2 and BMI<25 kg/m2 cohorts, respectively. Patients with BMI≥25 kg/m2 had a 49% lower risk of all-cause mortality compared with those with BMI<25 kg/m2 (Hazard ratio (HR), 0.51 [95% CI: 0.33-0.81]). In patients treated with chemotherapy, there were no differences in all-cause mortality(HR, 0.89 [95% CI: 0.72-1.10]).
Conclusions
A higher BMI (≥25 kg/m2) was associated with a lower all-cause mortality among patients with breast cancer receiving pembrolizumab.
Northern New England Clinical Oncology Society
P.O. Box 643
Sandown, NH 03873-0643
Telephone (603) 887-1948
info@nnecos.org
This website brought to you by:
