Cancer survivorship challenges of rural older adults: a qualitative study

BACKGROUND

Although research has advanced the field of oncologic geriatrics with survivors to assess their cancer-related needs and devise patient-centered interventions, most of that research has excluded rural populations. This study aimed to understand the survivorship challenges and recommendations in the perspective of rural older adults.

METHODS

This was a qualitative study that explored the survivorship challenges and recommendations of rural older adults who have completed curative intent chemotherapy for a solid tumor malignancy in the 12 months prior to enrollment in the present study.

RESULTS

Twenty-seven older adult survivors from rural areas completed open-ended semi-structured interviews. The mean age was 73.4 (SD = 5.0). Most participants were non-Hispanic White (96.3%), female (59.3%), married (63.0%), and had up to a high school education (51.9%). Rural older survivors reported a general lack of awareness of survivorship care plans, communication challenges with healthcare team, transportation challenges, financial toxicity, psychological challenges, and diet and physical challenges. Rural older survivors recommend the provision of nutritional advice referral to exercise programs, and social support groups and for their healthcare providers to discuss their survivorship plan with them.

CONCLUSIONS

Although study participants reported similar survivorship challenges as urban older adult survivors, additional challenges reported regarding transportation and consideration of farm animals have not been previously reported. Heightened awareness of the survivorship needs of rural older adults may result in better survivorship care for this population.

Ipilimumab-Induced Neutropenia in Melanoma

Ipilimumab is a human monoclonal IgG1 antibody against CTLA-4 that has been shown to prolong the overall survival of advanced melanoma. The most common adverse events associated with ipilimumab are immune-related. Severe hematological toxicity is rare. We report a case of severe neutropenia following ipilimumab therapy that fully resolved after the administration of prednisone, cyclosporine, and anti-thymocyte globulin therapies.

High-dose therapy and autologous stem cell transplant for transformed non-Hodgkin lymphoma in the rituximab era

The impact of rituximab on the outcome of high-dose therapy and autologous stem cell transplant (HD-ASCT) for transformed non-Hodgkin lymphoma (NHL) has not been previously described. We analyzed 18 consecutive patients with indolent NHL who transformed to diffuse large B-cell lymphoma (DLBCL), received rituximab-containing therapy either before or after transformation and underwent subsequent HD-ASCT. With a median follow-up of 40 months, the 2-year progression-free survival (PFS) was 59% and the 2-year overall survival (OS) was 82%. Six patients did not receive rituximab pre-transformation. This group had a significantly better PFS at 2 years post-HD-ASCT compared to 12 patients who were exposed to rituximab pre-transformation (p = 0.03). HD-ASCT remains an effective therapeutic option for transformed NHL in the rituximab era. However, patients exposed to rituximab pre-transformation appear to have inferior HD-ASCT outcomes, and thus may benefit from novel conditioning and maintenance regimens in the setting of HD-ASCT.

Heparin induced thrombocytopenia and thrombosis in a tertiary care hospital

Heparin-induced thrombocytopenia (HIT) results from development of an antibody to a complex of heparin and platelet factor 4 (PF4) resulting in thrombocytopenia and a prothrombotic state with serious clinical consequences. The diagnosis depends on a combination of both the clinical presentation and laboratory detection of an appropriate antibody.

OBJECTIVE

To determine the frequency, clinical characteristics and laboratory correlates of HIT in a tertiary care hospital.

METHODS

A retrospective review of all case of HIT over a thirty month period in a tertiary care hospital was conducted.

RESULTS

HIT was diagnosed in 136 patients including 114/28,091 (0.48%) of those receiving only unfractionated heparin, 22/6,559 (0.33%) of those that received both unfractionated and low-molecular-weight heparin (LMWH) and in 2/2498 (0.08%) of those receiving only LMWH (P=0.02 compared to those receiving only unfractionated heparin). HIT occurred in 62/16,939 patients (0.39%) of patients receiving subcutaneous (SC) heparin or LMWH compared to 69/11,152 (0.62%) of patients receiving intravenous (IV) therapy (P=0.003). Of all patients with exposure to heparin products, 41/34,650 (0.1%) developed symptomatic thrombosis. The optical density (OD) of the ELISA was significantly higher in patients with HIT and thrombosis (1.2 +/- 0.8) compared to those without thrombosis (0.9 +/- 0.6, P=0.03).

CONCLUSION

HIT develops in approximately 0.4% of all patients exposed to heparin at a tertiary care hospital but is significantly less frequent in those treated with LMWH only than in those who receive unfractionated heparin. A higher antibody titer is associated with the development of thrombosis. The occurrence of HIT could be decreased by reducing exposure to unfractionated heparin, and the diagnosis could be improved by reporting the OD of the ELISA test result.

Diffuse large B cell lymphoma presenting as a cardiac mass and odynophagia

Cardiac involvement as an initial presentation of malignant lymphoma is a rare occurrence. We describe the case of a 77-year-old man who had initially been diagnosed with a left atrial mass on an echocardiogram, presenting with progressive dyspnea, dysphagia, odynophagia and fevers. The cardiac mass had been managed as an outpatient with full anticoagulation for the suspicion of clot. On admission, cardiac magnetic resonance imaging revealed a large mediastinal mass invading the left atrium that originated from the oesophagus. A barium oesophagram revealed an apple core lesion involving the distal third of the oesophagus. A subsequent computed tomography scan demonstrated a large mediastinal soft tissue mass and paratracheal lymphadenopathy. A flexible upper endoscopy revealed an oesophageal mass that was approximately 10 cm in length, irregular at the margins, and with a very necrotic appearance. This was biopsied, revealing findings consistent with high grade diffuse large B cell lymphoma. This case illustrates lymphoma presenting with dyspnea, odynophagia and a left atrial mass. To our knowledge, there are no reported cases of diffuse large B cell lymphoma presenting as odynophagia and a cardiac mass.