Leukemia in hospitalized patients with inflammatory bowel disease: An analysis of the National Inpatient Sample (NIS) database

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Background: Inflammatory bowel disease (IBD) and use of immunosuppressive therapy in IBD is linked with increased risk of leukemia. We studied the NIS database from 2003-2017 to analyze trends in any type of leukemia in IBD hospitalizations over time and examined the role of age, sex, and race. Methods: We analyzed NIS data of all adult hospitalizations for ulcerative colitis (UC) or Crohn’s disease (CD) with any type of leukemia as a primary or secondary diagnosis using validated ICD 9/10 codes. Age, sex, and racial demographics were collected. Trend analysis of leukemia was performed with Cochran-Armitage and Jonckheere-Terpstra tests. Results: Overall Trends: From 2003-2017, a total of 11,385 of 2,235,413 (0.51%) CD hospitalizations and 8,105 of 1,324,746 (0.61%) UC hospitalizations contained diagnosis of leukemia. An increase in leukemia was seen in both CD and UC group from 0.24% to 0.79% (pTrend < 0.0001) and 0.28% to 0.81% (pTrend < 0.0001) respectively. Sex: In both UC and CD patients, leukemia diagnoses were predominantly male in 2003 but approximated a near 1:1 ratio by 2017 (Table). In CD, the proportion of female (FEM) leukemia diagnoses grew from 31.33% to 45.05% from 2003 to 2017 (pTrend = 0.1898). In UC, the proportion of female leukemia diagnoses grew from 27.49% to 45.79% from 2003 to 2017 (pTrend = 0.0030). Age: Leukemia was more common with increasing age, with no significant changes in proportion of cases between age groups over time (pTrend >.05). Ethnicity: White patients composed 87.80% and 84.24% of leukemia diagnoses in CD and UC, respectively. In CD, an increasing proportion of leukemia diagnoses occurred in black (BK) patients, and a decreasing proportion occurred in white patients (pTrends <.0001; Table 1) during the study time. No trends in race were observed in the UC group (pTrend = 0.4229). Conclusions: Our study showed an increased prevalence of leukemia in CD and UC hospitalizations from 2003-2017 which may be related to increasing use of immunosuppressants such as anti-TNF medications. In both CD and UC, leukemia was male-predominant, but increasingly female by 2017. Rate of leukemia diagnosis increased with age. In the CD group but not the UC group, leukemia was increasingly prevalent in black patients.[Table: see text]

Oncology fellows’ survivorship clinic: An opportunity for education and multidisciplinary care delivery

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Background: Cancer survivors in the U.S. are expected to exceed 20 million by 2026. Most fellows do not receive formal training in survivorship during oncology fellowship despite cancer survivorship comprising 2% of the American Board of Internal Medicine's Oncology examination and the recent accreditation standards related to survivorship care from the Commission on Cancer. Methods: We developed a survivorship curriculum and a multidisciplinary survivorship clinic staffed by a medical oncologist and physiatrist in September 2018. Oncology fellows rotated during their ambulatory block and completed surveys assessing skills and perceptions of competence at the beginning and end of the academic year. Results: 8 fellows completed the pre-survey and 6 of them completed the post-survey. While only a quarter had delivered a survivorship care plan/treatment summary prior to starting clinic, all fellows had delivered these (median=2, range=2-8) at the end of the year. Most fellows had seen survivors of breast, colorectal and hematologic malignancies prior to starting clinic; few had seen survivors with lung (12.5%), GU (0%) or head and neck (25%) cancer. These numbers increased, particularly with fellows’ seeing survivors of GU (50%) and head and neck cancers (100%) at the end of the year. Prior to the rotation less than half the fellows had assisted with managing cancer survivors’ treatment consequences or provided continuity of care through a multidisciplinary team. Similarly, only 25% had counseled cancer survivors with psychosocial concerns. On the post-survey, 100% of fellows reported practicing and feeling experienced in these domains. Post- survey showed improvement in self-reported competence levels in caring for cancer survivors (see Table). Conclusions: Participating in a survivorship clinic has a positive impact on oncology fellows’ experience and competence in caring for cancer survivors. Future directions are geared toward expansion of fellows’ skills to include areas related to cardiovascular and physical medicine. [Table: see text]

Scalp cooling to prevent chemotherapy induced alopecia (CIA) in black patients: Differences in efficacy?

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Background: The Paxman scalp cooling device has been used for over 20 years to prevent CIA, obtaining FDA clearance in the U.S. in 2017. Prior studies reported 50-80% success and high patient satisfaction yet included few or no black patients. In the U.S. this may reflect disparities in access due to cost, awareness, or availability. We opened a prospective observational study combining patient-reported outcomes with clinical assessments of alopecia and planned to deliver scalp cooling to 30 black patients receiving chemotherapy for breast cancer. Methods: Patients who self-identified racially as black, had a new diagnosis of stage I-III breast cancer, and planned to receive chemotherapy with taxane-containing regimens were eligible. Anthracycline (AC) and non-anthracycline (NAC) chemotherapy agents were included; costs for the intervention were covered by Paxman and internal philanthropic funding. Patients who declined scalp cooling were approached for enrollment as controls. Primary endpoints were grade of alopecia as measured by providers and patient self-report using Modified Dean Scale and Visual Analog Scale (VAS) respectively. Hair preservation was defined as <50% hair loss (<grade 2) by Dean and score < 50 on VAS. Secondary endpoints were alopecia by NCI grading scale and psychosocial from CADS and EORTC QLQ BR45 questionnaires. Results: 15 out of 30 planned participants enrolled by February 2020 with interim analysis and hold in accrual due to lack of efficacy. Four patients remain on treatment. Of 11 scalp cooling patients who completed chemotherapy, 0 prevented significant alopecia. Nine discontinued use of scalp cooling before completion (1 due to scheduling, 8 due to >grade 3 alopecia). The 2 patients who used scalp cooling for the duration had >grade 3 alopecia before the last cycle of treatment. Conclusions: Scalp cooling is an important supportive therapy that can reduce chance of alopecia, a bothersome side effect for patients. Our experience indicates decreased efficacy in black patients with both AC and NAC regimens. This is an important negative result to explore. Discussions with the Paxman team and providers with expertise in alopecia are underway to explore contributing factors such as hair thickness, prior hair treatments, and cap design. [Table: see text]

Associations between patient-reported outcomes and physiatry assessments in an integrative model of a survivorship clinic

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Background: The Institute of Medicine and Commission on Cancer recommends delivery of comprehensive survivorship care to all cancer survivors. While models exist for high-quality survivorship care, institutions encounter barriers such as lack of resources and training in cancer survivorship. We introduce a shared-care model with physical medicine and rehab (PM&R) to provide comprehensive care to cancer survivors at MedStar Washington Hospital Center. Methods: We implemented a bimonthly survivorship clinic in September 2018, staffed by a medical oncologist, oncology fellow and a cancer rehabilitation fellow. We assessed patient reported outcomes through PROMIS short forms for physical functioning, companionship, satisfaction with social roles and depression. Physiatry assessments included the 6-minute walk test and the Timed Up and Go test. All patients received a treatment summary and survivorship care plan. Results: We evaluated 30 cancer survivors between Sept 2018 and December 2019; mean age was 55.6 years (SD = 10.6 years). Majority were female (60%) and Black (60%). Most patients were overweight or obese (93%) with a mean body mass index of 30.6 mg/m2 (SD = 4.7). Breast (43%) and hematologic malignancy (33%) were the most common cancer diagnoses. The median time between cancer remission and the clinic visit was 16 months (Range = 1 to 65 months). The average score for Timed Up and Go test was within the reference normal value of < 12 sec (8.22 seconds, n = 23). Average distance for the 6-minute walk test was 465.87 meters (n = 18). Survivor age was negatively correlated with the distance walked for the 6-min walk test (r = -0.51, p = 0.027). Better psychosocial functioning assessed with PROMIS were significantly associated with lower scores on the Timed Up and Go Test: satisfaction with social roles (r = -0.67, p = 0.033) and companionship (r = -0.64, p = 0.046); we identified a trend between Timed Up and Go scores and depression (r = 0.47, p = 0.099). Conclusions: An integrative survivorship clinic to provide multidisciplinary survivorship care is a feasible model and results suggest that patients’ physical functioning is significantly associated with psychosocial outcomes. Our approach highlights the importance of assessing both physical functioning and patient-reported outcomes. Future research can evaluate assessments of these outcomes over time.

Innovation, education, and research: A multidisciplinary survivorship care model

10519

Background: Advances in early detection, therapeutics, and an aging population are expected to lead to an increase in the number of cancer survivors in the United States to 20 million by year 2026. The Institute of Medicine and Commission on Cancer recommends delivery of survivorship care plans on completion of curative treatment. While models exist for high-quality survivorship care, institutions encounter barriers such as lack of resources and limited training in survivorship. Our institution piloted a unique model combining fellows’ education with guideline-driven recommendations from a multidisciplinary team to provide consolidated survivorship care. Methods: A survey for self-reported competence and experience was conducted amongst the hematology and oncology fellows at the MedStar Washington Hospital Center. A bimonthly clinic staffed by a medical oncologist, oncology fellow and a cancer rehabilitation fellow was initiated in September 2018. Didactic lectures, curriculum syllabus and recommended assessments were established. Screening tools for distress, patients’ confidence in knowledge about survivorship and physical function via PROMIS 20a were administered; clinical assessments including the “6-minute walk test” were used to assess cardiovascular health. Results: Most fellows had not encountered a survivor of lung (16%), GU (0%) and head and neck cancer (33%). Majority of the fellows had never delivered a survivorship care plan. Scores were low in competence and experience in survivorship. By December 2018, 15 patients with 17 diagnoses of cancer were referred to the clinic. 10 were survivors of hematologic malignancies while 7 were of solid tumors. The no-show rate was 40%. Fellows conducted the assessments and were supervised by an oncology attending. Of the 9 patients seen, 4 were referred for physical therapy; additional referrals for psychology and cardiology were frequent. Conclusions: A comprehensive multidisciplinary survivorship clinic focusing on fellows’ education is a feasible model for delivery of survivorship care and aims to bridge the gap in experience and competence of fellows. Future goals include re-assessment of patient-reported outcomes, physical function, and competence of fellows.

Weight change after (neo)adjuvant chemotherapy in a cohort of breast cancer survivors: Trends by race, hormone positivity, and chemotherapy regimen

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Background: It is estimated that over 50% of breast cancer survivors gain weight during treatment; patients receiving chemotherapy are at higher risk for weight gain. Previous studies have reported limited information about weight gain with current chemotherapy regimens. Methods: Individual data were collected from a cohort of 98 breast cancer patients treated with neoadjuvant or adjuvant chemotherapy between 2015 and 2017 at Lombardi Comprehensive Cancer Center. Weight was recorded from baseline visits and ≥ 1 visit following completion of chemotherapy. Regimens were grouped into anthracycline- (AC) and non-anthracycline-based (NAC) chemotherapy. Results: Overall, 49% ( n = 48) of patients gained weight after chemotherapy, though African-American patients demonstrated higher baseline BMI. Patients with ER-positive cancers displayed greater weight gain than hormone-negative counterparts ( p = 0.04); PR- or HER2-status was not associated statistically significant changes in weight ( p = 0.12 and 0.82, respectively). Among patients who did gain weight, NAC was associated with greater weight gain (4.47kg) than AC-based regimens (2.54kg) ( p = 0.03). Conclusions: ER positivity and NAC may serve as independent predictors of weight gain during chemotherapy. Further studies might consider further analyzing these trends to demonstrate additional long-term patterns. Baseline and After Chemotherapy BMI (kg/m2) and Weight Change (kilograms and percentage change) (P* derived from ANOVA). [Table: see text]

Survivorship care: Improving delivery of care plans for hematology patients at the Washington Cancer Institute (WCI)

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Background: Cancer and long-term sequalae of its treatment impact the future health and psychosocial wellness of these survivors. ASCO guidelines recommend providing survivorship care to cancer patients who have completed treatment with curative intent. The Commission on Cancer (COC) recommends that survivorship care including treatment summaries be delivered to 50% of eligible patients. In our ASCO Quality Training Program project, we aimed to achieve this COC goal of 50% for the year 2018. Methods: Baseline data collected from Jan 1, 2016 to June 30, 2018 indicated that 33% of hematologic malignancy survivors at WCI received treatment summaries and survivorship care. For the year 2018, there were 11 survivors of hematologic malignancy, and 4 of them (36%) had received survivorship care prior to initiation of the project. We surveyed 12 providers to obtain data for perceived challenges to deliver survivorship care. Large volume of patients, lack of resources, no standardized process and high no-show rates were identified as the most important barriers. A bi-monthly survivorship clinic run by hematology/oncology fellows was initiated in September 2018 to address some of these barriers. Patient referral forms were mounted in the clinic work rooms to assist providers with identifying patients that qualify for survivorship; a pathway for referrals to the survivorship clinic was created and providers were informed about the clinic. Information flyers regarding survivorship care and the clinic were placed in the waiting room to increase awareness amongst patients. Results: By November 30, 2018, 63% of hematological cancer survivors received survivorship care and treatment summaries. Compared to the average from the preceding two years, survivorship care delivery increased by 30%. Conclusions: Our institution was able to meet the COC requirement by delivering survivorship care to 63% of survivors of hematological malignancies through the intervention from this quality improvement study. We intend to extend this process to other tumor types to increase the delivery of consolidated survivorship care at the WCI.

Integrative therapies for symptom management in cancer survivors: Assessment of an on-site integrative medicine (IM) program

142

Background: Up to 89% of oncology patients utilize integrative therapies with reported improvements in quality of life. However, less than half of patients report IM use to providers, potentially impeding optimal care. In September 2016, MedStar Montgomery Medical Center (MMMC), part of the MedStar Georgetown Cancer Network, opened the Center for Integrative Medicine (CIM) with support from MedStar’s Institute for Innovation (MI2). This clinical program offers IM consultation, acupuncture, mindfulness, psychology services, nutrition, and reiki. The purpose of this analysis is to examine oncology patient utilization of the CIM. Methods: Medical records of 174 patients seen September 2016 - October 2017 were reviewed, and 39 patients with a cancer diagnosis identified. Data regarding chief complaints, treatments, number of visits, and outcomes were analyzed. Results: 39 (22%) of 174 patients had a cancer diagnosis. After initial consultation, 29 of these patients received IM treatment; 14 returned for ≥5 treatments. Most common chief complaints were pain, stress/anxiety, fatigue, insomnia, and arthralgias (Table 1). The majority of CIM’s oncology patients was female and referred from in-network clinicians. The CIM referred 7 patients to other medical providers for unexpected medical issues and 2 required same-day appointments arranged by the CIM. Conclusions: These data illustrate oncology patients’ utilization and benefit of IM services within a hospital network. Communication between IM and referring providers may address unexpected clinical situations, potentially avoiding care delays and facilitating transparency with the use of IM services. Unpleasant symptom treatment may improve therapy adherence and quality of life. This review illustrates feasibility for an on-site CIM and the benefit to cancer survivors when IM services are offered collaboratively.[Table: see text]

Loss of nuclear p27KIP1 (p27) expression as a predictor of lymph node spread in T1 breast cancer

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Background: We originally reported that p27 loss in T1a/b breast carcinomas was associated with lack of estrogen and progesterone (ER/PR) hormone receptors, but not in T1c node negative tumors (Mirchandani et al, Anticancer Research 2011). The current study explored the association of p27 expression with lymph node (N) status. Methods: 217 consecutive patients with T1 tumors were identified from 2001-2003. All patients underwent sentinel node biopsy (and complete lymphadenectomy when positive on frozen section): 111 were N0 and 106 were N+. Immunohistochemistry was performed for ER/PR, Her2, and nuclear p27 (low vs normal) and tumors were graded (well, moderate, and poorly differentiated). Analysis was conducted to define associations between standard variables and p27 expression among node positive and node negative tumor carriers (Table). Results: Low p27 expression was found in 21% of N0 and 36% of N+ T1 breast cancer patients (Chi-square=6.14, p-value=0.01). However from a series of multivariable analyses, only tumor size was significantly associated with node positivity. Conclusions: Poorly differentiated tumors, T1c tumors, and low p27 expression were associated with lymph node positivity, but only tumor size was significant in multivariable analysis. Contrary to our prior report, the relationship between low p27 and ER/PR- is strongest in the T1c subset (data not shown). Future studies will expand study cohorts to explore whether low p27 expression is a biomarker of poor outcome at 10 years in patients with T1 tumors treated with antiestrogens. [Table: see text]