Oncology practice changes during a multistep Oncology Care Model practice transformation project

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Background: Treatment of lung cancer has seen a paradigm shift in recent years. While the availability of newer treatment options such as targeted therapy and immunotherapy have provided new hope for better outcomes, this has added to the cost of care. Participation in the Center for Medicare Services’ Oncology Care Model (OCM) provides opportunities for oncology practices to identify practice transformation (PT) change strategies that result in improved quality of care (QOL) and cost savings. Methods: A lung cancer PT team convened to facilitate changes that improve patient outcomes and decrease costs at an OCM organization. The year-long project included clinical treatment updates, quantitative and qualitative assessments, and data sharing. Practice changes focused on biomarker driven treatment selection, nurse navigation to better manage symptoms and decrease emergency department (ED) visits and hospitalizations, and earlier advanced care planning (ACP) discussions. Surveys were completed by oncology physicians and nurse practitioners at baseline (n = 9) and end of the project (n = 7). Results: After education, there were more correct responses in 3 of 6 knowledge questions and providers noted less concern about performance status or co-morbidities when prescribing immunotherapy. Providers noted fewer barriers with biomarker documentation; self-reported confidence in 4 questions of biomarker selection was unchanged. Providers reported increased participation of nurse navigators to impact ED visits and hospitalizations over time. Documentation of ACP discussions increased, 42% (8/19) to 56% (13/23), but did not reach statistical significance due to sample size. Although providers reported changes toward earlier ACP discussions, 1 in 3 still wait until performance status declines to initiate discussion. Conclusions: Systematic PT can improve quality of patients care and measures used in value-based care reimbursement models. Providers need ongoing education, practice feedback, and organizational support to effect positive practice changes. In addition, new strategies to increase provider ability to initiate end of life discussions need to be explored.

A practice transformation model to improve lung cancer care

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Background: Lung cancer has the highest cause of cancer death, treatment of which is both complicated and expensive. Emerging actionable biomarkers and treatments provide both opportunity and treatment challenges. Adherence to evidence-based treatment and advanced care discussions add value to care. Oncology practices need to document the above to participate in value-based care reimbursement models. A Practice Transformation (PT) model was implemented to address quality and cost issues. Methods: After IRB approval, baseline data on lung cancer patients diagnosed during a 6-month period (Jul-Dec 2017) were collected through chart abstraction and treatment planning surveys. Rates of molecular testing ordered, results available at time of treatment decision-making, guideline concordant treatment decisions, and documentation of advanced care discussions were presented to the PT team. After education on recent clinical trial results and NCCN treatment guidelines, the PT team determined strategies for change. The PT team met after two 3-month periods of PT for education updates and progress reports. Data was compared on newly diagnosed patients during a 6-month period (Jul-Dec 2018), one year after the baseline period. Results: A total of forty-two patients were diagnosed in two 6-month periods, baseline and study period. Average age was 65 years, 57% male, 71% Caucasian, 95% ever smokers, 71% adenocarcinoma histology. Rate of ordering any molecular testing was (16/19) 84% in the baseline period vs (20/23) 86% in the study period. However, extended molecular testing increased from 16% (3/19) to 60% (12/20), p = .05 Fishers exact test. At treatment initiation, evidence-based treatment selections went from 47% to 52%. Documentation of advanced care discussions, 42% (8/19) to 56% (13/23), did not change significantly. Conclusions: A PT model that included education, and two cycles of implementation and feedback, resulted in increased molecular testing to inform evidence-based treatment selections. Increased awareness of the lack of documentation of advanced care discussions provides opportunity for continued improvement to effect quality care.

Tumor mutation burden to predict progression in high-risk non-muscle invasive bladder cancer

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Background: The genetic mechanisms associated with progression of high-risk non-muscle-invasive bladder cancer (HR-NMIBC) have not been described. We conducted next-generation sequencing (NGS) of HR-NMIBC and compared the genomic profiles of cancers that responded to intravesical therapy and those that progressed to muscle-invasive or advanced disease. Methods: DNA was extracted from formalin-fixed paraffin-embedded sections of tumor from 25 patients with HR-NMIBC (23 with T1HG; 3 with TaHG and carcinoma in situ). Ten patients with HR-NMIBC developed progression (pT2+ or N+) (“progressors”). Fifteen patients had no progression (“non-progressors”). Tissue from 11 patients with metastatic bladder cancer (BC) were analyzed for comparison. Results: We identified no difference in the frequency of mutations of TP53, PIK3CA, or KMT2D between the primary tumors of progressors compared to non-progressors and metastatic tumors. An increased frequency of mutations and deletions causing loss of function of CDKN2A and CDKN2B was identified in tumors at progression (37%) compared to non-progressors (6%) (p=0.10). We found a significant decrease in total mutational burden (TMB) comparing non-progressors, progressors and metastatic tumors at 15, 10.1 and 5.1 mutations/MB respectively (p=0.02). This association suggests more advanced tumors have decreased neoantigen burden and may potentially explain the mechanism of BCG response in non-progressors. Conclusions: TMB was significantly greater in non-progressors compared to progressors. We found no novel genetic drivers in tumors that progressed and HR-NMIBC had many genetic features similar to metastatic BC. The loss of CDKN2A appears to occur late in the process of invasion of BC and may represent an important step in progression. Further research is necessary to evaluate loss of CDKN2A as a biomarker for progression of NMIBC.

Single-center early experience of optical coherence tomography (OCT) for evaluation of high-grade dysplasia or early cancer in Barrett's esophagus

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Background: Barrett’s esophagus is a well-known risk factor for esophageal cancer. Surveillance esophagogastroduodenoscopy (EGD) and procedures like endoscopic mucosal resection (EMR) and radio frequency ablation (RFA) are adopted to mitigate risk of evolution to high grade dysplasia and cancer. Newer imaging modalities are expected to improve diagnostic accuracy and guide management. Here we describe our early experience with optical coherence tomography (OCT) which is an near infra-red light imaging technique for diagnosing high grade dysplasia and early stage cancer in patients with Barrett’s esophagus. Methods: Patients who underwent EGD and diagnosed with Barrett’s esophagus and endoscopic features worrisome for high grade dysplasia or early cancer were selected for the procedure. Patients underwent OCT for further characterizations of these lesions. Clinical and endoscopic findings, imaging studies and OCT findings were recorded and analyzed. Results: 5 patients were studied in this early series and details are tabulated below. (OCT images will accompany final presentation.) Conclusions: Early detection of high grade lesions and early cancer with image directed therapy in Barrett’s esophagus may positively impact survival. Our early experience suggests OCT is helpful in detecting cryptic dysplastic changes, especially in the aftermath of previous ablation and can guide additional endoscopic treatment. Further studies are necessary to determine efficacy of such an approach. [Table: see text]

Outcomes of neoadjuvant chemotherapy with FOLFOX/FOLFIRINOX and chemoradiotherapy in borderline resectable pancreatic cancer: Single-institution experience

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Background: The clinical benefit of neoadjuvant treatment in locally advanced pancreatic adenocarcinoma (borderline/unresectable) has not been well established. However, the challenge of managing locally advanced pancreatic adenocarcinoma has led to the incorporation of neoadjuvant treatment into clinical practice. FOLFIRINOX has been increasingly used as neoadjuvant chemotherapy, but may not be well tolerated especially in older patients due to adverse effect profile. In our institution, we have used FOLFOX as an alternative for older patients and patients with poor performance status based on our retrospective observation of FOLFOX in metastatic/advanced pancreatic adenocarcinoma. Methods: We conducted a retrospective analysis of locally advanced pancreatic cancer patients from January 1, 2011 to February 28, 2013 treated with neoadjuvant chemotherapy (FOLFOX/FOLFIRINOX) with the intention of future resection. In addition patients also received neoadjuvant chemo-radiotherapy. Imaging studies, operative notes and Pathology reports were reviewed. Results: 27 patients were analyzed, 10 received FOLFIRINOX and 17 received FOLFOX regimen. Mean age of patients were 57.28 ± 11.68 SD and 68.66± 11.21 SD in the two groups respectively. Patients received 4.2 ± 0.92 SD and 3.59 ±1.06 SD cycles of chemotherapy in FOLFIRINOX and FOLFOX groups respectively. Mean duration of follow up was similar in both groups. 5 patients on FOLFOX and 1 patient on FOLFIRINOX had disease progression thereby precluding surgery. The Rate of R0 resections was 64.7 % and 60% (P 0.27) in the two groups respectively. Overall survival was not statistically significant between the two groups. (Kaplan Meier survival graphs will accompany final presentation). Conclusions: In our study, FOLFIRINOX was administered in younger patients. However the R0 resection rates were similar in both the groups. FOLFOX may be acceptable neoadjuvant chemotherapy of choice in patients with borderline functional status. Randomized trials are needed to define this better.

Cataract surgery in camp patients: a study on visual outcomes

AIM

To assess the complications and visual outcomes associated with cataract surgery in camp patients operated at a tertiary centre.

MATERIALS AND METHODS

In a retrospective study, 206 outreach camp patients had undergone cataract surgeries with posterior chamber intraocular lens implantation under peribulbar anesthesia over a period of 6 months. Post-operative complications on Day 1 were graded as per Oxford Cataract Treatment and Evaluation Team (OCTET) definitions. One month postoperative complications, best corrected visual acuity and refractive errors were assessed.

RESULTS

206 eyes underwent cataract extraction with PCIOL implantation. Small incision cataract surgery (SICS) was the commonest method (78.6%) used. The most common first post-operative day complication was mild iridocyclitis (26.2%). The complications were based on OCTET definitions, and showed that 33 % had Grade I and 3.4 % had Grade II complications. The major post-operative complication after 4 weeks of surgery was posterior capsular opacity. 89.8 % of the eyes had a 4 week-post-operative best corrected visual acuity of e± 6/24. The commonest refractive error was myopia with against the rule astigmatism, seen in 86 out of 150 cases.

CONCLUSION

High quality cataract surgery with a low rate of intra-operative complications and good visual outcome can be attained in camp patients operated in the base hospitals, thus justifying more similar screening camps to clear the vast cataract backlog.

Microbial degradation of mefenoxam in rhizosphere of Zinnia angustifolia

The fate of the fungicide mefenoxam was studied in a containerized rhizosphere system. The rhizosphere system used Zinnia angustifolia (Tropic Snow) in a bark/sand potting mix and was compared to bulk potting mix (no plants). Rhizosphere microbial populations were allowed to establish for 3 weeks prior to fungicide addition (20 microg per g mix). Mefenoxam and degradation product concentrations were determined by High HPLC or capillary electrophoresis after extraction. Seventy eight percent of the fungicide originally applied to the rhizosphere was degraded after 21 days compared to 44% in bulk system (no plant). The primary degradation product was the free acid N-(2,6-dimethylphenyl)-N-(methoxyacetyl)-DL-alanine, which accounted for 71% of the applied parent chemical after 30 days. N-(2,6-dimethylphenyl)-acetamide was also detected, but in lesser amounts. Bacterial populations in the rhizosphere increased during the 30-day period, which correlated with an increase in degradation of the parent compound. Pure cultures of Pseudomonas fluorescens and Chrysobacterium indologenes isolated from the rhizosphere system could degrade the applied fungicide (10 microg/ml) almost completely to the free acid within 54 h.

Restoration of phytanic acid oxidation in Refsum disease fibroblasts from patients with mutations in the phytanoyl-CoA hydroxylase gene

Refsum disease (RD) is biochemically characterized by the excessive accumulation of phytanic acid in tissues and body fluids due to deficiency of phytanoyl-CoA hydroxylase (PAHX). In this study, we screened three RD patients and identified a novel deletion (88 amino acids), and a missense mutation (Arg275Trp) in the previously reported PAHX cDNA (Jansen et al., 1997; Mihalik et al., 1997). Moreover, transfection of skin fibroblasts from two RD patients with wild-type PAHX gene restored the activity for alpha-oxidation of phytanic acid. Southern analysis on a somatic cell hybrid panel detected the PAHX gene on chromosome 10, corroborating radiation hybrid and homozygosity mapping data (Mihalik et al., 1997; Nadal et al., 1995).

Fetal cerebrohepatorenal (Zellweger) syndrome: dysmorphic, radiologic, biochemical, and pathologic findings in four affected fetuses

Four fetuses with positive family histories for cerebrohepatorenal (Zellweger) syndrome (CHRS) underwent diagnostic amniocentesis or chorionic villus biopsy. Cultured amniocytes or fibroblasts from all of the fetuses displayed abnormal fatty acid ratios, and the parents elected therapeutic abortions. Dysmorphic features in one fetus consisted of micrognathia, proximal implantation of toes, and bilateral talipes equinovarus. Radiologic examination of the fetus confirmed the dysmorphic features and revealed foci of mineralization in the patellae. Biochemical analysis of three of the fetuses demonstrated markedly increased levels of very-long-chain fatty acids, both saturated and monounsaturated, in liver, kidney, adrenal, and brain. Pathologic findings consisted of premature mineralization of patellae; renal cystic tubular dilations; striated cells in adrenal fetal zone and testicular interstitium; dysplastic alterations of inferior olivary nuclei, dentate nuclei, and cerebral cortex; equivocal increases in portal fibrous tissue; and abnormal cytosomes in fetal zone adrenocortical cells, testicular and renal interstitial cells, and brain macrophages. Iron deposition, probably physiologic, was observed only in liver tissue. Distributions of immunoreactive catalase were identical in the fetuses with CHRS and age-matched control subjects. These findings document the accuracy of the prenatal diagnostic test and provide insights into the morphogenesis and pathogenesis of CHRS.