Alyssa G. Rieber

Genome-wide association study confirms lung cancer susceptibility loci on chromosomes 5p15 and 15q25 in an African-American population

OBJECTIVES Genome-wide association studies (GWAS) of lung cancer have identified regions of common genetic variation with lung cancer risk in Europeans who smoke and never-smoking Asian women. This study aimed to conduct a GWAS in African Americans, who have higher rates of lung cancer despite smoking fewer cigarettes per day when compared with Caucasians. This population provides a different genetic architecture based on underlying African ancestry allowing the identification of new regions and exploration of known regions for finer mapping. MATERIALS AND METHODS We genotyped 1,024,001 SNPs in 1737 cases and 3602 controls in stage 1, followed by a replication phase of 20 SNPs (p<1.51×10(-5)) in an independent set of 866 cases and 796 controls in stage 2. RESULTS AND CONCLUSION In the combined analysis, we confirmed two loci to be associated with lung cancer that achieved the threshold of genome-wide significance: 15q25.1 marked by rs2036527 (p=1.3×10(-9); OR=1.32; 95% CI=1.20-1.44) near CHRNA5, and 5p15.33 marked by rs2853677 (p=2.8×10(-9); OR=1.28; 95% CI=1.18-1.39) near TERT. The association with rs2853677 is driven by the adenocarcinoma subtype of lung cancer (p=1.3×10(-8); OR=1.37; 95% CI=1.23-1.54). No SNPs reached genome-wide significance for either of the main effect models examining smoking - cigarettes per day and current or former smoker. Our study was powered to identify strong risk loci for lung cancer in African Americans; we confirmed results previously reported in African Americans and other populations for two loci near plausible candidate genes, CHRNA5 and TERT, on 15q25.1 and 5p15.33 respectively, are associated with lung cancer. Additional work is required to map and understand the biological underpinnings of the strong association of these loci with lung cancer risk in African Americans.

Automated pain intervention for underserved minority women with breast cancer

Minority patients with breast cancer are at risk for undertreatment of cancer‐related pain. The authors evaluated the feasibility and efficacy of an automated pain intervention for improving pain and symptom management of underserved African American and Latina women with breast cancer.

Implementation of the edmonton symptom assessment systemfor symptom distress screening at a community cancer center: A pilot program

A better understanding of how the Edmonton Symptom Assessment System (ESAS) can be used for distress screening may facilitate its use to improve patient care. In 2015, the General Medical Oncology Outpatient Clinic at Lyndon B. Johnson Hospital implemented a pilot project with ESAS for distress screening. The impact of ESAS screening on access to psychosocial care before and after program implementation is reported here.

Feasibility and savings of a suspicion of cancer clinic at a large county hospital.

104 Background: The Lyndon B. Johnson General Hospital (LBJGH) is part of the Harris County Hospital District (HCHD), serving the third largest county in the United States. Many patients are admitted to the hospital for expedited workup when cancer is suspected to avoid outpatient delays. We sought to establish the main contributors to delays in cancer diagnosis and to calculate the potential savings, both in terms of time and expense, of an ambulatory Suspicion of Cancer Clinic. METHODS The charts of 327 consecutive new patients to the LBJGH medical oncology clinic between June 2011 and November 2011 were reviewed. Only patients whose cancer was diagnosed within HCHD (n=165) were included in the analysis. Dates of initial presentation, emergency department (ED) visits, abnormal imaging, admissions, diagnosis, and initial oncology visit were collected, along with the method of diagnosis. Additional chart review was performed to determine which admissions were solely for expedited work up based on the documentation provided. The project was approved by the MD Anderson Quality Improvement Assessment Board. RESULTS 60% of cancer diagnoses were made in the ambulatory setting, whereas 40% of patients were diagnosed inpatient. Breast cancer was the most frequent cancer diagnosis. The mean time from presentation to diagnosis in the inpatient setting was 3.9 days for breast cancer, 12.9 days for colon cancer, and 5.5 days for lung cancer. For patients diagnosed in the ambulatory setting, the times were 77.1 days, 65.4 days, and 70.8 days respectively. 15.6% of patients were admitted to the hospital for expedited work up, accounting for 130 hospital days. Based on the average costs in HCHD, elimination of hospitalizations and multiple ED visits using an ambulatory suspicion of cancer clinic could save more than

Complementary and Alternative Medicine Use in Minority and Medically Underserved Oncology Patients: Assessment and Implications

300,000 annually. CONCLUSIONS We propose a Suspicion of Cancer Clinic to expedite outpatient diagnostic workup, in collaboration with diagnostic imaging, surgical specialties, and pathology. The establishment of a Suspicion of Cancer Clinic could reduce ambulatory diagnostic times, decrease the frequency of admissions, and potentially improve patient outcomes. Piloting of this clinic is underway.

The β-HPV Subtypes—Cornerstone of the Next-Generation Vaccine

Introduction: Complementary and alternative medicine (CAM) use in minority and medically underserved oncology patients is not well documented. We assessed knowledge and utilization of CAM in a sample of these patients receiving treatment at an urban community hospital. Methods: Patients with cancer were interviewed using an electronic application that depicted specific CAM therapies. Patients were questioned on their knowledge and utilization of therapies, deterrents to use, and interest in using these therapies if they were made available. Results: Patients (n = 165) reported a high awareness and use of CAM therapies. CAM use was highest for prayer (85%), relaxation (54%), special diet (29%), meditation (19%), and massage (18%). Patients’ interest in using CAM was high for nearly all therapies. Lack of adequate knowledge and cost of use were reported as deterrents to use. Female patients reported higher use of aromatherapy relative to males (37.1% vs 19.4%, P = .02); those with higher education reported greater use of relaxation (60.8% vs 28.6%, P = .02); non-Hispanics reported higher use of relaxation relative to Hispanics (63.5% vs 44.2%, P = .03), and African American patients reported higher use of relaxation relative to White patients (69.2% vs 50%, P = .03). Conclusions: CAM use in minority and medically underserved cancer patients is common, but not professionally guided; thus, concerns remain regarding its safe use. Our data underscore the importance of patient-physician dialogue regarding CAM use in this patient population, and interest in access to the medically guided integration of evidence-based CAM therapies.

Reducing the Time From Diagnosis to Treatment of Patients With Stage II/III Rectal Cancer at a Large Public Hospital

On January 12, 2016, President Barack Obama, began his final year in office by announcing during his State of the Union Address to Congress a “moonshot” to cure cancer. During an era when physicians are called on for action to find a cure for cancer, we tend to forget that we have available at our disposal a human papillomavirus (HPV) vaccine that prevents multiple types of cancers. The first US president, George Washington, said “disorders are easier prevented than cured,” and that is how we today hope to prevent all HPV-related cancers. Human papillomavirus comprises a family of at least 125 viruses classified into 5 genera; α-HPV, β-HPV, γ-HPV, μ-HPV, and ν-HPV. The current vaccines provide coverage only against the sexually transmitted α-HPVs, essential etiological types in cervical, anal, penile, vaginal, vulvar, and some oropharyngeal cancers, but not against β-HPV types. The causal role of β-HPV in the development of cutaneous squamous cell carcinoma (cSCC) and oropharyngeal cancers (OPC) is established in immunocompromised patients. Growing evidence supports this association in the general population, as scientists clarify the β-HPV type-specific molecular pathways involved in oncogenesis and provide robust epidemiological evidence. Recently, published data by Agalliu et al and our group,1,2 highlighted the strong association of β-HPV types 5 and 38 with the development of OPC and cSCC in immunocompetent individuals. On January 27, 2016, the directors of 69 National Cancer Institute (NCI)-designated cancer centers in the United States recognized low rates of HPV vaccination as a public health problem and issued a call to action to improve vaccination rates. We believe that a nextgeneration vaccine is needed to improve uptake rates and broaden the coverage. Such an HPV vaccine protecting against β-HPV subtypes would offer children precise prevention without being type-restricted, to prevent cSCC and OPC as well. This Viewpoint highlights the major benefits and expected challenges of this nextgeneration HPV vaccine.

Abstract B78: Using the Quality in the Continuum of Cancer Care framework to develop a multilevel intervention to improve cancer screening and follow-up among the medically underserved

Curative-intent therapy for stage II/III rectal cancer is necessarily complex. Current guidelines by the National Comprehensive Cancer Network recommend preoperative concurrent chemoradiation followed by resection and additional adjuvant chemotherapy. We used standard quality improvement methodology to implement a cost-effective intervention that reduced the time from diagnosis to treatment of patients with stage II/III rectal cancer by approximately 30% in a large public hospital in Houston, Texas. Implementation of the program resulted in a reduction in time from pathologic diagnosis to treatment of 29% overall, from 62 to 44 days. These gains were cost neutral and resulted from improvements in scheduling and coordination of care alone. Our results suggest that: (1) quality improvement methodology can be successfully applied to multidisciplinary cancer care, (2) effective interventions can be cost neutral, and (3) effective strategies can overcome complexities such as having multiple sites of care, high staff turnover, and resource limitations.

Reducing the time from diagnosis to treatment of patients with stage II/III rectal cancer at a large county hospital.

Introduction: Screening for cervical, colorectal, and breast cancer is an evidence-based strategy to reduce the morbidity and mortality from these cancers. However a large proportion of medically underserved individuals do not obtain regular screening. Using the Quality in the Continuum of Cancer Care (QCCC) framework, we developed and implemented a comprehensive systems design intervention to improve the delivery, uptake, and follow-up of cervical, colorectal, and breast cancer screening within a network of healthcare institutions that serve the medically underserved in Harris County, Texas. Methods: An academic-community partnership, the Community Network for Cancer Prevention, was established between an academic cancer center, the county9s safety net healthcare system, and several academic and community-based healthcare institutions. Clinical advisory boards, comprised of physicians, nurses, and public health professionals, were established for each cancer line. The QCCC framework was used to identify system-level failures that impede processes and transitions in the continuum of care from risk assessment to detection and from detection to diagnosis. Project components were developed to address the identified failures. Results: System failures identified at the risk assessment to detection phases included 1) failure to identify individuals in need of screening, 2) inadequate capacity to screen, and 3) inadequate access to care. Failures identified at the detection to diagnosis phases included 1) failures in the screening test results notification system, 2) failures in inter-provider communication, 3) failures in inter-institutional referrals for clinical follow-up, 4) patient non-adherence, and 5) inadequate access to care. Project components to address the identified failures include community outreach, patient education, and patient navigation. Community outreach involves a community theater program aimed to increase awareness of cancer risk and the current cancer screening guidelines among medically underserved individuals in the larger community; healthcare access navigators available at each performance assist audience members in applying for healthcare coverage through the safety net healthcare system. Patient education involves using the electronic medical record to identify patients due or past due for cervical, colorectal, and/or breast cancer screening. These patients are then targeted for a video-based patient education intervention while they wait to be seen by their healthcare provider. Motivational messaging in the videos encourages patients to discuss the particular screening test with their provider. Finally, patient navigation involves a team of navigators who actively communicate with patients and providers to ensure follow-up among patients with an abnormal screening test result. A real-time tracking database is used to monitor all screen-test positive patients as they move through the different stages of diagnostic and therapeutic follow-up. Conclusion: The QCCC provides a systematic approach for assessing factors that influence cancer care processes at the risk assessment, screening, detection, and diagnosis phases, as well as transitions between them. Focusing on transitions between phases is particularly useful for developing systems-level interventions to improve the delivery, uptake, and follow-up of cancer screening. Citation Format: Jane R. Montealegre, Loretta Hanser, Maria Daheri, Roshanda Chenier, Ivan Valverde, Glori S. Chauca, Luis O. Rustveld, Matthew L. Anderson, Lois Ramondetta, Milena Gould-Suarez, Musher L. Benjamin, Larry D. Scott, Juli R. Nangia, Brian C. Reed, Janet Hoagland-Sorensen, Alyssa Rieber, Maria L. Jibaja-Weiss. Using the Quality in the Continuum of Cancer Care framework to develop a multilevel intervention to improve cancer screening and follow-up among the medically underserved. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B78.

Improving the care of acute lymphocytic leukemia (ALL) at a large county hospital.

141 Background: The treatment of stage II/III rectal cancer is complex and requires multidisciplinary collaboration. Delays in definitive treatment may increase morbidity and compromise outcomes. The goal was to reduce the time from pathologic diagnosis to initiation of treatment by 30% for patients with stage II/III rectal cancer at Lyndon B. Johnson General Hospital (LBJGH), which provides care to uninsured and underinsured patients in Harris County, TX. METHODS The charts of 32 patients with rectal cancer diagnosed between July 2012 and December 2013 were reviewed. Baseline data regarding diagnostic and treatment time points were collected. Potential areas for improvement were identified through analysis of the baseline data, affinity sorting, and fishbone diagrams. A multidisciplinary rectal cancer working group with all relevant administrative and subspecialty stakeholders was created to discuss potential interventions and implementation strategies. The project was approved by the MD Anderson Quality Improvement Assessment Board. RESULTS Twenty-four of the thirty-two patients reviewed had stage II/III rectal cancer and were eligible for multimodality therapy with curative intent. The median time from pathologic diagnosis to treatment initiation was 62 days. The referral process was identified as the greatest source of delays. The median times from diagnosis to medical oncology and radiation oncology referral were 15 and 32 days, respectively. The median time for eligibility verification and clinical review by Case Management was 13 days. CONCLUSIONS Based on these findings, two primary interventions have been instituted: (1) A synchronized referral process that will result in simultaneous consultation of all involved subspecialty services (surgery, medical oncology, and radiation oncology) was created for patients with rectal cancer; (2) Redundancy in the clinical review process was eliminated by coordination between Case Management and the Medical Oncology Chief Fellow. In tandem, these interventions are projected to reduce the time from diagnosis to treatment by approximately 50% (from 62 to 29 days).