Brendan F. Curley

Limited Utility of Surveillance Imaging for Detecting Disease Relapse in Patients With Non-Hodgkin Lymphoma in First Complete Remission

INTRODUCTION Surveillance imaging with computed tomography (CT) or positron emission tomography with CT (PET/CT) is commonly used in practice in patients with non-Hodgkin lymphoma (NHL) who are in remission after front-line therapies. We aimed to determine the utility of routine imaging for detecting first relapse in patients with NHL in complete remission (CR) after first-line therapies. PATIENTS AND METHODS We retrospectively analyzed patients with NHL who achieved CR after first-line therapies and then subsequently had disease relapse. We evaluated whether the relapse was detected solely by surveillance CT or PET/CT or by patient-reported symptoms or physical examination findings, or both. Subgroup analysis was performed on baseline histologic type (indolent vs. aggressive NHL). Data were also collected to determine the cost of surveillance PET/CT and the number of additional diagnostic imaging procedures, invasive procedures, and iatrogenic complications directly resulting from an abnormality detected on a surveillance scan. RESULTS One hundred sixty-three patients with first relapse of NHL between January 1, 2000 and December 31, 2010 were included. The majority of the relapses were detected by patient-reported symptoms or physical examination, or both, as opposed to surveillance imaging (77.9% [n = 127] vs. 22.1% [n = 36]; P < .0001). There was no overall survival difference between the 2 groups (P = .66). Patient-reported symptoms led to the detection of the majority of relapses in aggressive (85.7% [n = 72] vs. 14.3% [n = 12]; P < .0001) as well as indolent NHL (69.6% [n = 55] vs. 30.4% [n = 24]; P = .0007). Surveillance PET/CT contributed to more than 75% of follow-up health care costs in the first 2 years of monitoring for relapse. The surveillance imaging group had 1 reported case of iatrogenic pneumothorax. CONCLUSION Our retrospective analysis suggests that there is a limited role for surveillance imaging by CT or PET/CT in detecting first relapse in NHL. There was no difference in survival outcomes between the 2 groups in our study.

You've Lived a Good Life

DOI: 10.1200/JCO.2015.63.3206 Our aging population places a strain on all aspects of the health care system, including oncology services. In an article published in The ASCO Post, Holland and Greenstein discussed the need to prepare younger oncologists to care for much older patients. I typically prepare for new patients by reviewing their pathology, radiology, and comorbid conditions. Age is always listed, and although it is something I think about, I need to see the patient to truly get a feeling for his or her performance status, level of social support, and comorbid conditions. We have all seen patients who appear their stated age and patients who do not. Sometimes, we can obtain useful information from performance status or the descriptor of frail included in the medical record; however, the accurate decisions are made in the examination room, whether the patient is 59 or 89 years of age. Several months ago, I met Ted, an 89-year-old patient who was in fantastic shape. He liked to tinker around the house, tend his garden, and spend time with his girlfriend. He did his own grocery shopping, liked a glass (or two) of wine with his lunch, and had a great social support system. He presented to his primary care physician in January after an abnormal chest x-ray and computed tomography (CT) scan showed a 3-cm mass, noted by radiology to likely be lung cancer. “Wait and see,” he was told. Well, he waited, and it grew. Repeat scans in March (CT and positron emission tomography/CT) and July (CT) showed that the mass was growing. Ted continued to live his life, but wondered, “Why is no one going after this?” He saw his pulmonologist and was told that the mass was likely lung cancer, but testing for lung cancer was so hard—biopsy, more scans, chemotherapy. Who wants that? Well, Ted wanted that. He was 89 years old, but he felt much younger. Older patients are often excluded from clinical trials in oncology, either because of rigid eligibility criteria or because of bias on the part of enrolling oncologists. The problem with the older patient is the other things that come with them, such as frailty, multiple medical comorbidities, and worsening social support systems, all of which may interfere with the patient’s ability to withstand anticancer therapy. So what is the oncologist to do? Back to Ted. He followed up again in October, 9 months after the mass was initially identified. The scan now showed that the primary mass had continued to grow and that there were enlarged lymph nodes and bone lesions suggestive of metastatic disease. There was now little doubt that he had progressive lung cancer and that his window of opportunity for curative therapy had closed. Finally, Ted put his foot down and demanded a biopsy. It was, as expected, primary non–small-cell adenocarcinoma of the lung. Magnetic resonance imaging of the brain was negative, and he was evaluated by radiation oncology, but no therapy was offered, because what had been localized disease was now metastatic. He saw a medical oncologist and was offered singleagent chemotherapy, not a standard platinumbased doublet. Why? He was too old. He was told by his oncologist, “You’ve lived a good life.” There is always a debate in an oncologist’s mind about who should receive chemotherapy and who should not. We have predictive models, guidelines, Eastern Cooperative Oncology Group performance status requirements, and geriatric assessment tools that allow us to estimate an individual’s ability to tolerate chemotherapy, but in the end, it is frequently a gut decision. I always tell my patients with advanced disease that my goal is to optimize their quantity and quality of life. If one of these is compromised, we need to re-evaluate our goals of care. I met Ted 3 days before Christmas for his initial consultation, a full 11 months since the first CT of his chest showed probable lung cancer. He was still sharp as a tack, and I was a little embarrassed to admit that he was dressed much more sharply than I was. All of his records and scans were available for my review. I was interested in his functional status and asked my office staff if he had walked in by himself. Did he come alone? Ted was interactive, gregarious, and entertaining. He brought his A game to see me and was ready to fight. I spoke with his daughter via cell phone, and she confirmed that he was extremely active at home. His girlfriend was with him. He told me he wanted someone to believe in him. I consulted my former fellowship classmates and my partner in the office next door for advice. JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 33 NUMBER 34 DECEMBER 1 2015

Acute Myeloid Leukemia Presenting as Acute Appendicitis

Appendicitis in leukemic patients is uncommon but associated with increased mortality. Additionally, leukemic cell infiltration of the appendix is extremely rare. While appendectomy is the treatment of choice for these patients, diagnosis and management of leukemia have a greater impact on remission and survival. A 59-year-old Caucasian female was admitted to the surgical service with acute right lower quadrant pain, nausea, and anorexia. She was noted to have leukocytosis, anemia, and thrombocytopenia. Abdominal imaging demonstrated appendicitis with retroperitoneal and mesenteric lymphadenopathy for which she underwent laparoscopic appendectomy. Peripheral smear, bone marrow biopsy, and surgical pathology of the appendix demonstrated acute myeloid leukemia (AML) with nonsuppurative appendicitis. In the setting of AML, prior cases described the development of appendicitis with active chemotherapy. Of these cases, less than ten patients had leukemic infiltration of the appendix, leading to leukostasis and nonsuppurative appendicitis. Acute appendicitis with leukemic infiltration as the initial manifestation of AML has only been described in two other cases in the literature with an average associated morbidity of 32.6 days. The prompt management in this case of appendicitis and AML resulted in an overall survival of 185 days.

Assessing the impact of a targeted electronic medical record intervention on the use of growth factor in cancer patients.

BACKGROUND Patients receiving chemotherapy are at risk for febrile neutropenia following treatment. The American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) recommend screening patients for risk of febrile neutropenia and risk stratification based on likelihood of febrile neutropenia events. The impact of the implementation of an electronic medical record (EMR) system on physician compliance with growth factor support guidelines has not been studied. OBJECTIVE To investigate whether implementation of automated orders in EMRs can improve adherence to national guidelines in prophylactic G-CSF use in chemotherapy patients. METHODS A retrospective chart review of cancer patients receiving chemotherapy from January 1, 2007 to August 1, 2008 (pre- EMR) and January 1, 2011 to December 31, 2011 (post-EMR) was conducted. Institutional adherence to ASCO and NCCN guidelines for G-CSF after the implementation of automatic electronic orders for pegfilgrastim in patients who received a high-risk chemotherapy regimen were examined. The results were compared with a similar study that had been conducted before the implementation of the EMR system. RESULTS The number of regimens that included guideline-driven growth factor usage and nonusage was 75.6% in the post-intervention arm, compared with 67.5% in the pre-intervention arm. This is a statistically significant difference between the pre-EMR and post-EMR compliance with national guidelines on growth factor usage ( P = .041, based on chi-square test). The post-EMR implementation data of 1,042 individual new chemotherapy regimens showed correct use of G-CSF in 89.13% high-risk chemotherapy regimens and 58.74% intermediate-risk regimens, with risk factors and incorrect usage in 26.23% of intermediate-risk regimens without risk factors and 19.34% of low-risk regimens. The appropriateness of use in high- and low-risk regimens was the most compliant, because growth factor was built into chemotherapy plans of high-risk regimens and omitted from low-risk regimens. LIMITATIONS This project was limited by a change in EMR systems at West Virginia University hospitals on January 1, 2009. All pre- EMR data was collected before 2009 and could not be further collected once the project began in 2013. CONCLUSIONS Appropriateness of growth factor usage can be improved when integrated into an EMR. This can improve compliance and adherence to national recommendations. Further development and understanding of EMR is needed to improve usage to meet national guidelines, with particular attention paid to integration of risk factors into EMR to improve growth factor usage compliance.

Pilot study of incorporating a supportive care program into a small community oncology practice.

149 Background: Incorporation of supportive care has become standard of care in patients with advanced or metastatic cancer undergoing palliative chemotherapy. Implementation of a supportive care program is often difficult in a small community practice due to a multitude of factors. METHODS We piloted a supportive care program with the partnership of Sage Hospice & Palliative Care in which patients with advanced or metastatic cancer undergoing chemotherapy would be evaluated by a certified nurse practitioner (CNP). Patients were selected for evaluation based on age, stage of cancer, and likelihood of needing additional supportive measures during their oncologic treatment. Patients were enrolled in the program by seeing the CNP and being followed throughout their chemotherapy, or until their death. Home visits were done by the CNP after hours, on weekends, or during business hours if it was noted to be medically necessary. RESULTS Forty-four patients were enrolled in the supportive care program. All patients either had metastatic or advanced cancer that required chemotherapy. The most common diagnoses are breast, pancreatic, prostate and lung cancer. The average number of patient home visits was 3.35 visits. Interventions varied, but the most common tasks performed were IV hydration, pain control and symptom management. Of the 44 patients, only 7 required an inpatient stay (15.9%) and none of these patients required a second hospital stay or were noted to be a 30 day readmission. Ten patients were enrolled in hospice, and 7 of those patients died. Zero patients died while on treatment or died without being enrolled on hospice. CONCLUSIONS Incorporation of a supportive care program is feasible in a small community practice. The benefits may include improved patient outcomes, decreased hospitalizations, and smoother transition to end of life care.

Quality versus queasy: Trends in the use of antiemetics.

203 Background: The American Society of Clinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI) program in 2010, to promote quality cancer care. Subsequently, ASCO has influenced the use of the neurokinin 1 (NK1) receptor antagonists aprepitant/fosaprepitant through peer-reviewed publications and the Choosing Wisely Campaign. These agents increase cost and, via CYP3A4 inhibition, may lead to drug interactions. Here we report our survey results that explored prescribing patterns of these agents among QOPI-certified and non-certified oncologists. METHODS An anonymous online survey was distributed to oncologists in four states. Respondents were asked 12 questions about the use of aprepitant/fosaprepitant in their clinical practice. Responses were analyzed in aggregate using likelihood ratio Chi-square tests. P-values of < 0.05 are significant. Descriptive statistics describe differences between groups. RESULTS We analyzed 157 responses and excluded 10 respondents that did not identify themselves as medical oncologists. 62.1% of the practitioners practice in a QOPI-certified practice (90/145). Compared with non-QOPI practitioners, QOPI physicians are significantly more likely to use NK1 antagonists with intermediate/low emetogenicity regimens like weekly cisplatin for head & neck cancer (83.3 vs. 28.0%, p: < 0.001), cervical & bladder cancer (85.2 vs. 34.0%, p: < 0.001), and with CHOP ± rituximab for lymphoma (82.4 vs. 18.0%, p: < 0.001). Significantly, the majority of QOPI-certified physicians report using these agents for the sole purpose of earning/maintaining QOPI certification (81.4-85.4%). QOPI-certified physicians are also significantly more likely to appropriately prescribe NK1 antagonists with doxorubicin ≥ 60 mg/m2 (86.4 vs. 51.9%, p: < 0.001), cisplatin ≥ 50 mg/m2 (96.3 vs. 76.9%, p: < 0.001) and dacarbazine (84.6 vs. 55.8%, p: < 0.001). CONCLUSIONS Although QOPI-certified physicians are significantly more likely to use NK1 antagonists than non-QOPI physicians, our findings indicate that their motivation is to satisfy QOPI guidelines instead of perceived necessity. A prospective study may be beneficial to further define the role of NK1 antagonists with intermediate/low emetogenicity regimens.

Patient Understanding and Impression of Hematology/Oncology Fellows

Background:Hematologists/Oncologists spend years of training in a fellowship program. At academic centers, patients receiving treatment are often seen by fellows. It has not been established what patients understand about fellowship training, therefore the purpose of this study was to explore their understanding and whether they are content with fellows taking part in their care. Methods:At West Virginia University/Mary Babb Randolph Cancer Center, the authors drafted a survey. This anonymous and voluntary survey abstracted basic patient demographic data and experience being cared for by fellows and basic knowledge of a Hematology/Oncology fellowship. Multiple-choice questions were drafted with 4 to 6 answer choices with no option for unknown. Surveys were collected over a 3-week period in July 2012. Patients were surveyed at outpatient appointments, infusion center visits, and laboratory draws. Results:Two hundred twenty-six surveys were collected. Statistical analysis was performed and a binomial regression was fit to the data. There is evidence that higher levels of education are more likely to give correct answers (P = 0.035). Patients who stated that they had not seen a fellow or were unsure whether they had seen a fellow were more likely to select incorrect answers (P = 0.001). There is no statistical significance differentiating between cancer types in likelihood of getting answers correct. Of those surveyed, 1.77% felt that they completely understand the role of a fellow in their care, whereas 80.45% desired further information about fellows. Only 2.2% disliked having a fellow involved in their care. Conclusions:Patients at academic centers being seen by Hematology/Oncology fellows appear to have a lack of knowledge of a fellows role and background but have a desire to be educated. Educational initiatives can be introduced to teaching institutions to help patients better understand the role of a fellow.

Assessing the impact of a targeted electronic medical record intervention on growth factor usage in cancer patients.

262 Background: Patients receiving chemotherapy are at risk for febrile neutropenia following treatment. The American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) recommend screening patients for risk of febrile neutropenia and risk stratification based on likelihood of febrile neutropenia events. Prophylactic growth factors (G-CSF) should be in patients receiving high-risk regimens or intermediate-risk regimens with individual risk factors. The impact of electronic medical record system (EMR) implementation on compliance with G-CSF support guidelines has not been studied. METHODS At West Virginia University/Mary Babb Randolph Cancer Center we conducted an IRB approved retrospective chart review of cancer patients receiving chemotherapy from January 1, 2007 to August 1, 2008 (pre-EMR) and January 1, 2011 to December 31, 2011 (post-EMR). We reviewed the chemotherapy regimens and patient risk factors for developing febrile neutropenia, and determined if the G-CSF usage was consistent with guideline recommendations. RESULTS Compliance with prophylactic G-CSF guidelines was 75.6% in the post-EMR arm, compared to 67.5% in the pre-EMR arm (p=0.041, ch-square). The post EMR data of 1,042 new chemotherapy initiations showed: (see Table). The appropriateness of usage in high and low risk patients were the most compliant, as G-CSF orders were built into chemotherapy plans of high risk regimens and omitted from low risk regimens. CONCLUSIONS Appropriate prophylactic G-CSF usage can be improved when orders are integrated into standard chemotherapy order sets in an EMR. An area of further improvement would include automatic identification of individual risk factors by the EMR. [Table: see text].

Palliative care training: A national survey of U.S. hematology/oncology fellows.

28 Background: The American Society of Clinical Oncology (ASCO) has recommended integration of palliative care into oncology practice at the time of diagnosis of advanced cancer. The attitudes, knowledge, and skills of Hematology/Oncology fellows in palliative medicine to implement this recommendation have not been assessed. METHODS In 2013 we surveyed current US Hematology/Oncology fellows to assess their attitudes and the quality of teaching in palliative care received during fellowship and their perceived preparedness to care for patients at End of Life (EOL). Trainees at all US programs were surveyed via Research Electronic Data Capture. The survey was IRB approved, anonymous and voluntary. RESULTS 176 surveys were collected. Statistical analysis was performed with t-test for numeric and Fishers exact test for categorical variables. 98% of respondents felt that providing care for dying patients was important. 99% indicated that physicians have a responsibility to help patients at EOL. Fellows felt their overall training in fellowship was superior to their quality of training (p<0.0001) or teaching (p <0.0001) on EOL. Pearson correlation showed that those with training in palliative care felt more prepared caring for patients at EOL (p <0.0001). Fellows who had training in palliative care during fellowship (45.4% of those surveyed) felt they had better teaching on managing a patient at EOL than those who did not (p<0.0001). There was no statistical significance noted with self-identified roles of spirituality or religion in attitudes, knowledge, or skills. 64% reported having conducted over ten family meetings regarding EOL. Only 18.9% were supervised (p<0.0001) and only 13.1% were given feedback more than ten times (p<0.0001). 89.7% of fellows surveyed stated they have disagreed with treatment without palliative care on at least one occasion. 40% of respondents did not know how to respond to a request to stop chemotherapy. CONCLUSIONS Hematology/Oncology fellows believe that EOL care is important. Education about EOL is not at the same level of their overall fellowship training despite the recognition of the benefit of palliative care in Oncology. Educational initiatives need to be introduced to improve training on EOL care.

Physician orders for scope of treatment (POST) forms in metastatic cancer patients: A 3-year single-university–institution retrospective review.

133 Background: Physician orders for dcope of treatment (POST) forms are standardized forms for patient preferences for end-of-life care. These forms contain orders by a physician who has identified a patient who is seriously ill with life-limiting progressive, advanced illness. Utilization of the POST form in advanced and metastatic cancer patients has not yet been evaluated. METHODS At West Virginia University/Mary Babb Randolph Cancer Center, we performed an IRB approved retrospective chart review of all patients who died of metastatic or advanced malignancies from 2010-2012. Statistical analysis was performed with SPSS Version 20. RESULTS 139 patients were identified who were diagnosed with metastatic cancer and treated at West Virginia University who died from 2010-2012. Of those 139 patients, 26 (18.7%) completed POST forms. 51 (36.7%) patients received systemic oncologic treatment in their last thirty days of life. In the last ninety days of life, patients averaged 16.2 days hospitalized. 123 (88.4%) patients had at least one hospital stay in their last three months of life, with 82 (58.7%) having two or more stays. 65 (46.8%) patients had a hospital readmission within thirty days. 39 (28.1%) patients had an ICU stay with an average duration of 2.6 days. Almost half of all patients reviewed (67, 48.2%) died in the hospital. Patients averaged 2.9 CT scans and 5.2 X-rays over the last ninety days of their life. 116 (83.5%) patients had an end-of-life discussion, with an average time from discussion to date of death of 24.5 days. Only 60 (43.2%) were identified as having a palliative care consult completed. CONCLUSIONS The American Society of Clinical Oncology (ASCO) recommends implementation of Palliative Care at the time of diagnosis of advanced cancer. POST forms appear to have a positive impact on end-of-life care in this population of advanced cancer patients. Increasing their implementation in metastatic oncology patients will likely improve end-of-life care. [Table: see text].