Michael Cecchini

Immune therapy of metastatic melanoma developing after allogeneic bone marrow transplant

Metastatic melanoma is frequently treated with immune activating therapy, which poses a theoretical risk of inducing graft versus host disease (GVHD) in those who have received allogeneic stem cell transplantation. The literature reporting the safety of immunotherapy in post transplant patients is limited. We report two patients with metastatic melanoma who received treatment with immunotherapy after allogeneic stem cell transplantation that did not result in GVHD.

Electronic Intervention to Improve Structured Cancer Stage Data Capture

PURPOSE Cancer staging is critical for prognostication, treatment planning, and determining clinical trial eligibility. Electronic health records (EHRs) have structured staging modules, but physician use is inconsistent. Typically, stage is entered as unstructured free text in clinical notes and cannot easily be used for reporting. METHODS We created an Epic Best Practice Advisory (BPA) decision support tool that requires physicians to enter cancer stage in a structured module. If certain conditions are met, the BPA is triggered as a hard stop, and the physician cannot chart until staging is complete or a reason for not staging is selected. We used Plan, Do, Study, Act methodology to inform the intervention and compared preexisting staging rates to rates at 4, 8, and 12 months postintervention. RESULTS For 12 months before BPA implementation, 1,480 of 5,222 (28%) patients had cancer stage structured within the Epic problem list. From 1 to 4 months after the BPA 2,057 of 1,788 (115%) cases were staged in Epic. In the 5- to 8-month period after the BPA, 1,057 of 1,893 (56%) cases were staged, and 9 to 12 months after the BPA 1,082 of 1,817 (60%) were staged. CONCLUSION Electronic decision support improves the rate of structured cancer staging at our institution. The staging rates between 56% and 60% for the 5- to 8-month and 9- to 12-month periods likely reflect accurate postintervention staging rates, whereas the initial 115% rate for 1 to 4 months is inflated by providers staging cancers diagnosed before the BPA.

The implementation of electronic hematology consults at a VA Hospital

To the editor: The widespread implementation of electronic medical records (EMR) allow providers ready access to large amounts of patient information, and for some specialties much of the data needed to provide recommendations can be gathered electronically.[1][1] Electronic consultation (e-consult

EGFR Exon 19 Deletion in Pancreatic Adenocarcinoma Responds to Erlotinib, Followed by T790M-Mediated Resistance

The prognosis of metastatic pancreatic cancer remains poor despite recent advances in treatment with multidrug chemotherapy regimens. Use of immune checkpoint inhibitors and molecular targeted therapies has so far been disappointing. This report describes a patient with chemotherapy-refractory metastatic pancreatic ductal adenocarcinoma (PDAC) whose tumor was characterized by an activating mutation in exon 19 of the epidermal growth factor receptor (EGFR). He experienced response to erlotinib for 10 months, and then developed disease progression in association with emergence of the T790M mutation. Activating EGFR mutations in cancers other than lung are uncommon, but when present may predict response to EGFR tyrosine kinase inhibitors (TKIs). Development of the T790M mutation in this case suggests that EGFR-targeted TKIs may follow similar patterns of resistance regardless of tumor type. Although actionable mutations are detected infrequently in PDAC, this case illustrates the potential benefit of offering genomic analysis to all patients with advanced disease.