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Optimization of Palliative Oncology Care Within the VA Healthcare System–Assessing the Availability of Outpatient Palliative Care Within VA Oncology Clinic
Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.
Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.
Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.
Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.
Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.
Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.
Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.
Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.
Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.
Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.
Purpose: Palliative care is essential to oncology. The purpose of this project was to characterize the interface between VA oncologists and palliative care specialists in the outpatient setting and to identify barriers to outpatient palliative oncology care in the VA.
Background: The American Society of Clinical Oncology (ASCO) recommends palliative care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. The VA mandates palliative care inpatient consult teams for all medical facilities. It is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. The 2016 VHA Cancer Care Survey was a comprehensive assessment of 140 VA facilities regarding their cancer care infrastructure. On this survey, 23% of sites (N=32) reported that they were not able to provide adequate palliative oncology care in the outpatient setting.
Methods: We contacted clinicians at each of these 32 sites to characterize the outpatient oncology/palliative care interface and identify potential barriers.
Results: Of the 32 sites, 17 reported that they provided limited oncologic care and generally referred patients to other facilities for cancer treatment. The remaining 15 sites reported providing full oncology services. These 15 sites employed a variety of methods to engage palliative care specialists. These included referring patients to a separate outpatient palliative care clinic or a home-based provider; consulting the inpatient palliative care team to evaluate the patient while in the cancer clinic; working with an oncology social worker; or arranging a tele-consult with a remote palliative care specialist. Barriers to providing outpatient palliative care included not enough palliative care staff, not enough clinic space, and patients or oncologists declining a palliative care referral. Clinicians expressed that they would provide more outpatient palliative care if they
had more palliative care staff, more clinic space, and more palliative care training for oncologists.
Conclusions: This project identified that some sites have found creative approaches to providing outpatient palliative oncology care. In addition, clinicians emphasized the ongoing need for additional specialty palliative care staff, primary palliative care training for oncologists, and clinic space in order to provide optimal outpatient palliative oncology care for VA patients.
Rapid Onset of Severe Transaminitis in a Patient With Non-Small Cell Lung Cancer Receiving 480-mg Nivolumab
Background: This case describes severe transaminitis resulting 21 days after administration of the first dose of nivolumab 480 mg for non-small cell lung cancer (NSCLC) adenocarcinoma. The patient was an 81-year-old male whose disease had progressed after 3 cycles of carboplatin/pemetrexed. Molecular tumor marker testing did not reveal any actionable mutations prior to treatment.
Case Report: The patient initially presented with headaches, worsening shortness of breath and Grade 4 transaminitis (AST/ALT > 10x ULN). During hospitalization, he was treated with PO prednisone and IV methylprednisolone with a decrease in transaminases. Due to ongoing psychoses and worsening myopathies, the steroid doses were reduced. On day 14 of hospitalization, mycophenolate mofetil (MMF) 500 mg PO BID was initiated due to steroid refractory transaminitis. The patient was put on infection prophylaxis with sulfamethoxazole/trimethoprim and fluconazole at the time of MMF initiation. Valacyclovir was initiated when MMF was increased to 1,000 mg PO BID after three days without a response to lower doses. Ultimately the patient expired from cardiac failure 18 days after
hospitalization.
Discussion: Nivolumab recently received US Food and Drug Administration approval for every 4-week dosing based on pharmacokinetic data. Without clinical evidence, it was concluded that this increased dosing would not differ in safety or efficacy from previously approved doses, despite steady-state peak and average time concentrations predicted to be higher than the every 2-week dosing regimen. Both the National Comprehensive Cancer Network and American Society of Clinical Oncology recommend initiation of MMF for steroid refractory irAE transaminitis. These recommendations are based on case reports in patients receiving ipilimumab or nivolumab. The specific dosing and timing of initiation is not well elucidated. Additionally, there are case reports of use of antithymocyte globulin for management of irAEs.
Conclusions: Administration of 480-mg nivolumab may lead to more rapid onset of severe transaminitis. Administration of this dosing should be delayed until a patient demonstrates tolerability to the 240-mg dosing. High-dose steroids, in combination with MMF may provide more rapid clinical improvement. All patients on increased doses of immunosuppressive agents should receive opportunistic infection prophylaxis.
Background: This case describes severe transaminitis resulting 21 days after administration of the first dose of nivolumab 480 mg for non-small cell lung cancer (NSCLC) adenocarcinoma. The patient was an 81-year-old male whose disease had progressed after 3 cycles of carboplatin/pemetrexed. Molecular tumor marker testing did not reveal any actionable mutations prior to treatment.
Case Report: The patient initially presented with headaches, worsening shortness of breath and Grade 4 transaminitis (AST/ALT > 10x ULN). During hospitalization, he was treated with PO prednisone and IV methylprednisolone with a decrease in transaminases. Due to ongoing psychoses and worsening myopathies, the steroid doses were reduced. On day 14 of hospitalization, mycophenolate mofetil (MMF) 500 mg PO BID was initiated due to steroid refractory transaminitis. The patient was put on infection prophylaxis with sulfamethoxazole/trimethoprim and fluconazole at the time of MMF initiation. Valacyclovir was initiated when MMF was increased to 1,000 mg PO BID after three days without a response to lower doses. Ultimately the patient expired from cardiac failure 18 days after
hospitalization.
Discussion: Nivolumab recently received US Food and Drug Administration approval for every 4-week dosing based on pharmacokinetic data. Without clinical evidence, it was concluded that this increased dosing would not differ in safety or efficacy from previously approved doses, despite steady-state peak and average time concentrations predicted to be higher than the every 2-week dosing regimen. Both the National Comprehensive Cancer Network and American Society of Clinical Oncology recommend initiation of MMF for steroid refractory irAE transaminitis. These recommendations are based on case reports in patients receiving ipilimumab or nivolumab. The specific dosing and timing of initiation is not well elucidated. Additionally, there are case reports of use of antithymocyte globulin for management of irAEs.
Conclusions: Administration of 480-mg nivolumab may lead to more rapid onset of severe transaminitis. Administration of this dosing should be delayed until a patient demonstrates tolerability to the 240-mg dosing. High-dose steroids, in combination with MMF may provide more rapid clinical improvement. All patients on increased doses of immunosuppressive agents should receive opportunistic infection prophylaxis.
Background: This case describes severe transaminitis resulting 21 days after administration of the first dose of nivolumab 480 mg for non-small cell lung cancer (NSCLC) adenocarcinoma. The patient was an 81-year-old male whose disease had progressed after 3 cycles of carboplatin/pemetrexed. Molecular tumor marker testing did not reveal any actionable mutations prior to treatment.
Case Report: The patient initially presented with headaches, worsening shortness of breath and Grade 4 transaminitis (AST/ALT > 10x ULN). During hospitalization, he was treated with PO prednisone and IV methylprednisolone with a decrease in transaminases. Due to ongoing psychoses and worsening myopathies, the steroid doses were reduced. On day 14 of hospitalization, mycophenolate mofetil (MMF) 500 mg PO BID was initiated due to steroid refractory transaminitis. The patient was put on infection prophylaxis with sulfamethoxazole/trimethoprim and fluconazole at the time of MMF initiation. Valacyclovir was initiated when MMF was increased to 1,000 mg PO BID after three days without a response to lower doses. Ultimately the patient expired from cardiac failure 18 days after
hospitalization.
Discussion: Nivolumab recently received US Food and Drug Administration approval for every 4-week dosing based on pharmacokinetic data. Without clinical evidence, it was concluded that this increased dosing would not differ in safety or efficacy from previously approved doses, despite steady-state peak and average time concentrations predicted to be higher than the every 2-week dosing regimen. Both the National Comprehensive Cancer Network and American Society of Clinical Oncology recommend initiation of MMF for steroid refractory irAE transaminitis. These recommendations are based on case reports in patients receiving ipilimumab or nivolumab. The specific dosing and timing of initiation is not well elucidated. Additionally, there are case reports of use of antithymocyte globulin for management of irAEs.
Conclusions: Administration of 480-mg nivolumab may lead to more rapid onset of severe transaminitis. Administration of this dosing should be delayed until a patient demonstrates tolerability to the 240-mg dosing. High-dose steroids, in combination with MMF may provide more rapid clinical improvement. All patients on increased doses of immunosuppressive agents should receive opportunistic infection prophylaxis.
Efficacy and Toxicity of XELOX vs FOLFOX in Adjuvant and Metastatic Treatment of Colorectal Cancer in Veterans
Purpose: To determine the efficacy and toxicity of fluorouracil/leucovorin/oxaliplatin (FOLFOX) vs capecitabine/oxaliplatin (XELOX or CAPOX) in the treatment of colorectal cancer (CRC) in both the adjuvant (aCRC) and metastatic (mCRC) setting in Veterans at the Southern Arizona Veteran Affairs Health Care System (SAVAHCS).
Methods: A retrospective chart review was conducted to collect efficacy and toxicity data. Subjects were included based on age, treatment setting, and regimen in the preset 5-year period, and appropriate diagnosis via International Classification of Diseases-Revision 9 (ICD-9) codes. Efficacy was measured via 1-year disease-free survival (DFS) for aCRC, progression-free survival (PFS) for mCRC, and overall survival (OS) for both settings.
Results: A total of 79 subjects were initially evaluatedwith 51 and 54 all-male subjects included in the efficacy and toxicity analysis, respectively. Mean range of age was 63-72 years old. Subjects were divided into four groups: FOLFOX aCRC (N = 17) and mCRC (N = 19), XELOX aCRC (N = 10) and mCRC (N = 8). No difference was found in 1-year DFS and OS between aCRC treatment groups, and PFS between mCRC groups. A higher incidence of 1-year OS with FOLFOX in the mCRC setting was noted (P = .03). No difference was found in the incidence of most of the toxicities between FOLFOX and XELOX, except a higher incidence of hand-foot syndrome was seen in XELOX (P = .0007) treated patients.
Conclusions: In this patient population, the efficacy between FOLFOX and XELOX in aCRC and mCRC was similar, while toxicity was slightly more prevalent with XELOX treatment due to increased hand-foot syndrome incidence. These findings are consistent with the results reported by previous larger prospective clinical trials.
Purpose: To determine the efficacy and toxicity of fluorouracil/leucovorin/oxaliplatin (FOLFOX) vs capecitabine/oxaliplatin (XELOX or CAPOX) in the treatment of colorectal cancer (CRC) in both the adjuvant (aCRC) and metastatic (mCRC) setting in Veterans at the Southern Arizona Veteran Affairs Health Care System (SAVAHCS).
Methods: A retrospective chart review was conducted to collect efficacy and toxicity data. Subjects were included based on age, treatment setting, and regimen in the preset 5-year period, and appropriate diagnosis via International Classification of Diseases-Revision 9 (ICD-9) codes. Efficacy was measured via 1-year disease-free survival (DFS) for aCRC, progression-free survival (PFS) for mCRC, and overall survival (OS) for both settings.
Results: A total of 79 subjects were initially evaluatedwith 51 and 54 all-male subjects included in the efficacy and toxicity analysis, respectively. Mean range of age was 63-72 years old. Subjects were divided into four groups: FOLFOX aCRC (N = 17) and mCRC (N = 19), XELOX aCRC (N = 10) and mCRC (N = 8). No difference was found in 1-year DFS and OS between aCRC treatment groups, and PFS between mCRC groups. A higher incidence of 1-year OS with FOLFOX in the mCRC setting was noted (P = .03). No difference was found in the incidence of most of the toxicities between FOLFOX and XELOX, except a higher incidence of hand-foot syndrome was seen in XELOX (P = .0007) treated patients.
Conclusions: In this patient population, the efficacy between FOLFOX and XELOX in aCRC and mCRC was similar, while toxicity was slightly more prevalent with XELOX treatment due to increased hand-foot syndrome incidence. These findings are consistent with the results reported by previous larger prospective clinical trials.
Purpose: To determine the efficacy and toxicity of fluorouracil/leucovorin/oxaliplatin (FOLFOX) vs capecitabine/oxaliplatin (XELOX or CAPOX) in the treatment of colorectal cancer (CRC) in both the adjuvant (aCRC) and metastatic (mCRC) setting in Veterans at the Southern Arizona Veteran Affairs Health Care System (SAVAHCS).
Methods: A retrospective chart review was conducted to collect efficacy and toxicity data. Subjects were included based on age, treatment setting, and regimen in the preset 5-year period, and appropriate diagnosis via International Classification of Diseases-Revision 9 (ICD-9) codes. Efficacy was measured via 1-year disease-free survival (DFS) for aCRC, progression-free survival (PFS) for mCRC, and overall survival (OS) for both settings.
Results: A total of 79 subjects were initially evaluatedwith 51 and 54 all-male subjects included in the efficacy and toxicity analysis, respectively. Mean range of age was 63-72 years old. Subjects were divided into four groups: FOLFOX aCRC (N = 17) and mCRC (N = 19), XELOX aCRC (N = 10) and mCRC (N = 8). No difference was found in 1-year DFS and OS between aCRC treatment groups, and PFS between mCRC groups. A higher incidence of 1-year OS with FOLFOX in the mCRC setting was noted (P = .03). No difference was found in the incidence of most of the toxicities between FOLFOX and XELOX, except a higher incidence of hand-foot syndrome was seen in XELOX (P = .0007) treated patients.
Conclusions: In this patient population, the efficacy between FOLFOX and XELOX in aCRC and mCRC was similar, while toxicity was slightly more prevalent with XELOX treatment due to increased hand-foot syndrome incidence. These findings are consistent with the results reported by previous larger prospective clinical trials.
How Can VA Optimize Palliative Oncology Care? Updates on AVAHO Palliative Care Research Committee Projects
Purpose: Palliative care is essential to oncology. This abstract describes the AVAHO Palliative Care Research Committee, its objectives, and ongoing projects that highlight the committee’s productive multidisciplinary and interinstitutional collaboration.
Background: The American Society of Clinical Oncology recommends palliative care for patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates inpatient palliative care services for all medical facilities. However, it is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. In addition, questions remain regarding the optimal way(s) to provide palliative oncology care. Established in 2015, the AVAHO Palliative Care Research Committee currently has over a dozen members from different VA institutions. The Committee’s mission is to develop partnerships among clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal palliative oncology care within the VA.
Methods: Last year, we identified 2 initial approaches to address these questions, and this year we will report on our progress. First, we submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal palliative care delivery methods and the feasibility of providing on-site palliative care embedded into VA oncology clinics. The ESP accepted our proposal and plans to complete their review July 2017. Second, we proposed a project to assess on-site palliative care availability in VA oncology clinics. With the support of the 2017 AVAHO Research Scholarship, we are moving forward with this project to work with VA oncology providers to understand their referral patterns, available palliative care resources, and barriers to providing optimal palliative care.
Results: At the AVAHO 2017 meeting, we will review the VA ESP results on optimal palliative oncology care delivery. In addition, we will share the progress on our ongoing project to better understand VA oncologist’s referral patterns, resources, and barriers to providing optimal palliative oncology care.
Conclusions: The AVAHO Palliative Care Research Committee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA palliative oncology care. This committee is a model of how AVAHO can foster productive collaborations.
Purpose: Palliative care is essential to oncology. This abstract describes the AVAHO Palliative Care Research Committee, its objectives, and ongoing projects that highlight the committee’s productive multidisciplinary and interinstitutional collaboration.
Background: The American Society of Clinical Oncology recommends palliative care for patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates inpatient palliative care services for all medical facilities. However, it is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. In addition, questions remain regarding the optimal way(s) to provide palliative oncology care. Established in 2015, the AVAHO Palliative Care Research Committee currently has over a dozen members from different VA institutions. The Committee’s mission is to develop partnerships among clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal palliative oncology care within the VA.
Methods: Last year, we identified 2 initial approaches to address these questions, and this year we will report on our progress. First, we submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal palliative care delivery methods and the feasibility of providing on-site palliative care embedded into VA oncology clinics. The ESP accepted our proposal and plans to complete their review July 2017. Second, we proposed a project to assess on-site palliative care availability in VA oncology clinics. With the support of the 2017 AVAHO Research Scholarship, we are moving forward with this project to work with VA oncology providers to understand their referral patterns, available palliative care resources, and barriers to providing optimal palliative care.
Results: At the AVAHO 2017 meeting, we will review the VA ESP results on optimal palliative oncology care delivery. In addition, we will share the progress on our ongoing project to better understand VA oncologist’s referral patterns, resources, and barriers to providing optimal palliative oncology care.
Conclusions: The AVAHO Palliative Care Research Committee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA palliative oncology care. This committee is a model of how AVAHO can foster productive collaborations.
Purpose: Palliative care is essential to oncology. This abstract describes the AVAHO Palliative Care Research Committee, its objectives, and ongoing projects that highlight the committee’s productive multidisciplinary and interinstitutional collaboration.
Background: The American Society of Clinical Oncology recommends palliative care for patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates inpatient palliative care services for all medical facilities. However, it is not clearly known how palliative care is integrated into standard VA outpatient oncology practice. In addition, questions remain regarding the optimal way(s) to provide palliative oncology care. Established in 2015, the AVAHO Palliative Care Research Committee currently has over a dozen members from different VA institutions. The Committee’s mission is to develop partnerships among clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal palliative oncology care within the VA.
Methods: Last year, we identified 2 initial approaches to address these questions, and this year we will report on our progress. First, we submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal palliative care delivery methods and the feasibility of providing on-site palliative care embedded into VA oncology clinics. The ESP accepted our proposal and plans to complete their review July 2017. Second, we proposed a project to assess on-site palliative care availability in VA oncology clinics. With the support of the 2017 AVAHO Research Scholarship, we are moving forward with this project to work with VA oncology providers to understand their referral patterns, available palliative care resources, and barriers to providing optimal palliative care.
Results: At the AVAHO 2017 meeting, we will review the VA ESP results on optimal palliative oncology care delivery. In addition, we will share the progress on our ongoing project to better understand VA oncologist’s referral patterns, resources, and barriers to providing optimal palliative oncology care.
Conclusions: The AVAHO Palliative Care Research Committee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA palliative oncology care. This committee is a model of how AVAHO can foster productive collaborations.
Treatment Patterns Among Men With Metastatic Castrate-Resistant Prostate Cancer Within the United States Veterans Affairs Health System
Background: Therapeutic options for men with metastatic castrate-resistant prostate cancer (mCRPC) have expanded significantly over the past 5 years with several new agents demonstrating improved survival, including 2 oral agents. Abiraterone acetate (AA), a CYP-17 androgen synthesis inhibitor, obtained initial FDA approval in 2011 for post-docetaxel (DXT) use and gained expanded approval in 2012 for pre-DXT use. Enzalutamide (ENZ), an androgen receptor signaling inhibitor, also gained FDA approval in 2012 (post-DXT) and indication was expanded in 2014 (pre-DXT).
Purpose: The objective is to provide insight into the uptake of novel therapeutics and its impact on treatment for patients with mCRPC.
Methods: For this observational study, Veterans Affairs (VA) healthcare system data (including hospitalizations, outpatient visits, and pharmacy) were used to identify male veterans who received treatment for mCRPC between fiscal years 2008 and 2014. Sequencing patterns and treatment duration were assessed. Descriptive statistics were employed.
Results: During the study period, 8,774 patients initiated advanced lines of therapy associated with mCRPC. AA, DXT, and ketoconazole (KCZ) were the most commonly used firstlines of advanced therapies (24.6%, 24.8%, 47.0%, respectively). Between 2008 and 2013, the proportion of mCRPC patients treated with first-line DXT or KCZ dropped from 98% to 38% (P < .0001) while the proportion who received first-line AA increased to 58% (P < .0001). Furthermore, among the 4,169 patients treated with AA between 2011 and 2014, the proportion treated pre-DXT increased from 32% to 80% (P < .0001). AA was also the most common second-line treatment received. Between 2012 and 2013, ENZ use was low but increased dramatically. Among patients who initiated DXT, KCZ, or AA as first-line treatment in 2011/2012, median time on initial treatment was 5.9, 9.1, 11.5 months, respectively.
Conclusions: The FDA approval of AA and ENZ had a significant impact on treatment patterns for men with mCRPC within VA and was associated with decreased use of KCZ and delayed use of chemotherapy. Further information regarding patient and disease characteristics is needed. The rapid uptake of these novel agents has significant implications for disease-related outcomes.
Background: Therapeutic options for men with metastatic castrate-resistant prostate cancer (mCRPC) have expanded significantly over the past 5 years with several new agents demonstrating improved survival, including 2 oral agents. Abiraterone acetate (AA), a CYP-17 androgen synthesis inhibitor, obtained initial FDA approval in 2011 for post-docetaxel (DXT) use and gained expanded approval in 2012 for pre-DXT use. Enzalutamide (ENZ), an androgen receptor signaling inhibitor, also gained FDA approval in 2012 (post-DXT) and indication was expanded in 2014 (pre-DXT).
Purpose: The objective is to provide insight into the uptake of novel therapeutics and its impact on treatment for patients with mCRPC.
Methods: For this observational study, Veterans Affairs (VA) healthcare system data (including hospitalizations, outpatient visits, and pharmacy) were used to identify male veterans who received treatment for mCRPC between fiscal years 2008 and 2014. Sequencing patterns and treatment duration were assessed. Descriptive statistics were employed.
Results: During the study period, 8,774 patients initiated advanced lines of therapy associated with mCRPC. AA, DXT, and ketoconazole (KCZ) were the most commonly used firstlines of advanced therapies (24.6%, 24.8%, 47.0%, respectively). Between 2008 and 2013, the proportion of mCRPC patients treated with first-line DXT or KCZ dropped from 98% to 38% (P < .0001) while the proportion who received first-line AA increased to 58% (P < .0001). Furthermore, among the 4,169 patients treated with AA between 2011 and 2014, the proportion treated pre-DXT increased from 32% to 80% (P < .0001). AA was also the most common second-line treatment received. Between 2012 and 2013, ENZ use was low but increased dramatically. Among patients who initiated DXT, KCZ, or AA as first-line treatment in 2011/2012, median time on initial treatment was 5.9, 9.1, 11.5 months, respectively.
Conclusions: The FDA approval of AA and ENZ had a significant impact on treatment patterns for men with mCRPC within VA and was associated with decreased use of KCZ and delayed use of chemotherapy. Further information regarding patient and disease characteristics is needed. The rapid uptake of these novel agents has significant implications for disease-related outcomes.
Background: Therapeutic options for men with metastatic castrate-resistant prostate cancer (mCRPC) have expanded significantly over the past 5 years with several new agents demonstrating improved survival, including 2 oral agents. Abiraterone acetate (AA), a CYP-17 androgen synthesis inhibitor, obtained initial FDA approval in 2011 for post-docetaxel (DXT) use and gained expanded approval in 2012 for pre-DXT use. Enzalutamide (ENZ), an androgen receptor signaling inhibitor, also gained FDA approval in 2012 (post-DXT) and indication was expanded in 2014 (pre-DXT).
Purpose: The objective is to provide insight into the uptake of novel therapeutics and its impact on treatment for patients with mCRPC.
Methods: For this observational study, Veterans Affairs (VA) healthcare system data (including hospitalizations, outpatient visits, and pharmacy) were used to identify male veterans who received treatment for mCRPC between fiscal years 2008 and 2014. Sequencing patterns and treatment duration were assessed. Descriptive statistics were employed.
Results: During the study period, 8,774 patients initiated advanced lines of therapy associated with mCRPC. AA, DXT, and ketoconazole (KCZ) were the most commonly used firstlines of advanced therapies (24.6%, 24.8%, 47.0%, respectively). Between 2008 and 2013, the proportion of mCRPC patients treated with first-line DXT or KCZ dropped from 98% to 38% (P < .0001) while the proportion who received first-line AA increased to 58% (P < .0001). Furthermore, among the 4,169 patients treated with AA between 2011 and 2014, the proportion treated pre-DXT increased from 32% to 80% (P < .0001). AA was also the most common second-line treatment received. Between 2012 and 2013, ENZ use was low but increased dramatically. Among patients who initiated DXT, KCZ, or AA as first-line treatment in 2011/2012, median time on initial treatment was 5.9, 9.1, 11.5 months, respectively.
Conclusions: The FDA approval of AA and ENZ had a significant impact on treatment patterns for men with mCRPC within VA and was associated with decreased use of KCZ and delayed use of chemotherapy. Further information regarding patient and disease characteristics is needed. The rapid uptake of these novel agents has significant implications for disease-related outcomes.
How Can VA Optimize Palliative Oncology Care? The AVAHO Palliative Care Research Subcommittee Is Laying the Groundwork for Productive Collaboration
Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.
Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.
Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.
Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.
Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.
Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.
Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.
Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.
Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.
Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.
Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.
Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.
Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.
Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.
Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.
Incidence of Venous Thromboembolism in Surgical Oncology Patients
Purpose: The purpose of this study was to assess the incidence of venous thromboembolism (VTE) in high-risk surgical oncology patients at a Veterans Affairs institution.
Background: Oncology patients undergoing abdominal or pelvic surgeries are at high-risk of developing postoperativeVTE. Current guidelines published by the American Societyof Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), and American College of Chest Physicians(ACCP) recommend at least 4 weeks of pharmacologic thromboprophylaxis postoperatively in high-risk oncology patients.
Methods: Electronic medical records were utilized to identify oncology patients aged 18 to 89 years undergoing general or urologic surgeries from June 1, 2013 to June 30, 2015. The primary objective was the incidence of VTE up to 30 days postoperatively in patients receiving optimal (OT) (4 weeks of anticoagulation if no contraindications) versus suboptimal (ST) thromboprophylaxis. Secondary objectives included incidence of early (days 0 to 7) and late (days 8 to 30) postoperative VTE, severity of VTE, and hematologic toxicities associated with VTE prophylaxis.
Data Analysis: Logistics regression with an alpha of 0.05 was utilized to analyze the primary outcome. Other outcomes were reported as descriptive statistics.
Results: A total of 167 patients were assessed (136 patients in the ST group and 31 patients in the OT group). There were 4 (2.9%) and 1 (3.2%) VTEs in the ST and OT groups, respectively (OR = 0.10; 95% CI, -2.13 to 2.32; P > 0.05). All VTEs occurred during the late postoperative period. In the ST group, 3 patients had an uncomplicated pulmonary embolism (PE) or deep venous thromboembolism, and 1 patient died due to thromboembolic complications. In the OT group, 1 patient had an uncomplicated PE. There were no significant differences in postoperative bleeding (11.4% versus 14.4%) or thrombocytopenia (45.7% versus 47.4%) in patients receiving pharmacologic versus non-pharmacologic thromboprophylaxis.
Implications: Provision of optimal thromboprophylaxis was low for high-risk surgical oncology patients; however, this was not associated with an increase in VTEs. Use of pharmacologic thromboprophylaxis did not increase rates of bleeding or thrombocytopenia. Education is needed to increase compliance with guideline recommendations for postoperative thromboprophylaxis in high-risk surgical oncology patients at our institution.
Purpose: The purpose of this study was to assess the incidence of venous thromboembolism (VTE) in high-risk surgical oncology patients at a Veterans Affairs institution.
Background: Oncology patients undergoing abdominal or pelvic surgeries are at high-risk of developing postoperativeVTE. Current guidelines published by the American Societyof Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), and American College of Chest Physicians(ACCP) recommend at least 4 weeks of pharmacologic thromboprophylaxis postoperatively in high-risk oncology patients.
Methods: Electronic medical records were utilized to identify oncology patients aged 18 to 89 years undergoing general or urologic surgeries from June 1, 2013 to June 30, 2015. The primary objective was the incidence of VTE up to 30 days postoperatively in patients receiving optimal (OT) (4 weeks of anticoagulation if no contraindications) versus suboptimal (ST) thromboprophylaxis. Secondary objectives included incidence of early (days 0 to 7) and late (days 8 to 30) postoperative VTE, severity of VTE, and hematologic toxicities associated with VTE prophylaxis.
Data Analysis: Logistics regression with an alpha of 0.05 was utilized to analyze the primary outcome. Other outcomes were reported as descriptive statistics.
Results: A total of 167 patients were assessed (136 patients in the ST group and 31 patients in the OT group). There were 4 (2.9%) and 1 (3.2%) VTEs in the ST and OT groups, respectively (OR = 0.10; 95% CI, -2.13 to 2.32; P > 0.05). All VTEs occurred during the late postoperative period. In the ST group, 3 patients had an uncomplicated pulmonary embolism (PE) or deep venous thromboembolism, and 1 patient died due to thromboembolic complications. In the OT group, 1 patient had an uncomplicated PE. There were no significant differences in postoperative bleeding (11.4% versus 14.4%) or thrombocytopenia (45.7% versus 47.4%) in patients receiving pharmacologic versus non-pharmacologic thromboprophylaxis.
Implications: Provision of optimal thromboprophylaxis was low for high-risk surgical oncology patients; however, this was not associated with an increase in VTEs. Use of pharmacologic thromboprophylaxis did not increase rates of bleeding or thrombocytopenia. Education is needed to increase compliance with guideline recommendations for postoperative thromboprophylaxis in high-risk surgical oncology patients at our institution.
Purpose: The purpose of this study was to assess the incidence of venous thromboembolism (VTE) in high-risk surgical oncology patients at a Veterans Affairs institution.
Background: Oncology patients undergoing abdominal or pelvic surgeries are at high-risk of developing postoperativeVTE. Current guidelines published by the American Societyof Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), and American College of Chest Physicians(ACCP) recommend at least 4 weeks of pharmacologic thromboprophylaxis postoperatively in high-risk oncology patients.
Methods: Electronic medical records were utilized to identify oncology patients aged 18 to 89 years undergoing general or urologic surgeries from June 1, 2013 to June 30, 2015. The primary objective was the incidence of VTE up to 30 days postoperatively in patients receiving optimal (OT) (4 weeks of anticoagulation if no contraindications) versus suboptimal (ST) thromboprophylaxis. Secondary objectives included incidence of early (days 0 to 7) and late (days 8 to 30) postoperative VTE, severity of VTE, and hematologic toxicities associated with VTE prophylaxis.
Data Analysis: Logistics regression with an alpha of 0.05 was utilized to analyze the primary outcome. Other outcomes were reported as descriptive statistics.
Results: A total of 167 patients were assessed (136 patients in the ST group and 31 patients in the OT group). There were 4 (2.9%) and 1 (3.2%) VTEs in the ST and OT groups, respectively (OR = 0.10; 95% CI, -2.13 to 2.32; P > 0.05). All VTEs occurred during the late postoperative period. In the ST group, 3 patients had an uncomplicated pulmonary embolism (PE) or deep venous thromboembolism, and 1 patient died due to thromboembolic complications. In the OT group, 1 patient had an uncomplicated PE. There were no significant differences in postoperative bleeding (11.4% versus 14.4%) or thrombocytopenia (45.7% versus 47.4%) in patients receiving pharmacologic versus non-pharmacologic thromboprophylaxis.
Implications: Provision of optimal thromboprophylaxis was low for high-risk surgical oncology patients; however, this was not associated with an increase in VTEs. Use of pharmacologic thromboprophylaxis did not increase rates of bleeding or thrombocytopenia. Education is needed to increase compliance with guideline recommendations for postoperative thromboprophylaxis in high-risk surgical oncology patients at our institution.