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VHA-Wide Automated Assessment of EGFR Mutation Testing in Advanced Stage, Non-Squamous, Non-Small Cell Lung Cancer (nsNSCLC)
Purpose: To assess feasibility of implementing an automated method to identify patients who should have EGFR testing, and whether they have been tested, as a tool for quality improvement.
Background: Approximately 7% of veterans with metastatic, nsNSCLC have sensitizing mutation of EGFR, which predicts sensitivity to oral EGFR inhibitors. Prior studies have shown under testing for EGFR mutations in this population in VHA.
Methods: An endorsed quality measure (NQF and ASCO) for EGFR testing was utilized. Data to implement the measure were extracted from the cancer registry (ONC RAW), problem and encounter ICD codes, national oncology note template-generated health factors, laboratory test results, National Precision Oncology Program NGS testing, vital status, and pharmacy drug file to populate a SQL database. A dashboard in SharePoint allowed users to retrieve data based on national data access permissions. Descriptive statistics were used.
Results: The initial algorithm implementation was evaluated by comparison to manual review of patient records from one medical center. The second generation algorithm was then evaluated in the same manner at a second medical center (MC2). Among 117 cases identified during 2018, 68 (58%) were identified as having been tested and 49 (42%) not tested (31 living and 18 deceased patients). 48 of the non-tested samples were reviewed: 28 had not been tested, 14 had data documentation or coding problems (11 correctable by using the national note template), 1 correctable limitation of the national note template, and 5 limitations of the algorithm (all but 1 of which has been corrected). For stage 3 and stage VA-wide, there were 871 and 2832 cases, respectively, with documented testing rates of 26% and 36%, and a facility testing rate range of 0% to 100%.
Implications: The EGFR testing dashboard, in conjunction with appropriate structured documentation, has high accuracy of EGFR testing in patients with metastatic nsNSCLC. Current documented testing rates vary widely with a low system-wide rate, that can be improved through utilization of the dashboard.
Purpose: To assess feasibility of implementing an automated method to identify patients who should have EGFR testing, and whether they have been tested, as a tool for quality improvement.
Background: Approximately 7% of veterans with metastatic, nsNSCLC have sensitizing mutation of EGFR, which predicts sensitivity to oral EGFR inhibitors. Prior studies have shown under testing for EGFR mutations in this population in VHA.
Methods: An endorsed quality measure (NQF and ASCO) for EGFR testing was utilized. Data to implement the measure were extracted from the cancer registry (ONC RAW), problem and encounter ICD codes, national oncology note template-generated health factors, laboratory test results, National Precision Oncology Program NGS testing, vital status, and pharmacy drug file to populate a SQL database. A dashboard in SharePoint allowed users to retrieve data based on national data access permissions. Descriptive statistics were used.
Results: The initial algorithm implementation was evaluated by comparison to manual review of patient records from one medical center. The second generation algorithm was then evaluated in the same manner at a second medical center (MC2). Among 117 cases identified during 2018, 68 (58%) were identified as having been tested and 49 (42%) not tested (31 living and 18 deceased patients). 48 of the non-tested samples were reviewed: 28 had not been tested, 14 had data documentation or coding problems (11 correctable by using the national note template), 1 correctable limitation of the national note template, and 5 limitations of the algorithm (all but 1 of which has been corrected). For stage 3 and stage VA-wide, there were 871 and 2832 cases, respectively, with documented testing rates of 26% and 36%, and a facility testing rate range of 0% to 100%.
Implications: The EGFR testing dashboard, in conjunction with appropriate structured documentation, has high accuracy of EGFR testing in patients with metastatic nsNSCLC. Current documented testing rates vary widely with a low system-wide rate, that can be improved through utilization of the dashboard.
Purpose: To assess feasibility of implementing an automated method to identify patients who should have EGFR testing, and whether they have been tested, as a tool for quality improvement.
Background: Approximately 7% of veterans with metastatic, nsNSCLC have sensitizing mutation of EGFR, which predicts sensitivity to oral EGFR inhibitors. Prior studies have shown under testing for EGFR mutations in this population in VHA.
Methods: An endorsed quality measure (NQF and ASCO) for EGFR testing was utilized. Data to implement the measure were extracted from the cancer registry (ONC RAW), problem and encounter ICD codes, national oncology note template-generated health factors, laboratory test results, National Precision Oncology Program NGS testing, vital status, and pharmacy drug file to populate a SQL database. A dashboard in SharePoint allowed users to retrieve data based on national data access permissions. Descriptive statistics were used.
Results: The initial algorithm implementation was evaluated by comparison to manual review of patient records from one medical center. The second generation algorithm was then evaluated in the same manner at a second medical center (MC2). Among 117 cases identified during 2018, 68 (58%) were identified as having been tested and 49 (42%) not tested (31 living and 18 deceased patients). 48 of the non-tested samples were reviewed: 28 had not been tested, 14 had data documentation or coding problems (11 correctable by using the national note template), 1 correctable limitation of the national note template, and 5 limitations of the algorithm (all but 1 of which has been corrected). For stage 3 and stage VA-wide, there were 871 and 2832 cases, respectively, with documented testing rates of 26% and 36%, and a facility testing rate range of 0% to 100%.
Implications: The EGFR testing dashboard, in conjunction with appropriate structured documentation, has high accuracy of EGFR testing in patients with metastatic nsNSCLC. Current documented testing rates vary widely with a low system-wide rate, that can be improved through utilization of the dashboard.
Structuring Data to Automate Cancer Survivorship Care Plans
Purpose: To provide reusable data to facilitate standardized oncology care documentation in CPRS for survivorship care plans (SCP) and other notes.
Background: SCP are guideline-recommended documents to engage patients in their post-treatment care. Creating a SCP manually by reviewing progress notes and redocumenting this information in a survivorship care plan is time consuming and tedious, which reduces completion rates and accuracy. The National Oncology Program office seeks to provide automated tools for VA facilities and providers to create SCPs that are timely, accurate, readily available and easily updated. SCPs created with structured data also allow for tracking of delivery of planned care.
Methods: Sixteen reminder note templates were developed that included SCPs for breast, colorectal, prostate, and lung cancers. Content for the SCP are based on Commission on Cancer (CoC) standards and determined by evidence-based quality measures from ASCO QOPI standards.
Each template has embedded patient data objects (health factors) that display previously entered information, eliminating the need for provider review of prior records. Updates to the SCP are accomplished by relaunching the SCP note template to import new health factor data. Health factor data were extracted from the VA Corporate Data Warehouse.
Results: All of the reminder dialogs have undergone formal usability testing. Changes were made to the reminder dialogs based upon this feedback. Several sections in the SCPs were made ‘local’ so that VA facilities can make edits, which reduces end-user data entry. The reminder dialogs were released nationally in April 2017, and their use to create SCPs has been endorsed by the CoC. As of June 2017, 2,775 health factors were generated on 458 patients,
and 58 SCPs have been completed.
Conclusions: Using patient data objects in progress notes offers a tool for oncology providers to use that can autocreate SCPs. Additional SCP are planned for H&N, liver, melanoma and hematological malignancies. Using patient data elements in CPRS identified by clinicians at the time
of care delivery allows core components of patient care to be structured and reused to greatly facilitate completion of SCPs.
Purpose: To provide reusable data to facilitate standardized oncology care documentation in CPRS for survivorship care plans (SCP) and other notes.
Background: SCP are guideline-recommended documents to engage patients in their post-treatment care. Creating a SCP manually by reviewing progress notes and redocumenting this information in a survivorship care plan is time consuming and tedious, which reduces completion rates and accuracy. The National Oncology Program office seeks to provide automated tools for VA facilities and providers to create SCPs that are timely, accurate, readily available and easily updated. SCPs created with structured data also allow for tracking of delivery of planned care.
Methods: Sixteen reminder note templates were developed that included SCPs for breast, colorectal, prostate, and lung cancers. Content for the SCP are based on Commission on Cancer (CoC) standards and determined by evidence-based quality measures from ASCO QOPI standards.
Each template has embedded patient data objects (health factors) that display previously entered information, eliminating the need for provider review of prior records. Updates to the SCP are accomplished by relaunching the SCP note template to import new health factor data. Health factor data were extracted from the VA Corporate Data Warehouse.
Results: All of the reminder dialogs have undergone formal usability testing. Changes were made to the reminder dialogs based upon this feedback. Several sections in the SCPs were made ‘local’ so that VA facilities can make edits, which reduces end-user data entry. The reminder dialogs were released nationally in April 2017, and their use to create SCPs has been endorsed by the CoC. As of June 2017, 2,775 health factors were generated on 458 patients,
and 58 SCPs have been completed.
Conclusions: Using patient data objects in progress notes offers a tool for oncology providers to use that can autocreate SCPs. Additional SCP are planned for H&N, liver, melanoma and hematological malignancies. Using patient data elements in CPRS identified by clinicians at the time
of care delivery allows core components of patient care to be structured and reused to greatly facilitate completion of SCPs.
Purpose: To provide reusable data to facilitate standardized oncology care documentation in CPRS for survivorship care plans (SCP) and other notes.
Background: SCP are guideline-recommended documents to engage patients in their post-treatment care. Creating a SCP manually by reviewing progress notes and redocumenting this information in a survivorship care plan is time consuming and tedious, which reduces completion rates and accuracy. The National Oncology Program office seeks to provide automated tools for VA facilities and providers to create SCPs that are timely, accurate, readily available and easily updated. SCPs created with structured data also allow for tracking of delivery of planned care.
Methods: Sixteen reminder note templates were developed that included SCPs for breast, colorectal, prostate, and lung cancers. Content for the SCP are based on Commission on Cancer (CoC) standards and determined by evidence-based quality measures from ASCO QOPI standards.
Each template has embedded patient data objects (health factors) that display previously entered information, eliminating the need for provider review of prior records. Updates to the SCP are accomplished by relaunching the SCP note template to import new health factor data. Health factor data were extracted from the VA Corporate Data Warehouse.
Results: All of the reminder dialogs have undergone formal usability testing. Changes were made to the reminder dialogs based upon this feedback. Several sections in the SCPs were made ‘local’ so that VA facilities can make edits, which reduces end-user data entry. The reminder dialogs were released nationally in April 2017, and their use to create SCPs has been endorsed by the CoC. As of June 2017, 2,775 health factors were generated on 458 patients,
and 58 SCPs have been completed.
Conclusions: Using patient data objects in progress notes offers a tool for oncology providers to use that can autocreate SCPs. Additional SCP are planned for H&N, liver, melanoma and hematological malignancies. Using patient data elements in CPRS identified by clinicians at the time
of care delivery allows core components of patient care to be structured and reused to greatly facilitate completion of SCPs.
Development of Templates to Standardize Oncology Documentation and Automate Measurement of Quality of Cancer Care
Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.
Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status, chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.
To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.
Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.
Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.
Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.
Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.
Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status, chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.
To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.
Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.
Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.
Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.
Introduction: The National Oncology Program office seeks to provide tools that can electronically capture data elements that can help VA facilities and programs assess the quality of cancer care being provided to veterans. Manual extraction of standards-of-care data from CPRS is resource intensive and difficult to sustain. This is particularly true for data elements embedded in large text fields such as progress notes.
Methods: Nine reminder dialogs were developed: treatment plan, treatment summary, multidisciplinary conference note (breast, prostate, colorectal), breast cancer, colorectal cancer,
symptom management tool, and an interval note. Each reminder dialogs include data elements that can be used to assess quality indicators (e.g., date of diagnosis, stage, performance status, chemotherapy agents used, radiation therapy sites, start/stop dates, surgery types, and outcomes) that align with the Commission on Cancer guidelines and the American Society of Clinical Oncology Quality Oncology Practice Initiative (QOPI) standards.
To extract the data electronically, distinct health factors are embedded with each of the data elements. Sequential Query Language (SQL) software is used to extract these health factors from the Corporate Data Warehouse. SQL code can be run as a script to update data iteratively (e.g., every 24 hours), thus eliminating manual data extractions.
Results: The reminder dialogs have undergone or will undergo formal usability testing (UT) prior to national release in fall 2016. The UT participants were selected because they are potential end users, and their input is vital to ensuring the dialogs follows current workflow.
Key improvements were made based upon the UT feedback. The breast cancer reminder dialog had additional surgery types added and a section to document why chemotherapy and radiation standards of care were not followed (patient refusal and contraindicated). Every date field in all 9 reminder dialogs was changed to facilitate ease of data entry.
Conclusion: Reminder dialogs provide a standardized documentation tool for QOPI oncology programs. SQL software provides a mechanism for streamlining QOPI data reporting. Both provide a way for VA to monitor cancer quality care in VA.
Implementation and Utility of the VA Symptom Management Tool (VAST)
Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.
Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.
Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).
Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.
Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.
Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.
Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).
Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.
Introduction: Cancer patients experience a variety of symptoms, which can be measured and documented using the VSAS (VA Symptom Assessment Scale) in CPRS.We recently developed VAST (VA Symptom Management Tool ) to create and document symptom management plans. We describe 3 VAST templates that address pain, constipation, and distress, and outline initial VAST implementation results.
Methods: We retrospectively identified a cohort in the Durham VA Hematology/Oncology clinic. The cohort was limited to patients with moderate to severe symptoms, rated at scores of ≥ 4 (0 – 10 scale with 10 = most severe). We evaluated pain, constipation, and distress VSAS pre- and post-VAST, evaluating mean values and using the paired t-test. A control cohort consisted of patients with VSAS scores of ≥ 4 for the same symptoms, but for which no VAST plan was documented.
Results: Between 11/16/15 and 6/14/16, we identified 78, 36, and 76 Veterans with moderate to severe pain, distress, and constipation, respectively. The mean number of days between the pre-VAST and post-VAST documentation was 36, 29, and 55 for pain, distress, and constipation. Pre-VAST and post-VAST mean scores were 6.42 and 3.82 for pain (P < .0001, 41% reduction), 6.28 and 4.81 for distress (P = .006, 23% reduction), and 6.38 and 3.96 for constipation (P < .0001, 38% reduction). In the control cohort, 542, 243, and 315 Veterans had pain, distress, and constipation scores documented in the same time frame. The mean number of days between the first and second VSAS score documentation were 122, 62, and 119 for pain, distress, and constipation. In the control cohort, pain scores fell from 6.41 to 4.87 (24% reduction), distress scores fell from 6.63 to 4.63 (30% reduction), and constipation scores fell from 6.21 to 4.27 (31% reduction).
Discussion: The VAST is a tool to document and address cancer-related symptom management using a template form, so data can be extracted from the CDW for quality assessment and improvement. VAST may improve the management of and the severity of cancer-related symptoms. Future plans include development of other VAST symptom templates and integration of VAST with nationally used oncology quality measurement tools, such as ASCO QOPI.
VA Precision Oncology Program
Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.
Methods: Standard project management techniques and descriptive statistics were used.
Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.
Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.
Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.
Methods: Standard project management techniques and descriptive statistics were used.
Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.
Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.
Purpose: The White House Cancer Moonshot Initiative aims to double the rate of progress against cancer. A component of VA’s efforts to support Cancer Moonshot is VA’s national Precision Oncology Program (POP), which aims to (1) create best practices to provide genomic testing and reporting of tumor samples from patients; (2) provide annotation of tumor molecular analysis panels and consultative services to cancer care providers; (3) facilitate access to matching approved and novel therapies; and (4) institute a learning healthcare system for administrative, clinical care and research purposes. The aspirational goal of POP is to double the survival of patients with advanced NSCLC.
Methods: Standard project management techniques and descriptive statistics were used.
Results: As of June 2016, a Director of POP and an interim advisory group have been appointed. 32 facilities have been contacted and provided an initial response. 18 facilities are enrolled in POP and have sent at least 1 tumor sample; 8 additional facilities are in the activation process. A total of 347 tumor samples have been sent for profiling through one of two vendors, including 231 lung cancer cancers and 75 melanomas. Support for annotation of tumor genetic panels is available from N-of-One and IBM Watson for Oncology. To date, 13 patients have received targeted agents after tumor panel testing including erlotinib or gefitinib (n = 5), crizotinib (n = 3), and 1 patient each for dabrafenib + trametinib, vemurafenib, olaparib, pazopanib, and sunitinib. Research partnerships with other governmental agencies, non-profit organizations, and industry are being pursued to expand access to novel therapies. “Smart” CPRS templates that structure core clinical data elements have been designed to support clinician documentation needs, POP activities, and the learning healthcare system.
Implications: Implementation of the National Precision Oncology Program at all facilities treating patients with advanced cancer is planned.
Breast Cancer Risk Assessment and Utilization of Prevention Options Among Female Veterans: A Feasibility Pilot Study
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.