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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.
Brentuximab Vedotin in a Patient With Aggressive Systemic Mastocytosis and Pure Red Cell Aplasia
Backround: Mastocytosis is a rare disease with a variable clinical course. Pure red cell aplasia has not been frequently reported in association with aggressive systemic mastocytosis. CD30 is often expressed on mast cells in systemic mastocytosis. The CD30-directed antibody-drug conjugate brentuximab vedotin has shown in vitro activity against CD30-positive neoplastic mast cells. We describe a case of systemic mastocytosis with the development of severe hemolytic anemia, pure red cell aplasia, and evidence of weak bone marrow CD30 positivity. Brentuximab vedotin was administered with some evidence of clinical benefit.
Patient: A 64-year-old man presented with fatigue and a 20 pound weight loss. He was found to have transfusion-dependent anemia, a low reticulocyte count, and splenomegaly. Evaluation for gastrointestinal blood loss was unremarkable. Bone marrow biopsy showed mast cell aggregates, spindle-shaped mast cells, CD-2 and CD25-positivity, increased myelopoiesis and dysmegakaryopoiesis, red cell aplasia, eosinophilia, and increased reticulin fibrosis. The D816V c-kit mutation was present, and serum tryptase level was elevated at 114 ng/mL. He later developed Coombs-positive hemolysis and direct hyperbilirubinemia, concerning for mast cell liver infiltration.
Intervention: The patient received high-dose steroids and red blood cell transfusions. Interferon alpha and cladribine were contraindicated, given severe liver dysfunction. He was started on hydroxyurea. He received a dose of brentuximab vedotin 1.8 mg/kg IV. Thirteen days after starting steroids and 10 days after brentuximab, haptoglobin became detectable, and total bilirubin decreased to 18.4 mg/dL from 40.5 mg/dL. Red blood cell transfusion requirements decreased. He then developed severe neutropenia, pneumonia with sepsis, and respiratory failure, requiring intubation, maximal pressor support, and broad-spectrum antibiotics. Despite these measures, he expired.
Discussion/Conclusion: This is a rare case of pure red cellaplasia in the setting of aggressive systemic mastocytosis. Therapeutic options were limited in the setting of liver dysfunction, and therapy with brentuximab vedotin resulted in initial clinical benefit. Brentuximab vedotin is being investigated in patients with advanced systemic mastocytosis or mast cell leukemia.
Backround: Mastocytosis is a rare disease with a variable clinical course. Pure red cell aplasia has not been frequently reported in association with aggressive systemic mastocytosis. CD30 is often expressed on mast cells in systemic mastocytosis. The CD30-directed antibody-drug conjugate brentuximab vedotin has shown in vitro activity against CD30-positive neoplastic mast cells. We describe a case of systemic mastocytosis with the development of severe hemolytic anemia, pure red cell aplasia, and evidence of weak bone marrow CD30 positivity. Brentuximab vedotin was administered with some evidence of clinical benefit.
Patient: A 64-year-old man presented with fatigue and a 20 pound weight loss. He was found to have transfusion-dependent anemia, a low reticulocyte count, and splenomegaly. Evaluation for gastrointestinal blood loss was unremarkable. Bone marrow biopsy showed mast cell aggregates, spindle-shaped mast cells, CD-2 and CD25-positivity, increased myelopoiesis and dysmegakaryopoiesis, red cell aplasia, eosinophilia, and increased reticulin fibrosis. The D816V c-kit mutation was present, and serum tryptase level was elevated at 114 ng/mL. He later developed Coombs-positive hemolysis and direct hyperbilirubinemia, concerning for mast cell liver infiltration.
Intervention: The patient received high-dose steroids and red blood cell transfusions. Interferon alpha and cladribine were contraindicated, given severe liver dysfunction. He was started on hydroxyurea. He received a dose of brentuximab vedotin 1.8 mg/kg IV. Thirteen days after starting steroids and 10 days after brentuximab, haptoglobin became detectable, and total bilirubin decreased to 18.4 mg/dL from 40.5 mg/dL. Red blood cell transfusion requirements decreased. He then developed severe neutropenia, pneumonia with sepsis, and respiratory failure, requiring intubation, maximal pressor support, and broad-spectrum antibiotics. Despite these measures, he expired.
Discussion/Conclusion: This is a rare case of pure red cellaplasia in the setting of aggressive systemic mastocytosis. Therapeutic options were limited in the setting of liver dysfunction, and therapy with brentuximab vedotin resulted in initial clinical benefit. Brentuximab vedotin is being investigated in patients with advanced systemic mastocytosis or mast cell leukemia.
Backround: Mastocytosis is a rare disease with a variable clinical course. Pure red cell aplasia has not been frequently reported in association with aggressive systemic mastocytosis. CD30 is often expressed on mast cells in systemic mastocytosis. The CD30-directed antibody-drug conjugate brentuximab vedotin has shown in vitro activity against CD30-positive neoplastic mast cells. We describe a case of systemic mastocytosis with the development of severe hemolytic anemia, pure red cell aplasia, and evidence of weak bone marrow CD30 positivity. Brentuximab vedotin was administered with some evidence of clinical benefit.
Patient: A 64-year-old man presented with fatigue and a 20 pound weight loss. He was found to have transfusion-dependent anemia, a low reticulocyte count, and splenomegaly. Evaluation for gastrointestinal blood loss was unremarkable. Bone marrow biopsy showed mast cell aggregates, spindle-shaped mast cells, CD-2 and CD25-positivity, increased myelopoiesis and dysmegakaryopoiesis, red cell aplasia, eosinophilia, and increased reticulin fibrosis. The D816V c-kit mutation was present, and serum tryptase level was elevated at 114 ng/mL. He later developed Coombs-positive hemolysis and direct hyperbilirubinemia, concerning for mast cell liver infiltration.
Intervention: The patient received high-dose steroids and red blood cell transfusions. Interferon alpha and cladribine were contraindicated, given severe liver dysfunction. He was started on hydroxyurea. He received a dose of brentuximab vedotin 1.8 mg/kg IV. Thirteen days after starting steroids and 10 days after brentuximab, haptoglobin became detectable, and total bilirubin decreased to 18.4 mg/dL from 40.5 mg/dL. Red blood cell transfusion requirements decreased. He then developed severe neutropenia, pneumonia with sepsis, and respiratory failure, requiring intubation, maximal pressor support, and broad-spectrum antibiotics. Despite these measures, he expired.
Discussion/Conclusion: This is a rare case of pure red cellaplasia in the setting of aggressive systemic mastocytosis. Therapeutic options were limited in the setting of liver dysfunction, and therapy with brentuximab vedotin resulted in initial clinical benefit. Brentuximab vedotin is being investigated in patients with advanced systemic mastocytosis or mast cell leukemia.