bluuebunny/crossref_metadata_2025 huggingface dataset:
Prediction of histologic and molecular subsets of soft tissue sarcoma using deep learning.
Authors: Rosenberg Ari , Kochanny Sara , Dolezal James , Wang Cindy , Chen Heather , Kather Jakob Nikolas , Pearson Alexander T.
Published: May 2020

e23529

Background: Soft tissue sarcomas (STS) are histologically and molecularly heterogenous with variable biologic behavior and differential therapeutic responses. Molecular analysis of STS is commonly utilized to identify targetable mutations or identify STS subtypes that have predictive and prognostic implications. To address the challenge of rapid, accurate classification of STS subtypes, we sought to develop an approach using a form of artificial intelligence called deep learning to identify meaningful hidden information directly from digital H+E slide images. We trained a deep learning model using genotype and phenotype data from The Cancer Genome Atlas (TCGA) and companion diagnostic digital H+E slide images, in order to identify therapeutic biomarkers and prognostic molecular subtypes. Methods: Digital whole slide images (WSIs) from TCGA were downloaded and regions of tumor were annotated by pathologists. WSIs were carved into 604 um by 604 um square tiles within the tumor region and saved at an image size of 598 px by 598 px for a resolution of ~1um/px. These tiles were used as input to a deep convolution neural network (Xception model pretrained on imagenet). Performance results are reported at the as the average of three-fold cross-validation, averaged at the patient level. Results: 206 sarcomas available through the TCGA were used as training set. Sarcoma histologies include 80 leiomyosarcoma (LMS) (27 uterine LMS and 53 non-uterine LMS), 50 dedifferentiated liposarcoma (DDLPS), 44 undifferentiated pleomorphic sarcoma (UPS), 72 myxofibrosarcoma (MFS), and 10 synovial sarcoma (SS). FNCLCC grade 1 (n = 14), grade 2 (n = 112), and grade 3 (n = 80). Histology could be predicted automatically with very high accuracy for LMS (Area under Receiver-operator curve (AUROC) 0.93 and 0.95 for uterine and non-uterine LMS respectively), DDLPS (AUROC 0.70), UPS (AUROC 0.76), and MFS (AUROC 0.76). FNCLCC grade could be predicted for grade 3, 2, 1 with AUROC of 0.79, 0.73, and 0.81 respectively. High vs. low mitotic rate (threshold 15) could be predicted with AUROC of 0.70. Within non-uterine LMS, prognostic molecular cluster could be predicted with AUC of 0.62 for cluster with worse recurrence-free and disease specific survival. Within DDLPS, DNA methylation cluster 2 associated with worse disease specific survival was predicted with AUC of 0.80. Conclusions: Deep learning algorithm analysis of histologic slides was able to predict clinically meaningful characteristics and molecular clusters with reasonable accuracy. Retrospective and prospective validation is needed.
Multiscale omic assessment of EWSR1-NFATc2 fusion positive sarcomas to identify conserved fusion breakpoint and activation of the mTOR pathway.
Authors: Seligson Nathan David , Maradiaga Richard D , Stets Colin W. , Katzenstein Howard , Millis Sherri Z. , Hays John L. , Chen James Lin
Published: May 2020

e23536

Background: EWSR1-NFATc2 ( E-N) fusion positive sarcomas are rare cancers historically categorized as Ewing sarcomas. Emerging evidence suggests unique molecular characteristics and chemotherapy sensitivities in these cancers. Here we present the largest cohort of genomically profiled E-N fusion positive sarcomas and evaluate their breakpoints and putative pathway alterations. Methods: Comprehensive genomic profiling of 1,024 EWSR1 fusion positive sarcomas, including 14 E-N fusions, was obtained through the Foundation Medicine research database (FMI). Additional data from the Gene Expression Omnibus, the Genomics of Drug Sensitivity in Cancer (GDSC), and The Cancer Genome Atlas (TCGA) datasets were used. Descriptive statistics, principle component analysis, differential expression, and pathway analysis were used as appropriate. Results: E-N fusions identified in the FMI database demonstrated consistent breakpoints located between exon 2 and 3 on NFATc2; consistent with previous reports suggesting that the primary transactivation domain and regulatory domains of NFATc2 are conserved in the EWRS1-NFATc2 fusion. Cluster analysis demonstrated separate E-N fusion positive sarcoma grouping than other EWRS1 sarcomas, while identifying an enrichment of mTOR pathway variants in E-N fusion positive samples (p = 0.05). Gene expression data from E-N identified a significant activation of the mTOR pathway in E-N positive sarcomas compared to either EWSR1-ETS (p = 0.002) or CIC-DUX4 positive sarcomas (p < 0.001). In the GDSC database, NFATc2-High lines exhibited activation of the mTOR pathway (p < 0.0001) and were more sensitive to the mTOR inhibitor rapamycin (p = 0.0006). Pan-cancer analysis of 33 non-overlapping TCGA datasets, elevated NFATc2 mRNA expression was significantly associated with activated RICTOR and mTOR signaling (p < 0.0001). Elevated NFATc2 correlated with higher tumor grade and poorer progression-free survival and overall survival. Conclusions: Taken together, the data presented here suggests that E-N fusion positive sarcomas represent a distinct molecularly entity in comparison to traditional Ewing sarcomas. Conserved action of NFATc2 may correlate to mTOR over activation.
Sarcoma Treatment Efficacy Portal (STEP): A novel informatics portal providing real-time, real-world outcomes to clinicians.
Authors: Grosenbacher Nicholas , Phillips Audra , Liebner David A. , Tinoco Gabriel , Chen James Lin
Published: May 2020

e23538

Background: There are currently no informatics tools that are capable of providing complex clinical decision support using real-world outcomes (RWO) for patients with sarcoma. Although existing nomograms can provide prognostic scores based on clinical or genomics features, they typically are static and lack the ability to compare outcomes for patients managed with alternative treatment strategies. To address this need, we present STEP, a Sarcoma Treatment Efficacy Portal, a web-based tool designed for real-time exploration and visualization of patient data with the potential to be integrated into clinical decision workflows during outpatient visits. Methods: At The Ohio State University, clinical histories and omics data for sarcoma patients are captured in our prospective Sarcoma Registry (NCT0267796). STEP is an interactive web-based tool built in R/Shiny and supported by a pipeline written Python that processes, transforms, and caches clinical data extracted from the Sarcoma Registry in near real-time. Protected health information (PHI) is stored on a secure HIPAA compliant server behind the hospital firewall and migrated to a secure, deidentified staging database. Results: The STEP system is powered by detailed treatment specific data elements that are continuously abstracted for over 400 patients with bone and soft tissue sarcoma. This consists of manually annotated clinical histories in addition to nearly 10 million discrete data points are pulled from the EHR (labs, ICD-9/10 codes, medications, omics data). Importantly, STEP includes a cohort builder which allows users to define a treatment group of interest though any number of variables including tumor histology, chemotherapy, and omic features of interest. For any predefined cohort, STEP can provide information on overall survival and response to a variety of treatments. It also provides sorting mechanisms for identifying candidate treatments. A secure web interface allows a simple integration into a busy clinic flow. Conclusions: STEP provides a first in class, convenient, clinician friendly platform for delivering access to real-time, real-world treatment outcomes (RWO) in patients with a diagnosis of bone or soft tissue sarcoma. Additional usability testing is forthcoming.
Multi-institutional collaboration in sarcoma and central nervous system tumors.
Authors: Gillingham Jacob , Siontis Brittany , Robinson Steven Ian , Okuno Scott H.
Published: May 2020

e23544

Background: Rare diseases are defined as conditions that affect less than 200,000 people annually in the United States. Around 17000 cases of sarcoma will be diagnosed in 2020. Collaboration among institutions is needed to best understand rare diseases such as sarcoma. One measure of collaboration is publications with multiple institutions as authors. We sought to determine if collaboration in sarcoma has increased since 2011 and compared that to another rare disease, CNS tumors based on multi-institution-authored abstracts presented at ASCO. Methods: All sarcoma and CNS oral abstracts, clinical science symposia, poster presentations, poster discussions, and published-only ASCO Annual Meetings from 2011 to 2019 were reviewed. Collaboration was determined if the abstract authors were from more than one institution. Results: 2,134 abstracts were reviewed. Collaboration for sarcoma ranged from 0.603 to 0.720 and 0.582 to 0.755 for CNS. From 2011-2019 a positive linear trend in collaboration was found in CNS (P < 0.05), but not in sarcoma (P = NS). There was no significant trend in the incidence of collaboration in Sarcoma based on the type of presentation at ASCO. There was no difference in collaboration between bone or soft tissue sarcoma abstracts or median number of institutions collaborating between sarcoma and CNS. There were more international collaborations and absolute number of institutions in sarcoma vs CNS. Conclusions: Sarcoma collaboration has remained constant from 2011-2019 with greater number of institutions and more international collaborations as compared to CNS. CNS collaboration has increased from 2011-2019. Sarcoma collaboration at ASCO is robust and reflects the need for multi-institutional partnership.
Impact of upfront multidisciplinary tumor board (MTB) evaluation on breast sarcoma (BS) outcome.
Authors: Tolomeo Francesco , Chilà Giovanna , D'Ambrosio Lorenzo , Merlini Alessandra , Sgandurra Paola , Kubatzki Franziska , Sgrò Luca Giuseppe , Miano Sara , Manessi Giulia , Pisacane Alberto , Aliberti Sandra , Siatis Dimitrios , Gatti Marco , Biglia Nicoletta , Ponzone Riccardo , Aglietta Massimo , Grignani Giovanni
Published: May 2020

e23546

Background: Although sarcomas may arise in any site of the body, the intrinsic challenge of BS is to affect the female most frequent cancer site with a completely different and rare set of heterogeneous tumors. Unfortunately, we lack BS-specific prospective trials to precisely guide the clinical decision-making and BS patients are often sent to sarcoma referral centers only after surgery without upfront BS MTB evaluation. Recent evidences reported a significant prognosis improvement with upfront MTB evaluation in retroperitoneal or extremity sarcomas, but whether this strategy might benefit also BS is still not defined. We retrospectively evaluated our prospectively collected database to test whether an upfront MTB evaluation at BS referral centers might impact prognosis and/or the need of subsequent surgeries. Methods: Detailed information on primary surgery, diagnosis, and ≥2 years of follow-up for non-recurring patients were required. We tested the following outcomes: event-free survival (EFS), local EFS (LEFS), distant metastases EFS (DMEFS), overall survival (OS), margin status, subsequent surgeries rate. We evaluated the different outcomes according to upfront MTB evaluation. Kaplan-Meier method was used for survival analyses. Comparisons used hazard ratios (HR). Results: We included 93 patients treated between 1/2000 and 10/2019 at 2 reference BS Centers, median age 53 years (IQR 41-70), ECOG (0;1;2) 67:16:10, high/low grade 60:33. Histotypes were: malignant phyllodes tumor 42 (45%), angiosarcoma 26 (28%), other STS 25 (27%). 27 (29%) cases were considered radiation-induced with a median time from RT of 105 months (IQR 70-127). 44 patients (47%) were discussed upfront in BS MTB, whereas 49 (53%) were not. With a median follow up of 43 months, 5-year EFS, LEFS, DMEFS, and OS for the whole population were 54%, 64%, 60%, and 62%, respectively. LEFS at 5 years had a strong association with margin status (R0 74%; R1 55%, R2 0%, p < 0.001). Regardless of histology, upfront MTB was associated with a significant lower rate of subsequent surgeries (OR 0.16, 0.06-0.41), and with better EFS, LEFS, DMEFS, and OS (HRs 0.57, 0.54, 0.63, and 0.43, respectively). Conclusions: Though retrospective, this series is one of the largest reported to date in BS. Our results highlight the need for early inter-tumor board sharing of BS to take into account sarcoma specificity in the overall disease planning. Given BS rarity, these data will hardly ever be verified in a prospective fashion. Therefore, validation of these results in the Italian Sarcoma Group database is planned.
Patient journey and quality of life (QOL) among diffuse-type TGCT in the U.S.
Authors: Bernthal Nicholas M. , Spierenburg Geert , van de Sande Michiel , Healey John H. , Stacchiotti Silvia , Bauer Sebastian , Gelderblom Hans , Staals Eric , López Bastida Julio , Fronk Eva-Maria , Ye Xin , Laeis Petra , Palmerini Emanuela
Published: May 2020

e23565

Background: Diffuse Tenosynovial Giant Cell Tumor (d-TGCT) is a rare, locally aggressive neoplasm of joint and tendon sheath synovia, which may severely affect patients (pts) QOL due to pain, limited joint function and destruction of bone and local tissues. This study analyzes real-world data to describe d-TGCT pt journey and QOL in the US. Methods: The TGCT Observational Platform Project (TOPP), the first non-interventional prospective disease registry, enrolled d-TGCT pts at 10 Western European (EU) and 2 US sarcoma centers from Nov 2016 to Mar 2019, with prospective follow-up of 24 mo. Pts demographics, disease history and ongoing medical treatment and pt-reported outcomes (PROs) (pain, stiffness, PROMIS Physical Function [PF] and EQ-5D) were collected at baseline and every 6 mo during follow-up periods. Descriptive analyses from baseline compared US pts with Western EU pts (Table). Results: Of 166 d-TGCT pts, 30 were enrolled in the US. Mean age was 40.6 ± 12.82 y, with 63.3% female and 66.7% with tumor in knee. Median time from first symptom to diagnosis was 12 mo (range; 0–153). 28 pts (93.3%) had surgery, 4 pts (13.3%) had tyrosine kinase inhibitors (TKI), no pts had radiotherapy. 18 pts (60%) experienced >1 locoregional recurrence. Median Pain Severity Score (PSS) and Pain Interference Score (PIS) were 2.8 and 3.0, respectively. Median PROMIS PF Score was 39.8. Mean EQ-5D index score and visual analogue scale (VAS) were 0.73 ±0.229 and 75.5 ±13.31, respectively. Compared with Western EU pts, US pts reported similar PROs and QOL, were younger, had shorter delay in diagnosis, and lower use of systemic therapy or radiotherapy (Table). Conclusions: d-TGCT affects a relatively young population in the US, similar to Western EU, resulting in serious impairment in daily activities and QOL. Shorter diagnostic delay and less frequent use of non–surgical approach was observed in the US. [Table: see text]
Growth factor and its role in the treatment of patients with soft tissue extremity sarcoma receiving chemotherapy managed at an academic center: A retrospective study.
Authors: Pancholy Neha , Walter Vonn , Drabick Joseph J. , Fox Edward J , Zaorsky Nicholas George , Vasekar Monali K.
Published: May 2020

e23573

Background: Surgery still remains the mainstay of treatment with curative intent for high grade extremity soft tissue non rhabdomyosarcoma sarcomas (HG ESTS). Adjuvant/neoadjuvant Chemotherapy (CT) is still debatable, but most experts agree about its role in HG-ESTS in combination with radiation (R). Interdigitated CT+R is an attractive method of delivering these modalities of treatment in short time prior to surgery, however safety of using growth factor (GF) while administering CT+R in HG ESTS is largely unknown. We conducted a retrospective study of the toxicities associated with GF administration in this setting at a single institution. Methods: Electronic medical records at one institution were reviewed to identify patients having a diagnosis of extremity STS between October 2017- January 2020. Demographics, details of tumor characteristics, and treatment details were noted. Details of Interdigitated (ID)CRT were noted; the intended CT regimen was doxorubicin/ifosphamide/mesna (MAI) at 100% of the intended dosing. Data regarding the toxicities associated with GF administration were also evaluated in these patients; specifically, the development of febrile neutropenia, thrombocytopenia and pulmonary toxicity were evaluated. Patients who presented with metastatic disease were excluded from this analysis. Results: 22 patients were identified. Median age was 63 years. Of these, 9 patients (40%) were smokers. At diagnosis, 6 patients (27%) had metastatic disease. The most common site of primary disease was the thigh (50%). The most common histology was undifferentiated pleomorphic sarcoma (59%). CT monotherapy was administered in 3 patients. RT was administered in 14 patients, out of whom interdigitated CRT was administered in 10 patients. 60% of patients who initiated were able to receive 3 cycles of ID-CRT prior to Surgery. GF was administered in 14 patients who received regimens including CT. Of patients receiving ID-CRT who received GF, 60% completed ID-CRT without delays. No delays occurred due to thrombocytopenia. Febrile neutropenia occured in 22% of patients who received GF. Only 1 patient who received GF suffered prolonged thrombocytopenia. No patients who received GF were noted to have pulmonary toxicity. Conclusions: For adults with HG ESTS, GF administration with ID-CRT does not appear to cause any additional delay in treatment due to prolonged thrombocytopenia or lung toxicity. Inclusion of GF administration in further prospective trials of ID-CRT appears feasible.
Outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy +/- intraoperative radiation therapy in the management of peritoneal sarcomatosis: Real world experience.
Authors: Badran Ahmed ali , Elashwah Ahmed , Elshenawy Mahmoud Abdelsatar , Azzam Ayman , Alshibani Aisha , Alrakaf Reem , AbdelRehem Rania Naguib , Eldali Abdelmoniem , Amin Tarek
Published: May 2020

e23581

Background: Sarcomas are aggressive malignancy,30-40% of them originate from retroperitoneal space. which makes adequate free surgical margin after surgical debulking mostly not achievable. The addition of Hyperthermic intraperitoneal chemotherapy (HIPEC)+/- Intraoperative radiation therapy (IORT) may overcome local failure with an overall survival benefit. we studied the outcome of cytoreductive surgery (CRS)+ HIPEC +/- IORT on patients with peritoneal sarcomatosis,at our institute. Methods: Patients with peritoneal sarcomatosis treated with CRS+ HIPEC +/- IORT, in the period between 2011-2016 were included. Results: 24 patients identified;15(62.5%) were males. Median age was 58(31-77). Liposarcoma was the most frequent diagnosis in 50% of them. Neoadjuvant chemotherapy was received in 5 patients, while neoadjuvant radiation therapy was received in 3 patients. Cytoreduction completeness score (CC-0/1) was achieved in 19(79.17%), with median peritoneal cancer index (PCI) of 11 (3–28). Melphalan was the most commonly used agent for HIPEC chemotherapy, it was used in 16(66.67%) patients. IORT was given in 16(66.67%) patients. 8 patients developed grade III-IV Clavien-Dindo (CD) complications, with one died 5 days post operatively due to pulmonary embolism. Adjuvant chemotherapy was received in 9 patients. After a median follow up of 21 months, the mean, 2 years and estimated 4 years progression free survival was 19.6 months, 30.6% and 15.3% respectively, 13(54.2%) patients developed systemic progression, lung was the most affected site at time of progression in 8/13(61.5%) patients. Local progression occurred in two patients, while both systemic and local progression occurred in one patient. The 3 cases progressed locally underwent redo CRS and HIPEC with average 18 months between the first and redo surgery. The mean, 2 years and estimated 4 years overall survival was 21.2 months, 75.7% and 75.7% respective. In univariate analysis only CC score correlate with PFS, the mean PFS for those patients with CC (0-1) vs (2-3) was 13.7 vs 11.5 months ( p = 0.036). Conclusions: Addition of HIPEC+IORT to surgical debulking in the management of peritoneal sarcomatosis; seems to be safe and may improve local control rate with a questionable survival benefit, a larger cohort with a multicentric study is needed for further evaluation.
Impact of advance care planning on the place of death for cancer patients: A retrospective cohort study.
Authors: Orlovic Martina , Riley Julia , Droney Joanne
Published: May 2020

e24007

Background: Place of death is an important indicator of quality of end-of-life care (EOLC). Most patients do not want to die in hospital and hospital deaths are costly to healthcare organisations. Advance care planning (ACP) includes discussions about where patients want to die. Cancer patients often have a distinct illness trajectory with a clear terminal phase, enabling opportunities for EOLC planning. This work aims to explore the impact of ACP on the outcomes and place of death for cancer patients. Methods: A retrospective decedent cohort study of 10,727 cancer patients with a Coordinate My Care (CMC) record created 2011-2019. CMC is a digital platform that enables patients to record, revise and share their ACP and EOLC preferences with primary, secondary and urgent healthcare providers in London. Logistic regression analysis was applied to examine the relationship between in-hospital death and a range of individual characteristics and EOLC preferences. Results: Only 1% chose hospital as their preferred place of death. Overall, 71% died in their place of preference. Home (42%) was the most common place of death, while 20% died in hospital. The likelihood in-hospital death is positively associated with being older (OR = 1.12, p < 0.1), hospital being the preferred place of care (OR = 2.56, p < 0.001), hospital being the preferred place of death (OR = 2.85, p < 0.001) and if the preferred place of death is not recorded (OR = 1.32, p < 0.001). By contrast, patients who are severely frail (OR = 0.61, p < 0.001), who chose not to be resuscitated (OR = 0.56, p < 0.001) and who have a ceiling of treatment for symptomatic rather than intensive hospital based treatments (OR = 0.40, p < 0.001) are less likely to die in hospital. Conclusions: Most cancer patients prefer out-of-hospital death. Discussing, recording and sharing individual’s EOL preferences leads to better quality EOLC. Patient characteristics influence in-hospital deaths, but EOLC preferences exert stronger impact. Enabling cancer patients to die outside of hospital has positive implications for patients and their families and supports cost-effective use of healthcare resources.
Effectiveness of a medical student-led, advanced care planning intervention in an inpatient cancer population.
Authors: Nguyen Linda , Lo Shelly S. , Adams William , Hutchison Paul J.
Published: May 2020

e24010

Background: In an effort to provide patients with care that aligns with their values and goals, patients are encouraged to complete advance directives (ADs). While research has shown the benefits of advanced care planning (ACP) sessions, few studies have examined the thematic content of ACP discussions in an inpatient hematology or oncology population. Methods: We enrolled patients admitted to the hematology and oncology unit of an academic medical center who had never completed a power-of-attorney for healthcare form. One medical student 1) helped patients complete a power-of-attorney for healthcare form and 2) performed semi-structured interviews that explored patient's values, beliefs about end-of-life care, and preferences for medical treatments. Interviews were audio-recorded, transcribed, and analyzed through thematic analysis. Subjects completed pre- and post- surveys assessing their knowledge and attitudes about ACP. Results: All 48 patients enrolled in the study completed an advance directive. There was no significant change between pre- and post- intervention surveys evaluating patients’ trust in their physicians or family members to choose the right treatments for them in a life-threatening situation. Similarly, there was no change in patients’ comfort level discussing advance care planning after the interview. 79.2% of patients agreed or strongly agreed that they would recommend this ACP conversation to family and friends. 35.5% of patients agreed or strongly agreed that having this ACP conversation made them anxious. In the qualitative arm of the study, analysis suggests that cancer patients are willing to undergo further treatment unless it burdens their loved ones or interferes with quality time spent with family and friends. Motivating factors for patients included their spirituality and ability to fulfill a responsibility in a defined role. Conclusions: An ACP intervention performed by a medical student can increase the number of advance directives among patients admitted to inpatient hematology and oncology units. While this intervention may be anxiety-provoking for patients, it can illuminate the relative value patients place on the quality of their life versus their longevity.
Rate of complete chemotherapy as planned with comprehensive geriatric assessment guided intervention among vulnerable elderly cancer patients: A randomized-open-label study.
Authors: Maikami Manupol , Parinyanitikul Napa , Poovorawan Nattaya
Published: May 2020

e24021

Background: The Geriatric 8 (G8) is a simplified screening tool to select the appropriate elderly patients for chemotherapy. Vulnerable patients with impaired G8 score might need additional comprehensive geriatric assessment (CGA) with intervention for individual problem. However, the impact of CGA and therapeutic intervention on rate of complete chemotherapy among these patients is rarely addressed. This study aims to evaluate the benefit of CGA guided intervention. Methods: A single center, randomized, open-label study which included newly diagnosed elderly cancer patients (age ≥ 65) with impaired G8 score (≤ 14) who were designated for chemotherapy. After the enrollment, patients were randomized to 1:1 ratio to receive CGA guided intervention (intervention group) or usual care (control group). The primary end point was the rate of complete chemotherapy at 90-day. Associated factors for complete chemotherapy were evaluated. Results: Between June 2019 and December 2019, 52 patients were randomized (26 patients for intervention group and 26 patients for control group). Mean age was 72 years, 59.6% was female, 40.4% had breast cancer and 51.9% had early stage cancer. With G8 assessment, 55.8% had intermediate (score 11-14) and 44.2% had low (score < 11) impaired G8 score. All baseline characteristics were balanced. Using per protocol analysis, there was no significant difference in rate of complete chemotherapy between groups (61.9% vs 50%, OR 1.63; 95%Cl 0.51-5.23; p = 0.42). Considering subgroup analysis in the intermediate G8 score patients, the intervention group had a significant higher rate of complete chemotherapy than control group (81.8% vs 66.7%, OR 2.71; p = 0.02), but no significant difference in low G8 score group (40% vs 27.3%, OR 1.78; p = 0.58). In univariate analysis, age below 75 years, BMI > 20 kg/m2 and intermediate G8 score showed significant factors for improving rate of complete chemotherapy. Conclusions: This is the first study in south-east Asia using CGA and intervention to improve rate of completion in chemotherapy. Although the CGA and intervention had no significant difference but had tendency to be better in completion rate of chemotherapy than usual care. The intermediate-impaired G8 score subgroup is more likely to benefit from CGA guided intervention for complete chemotherapy as planned.
Post-operative delirium in older patients following cancer related and other high-risk surgeries.
Authors: Elias Rawad , Staff Ilene , Thompson Stephen , Waszynski Christine , Zanchi Jennifer , Dicks Robert
Published: May 2020

e24024

Background: Older adults are at increased risk for postoperative delirium (POD). This risk might be higher in patients with cancer as underlying malignancy and its complications predispose individuals to develop delirium. Therefore, it is important to evaluate the onset of delirium in this patient population especially as POD is associated with increased risk of rehospitalization, decline in cognitive function, morbidity and mortality. Methods: We performed a retrospective review of patients aged ≥ 70 years admitted January 2017 through July 2019 to a tertiary care referral center for a high-risk surgery, defined as associated with a mortality risk greater than 1%. Cancer related surgeries (CRS) were identified through cross matching with Cancer Registry. Patients who had delirium assessment in the postoperative setting using the Confusion Assessment Method (CAM) were included. Chi-square tests of proportion, Wilcoxon Ranked Sum and multivariate logistic regression analyses were conducted. Results: A total of 2340 patients were included in this analysis, 315 of whom had (CRS). Overall, the age (median, IQR) of patients at surgery was 76 years (72-80) and the length of stay (LOS) was 7 (4-11) days. Patients receiving CRS were younger (75, 72-79) than those with non-CRS (76, 72-81) (p = 0.022); had a shorter post-operative LOS (4, 2-7 vs. 5, 3-8; p > 0.001), and were less likely to develop POD (7.6% vs. 16.1%; p < 0.001). Among patients receiving CSR, those who developed POD were older (78 vs. 74; p = 0.008) and had longer post-operative LOS (14.0 vs. 4.0; p < 0.001). Those having experienced radiotherapy (RT) for cancer within the year before the surgery, were more likely to develop POD (40.0% vs. 6.6% p. < 0.001). Chemotherapy in the year prior to surgery did not increase the risk of POD (6.1% vs. 7.8%; p = 0.721). Among those having non-CRS, a cancer diagnosis did not affect POD. A logistic regression predicting POD indicated that the lower likelihood of POD following CRS was independent of age or gender (OR = 0.40; p < .001); RT within one year prior was independent predictor of higher POD (OR = 5.48; p = 0.003). Our data presentation will include further analysis of POD risk factors. Conclusions: Although older adults receiving CRS were significantly less likely to develop delirium than patients with other high-risk surgeries, it is still important to evaluate POD in this population due to its impact of patients’ outcomes. Further understanding of POD risk factors, such as preoperative RT, would allow the development of targeted interventions that might lessen the risk.
Patient-reported outcomes (PROs) in older adults with gastrointestinal (GI) cancer undergoing surgery.
Authors: Knight Helen Perry , Qian Carolyn L. , Kaslow-Zieve Emilia R. , Azoba Chinenye C. , Ferrone Cristina R. , Kunitake Hiroko , Fernandez-del Castillo Carlos , Lanuti Michael , Qadan Motaz , Ricciardi Rocco , Lillemoe Keith D. , Franco-Garcia Esteban , O'Malley Terrence A. , Jackson Vicki A. , Greer Joseph A. , El-Jawahri Areej , Temel Jennifer S. , Nipp Ryan David
Published: May 2020

e24032

Background: Older adults with GI cancer often experience poor surgical outcomes, yet little is known about their PROs, such as physical function, quality of life (QOL), and physical and psychological symptom burden. Methods: As part of a randomized trial of perioperative geriatric care, we prospectively enrolled older adults with GI cancer planning to undergo surgical resection. We asked patients preoperatively to self-report their physical function (ability to perform activities of daily living [ADLs] and instrumental ADLs [IADLs], higher scores indicate better functioning), QOL (EORTC QLQ-C30, higher scores indicate better QOL), symptom burden (Edmonton Symptom Assessment System [ESAS], higher scores indicate more severe symptoms, scores > 3 considered moderate/severe [mod/sev]), and depression symptoms (Geriatric Depression Scale [GDS], higher scores indicate more severe symptoms, scores > 4 represent a positive screen for depression). We used regression models to identify patient characteristics associated with these PROs. We also explored relationships among PROs and surgical outcomes (receiving planned surgery, postoperative readmissions, and survival). Results: We enrolled 160 of 221 (72.4%) patients approached. A minority of patients were independent in all ADLs (5.2%) and IADLs (47.7%). Patients reported an average of 2.56 mod/sev ESAS symptoms, and 27.7% screened positive for depression, with 53.1% reporting at least one comorbidity. The number of comorbidities was significantly associated with impaired ADLs (B = -0.63, P < .01) and lower QOL (EORTC: B = -2.74, P = .03). For surgical outcomes, patients with better physical function were more likely to receive their planned surgery (ADLs: OR = 1.21, P = .02; IADLS: OR = 1.30, P = .03). Higher QOL correlated with greater odds of receiving planned surgery (EORTC: OR = 1.03, P = .06), but this did not reach statistical significance. A higher number of mod/sev ESAS symptoms was associated with greater postoperative readmission risk within 90 days of surgery (HR = 1.13, P = .03). Better physical function was associated with better postoperative survival (ADLs: HR = 0.87, P = .02; IADLs: HR = 0.73, P < .01), and higher depression scores correlated with worse survival (GDS: HR = 1.13, P = .02). Conclusions: Older adults with GI cancer often have baseline functional limitations and a high physical and psychological symptom burden, all of which are associated with worse surgical outcomes. Future work should study whether addressing preoperative PROs could improve older patients’ surgical outcomes. Clinical trial information: NCT02810652 .
Clinician perspectives of complementary and integrative medicine (CIM) at an academic cancer center.
Authors: Husain Marium , Rogers Sherise C. , Klemanski Dori , Fullmer Michelle , Hreachmack Catherine , Kemper Kathi , Stephens Julie , Desai Payal Chandarana , Lustberg Maryam B.
Published: May 2020

e24047

Background: Surveys suggest up to 87% of patients with cancer use complementary and integrative (CIM) therapies such as herbal medicine, acupuncture, massage and mind-body practices. These therapies may assist with symptoms of pain, nausea and anxiety. However, several studies have demonstrated that many clinicians do not inquire about CIM use, which may be due to lack of education and/or limited evidence-based data. We sought to explore the perspectives of clinicians at an academic comprehensive cancer center on the use of CIM therapies. Methods: Physicians and advanced practice providers (APPs) who practice medical oncology, hematology, radiation oncology, surgical oncology and neuro-oncology in a Midwest tertiary comprehensive cancer center were asked to participate in a 9-question online survey which inquired about their personal knowledge and recommendation for 21 different CIM therapies (not all are offered at the cancer center). Responses were summarized using descriptive statistics. Results: The response rate for this survey was 24.5% (n = 49). Responders were from the following specialties: hematology (n = 17; 35%); solid tumor (n = 18; 37%); both hematology and solid tumor (n = 8; 16%), surgical oncology (n = 3; 6%); gynecologic oncology (n = 2; 4%) and radiation oncology (n = 1; 2%). Sixty-seven percent were attending physicians and hematology/oncology fellows (n = 33), and 33% were APPs (n = 16). Median age range was 30-39 years (range 20-59). The most recommended CIM therapy for cancer treatment-related effects was massage (80%), followed by deep breathing (55%). The least recommended CIM therapies were traditional Chinese medicine (TCM) and Ayurvedic medicine (2%), followed by vitamins/minerals and homeopathy (both 6%). Participants requested more education on CBD/CBD oil (59%) and herbs/botanicals (49%). Up to 14% of respondents already had education on five integrative therapies. Conclusions: Hematology/oncology clinicians do not routinely recommend most CIM therapies, except for massage therapy. Efforts should be made to educate clinicians regarding CIM therapies used by patients with cancer as well resources that appraise the efficacy, safety, and potential drug interactions of these therapies. Education could encourage informed decision-making and improved patient-clinician communication and satisfaction.
Safety and efficacy of fecal microbiota transplantation (FMT) in the management of recurrent clostridioides difficile infection (rCDI) in cancer patients.
Authors: Ali Hiba , Ma Weijie , Khurana Shruti , Jiang Zhi-Dong , DuPont Herbert L. , Okhuysen Pablo , Thomas Anusha , Wang Yinghong
Published: May 2020

e24048

Background: Cancer patients are at a significantly increased risk of rCDI by virtue of a compromised immune function from underlying malignancy, anti-cancer therapy and frequent antibiotic use for opportunistic infections. Furthermore, cancer patients have shown to have a lower response rate to standard oral antibiotics for CDI. Data is limited in regards to the safety and efficacy of FMT in managing rCDI in cancer patients. We aim to describe our experience of the same at a tertiary care cancer center. Methods: We conducted a retrospective study of cancer patients who underwent FMT for rCDI at the MD Anderson Cancer Center 06/2017-01/2020. FMT was performed through colonoscopy with universal donors’ stool. Baseline clinical data were collected and analyzed. Results: Our sample comprises 19 patients of whom 12 had solid tumors and 7 hematological malignancies, most of which were stage 4 at the time of FMT. The mean age was 66.5 years. Most patients received proton pump inhibitor, antibiotics and cancer therapy within 3-6 months of FMT. On average, each patient had 3 episodes of CDI, received 4 courses of antibiotic treatments, and required 4 CDI related hospitalizations within 1 year prior to FMT. Majority of the CDI episodes were managed with a combination of antibiotics. Bezlotoxumab was used in 4 cases. 18 patients received FMT once, while one patient was treated with FMT thrice. Clinical response was seen in 74% patients with a median time of 1 day. 5 patients had refractory CDI including 3 recurrent rCDI, and 2 persistent symptoms. Compared to patients with good response, these refractory cases received more frequent antibiotics following FMT (100% vs 43%, p=0.033). Side effects were mostly mild GI complaints in 15.8% patients with no serious adverse events or mortality related to FMT. Conclusions: Our study shows that FMT is a safe and effective treatment for rCDI in cancer patients and provides rapid resolution of symptoms; Subsequent antibiotic use for the management of cancer related complications can negatively affect the efficacy of FMT. [Table: see text]
Promoting patient health maintenance with cancer care planning at diagnosis and during treatment: baseline data of the Coleman Supportive Oncology Collaborative (CSOC).
Authors: Weldon Christine B. , Trosman Julia Rachel , Berardi Rosa , Benson Al Bowen , Roggenkamp Betty , Hand Mary Ellen , Stamp Michelle , Bao Jean J , Feldman Lawrence Eric , Pasquinelli Mary , Gradishar William John , Shah Ami N. , Kircher Sheetal Mehta , Foster Kelly Danielle , Nelson Valerie , Wiebe Lauren Allison , Baer Rachel Podrazik , England Gale M , Dalal Neil , Perez Claudia Beth
Published: May 2020

e24051

Background: CSOC conducts quality improvements (QI) for cancer patients that facilitate delivery of appropriate health maintenance and supportive cancer care at diagnosis and during treatment. CSOC is implementing a care planning QI starting at diagnosis using the 4R oncology model (Right Info / Care / Patient / Time), which provides patients a formal personalized care plan called Patient Care Sequence. Each Care Sequence includes health maintenance, cancer treatments and supportive care. As part of CSOC, we conducted provider surveys as a pre-intervention baseline to inform QI opportunities. Methods: Online survey of cancer providers from 8 cancer centers (4 academic, 4 community) conducted July 2018 - October 2019, prior to 4R implementation. The survey focused on current care planning practices and inclusion of guideline recommended health maintenance in care plans. Results: Survey response rate: 80% (180/225); respondents were 53% physicians, 20% advanced practice, 27% nurses. Only 59% (107/180) of respondents give patients care plans at diagnosis: 61% (65/107) verbally, 22% (24/107) written, 17% (18/107) using a printed form. Providers reported considerable gaps in including guideline-based health maintenance and promotion activities in care plans given to patients (Table). Additionally, 61% of providers reported concerns that it is challenging for their patients to manage their own health maintenance activities. Providers who are concerned about patients’ challenges in managing their own health maintenance are significantly more likely to give their patients a written or printed plan (76%, 32/42) compared to those providing care plans to patients verbally or not at all (56%, 77/138), p = .02. Conclusions: Guideline based health promotion activities are not consistently included in care plans, and care planning is not sufficiently conducted at cancer diagnosis. The CSOC 4R Oncology Model, which implements Patient Care Sequences at diagnosis, will address these gaps and examine the impact of formal care planning on improving utilization of health maintenance and promotion activities. [Table: see text]
Physical activity platform to improve bone health in cancer survivors.
Authors: Skinner Cathy
Published: May 2020

e24054

Background: Cancer treatment-induced bone loss and the risk of fractures is a significant burden on national health care with the annual cost of osteoporosis at $25.3 billion. Clinical studies report that moderate-intensity resistance exercises prevent a decline in bone health and reduce complications such as fatigue, muscle wasting, and bone loss. Only a small percentage cancer survivors engage in exercise. Several factors account for this low level of engagement such as poor awareness of the benefits, lack of motivation, and access to exercise programs for cancer survivors. Web- and mobile app-based programs that encourage physical activity can potentially address these problems and can be scaled for dissemination. Methods: Thrivors plus Bone Health (Thrivors+BH) is first-of-its-kind, clinically validated platform of bone health exercises that adapts to a cancer survivor's pain and energy levels with several interactive feedback features. The product has physical activity, mindfulness, nutrition, survivorship resources, and bone health education. The platform's back-end tracks and reports module activity. We conducted a single-blind RCT of 142 breast cancer survivors adherence to a 20-week program of resistance and impact exercises. Participants in the control arm accessed Thrivors Basic which lacked interactive feedback. Results: The primary outcome was higher adherence. High adherence equals completion of at least 40 of 60 recommended exercise sessions during the 20-week intervention. The intervention group showed higher measures of platform usage, duration and activity. Intervention group completed the validated jumping protocol after an 8-week program of strength training to prepare for increased intensity exercises. Although some participants discontinued due to various reasons (time constraints or health complications), the supportive modules and feedback from the PI influenced participants to resume exercise after a period of inactivity. The mean scores in the PAM and SF-36v surveys were higher for the intervention group. Conclusions: The study demonstrates breast cancer survivors' willingness to utilize a digital platform with prescribed exercise routines. Feedback suggests that more personalized and interactive features may encourage a higher frequency of engagement in bone-health specific physical activity. A follow-up study will examine the impact of the exercise program on bone health and the role of coaching to impact sustainable behavior change. Clinical trial information: NCT03651037 .
Objective and subjective vulvovaginal symptoms in breast cancer patients.
Authors: Goldfarb Shari Beth , Saban Sally , Arkema Ashley , Patil Sujata , Flynn Jessica , Goldfrank Deborah J. , Norton Larry , Carter Jeanne
Published: May 2020

e24056

Background: Breast cancer and its treatment adversely impact sexual function and QoL. As more women become survivors, information is needed about vulvovaginal symptoms, sexual concerns and treatment options. Methods: An IRB Limited Waiver of Authorization was obtained to evaluate the medical records of 650 breast cancer patients with initial sexual medicine consults between 7/19/12 & 3/5/19. All women completed the Clinic Assessment form including a pelvic exam checklist, vulvovaginal tissue quality assessment (Vaginal Assessment Scale (VAS)/Vulvar Assessment Scale (VuAS) and sexual function measures (FSFI, PROMIS-SF) at initial visit and 56% (366/650) completed it at follow-up visits. R v3.6.1 was used to perform statistical analysis. Results: Women were categorized at initial consult as either postmenopausal (PM), pre/perimenopausal or menopausal from ovarian suppression (OS). Median age at initial consult was 52 (range 26 to 83) and median endocrine exposure ranged from 12 months on Tamoxifen only to 52 months on Tamoxifen followed by an AI. Of the total sample, 60% reported no confidence in future sexual activity and 68% reported pelvic pain with exam at initial consult. Improvements were seen at the first follow-up in confidence about intimacy and sexual health concerns (p < .001). Vulvovaginal symptoms (VAS/VuAS) and dilator and vulvovaginal moisturizer use (p < .001) also improved from baseline to follow-up 1. The women most likely to attend first follow-up appointments were OS (70%) and PM women on AIs (64%) who also reported worse symptoms at baseline compared to pre/perimenopausal women on Tamoxifen. At initial presentation, PM on AIs and OS had poor exam outcomes respectively: pH > 5 (92%; 83%), poor vaginal elasticity (19%; 13%), vaginal dryness (88%; 68%), decreased rugosity (36%; 30%) and poor vascularity (33%; 21%). At initial consult, exam findings for pH, moisture, vulvar and vestibular irritation each correlated significantly with patient reported vaginal (VAS total score) and vulvar (VuAS total score) symptoms (p≤ .05). Conclusions: Breast cancer patients can benefit from coordinated multidisciplinary care addressing the long-term effects of premature menopause and endocrine therapy. Patient characteristics such as menopausal status and type/duration of endocrine therapy should be considered when assessing sexual health since aromatase inhibitors and ovarian suppression appear to worsen clinical exam and patient reported outcomes. Sexual health counseling and treatment can help women cope with sexual concerns during and after breast cancer therapy.