bluuebunny/crossref_metadata_2025_split huggingface dataset:
Quality of timely adjuvant chemotherapy for veterans with colorectal cancer.
Authors: Martin Richard Lewis , Edwards Gretchen C. , Samuels Lauren R. , Roumie Christianne L. 
Published: February 2020

78 Background: National Comprehensive Cancer Network (NCCN) recommends adjuvant chemotherapy for patients with high risk stage II or stage III colorectal cancer (CRC). Treatment within 8 weeks of surgery improves disease free survival and decreases recurrence. National Veterans Health Administration (VHA) CRC data demonstrated adherence to this standard; however, there was regional variation. We sought to describe time to treatment at a Southeast Regional VHA facility to determine local targets for quality improvement initiatives. Methods: We retrospectively reviewed 705 electronic medical records of patients who underwent colorectal surgery from January 1, 2000 to December 31, 2015 at VHA Tennessee Valley Healthcare System. Two trained clinician abstractors reviewed standard elements (k = 0.79 – 0.92). The population included patients with pathological stage high risk II or III CRC and excluded those with metastatic disease or documented NCCN defined exclusion from chemotherapy. We analyzed 2 populations; chemotherapy received and a sensitivity analysis population of patients who were eligible for, but did not receive, chemotherapy (no documentation of NCCN ineligibility or declined). The primary outcome was chemotherapy within 8 weeks of surgery, evaluated during three time periods due to changes in NCCN guidelines. Results: Of 705 colorectal surgeries, we excluded 262 for non-cancers, 220 for stage I or low-risk stage II cancers, and 46 for NCCN defined exclusion, yielding 177 cases: 120 colon and 57 rectal cancers. Patients were 98% male, 85% white, and median age 64 years [Interquartile Range 60, 70]. Among those receiving chemotherapy (123/177 [69.5%]), median time to treatment was 50.5 days [40,64]; with 63% receiving chemotherapy within 8 weeks. Results varied over time. Between 2000-2004 75% received within 8 weeks; 2005-2009, 62%; 2010-2015, 41%. Including all eligible patients, the proportion receiving timely treatment declined; overall 44%; 2000-2004, 57%; 2005-2009, 45%; 2010-2015, 25%. Conclusions: Improving care processes for patients with CRC can improve timely treatment. Exploring barriers such as prolonged hospitalization, wound healing, and port placement may reveal areas for quality improvement.
Impact of high-risk features for stage II adenocarcinoma of the appendix.
Authors: Akce Mehmet , Zakka Katerina Mary , Penely Mckenna , Jiang Renjian , Alese Olatunji B. , Shaib Walid Labib , Wu Christina , Behera Madhusmita , El-Rayes Bassel F. 
Published: February 2020

795 Background: Clinico-pathological high risk features are frequently utilized in adjuvant chemotherapy (AC) decisions in stage II colorectal cancer and their utility in stage II appendiceal adenocarcinoma (AA) is less established. The aim of this study is to determine the impact of high risk features on clinical outcomes and whether high risk features are predictive of AC benefit in stage II AA. Methods: Patients with pathological stage II AA between 2010 and 2015 were identified from the National Cancer Database (NCDB) using ICD-O-3 morphology and topography codes: 8140, 8480 and C18.1. High risk stage II AA was defined as having at least one of the following clinicopathological features: T4 tumor, < 12 lymph nodes examined, poorly differentiated histology, positive margins, or lymphovascular invasion. Patients with none of these features were defined as low-risk. Results: A total of 1,040 patients were identified. 51.0% males, 84.5% Caucasian; median age 61 (range, 19-90). 46.4% were determined to have high-risk stage II AA. High-risk status was associated with worse OS compared to low-risk in univariate (HR 1.55; 95% CI 1.18-2.02; p = 0.001) and multivariable analyses (HR 1.36; 95% CI 1.03-1.79; p = 0.028). High-risk stage II AA patients had significantly worse 5-year OS compared to low-risk patients (67.1% vs. 74.5%, p = 0.0013). AC was administered in 34.4% (n = 166) of high-risk patients and in 36.5% (n = 203) of low-risk patients. Among high-risk patients, AC was not associated with better OS in univariate (HR 0.86; 95% CI 0.59-1.26; p = 0.722) and multivariable analyses (HR 1.35; 95% CI 0.90-2.04; p = 0.324) compared to no AC. Similarly, among low-risk patients, AC was not associated with better OS in univariate (HR 0.92; 95% CI 0.60-1.39; p = 0.813) and multivariable analyses (HR 1.27; 95% CI 0.81-2.02; p = 0.334) compared to no AC. For high-risk patients, 5-year OS was 68.3% in patients that received AC vs. 66.5% in patients that did not (p = 0.722). For low-risk patients, 5-year OS was 74.0% in patients that received AC vs. 76.3% in patients that did not (p = 0.813). Conclusions: High-risk stage II AA patients had significantly worse 5-year OS compared to low-risk patients. AC did not improve survival regardless of high risk features in stage II AA.
Diagnostic performance of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the evaluation of hypermetabolic lymphadenopathy mediastinum lower, posterior, and middle, detected by PET-CT with 18F-FDG (PET) (APOGEE Study).
Authors: Bechade Dominique , Bellera Carine A. , Cantarel Coralie , Soubeyran Isabelle , Debled Marc , Chomy Francois , Roubaud Guilhem , Fonck Marianne , Cazeau Anne Laure 
Published: February 2020

798 Background: In the context of a new cancer or relapse, the high sensitivity (Se) (95-100%) of PET-CT with 18F-FDG can lead to the demonstration of hypermetabolic mediastinal adenopathies. Its lower specificity (Sp) (89%) can require histological examination. We report the results of a prospective, single-center study evaluating the diagnostic performance of EUS-FNA in this indication. Methods: Prospective single-center study featuring patients in whom PET had revealed hypermetabolic mediastinal lymphadenopathy requiring diagnostic certainty. All EUS-FNA were performed with a 19-gauge needle (EchoTip, Cook Endoscopy). Main objective: To evaluate the diagnostic performance in terms of Se and Sp of EUS-FNA in the characterization of hypermetabolic mediastinal adenopathies in PET in the context of a new cancer or relapse. Secondary objectives: To evaluate the negative predictive value (NPV) of the EUS-FNA and to evaluate the percentage of surgical diagnostic procedures avoided. The standard technique was a thoraco-abdominopelvic CT scan at 6 months and at 12 months. Results: 52 patients were eligible and evaluable for the primary endpoint. The most common primary cancers were mammary (17.3%) and bronchial (13.5%). The lymph nodes were analyzed as malignant in 44.2% of cases, benign in 50% of cases and atypical or suspicious in 3.8% of cases. The malignant lymph nodes were metastatic for breast cancer in 21.7% of cases, bronchial cancer in 17.4% of cases, colorectal cancer in 17.4% of cases and prostate cancer in 13% of cases. The Se of the EUS-FNA was 92% (95% CI 0.74-0.99) and the Sp 100%. NPV was 87% (95% CI: 0.59-0.98). A diagnostic surgical procedure was necessary in 2% of the cases. PET and EUS-FNA often allowed the modification of the therapeutic strategy. Conclusions: When a confirmed diagnosis is required, the diagnostic accuracy of the minimally invasive procedure of EUS-FNA, is sufficiently robust to avoid a surgical diagnosis technique. The combination of PET and EUS-FNA may alter the therapeutic strategy that would have been considered after PET alone. Clinical trial information: NCT01892501.
Encyclopedic liquid biopsies for guideline-compliant diagnostic work-up in gastrointestinal cancers.
Authors: Patil Revati , Akolkar Dadasaheb , Patil Darshana , Limaye Sewanti , Page Raymond , Crook Timothy , Datta Vineet , Schuster Stefan , Sims Cynthe , Srivastava Navin , Devhare Pradip , Fulmali Pradip , Patil Sanket , Patel Shoeb , Fulmali Pooja , Khan Shabista , Chougule Rohit , Dhasarathan Raja , Srinivasan Ajay , Datar Rajan 
Published: February 2020

799 Background: Definitive diagnosis of gastrointestinal (GI) malignancies is reliant on histopathological examination of tumor tissue obtained by invasive biopsies. However, invasive biopsies are associated with procedural risks, complications and expenses. A non-invasive technique for diagnosis of GI cancers is presently unavailable. Here we present a non-invasive diagnostic approach for GI cancers based on immunocytochemical (ICC) profiling of Circulating Tumor Associated Cells (C-TAC) enriched from peripheral blood. Methods: We collected 15 mL peripheral blood from 1052 patients with known diagnosis of Ca Oesophagus (244), Ca Stomach (170) and Ca Colorectum (638) and with histopathological information available from prior tissue analysis. CTACs were harvested following negative enrichment. C-TACs were identified by immunostaining with EpCAM and panCK. Deep ICC characterization was carried out in a subset of 203 samples (100 colorectal, 19 Gastric and 84 Esophageal) using organ specific markers. A subset of 19 samples from Gastric and 94 samples Esophageal cancers were profiled for Her2 and PD-L1 status. Results: C-TACs could be identified and enriched in 1012 out of 1052 patients (96.2% overall sensitivity). Immunostaining for organ-specific markers was possible in all 203 (100%) samples. Her2 positivity was observed in 2/19 Gastric and 19/84 Esophageal samples. PD-L1 (22C3) positivity was observed in 5/19 Gastric and 32/84 Esophageal samples while PD-L1 (28-8) positivity was observed in 2/19 Gastric and 16/84 Esophageal samples. Conclusions: Our results show that ICC profiling of C-TACs can provide necessary diagnostic information non-invasively to substitute conventional procedures dependent on tissue extraction. This approach fulfils most clinical decision-making requirements in GI malignancies.
Circulating ensembles of tumor-associated cells in gastrointestinal cancers.
Authors: Akolkar Dadasaheb , Patil Darshana , Page Raymond , Crook Timothy , Limaye Sewanti , Datta Vineet , Schuster Stefan , Fulmali Pradip , Fulmali Pooja , Srivastava Navin , Devhare Pradip , Apurwa Sachin , Patel Shoeb , Srinivasan Ajay , Datar Rajan 
Published: February 2020

808 Background: CEA and CA19-9 are non-specific markers for Gastrointestinal (GI) cancers. Molecular analysis of fecal blood is of limited utility in colorectal cancers. A non-invasive pan-GI-cancer blood-based test with high specificity and sensitivity is an unmet medical need. Considering that unprovoked thromboembolism is a significant risk in multiple cancers, we hypothesized that circulating thrombotic emboli in peripheral blood could comprise cancer cells and would serve as a reliable biomarker for detection of GI cancers. Methods: We obtained 15ml of blood from 7481 individuals, including 181 cases of Esophageal cancer, 125 cases of Gastric cancer, 448 cases of colorectal cancer and from 6727 asymptomatic individuals with age related elevated risk who underwent evaluation of serum CA19-9 and AFP. Peripheral blood mononuclear cells (PBMC) were isolated by centrifugation and further processes for negative enrichment and harvesting of circulating tumor cell clusters which were characterized by immunostaining. Circulating Ensembles of Tumor Associated Cells (C-ETACs) were defined as clusters of 3 or more cells which were positive for EpCAM and CK, irrespective of CD45 status. Results: C-ETACs were detected in 86.7% of esophageal cancers, 94.4% of gastric cancers and 91.3% of colorectal cancers respectively irrespective of extent (stage / metastatic status) of disease and prior treatments. Overall sensitivity among 754 cancer patients was 90.7%. Among the asymptomatic individuals, C-ETACs were detected in 31 / 366 (8.5%) individuals with elevated CEA and 10 / 152 (6.2%) individuals with elevated CA19-9. C-ETACs were detected in 160 / 5333 (2.9%) of the asymptomatic individuals who had no abnormal findings in any of the said markers. Conclusions: C-ETACs were ubiquitously detected in cancers of Oesophagus, Stomach and Colorectum regardless of stage and treatment status, and pose significant latent risk of thromboembolism and metastasis/recurrence. The relative undetectability of C-ETACs in the asymptomatic cohort indicates causative connection with malignancies and are suitable for screening for these cancers.
Emergency department use at the end of life in elderly patients with gastrointestinal malignancies and mental health comorbidities.
Authors: Kashyap Mehr , Harris Jeremy Phillip , Chang Daniel Tandel , Pollom Erqi L. 
Published: February 2020

811 Background: Aggressive care at the end-of-life can contradict patients’ wishes, negatively impact patient quality of life, and contribute to overall health care expenditures. Patients with mental disorders (MD) often experience disparities in medical care and have poorer clinical outcomes. We investigated the impact of mental disorders on emergency department (ED) use at the end of life among elderly patients with gastrointestinal (GI) malignancies. Methods: We conducted a retrospective cohort study using the SEER-Medicare database. We identified patients aged 66 years and older with GI malignancies (colorectal, pancreatic, gastric, hepatic, biliary, esophageal, small bowel, and anal cancer) diagnosed between 2004 and 2013 who had recorded death. We assessed the association between MD (depression, bipolar disorder, psychotic disorder, anxiety, dementia, and substance abuse) and ED use within 30 days of death using logistic regression models. Results: Of the 160,367 decedents included, 54,461 (34.1%) had at least one MD diagnosis between one year prior to cancer diagnosis and death. Those with MD were more likely to use the ED more than once in the last 30 days of life (14.7% vs. 12.4% p < 0.01). ED use was highest among decedents with anxiety disorder (15.8%) and substance abuse (16.3%). Among decedents with mental disorders, risk factors associated with ED use at end of life include being male (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 1.10 – 1.22), younger (aOR 1.14, 95% CI 1.06 - 1.23), and black (aOR 1.33, 95% CI 1.23 – 1.45), living in a lower income zip code (1.21, 95% CI 1.13 – 1.30), and having a higher Charlson comorbidity score (aOR 1.71, 95% CI 1.56 – 1.87). ED use was also associated with pancreatic (aOR 1.16, 95% CI 1.08 - 1.25), hepatic (aOR 1.21, 95% CI 1.11 - 1.33), biliary (aOR 1.16, 95% CI 1.03 - 1.30) and esophageal (aOR 1.16, 95% CI 1.04 - 1.29) cancer compared to colorectal cancer. Conclusions: MD is associated with increased ED use at the end of life among elderly patients with GI cancer. Palliative and supportive care including mental health services early in the disease course may improve quality of end-of-life care in this vulnerable population.
Hospice length of service in patients with advanced gastrointestinal cancers treated at an NCI-designated cancer center.
Authors: Gupta Arjun , Sedhom Ramy , Middleton Emily , Cooper Rhonda , Knight Louise , Laheru Dan , Smith Thomas J. 
Published: February 2020

812 Background: Hospice Length of service (LOS) is a Quality Oncology Practice Initiative (QOPI) measure, and an established metric of end-of-life (EOL) care. Short hospice LOS is associated with lower-quality EOL care, poor symptom control, and patient and caregiver dissatisfaction. Oncologist- and/ or system-specific factors may contribute to shorter hospice LOS. Methods: We conducted a retrospective chart review of patients with advanced gastrointestinal (GI) cancers referred to hospice from a comprehensive cancer center in 2018, and compared data to 2015. We analyzed LOS under hospice care, looking specifically at median LOS and percent of short enrollments (%LOS ≤ 7 days), and examined the variation between individual oncologists within the GI oncology division. The coefficient of variation (Cv) represents degree of variability between oncologists, and was calculated based on median LOS for each oncologist. Mean and SD of oncologist LOS were calculated. Cv was defined as SD/mean; Cv > 100% is typically considered a high variance distribution. Results: A total of 114 patients with advanced GI cancers were discharged to hospice in 2015, and 115 patients in 2018. The median age of patients was 66 years, 47% women, and 80% white. The number of GI oncologists were 9 in both years and median patients per oncologist were 12 in 2015, and 13 in 2018. The median hospice LOS was 16 days in 2015, which decreased to 9 days in 2018. The %LOS ≤ 7 days increased from 25% in 2015 to 47% in 2018. The Cv% was < 100% in both 2015 (63%) and 2018 (44%). Conclusions: In this retrospective study of hospice LOS among patients with advanced GI cancer at a single cancer center, median hospice LOS declined, and %LOS ≤ 7 days increased from 2015 to 2018. We did not find significant variation in hospice referral patterns between oncologists within the GI oncology division. These data point to system level factors responsible for sub-optimal hospice LOS. We will present our data at division meetings, and use mixed-methods design for investigating and eventually addressing barriers to low hospice LOS.
Implementation of an EMR integrated pathway for the management of malignant bowel obstruction.
Authors: Schuitevoerder Darryl , Vining Charles Christian , White Michael , Hoppenot Claire , Lazo Isabel , Sherman Scott K. , Kamm Alaine , Chavez Luz , Kallakuri Pujitha , Fenton Emily , Male Joshua , Tun Sandy , Ahmed Osmanuddin , Semrad Carol , Radovanovic Dragana , Eng Oliver , Micic Dejan , Lee Nita Karnik , Polite Blase N. , Turaga Kiran 
Published: February 2020

813 Background: Despite published evidence based interventions for malignant bowel obstruction (MBO), implementation of a standard pathway is challenging. We hypothesized that using industrial engineering techniques and a modified dynamic sustainability framework for implementation, we can implement an electronic medical record (EMR) based pathway in the management of MBO. Methods: A workflow in the management of MBO was developed using iterative meetings from 8/2018 to 4/2019 including gateway stakeholders (surgical oncology, gynecological oncology and medical oncology), interventional stakeholders (gastroenterology, interventional radiology) and supportive stakeholders (hospital medicine, palliative care, nutrition, nursing). Industrial engineers were utilized to study human factors, and perform a method study. EMR integration was performed using EPIC systems Agile MD pathway and educational materials were created. Interventions such as early placement of gastrostomy tubes, total parenteral nutrition and medications were protocolized. Results: Since implementation, over 6 months the pathway and order set has been activated 56 times. Orders have been employed 21 times through the AgileMD pathway demonstrating a pathway drift of 62.5%. Educational materials have been accessed routinely during this time. Conclusions: Feasibility of implementing an EMR integrated MBO pathway is demonstrated with early suggestion of pathway drift. Utilizing tools of implementation science are necessary to facilitate widespread adoption of evidence based interventions in the management of patients with MBO.
A retrospective analysis of factors affecting palliative care consult in patients undergoing cytoreductive surgery and HIPEC.
Authors: Babar Laila , Lo Herman , Ashraf Obaid , Sethi Ashish , Alvi Zara , Finley Gene Grant , Monga Dulabh K. , Schiffman Suzanne , Raj Moses S. 
Published: February 2020

815 Background: The National Cancer Institute defines palliative care as care given to improve the quality of life (QOL) for patients with life threatening diseases. The role of palliative care (PC) within oncology is ever evolving and as more studies are being conducted, its role in the improvement of QOL for patients is being widely recognized. Patients undergoing cytoreductive surgery (CRS) are at a higher risk for morbidity and mortality and often have severe post-operative symptoms that can worsen their QOL. Here we studied the factors affecting PC consult in order to better overcome them. Methods: We queried our Electronic Medical Record EPIC for a list of patients who underwent cytoreductive surgery with HIPEC or HITEC in the hospital from April 2016-April 2019. Data was manually extracted and patients who didn’t meet our criteria were excluded. Patients were divided on the basis of palliative care consults and differences between the groups were analyzed. Odds ratios(OR) with p-value 0.05 and confidence interval (CI) 95% were calculated. Results: We identified 55 patients of whom 34 met our inclusion criteria, 11 male and 23 female with an average age of 56.3 years at the time of diagnosis. 8 patients (23%) had PC; more than 1 comorbidity and age > 40 was associated with a higher likelihood of PC (OR:0.12; CI:0.02-0.76; p:0.02) and (OR: 0.015; CI: 0.0007-0.3029; P: 0.006) respectively. Gender, insurance type and marital status did not corelate with PC. Mean age (58.1 vs 55.7) showed a trend towards higher rates of PC in older population. Conclusions: Approximately one quarter of patients undergoing CRS with HIPEC had a concurrent PC consult. Though this is better than the national average of 11-16%, it continues to be a very small number. PC is not only an end of life service, in fact studies have shown early consultations lead to higher patient satisfaction, improved QOL and better communication. Efforts must be made to engage PC early in the course of treatment and recognize it as an integral part of cancer care.
Comparison of treatment plans feasible through AI enabled multidisciplinary online tumor board solution versus NCCN-based clinical decision support system (CDSS).
Authors: Sirohi Bhawna , Beriwal Sushil , Pramesh C. S. , Chopra Supriya , Goel Mahesh , Mathew Aju , Ostwal Vikas S. , Pandey Durgatosh , Rajagopalan Malolan Sri , Ramaswamy Anant , Sunil Bj , Badwe Rajendra A. 
Published: February 2020

816 Background: Multidisciplinary tumor boards at Academic Medical Centers (AMC) maximize cancer outcomes. Guidelines based CDSS are alternatives to determine care pathways. Since 2015, 300 AMC cancer experts in USA and India use an AI enabled online tumor board solution, “NAVYA,” to scale low cost access to multidisciplinary expertise, on 1-2 minutes of expert time per decision (ASCO 2017). Methods: GI patients who used NAVYA between 5/1/15-8/31/19 were analyzed. Actionable treatment plans generated by NAVYA were compared to NCCN. Actionable treatment plans include chemotherapy protocols (doses, frequencies), radiation protocols (sites, fractions), etc. Inactionable specialty level decisions (CT-RT vs. surgery) lack specificity. Results: 1302 patients (4638 treatment decisions) were analyzed: 61% (794) male, 80% between age 45 to 75, mostly with Colon, Pancreas, Gallbladder, Rectum, or Stomach cancer; 49.7% non-metastatic. Cohort was comparable to GLOBOCAN estimates. In 82.2% (3812/4638) decisions, NAVYA added value beyond NCCN. First, in 4.5% (212/4638), NAVYA recommended a patient-specific treatment plan that was not part of NCCN. Second, in 3.2% (148/4638), NAVYA recommended treatments plan for clinical scenarios not covered by NCCN, (for eg. 3rd line therapies). Third, in 74.5% (3452/4638), NAVYA used patient specific criteria including resource constraints and patient preference to choose a treatment plan amongst the multiple pathways provided by NCCN and added actionable treatment details. Conclusions: Guideline based CDSS are insufficient to make the vast majority of actionable treatment decisions. Scaling rapid access to multidisciplinary experts is critical. Leapfrogging existing guidelines based CDSS, NAVYA online tumor board makes actionable expert treatment plans possible at a large scale.