bluuebunny/crossref_metadata_2025_split huggingface dataset:
Dosimetric comparison of 3D-field-in-field technique and inverse planning IMRT for large-breasted patients treated in prone position.
Authors: Kabarriti Rafi , Savacool Michelle K. , Patel Shyamal , Hong Linda , Tome Wolfgang A. , Fox Jana Lauren , Kalnicki Shalom 
Published: February 2017

79 Background: Whole breast irradiation (WBI) leads to acute and late toxicities, which can be worse with plan dose inhomogeneities. This has been of clinical concern for large-breasted patients, especially with hypofractionation. Two approaches of 3D modulation of the radiation beam profile to optimize dose distribution and improve homogeneity are commonly employed. One is field-in-field forward planning wherein up to 3 or 4 subfields are generated within the initial radiation field. The other is inverse-planning IMRT, which typically utilizes 5 or more segments. In this study, we compare dosimetric parameters of WBI using the field-in-field technique with up to 3 subfields (3D-FiF) compared with inverse planning IMRT in large breasted patients. Methods: 10 large-breasted patients (planning target volume [PTV] >2500cc) treated between 2007-2013 with WBI in the prone position with hypofractionation (42.4 Gy in 16 fractions) were selected. For each, an inverse planning IMRT and a 3D-FiF plan were created for the treated breast. Plans were normalized so that V95% PTV coverage was the same. Dose-volume histograms were evaluated for volumes receiving > 105% (V105) and >107% (V107) of prescribed dose, and maximum dose (Dmax). Results: Median PTV was 3443cc (2675-3875) and median separation distance at the chestwall posterior field edge was 25.9cm (23.7-27.3). IMRT significantly (p<0.005, wilcoxan) reduced the volume receiving V105 and V107. Mean V105 and V107 for IMRT were 124cc (6-266) and 1.3cc (0-11.8), respectively. Mean V105 and V107 for 3D-FIF were 525.6cc (259-765) and 86 (6-171). IMRT also significantly reduced Dmax from a mean of 109.4% to 106.7%. 3D-FiF was able to limit max dose below 110% in 9 of 10 patients. Conclusions: 3D-FiF can achieve a maximum point dose under 110% of prescribed dose with similar target coverage to IMRT for most large breast patients. However, IMRT can significantly reduce the V105 and V107 in these women. Improved dose homogeneity is expected to provide a benefit in terms of acute skin toxicities and late breast fibrosis in such large breasted women receiving WBI with hypofractionation; however further study is needed to prove its true clinical benefit.
Efficacy of HER2-targeted therapy for patients with HER2-positive breast cancer according to hormone receptor status.
Authors: Murata Takeshi , Takahashi Maiko , Hayashida Tetsu , Jinno Hiromitsu , Kitagawa Yuko 
Published: February 2017

97 Background: Hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-positive tumors generally cluster within the luminal/HER2 subset; whereas HR-negative/HER2-positive tumors reside in HER2-enriched subset. We investigated whether the efficacy of HER2-targeted therapy for HER2-positive tumors differs by HR status. Methods: Sixty-eight patients with operable breast cancer received trastuzumab plus taxane based therapy before surgery at Keio University Hospital from March 2009 to April 2012. All tumors were HER2-positive by immunohistochemistry (IHC) or fluorescence in situ hybridization. Expressions of ER, PgR, and Ki67 were performed by IHC in core needle biopsy samples at baseline. Pathological complete response (pCR) defined as no invasive residuals in breast. All patients with luminal/HER2 tumors received adjuvant endocrine therapy in addition to adjuvant trastuzumab monothereapy. Results: Sixty-eight patients with HER2-positive tumors were divided into 35 (51.5%) patients with luminal/HER2 tumors and 33(48.5%) patients with HER2-enriched tumors, respectively. There were no significant differences in tumor size, clinical nodal status, nuclear grade, and Ki67 status between the two groups. Clinical complete response rate and objective response rate were similar between the two groups. Patients with luminal/HER2 tumors were significantly younger than patients with HER2-enriched tumors (median age (range): 53 (35-78) vs. 61 (31-72), p=0.041). Compared to patients with luminal/HER2 tumors, patients with HER2-enriched tumors had significantly higher pCR rate (28.6% vs. 69.7%, p=0.002). With 24 months median follow-up, no significant differences were observed between the two groups with respect to disease-free survival. Estimated 2-year disease-free survival for luminal/HER2 and HER2-enriched was 94.3% and 97.0%, respectively (p=1.000). Conclusions: HER2-enriched breast cancer showed significantly higher pCR rate to HER2-targeted therapy compared with luminal/HER2 breast cancer. However, there was no significant difference in disease-free survival between the two groups.
What type of feedback to clinicians best improves conformance to supportive care quality measures?
Authors: Kamal Arif , Abernethy Amy Pickar , Bull Janet , Nicolla Jonathan , Kelly Joseph , Stinson Charles Steven , Adams Martha 
Published: February 2017

102 Background: Supportive care is under-addressed in oncology and an important area for quality improvement. Regular, directed feedback is an important component of effective quality management. What type of feedback yields the highest conformance to supportive care measures? Methods: Within the Carolinas Palliative Care Consortium, we conducted a series of three PDSA cycles, each one month-long, to evaluate various types of clinician-directed feedback on conformance to two supportive care measures. We collected data using a web-based, mobile health platform called QDACT-PC (Quality Data Collection Tool for Palliative Care). Every four weeks, feedback to clinicians on performance was changed in a stepwise fashion, from “no feedback” to “personal feedback” to “comparative feedback” (personal conformance compared to the rest of the Consortium). We monitored weekly changes to conformance to two quality measures: documentation of timely management of constipation and dyspnea. To meet the measures, symptoms with intensity of >3/10 on the Edmonton Symptom Assessment Scale required documentation of intervention within 24 hours. Conformance rates were calculated and compared to a historical baseline. Results: 23 providers participated in this quality improvement project, which spanned 465 patient encounters across 104 unique patients. Baseline data generated from 3/2008-10/2011 demonstrated baseline conformance to the dyspnea and constipation measures at 6% (27/457) and 4% (14/398), respectively. After addition of an electronic, prospective quality monitoring system alone (QDACT-PC), conformance increased to 93% (42/45) and 92% (23/25), respectively. With personalized, weekly feedback, these rates increased to 94% for dyspnea and 100% for constipation. Feedback comparing personal performance to the average of the rest of the Consortium further increased this to 100% for both. Conclusions: Regular, weekly feedback on performance increases conformance to supportive care quality measures. Adding comparative feedback versus other peers solidifies this effect. Duration of the effect is being evaluated.
Incidence of breast cancer among women in the United States, by human epidermal growth factor receptor-2 status: An analysis of National Registry data 2010.
Authors: Lang Kathy , Hao Yanni , Huang Huan , Federico Victoria , Menzin Joseph 
Published: February 2017

112 Background: Few studies of breast cancer (BC) incidence by human epidermal growth factor receptor 2 (HER2) status exist as it is not routinely collected in population-based registries. This study used newly collected registry data to evaluate incidence of BC by HER2 status. Methods: The Surveillance, Epidemiology, and End Results (SEER) Program is a system of tumor registries designed to track cancer incidence and survival, covering about 25% of the US population. The SEER*Stat Database used for this analysis provides summary prevalence/incidence rates, frequencies, and case statistics. We evaluated age-adjusted (to the 2000 US population) incidence (number of cases per 100,000 females) of newly diagnosed female BC during 2010, by HER2 status, stratified by age, race, and stage at diagnosis. Cases with unknown values for any stratifier were excluded. Patients were classified as HER2+/HER2- based on a new HER2 status variable collected beginning in 2010. Results: There were 49,347 cases of newly diagnosed female BC in 2010 (7,331 [14.9%] HER2+ and 42,016 [85.1%] HER2-). Annual incidence of HER2+ BC was lower than incidence of HER2- BC (15.5 vs. 87.9 per 100,000 females; p<0.01). Incidence was highest among patients aged 65-74 years (42.4 [HER2+] and 318.1 [HER2-]), followed by 75+ (34.3 and 292.2), 45-64 (33.7 and 170.4) and under 45 (4.8 and 17.5). Incidence rates by race were as follows: Blacks (17.1 [HER2+] and 83.1 [HER2-]), Whites (15.5 and 91.3), Asian or Pacific Islanders (14.9 and 65.5), and American Indian/Alaska Natives (7.3 and 37.1). Incidence rates were highest for less advanced stages of BC: Stage I (6.1 [HER2+], 45.9 [HER2-]), II (5.5, 28.1), III (2.7, 9.9), and IV (1.2, 4.0). Differences in incidence rates across all strata among HER2+ and HER2- patients were statistically significant (p<0.01). Conclusions: This analysis is among the first to utilize the new SEER HER2 status variable. About 15% of newly diagnosed BC cases reported to SEER in 2010 were HER2+. Differences in incidence across age and stage followed a similar pattern for both HER2+ and HER2- BC, while slight differences by race were observed. Further outcomes studies by HER2 status are warranted.
Assessment of single-institution HER2 testing patterns, rate of HER2+ disease, and utilization of trastuzumab in early breast cancer.
Authors: Stenehjem David D. , Yoo Minkyoung , Unni Sudhir K. , Singhal Mukul , Bauer Hillevi , Saverno Kim , Quah Cheng Seok , Masaquel Anthony , Brixner Diana I. 
Published: February 2017

124 Background: Improved outcomes with HER2-directed therapies highlight the importance of standardized testing for HER2 positivity. This study aimed to assess HER2 testing practices, rate of HER2+ disease, and trastuzumab use in early breast cancer (EBC) at the Huntsman Cancer Institute (HCI) a National Cancer Institute-Designated Center and member of the National Comprehensive Cancer Network. Methods: Included patients’ records from the HCI electronic data warehouse (EDW) and the HCI tumor registry were female, age ≥ 18 years, ≥ 2 visits in the EDW and a stage I to IIIa EBC diagnosis from 2005 to 2012. HER2 testing patterns were identified through chart review of pathology and clinical notes in the EDW. HER2+ was defined as either FISH+ or IHC3+. Patient characteristics, HER2+ rate, and trastuzumab use were evaluated descriptively. Discordance rate associated with reflex testing (IHC 2+ retested by FISH) was also evaluated. Results: A total of 1,459 women were included with stage I (49%, n=720), IIa (26%, n=374), IIb (14%, n=197), and IIIa (12%, n=168) EBC. Mean age was 57 years. HER2+ disease was identified in 243 (17%) tumors. Of HER2+ tumors, 104 (43%) were ER+/PR+, 33 (14%) ER+/PR-, 1 (<1%) ER-/PR+, 79 (32%) ER-/PR-, and 26 (11%) unknown. Tumors were first tested for HER2 using: 1,192 (82%) IHC, 36 (3%) FISH, 227 (15%) unknown and 4 (<1%) other tests. First IHC results were scored 0 (23%), 1+ (33%), 2+ (26%), 3+ (17%), and unknown (<1%). Reflex testing within one month was performed in 301/308 (98%) of IHC 2+ tumors. The discordance rate of IHC/FISH was 10%. Trastuzumab was prescribed for 184/243 (76%) women whose tumors were considered HER2+ based on final interpretation and in 1 HER2 equivocal tumor. Documented reasons for lack of trastuzumab use in HER2+ patients (n=59) included low risk of recurrence based on stage or other treatments (n=18), loss to follow-up (n=13), unknown (n=11), not clinically appropriate due to age or comorbidity (n=10), and patient declined (n=7). Conclusions: This is one of few cancer registries assessing the rate of HER2+ disease in EBC. Reflex testing identified additional HER2+ tumors. The HER2+ rate was within range of previously published studies.
Trends in the cost of the futile cancer care near the end of life.
Authors: Lin Wender , Hsieh Chi-Jeng 
Published: February 2017

126 Background: Aggressive cancer care near the end of life may not only represent a quality-of-care issue, but also a futility issue. Under the constraint of health resources, it is of interest to know the cost trends of futile treatment for cancer patients near the end of their life. Methods: The definition of potential medical futility for cancer patients near the end of their life was developed based on the RAND/UCLA Appropriateness Method. Nine experts or academics from medical, political, social, or legal fields built a consensus that treatment after 7 days in the intensive care unit following a cardiopulmonary resuscitation for cancer patients who died within 3 months is probably futile. Based on this definition, we used death registry and Taiwan’s National Health Insurance claim data from 2000-2001 and 2009-2010 respectively to estimate the cost of potential futile treatment for cancer patients near the end of their life in 2001 and 2010. Results: The percentage of cancer patients receiving potentially futile treatment near the end of their life reduced from 2.68% in 2001 (883/32,993) to 1.58% in 2010 (649/41,046). The cost of potentially futile cancer care also decreased from $283 million NTD (New Taiwan Dollar) in 2001 to $255 million NTD in 2010 (1USD=30NTD). Nevertheless, the per capita cost of potentially futile cancer care slightly increased from $320 thousand NTD to $393 thousand NTD. Conclusions: Although the cost of potentially futile cancer care for patients near the end of life is not huge in Taiwan, its trend of decrease may indicate that supportive but not aggressive cancer care is more and more prevailing and acceptable by patients, their family, as well as health care providers.
Physician orders for scope of treatment (POST) forms in metastatic cancer patients: A 3-year single-university–institution retrospective review.
Authors: Curley Brendan F. , Khimani Farhad , Moss Alvin Howard 
Published: February 2017

133 Background: Physician orders for dcope of treatment (POST) forms are standardized forms for patient preferences for end-of-life care. These forms contain orders by a physician who has identified a patient who is seriously ill with life-limiting progressive, advanced illness. Utilization of the POST form in advanced and metastatic cancer patients has not yet been evaluated. Methods: At West Virginia University/Mary Babb Randolph Cancer Center, we performed an IRB approved retrospective chart review of all patients who died of metastatic or advanced malignancies from 2010-2012. Statistical analysis was performed with SPSS Version 20. Results: 139 patients were identified who were diagnosed with metastatic cancer and treated at West Virginia University who died from 2010-2012. Of those 139 patients, 26 (18.7%) completed POST forms. 51 (36.7%) patients received systemic oncologic treatment in their last thirty days of life. In the last ninety days of life, patients averaged 16.2 days hospitalized. 123 (88.4%) patients had at least one hospital stay in their last three months of life, with 82 (58.7%) having two or more stays. 65 (46.8%) patients had a hospital readmission within thirty days. 39 (28.1%) patients had an ICU stay with an average duration of 2.6 days. Almost half of all patients reviewed (67, 48.2%) died in the hospital. Patients averaged 2.9 CT scans and 5.2 X-rays over the last ninety days of their life. 116 (83.5%) patients had an end-of-life discussion, with an average time from discussion to date of death of 24.5 days. Only 60 (43.2%) were identified as having a palliative care consult completed. Conclusions: The American Society of Clinical Oncology (ASCO) recommends implementation of Palliative Care at the time of diagnosis of advanced cancer. POST forms appear to have a positive impact on end-of-life care in this population of advanced cancer patients. Increasing their implementation in metastatic oncology patients will likely improve end-of-life care. [Table: see text]
The impact of compliance to oncology pathways that include G-CSF rules for use on ER visits/hospitalizations in a multistate program.
Authors: Delgado Andrew , Kim Ted , Kreys Eugene , Koeller Jim M. 
Published: February 2017

135 Background: CareFirst BCBS initiated a multistate oncology pathway program in 2008, which reduced chemotherapy and hospitalization expenditures and also increased supportive care drug utilization. This study evaluated the impact of following pathways including supportive care versus not following pathways on ER visits/hospitalizations and associated costs as a result of anemia, neutropenia, and chemotherapy-induced nausea and vomiting (CINV). Methods: The CareFirst claims database was utilized to evaluate data two years after initiation of the pathways program. Frequency of ER visits/hospitalizations for neutropenia, anemia and CINV was the primary outcome measured and was compared between compliant and noncompliant pathway utilization of granulocyte colony-stimulating factors (G-CSFs), erythropoiesis-stimulating agents (ESAs), and antiemetics, respectively. Logistic regression analyses were used to control for expenditures of ESAs, CSFs, and antiemetics in the context of compliance and the corresponding visit types. Costs associated with ER visits/hospitalizations were also compared between compliant and noncompliant pathway utilization of supportive care. Results: Overall, 46 sites with 1,586 patients were evaluated. There were a total of 12 ER visits/hospitalizations for anemia, 231 for neutropenia, and 360 for CINV. G-CSF pathway compliance resulted in a relative reduction in ER visits/hospitalizations of 67.2% (from 28.3% to 11.5%, p<0.001). Logistic regression showed consistent results when controlling for costs with a 69.5% relative reduction of ER visits/hospitalizations (p<0.001). A comparison of ER visits/hospitalization costs as a result of neutropenia demonstrated G-CSF pathway compliance producing an average savings of $1,173 per line of therapy (p=0.001). Analogous analyses did not demonstrate a significant relationship between ESA and antiemetic utilizations and their corresponding ER visits/hospitalizations. Conclusions: Adherence to oncology pathways, including G-CSF use rules, is associated with a significantly lower ER visits/hospitalization rates and costs associated with febrile neutropenia.
Reduction in chemotherapy administered at the end of life (CAEOL) through quality improvement processes in a large community oncology clinic: The West Clinic experience.
Authors: Schwartzberg Lee Steven , Freiden Yonatan , Thul Aaron , Houts Arthur C. 
Published: February 2017

159 Background: Giving chemotherapy (CTX) near the end of life is futile and costly in human and financial terms. We analyzed patterns of chemotherapy administered at the end of life (CAEOL) by disease, provider, and line of therapy as part of a broad quality initiative. We hypothesized that measuring CAEOL in our practice could identify modifiable practice patterns. Methods: All patients (pts) with an ICD-9 diagnosis of cancer who died between 1/09 and 6/10 were identified by EMR or by searching SSDI records. We focused on the cohort receiving CTX within 14 or 28 days (d) of death, stratified by tumor type, provider and line of therapy by electronic chart review. Initial results were distributed to practice physicians for review and discussion with a clinic-wide goal to be below 5% and 10% at 14 and 28d, respectively. Subsequent cohorts were then evaluated periodically with results disseminated. Results: There was a 14.5% reduction in CAEOL within 14d and a 25% reduction within 28d over time (Table), meeting the clinic-wide standard. In the 2009-2010 cohort there was a difference in 1st line pts receiving CTX within 28 d for NSCLC (24/56 pts, 42.9%) or pancreas cancer (13/19, 68.4%) and the next 4 most common diagnoses: breast, colorectal, small cell lung, and head and neck cancer (15/84, 17.9%), p= .0024. CAEOL beyond 3rd line in non-breast, or >5th line in breast cancer was uncommon. In the 2013 cohort, 1st line accounted for 28/51 pts (54.9%) receiving CTX within 28 d with NSCLC (8/15), pancreas (3/3) and lymphoma (4/4) the most prevalent diagnoses. Conclusions: CAEOL is a relatively rare event in our practice, now meeting practice standards after measurement and delving into root causes. A certain irreducible number of pts will be treated at the end-of-life, including those with potentially life-prolonging intent. First line therapy represents the majority, so identifying inappropriate candidates at diagnosis remains a quality improvement opportunity. [Table: see text]
Developing and promoting evidence-based use of granulocyte colony stimulating factors (GCSF) in the palliative chemotherapy setting.
Authors: Elfiky Aymen , Kaymakcalan Marina , Stuver Sherri , Sweeney Christopher , Jacobson Joseph O. , Weingart Saul 
Published: February 2017

172 Background: National guidelines help define the standard for institutional clinical and insurance coverage policies, butdo not cover all chemo regimens or clinical scenarios. Given high utilization rates of primary granulocyte colony stimulating factors (GCSF) use in metastatic prostate cancer (CaP) patients treated with second-line cabazitaxel chemotherapy, we assessed indications and clinical rationale with goal of developing guidelines for appropriate use of GCSF in this population. Methods: We analyzed existing National Comprehensive Cancer Network (NCCN) and ASCO Myeloid Growth Factors supportive care guidelines as applied to specific chemo regimens, patient and laboratory risk factors (RF). We subsequently examined phase III TROPIC trial data for incidence of neutropenic events in CaP patients treated with cabazitaxel. Additionally, the medical records of the 25 Dana-Farber CaP patients treated with cabazitaxel from 1/2012 through 9/2012 who received primary GCSF prophylaxis were characterized by neutropenia/complications and their RF profiles using existing guidelines. Findings were presented to the genitourinary oncology providers with discussion culminating in consensusrecommendations for GCSF use. Results: Existing guidelines recommend 7 un-weighted factors to consider for GCSF use, in addition to febrile neutropenia (FN) risk > 20% for any chemo regimen. Cabazitaxel is listed as intermediate FN risk (10-20%). Trial data report FN incidence as 7% without primary prophylaxis. The number of NCCN RF for evaluated Dana-Farber CaP patients is represented below. Conclusions: Group consensus considered any of the following to place patients at high risk of neutropenic events: ECOG ≥2; prior episode of FN with any-line chemo; prior neutropenia resulting in treatment delay; and previous radiation comprising >25% bone marrow exposure. Final clinical consensus regarding high risk patients was to consider standard dose cabazitaxel (25mg/m2) with GCSF support versus dose reduced cabazitaxel (20mg/m2) without GCSF. In cases where provider posits there is no compromise of benefit to patient, initial consideration will be for dose reduction. [Table: see text]