AVAHO 2012 ABSTRACTS

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AVAHO 2012 ABSTRACTS


1.

Reference:
6330686


Denosumab for Giant Cell Tumor of the Spine



I. Introduction 32 y.o. Veteran diagnosed with a Giant Cell tumor of the spine in 2007. She was
initially treated with surgical resection, standard for this type of

tumor. In 2010, presented with
a paraspinal mass measuring 7.4 X 7.5 X 10.3cm, additional surgery was aborted due to high risk
of paralysis and/or death. She was then treated with radiation in hopes of shrinkage to allow for
resection. Despite this, he
r tumor grew to 9 X 8.9 X 10.4cm and no other options existed. II.
Methods Based on a Phase II trial in patients with Giant Cell tumors, she was treated with the
RANKL inhibitor denosumab at a dose of 120mg SQ monthly. At the time treatment was
initiat
ed her tumor measured 10.2 X 9.2cm with “significant mass effect on the carina and
mainstem bronchi”. III. Results After 15 months, the tumor shrank to 6.5 X 1.8 X 3.6cm,
allowing for a neuro/cardiothoracic surgical approach resulting in a near complete
resection.
She recovered completely with no neurological deficits as a result of the tumor or surgery. At 6
months post
-
op, she continues with MRI surveillance and monthly denosumab with plans to
begin increasing the interval between injections. She has

had no complications or side effects
attributed to denosumab. IV. Discussion Use of denosumab resulted in a major reduction in
tumor size, allowing for a surgical resection that was not otherwise possible. At 6 months post
-
op she continues to improve,
is off supplemental oxygen, and is no longer opiate dependent.


2.

Reference:
6349427


Outcomes of octogenarians treated with Stereotactic Body Radiation Therapy (SBRT) for early
stage lung Cancer



Purpose/Objective(s): With increasing life expectancy, earl
y stage lung cancer among elderly
veterans will pose a major therapeutic challenge. SBRT is a new approach and has emerged as
an alternative to surgery. We present outcomes data after SBRT in octogenarians with early
stage lung cancer. Materials/Methods:

Twenty
-
one octogenarians with stage I/II NSCLC were
treated with SBRT between 2007 and 2009 at a single center. The median tumor size was 22mm
(range 12
-
72mm). The median prescription dose was 48 Gy in 4 fractions. Estimates of local
failure (LF), nodal f
ailure (NF), distant failure (DF), and death from non
-
cancer causes
(competing mortality, CM) were performed using the cumulative incidence function. Toxicity
was graded by the Common Toxicity Criteria version 3.0. Results: Median follow
-
up for surviving

patients was 22 months. The 24
-
month disease
-
free survival was 43% (95% Confidence Interval
[C.I.]., 26
-
73%). The 24
-
month overall survival was 58% (95% C.I., 39
-
85%). No local failures
were observed during the period of observation. NF and DF occurred
1 and 4 patients,
respectively; the 24
-
month cumulative incidence of NF and DF were 6% (95% C.I., 3
-
26%) and
19% (95% C.I., 6
-
38%). The cumulative incidence of CM at 24
-
months was estimated at 31%
(95% C.I., 12
-
53%). No grade ≥ 3 early or late toxicities
were found. Conclusion: SBRT is an
effective and safe treatment modality for early stage lung cancer. Octogenarians tolerated SBRT
well with no serious toxicity. SBRT for elderly patients who are not surgical candidates is
justified.


3.

Reference:
6399593


Setting the Bar
-

Improving Care for Head and Neck Cancer Patients in the Veteran's Health
Administration



Purpose/Objectives: System redesign techniques have been the subject of several popular books
that outline their successes in the automotive and a
irline industries; they have now transcended
the business world and are being utilized in the health care setting. Head and neck cancer
patients constitute the most difficult and complex patients in the Veterans Administration
system due to the multidisci
plinary coordination of care that must occur prior to initial radiation
treatment. A Cancer Care Collaborative Initiative was created in order to find ways to decrease
treatment delays and improve quality as per validated studies. Methods: Three years

of data
was collected for head and neck cancer patients treated at the Indianapolis, Ft. Wayne, and
Danville Veteran's Administration Medical Centers in Indiana. Specific time points in the
patient's disease course were recorded including: time from prim
ary care physician referral to
ENT consultation, systemic workup and diagnosis, radiation consult and treatment planning,
surgery and/or chemotherapy administration, and further surveillance. These consultations also
include palliative care and end of lif
e issues. Quality control measures such as RTOG enrollment,
NCCN recommended treatment algorithms and customer satisfaction were documented.
Results: Individualized collaborative value stream map with run charts for each time point were
created. Pat
ient flow was adapted into a process map. Quality measures and staff/patient
survey responses were also evaluated. Conclusions: Increased time periods and poor quality
measures are directly addressed. Interim results have shown initial improvements
to the
aforementioned listed indices. The creation of a system
-
wide toolkit can streamline areas and
improve benchmarks.


4.

Reference:
6410020


Performance Measures



Premise of poster: Quality assurance and performance measures are a way to track care in a

uniform and consistent fashion in the VA by adding specific measures to the registry abstracts
and aggregating the data in VACCR for analysis.
Poster presentation only
.


5.

Reference:
6415532


Pathway to Care



Purpose: Project "Pathway to Care" developed from a perceived need to improve client
guidance for oncology clients at Northern Indiana Health Care System. The Pathway was
developed as a manual that is client centered so each Veteran and family can use t
his as a
resource and reference. Each Veteran is given a Pathway which contains information on a
variety of aspects of their care and treatment. It introduces them to their providers and contains
sections to help keep treatment plan updated. Symptom manage
ment, diet hints, personal care
issues and maps and instructions to tertiary facilities they may need to visit are included. This
allows the Veteran the ability to increase their knowledge of the disease process, decrease fear
and anxiety and allow the
Veteran and their support structure to be more a more active
participant in the decision making regarding their care. Process: Evolved from attending
conferences, participation in the Generation III Head and Neck Collaborative
--
NIHCS was the
spoke to In
diapolis VA's hub. Goal: Our goal is to increase support and ease the passage
through their care keeping the motto of our clinic in mind "We cannot direct the wind but we
can adjust the sails" present for those who seek our care.


6.

Reference:
6438601


Understanding the cancer screening behavior of the veterans



Introduction: Early diagnosis of cancer is needed to increase the survival and quality of life of
cancer patients. This study examined the cancer screening behavior of the veterans and
included

both males and females in a large dataset. Methods: We used BRFSS dataset of 2010.
We compared veterans with non veterans to examine the differences in cancer screening for
mammogram, Pap smear, PSA test, digital rectal examination, blood stool test and

colonoscopy/sigmoidoscopy. Chi
-
square test was carried out to examine the differences.
Results: Out of total 451,075 respondents, 15% were veterans and 38% were male. More male
veterans reported ever having a PSA test (83%% vs. 65%, p<0.001), digital re
ctal examination
(87% vs. 73%, p<0.001), stool blood test (48% vs. 33%, p<0.001), and colonoscopy/
sigmoidoscopy (73% vs. 61%, p<0.001) than non
-
veterans males. Female veterans were not
very different than female non
-
veterans in reporting of ever having a

mammogram (81% vs.
82%, p=0.22) or Pap smear (96% vs. 95%, p=0.20); however, more female veterans reported
ever having a physical breast exam by a doctor (94% vs. 91%, p<0.001). In general, white
veterans were more likely to report having a screening tes
t than African American and Hispanic
veterans. Discussions: Our study observed that male veterans had a higher rate of cancer
screening than male non
-
veterans. However, further examination is needed to confirm whether
they follow the clinical practice gu
idelines. There is still some room to increase the cancer
screening rates among the veterans to reduce their suffering from the deadly diseases.


7.

Reference:
6480413


Early Palliative Care Referral



Abstract Introduction: The level of complexity of medica
l care when one is diagnosed with
cancer can read like a road map: there are different treatment options depending on the cancer
stage, the need for additional medical specialists, and the patient’s response. Patients present
with a potential medical prob
lem and become anxious. Multiple diagnostic tests are performed
and patients are diagnosed with cancer. Then, there are referrals to specialists, treatments are
proposed, and patients have two common questions, “how long do I have to live, and where do
I

go from here?” Method: This review will discuss the role of the physician assistant (PA) in
cancer care, the important role of palliative care (PC), and three major obstacles that prevent
early clinical referral to this service: finances, title stigma,

and spiritual bias. A collection of
research articles and palliative care specialist discuss the importance of palliative care and its
need and role for early referral. Results: Early palliative care referral can allow patients to be
better equipped to
manage their symptoms and come to terms with their prognosis when
diagnosed with a terminal illness. Discussion: The importance of palliative lay in its history and
the role played in oncology care today.


8.

Reference:
6494933


Improving Oncology and Hemato
logy Care by Telemedicine for Rural Veterans receiving
Health Care at CBOCs associated with the Michael E DeBakey VAMC



Background: The Michael E DeBakey VAMC (MEDVAMC) is the referral center for cancer and
hematology care for seven Community Based Outp
atient Clinics (CBOCS). About 30,000 rural
veterans live in these areas, and over 8,000 have cancer and/or hematologic disease. In
September 2011 the MEDVAMC started a program of Telemedicine for care of rural veterans
from these CBOCs, through a grant fun
ded by the Office of Rural Health. Goals: The goals of
the project were to enhance 1) Supervision and accessibility of cancer/hematology care; 2)
Patient and caregiver education; 3) Veterans’ satisfaction through virtual cancer education
clinic; and 4
) Palliative and supportive care services for rural veterans. Results: The project
was piloted with veterans from 2 CBOCs for conditions like anemia, ITP, lymphoma,
myelodysplasia, lung cancer and colon cancer. From December 2011 to July 2012, a total
of 19
V
-
tel encounters (14 Hematology and 5 Oncology) were performed by 3 providers. Patient
overall satisfaction was 5 (out of a maximum score of 5) for the 19 encounters. More than 90%
of patients wanted to continue care with V
-
tel encounters. Futur
e goals are to expand the
types of telemedicine clinics to involve more palliative care/social support services and nutrition
services as well as expand to all CBOCs of the MEDVAMC. Conclusion: Telemedicine (V
-
tel)
plays an emerging and important role i
n delivering efficient health care services for rural
veterans in hematology and oncology without the need to travel long distances. Funding:
Supported by a grant received from the Office of Rural Health.


9.

Reference:
6495588


RAPID ARC THERAPY: NEWLY EV
OLVING STATE OF THE ART STEREOTACTIC RADIOTHERAPY



INTRODUCTION: RapidArc Therapy, also called Volumetric Modulated Arc Radiotherapy (VMAT),
is one step advanced, new generation of radiation therapy technology. ArcTherapy delivers
radiation with the same precision as Intensity Moudulated Radiation Therapy
(IMRT) but in a
shorter timeframe. ArcTherapy delivers of radiation to the target volume as a whole, rather than
beam by beam, as used in IMRT technology. In IMRT, the linear accelerator stops several times
to deliver radiation during its rotation around t
he patients while ArcTherapy continuously
delivers radiation to the whole target volume without interruption as the accelerator turns
around 360 degrees around patients. METHODS: The ArcTherapy is especially valuable for
radiating tumors adjacent to vit
al organs, such as spinal metastases. Traditionally, conventional
radiotherapy delivers the same dose to spinal vertebrae and the cord, leading to limited low
-
dose because of intolerance of spinal cord. ArcTherapy enable one to deliver higher doses to
the

spine while sparing the cord from excessive high radiation. RESULTS: Arctherapy delivers
highly precise treatment much faster than conventional therapy. ArcTherapy allows optimum
radiation to the spine for spinal metastases, including reirradiation
of recurrent tumor which
was prohibited previously. Treatment which used to take 15
-
30 minutes, can be as short as 2
minutes. DISCUSSION: ArcTherapy is more precise and provides quicker treatment as well as
less scattering of the radiation outside the tu
mor (reducing secondary tumor). ArcTherapy
modulates continuously throughout treatment; radiation is shaped and reshaped focusing on
the target while radiation is delivered. Further details will be presented.


10.

Reference:
6500535


Case reports and a retros
pective investigation of PSA and incidence of adverse drug events
(ADE) of Abiraterone Acetate in Men With Castrate Resistant Prostate Cancer



Per Package insert, After oral administration the median time to maximum plasma abiraterone
concentrations is
2 hours. Steady
-
state AUC is approximately 2
-
fold higher than exposure after
a single 1000 mg dose. At the dose of 1000 mg daily, mean steady
-
state values of Cmax were
226 +/
-

178 ng/ml and of AUC were 1173 +/
-

690 ng hr/ml. No major deviation from dose
p
roportionality was observed in the dose range of 250 mg to 1000 mg. Systemic exposure of
abiraterone is increased when administered with food. Cmax and systemic exposure were
approximately 7
-

and 5
-
fold higher, respectively, when abiraterone acetate was ad
ministered
with a low
-
fat meal (7% fat, 300 calories) and approximately 17
-

and 10
-
fold higher,
respectively, when the drug was administered with a high
-
fat meal (57% fat, 825 calories). Per
manufacture recommendations, given the usual variation in meal co
ntent and composition,
taking abiraterone with meals may result in highly variable exposures. Therefore, no food should
be consumed for at least 2 hours before the abiraterone dose is taken and for at least 1 hour
after the dose is taken.1 It has been su
ggested that abiraterone acetate could potentially be
used to treat metastatic, castration
-
resistant prostate cancer (mCRPC) at a much lower daily
maintenance dose than that currently approved.2 This review is an attempt to answer the above
hypothesis.

1.Zytiga (abiraterone acetate) package insert. Mississauga, Canada: Patheon Inc.;
2011 Dec. 2.J Clin Oncol. 2010 March 20; 28(9): 1481

1488. Published online 2010 February 16.
doi: 10.1200/JCO.2009.24.1281 3.http://clinicaltrials.gov/ct2/show/NCT015
43776







11.

Reference:
6501943


Combined Intensity Modulated Radiation Therapy and Cyberknife Radiosurgery for Spinal
Metastasis



We report a case involving a T8 spinal metastasis from a lung cancer primary treated with
combined IMRT and Radiosurgery.
The patient is an 80
-
yr old male, who underwent a surgical
resection of a pT4N0M0 Squamous cell carcinoma of left lung in 2009. Post operatively, the
patient underwent 3 cycles of Taxol/Carboplatin, followed by serial CT imaging. In June 2011, 21
month
s after surgery, surveillance CT showed an asymptomatic osteolytic lesion involving the
right transverse process and posterior element of T8 along with a soft tissue mass. MRI and PET
confirmed T8 lesion without other metastases. Following the diagnosi
s of metastasis, the T8
vertebral body and the entire lesion were treated at 2Gy/day to a total of 40Gy, followed by a
single fraction 10Gy Radiosurgery boost to the gross tumor; the dose to all portions of spinal
cord was kept below 45Gy. Up until the

last follow
-
up at 10 months, the patient remains pain
free and neurologically intact. Repeat PET imaging at 3 months shows disappearance of all
uptake at T8, a finding that persists through a total of 10 months post
-
XRT follow up.
Conclusion: In caref
ully selected patients, conventionally fractionated XRT combined with
radiosurgery can result in complete tumor response and the possibility of rendering some
patients cancer
-
free, despite an initial metastatic presentation. Although the ultimate likelihoo
d
of cure remains unknown, this new approach promises improved disease free survival and
quality of life.


12.

Reference:
6509957


Quality of Colorectal Cancer Care (CRC) in the Veterans Affairs (VA) Healthcare System


Examining Potential Colorectal Cancer Ca
re Disparities in an Equal Access System



Introduction: Racial disparities in cancer treatment and outcomes are a national problem. The
presence or extent of racial disparities in CRC treatment and outcomes within the Veterans
Affairs (VA) is poorly under
stood. We examined the relationship between race and receipt of
National Comprehensive Cancer Network guideline
-
concordant VA CRC care. Methods: We
identified 2,896 patients diagnosed with incident CRC between 10
-
1
-
2003 and 3
-
31
-
2006 from
128 VAMCs. We
included white and black patients with invasive, non
-
metastatic disease, known
comorbidity status, age, and marital status. Multivariable logistic regression examined
associations between race and receipt of guideline
-
concordant care (CT scan, preoperative

CEA,
clear surgical margins, referral to medical oncology for Stages II
-
III; 5FU
-
based adjuvant
chemotherapy for Stage III; surveillance colonoscopy for Stages I
-
III). Explanatory variables
included demographic and disease characteristics. Results: I
n the final sample of 2,022 men,
mean age at diagnosis was 68 years; 85% were white, 52%, married, and 38% lived in the South.
Stage was evenly distributed. No significant racial differences existed for most guidelines.
Compared to blacks, whites were more

likely to undergo surveillance colonoscopy 6
-
18 months
following surgery (OR=1.32, 95% CI 1.01
-
1.73, p=0.04) and marginally more likely to be referred
to medical oncology (OR=1.46, 95% CI 1.00
-
2.13, p=0.05). Patients who were 75 years or older
at diagnos
is (p<0.01) or with cardiovascular
-
related comorbidities (OR=0.65, 95% CI 0.50
-
0.89,
p=0.01) were less likely to be referred to medical oncology than their younger, healthier
counterparts. Discussion: In general, VA provides high quality, equal access c
ancer care.
However, there may be room for improvement.


13.

Reference:
6510471


Multiple Primary Malignances in US Veterans: Analysis of the Minneapolis VA Tumor Registry



Introduction: Multiple primary malignancies (MPMs) are increasing as cancer
survivorship
improves. A large analysis of the SEER database estimates the prevalence of MPMs in the
general population at 7.9%. The purpose of this study is to estimate the number of MPM
diagnoses and to define their distribution in the VA population.

Methods: The primary
objective of study was to determine the proportion of second or higher order cancer diagnoses
at the Minneapolis VA Medical Center from January 1st, 2005
-
December 31st, 2009. The
secondary objectives were to analyze and compare corre
lative demographic, exposure, clinical
and tumor data among those with synchronous and metachronous malignancies. Results: A
total of 4,449 patients were diagnosed with malignancies that met our inclusion criteria during
the study period. Of these, 50
6 patients (11.4% of cancer diagnoses) had a diagnosis of a
second or higher order malignancy. Of the 506 patients, 123 (24.26%) had synchronous
malignancies and 383 (75.54%) had metachronous malignancies. The most common malignancy
pairing was prostate

with bladder cancer (12.05% of MPM diagnoses). Further data regarding
survival, time to second malignancy, and patient and tumor characteristics will be presented at
the conference. Discussion: Multiple primary malignancies are of interest in cancer
s
urvivorship. At our institution more than 1 in 9 new cancer diagnoses, during the study period,
were second or higher order malignancies. Our data suggests that the VA population may be at
a higher risk for MPMs. Further analysis of this population is w
arranted.


14.

Reference:
6510485


Cancer Biomarkers: Class III Beta Tubulin Expression in Small Cell Lung Cancer



Introduction: Class III beta tubulin (TUBB3) is a potential biomarker in many cancers. TUBB3
correlates with more aggressive disease and resist
ance to taxanes and vinca alkaloids. To date,
there is little data on TUBB3 expression in small cell lung carcinomas (SCLC). Methods: The
primary objective of study is to determine the expression of TUBB3 in SCLCs.
Immunohistochemical staining of SCLC

tumor specimens from the VA Tumor Bank was
performed using standard procedures. Distribution of staining (% cells) and intensity of staining
(0
-
none, 1
-
weak, 2
-
moderate, 3
-
strong) were evaluated. Clinical and tumor data for each
patient was obtained fro
m the tumor registry. Analysis of these characteristics will be
compared with the degree of TUBB3 expression. Results: Thus far, a total of 70 SCLCs were
evaluable for TUBB3 expression. The mean distribution of staining for the specimens was 85.1
± 2
.2% (mean ± SE). The majority of specimens (n = 65, 93%) had > 50% of cells staining positive
for TUBB3 with ≥ 2+ intensity. There appears to be a trend for a higher distribution of staining
(94.1 ± 15.2%) and higher intensity of staining (100% of sample
s ≥ 2+ intensity) in metastatic
lesions. Further data regarding tumor and patient characteristics will be discussed at the
conference. Discussion: Initial data from our study confirms that TUBB3 expression in SCLC is
high. Resistance to microtubule in
hibitors such as the taxanes and vinca alkaloids may be
related to this finding. Attempts at microtubule inhibition with novel agents may be able to
overcome this resistance mechanism.


15.

Reference:
6510500


Pain Characteristics, Pain Treatments and Patient
-
Reported Outcomes (PROs) among Patients
diagnosed with Cancer: An Analysis using the National Survey Data



Objective:To evaluate characteristics and treatments of pain, and patient
-
reported outcomes
(PROs) among cancer patients. Methods:Respondents to t
he online 2011 US National Health
and Wellness Survey (NHWS) of 75000 adults, indicating any cancer diagnosis in the past, were
included. The NHWS collected self
-
reported data on pain severity, frequency, and intensity in
the past week (11
-
point numeric ra
ting scale); pain treatments, side
-
effects and satisfaction (7
-
point categorical scale); and other PROs including daily
-
activity impairment. Results:Among
7883 cancer patients (mean age=62 years; 51.2% males; 86.4% whites; 36.5% employed), skin
(37.2%), p
rostate (13.9%) and breast (12.3%) cancer were the most common conditions. A total
of 3507 (44.5%) cancer patients reported pain in the past year, of them, 2987 (85.2%) indicated
diagnosis of pain; of those, 1536 (51.4%) were using a prescription pain medi
cation. When asked
about their current pain, 68.5% reported moderate
-
to
-
severe pain, 54.9% reported daily pain
and an average pain
-
intensity of 5.1. Back (56.0%)/arthritis (49.7%)/joint (48.7%) pain were
frequently reported pain conditions. Sleep difficult
ies (26.4%)/insomnia (16.9%)/depression
(19.8%)/anxiety (16.6%) were common pain
-
related comorbidities. Among prescription users,
20.1% and 47.5% were using a strong or weak opioid, respectively, and 44.0% indicated
satisfaction with their medication. The
most common side
-
effects were constipation
(55.4%)/sleepiness (37.6%)/dizziness (25.3%)/trouble thinking clearly (23.1%)/nausea (19.9%).
Additionally, 34.8% of these cancer patients reported high (>40%) daily
-
activity impairment due
to health. Conclusion:
Moderate
-
to
-
severe pain is prevalent among cancer patients. This analysis
suggests undertreatment of pain, and frequent side
-
effects/low satisfaction among the treated
patients. Further analyses will elucidate the impact of cancer pain on other patient
-
rep
orted
outcomes.


16.

Reference:
6511088


Implementing VCM: Tales from the Trenches



Chemotherapy safety is an important issue for all oncology professionals, including accurate
chemotherapy order writing. Many computer software programs are available for thi
s purpose,
but most are not compatible with existing systems within VHA. Vista Chemotherapy Manager
(VCM) is a product that was specifically developed for this use within VHA. The purpose of this
presentation is to describe one facility’s process in inc
orporating VCM and share “lessons
learned” for other facilities planning to use this software. A project team, consisting of a
hematology attending physician, clinical nurse specialist and pharmacist, was tasked with
implementing VCM at our institution.

Business rules were established and vetted with other
facility hematologists/oncologists. Using the skill sets of individuals from varied disciplines
afforded more robust order set development, but slowed the implementation process. Enlisting
experti
se from other services was crucial and not always intuitive as the project began.
Processes not initially obvious to the project team included mapping lab tests from VISTA to
VCM, making necessary modifications for including non
-
formulary drugs, and metho
ds for
testing treatment plans. In retrospect, a more thorough understanding of the entire process
involved in implementing VCM prior to initiating treatment plan development would have
diminished problems and delays in successful implementation. Team me
mbers responsible for
developing treatment plans need a good understanding of how the software functions and need
committed on
-
going support from pharmacy service, clinical applications, and OI&T staff. Role
clarification and on
-
going communication betwe
en the project team and VCM staff was crucial
in moving the project forward.


17.

Reference:
6512916


Speed Of Care: Getting patients into chemotherapy appointments more quickly and efficiently



Introduction: Numerous patient complaints related to delays in

the Chemotherapy infusion
clinic prompted a need for process improvement. The Infusion Center was experiencing many
problems, the primary one being a steady decline in patient satisfaction especially with regards
to wait times. Methods: A team of nurses,

pharmacists, laboratory and administration focused
on the processes surrounding chemotherapy appointments, aiming to move patients through
their infusions more efficiently. The Team mapped the current state, identified issues, and
prioritized solutions. T
he constraints were categorized into three main groups: pharmacy,
laboratory processing, and scheduling. Review of response time variances from start to finish
revealed difficulties in prediction, scheduling and planning to meet clinic needs. Results: The

team’s changes have reduced the average time between the patients arrival for laboratory,
pharmacy preparation to the start of patient infusion from two hours to one hour less than half
of the previous wait Discussions: Scheduling is still the process th
at causes the most frustrations
due to the variability in patient arrivals, delays in clinic, treatment reactions, etc. We continue
to monitor the new profile to validate achieving the desired results of reduced wait times,
accurate utilization rates, inc
reased clinic efficiency, more accurate patient expectation and
increased transparency into other causes of patient delays. We have plans to create a fast track
clinic for patients requiring less than 1 hour treatments and to account for any add
-
ons, based

on how often this occurs.


https://fs20.formsite.com//sclentz/files/f
-
0
-
25
-
6512916_aaQnAnPg_ChemotherapyInfusionClinic.pptx


18.

Reference:
6513466


Survival outcome of veterans with myelodysplastic syndrome (MDS) treated with statins



Introduction:Recent studies have shown promising risk modifying effects of statins in
hematologic and solid tumors,such as ability to induce apoptosis in acute

myeloid leukemia cells
in
-
vitro.The impact on MDS treatment outcome has not been evaluated.In this retrospective
study,we have examined the overall survival(OS) in veteran MDS patients(pts) with and without
exposure to statin with the hypothesis that it m
ay impact OS.Methods:After IRB approval,data
was collected from Michael E DeBakey VAMC Cancer Registry from January 2000 to October
2011.Pts were included if they had morphological evidence of MDS at the time of
diagnosis.Statin exposure was defined as con
current statin use for at least 6 months prior to and
at the time of diagnosis.The primary end
-
point was OS before and after adjustment with MDS
Co
-
morbidity Index(MDS
-
CI).Results:104 pts with MDS were identified(Baseline
characteristics:Table1).OS of pts
exposed to statin was significantly longer when compared with
pts not exposed to statin(950dvs419d, p2)(1062dvs219d, p<0.05) and specifically in those with
higher cardiac comorbidities.OS in pts with lower MDS
-
CI scores was higher in patients on statin
but

there was no statistical significance (901dvs663d, p=0.57).Discussion:In this study,statin
exposure significantly improved OS in pts with MDS.This improvement,however,was statistically
significant in pts with higher overall and cardiovascular co
-
morbiditi
es.These findings suggest a
limited direct anti
-
tumor benefit of statin in MDS,although the results may have been influenced
by the sample size and retrospective design.Prospective studies after stratification by IPSS and
MDS
-
CI are needed to further evalu
ate the risk
-
modifying effects of statin in MDS.




19.

Reference:
6515926


A new portable telehealth device for ototoxicity monitoring, the OtoID



Introduction: Cisplatin is a potent and effective treatment for certain cancers but can result in
permanent hearing loss and tinnitus in 40
-
50% of patients. Veterans undergoing chemotherapy
often travel distances for treatment with the hope of returning ho
me the same day.
Cumbersome sound booth hearing testing cannot always be accommodated on the treatment
day. We have developed a device, the OtoID, that is capable of providing accurate hearing
testing either on the treatment unit during treatment or at hom
e (patient self
-
testing) just prior
to treatment. Methods: 40 subjects young and older with and without hearing loss not on
chemotherapy were tested in a sound suite and on the Chemotherapy Unit at Portland VAMC.
An additional 10 Veteran patients undergoi
ng treatment with cisplatin were tested on the
Chemotherapy Unit. Tested was completed by an audiologist and by each patient using the self
-
testing mode of the OtoID. Results: Results from subjects not on chemotherapy were
compared for test bias, repeata
bility, and false
-
positive (for ototoxicity) rates. The device was
well within tolerance for all three measures except at the highest test frequencies (18
-
20 kHz).
Results from Veterans undergoing chemotherapy demonstrated that the device is accurate,
stab
le, and easy to use by the patient. Discussion: Development of this portable, easy to use
device will further the goal of providing ototoxicity monitoring for all Veterans. The device will
be available for demonstration. The telemedicine capabilities and

at
-
home testing application of
the device will be demonstrated and discussed.


20.

Reference:
6515949


Impact of race on early
-
stage lung cancer treatment and outcome



Introduction: The purpose of this study was to investigate whether racial differences exis
t in
lung cancer treatment and outcome among patients with early stage non
-
small cell lung cancer.
We hypothesize that patients receiving similar treatment will have similar outcomes. Methods:
Data were from the EPRP Lung Cancer Special Study. Analyses we
re restricted to patients with
Stage I/II NSCLC (N=1426; 1229 Whites, 197 Blacks). Multivariate logistic regression was used to
estimate odds ratios (OR) and 95% confidence intervals (95%CI). Results: The proportion of
Blacks who had surgery was signific
antly less than that among Whites (OR: 0.56, 95%CI 0.39
-
0.79). There was no racial difference in receipt of adjuvant therapy (chemotherapy and/or
radiation therapy) among patients who had surgery (p=0.08). Among patients who did not
undergo surgery, Blac
ks were more likely to refuse surgery (OR: 2.30, 95%CI 1.29
-
4.13),
although the proportion of patients with contraindications to surgery and those receiving
palliative treatment were similar in both race groups. Race was not a predictor of survival when
c
ontrolling for receipt of surgery (p=0.76). The 2
-
year survival rate was 82% among patients who
had surgery, 48% among patients who did not have surgery, and 55% specifically among those
who refused surgery. Discussion: We observed a racial disparity in s
urgery, partially due to the
greater rate of refusal among Blacks, but not adjuvant or palliative treatment. There was no
survival difference by race. These findings stress the need to better understand patient
preferences regarding surgery and identify
ways to reduce this variation in surgical treatment.


21.

Reference:
6515993


Pre
-
treatment ototoxicity risk assessment for Veterans prescribed cisplatin



Introduction: Cisplatin, a common anti
-
cancer medication, is the most ototoxic compound in
clinical use and annually puts more than 4000 Veterans at risk for permanent hearing shifts and
tinnitus. Furthermore, most of these Veterans begin treatment with h
earing loss such that
minor hearing shifts in the speech frequency region can substantially influence communication
and quality of life. Methods for assessing cisplatin pre
-
treatment risk of hearing shift may be
helpful for oncology treatment planning with

the potential to mitigate hearing shift and for
oncology/audiology pre
-
treatment patient counseling. Our previous work with two samples of
cisplatin patients (n=19; n=24) found that knowledge of pre
-
treatment hearing thresholds
combined with prescribed ci
splatin dose accurately predicted high frequency hearing shifts
among Veterans. We extended the analysis to include risk profiles for the functional speech
frequencies. Methods: Hearing testing was performed at each cisplatin treatment interval.
Hearing
shift risk models were developed on a sample of 48 ears in 27 Veterans and validated in
a hold
-
out sample of 14 ears in 7 Veterans. Results: The model is accurate, yielding an overall
accuracy of 4.9 to 9.3 dB prediction error in the functional speech fr
equency range. Case
applications of the model will be discussed as will ototoxicity monitoring protocols. Discussion:
With improved survivability following cancer treatment, Veterans treated with cisplatin should
be approached with the dual goals of effe
ctive treatment and preserved quality of life including
hearing preservation, when possible. Pre
-
treatment risk assessment is a valuable tool in
achieving this goal.


22.

Reference:
6516172


Infrequent removal of retrievable IVC filters



Background: The use
of retrievable inferior vena cava (IVC) filters has increased significantly
over recent years. IVC filters left beyond clinical indication have led to increased long
-
term
morbidity & mortality. Despite the ease of removal, we hypothesized that a minority o
f IVC
filters are actually removed regardless of the initial indication for placement. Methods: A
retrospective chart review using CPT radiology codes and radiology consult requests For the
indications, complications follow up and retrieval rates
of IVC filters placed from January 1st,
2006, to December 1st, 2011, at the VAMCs in DC and Baltimore. Results: Of the 85 patients
with retrievable IVC filters placed during the study period, only 6 (11%) patients underwent IVC
filter removal. Only 21

patients had “IVC Filter” listed on their problem list. We observed that a
patient was nearly twice as likely to have an IVC filter removed if it was listed as an active
problem. Discussion: Although the VA electronic medical record system (VistA) can

enumerate
active problems and alert physicians to the need to re
-
evaluate patients with IVC filters for
retrieval, the EMR is underutilized for this function. We observed that patients who had IVC
filter listed as an active problem were twice as likely to

have their filters removed. Based upon
this finding, we plan to develop an electronic alert system integrated into the current EMR
system and an e consult system with the goal of increasing the rate of IVC filter removal.







23.

Reference:
6518886


Compari
son of clinical parameters and survival in Vietnam era (V) versus non
-
Vietnam era
(non
-
V) veterans with non
-
Hodgkin lymphoma (NHL).



Introduction: Incidence of NHL has been increasing in the US population. Agent Orange
exposure has been implicated in the
development of B cell Lymphoproliferative disorders. We
explored differences in the clinical, lab parameters and predictors of survival in (V) versus (Non
-
V) veterans with diagnosis of NHL. Methods: Records of veterans diagnosed with NHL from
January 1997
to December 2011 were reviewed for demographic, clinical, and pathology data,
including HIV, Hep B, Hep C titers, Vietnam Veteran status and survival. We tabulated the ECOG
Performance Status (PS), International Prognosis Index (IPI)/ Follicular Lymphoma I
nternational
Prognostic Index (FLIPI), Charlson Co morbidity Index (CMI), the Kaplan
-
Feinstein Index (KFI), the
Cumulative Illness Rating Scale (CIRS) and Vietnam status. Cox regression analyses were
performed to determine predictors of survival. Results
: There were 152 veterans who met the
eligibility criteria; 78 V and 74 non
-
V; the groups did not differ by PS, stage, beta 2microglobulin
(b2m), and HIV status, IPI / FLIPI. Differences in their clinical features are summarized (Table).
Survival predictor
s for both the V and non
-
V veterans were the age, PS, hemoglobin, LDH,
albumin, grade, IPI/FLIPI. However, in V veterans, b2m (p< 0.001) and stage were additional
predictors of survival. Median survival for V veterans was 1454 days (95%CI 864
-
3377) and N
on
-
V was 1824 days (95% CI 560
-
2075) Discussions: The V veterans were younger with higher
grade disease compared to the Non
-
V veterans. While their stage and PS was not different
survival was shorter. These should be studied further in a larger sample.


Parameters

V

Non
-
V

P value

Age (years)

Median 57 (27
-
77)

75 (37
-
92

< 0.001

Race (AA)

24 (32%)

7 (7.04%)

< 0.008

LDH

216 (127
-
1,905)

190 (86
-
1,368)

< 0.0062

Hep C positive pts

18

2

< 0.01

Lymphoma grade

Low grade

Aggressive

36 (46.15%)

42 (53.85%)

43 (58.11%)

31 (41.89%)

0.0364

Charlson comorbidity index

6.5(0.7
-
120

5(1
-
12)

< 0.004

Survival (days) (95%CI)

1,454

(864
-
3377)

1,824

(560
-
2075)

0.03


24.

Reference:
6519176


A worldwide survey to assess the treatment approach to patients with
cancer
-
associated
venous thromboembolism (CAT)



Introduction Low
-
molecular
-
weight heparin (LWMH) has been recommended as the preferred
anticoagulant over vitamin K antagonists (VKAs) for CAT since the CLOT trial was published in
2003. We assessed the current anticoagulation practice of CAT in various c
ountries. Methods
An electronic tool containing 49 questions on different aspects of the treatment of CAT was
used for survey; personal links were sent to different specialists. Results Of the 234 surveys
sent between 12/2010
-
3/2012, 141(53%) wer
e available for analysis. Responses received from
Europe, United States (US) and other countries were 58%, 35% and 7%, respectively, including
23% haematologist, 18% oncologist, 15% pulmonologist and 15% internists. The majority (82%)
use LMWH for long
-
ter
m anticoagulation as first line. Use of LMWH is significantly higher
(p=0.004) among European respondents (90%) vs US (69%). 60% use therapeutic doses of
LMWH, while the remainder dose
-
reduce after a period of time. For long
-
term treatment, 44%
prefer LMW
H and 10% VKAs. For recurrent VTE, 44% of the respondents increased the dose of
LWMH, 8.2% added VKA to LMWH and 30% would insert an IVC filter. Cost, reimbursement and
administration of LMWH were the main concerns for not using LMWH in US. Discussion:

With
respect to the type of anticoagulant used for the long
-
term treatment of CAT, a relatively high
number of respondent followed guidelines. As predicted, a lower use of LMWH in CAT was
observed in the US compared to Europe principally due to cost and l
ack of reimbursement.


25.

Reference:
6521505


INTRAORBITAL LYMPHOMA: CURRENT MANAGMEENT STRATEGIES



Introduction: Non
-
Hodgkin lymphoma (NHL) is the seventh most frequent type of cancer. The
incidence of NHL has increased considerably in Western countries ove
r the last decades.
Ophthalmic lymphomas are the most common primary orbital malignancy, constituting
approximately 10% of all orbital tumors and 40% to 60% of lymphoproliferative disease in the
orbit. Radiotherapy successfully controls local disease but t
he risk of distant relapse is not
insignificant with radiotherapy alone. Current management including modern technology is
critically reviewed. Methods: A 59 year
-
old male who was referred to us because of right orbital
lymphoma: extranodular B
-
cell lymph
oma, stage IE. His complaints were constant tearing and
upper eye lid prolapse. CT scan revealed soft tissue density in the right orbit. A biopsy confirmed
low
-
grade Non
-
Hodgkin Lymphoma. Following evaluation, he received 4600 cGy of radiation
therapy in 2
3 fractions with good response to the therapy. Results: He is now almost six years
since his radiation therapy and doing well with no evidence of recurrence. He has been regularly
followed by Eye Clinic with meticulous eye examination and CT/MRI scans. M
ost recent imaging
studies showed no evidence of recurrent disease. There were no significant late sequelae, such
as visual problems or pain, but some dry eye. Discussions: Although radiotherapy is very
successful in local control of tumor without signif
icant sequelae, the risk of distant failure is
significant in more aggressive histological types. Newly developing modern radiotherapeutic
technique along with current management strategies will be presented in detail.



26.

Reference:
6521605


A Comparison o
f Chemotherapy Use in Stage IV Pancreatic Cancer at the VAH Versus Other
Types of Health Coverage



Background: Palliative chemotherapy is the standard of care for stage IV pancreatic cancer
patients (SFPC). This is the largest study to date that compares
treatment of SFPC. Methods:
This study compares the amount of SFPC given at Veterans’ Administration Hospital (VAH)
against other insurance types (Medicare, Uninsured, etc) using the National Cancer Database
(NCDB), which contains 70% of US cancer case
s. Results: The NCDB reported 115,512 patients
diagnosed with SFPC from 2000
-
2009. VAH provided significantly less chemotherapy (28.3%) to
SFPC patients as compared to Managed Care (48.2%), Private Insurance (46.7%), Tricare/Military
(42.8%), Medicaid
(37.8%), Medicare Plus Supplement (35.5%), and Uninsured (34.4%). The rate
at the VAH was similar to Medicare (29.7%). Overall, 38.3% of SFPC patients received
chemotherapy. From 2000
-
2009, the rate of chemotherapy for SFPC increased for both VAH
(22.
9% to 34.3%) and non
-
VAH (31.1% to 44.1%). However, each year, the VAH provided
significantly less chemotherapy than the average of non
-
VAH patients. At diagnosis, the
percent of patients less than 60 at the VAH was 32%, non
-
VAH was 25.5% and Medicare w
as 7%.
From age 20
-
59, the rate of chemo was stable at approximately 49%, but each successive
decade demonstrated a marked reduction in use of chemotherapy (from 44% for 60
-
69 years of
age to 5% for >90). Conclusion: Patients treated within the VAH w
ere less likely to receive
chemotherapy compared to other patients (including Uninsured, Medicaid, etc) and receive a
similar amount of chemotherapy as compared to Medicare patients, who tend to be older at
time of diagnosis.


Graph I. Percent of Stage IV
Pancreatic Cancer Treated with Chemotherapy (2000
-
2009)


*Denotes statistically significant (p<0.05) difference as compared to VAH.



Table I
. Treatment of SFPC vs. Age

for All Patients

Age at Diagnosis of SFPC

% Chemotherapy

<20

36

20
-
29

48

30
-
39

51

40
-
49

48

50
-
59

48

60
-
69

44

70
-
79

36

80
-
89

21

>90

5


27.

Reference:
6522355


SURGERY AND CHEMORADIOTHERAPY IN STAGE II AND III ESOPHAGEAL CANCER


A
RETROSPECTIVE ANALYSIS OF THE VETERANS AFFAIRS SYSTEM AS COMPARED WITH OTHER
INSURANCES USING THE NCDB



Introduction: The current standard of care for Stage II and III esophageal carcinoma for patients
who can withstand aggressive therapy is chemotherapy, radiotherapy and surgery (tri
-
modality
therapy). This is the largest study to analyze treatment practice
s for esophageal carcinoma
across insurances. Methods: Using the National Cancer Database (NCDB) 46,758 patients
diagnosed with stage II and III esophageal carcinoma between 2000 and 2009 were identified
and treatment modalities were analyzed by age an
d insurance status. The NCDB database
includes data from 70% of all cancer patients in the U.S. Results: In Stage II and III esophageal
cancer private insurance holders received more tri
-
modality therapy (39%) than VAH (18%),
Medicaid (22%), Medicare (
18%), and the uninsured (19%) (p<0.0001). There was no statistically
significant difference in the amount of tri
-
modality therapy received in patients with VAH,
Medicare, or no insurance, however Medicaid patients received more tri
-
modality therapy than
VA
H patients (p<0.0003). VAH and uninsured patients received no treatment more frequently
(13%) than those with private insurance (5%), Medicare (10%), and Medicaid (9%) (p<0.0003).
Patients over 70 less frequently underwent tri
-
modality therapy (13%) as co
mpared to those
under age 70 (34%, p<0.0001). Discussions: Only 18% of VAH patients received tri
-
modality
therapy. Although VAH, Medicare, Medicaid and the uninsured patients received similar rates of
tri
-
modality therapy (18
-
22%), it was much less tha
n private insurance holders (39%). Medicaid
patients received less tri
-
modality therapy than private insurance holders despite similar ages.
Uninsured patients received a similar amount of tri
-
modality therapy as those with VAH and
Medicare.




Table 1:

St
age II and III Esophageal Carcinoma Treatment Modalities vs. Age and Insurance
Status



Surgery

Radiation

Chemotherapy and
Radiation

Surgery, Radiation, and
Chemotherapy

No First Treatment

Age











<70

3311 (
12%
)

1029 (
4%
)

9400 (
34%
)

9519 (
34%
)

1712 (
6%
)

>70

2848 (
15%
)

2060 (
11%
)

7737 (
41%
)

2371 (
13%
)

2259 (
12%
)

Insurance











Private

574 (
12%
)

159 (
3%
)

1507 (
31%
)

1921 (
39%
)

250 (
5%
)

Managed

1268 (
12%
)

340 (
3%
)

3188 (
30%
)

4203 (
39%
)

559 (
5%
)

Uninsured

144 (
10%
)

82 (
6%
)

567 (
40%
)

273 (
19%
)

189 (
13%
)

Medicare

3237 (
15%
)

1980 (
9%
)

8899 (
40%
)

3940 (
18%
)

2230 (
10%
)

Medicaid

240 (
10%
)

232 (
8%
)

856 (
42%
)

370 (
22%
)

217 (
9%
)

VA

209 (
10%
)

232 (
11%
)

856 (
41%
)

370 (
18%
)

264 (
13%
)


Figure 1:
Percentage of Patients receiving
tri
-
modality
therapy

versus Insurance Status


Table
2
:

Insurance status and Age Group amongst Stage II and III Esophageal Cancer Patients

Insurance

<70

>70

Medicaid

93%

7%

Medicare

33%

67%

VA

66%

34%

Private

90%

10%




0%
10%
20%
30%
40%
50%
Private
Managed
Care
Uninsured
Medicare
Medicaid
VAH
Percentage of Patients
Receiving Standard of
Care Treatment

Insurance Status

28.

Reference:
6523558


Utilization of
Erlotinib for Lung Cancer Treatment in VA



Introduction: Erlotinib (Tarceva), a tyrosine kinase inhibitor of the epidermal growth factor
receptor (EGFR), has been emerging as one of evidence
-
based treatment options for advanced
lung cancer. However, littl
e information is available about its use in Veterans diagnosed with
lung cancer in the VA healthcare system. The primary aim of this study was to assess the
utilization of tarceva among Veterans with lung cancer. Method: Veterans with lung cancer in
a

period of October 1, 2008 and September 30, 2009 were identified from the VA Decision
Support System (DSS) databases. The lung cancer cases were ascertained according to ICD
-
9
-
CM
diagnosis codes:162.00
-
162.09. Prescriptions of tarceva were identified from

the DSS pharmacy
dataset based on the National Drug Codes (NDC). Descriptive statistics and multivariate logistic
regression analyses were performed. Result: Of Veterans with lung cancer patients in the
study period, 79% were white, 13% African Amer
icans (AA), 3% other race, and 5% with missing
race; the mean age was 70yr; 98% were male; 69% were living in metropolitan areas; 5% were
with COPD and 23% with diabetes. The proportion of these patients prescribed with tarceva was
less than 3.5 %. The
significant factors associated with the prescriptions of tarceva included
-

AA, peripheral artery disease, living in a suburban area, and metastatic cancer (p<0.01).
Discussion: Tarceva demonstrates less cytotoxic effects and is better tolerated by p
atients
relative to conventional chemotherapeutic agents in lung cancer care. The relatively low rate of
utilization in tarceva among the study patients needs further studies.


29.

Reference:
6523865


The Physical and Psychological Burden of Oral
-
Digestive Can
cer on Veteran Cancer Survivors



Introduction: Cancer survivorship is increasingly common given the high lifetime risk of cancer in
combination with improvements in treatment. The process of cancer diagnosis and treatment,
as well as various complications

of treatment, can take a physical and emotional toll on many
survivors. Although research on cancer survivorship has grown, there is little survivorship
-
related data on older Veterans with oral
-
digestive cancers. Methods: 170 veterans were
recruited a
s part of the Veterans Cancer Rehabilitation Study from cancer registries at the
Boston and Houston VA Healthcare Systems. Baseline interviews occurred 6 months after
diagnosis and assessed sociodemographic traits, clinical, mental health, psychosocial, an
d
functional status, using the Short Physical Performance Battery and a quality of life
measure(PROMIS
-
29). Follow
-
up assessments at 12 and 18 months are ongoing. Results:
Participants were 64±9 years and 80% white. Cancer diagnoses included head and n
eck(39%),
colorectal(50%), and esophageal or gastric cancers(11%) with a balanced distribution of
stage(I=24%; II=28%; III=22%; IV=26%). Age was related to physical health(p<.001), emotional
health(p<.001), pain impact(p<.007), and pain intensity(p<0.007)
on PROMIS
-
29.Social
satisfaction was related to cancer type(p<.037). Gait speed for those with metastatic cancer was
significantly lower than those with non
-
metastatic(p<0.05). Participants were mild to
moderately impaired by fatigue(24%), pain(24%), sleep

disturbances(17%), anxiety(11%), and
depression(14%). Participants were severely impaired by fatigue(5%), pain(7%), sleep
disturbance(4%), anxiety(2%), and depression(4%). Discussion: Younger age was associated
with worse quality of life across physica
l and emotional domains. At baseline many participants
have moderate to severe impairments in fatigue, pain, sleep and depressive symptoms.


30.

Reference:
6523869


VA CT Cancer Care Tracking System


An Innovative Tool to Facilitate Cancer Care



Introduction: VA Connecticut Healthcare System developed a web
-
based, VistA
-
linked Cancer
Care Tracking System (CCTS) to facilitate tracking and follow
-
up of patients with imaging
abnormalities concerning for lung or liver cancer. Methods: CCTS was e
nvisioned in 2007
when VACT hired a Cancer Care Coordinator (CCC) and implemented a radiology coding system
to identify potential cancers. This created the need for a tool to process abnormal images and
track patients with cancer. In addition to case disc
overy, it offers easy access to patient
information with live links to VistA, a surveillance feature, scheduling, alerting and reporting
functions. CCTS gathers abnormal images based on national VA radiology coding schemes, and
in 2011 the system was enha
nced with a natural language processing (NLP) program. Results:
CCTS has been in daily operation since February 2010, with 1778 patients and 2503 patients
tracked in 2010 and 2011, respectively. The NLP system identified 21% of all new cases with
poten
tial malignancies whose management could have been delayed through coding omissions
or errors. Benefits of CCTS and our cancer care coordination program have included a decrease
of 25 days in the time from abnormal image to treatment of lung cancer, a sig
nificant increase in
the diagnosis of stage I/II lung cancers from 32% to 48%, and an increase in the incidence of liver
cancer from 1% to 5% of all cancers at VACT. Conclusion: A CCC coupled with CCTS improved
liver and lung cancer care at VACT. CCTS i
s applicable to the entire VA Healthcare System.




31.

Reference:
6524084


Targeting metabolism and signaling in melanoma



Melanomas do not express argininosuccinate synthetase (ASS
-
)and hence are auxotrophic for
arginine. We have translated this concept into clinical trial using an arginine degrading enzyme
ADI
-
PEG20 (Polaris Inc), and responses were noted in ASS
-

patients.
In our trial we found that
tumor cells undergo autophagy and subsequently turn on the ASS gene which results in drug
resistance. We have investigated two strategies to overcome drug resistance. Firstly, to halt
autophagy and accelerate apoptosis by com
bining with TRAIL (BBRC 394:760,2010). Secondly, to
inhibit ASS expression, we have found that HIF1α functions as a negative transcriptional
regulator for ASS while c
-
Myc functions as a positive regulator. Arginine deprivation leads to
the phosphorylatio
n of c
-
Myc (T58&S62) by GSK
-
3 and ERK, respectively, which stabilizes c
-
Myc
through the attenuation of its ubiquitination. Thus, inhibition of the RAS
-
RAF
-
ERK pathway may
decrease the phosphorylation of c
-
Myc and hence re
-
expression of ASS. We have proved

this
concept using combination of PLX
-
4032 and ADI
-
PEG20 in 6 melanoma cell lines: A375, Mel
-
1220 (ASS
-

and BRAF+), A2058 and GP (ASS slightly positive but inducible and BRAF+), and
MEWO (ASS
-

and BRAF
-
). Our data showed that combination treatment is eff
ective with 15%
increase in apoptosis in Mel
-
1220, A375 and GP, but minor increase in A2058. PLX
-
4032 also
prevents re
-
expression of ASS and inhibits the development of ADI
-
PEG20 resistance.
Combination treatment also aborts cell cycle arrest by either

agent alone and leads to increase
in sub
-
G0 population. Thus, PLX
-
4032 with ADI
-
PEG20 should be explored for future treatment
of ASS(
-
) and BRAF (+) patients.


32.

Reference:
6524103


30 Day Mortality of Surgeries in Disseminated Cancer Patients. An analysis

using NSQIP,
dividing surgeries into low, medium and high risk.



Background: This study is the first comprehensive analysis of surgical outcomes in disseminated
cancer patients. Methods: The American College of Surgeons (ACS) National Surgical Quality
Improvement Program (NSQIP) was inspired by the success of the original NSQIP database from
the Veterans Association. ACS NSQIP has 30
-
day mortality data on 3,250 disseminated cancer
patients and 144,199 patients who did not have disseminated cancers who u
nderwent major
surgery. Results: The most common procedures performed on disseminated cancer patients
include a partial removal of the colon (10.9%), partial removal of the liver (9.3%), partial removal
of the small intestine (5.2%), and an exploration o
f the abdomen (4.9%). The 30
-
day mortality
for surgeries for cancer patients can be divided into low risk (<3%), moderate risk (3
-
15%), and
high risk (19
-
44%). Low risk surgeries include mastectomy, partial removal of the liver, and
repair of the bowel ope
ning (none of which were performed as an emergency). Moderate risk
includes non
-
emergent small intestine removal, bowel
-
to
-
bowel fusion, colon removal, and
partial removal of the colon. High risk includes a non
-
emergent exploration of the abdomen, and
the
following surgeries if performed as an emergency: bowel
-
to
-
bowel fusion, colon removal,
small intestine removal, cholecystectomy, or partial removal of the colon. Discussion: The 30
day operative risk for disseminated cancer can be divided into low, medi
um and high risk
surgeries. All procedures performed under emergency circumstances have a 30
-
day mortality
greater than 18%. Mastectomies, partial removals of the liver, and bowel opening repairs have a
30
-
day mortality of less than 3%.



30
-
Day Mortality
Rates



33.

Reference:
6524337


Treatment Trends for Stage III Non
-
Small Cell Lung Cancer in the Veteran Affairs System
compared to other insurances, a National Cancer Database
analysis



Introduction: The National Cancer Database (NCDB) tabulates 70% of all new cancer case in the
United States. This study investigated trends in management of stage III NSCLC in Veteran’s
Affairs patients compared to other insurance types using
the NCDB. Methods: 281,277 patients
with Stage III NSCLC were identified from 2000 to 2009 using the NCDB. Reported use of
surgery, radiation, chemotherapy, or no treatment were analyzed by insurance, race, and age.
Results: VAH patients with stage
III NSCLC were most often treated with
radiation/chemotherapy(36.5%), as were Medicare(31.3%), Medicaid(42.3%), private
insured(43.9%), and non
-
insured(41.7%). VAH patients underwent more radiation
-
only
treatment than the private insured(17.2% vs. 5.9%, p
90). Discussion: Combination
chemotherapy/radiation for stage III NSCLC was given most often regardless of insurance status.
VAH patients and non
-
insured patients received no treatment more than privately insured
patients. VAH patients underwent more rad
iation
-
only treatment than privately insured
patients, who received more tri
-
modality treatment. Hispanics were more likely to receive no
treatment than Caucasians or African
-
Americans. Older patients received no treatment more
often than younger.


Insuran
ce

Surgery

Only

Radiation

Only

Surgery &

Chemotherap
y

Radiation &

Chemotherap
y

Chemotherap
y

Only

Surgery,
Radiation &

Chemotherap
y

Other
Specified

Therapy

No 1st Course

Rx

Veteran
Affairs

398 (4.3%)

1607 (17.2%)

297 (3.2%)

3415 (36.5%)

1059 (11.3%)

318
(3.4%)

270 (2.9%)

1980 (21.2%)

Medicare

3120 (6.1%)

8090 (15.8%)

1457 (2.8%)

15994 (31.3%)

6275 (12.3%)

1888 (3.7%)

1742 (3.4%)

12564 (24.6%)

Medicaid

631 (4.5%)

1651 (11.9%)

482 (3.5%)

5885 (42.3%)

1625 (11.7%)

867 (6.2%)

427 (3.1%)

2339 (16.8%)

Private
1447 (5.9%)

1782 (7.3%)

1201 (4.9%)

10691 (43.9%)

3016 (12.4%)

2476 (10.2%)

886 (3.6%)

2849 (11.7%)

Procedure

Disseminated
Cancer

NOT Disseminated
Cancer

Disseminated Cancer &
Emergency

High Risk (>15%)



All High Risk (>18%)

Exploration of the Abdomen

21.3%

15.4%

44.2%

Moderate Risk (3%
-
15%)




Removal of the Small Intestine

14.9%

9.2%

30.4%

Bowel to Bowel Fusion

12.5%

7.1%

33.3%

Colon Removal

11.0%

5.5%

30.8%

Colostomy

10.7%

4.7%

18.8%

Partial Removal of the Colon

10.4%

4.9%

22.2%

Cholecystectomy

10.0%

0.5%

23%

Low Risk (<3%)




Repair of Bowel Opening

1.8%

0.9%

None performed

Partial

Removal of the Liver

1.3%

2.9%

None performed

Mastectomy

1.0%

0.1%

None performed

Insurance

No Insurance

314 (3.8%)

832 (10%)

242 (2.9%)

3468 (41.7%)

1121 (13.5%)

380 (4.6%)

232 (2.8%)

1730 (20.8%)


Race

Surgery

Only

Radiation

Only

Surgery &

Chemotherap
y

Radiation &

Chemotherap
y

Chemotherap
y

Only

Surgery,
Radiation &

Chemotherap
y

Other
Specified

Therapy

No 1st Course

Rx

Caucasian

15428 (6.6%)

28919 (12.9%)

9763 (4.2%)

83499 (35.9%)

29400 (12.6%)

14944 (6.4%)

7712 (3.3%)

42849
(18.4%)

African Amer.

1409 (4.3%)

4749 (14.4%)

1038 (3.1%)

12359 (37.4%)

4385 (13.3%)

1586 (4.8%)

999 (3%)

6497 (19.7%)

Hispanic

426 (6%)

802 (11.3%)

274 (3.9%)

2164 (30.5%)

1120 (15.8%)

385 (4.8%)

267 (3.8%)

1657 (23.4%)

API

307 (5.9%)

551 10.6%)

277
(5.3%)

1543 (29.7%)

906 (17.5%)

361 (7%)

186 (3.6%)

1056 (20.4%)

Native Amer.

34 (5.8%)

61 (10.5%)

30 (5.2%)

243 (41.8%)

73 (12.5%)

23 (4%)

17 (2.9%)

101 (17.4%)

Other/
Unknown

216 (7.5%)

325 (11.3%)

101 (3.5%)

917 (31.9%)

376 (13.1%)

176 (6.1%)

96
(3.3%)

670 (23.3%)


Age

Surgery

Only

Radiation

Only

Surgery &

Chemotherap
y

Radiation &

Chemotherap
y

Chemotherap
y

Only

Surgery,
Radiation &

Chemotherap
y

Other
Specified

Therapy

No 1st Course

Rx

20
-
29

19 (15.1%)

6 (4.8%)

14 (11.1%)

34 (27%)

20 (15.9%)

16
(12.7%)

6 (4.8%)

11 (8.7%)

30
-
39

111 (6.8%)

66 (4%)

101 (6.2%)

650 (39.8%)

252 (15.4%)

232 (14.2%)

56 (3.4%)

166 (10.2%)

40
-
49

738 (4.8%)

868 (5.7%)

807 (5.3%)

6938 (45.5%)

1957 (12.8%)

1876 (12.3%)

482 (3.2%)

1593 (10.4%)

50
-
59

2437 (5.2%)

3458 (7.3%)

2539 (5.4%)

21194 (45%)

5918 (12.6%)

4700 (10%)

1545 (3.3%)

5288 (11.2%)

60
-
69

5349 (6.4%)

7641 (9.2%)

4225 (5.1%)

34606 (41.5%)

10712 (12.8%)

6393 (7.7%)

2785 (3.3%)

11698 (14%)

70
-
79

6798 (7.4%)

13460 (14.6%)

3326 (3.6%)

30108 (32.7%)

12560 (13.6%)

3860 (4.2%)

3212 (3.5%)

18813 (20.4%)

80
-
89

2310 (5.9%)

9332 (23.9%)

465 (1.2%)

7069 (18.1%)

4670 (12%)

395 (1%)

1143 (2.9%)

13685 (35%)

90 and over

53 (2.1%)

576 (22.7%)

4 (0.2%)

120 (4.7%)

168 (6.6%)

1 (0.04%)

48 (1.9%)

1573 (61.9%)


34.

Reference:
6524434


Outcome of Myelodysplastic Syndrome in Veterans Treated with 5
-
Azacitidine and Decitabine



Background: Azanucleosides like 5
-
azacitidine (AZA) and decitabine
-
5
-
aza
-
2’
-
deoxycytidine
(DAC) improve survival in myelodysplastic syndrome (MDS). In th
is retrospective study, we
aimed to evaluate the clinical and survival outcomes in MDS among Veterans treated with either
hypomethylating agent. Methods & Materials Data was collected from the Michael E. DeBakey
VA Medical Center between 1/1/2000 and 6/1
/ 2011. This included all patients with
morphological evidence of MDS treated with either hypomethylating agents. Results A total of
21 patient were available for analysis, of which 2(10%) were male and 19 (90%) female. 13/21
(62%) and 8/21 (38%) pts re
ceived AZA and DAC, respectively. ORR was 15% vs. 38%, for AZA vs.
DAC (P=0.618). Pts who responded to therapy, had superior OS compared to pts with stable or
progressive disease (411d vs. 194d, P= 0.01). OS in pts receiving ≥4 or <4 cycles of treatment
wa
s 486d vs. 187d for AZA
-
treated pts (P=0.005) and 411d vs. 174d for DAC group (P=0.04).
Leukemia transformation was seen in 5 vs. 2 pts treated with AZA and DAC. For this subset, Time
to Leukemia transformation (TTL) was 102d vs. DAC 272d (P=0.65). Con
clusion Treatment
with AZA and DAC was associated with ORR comparable to historical data of about 25%. OS was
superior in pts receiving ≥4 cycles of treatment of either regimen. Despite the small number of
pts and retrospective nature of our study, our da
ta suggest that TTL is similar for both agents.
Prospective studies, in veteran pts, evaluating efficacy of AZA vs. DAC are needed.




35.

Reference:
6524592


Nursing Considerations Long Term Survivors Allogeneic Hematopoietic Stem Cell Transplant



Allogenei
c hematopoietic stem cell transplant (allo
-
HSCT) long term survival has improved due
to changes in treatment regimens, and understanding of the post
-

transplant care required in
this population. Allo
-

HCST annual rates are increasing significantly with m
ore than 50,000
transplants worldwide. Allo
-

HSCT patients surviving 2 years post transplant have shown
increased long term survival rates as high as 85% at 10 years. The transplant team is a specialty
that provides a comprehensive plan of care for each Ve
teran returning home post
-

transplant.
Veterans that return back to the referring centers require long term follow up care. Nurses are
an important part of this team providing assessments, evaluations and plans of care helping to
meet the individualized n
eeds of this patient population. In the 40 years that bone marrow
transplant has evolved transplant nurses have made continuous improvements in supportive
care meeting the needs of the long term allo
-

HSCT patient. Advancements in transplant include
asse
ssment of signs and symptoms of complications related to HCT including chronic graft
versus host disease infections, organ toxicities, and psychosocial considerations. Promotion of
healthy lifestyles following HCT nutrition, exercise and revaccination as r
ecommended. To
provide quality nursing care to a rapidly changing patient population, transplant nurses have a
knowledge base to share to help educate nurses in the Veterans Administration to recognize
and provide supportive care to the long term allo
-

HS
CT patient.





36.

Reference:
6524728


Melanoma/Skin Cancer Screening: VANJHCS Experience



Melanoma/Skin Cancer Screening: VANJHC Experience Philip J. Cohen, MD, Patricia M. Goyer,
APN, Yolanda L. Jackson, RN, Annemarie Staton, APN, and Mirseyed Mohit, MD

Introduction:
We serve a population at increased risk for skin cancer. To determine the response of veterans
to a self
-
referred skin cancer screening examination, we initiated Skin Cancer Screening Day, co
-
sponsored by the American Academy of Dermato
logy (AAD). Staff participation included nurse
practitioners, specialty clinic nurses, dermatology attending physicians, and residents. Methods:
Approximately 2 months prior to the event, we advertised via signs, electronic information
boards, and the in
ternet throughout VANJHCS. Veterans desirous of skin cancer screening were
self
-
referred, and were seen as walk
-
in during the hours advertised. The screening was held
during normal clinic hours, while the regular dermatology clinic convened. The dermatolo
gy
attendings and residents provided the examinations; the APNs completed the screening forms
and referrals. All patients received educational materials provided by AAD on skin self exams,
risk factors, signs and symptoms of skin cancers, sun protection, a
nd skin cancer in skin of color.
Results: Eighteen veterans were screened; 28% were recommended for biopsy, and 50% were
referred for a follow
-
up exam with a dermatologist. All screened veterans (100%) expressed a
high level of satisfaction and the intent
ion to repeat the skin screening annually. Discussions:
Skin cancer screening produced a significant yield of suspicious lesions. Veterans who
participated had a high level of satisfaction, which was likely facilitated by the ease of access.
We will cont
inue skin cancer screening as an annual event.


37.

Reference:
6524947


Current novel therapeutic strategies for esophageal cancer: An in
-
depth review and update.



Introduction: Esophageal cancers are the ninth most common cancer worldwide and sixth most
comm
on cause of cancer death. The prognosis of esophageal cancer has slightly improved over
the past few years but the 5
-
year survival rate is still merely 30% to 35% in patients with
resectable cancer. The overall 5
-
year survival rate in all patients is still

less than 20%. Methods:
The best curative treatment of esophageal cancer still remains a challenging issue and continues
to be highly controversial. As there have been no substantial improvements in survival of
patients, newly developing technologies ar
e emerging in order to enhance therapeutic
outcomes. Authors conducted literature reviews which published in the past decade, and
analyzed the pros and cons of therapeutic strategies. Results: We found that endoscopic
therapy (ablative therapy or endosc
opic mucosal resection: EMR) might be promising therapy
for early stage cancer (superficial cancer limited to the mucosa), especially for high quality of
life. Robotic surgery is safe and sound surgical technique. Advanced technologies in
radiotherapy are
Intensity Modulated Radiotherapy, Image Guided Radiotherapy, and Proton
therapy. Discussions: Robotic surgery can be done in a short period of time with good
outcomes: a 100 patient retrospective series reported only one patient death, 6 distant
metastas
es and no operative deaths with a 32 months median follow
-
up. Ell et al. reported 99%
complete local remission using EMR therapy in a large series of100 patient. Benefits and
disadvantages as well as outcomes of newly emerging therapeutic modalities includ
ing new
radiation technologies will be critically reviewed.


38.

Reference:
6525129


Antineoplastic therapy utilization for advanced stage lung cancer at the Iowa City Veteran
Affairs Health Care System



BACKGROUND: Very few studies have adequately described
the utilization of antineoplastic
medications in routine practice, limiting the utility of any local or national assessment of the
clinical and financial appropriateness of care. OBJECTIVE: The primary objective of this study is
to describe the antineo
plastic medications used at each line of therapy for patients with stage
IIIb/IV non
-
small cell lung cancer (NSCLC) or extensive stage small cell lung cancer (SCLC).
METHODS: This study was designed as a single
-
site retrospective chart review of patien
ts with
stage IIIb or IV NSCLC or extensive stage SCLC treated at the Iowa City VAHCS since January
2010. Selection of anti
-
neoplastic regimen for first line therapy was assessed and recorded
along with ECOG performance status and baseline demographics.
Upon disease progression,
the subsequent lines of therapy (second line, third line, fourth line… nth line) were evaluated
and reason for progression, drug regimen, and performance status were recorded. Specific
medications and the quantity used in anti
-
ne
oplastic regimens were collected; costs associated
with these medications were calculated using vendor database drug costs. ANALYSIS: The
proportion (and percentage) of patients receiving each anti
-
neoplastic regimen at each line of
therapy will be an
alyzed. These data will be stratified by type of lung cancer and compared
descriptively. Total and average costs for each line of therapy will be calculated. RESULTS: We
identified 85 subjects receiving treatment for stage IIIb or IV NSCLC or extensi
ve stage SCLC at
the Iowa City VAHCS from January 2010 through December 2011. Data analysis is pending.


39.

Reference:
6525511


The emerging role of thioredoxin
-
1 on ROS and metabolic pathway in cisplatin resistant lung
cancer



Background: Although cisplati
n resistance is complex, we have found that all cisplatin resistant
(CR)cell lines possess high levels of ROS and decreased TRX1 levels secondary to secretion. We
have studied alteration in metabolism due to these biochemical changes. Methods:
Ov
erexpressing TRX1 in CR cell (SR2TRX+ ) and silencing TRX1 in parental cells (SCLC1TRX
-
) were
used to study alterations in metabolism . Immunoblots were used to quantify metabolic
enzymes. Results and Discussion: We have found that CR cells are less g
lycolytic with lower
levels of hexokinase (HKII) and lactic
-
dehydrogenase
-
A (LDHA). These cells rely more on
oxidative phosphorylation (OXPHOS) with increased oxygen consumption and higher expression
of ACC (acetyl
-
CoA
-
carboxlase) and FAS (fatty acid synt
hetase) levels. CR cells also showed
increased sensitivity to TOFA (ACC inhibitor). However, its TRX1 transfectant , SR2TRX+ , had
lower levels of ROS and increased cisplatin sensitivity. The sensitivity to TOFA is also less. In
contrast, silencing TRX1

in parental cells showed less sensitivity to cisplatin, and less glycolytic
activity(lower HKII and LDHA) but increased sensitivity to TOFA. Our findings suggest that TRX1
may play a role in CR. We plan to study the clinical relevance of these findings

by assaying TRX1
serum levels both pre and post cisplatin treatment and correlating the levels with response.
Since CR cells rely more in OXPHOS, this could explained why certain patients show disease
progression by CT scan after cisplatin but do

not take up fluorodeoxyglucose (PET negative).
We plan a systemic investigation into this question.


40.

Reference:
6525547


CHANGE IN FIRST COURSE OF TREATMENT FOR GLIOBLASTOMA BEFORE AND AFTER THE
“STUPP” TRIAL AT VA COMPARED TO OTHER INSURANCE STATUS USIN
G NCDB.



Introduction: Glioblastoma is the most common, rapidly fatal primary brain tumor in adults. This
study compared difference in frequency of tri
-
modality treatment for Glioblastoma during 2000
-
2004 with 2005
-
2009. The NEJM article based on STUPP cl
inical trial, which was published on
03/10/2005 established tri
-
modality treatment as the new standard of care for Glioblastoma.
Methods: Using the NCDB, 76285 patients with Glioblastoma with different Insurance status
were analyzed by year, insurance st
atus and first course of treatment. This is the largest study to
analyze treatment practices for Glioblastoma across years and insurances. Results: The rate of
tri
-
modality therapy for Glioblastoma increased from 2000
-
2004 to 2005
-
2009 from 27.6% to
45.1
0 for the overall group; 36.4% to 53.1% for private insurance; 38.0% to 56.8% for Managed
Care; 21.4% to 46.0% for VAH; 22.6% to 39.2% for Uninsured; 28.4% to 43.8% for Medicaid;
16.2% to 31.9% for Medicare; 18.8% to 35.9% for Medicare w/supplement. Conc
lusion: Before
2005 VA and Uninsured received similar % of tri
-
modality treatment, but after 2005 VA received
a higher % than Uninsured. The % increase in number of patients getting tri
-
modality is
remarkable among VA (114.9%), Medicare (96.9%) and Medicar
e with supplement (90.9%)
when compared to Medicaid (54.2%), Managed Care (49.5%), Private Insured (45.9%). Medicare
received the least % of tri
-
modality therapy both before and after 2005. All these changes in %
from 2000
-
04 compared to 2005
-
09 are statis
tically significant (p<0.0001). Summary statement:
The VAH had the highest increase (114.9%) in uptake of tri
-
modality therapy of any insurance
group.


https://fs20.formsite.com//sclentz/files/f
-
0
-
25
-
6525547_tghsbQvk_Arun_abstract_AVAHO.docx

41.

Reference:
6525953


Metastatic Colon Cancer Cost Effective Mul
tidisciplinary Management Utilizing Tele Health:
The DC VAMC pilot case



Introduction: Curative resection for liver only metastatic colon cancer has been increasingly
offered to qualified candidates. A multidisciplinary team of medical oncologists, exper
t
surgeons, general and interventional radiologists is essential to achieving cure. Brief course of
conversion chemotherapy allowing for R0 hepatic resection has been proposed while
maintaining a close and timely communication among the multidisciplinary
team members to
avoid increased number of preoperative cumulative chemotherapy doses and perioperative
hepatic complications. Due to the need to individualize the surgical approach and the scarcity of
such unique surgical expertise in different geographic
locations, a need to connect and
communicate across VISNs was piloted. Methods: A 44 year old male with metastatic colon
cancer to the liver at the DC VAMC had a Clinical Video Teleconferencing (CVT) with expert
surgical team located at the Palo Alto

VA post four cycles of conversion chemotherapy with
GONO FOLFOXIRI. A surgical consultation was set up via an inter facility consultation, an MUO
and TSA (TeleHealth Service Agreement) were completed by both facilities prior to the CVT.
Travel and social
issues were addressed during the consultation as well. Results: Veteran
successfully underwent primary hemicolectomy, staged hepatectomy at the Palo Alto VA. He
returned for adjuvant chemotherapy at the DC VAMC 2 ½ months later. Discussions:
Telehealth allowed the utilization of VA internal resources albeit across VISNs while delivering
quality care, guideline adherence and financial savings. A need to identify and develop a
database of potential experts within the VA for future telehealth ba
sed care is critical.


42.

Reference:
6526066


Use of Surgery and Chemoradiation in Stage II and III Rectal Cancer: A Retrospective
Comparison of Veterans Affairs Health Insurance Versus Other Insurances Using the NCDB



Introduction: The standard of care (S
OC) for Stage II and III rectal cancer is neoadjuvant
chemoradiation plus surgical resection. Utilizing data from the National Cancer Database (NCDB)
we aim to compare the treatment practices for patients with Stage II and III rectal cancer with
VAH insura
nce against other insurance types. Methods: Using the NCDB, we analyzed the
treatment patterns of 91,782 patients diagnosed with Stage II and III rectal cancer from 2000
-
2009. The NCDB includes data from 70% of all US cancer patients. This is the la
rgest study of
this kind to date. Results: In Stage II and III rectal cancer, patients with private insurance
received more SOC treatment (70.3%) than patients with VAH (56.6%), Medicare (46.9%),
Medicaid (66.5%), or no insurance (61.7%) (p<.0001). P
atients with VAH received less SOC
treatment than Medicaid or non
-
insured patients (p<.0001). Medicare patients (26.9%) were
treated with surgery alone more often than patients with private insurance (9.8%), Medicaid
(10.4%), VAH (12.2%) or no insuranc
e (9.4%) (p<.0001). VAH (4.8%) and Medicare (4.3%)
patients more often did not receive any “First Course Treatment” than patients with private
insurance (1.3%) (p<.0001) Patients over 70yo received less SOC treatment than patients
under 70yo (42
.2%, 68.9% respectively; p<.0001) and received more surgery without
chemotherapy or radiation than patients less than 70yo (29.3%, 9.2% respectively; p<.0001)
Discussion: VAH patients received significantly less SOC treatment than other insurance type
s,
including patients without any insurance. Patients with Medicare and those over 70yo receive
more surgery
-
only treatment than the other groups.



Table 1: Stage II and III Rectal Cancer Treatment


Surgery Only

Surgery +
Chemotherapy

Chemotherapy
+

Radiation

Surgery,
Radiation, +
Chemotherapy

(SOC)

No First
Treatment

Age






<70

5251 (9.2%)

4021 (7.1%)

4822 (8.5%)

39208 (68.9%)

900 (1.6%)

>70

10219 (29.3%)

2117 (6.1%)

3415 (9.8%)

14709 (42.2%)

1292 (3.7%)

Insurance Type






Not Insured

304
(9.4%)

155 (4.8%)

443 (13.7%)

1988 (61.7%)

121 (3.8%)

Private
Insurance

1108 (9.8%)

818 (7.2%)

769 (6.8%)

7985 (70.3%)

151 (1.3%)

Managed Care

2592 (10.5%)

1828 (7.1%)

1831 (7.4%)

18073 (73.1%)

401 (1.6%)

Medicaid

394 (10.4%)

251 (6.6%)

519 (13.7%)

2513

(66.5%)

103 (2.72%)

Medicare

3237 (26.9%)

792 (6.6%)

1325 (11%)

6162 (46.9%)

516 (4.3%)

VAH

256 (12.2%)

105 (5%)

448 (21.4%)

1184 (56.6%)

100 (4.8%)


Table 2: Stage II and III Rectal Cancer: Insurance Status by Age

Insurance

<70yo

>70yo

Not insured

94.8%

5.2%

Private Insurance

92.6%

7.4%

Medicaid

91.3%

8.7%

Medicare

36.0%

64.0%

VAH

63.4%

36.6%




43.

Reference:
6526113


Analysis of stage of melanoma diagnosis of Veterans Affairs hospitals in relation to other
insurance types and income as indicator

of early/late diagnosis



Introduction: This study compares the average stage of melanoma diagnosis for the Veterans
Affairs hospitals to other insurance status and household income. This is the largest such study
for melanoma to date. Methods: Using t
he National Cancer Database (NCDB) we examined
299,214 patients with melanoma between 2000 and 2009 at 1408 hospitals. Results: The VAH
0%
50%
100%
Insurance Type

Percent of Stage II and III Rectal Cancer Recieving
Chemotherapy, Radiation and Surgery (SOC)

Chemotherapy,
Radiation, and Surgery
(Tri-Modal)
population had the lowest average stage of diagnosis (0.89) with Medicaid exhibiting the highest
(1.87, p<0.0001). Th
e VAH was lower than Tricare which had an average diagnosis of 1.11
(p<0.0001), private insurance 1.20 (p<0.0001), Medicare 1.34 (p<0.0001), and uninsured 1.70
(p<0.0001). Stage IV was lowest in private insurance (3.31%), with Tricare at 3.67% (p<0.0001),
VAH 4.46% (p<0.0001), Medicare 5.74% (p<0.01), uninsured 10.12% (p<0.0001), and the highest
rate was among Medicaid (14.35%, p<0.0001). The highest income category (≥$49K) had the
lowest average stage at diagnosis (1.16), compared to $39K
-
$48K (1.28, p<
0.0001), $33K
-
$38K
(1.35, p<0.0001), $28K
-
$32K (1.40, p<0.0001), and the lowest income group (<$28K) had the
highest average stage of diagnosis (1.46, p<0.0001). The rate of Stage IV diagnosis increased
from the highest income group (3.68%), followed by $3
9K
-
$48K (4.69%, p<0.0001), $33K
-
$38K
(5.17%, p<0.0001), $28K
-
$32K (5.89%, p<0.0001), and less than $28K (6.92%, p<0.0001).
Discussion: VAH, higher income and private insurance patients were diagnosed with earlier
stage melanoma compared to those with no i
nsurance and Medicaid, who were more
frequently diagnosed with stage IV disease. The VAH provision of high quality care, particularly
preventative care, can result in improved detection of early stage cancer (Landrum et al, 2012).


Table 1
:
Insurance status
and stage of melanoma diagnosis

Insurance Status


Stage


Weighted
Average
Stage of
Diagnosis

p
-
value of
average
diagnosis†

p
-
value of
χ2
statistic
for VA vs
Other Ins

Totals




0


I


II


III


IV


N

%


Veterans Affairs

3758‡

3068

823

422‡

377‡

0.89





8448

2.82%



44.48%

36.32%

9.74%

5.00%

4.46%







100%




TRICARE/Military

1017

1813‡

401‡

309‡

135‡

1.11

<0.0001

<0.0001

3675

1.23%



27.67%

49.33%

10.91%

8.41%

3.67%







100%




Private Insurance

36952‡

89811‡

21346

16183


5623

1.20

<0.0001

<0.0001

169915

56.79%




21.75%

52.86%

12.56%

9.52%

3.31%







100%




Medicare

24312‡

42255‡

21025

10308


5965

1.34

<0.0001

<0.0001

103865

34.71%



23.41%

40.68%

20.24%

9.92%

5.74%







100%




Not Insured

952

3080

1324‡

1290

748

1.70

<0.0001

<0.0001

7394

2.47%



12.88%

41.66%

17.91%

17.45
%

10.12%







100%




Medicaid

751‡

2161‡

946

1210

849

1.87

<0.0001

<0.0001

5917

1.98%



12.69%

36.52%

15.99%

20.45
%

14.35%







100%




TOTAL

67742

142188

45865

29722

13697







299214

100.00%



22.64%

47.52%

15.33%

9.93%

4.58%







100%



† p
-
value based on student t
-
statistic calculated for weighted average stage of diagnosis. Veterans Affairs is the comparison category.

‡ χ
2
p
-
value <0.0001 based on individual χ
2

tests between reference group and all other insurance groups by stage of diagnosis.

Data source: The National Cancer Data Base (NCDB).


Table 2
: Household income and stage of melanoma diagnosis

Household
Income


Stage


Weighted
Average
Stage of
Diagnosis

p
-
value of
average
diagnosis


p
-
value of χ2
test for
highest
income vs
other

Totals


0


I


II


III


IV


N

%


< $28,000

2881


6411


2835


1930


1045


1.46

<0.0001

<0.0001

15102

5%



19.08%

42.45%

18.77%

12.78%

6.92%







100%




$28,000
-

$32,999

5817


13441


5479


3601


1775


1.40

<0.0001

<0.0001

30113

10%



19.32%

44.64%

18.19%

11.96%

5.89%







100%




$33,000
-

$38,999

9858


22387


8118


5471


2498


1.35

<0.0001

<0.0001

48332

16%



20.40%

46.32%

16.80%

11.32%

5.17%







100%




$39,000
-

$48,999

15802


33774


11205


7254


3346


1.28

<0.0001

<0.0001

71381

24%



22.14%

47.32%

15.70%

10.16%

4.69%







100%




$49,000 +

33007


62745


17134


10895


4729


1.16





128510

44%



25.68%

48.82%

13.33%

8.48%

3.68%







100%




TOTAL

67365

138758

44771

29151

13393







293438

100%



0.23

0.47

0.15

0.10

0.05







100%



† p
-
value based on student t
-
statistic calculated for weighted average stage of diagnosis. Income of $49,000 is the comparison category.

‡ χ
2
p
-
value
<0.0001 based on individual χ
2

tests between reference group and all other insurance groups by stage of diagnosis.

Data source: The National Cancer Data Base (NCDB).


44.

Reference:
6526254


A RETROSPECTIVE ANALYSIS OF GALLBLADDER CANCER: USING THE NCDB TO
ANALYZE AGE,
STAGE, TREATMENT, AND INSURANCE TYPE



Introduction: Due to the rarity of gallbladder cancer (GBC), there exist few large
-
scale studies
examining factors such as insurance, stage at diagnosis, or treatments. Utilizing data from the
National Cancer Database (NCDB), we aim to perform a descript
ive analysis of these topics as
they relate to GBC. Methods: We analyzed the treatment patterns of 25,561 patients
diagnosed with GBC from 2000
-
2009. The NCDB includes data from 70% of all US cancer
patients. This is the largest study of this kind to
date. Results: Stage IV is the most common
stage at diagnosis (32.19%). The average stage at diagnosis is 2.56 The percentage of patients
diagnosed with GBC increased with age, up to age 80. The age group 70
-
79 contained the largest
percentage (30.3%)
. Surgery only was most often the first course treatment (47.30%), followed
by No first course treatment (19.10%)(p<.0001). More VAH patients received no first course
treatment (38.30%) than uninsured (22.20%), private insurance (14.30%), Medicaid (22.20
%)
and Medicare patients (22.60%) (p<0.0001). VAH patients were less likely to receive treatment
within 23 days of diagnosis (79.20%) than uninsured (88.50%) and Medicare patients (90.50%)
(p<0.02). Discussion: GBC was most often diagnosed at stage IV

with an average stage at
diagnosis of 2.56. The plurality of diagnoses occurred between the ages of 70
-
79 years. Surgery
was the most common first course treatment. However, VAH patients were significantly more
likely to receive no first course treatment
than other insurance types and less likely to begin
treatment within 23 days of diagnosis.


Figure 1. Stage of gallbladder cancer at diagnosis


Figure 2. Percent of total gallbladder cancer diagnoses by age

group



0
1000
2000
3000
4000
5000
6000
7000
8000
9000
CIS
Stage I
Stage II
Stage III
Stage IV
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
20-29
30-39
40-49
50-59
60-69
70-79
80-89
>89
Table 1. First course treatment by insurance type.

45.

Reference:
6526947


Liver cancer diagnosis and stage at diagnosis in VA patients vs.
other types of insurance



Introduction: The incidence of liver cancer has increased recently. This study seeks to determine
the most common stage at diagnosis and if an increase in the number of VA patients diagnosed
with liver cancer is similarly
observed using the National Cancer Database (NCDB). Method:
Using the NCDB, 113,536 patients were identified as diagnosed with liver cancer from 2000 to
2009. VA patients, who comprised 5,616 patients in this cohort, were compared to other type of
insuran
ce with regards to the number of patients diagnosed by year and stage at diagnosis.
Results: The number of patients diagnosed with liver cancer among all types of insurance
increased from 7,850 patients in 2000 to 15,813 in 2009. VA patients with liver c
ancer increased
from 248 (3.2%) in 2000 to 952 (6.2%) in 2009. The total number of cancer patients increased
from 1,028,210 in 2000 to 1,161,692 in 2009. The liver cancer cases increased from 0.76% to
1.36% of all cases. The average stage at diagnosis in
VA patients was 2.48. The average stage at
diagnosis was higher among other insurance types including private insurance, non
-
insured, and
Medicare and found to be 2.62, 2.9, and 2.55, respectively (p value< 0.0001) and there was
statistically significant d
ifference. Discussion: The total number of patients with liver cancer has
been increasing from 2000 to 2009 with disproportionally larger increases in the VA patient
population. The average stage at diagnosis is earlier in VA patients compared to other t
ypes of
insurance which may reflect active VA surveillance programs.



Surgery
only

Surgery &
Chemotherapy

Chemotherapy
only

Surgery, Chemotherapy, &
Radiation

Other

No first Course
Treatment

N

Insurance
Type















Uninsured

45.70%

11%

7.50%

6.50%

7.20%

22.20%

939

Private

41.50%

12%

11.90%

12.10%

8.20%

14.30%

1990

Medicaid

41.00%

10.60%

9.90%

8.70%

7.60%

22.20%

1363

Medicare

51.80%

6.70%

6.40%

6.50%

6.10%

22.60%

4877

VAH

35.70%

5.10%

8.20%

6.10%

6.60%

38.30%

196


Liver cancer diagnosis in VA patients vs all patients diagnosed by year


VA patients

Total no of patients

Percentage

2000

248

7850

3.2%

2001

329

8418

3.9%

2002

365

9172

4%

2003

432

9727

4.4%

2004

518

10515

4.9%

2005

588

11386

5.2%

2006

643

12443

5.2%

2007

761

13635

5.6%

2008

780

14577

5.4%

2009

952

15813

6%


46.

Reference:
6527981


A comparison of stage at diagnosis of colon cancer for four different insurance statuses over a
ten
year period



The study, the largest completed, will identify which stage of colon cancer is diagnosed more
prevalently for four different insurance statuses: not insured, private insurance, Medicare, and
Veteran’s Affairs from 2000
-
2009. It will also comp
are the age at diagnosis and at what stage.
Over 248,186 cases were analyzed from the National Cancer Database. Variables used in the
study were: insurance status, age, and stage. For non
-
insured, average stage at diagnosis was
2.5, highest number stage
IV (27.8%). For private insurance, average stage at diagnosis was 2.1,
highest number stage III (23.6%). For Medicare, average stage at diagnosis was 2, highest
number stage II (26%). For VA, average stage at diagnosis was 1.95, highest number stage I
(24.
1%). The highest number of uninsured diagnosed were age 50
-
59, average stage 2.68, most
common stage IV (28.2%). The highest number of private insurance diagnosed were age 50
-
59,
average stage 2.26, most common stage III (23.7%). The highest number of Medi
care diagnosed
were age 70
-
79, average stage 2.0, most common stage II (25.8%). The majority of VA diagnosed
were 60
-
79, highest number of 60
-
69 age group stage I (26.3%), average stage 2.03, at 70
-
79
0
5000
10000
15000
20000
2000
2003
2006
2009
relationship between number of
cases with liver cancer and diagnosis
year

VA patients
all patients
stage I and II (24% each), average stage 2.09. The VA
and Medicare insurance statuses diagnose
colon cancer at lower stages, private insurance and uninsured diagnose at higher stages.
Average stage at diagnosis was highest with uninsured and lowest with VA. Older populations in
the VA and Medicare are diagnos
ed at lower stages than younger in the private and uninsured.


Stage at Diagnosis (percentage) of Colon Cancer vs. Insurance Status


47.

Reference:
6527989


The use of adjuvant chemotherapy for stage III colon cancer, considering income, race, age,
and insura
nce status



This study, the largest analyzed, will determine the use of adjuvant chemotherapy for stage III
colon cancer. Per the National Cancer Institute (National Institute of Health
-

Physician Data
Query), stage III colon cancer should be treated with

surgery and adjuvant chemotherapy for fit
patients less than 70 years of age. A pool of 178,504 cases of stage III colon cancer was analyzed
from the National Cancer Database from 2000
-
2009. Variables used in the study were: first
course treatment, age,
race, income, and insurance status. Comparing income, 58.7% of
>$49,000 income received surgery and chemotherapy for stage III, while only 54.3% of those
<$28,000 income receiving surgery and chemotherapy (p
-
value 0). Blacks and Hispanics received
surgery

and chemotherapy 59% of the time, with whites receiving it 57% (p
-
value 0). Surgery
and chemotherapy was used 76% of the time from 30
-
49, 74% from 50
-
59, 71% from 60
-
69, 58%
from 70
-
79, and 27% from 80
-
89. Medicare was the only insurance where less than 5
0%
received adjuvant chemotherapy; with majority ages 70
-
89. A higher proportion of individuals
received the recommended adjuvant chemotherapy for stage III colon cancer with the highest
income. Over 60% of patients with no insurance, private insurance an
d VAH received adjuvant
chemotherapy at similar amounts. 48% of Medicare patients received adjuvant chemotherapy
with the reduction in the use due possibly to an older age group. There was only minimal
difference between the use of adjuvant chemotherapy b
y race, but a marked decrease in
patients over the age of 70.

0
5
10
15
20
25
30
No Insurance
Private Ins.
Medicare
Veteran's Affairs
Stage 0
Stage I
Stage II
Stage III
Stage IV

https://fs20.formsite.com//sclentz/files/f
-
0
-
25
-
6527989_4YUYbuhF_Abstract2
-
stageIII.docx

48.

Reference:
6528217


CHFR protein expression predicts outcomes to taxane
-
based first line therapy in metastatic
NSCLC



Introduction: The identification of resistance mechanisms for conventional chemotherapy in
lung cancer is of fundamental importance not
only for personalization of chemotherapy but also
for the development of novel targeted approaches to overcome this resistance. Currently, there
is no clinically validated test for the prediction of response to tubulin
-
targeting agents in NSCLC.
Here, we
investigated the significance of nuclear expression of the mitotic checkpoint gene
CHFR as predictor of response and overall survival after taxane
-
based first
-
line chemotherapy in
NSCLC. Methods: We studied a cohort of 41 patients (median age 63 years)
with advanced
NSCLC treated with taxane
-
containing frontline regimens at the Atlanta VA Medical Center
between 1999 and 2010. CHFR expression was determined by immunohistochemistry. Intensity
of staining was correlated with clinical outcome including obje
ctive response and median overall
survival using Chi
-
Square test and Cox proportional models. Results: High expression of CHFR is
strongly associated with adverse outcomes: the risk for progressive disease (PD) after first
-
line
chemotherapy with carbopl
atin
-
paclitaxel was 52% in patients with CHFR
-
high vs. only 19% in
those with CHFR
-
low tumors (p=0.033). Median overall survival was strongly correlated with
response to first
-
line therapy (clinical benefit: 9.6 months; PD: 5.2 months; p<0.001) and with
C
HFR expression status (CHFR low: 9.9 months; CHFR high: 6.2 months; p =0.002). After
multivariate adjustment reduced CHFR expression remained a powerful predictor of improved
overall survival (HR 0.24 (95% CI 0.1
-
0.58, p=0.002). Conclusions: CHFR expres
sion is a novel
predictive marker of response and overall survival in NSCLC patients treated with taxane
-
containing chemotherapy.


49.

Reference:
6529215


TIME TO FIRST COURSE TREATMENT OF NON
-
SMALL CELL LUNG CANCER : HOW IS THE
VETERANS AFFAIRS SYSTEM DOING



Introduction: Lung cancer is a leading cause of death in the United States and among veterans.
Treatment is complex and involves surgery, chemotherapy and radiation therapy in various
combinations depending upon stage. This study compares time taken to de
liver first course
treatment for veterans diagnosed with non
-
small cell lung cancer (NSCLC) compared to other
insurance settings. Methods: We analyzed National Cancer Data Base (NCDB) for time taken to
deliver first course treatment after diagnoses of NS
CLC amongst patients from different health
insurance agencies. Results: 687,015 patients with NSCLC received first course treatment in
1407 hospitals from 2000 to 2009. 19,775 (2.9%) of these patients were treated by VA
hospitals. Data was available as

number of patients receiving first course treatment within 6,
21, 40 and 64 days of diagnoses. Within 21 days of diagnoses, 7,260 (37%) of patients treated by
the VA health system received first course treatment compared with 59%, 56%, 52% and 49% of
pati
ents with no insurance, private insurance, Medicaid and Medicare respectively (p<0.0001 for
all comparisons) (table1). Amongst VA patients < 50% of patients with stage I or II NSCLC
received first course treatment within 40 days of diagnoses (table 2).
Discussions: Time to
deliver first course treatment after diagnosis of non
-
small cell cancer is significantly more in
patients under the VA health system compared to other health insurances and even un
-
insured
population. More than half of patients with e
arly stage (I/II) don’t receive first course treatment
at VA within 40 days of diagnoses.


Figure 1: Days to first course treatment of NSCLC across different insurances from 2000
to 2009.


<

6 days


<

21 days


<

40 days


<

64 days



>

65 days


INSURANCE






Veterans
Affairs


3531

(18%)

7260

(37%)

11549

(59%)

15438

(78%)

4337

(22%)

Not Insured


6511

(29%)

13114

(59%)

17569

(79%)

20213

(90%)

2166

(10%)

Private

18623
(27%)

38154

(56%)

54532

(80%)

63086

(92%)

5378

(8%)

Medicaid


9524

(26%)

19146

(52%)

26692

(73%)

31747

(87%)

4785

(13%)

Medicare


27135

(24%)

55407

(49%)

81099

(72%)

98358

(87%)

14364

(13%)

Total


171092

(25%)

346971

(51%)

509399

(74%)

611137

(89%)

75878

(11%)


Table 2: Days to first course treatment of Stage I to IV NSCLC at
VA hospitals from 2000
to 2009.


<

6 days

<

21 days

<

40 days

<

64 days

>

65 days

STAGE






I

1238

(26%)

1591

(34%)

2360

(50%)

3299
(70%)

1448

(31%)

II

243

(15%)

418

(26%)

773

(48%)

1138

(71%)

463

(29%)

III

583

(10%)

1641

(28%)

3057

(53%)

4451

(77%)

1357

(23%)

IV

1328

(19%)

3368

(48%)

5007
(71%)

6099

(87%)

939

(13%)



50.

Reference:
6529219


STAGE AT DIAGNOSIS OF NON
-
SMALL CELL LUNG CANCER IN 2005 vs 2009: A RETROSPECTIVE
ANALYSIS OF THE VETERANS AFFAIRS SYSTEM AS COMPARED WITH OTHER INSURANCES



Introduction: Early stages of non
-
small cell lung cancer (NSCLC) carry a better prognosis than
later stages. This study compares the stage of diagnosis of NSCLC at VA hospitals in 2005 and
2009 compared to nationwide. Methods: We analyzed National Cance
r Data Base (NCDB) for
stage at diagnosis of NSCLC at VA hospitals and overall in 2005 and 2009. Results: 2,709
patients were diagnosed with NSCLC in VA hospitals in 2009. The average stage at diagnoses of
NSCLC at VA hospitals was 2.64 which was signifi
cantly earlier than uninsured population
(average stage 3.01, p<0.001) and Medicaid (average stage 2.80, p=0.03). There was no
significant difference when compared to patients with private insurance but was significantly
later than patients with Medicare (
average stage 2.51, p=0.04) as well as all patients combined
(includes insured and uninsured population) (average stage 2.52, p=0.04) (figure 1). Also as
compared to 2005, average stage at diagnoses of NSCLC in 2009 in all patients combined
showed a signif
icant increase (2.42 vs 2.52 in 2005 vs 2009, p<0.0001) but non
-
significant
decrease was observed at VA (2.66 vs 2.64 in 2005 vs 2009, p=0.78). Discussions: Even in the
absence of routine lung cancer screening, the average stage at diagnoses of NSCLC is
significantly earlier in VA health system than uninsured population and is comparable to private
insurance. Even though, the average stage of diagnoses was later in 2009 as compared to 2005
nationwide, there was no significant change amongst VA health syst
em.


Figure 1: Average Stage of diagnoses of NSCLC at VA compared to other insurances in 2005
and 2009