AVAHO

Background

Oncogenic fusions within Neurotrophic Tyrosine Receptor Kinase (NTRK) 1, 2, or 3 drive constitutive hyperproliferative activity of (TRK) A, B, and C, respectively. Two TRK inhibitors have been approved for patients with advanced solid tumors bearing oncogenic fusions in NTRK1-3. We sought to describe the prevalence of NTRK fusions and rearrangements and to evaluate treatment outcomes among veterans treated with TRK inhibitors.

Methods

Patients with NTRK1-3 gene fusions or rearrangements were identified from the VA National Precision Oncology Program (NPOP) database. Separately, patients with orders for larotrectinib or entrectinib were identified from the Corporate Data Warehouse (CDW) and associated patient demographics and vital status were obtained. The prevalence of NTRK1-3 gene fusions and rearrangements was computed for all patients who had testing within NPOP. For patients who received either larotrectinib or entrectinib, duration of drug use, tumor response, reasons for drug discontinuation and toxicities were abstracted from medical records. For patients not treated with either drug, medical records were used to identify the reason for no drug use.

Results

Among 14,515 samples sequenced through NPOP (11,714 tissue DNA ,176 tissue DNA/RNA and 2625 liquid biopsy DNA tests), 14 (0.096%) had NTRK1-3 gene fusions or rearrangements (6 canonical fusions, 2 non-canonical fusions and 6 non-fusion gene rearrangements). Two patients tested outside of NPOP had canonical fusions. Among the 16 patients, 5 had prostate, 4 lung, 2 thyroid, 2 sarcoma, 1 bladder, 1 gastric, and 1 colorectal cancer. Twelve patients had metastatic disease, and 4 had early-stage disease. Eight patients were prescribed a TRK inhibitor (larotrectinib 5, entrectinib 3). Median duration of treatment was 59 (29 – 88) days. No responses were observed in the 7 evaluable patients. One patient developed neurotoxicity requiring temporary cessation of larotrectinib, and one patient treated with entrectinib developed volume overload requiring hospitalization leading to drug discontinuation.

Conclusion

Among veterans tested in NPOP, oncogenic NTRK fusions and rearrangements are very uncommon, and no patient had a response to treatment with a TRK inhibitor. Reconsideration of NTRK1-3 testing methodology and recommendations is warranted.

Background

Oncogenic fusions within Neurotrophic Tyrosine Receptor Kinase (NTRK) 1, 2, or 3 drive constitutive hyperproliferative activity of (TRK) A, B, and C, respectively. Two TRK inhibitors have been approved for patients with advanced solid tumors bearing oncogenic fusions in NTRK1-3. We sought to describe the prevalence of NTRK fusions and rearrangements and to evaluate treatment outcomes among veterans treated with TRK inhibitors.

Methods

Patients with NTRK1-3 gene fusions or rearrangements were identified from the VA National Precision Oncology Program (NPOP) database. Separately, patients with orders for larotrectinib or entrectinib were identified from the Corporate Data Warehouse (CDW) and associated patient demographics and vital status were obtained. The prevalence of NTRK1-3 gene fusions and rearrangements was computed for all patients who had testing within NPOP. For patients who received either larotrectinib or entrectinib, duration of drug use, tumor response, reasons for drug discontinuation and toxicities were abstracted from medical records. For patients not treated with either drug, medical records were used to identify the reason for no drug use.

Results

Among 14,515 samples sequenced through NPOP (11,714 tissue DNA ,176 tissue DNA/RNA and 2625 liquid biopsy DNA tests), 14 (0.096%) had NTRK1-3 gene fusions or rearrangements (6 canonical fusions, 2 non-canonical fusions and 6 non-fusion gene rearrangements). Two patients tested outside of NPOP had canonical fusions. Among the 16 patients, 5 had prostate, 4 lung, 2 thyroid, 2 sarcoma, 1 bladder, 1 gastric, and 1 colorectal cancer. Twelve patients had metastatic disease, and 4 had early-stage disease. Eight patients were prescribed a TRK inhibitor (larotrectinib 5, entrectinib 3). Median duration of treatment was 59 (29 – 88) days. No responses were observed in the 7 evaluable patients. One patient developed neurotoxicity requiring temporary cessation of larotrectinib, and one patient treated with entrectinib developed volume overload requiring hospitalization leading to drug discontinuation.

Conclusion

Among veterans tested in NPOP, oncogenic NTRK fusions and rearrangements are very uncommon, and no patient had a response to treatment with a TRK inhibitor. Reconsideration of NTRK1-3 testing methodology and recommendations is warranted.

Background

Oncogenic fusions within Neurotrophic Tyrosine Receptor Kinase (NTRK) 1, 2, or 3 drive constitutive hyperproliferative activity of (TRK) A, B, and C, respectively. Two TRK inhibitors have been approved for patients with advanced solid tumors bearing oncogenic fusions in NTRK1-3. We sought to describe the prevalence of NTRK fusions and rearrangements and to evaluate treatment outcomes among veterans treated with TRK inhibitors.

Methods

Patients with NTRK1-3 gene fusions or rearrangements were identified from the VA National Precision Oncology Program (NPOP) database. Separately, patients with orders for larotrectinib or entrectinib were identified from the Corporate Data Warehouse (CDW) and associated patient demographics and vital status were obtained. The prevalence of NTRK1-3 gene fusions and rearrangements was computed for all patients who had testing within NPOP. For patients who received either larotrectinib or entrectinib, duration of drug use, tumor response, reasons for drug discontinuation and toxicities were abstracted from medical records. For patients not treated with either drug, medical records were used to identify the reason for no drug use.

Results

Among 14,515 samples sequenced through NPOP (11,714 tissue DNA ,176 tissue DNA/RNA and 2625 liquid biopsy DNA tests), 14 (0.096%) had NTRK1-3 gene fusions or rearrangements (6 canonical fusions, 2 non-canonical fusions and 6 non-fusion gene rearrangements). Two patients tested outside of NPOP had canonical fusions. Among the 16 patients, 5 had prostate, 4 lung, 2 thyroid, 2 sarcoma, 1 bladder, 1 gastric, and 1 colorectal cancer. Twelve patients had metastatic disease, and 4 had early-stage disease. Eight patients were prescribed a TRK inhibitor (larotrectinib 5, entrectinib 3). Median duration of treatment was 59 (29 – 88) days. No responses were observed in the 7 evaluable patients. One patient developed neurotoxicity requiring temporary cessation of larotrectinib, and one patient treated with entrectinib developed volume overload requiring hospitalization leading to drug discontinuation.

Conclusion

Among veterans tested in NPOP, oncogenic NTRK fusions and rearrangements are very uncommon, and no patient had a response to treatment with a TRK inhibitor. Reconsideration of NTRK1-3 testing methodology and recommendations is warranted.

Background

An association between vaccines and the rare development of immune thrombocytopenic purpura (ITP) has been reported in the literature. More recently, there have been a few case reports published describing patients developing ITP shortly after COVID- 19 vaccination, but this has not been reported specifically in the Veteran population. The SVAHCS has three cases of Veterans diagnosed with new or relapsed ITP within two months of receiving the second COVID-19 vaccine (all Pfizer brand). The treatment(s) and current outcome for each patient is summarized below.

Case Reports

Case 1 is a 78-year-old male Veteran who received his second COVID-19 vaccine on 2/10/21. Patient was diagnosed with ITP 4/27/21, hospitalized multiple times and treated with pulse dexamethasone, prednisone taper, rituximab IV weekly and romiplostim injections. Currently, patient has a thrombocytosis and romiplostim injections are on hold. Case 2 is a 90-yearold male Veteran who received his second COVID-19 vaccine on 3/16/21. Patient was diagnosed on 5/3/21 and treated with pulse dexamethasone, prednisone taper and rituximab IV weekly. Platelet count is currently normal. Case 3 is a 75-year-old male Veteran who received his second COVID-19 vaccine on 2/1/21. He has a history of ITP diagnosed 12/12/14 that has been well controlled with weekly romiplostim injections until 4/9/21. Patient was hospitalized and treated with pulse dexamethasone and prednisone taper. Upon discharge, therapy was changed from romiplostim to fostamatinib. Currently, platelet count recovered and is stable.

Conclusions

The two Veterans with de novo ITP exhibited resistant disease and had prolonged treatment courses, taking approximately a month to recover their platelet counts. In contrast, the Veteran with relapsed ITP exhibited a faster recovery period of approximately two weeks. In the safety trials conducted for the Pfizer COVID-19 vaccine, participants received vaccination or placebo and had a follow-up for an average of two months which may explain why ITP was not reported as a possible association until after marketing. After treating the above cases, the SVAHCS plans to use thrombopoietin receptor agonists (TPO-RAs) earlier in the treatment of ITP that may be associated with the COVID-19 vaccine as this has recently been recommended in case reports from the general population.

Background

An association between vaccines and the rare development of immune thrombocytopenic purpura (ITP) has been reported in the literature. More recently, there have been a few case reports published describing patients developing ITP shortly after COVID- 19 vaccination, but this has not been reported specifically in the Veteran population. The SVAHCS has three cases of Veterans diagnosed with new or relapsed ITP within two months of receiving the second COVID-19 vaccine (all Pfizer brand). The treatment(s) and current outcome for each patient is summarized below.

Case Reports

Case 1 is a 78-year-old male Veteran who received his second COVID-19 vaccine on 2/10/21. Patient was diagnosed with ITP 4/27/21, hospitalized multiple times and treated with pulse dexamethasone, prednisone taper, rituximab IV weekly and romiplostim injections. Currently, patient has a thrombocytosis and romiplostim injections are on hold. Case 2 is a 90-yearold male Veteran who received his second COVID-19 vaccine on 3/16/21. Patient was diagnosed on 5/3/21 and treated with pulse dexamethasone, prednisone taper and rituximab IV weekly. Platelet count is currently normal. Case 3 is a 75-year-old male Veteran who received his second COVID-19 vaccine on 2/1/21. He has a history of ITP diagnosed 12/12/14 that has been well controlled with weekly romiplostim injections until 4/9/21. Patient was hospitalized and treated with pulse dexamethasone and prednisone taper. Upon discharge, therapy was changed from romiplostim to fostamatinib. Currently, platelet count recovered and is stable.

Conclusions

The two Veterans with de novo ITP exhibited resistant disease and had prolonged treatment courses, taking approximately a month to recover their platelet counts. In contrast, the Veteran with relapsed ITP exhibited a faster recovery period of approximately two weeks. In the safety trials conducted for the Pfizer COVID-19 vaccine, participants received vaccination or placebo and had a follow-up for an average of two months which may explain why ITP was not reported as a possible association until after marketing. After treating the above cases, the SVAHCS plans to use thrombopoietin receptor agonists (TPO-RAs) earlier in the treatment of ITP that may be associated with the COVID-19 vaccine as this has recently been recommended in case reports from the general population.

Background

An association between vaccines and the rare development of immune thrombocytopenic purpura (ITP) has been reported in the literature. More recently, there have been a few case reports published describing patients developing ITP shortly after COVID- 19 vaccination, but this has not been reported specifically in the Veteran population. The SVAHCS has three cases of Veterans diagnosed with new or relapsed ITP within two months of receiving the second COVID-19 vaccine (all Pfizer brand). The treatment(s) and current outcome for each patient is summarized below.

Case Reports

Case 1 is a 78-year-old male Veteran who received his second COVID-19 vaccine on 2/10/21. Patient was diagnosed with ITP 4/27/21, hospitalized multiple times and treated with pulse dexamethasone, prednisone taper, rituximab IV weekly and romiplostim injections. Currently, patient has a thrombocytosis and romiplostim injections are on hold. Case 2 is a 90-yearold male Veteran who received his second COVID-19 vaccine on 3/16/21. Patient was diagnosed on 5/3/21 and treated with pulse dexamethasone, prednisone taper and rituximab IV weekly. Platelet count is currently normal. Case 3 is a 75-year-old male Veteran who received his second COVID-19 vaccine on 2/1/21. He has a history of ITP diagnosed 12/12/14 that has been well controlled with weekly romiplostim injections until 4/9/21. Patient was hospitalized and treated with pulse dexamethasone and prednisone taper. Upon discharge, therapy was changed from romiplostim to fostamatinib. Currently, platelet count recovered and is stable.

Conclusions

The two Veterans with de novo ITP exhibited resistant disease and had prolonged treatment courses, taking approximately a month to recover their platelet counts. In contrast, the Veteran with relapsed ITP exhibited a faster recovery period of approximately two weeks. In the safety trials conducted for the Pfizer COVID-19 vaccine, participants received vaccination or placebo and had a follow-up for an average of two months which may explain why ITP was not reported as a possible association until after marketing. After treating the above cases, the SVAHCS plans to use thrombopoietin receptor agonists (TPO-RAs) earlier in the treatment of ITP that may be associated with the COVID-19 vaccine as this has recently been recommended in case reports from the general population.

Background

Evans’ syndrome is a rare entity characterized by concomitant or sequential multilineage cytopenia particularly autoimmune hemolytic anemia, ITP and very rarely autoimmune neutropenia. Although more common in young adults, it can occur in elderly usually associated with malignancies like CLL.

Case Report

A 74 years old Veteran presented with complaints of fatigue and worsening dyspnea on exertion. His physical exam was unremarkable except jaundice. His labs were significant for macrocytic anemia with Hemoglobin of 7.4g/dl compared to 11.7g/dl 6 months prior, MCV 106.9 fL, LDH 809U/L, indirect bilirubin 4.1mg/dl, absolute reticulocyte 0.16M/uL, Haptoglobin <15mg/dl and Positive DAT. Platelets were mildly decreased at 111K/ul. No lymphocytosis was noted. Initially, the hemolysis was thought to be cephalosporin- related given that the patient had taken cephalexin recently for cellulitis. As part of the workup for anemia, the patient underwent EGD and colonoscopy which was initially unrevealing. However, random biopsies from the descending colon and terminal ileum returned with a small lymphocytic infiltrate consistent with SLL/CLL. Cytogenetics showed trisomy-12 which is associated with intermediate prognosis for CLL. PET scan done subsequently revealed only a reactive marrow and an enlarged 15.8cm non-hypermetabolic spleen. This veteran having anemia, positive DAT, thrombocytopenia, and splenomegaly got diagnosed with Evans’s syndrome. This syndrome was the initial manifestation of his underlying CLL. We started the patient on a prednisone taper for 4 weeks to which anemia and thrombocytopenia barely responded, ultimately Rituximab 375mg/m2 x4 weekly doses was started which led to complete resolution of anemia and thrombocytopenia. We closely followed the patient and monitored CBC and hemolytic markers. The patient relapsed in two years which was subsequently managed with another course of Rituximab 375mg/m2 x4 weekly doses.

Conclusions

This case report aims to call attention to this relatively rare entity which is difficult to treat and often associated with frequent relapses. Though rare, physicians should maintain high suspicion for this syndrome in patients with multi-lineage cytopenia which are usually not even responding well to the common treatment for cytopenia. Furthermore, there is room for improvement in Evans’ syndrome management since mortality remains higher in these patients than in those with isolated autoimmuce cytopenias.

Background

Evans’ syndrome is a rare entity characterized by concomitant or sequential multilineage cytopenia particularly autoimmune hemolytic anemia, ITP and very rarely autoimmune neutropenia. Although more common in young adults, it can occur in elderly usually associated with malignancies like CLL.

Case Report

A 74 years old Veteran presented with complaints of fatigue and worsening dyspnea on exertion. His physical exam was unremarkable except jaundice. His labs were significant for macrocytic anemia with Hemoglobin of 7.4g/dl compared to 11.7g/dl 6 months prior, MCV 106.9 fL, LDH 809U/L, indirect bilirubin 4.1mg/dl, absolute reticulocyte 0.16M/uL, Haptoglobin <15mg/dl and Positive DAT. Platelets were mildly decreased at 111K/ul. No lymphocytosis was noted. Initially, the hemolysis was thought to be cephalosporin- related given that the patient had taken cephalexin recently for cellulitis. As part of the workup for anemia, the patient underwent EGD and colonoscopy which was initially unrevealing. However, random biopsies from the descending colon and terminal ileum returned with a small lymphocytic infiltrate consistent with SLL/CLL. Cytogenetics showed trisomy-12 which is associated with intermediate prognosis for CLL. PET scan done subsequently revealed only a reactive marrow and an enlarged 15.8cm non-hypermetabolic spleen. This veteran having anemia, positive DAT, thrombocytopenia, and splenomegaly got diagnosed with Evans’s syndrome. This syndrome was the initial manifestation of his underlying CLL. We started the patient on a prednisone taper for 4 weeks to which anemia and thrombocytopenia barely responded, ultimately Rituximab 375mg/m2 x4 weekly doses was started which led to complete resolution of anemia and thrombocytopenia. We closely followed the patient and monitored CBC and hemolytic markers. The patient relapsed in two years which was subsequently managed with another course of Rituximab 375mg/m2 x4 weekly doses.

Conclusions

This case report aims to call attention to this relatively rare entity which is difficult to treat and often associated with frequent relapses. Though rare, physicians should maintain high suspicion for this syndrome in patients with multi-lineage cytopenia which are usually not even responding well to the common treatment for cytopenia. Furthermore, there is room for improvement in Evans’ syndrome management since mortality remains higher in these patients than in those with isolated autoimmuce cytopenias.

Background

Evans’ syndrome is a rare entity characterized by concomitant or sequential multilineage cytopenia particularly autoimmune hemolytic anemia, ITP and very rarely autoimmune neutropenia. Although more common in young adults, it can occur in elderly usually associated with malignancies like CLL.

Case Report

A 74 years old Veteran presented with complaints of fatigue and worsening dyspnea on exertion. His physical exam was unremarkable except jaundice. His labs were significant for macrocytic anemia with Hemoglobin of 7.4g/dl compared to 11.7g/dl 6 months prior, MCV 106.9 fL, LDH 809U/L, indirect bilirubin 4.1mg/dl, absolute reticulocyte 0.16M/uL, Haptoglobin <15mg/dl and Positive DAT. Platelets were mildly decreased at 111K/ul. No lymphocytosis was noted. Initially, the hemolysis was thought to be cephalosporin- related given that the patient had taken cephalexin recently for cellulitis. As part of the workup for anemia, the patient underwent EGD and colonoscopy which was initially unrevealing. However, random biopsies from the descending colon and terminal ileum returned with a small lymphocytic infiltrate consistent with SLL/CLL. Cytogenetics showed trisomy-12 which is associated with intermediate prognosis for CLL. PET scan done subsequently revealed only a reactive marrow and an enlarged 15.8cm non-hypermetabolic spleen. This veteran having anemia, positive DAT, thrombocytopenia, and splenomegaly got diagnosed with Evans’s syndrome. This syndrome was the initial manifestation of his underlying CLL. We started the patient on a prednisone taper for 4 weeks to which anemia and thrombocytopenia barely responded, ultimately Rituximab 375mg/m2 x4 weekly doses was started which led to complete resolution of anemia and thrombocytopenia. We closely followed the patient and monitored CBC and hemolytic markers. The patient relapsed in two years which was subsequently managed with another course of Rituximab 375mg/m2 x4 weekly doses.

Conclusions

This case report aims to call attention to this relatively rare entity which is difficult to treat and often associated with frequent relapses. Though rare, physicians should maintain high suspicion for this syndrome in patients with multi-lineage cytopenia which are usually not even responding well to the common treatment for cytopenia. Furthermore, there is room for improvement in Evans’ syndrome management since mortality remains higher in these patients than in those with isolated autoimmuce cytopenias.

Introduction

Rectal carcinoid tumors are rare but the second most common carcinoid in the gastrointestinal tract. They are usually found incidentally during endoscopic or rectal examination. They do not often produce carcinoid syndrome like manifestations although they may manifest as rectal bleeding. Rectal carcinoid patients also have a higher morbidity for other cancers such as stomach, small intestine, or secondary lung cancer.

Methods

We retrospectively explored factors associated with survival in Veterans with rectal carcinoid tumors over a ten-year period from 2007-2017 using the National Veterans Affairs Cancer Cube Registry using specific histological ICD-03 coding. We identified 1110 cases of rectal carcinoid. Chi-squared tests were used for statistical analysis.

Results

Regarding age distribution in our cohort, there were 2.61% of patients ages 40-50 group, 14.0% in the 50-60 age group, 41.5% in the 60-70 age group, and 40.7% above ages 70. There was a higher proportion of rectal cancer in stage 1 compared to other stages (86.3%). The majority of diagnoses occur after age 50 (89.8%). A higher proportion of rectal carcinoid was identified in the 60-70 years category compared to <60 and >70 years old. In the general VA population, there are 80.2% White and 12.8% Black patients. We found a higher proportion of rectal carcinoid in Black patients (47.8%) over White patients (42.8%, p=0.02), which differs significantly from the racial makeup of the VA population (12.8% Black vs 80.3% White). Looking at survival time based on diagnosis, it is notable that 82.7% of individuals survive longer than 5 years when the diagnosis is made in ages 50-60 when compared to 68.7% when the diagnosis is made between ages 60-70 (p<0.001).

Conclusions

Our data is consistent with the SEER data in that the incidence and prevalence of rectal carcinoid are higher in Black patients compared to White patients. Further analysis into reasons for this racial disparity may prove beneficial to our understanding of this malignancy in the Veteran population. Further research is needed to determine whether diagnosis at a younger age offers a survival advantage in rectal carcinoid.

Introduction

Rectal carcinoid tumors are rare but the second most common carcinoid in the gastrointestinal tract. They are usually found incidentally during endoscopic or rectal examination. They do not often produce carcinoid syndrome like manifestations although they may manifest as rectal bleeding. Rectal carcinoid patients also have a higher morbidity for other cancers such as stomach, small intestine, or secondary lung cancer.

Methods

We retrospectively explored factors associated with survival in Veterans with rectal carcinoid tumors over a ten-year period from 2007-2017 using the National Veterans Affairs Cancer Cube Registry using specific histological ICD-03 coding. We identified 1110 cases of rectal carcinoid. Chi-squared tests were used for statistical analysis.

Results

Regarding age distribution in our cohort, there were 2.61% of patients ages 40-50 group, 14.0% in the 50-60 age group, 41.5% in the 60-70 age group, and 40.7% above ages 70. There was a higher proportion of rectal cancer in stage 1 compared to other stages (86.3%). The majority of diagnoses occur after age 50 (89.8%). A higher proportion of rectal carcinoid was identified in the 60-70 years category compared to <60 and >70 years old. In the general VA population, there are 80.2% White and 12.8% Black patients. We found a higher proportion of rectal carcinoid in Black patients (47.8%) over White patients (42.8%, p=0.02), which differs significantly from the racial makeup of the VA population (12.8% Black vs 80.3% White). Looking at survival time based on diagnosis, it is notable that 82.7% of individuals survive longer than 5 years when the diagnosis is made in ages 50-60 when compared to 68.7% when the diagnosis is made between ages 60-70 (p<0.001).

Conclusions

Our data is consistent with the SEER data in that the incidence and prevalence of rectal carcinoid are higher in Black patients compared to White patients. Further analysis into reasons for this racial disparity may prove beneficial to our understanding of this malignancy in the Veteran population. Further research is needed to determine whether diagnosis at a younger age offers a survival advantage in rectal carcinoid.

Introduction

Rectal carcinoid tumors are rare but the second most common carcinoid in the gastrointestinal tract. They are usually found incidentally during endoscopic or rectal examination. They do not often produce carcinoid syndrome like manifestations although they may manifest as rectal bleeding. Rectal carcinoid patients also have a higher morbidity for other cancers such as stomach, small intestine, or secondary lung cancer.

Methods

We retrospectively explored factors associated with survival in Veterans with rectal carcinoid tumors over a ten-year period from 2007-2017 using the National Veterans Affairs Cancer Cube Registry using specific histological ICD-03 coding. We identified 1110 cases of rectal carcinoid. Chi-squared tests were used for statistical analysis.

Results

Regarding age distribution in our cohort, there were 2.61% of patients ages 40-50 group, 14.0% in the 50-60 age group, 41.5% in the 60-70 age group, and 40.7% above ages 70. There was a higher proportion of rectal cancer in stage 1 compared to other stages (86.3%). The majority of diagnoses occur after age 50 (89.8%). A higher proportion of rectal carcinoid was identified in the 60-70 years category compared to <60 and >70 years old. In the general VA population, there are 80.2% White and 12.8% Black patients. We found a higher proportion of rectal carcinoid in Black patients (47.8%) over White patients (42.8%, p=0.02), which differs significantly from the racial makeup of the VA population (12.8% Black vs 80.3% White). Looking at survival time based on diagnosis, it is notable that 82.7% of individuals survive longer than 5 years when the diagnosis is made in ages 50-60 when compared to 68.7% when the diagnosis is made between ages 60-70 (p<0.001).

Conclusions

Our data is consistent with the SEER data in that the incidence and prevalence of rectal carcinoid are higher in Black patients compared to White patients. Further analysis into reasons for this racial disparity may prove beneficial to our understanding of this malignancy in the Veteran population. Further research is needed to determine whether diagnosis at a younger age offers a survival advantage in rectal carcinoid.

Case Report

73-year-old white male presented with large right shoulder soft tissue mass (17x5 cm) near the scapula, and was subsequently sent for surgical resection by his primary care. Pathology showed nodular melanoma with positive margin, lymphovascular invasion and neurotropism present with high mitosis. PET-CT scan showed positive uptake in axillary and supraclavicular lymph nodes as well as uptake in the left proximal tibia. Biopsy of the bone was also positive for melanoma. Molecular study showed BRAF mutation at L597, high tumor mutation burden (24 mutations/Mb), and PD-L1 positive in 60% of tumor cells and PD-1 was positive in immune cells, but not in tumor cells. One other distinct feature of this clinical presentation was the abundance of macrophages (CD68+) in the tumor microenvironment. Patient was initiated therapy with pembrolizumab. However, three weeks after his second cycle, he was admitted to hospital due to severe weakness in both upper extremities and pain at night. He also experienced a new onset of polyarthralgia in both hands, unable to play musical instruments. He was started on steroid treatment and showed significant improvement. Once steroid was tapered off, the sensation of pain substantially decreased but persisted. EMG showed right median motor neuropathy and left median sensory neuropathy. Blood test detected ANA positive, and as TSH was high, levothyroxine was initiated.

Outcome

His PET-CT scan showed improvement after only two cycles of treatment and has remained stable for over ten months without any treatment (patient elected to stop pembrolizumab treatment due to frequent traveling). We have performed a more detailed study of the macrophages in his tumor sample and interestingly, the majority of macrophages were type-1 (CD 80+), with some, type-2 macrophages (CD163+). It is known that type-1 macrophages are pro-inflammatory and have antitumor effect, while type-2 macrophages have opposite effect and often promote tumor growth and metastasis. This could explain the side effect and long duration of response despite only two cycles of pembrolizumab treatment. Characteristics of macrophages in melanoma tumor samples may be an important parameter to predict side effect and tumor response beyond PD1 or PD-L1 expression.

Case Report

73-year-old white male presented with large right shoulder soft tissue mass (17x5 cm) near the scapula, and was subsequently sent for surgical resection by his primary care. Pathology showed nodular melanoma with positive margin, lymphovascular invasion and neurotropism present with high mitosis. PET-CT scan showed positive uptake in axillary and supraclavicular lymph nodes as well as uptake in the left proximal tibia. Biopsy of the bone was also positive for melanoma. Molecular study showed BRAF mutation at L597, high tumor mutation burden (24 mutations/Mb), and PD-L1 positive in 60% of tumor cells and PD-1 was positive in immune cells, but not in tumor cells. One other distinct feature of this clinical presentation was the abundance of macrophages (CD68+) in the tumor microenvironment. Patient was initiated therapy with pembrolizumab. However, three weeks after his second cycle, he was admitted to hospital due to severe weakness in both upper extremities and pain at night. He also experienced a new onset of polyarthralgia in both hands, unable to play musical instruments. He was started on steroid treatment and showed significant improvement. Once steroid was tapered off, the sensation of pain substantially decreased but persisted. EMG showed right median motor neuropathy and left median sensory neuropathy. Blood test detected ANA positive, and as TSH was high, levothyroxine was initiated.

Outcome

His PET-CT scan showed improvement after only two cycles of treatment and has remained stable for over ten months without any treatment (patient elected to stop pembrolizumab treatment due to frequent traveling). We have performed a more detailed study of the macrophages in his tumor sample and interestingly, the majority of macrophages were type-1 (CD 80+), with some, type-2 macrophages (CD163+). It is known that type-1 macrophages are pro-inflammatory and have antitumor effect, while type-2 macrophages have opposite effect and often promote tumor growth and metastasis. This could explain the side effect and long duration of response despite only two cycles of pembrolizumab treatment. Characteristics of macrophages in melanoma tumor samples may be an important parameter to predict side effect and tumor response beyond PD1 or PD-L1 expression.

Case Report

73-year-old white male presented with large right shoulder soft tissue mass (17x5 cm) near the scapula, and was subsequently sent for surgical resection by his primary care. Pathology showed nodular melanoma with positive margin, lymphovascular invasion and neurotropism present with high mitosis. PET-CT scan showed positive uptake in axillary and supraclavicular lymph nodes as well as uptake in the left proximal tibia. Biopsy of the bone was also positive for melanoma. Molecular study showed BRAF mutation at L597, high tumor mutation burden (24 mutations/Mb), and PD-L1 positive in 60% of tumor cells and PD-1 was positive in immune cells, but not in tumor cells. One other distinct feature of this clinical presentation was the abundance of macrophages (CD68+) in the tumor microenvironment. Patient was initiated therapy with pembrolizumab. However, three weeks after his second cycle, he was admitted to hospital due to severe weakness in both upper extremities and pain at night. He also experienced a new onset of polyarthralgia in both hands, unable to play musical instruments. He was started on steroid treatment and showed significant improvement. Once steroid was tapered off, the sensation of pain substantially decreased but persisted. EMG showed right median motor neuropathy and left median sensory neuropathy. Blood test detected ANA positive, and as TSH was high, levothyroxine was initiated.

Outcome

His PET-CT scan showed improvement after only two cycles of treatment and has remained stable for over ten months without any treatment (patient elected to stop pembrolizumab treatment due to frequent traveling). We have performed a more detailed study of the macrophages in his tumor sample and interestingly, the majority of macrophages were type-1 (CD 80+), with some, type-2 macrophages (CD163+). It is known that type-1 macrophages are pro-inflammatory and have antitumor effect, while type-2 macrophages have opposite effect and often promote tumor growth and metastasis. This could explain the side effect and long duration of response despite only two cycles of pembrolizumab treatment. Characteristics of macrophages in melanoma tumor samples may be an important parameter to predict side effect and tumor response beyond PD1 or PD-L1 expression.

Introduction

Epstein-Barr virus (EBV) is a herpes virus that commonly causes infectious mononucleosis (IM) and linked to different hematological conditions. Here we present a case of EBV-triggered Hemolytic Uremic Syndrome (HUS) with pulmonary involvement.

Case Presentation

A 20-year-old male presented with fever, thrombocytopenia, and splenomegaly. Acute EBV serology was positive. Creatinine and hemoglobin were normal. He was diagnosed with IM. platelet count improved within 3 weeks. 4 weeks later, he returned with severe hemoptysis. Hgb 6.8g/dL, platelet 133,000/uL, lactate dehydrogenase 969u/L, creatinine 21mg/dL, and schistocytes on peripheral smear. Chest computed tomography showed bilateral opacities consistent with diffuse alveolar hemorrhage (DAH). Emergent hemodialysis and plasmapheresis were started. Infectious work up was negative. Autoimmune work up was also negative (anti-neutrophil cytoplasmic, anti-basement membrane antibodies, ANA). Aadamts13 activity was 62% (normal ~66%) ruling out thrombotic thrombocytopenic purpura (TTP). Kidney biopsy revealed thrombotic microangiopathic process. The patient was eventually diagnosed with HUS and treated with Eculizumab. 4 months later his renal function has partially recovered and no longer needs hemodialysis.

Discussion

HUS is a rare entity that is known to be triggered by different underlying pathologies. However, its link to EBV remains unclear. Literature review has revealed only two cases of EBV-triggered HUS, even though almost 90-95% of adults are EBV-seropositive. What unique about our case is the patient initially presented with documented IM, and HUS happened a month later. This raises the theory that HUS could be a sequela of the infection, rather than an effect of acute viral phase and this is the first case to report such correlation. The other unique thing is pulmonary involvement in HUS. With consultation with pulmonary service, we believe our patient had DAH based on clinical and radiographic findings. To our knowledge this is the first case to show this association.

Conclusion

EBV is a common virus with high seropositivity among world’s population. Its link to HUS remains unclear and needs more investigation. Providers should recognize HUS as a complication of EBV infection, either in the acute phase or as a sequela. Adolescents are at higher risk for such complication since IM is common in this population.

Introduction

Epstein-Barr virus (EBV) is a herpes virus that commonly causes infectious mononucleosis (IM) and linked to different hematological conditions. Here we present a case of EBV-triggered Hemolytic Uremic Syndrome (HUS) with pulmonary involvement.

Case Presentation

A 20-year-old male presented with fever, thrombocytopenia, and splenomegaly. Acute EBV serology was positive. Creatinine and hemoglobin were normal. He was diagnosed with IM. platelet count improved within 3 weeks. 4 weeks later, he returned with severe hemoptysis. Hgb 6.8g/dL, platelet 133,000/uL, lactate dehydrogenase 969u/L, creatinine 21mg/dL, and schistocytes on peripheral smear. Chest computed tomography showed bilateral opacities consistent with diffuse alveolar hemorrhage (DAH). Emergent hemodialysis and plasmapheresis were started. Infectious work up was negative. Autoimmune work up was also negative (anti-neutrophil cytoplasmic, anti-basement membrane antibodies, ANA). Aadamts13 activity was 62% (normal ~66%) ruling out thrombotic thrombocytopenic purpura (TTP). Kidney biopsy revealed thrombotic microangiopathic process. The patient was eventually diagnosed with HUS and treated with Eculizumab. 4 months later his renal function has partially recovered and no longer needs hemodialysis.

Discussion

HUS is a rare entity that is known to be triggered by different underlying pathologies. However, its link to EBV remains unclear. Literature review has revealed only two cases of EBV-triggered HUS, even though almost 90-95% of adults are EBV-seropositive. What unique about our case is the patient initially presented with documented IM, and HUS happened a month later. This raises the theory that HUS could be a sequela of the infection, rather than an effect of acute viral phase and this is the first case to report such correlation. The other unique thing is pulmonary involvement in HUS. With consultation with pulmonary service, we believe our patient had DAH based on clinical and radiographic findings. To our knowledge this is the first case to show this association.

Conclusion

EBV is a common virus with high seropositivity among world’s population. Its link to HUS remains unclear and needs more investigation. Providers should recognize HUS as a complication of EBV infection, either in the acute phase or as a sequela. Adolescents are at higher risk for such complication since IM is common in this population.

Introduction

Epstein-Barr virus (EBV) is a herpes virus that commonly causes infectious mononucleosis (IM) and linked to different hematological conditions. Here we present a case of EBV-triggered Hemolytic Uremic Syndrome (HUS) with pulmonary involvement.

Case Presentation

A 20-year-old male presented with fever, thrombocytopenia, and splenomegaly. Acute EBV serology was positive. Creatinine and hemoglobin were normal. He was diagnosed with IM. platelet count improved within 3 weeks. 4 weeks later, he returned with severe hemoptysis. Hgb 6.8g/dL, platelet 133,000/uL, lactate dehydrogenase 969u/L, creatinine 21mg/dL, and schistocytes on peripheral smear. Chest computed tomography showed bilateral opacities consistent with diffuse alveolar hemorrhage (DAH). Emergent hemodialysis and plasmapheresis were started. Infectious work up was negative. Autoimmune work up was also negative (anti-neutrophil cytoplasmic, anti-basement membrane antibodies, ANA). Aadamts13 activity was 62% (normal ~66%) ruling out thrombotic thrombocytopenic purpura (TTP). Kidney biopsy revealed thrombotic microangiopathic process. The patient was eventually diagnosed with HUS and treated with Eculizumab. 4 months later his renal function has partially recovered and no longer needs hemodialysis.

Discussion

HUS is a rare entity that is known to be triggered by different underlying pathologies. However, its link to EBV remains unclear. Literature review has revealed only two cases of EBV-triggered HUS, even though almost 90-95% of adults are EBV-seropositive. What unique about our case is the patient initially presented with documented IM, and HUS happened a month later. This raises the theory that HUS could be a sequela of the infection, rather than an effect of acute viral phase and this is the first case to report such correlation. The other unique thing is pulmonary involvement in HUS. With consultation with pulmonary service, we believe our patient had DAH based on clinical and radiographic findings. To our knowledge this is the first case to show this association.

Conclusion

EBV is a common virus with high seropositivity among world’s population. Its link to HUS remains unclear and needs more investigation. Providers should recognize HUS as a complication of EBV infection, either in the acute phase or as a sequela. Adolescents are at higher risk for such complication since IM is common in this population.

Purpose

Prostate cancer is the fifth leading cause of death in the United States. Genomic testing is essential to guide treatment decisions in patients with metastatic castration resistant prostate cancer (mCRPC), the most advanced stage of prostate cancer. However, identifying mCRPC patients from administrative data is challenging and hinders researchers’ ability to assess testing among these patients. This study aims to develop algorithms using structured data and unstructured data with Natural language processing (NLP) methods to identify veterans by disease stage and hormone sensitivity, and to assess patient characteristics as well as receipt of tumor NGS testing.

Methods

We used biopsy, pathology, and diagnosis codes, to identify veterans with newly diagnosed PC within the Veterans Health Administration (VA) from January 1, 2017 to December 31, 2020. We developed and deployed: 1. A structured algorithm that used medication and Prostate-Specific Antigen (PSA) data to assess hormone sensitivity. 2. NLP tools to extract disease stage and hormone sensitivity from clinical notes. We report descriptive statistics on patient demographics, clinical characteristics, disease status, androgen deprivation therapy (ADT), and receipt of tumor NGS testing.

Results

There were 42,485 veterans with newly diagnosed prostate cancer between 2017-2020. This represented ~0.18% of veterans served in the VA and consisted of Whites (57%), Blacks (33%), and others (10%). During the study period, 3,113 (7.3%) patients had documentation of assessment for intraductal carcinoma, 5,160 (12.1%) had ADT treatment, 1,481 (3.5%) had CRPC, and 3,246 (7.6%) had metastatic disease. Among the 42,485 veterans, 422 received tumor NGS testing within VA, and 300 of them had metastatic disease. NLP tool and structured data algorithm collectively showed that 38% of the 422 tumor NGS testing recipients had mCRPC. Among all newly diagnosed PC patients, White patients had highest rates of tumor-based testing (2.3%), then Native Hawaiians (1.7%), Asians and Blacks (1.2% each), compared to Native Americans (0.4%).

Implications

NLP tools alongside structured data algorithms successfully identified variables required to measure access to tumor NGS testing. Efforts to validate and apply this method is ongoing to assess receipt of precision prostate cancer care in VA.

Purpose

Prostate cancer is the fifth leading cause of death in the United States. Genomic testing is essential to guide treatment decisions in patients with metastatic castration resistant prostate cancer (mCRPC), the most advanced stage of prostate cancer. However, identifying mCRPC patients from administrative data is challenging and hinders researchers’ ability to assess testing among these patients. This study aims to develop algorithms using structured data and unstructured data with Natural language processing (NLP) methods to identify veterans by disease stage and hormone sensitivity, and to assess patient characteristics as well as receipt of tumor NGS testing.

Methods

We used biopsy, pathology, and diagnosis codes, to identify veterans with newly diagnosed PC within the Veterans Health Administration (VA) from January 1, 2017 to December 31, 2020. We developed and deployed: 1. A structured algorithm that used medication and Prostate-Specific Antigen (PSA) data to assess hormone sensitivity. 2. NLP tools to extract disease stage and hormone sensitivity from clinical notes. We report descriptive statistics on patient demographics, clinical characteristics, disease status, androgen deprivation therapy (ADT), and receipt of tumor NGS testing.

Results

There were 42,485 veterans with newly diagnosed prostate cancer between 2017-2020. This represented ~0.18% of veterans served in the VA and consisted of Whites (57%), Blacks (33%), and others (10%). During the study period, 3,113 (7.3%) patients had documentation of assessment for intraductal carcinoma, 5,160 (12.1%) had ADT treatment, 1,481 (3.5%) had CRPC, and 3,246 (7.6%) had metastatic disease. Among the 42,485 veterans, 422 received tumor NGS testing within VA, and 300 of them had metastatic disease. NLP tool and structured data algorithm collectively showed that 38% of the 422 tumor NGS testing recipients had mCRPC. Among all newly diagnosed PC patients, White patients had highest rates of tumor-based testing (2.3%), then Native Hawaiians (1.7%), Asians and Blacks (1.2% each), compared to Native Americans (0.4%).

Implications

NLP tools alongside structured data algorithms successfully identified variables required to measure access to tumor NGS testing. Efforts to validate and apply this method is ongoing to assess receipt of precision prostate cancer care in VA.

Purpose

Prostate cancer is the fifth leading cause of death in the United States. Genomic testing is essential to guide treatment decisions in patients with metastatic castration resistant prostate cancer (mCRPC), the most advanced stage of prostate cancer. However, identifying mCRPC patients from administrative data is challenging and hinders researchers’ ability to assess testing among these patients. This study aims to develop algorithms using structured data and unstructured data with Natural language processing (NLP) methods to identify veterans by disease stage and hormone sensitivity, and to assess patient characteristics as well as receipt of tumor NGS testing.

Methods

We used biopsy, pathology, and diagnosis codes, to identify veterans with newly diagnosed PC within the Veterans Health Administration (VA) from January 1, 2017 to December 31, 2020. We developed and deployed: 1. A structured algorithm that used medication and Prostate-Specific Antigen (PSA) data to assess hormone sensitivity. 2. NLP tools to extract disease stage and hormone sensitivity from clinical notes. We report descriptive statistics on patient demographics, clinical characteristics, disease status, androgen deprivation therapy (ADT), and receipt of tumor NGS testing.

Results

There were 42,485 veterans with newly diagnosed prostate cancer between 2017-2020. This represented ~0.18% of veterans served in the VA and consisted of Whites (57%), Blacks (33%), and others (10%). During the study period, 3,113 (7.3%) patients had documentation of assessment for intraductal carcinoma, 5,160 (12.1%) had ADT treatment, 1,481 (3.5%) had CRPC, and 3,246 (7.6%) had metastatic disease. Among the 42,485 veterans, 422 received tumor NGS testing within VA, and 300 of them had metastatic disease. NLP tool and structured data algorithm collectively showed that 38% of the 422 tumor NGS testing recipients had mCRPC. Among all newly diagnosed PC patients, White patients had highest rates of tumor-based testing (2.3%), then Native Hawaiians (1.7%), Asians and Blacks (1.2% each), compared to Native Americans (0.4%).

Implications

NLP tools alongside structured data algorithms successfully identified variables required to measure access to tumor NGS testing. Efforts to validate and apply this method is ongoing to assess receipt of precision prostate cancer care in VA.

Objective

To determine whether Black Veterans are at higher risk for prostate cancer diagnosis on their first prostate biopsy compared to non-Hispanic White (White) Veterans.

Background

Prostate-specific antigen (PSA) testing is widely used to screen for prostate cancer. Although men of African ancestry display an increased incidence of prostate cancer and more aggressive disease, specific PSA thresholds for biopsy referral have yet to be proposed for this population.

Methods

We used the VHA’s electronic medical record data to collect Veterans’ demographic and clinical characteristics including self-identified race/ethnicity, age, date of first prostate biopsy, PSA results, and prostate cancer diagnosis. Veterans’ ZIP code of residence was used to determine urban/rural status, income, and education. We estimated multivariable logistic regression models to predict the likelihood of prostate cancer diagnosis on the first biopsy using race, baseline PSA, age at first PSA test, age at initial biopsy, smoking status, use of statins, and socioeconomic factors as predictors. We calculated adjusted predicted probabilities of cancer detection on the first prostate biopsy from the logistic models at different PSA levels.

Results

We identified 246,056 White and 71,653 Black Veterans who underwent their first prostate biopsy through February 28, 2020 and who had no previous prostate cancer diagnosis or treatment prior to that biopsy. Black Veterans appeared to receive their first PSA test four years earlier and undergo their first prostate biopsy two years earlier than their White counterparts (median age of 57 vs. 61 and 63 vs. 65, respectively). After controlling for selected covariates, we found that Black Veterans were 52% more likely to be diagnosed with prostate cancer on their first prostate biopsy compared to White Veterans (OR 1.52, 95% CI 1.49-1.55). Our model indicated that a Black Veteran with a PSA of 4.0 ng/ml has an equivalent risk of prostate cancer detection as a White Veteran with a PSA of 9.7 ng/ml.

Implications

Our findings suggested that developing a risk-based PSA threshold for referral to prostate biopsy may lead to earlier diagnosis of clinically significant prostate cancer in a population of Veterans known to have an increased incidence and risk of aggressive disease.

Objective

To determine whether Black Veterans are at higher risk for prostate cancer diagnosis on their first prostate biopsy compared to non-Hispanic White (White) Veterans.

Background

Prostate-specific antigen (PSA) testing is widely used to screen for prostate cancer. Although men of African ancestry display an increased incidence of prostate cancer and more aggressive disease, specific PSA thresholds for biopsy referral have yet to be proposed for this population.

Methods

We used the VHA’s electronic medical record data to collect Veterans’ demographic and clinical characteristics including self-identified race/ethnicity, age, date of first prostate biopsy, PSA results, and prostate cancer diagnosis. Veterans’ ZIP code of residence was used to determine urban/rural status, income, and education. We estimated multivariable logistic regression models to predict the likelihood of prostate cancer diagnosis on the first biopsy using race, baseline PSA, age at first PSA test, age at initial biopsy, smoking status, use of statins, and socioeconomic factors as predictors. We calculated adjusted predicted probabilities of cancer detection on the first prostate biopsy from the logistic models at different PSA levels.

Results

We identified 246,056 White and 71,653 Black Veterans who underwent their first prostate biopsy through February 28, 2020 and who had no previous prostate cancer diagnosis or treatment prior to that biopsy. Black Veterans appeared to receive their first PSA test four years earlier and undergo their first prostate biopsy two years earlier than their White counterparts (median age of 57 vs. 61 and 63 vs. 65, respectively). After controlling for selected covariates, we found that Black Veterans were 52% more likely to be diagnosed with prostate cancer on their first prostate biopsy compared to White Veterans (OR 1.52, 95% CI 1.49-1.55). Our model indicated that a Black Veteran with a PSA of 4.0 ng/ml has an equivalent risk of prostate cancer detection as a White Veteran with a PSA of 9.7 ng/ml.

Implications

Our findings suggested that developing a risk-based PSA threshold for referral to prostate biopsy may lead to earlier diagnosis of clinically significant prostate cancer in a population of Veterans known to have an increased incidence and risk of aggressive disease.

Objective

To determine whether Black Veterans are at higher risk for prostate cancer diagnosis on their first prostate biopsy compared to non-Hispanic White (White) Veterans.

Background

Prostate-specific antigen (PSA) testing is widely used to screen for prostate cancer. Although men of African ancestry display an increased incidence of prostate cancer and more aggressive disease, specific PSA thresholds for biopsy referral have yet to be proposed for this population.

Methods

We used the VHA’s electronic medical record data to collect Veterans’ demographic and clinical characteristics including self-identified race/ethnicity, age, date of first prostate biopsy, PSA results, and prostate cancer diagnosis. Veterans’ ZIP code of residence was used to determine urban/rural status, income, and education. We estimated multivariable logistic regression models to predict the likelihood of prostate cancer diagnosis on the first biopsy using race, baseline PSA, age at first PSA test, age at initial biopsy, smoking status, use of statins, and socioeconomic factors as predictors. We calculated adjusted predicted probabilities of cancer detection on the first prostate biopsy from the logistic models at different PSA levels.

Results

We identified 246,056 White and 71,653 Black Veterans who underwent their first prostate biopsy through February 28, 2020 and who had no previous prostate cancer diagnosis or treatment prior to that biopsy. Black Veterans appeared to receive their first PSA test four years earlier and undergo their first prostate biopsy two years earlier than their White counterparts (median age of 57 vs. 61 and 63 vs. 65, respectively). After controlling for selected covariates, we found that Black Veterans were 52% more likely to be diagnosed with prostate cancer on their first prostate biopsy compared to White Veterans (OR 1.52, 95% CI 1.49-1.55). Our model indicated that a Black Veteran with a PSA of 4.0 ng/ml has an equivalent risk of prostate cancer detection as a White Veteran with a PSA of 9.7 ng/ml.

Implications

Our findings suggested that developing a risk-based PSA threshold for referral to prostate biopsy may lead to earlier diagnosis of clinically significant prostate cancer in a population of Veterans known to have an increased incidence and risk of aggressive disease.

Background

Survival for early-stage non-small cell lung cancer (NSCLC) has dramatically improved with advancement in surgical and radiation techniques over last two decades but there exists a disparity for African Americans (AA) having worse overall survival (OS) in recent studies on the general US population. We studied this racial disparity in Veteran population.

Methods

Data for 2589 AA and 14184 Caucasian Veterans diagnosed with early-stage (I, II) NSCLC between 2011-2017 was obtained from the Cancer Cube Registry (VACCR). IRB approval was obtained.

Results

The distribution of newly diagnosed cases of Stage I (73.92% AA vs 74.71% Caucasians) and Stage II (26.07% vs 25.29%) between the two races was comparable (p = .41). More Caucasians were diagnosed above the age of 60 compared to AA (92.22% vs 84.51%, p < .05). More AA were diagnosed with adenocarcinoma at diagnosis (56.01% vs 45.88% Caucasians, p < .05) for both Stage I and II disease. For the limited number of Veterans with reported performance status (PS), similar proportion of patients had a good PS defined as ECOG 0-2 among the two races (93.70% AA vs 93.97% Caucasians, p = .73). There was no statistically significant difference between 5-year OS for AA and Caucasians (69.81% vs 70.78%, p = .33) for both Stage I and II NSCLC. Both groups had similar rate of receipt of surgery as first line treatment or in combination with other treatments (58.90% AA vs 59.07% Caucasians, p = .90). Similarly, the rate of receiving radiation therapy was comparable between AA and Caucasians (42.4% vs 42.3%, p = .96). Although both races showed improved 5-year OS after surgery, there was no statistical difference in survival benefit between AA and Caucasians (69.8% vs 70.8%, p = .33).

Conclusion

In contrast to the studies assessing general US population trends, there was no racial disparity for 5-year OS in early-stage NSCLC for the Veteran population. This points to the inequities in access to treatment and preventive healthcare services as a possible contributing cause to the increased mortality in AA in general US population and a more equitable healthcare delivery within the VHA system.

Background

Survival for early-stage non-small cell lung cancer (NSCLC) has dramatically improved with advancement in surgical and radiation techniques over last two decades but there exists a disparity for African Americans (AA) having worse overall survival (OS) in recent studies on the general US population. We studied this racial disparity in Veteran population.

Methods

Data for 2589 AA and 14184 Caucasian Veterans diagnosed with early-stage (I, II) NSCLC between 2011-2017 was obtained from the Cancer Cube Registry (VACCR). IRB approval was obtained.

Results

The distribution of newly diagnosed cases of Stage I (73.92% AA vs 74.71% Caucasians) and Stage II (26.07% vs 25.29%) between the two races was comparable (p = .41). More Caucasians were diagnosed above the age of 60 compared to AA (92.22% vs 84.51%, p < .05). More AA were diagnosed with adenocarcinoma at diagnosis (56.01% vs 45.88% Caucasians, p < .05) for both Stage I and II disease. For the limited number of Veterans with reported performance status (PS), similar proportion of patients had a good PS defined as ECOG 0-2 among the two races (93.70% AA vs 93.97% Caucasians, p = .73). There was no statistically significant difference between 5-year OS for AA and Caucasians (69.81% vs 70.78%, p = .33) for both Stage I and II NSCLC. Both groups had similar rate of receipt of surgery as first line treatment or in combination with other treatments (58.90% AA vs 59.07% Caucasians, p = .90). Similarly, the rate of receiving radiation therapy was comparable between AA and Caucasians (42.4% vs 42.3%, p = .96). Although both races showed improved 5-year OS after surgery, there was no statistical difference in survival benefit between AA and Caucasians (69.8% vs 70.8%, p = .33).

Conclusion

In contrast to the studies assessing general US population trends, there was no racial disparity for 5-year OS in early-stage NSCLC for the Veteran population. This points to the inequities in access to treatment and preventive healthcare services as a possible contributing cause to the increased mortality in AA in general US population and a more equitable healthcare delivery within the VHA system.

Background

Survival for early-stage non-small cell lung cancer (NSCLC) has dramatically improved with advancement in surgical and radiation techniques over last two decades but there exists a disparity for African Americans (AA) having worse overall survival (OS) in recent studies on the general US population. We studied this racial disparity in Veteran population.

Methods

Data for 2589 AA and 14184 Caucasian Veterans diagnosed with early-stage (I, II) NSCLC between 2011-2017 was obtained from the Cancer Cube Registry (VACCR). IRB approval was obtained.

Results

The distribution of newly diagnosed cases of Stage I (73.92% AA vs 74.71% Caucasians) and Stage II (26.07% vs 25.29%) between the two races was comparable (p = .41). More Caucasians were diagnosed above the age of 60 compared to AA (92.22% vs 84.51%, p < .05). More AA were diagnosed with adenocarcinoma at diagnosis (56.01% vs 45.88% Caucasians, p < .05) for both Stage I and II disease. For the limited number of Veterans with reported performance status (PS), similar proportion of patients had a good PS defined as ECOG 0-2 among the two races (93.70% AA vs 93.97% Caucasians, p = .73). There was no statistically significant difference between 5-year OS for AA and Caucasians (69.81% vs 70.78%, p = .33) for both Stage I and II NSCLC. Both groups had similar rate of receipt of surgery as first line treatment or in combination with other treatments (58.90% AA vs 59.07% Caucasians, p = .90). Similarly, the rate of receiving radiation therapy was comparable between AA and Caucasians (42.4% vs 42.3%, p = .96). Although both races showed improved 5-year OS after surgery, there was no statistical difference in survival benefit between AA and Caucasians (69.8% vs 70.8%, p = .33).

Conclusion

In contrast to the studies assessing general US population trends, there was no racial disparity for 5-year OS in early-stage NSCLC for the Veteran population. This points to the inequities in access to treatment and preventive healthcare services as a possible contributing cause to the increased mortality in AA in general US population and a more equitable healthcare delivery within the VHA system.

Introduction

Veterans with early-stage NSCLC who do not receive any form of treatment have been shown to have a worse overall survival compared to those who receive treatment. Factors that may influence the decision to administer treatment including age, performance status (PS), comorbidities, and racial disparity have not been assessed on a national level in recent years.

Methods

Data for 31,966 veterans diagnosed with early-stage (0, I) NSCLC between 2003-2017 was obtained from the Cancer cube registry (VACCR). IRB approval was obtained.

Results

Patients were divided into treatment (26,833/31,966, 83.16%) and no-treatment group (3096/31966, 9.68%). Of the no-treatment group, 3004 patients were stage I and 92 were stage 0 whereas in the treatment group, the distribution was 26,584 and 249 respectively. Gender, race, and histology distribution were comparable between the two. Patients with poor PS (defined as ECOG III and IV) received less treatment with any modality compared to those with good PS (ECOG I and II) (15.07% in no treatment group vs 4.03% in treatment group, p<0.05). The treatment group had a better 5-year overall survival (OS) as compared to no-treatment group (43.1% vs 14.7%, p<0.05). Regardless of treatment, patients above the age of 60 (41% vs 13.4%, p<0.05) and those with poor PS (19.6% vs 5.8%, p<0.05) had worse 5-year survival, with the effect being greater in the treatment group. Adenocarcinoma had a better 5-year survival compared to squamous cell carcinoma (SCC) in both groups (49.56% vs 39.1% p<0.05). There was no clinically significant OS difference in terms of race (Caucasian or African American) or tumor location (upper, middle, or lower lobe) in between the two groups. Our study was limited by lack of patient- level data including smoking status or reason why no treatment was given.

Conclusion

Patients with early-stage NSCLC who receive no treatment based on poor PS have a worse overall survival compared to the patients that receive treatment. Further investigation is required to assess what other criteria are used to decide treatment eligibility and whether these patients would be candidates for immunotherapy or targeted therapy in the future.

Introduction

Veterans with early-stage NSCLC who do not receive any form of treatment have been shown to have a worse overall survival compared to those who receive treatment. Factors that may influence the decision to administer treatment including age, performance status (PS), comorbidities, and racial disparity have not been assessed on a national level in recent years.

Methods

Data for 31,966 veterans diagnosed with early-stage (0, I) NSCLC between 2003-2017 was obtained from the Cancer cube registry (VACCR). IRB approval was obtained.

Results

Patients were divided into treatment (26,833/31,966, 83.16%) and no-treatment group (3096/31966, 9.68%). Of the no-treatment group, 3004 patients were stage I and 92 were stage 0 whereas in the treatment group, the distribution was 26,584 and 249 respectively. Gender, race, and histology distribution were comparable between the two. Patients with poor PS (defined as ECOG III and IV) received less treatment with any modality compared to those with good PS (ECOG I and II) (15.07% in no treatment group vs 4.03% in treatment group, p<0.05). The treatment group had a better 5-year overall survival (OS) as compared to no-treatment group (43.1% vs 14.7%, p<0.05). Regardless of treatment, patients above the age of 60 (41% vs 13.4%, p<0.05) and those with poor PS (19.6% vs 5.8%, p<0.05) had worse 5-year survival, with the effect being greater in the treatment group. Adenocarcinoma had a better 5-year survival compared to squamous cell carcinoma (SCC) in both groups (49.56% vs 39.1% p<0.05). There was no clinically significant OS difference in terms of race (Caucasian or African American) or tumor location (upper, middle, or lower lobe) in between the two groups. Our study was limited by lack of patient- level data including smoking status or reason why no treatment was given.

Conclusion

Patients with early-stage NSCLC who receive no treatment based on poor PS have a worse overall survival compared to the patients that receive treatment. Further investigation is required to assess what other criteria are used to decide treatment eligibility and whether these patients would be candidates for immunotherapy or targeted therapy in the future.

Introduction

Veterans with early-stage NSCLC who do not receive any form of treatment have been shown to have a worse overall survival compared to those who receive treatment. Factors that may influence the decision to administer treatment including age, performance status (PS), comorbidities, and racial disparity have not been assessed on a national level in recent years.

Methods

Data for 31,966 veterans diagnosed with early-stage (0, I) NSCLC between 2003-2017 was obtained from the Cancer cube registry (VACCR). IRB approval was obtained.

Results

Patients were divided into treatment (26,833/31,966, 83.16%) and no-treatment group (3096/31966, 9.68%). Of the no-treatment group, 3004 patients were stage I and 92 were stage 0 whereas in the treatment group, the distribution was 26,584 and 249 respectively. Gender, race, and histology distribution were comparable between the two. Patients with poor PS (defined as ECOG III and IV) received less treatment with any modality compared to those with good PS (ECOG I and II) (15.07% in no treatment group vs 4.03% in treatment group, p<0.05). The treatment group had a better 5-year overall survival (OS) as compared to no-treatment group (43.1% vs 14.7%, p<0.05). Regardless of treatment, patients above the age of 60 (41% vs 13.4%, p<0.05) and those with poor PS (19.6% vs 5.8%, p<0.05) had worse 5-year survival, with the effect being greater in the treatment group. Adenocarcinoma had a better 5-year survival compared to squamous cell carcinoma (SCC) in both groups (49.56% vs 39.1% p<0.05). There was no clinically significant OS difference in terms of race (Caucasian or African American) or tumor location (upper, middle, or lower lobe) in between the two groups. Our study was limited by lack of patient- level data including smoking status or reason why no treatment was given.

Conclusion

Patients with early-stage NSCLC who receive no treatment based on poor PS have a worse overall survival compared to the patients that receive treatment. Further investigation is required to assess what other criteria are used to decide treatment eligibility and whether these patients would be candidates for immunotherapy or targeted therapy in the future.