AVAHO

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

INTRODUCTION: Cerebral venous thrombosis (CVT) is a rare type of stroke and can be challenging to diagnose. It is seen in most commonly young females and has been linked to thrombophilia, pregnancy, and contraceptive pills. Here we present a rare case of CVT in a young female with iron deficiency anemia.

CASE REPORT: A 19-year-old female patient presented with severe headache, CT scan of the head on admission showed acute superior sagittal sinus thrombosis which was confirmed with CT venogram and MRI of the brain. The patient had intact neurologic exam upon admission. She was started on heparin and admitted for monitoring. Later on she developed expressive aphasia and right sided weakness. She ultimately underwent catheter directed thrombolysis. Follow up CT and MRI scans showed significant decrease in clot burden, and the patient’s neurologic function started to improve.

Her initial labs were significant for thrombocytosis with platelet count 840,000/μL, and microcytic anemia with hemoglobin 9.6 g/dL and MCV 79 fL. She had low serum ferritin and iron levels with high total iron binding capacity consistent with iron deficiency anemia. An extensive hypercoagulable work up was done including antithrombin, protein C and S, factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia, antiphospholipid antibodies, anti-nuclear antibodies which all came back negative. Given her high platelet count, a myeloproliferative disorder was entertained however testing of mutations JAK2V617F, CALR, MPL, and BCR-ABL was negative. She also had a bone marrow biopsy that revealed normal bone marrow. The patient had no prior personal or family history of venous thrombosis, she was not taking any hormonal mediation and pregnancy test was negative. She did report menorrhagia for couple of months prior to admission.

CONCLUSION: After ruling out genetic prothrombotic states, autoimmune disease, and bone marrow disorders. We determined this was a case of cerebral venous thrombosis secondary to reactive thrombocytosis in setting of untreated iron deficiency and menorrhagia. The patient was started on iron supplements with improvement in her iron and hemoglobin levels, and subsequent decrease in her platelet count to normal values. She continued anticoagulation with rivaroxaban for 3-6 months period.

BACKGROUND: Availability of clinical trials for veterans is limited and more clinical trials are needed. Central Texas Veterans Health Care System (CTVHCS) has been actively involved with hematologic oncologic clinical trials over the last 10 years. This poster describes the number and types of hematology/oncology clinical trials that are either active or completed, and the processes of opening clinical trials, identifying patients, and trial management.

METHODS: Locating clinical trials is key to veteran enrollment into active trials and is accomplished through networking at medical meetings and VA work groups. Developing a clinical trial program requires working closely with the research department/foundations and becoming comfortable with the IRB oversight process. Conduct of a clinical trial is a team effort, with individual members having delegated responsibilities of patient care, data collection, and adverse effect reporting to the sponsors and IRB. The CTVHCS Oncology Section has been active in recruiting and enrolling veterans in clinical trials for treatment of many hematologic malignancies and solid tumors.

RESULTS: At the time of this presentation, 49 veterans have been successfully enrolled in 1 of 9 hematology/ oncology clinical trials ranging from phase Ib to phase III from 2011-2020. Advantages to opening clinical trials include academic scholarship, authorship in publications, generating revenue and most importantly to provide state of the art treatment for our cancer patients. We have been able to effectively accrue/enroll patients into clinical trials through a collaborative effort between the research department and our oncology department by identifying open clinical trials that fit our unique patient population and having a team of providers aiding in the management and care of these enrolled veterans.

BACKGROUND: Availability of clinical trials for veterans is limited and more clinical trials are needed. Central Texas Veterans Health Care System (CTVHCS) has been actively involved with hematologic oncologic clinical trials over the last 10 years. This poster describes the number and types of hematology/oncology clinical trials that are either active or completed, and the processes of opening clinical trials, identifying patients, and trial management.

METHODS: Locating clinical trials is key to veteran enrollment into active trials and is accomplished through networking at medical meetings and VA work groups. Developing a clinical trial program requires working closely with the research department/foundations and becoming comfortable with the IRB oversight process. Conduct of a clinical trial is a team effort, with individual members having delegated responsibilities of patient care, data collection, and adverse effect reporting to the sponsors and IRB. The CTVHCS Oncology Section has been active in recruiting and enrolling veterans in clinical trials for treatment of many hematologic malignancies and solid tumors.

RESULTS: At the time of this presentation, 49 veterans have been successfully enrolled in 1 of 9 hematology/ oncology clinical trials ranging from phase Ib to phase III from 2011-2020. Advantages to opening clinical trials include academic scholarship, authorship in publications, generating revenue and most importantly to provide state of the art treatment for our cancer patients. We have been able to effectively accrue/enroll patients into clinical trials through a collaborative effort between the research department and our oncology department by identifying open clinical trials that fit our unique patient population and having a team of providers aiding in the management and care of these enrolled veterans.

BACKGROUND: Availability of clinical trials for veterans is limited and more clinical trials are needed. Central Texas Veterans Health Care System (CTVHCS) has been actively involved with hematologic oncologic clinical trials over the last 10 years. This poster describes the number and types of hematology/oncology clinical trials that are either active or completed, and the processes of opening clinical trials, identifying patients, and trial management.

METHODS: Locating clinical trials is key to veteran enrollment into active trials and is accomplished through networking at medical meetings and VA work groups. Developing a clinical trial program requires working closely with the research department/foundations and becoming comfortable with the IRB oversight process. Conduct of a clinical trial is a team effort, with individual members having delegated responsibilities of patient care, data collection, and adverse effect reporting to the sponsors and IRB. The CTVHCS Oncology Section has been active in recruiting and enrolling veterans in clinical trials for treatment of many hematologic malignancies and solid tumors.

RESULTS: At the time of this presentation, 49 veterans have been successfully enrolled in 1 of 9 hematology/ oncology clinical trials ranging from phase Ib to phase III from 2011-2020. Advantages to opening clinical trials include academic scholarship, authorship in publications, generating revenue and most importantly to provide state of the art treatment for our cancer patients. We have been able to effectively accrue/enroll patients into clinical trials through a collaborative effort between the research department and our oncology department by identifying open clinical trials that fit our unique patient population and having a team of providers aiding in the management and care of these enrolled veterans.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

PURPOSE: A quality improvement pilot study was conducted to assess the feasibility of implementing virtual tumor boards (VTBs) to address barriers in cancer care for Veterans at the VA North TexasHealth Care System (VANTHCS) located in Dallas, Texas.

BACKGROUND: The VANTHCS is the second largest VA health care system in the country, serving more than 129,000 veterans with 1.4 million outpatient episodes of care in the FY2017. Cancer is one of the leading causes of these episodes of care. This specific population faces unique needs due to the complexity of cancer care. Multidisciplinary tumor boards (MTBs) can serve as facilitators in augmenting quality cancer care for veterans. Specifically, MTBs have been shown to support diagnostic decision-making, adherence to evidence-based guidelines, as well as enhance collaboration and care coordination. The VANTHCS Cancer Program hosts seven accredited disease-site specific MTBs that meet in a face-to-face conference. However, the COVID-19 pandemic created a gap in continuity cancer care through use of MTBs. Prior to the initiation of this study, no VTBs had previously been implemented.

METHODS: In March 2020, key stakeholders within the cancer program formulated a plan to continue MTBs during the pandemic. A multidisciplinary cancer conference coordinator (MCCC) lead this task utilizing a web-based platform in addition to Biomedical Engineering assistance ensuring appropriate applications were correctly interfaced on all VA Computers to properly support imaging. A Plan-Do-Study-Act was conducted to assess for any changes.

RESULTS: Data were collected and analyzed from January 2, 2020 until July 2, 2020, utilizing a cancer conference tracking tool conducted by the MCCC. A total of 72 MTBs were completed as well as 446 prospective cases were presented. After implementation of VTBs, data showed a 26.8% increase in interdisciplinary attendance rate for MTBs.

CONCLUSION: This innovative pilot study provided a unique approach to meet the demands of the COVID- 19 pandemic as well as showed the feasibility in enhancing quality cancer care. Virtual tumors boards provide an effective tool in improving accessibility through increased participation at MTBs. This may have future implications in which further research is needed including cancer survival and patient satisfaction rates.

BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.

CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.

CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.

BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.

CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.

CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.

BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.

CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.

CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.

BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.

METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.

RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.

CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.

BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.

METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.

RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.

CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.

BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.

METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.

RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.

CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.

INTRODUCTION: In diffuse large B-cell lymphoma (DLBCL), approximately 5-10% of patients develop secondary central nervous system (CNS) involvement. CNS disease is associated with very poor outcomes. Therefore, it is important to identify patients at risk, via the CNS International Prognostic Index (IPI), in order to initiate appropriate interventions. Additional independent risk factors for CNS involvement include HIV-related lymphoma and high-grade B-cell lymphomas. The purpose of this study was to assess for appropriate CNS evaluation and prophylaxis in DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between January 1, 2011 and December 31, 2017. We included patients diagnosed with DLBCL and excluded patients diagnosed or treated outside the VHA. We evaluated CNS IPI score, HIV status, pathology reports to identify high-grade lymphomas, performance of lumbar puncture (LP), and administration of CNS prophylaxis.

RESULTS: A total of 725 patients met our inclusion criteria. Patients were predominantly male (96.8%), white (74.5%), had a median age of 67, and presented with advanced disease (stage III 26.5%, stage IV 40.3%). From the included population, 190 (26.2%) had a highrisk CNS IPI score. Of those with high-risk CNS IPI scores, 64 (33.7%) underwent LP and 46 (24.2%) were treated with CNS prophylaxis. 23 (3.2%) were HIV positive; of those, 14 (60.8%) underwent LP and 4 (17.4%) were treated with CNS prophylaxis. FISH results were available in only 242 (33.4%) of patients and of these, 25 (10.3%) met criteria for high-grade lymphoma. Of those with high-grade lymphoma, 9 (36%) underwent LP and 7 (28%) were treated with CNS prophylaxis.

CONCLUSIONS: The National Comprehensive Cancer Network guidelines recommend that patients at high risk for CNS involvement undergo LP and treatment with CNS prophylaxis. This study found that within the VHA, patients with DLBCL at high risk for CNS involvement are not being evaluated with LPs or treated with CNS prophylaxis as often as indicated, based on CNS IPI, HIV status, and high-grade pathology. We demonstrate a need for improvement in the evaluation and treatment of these patients in order to improve outcomes.

INTRODUCTION: In diffuse large B-cell lymphoma (DLBCL), approximately 5-10% of patients develop secondary central nervous system (CNS) involvement. CNS disease is associated with very poor outcomes. Therefore, it is important to identify patients at risk, via the CNS International Prognostic Index (IPI), in order to initiate appropriate interventions. Additional independent risk factors for CNS involvement include HIV-related lymphoma and high-grade B-cell lymphomas. The purpose of this study was to assess for appropriate CNS evaluation and prophylaxis in DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between January 1, 2011 and December 31, 2017. We included patients diagnosed with DLBCL and excluded patients diagnosed or treated outside the VHA. We evaluated CNS IPI score, HIV status, pathology reports to identify high-grade lymphomas, performance of lumbar puncture (LP), and administration of CNS prophylaxis.

RESULTS: A total of 725 patients met our inclusion criteria. Patients were predominantly male (96.8%), white (74.5%), had a median age of 67, and presented with advanced disease (stage III 26.5%, stage IV 40.3%). From the included population, 190 (26.2%) had a highrisk CNS IPI score. Of those with high-risk CNS IPI scores, 64 (33.7%) underwent LP and 46 (24.2%) were treated with CNS prophylaxis. 23 (3.2%) were HIV positive; of those, 14 (60.8%) underwent LP and 4 (17.4%) were treated with CNS prophylaxis. FISH results were available in only 242 (33.4%) of patients and of these, 25 (10.3%) met criteria for high-grade lymphoma. Of those with high-grade lymphoma, 9 (36%) underwent LP and 7 (28%) were treated with CNS prophylaxis.

CONCLUSIONS: The National Comprehensive Cancer Network guidelines recommend that patients at high risk for CNS involvement undergo LP and treatment with CNS prophylaxis. This study found that within the VHA, patients with DLBCL at high risk for CNS involvement are not being evaluated with LPs or treated with CNS prophylaxis as often as indicated, based on CNS IPI, HIV status, and high-grade pathology. We demonstrate a need for improvement in the evaluation and treatment of these patients in order to improve outcomes.

INTRODUCTION: In diffuse large B-cell lymphoma (DLBCL), approximately 5-10% of patients develop secondary central nervous system (CNS) involvement. CNS disease is associated with very poor outcomes. Therefore, it is important to identify patients at risk, via the CNS International Prognostic Index (IPI), in order to initiate appropriate interventions. Additional independent risk factors for CNS involvement include HIV-related lymphoma and high-grade B-cell lymphomas. The purpose of this study was to assess for appropriate CNS evaluation and prophylaxis in DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected patients seen in the VHA nationwide who were diagnosed with lymphoma between January 1, 2011 and December 31, 2017. We included patients diagnosed with DLBCL and excluded patients diagnosed or treated outside the VHA. We evaluated CNS IPI score, HIV status, pathology reports to identify high-grade lymphomas, performance of lumbar puncture (LP), and administration of CNS prophylaxis.

RESULTS: A total of 725 patients met our inclusion criteria. Patients were predominantly male (96.8%), white (74.5%), had a median age of 67, and presented with advanced disease (stage III 26.5%, stage IV 40.3%). From the included population, 190 (26.2%) had a highrisk CNS IPI score. Of those with high-risk CNS IPI scores, 64 (33.7%) underwent LP and 46 (24.2%) were treated with CNS prophylaxis. 23 (3.2%) were HIV positive; of those, 14 (60.8%) underwent LP and 4 (17.4%) were treated with CNS prophylaxis. FISH results were available in only 242 (33.4%) of patients and of these, 25 (10.3%) met criteria for high-grade lymphoma. Of those with high-grade lymphoma, 9 (36%) underwent LP and 7 (28%) were treated with CNS prophylaxis.

CONCLUSIONS: The National Comprehensive Cancer Network guidelines recommend that patients at high risk for CNS involvement undergo LP and treatment with CNS prophylaxis. This study found that within the VHA, patients with DLBCL at high risk for CNS involvement are not being evaluated with LPs or treated with CNS prophylaxis as often as indicated, based on CNS IPI, HIV status, and high-grade pathology. We demonstrate a need for improvement in the evaluation and treatment of these patients in order to improve outcomes.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.

RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.

CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.

RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.

CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.

INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).

METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.

RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.

CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.

BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.

METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.

RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.

CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.

BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.

METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.

RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.

CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.

BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.

METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.

RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.

CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.

BACKGROUND: The purpose of this work is to assess the current utilization patterns of telehealth for oncology care and identify opportunities for increased utilization for underserved regions. In order to accurately and efficiently obtain this information a national data extraction and analysis was required to better understand the current needs. Approximately 33% of veterans are considered to live in rural America. A significant proportion of cancer patients must travel long distances to access cutting-edge VA cancer care. Some VAMCs provide academic subspecialized oncology care including next generation sequencing (NGS), genetic counseling, opportunities to enroll in clinical trials, and world-renowned clinical expert consultation. These services are not conveniently accessible for veterans therefore requiring a program which supports access to all.

METHODS: Baseline assessment measurements were identified to understand resource supply, demand, and telehealth utilization needs. Data were extracted from VA’s CDW and VSSCs Service Analysis Services cubes. 15 data measures from 8 data sources were pulled for 141 VAMCs spanning in time period from FY18 to March FY20.

Cluster Analysis, k-means clustering method, were used to classify VAMCs into distinct groups to identify facilities with the highest needs for oncology telehealth services. The evolutionary solving method was used to find the minimum sum of squared estimate of errors (SSE) allowing a more diversified approach in cluster assignment. Three cluster analysis were performed which include a combination of three variables specific to oncology staffing, telehealth usage, patient rurality, and community care consults (CCC).

RESULTS: Results show that 30 (21%) VAMCs are categorized as high need for TeleOncology. These facilities have low staff support, high CCC, and low telehealth usage. Of these, 11 (37%) VAMCs have high percent of rural patients. Eleven (8%) of all VAMCs are categorized as having high staff support, low CCC, and high telehealth usage; good hub site candidates for the National TeleOncology Program.

CONCLUSION: VA is expanding the National TeleOncology Program to offer oncology services to underserved VAMCs and Veterans across the United States. Results of this analysis are being applied to determine where to prioritize telehealth services for oncology care and which sites may serve as hubs.

BACKGROUND: The purpose of this work is to assess the current utilization patterns of telehealth for oncology care and identify opportunities for increased utilization for underserved regions. In order to accurately and efficiently obtain this information a national data extraction and analysis was required to better understand the current needs. Approximately 33% of veterans are considered to live in rural America. A significant proportion of cancer patients must travel long distances to access cutting-edge VA cancer care. Some VAMCs provide academic subspecialized oncology care including next generation sequencing (NGS), genetic counseling, opportunities to enroll in clinical trials, and world-renowned clinical expert consultation. These services are not conveniently accessible for veterans therefore requiring a program which supports access to all.

METHODS: Baseline assessment measurements were identified to understand resource supply, demand, and telehealth utilization needs. Data were extracted from VA’s CDW and VSSCs Service Analysis Services cubes. 15 data measures from 8 data sources were pulled for 141 VAMCs spanning in time period from FY18 to March FY20.

Cluster Analysis, k-means clustering method, were used to classify VAMCs into distinct groups to identify facilities with the highest needs for oncology telehealth services. The evolutionary solving method was used to find the minimum sum of squared estimate of errors (SSE) allowing a more diversified approach in cluster assignment. Three cluster analysis were performed which include a combination of three variables specific to oncology staffing, telehealth usage, patient rurality, and community care consults (CCC).

RESULTS: Results show that 30 (21%) VAMCs are categorized as high need for TeleOncology. These facilities have low staff support, high CCC, and low telehealth usage. Of these, 11 (37%) VAMCs have high percent of rural patients. Eleven (8%) of all VAMCs are categorized as having high staff support, low CCC, and high telehealth usage; good hub site candidates for the National TeleOncology Program.

CONCLUSION: VA is expanding the National TeleOncology Program to offer oncology services to underserved VAMCs and Veterans across the United States. Results of this analysis are being applied to determine where to prioritize telehealth services for oncology care and which sites may serve as hubs.

BACKGROUND: The purpose of this work is to assess the current utilization patterns of telehealth for oncology care and identify opportunities for increased utilization for underserved regions. In order to accurately and efficiently obtain this information a national data extraction and analysis was required to better understand the current needs. Approximately 33% of veterans are considered to live in rural America. A significant proportion of cancer patients must travel long distances to access cutting-edge VA cancer care. Some VAMCs provide academic subspecialized oncology care including next generation sequencing (NGS), genetic counseling, opportunities to enroll in clinical trials, and world-renowned clinical expert consultation. These services are not conveniently accessible for veterans therefore requiring a program which supports access to all.

METHODS: Baseline assessment measurements were identified to understand resource supply, demand, and telehealth utilization needs. Data were extracted from VA’s CDW and VSSCs Service Analysis Services cubes. 15 data measures from 8 data sources were pulled for 141 VAMCs spanning in time period from FY18 to March FY20.

Cluster Analysis, k-means clustering method, were used to classify VAMCs into distinct groups to identify facilities with the highest needs for oncology telehealth services. The evolutionary solving method was used to find the minimum sum of squared estimate of errors (SSE) allowing a more diversified approach in cluster assignment. Three cluster analysis were performed which include a combination of three variables specific to oncology staffing, telehealth usage, patient rurality, and community care consults (CCC).

RESULTS: Results show that 30 (21%) VAMCs are categorized as high need for TeleOncology. These facilities have low staff support, high CCC, and low telehealth usage. Of these, 11 (37%) VAMCs have high percent of rural patients. Eleven (8%) of all VAMCs are categorized as having high staff support, low CCC, and high telehealth usage; good hub site candidates for the National TeleOncology Program.

CONCLUSION: VA is expanding the National TeleOncology Program to offer oncology services to underserved VAMCs and Veterans across the United States. Results of this analysis are being applied to determine where to prioritize telehealth services for oncology care and which sites may serve as hubs.

INTRODUCTION: American Society of Clinical Oncology (ASCO) has developed guidelines on the management of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICPIs). However, many irAEs are under-reported and the studies to investigate predictive factors are limited with variable results.

METHODS: A total of 66 patients who received ICPIs at Stratton VAMC Albany between January 2015 to December 2018 were studied. Computerized Patient Record System (CPRS) was used to do a retrospective chart review to identify irAEs and related parameters. IRB approval was obtained.

RESULTS: Sixty-three patients received PD-1 inhibitors (62 males). Our study included 39 patients with lung, 10 renal, 6 head and neck, 4 skin (melanoma), and 2 bladder cancers, and 1 metastatic cancer with unknown primary. Median age of patients with irAEs was 69.5 years versus 66.7 years for patients without irAEs. 23 (36.5%) patients experienced 28 irAEs. 45 patients received nivolumab, 18 (40%) of which had 21 irAEs. 17 got pembrolizumab and 5 (35.2%) had 7 irAEs. Majority of the irAEs were grade I (n=10, 35.7%) or grade II (n=11, 39.2%), while 6 (21.4%) grade III and only 1 (3.5%) grade IV irAE was observed. Median time to appearance of irAEs was 2 cycles. Immunotherapy was continued in 12, temporarily held in 7 and permanently discontinued only in 4 patients. No death was attributed to irAEs. Six patients developed diarrhea, 4 hepatitis, 6 skin rash, 5 thyroid issues and 3 pneumonitis. Rare irAEs included cardiac tamponade (grade IV), uveitis (grade II), central adrenal insufficiency and mild neutropenia in one patient each. 2 patients had pre-existing autoimmune conditions (rheumatoid arthritis and chronic dermatitis), both had transient flares though immunotherapy was continued. Of note, only 3 patients received PDL-1 inhibitors and 1 developed grade II polymyalgia rheumatica and hypothyroidism.

Using multivariate logistic regression, we found no significant association between irAEs and age, body mass index, derived neutrophil to lymphocyte ratio, chronic kidney disease or environmental/medical allergies.

CONCLUSIONS: ICPIs were generally well tolerated in our population, though prompt recognition of rare and severe irAEs is essential. Larger studies are needed to investigate the predictive risk factors for irAEs.

INTRODUCTION: American Society of Clinical Oncology (ASCO) has developed guidelines on the management of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICPIs). However, many irAEs are under-reported and the studies to investigate predictive factors are limited with variable results.

METHODS: A total of 66 patients who received ICPIs at Stratton VAMC Albany between January 2015 to December 2018 were studied. Computerized Patient Record System (CPRS) was used to do a retrospective chart review to identify irAEs and related parameters. IRB approval was obtained.

RESULTS: Sixty-three patients received PD-1 inhibitors (62 males). Our study included 39 patients with lung, 10 renal, 6 head and neck, 4 skin (melanoma), and 2 bladder cancers, and 1 metastatic cancer with unknown primary. Median age of patients with irAEs was 69.5 years versus 66.7 years for patients without irAEs. 23 (36.5%) patients experienced 28 irAEs. 45 patients received nivolumab, 18 (40%) of which had 21 irAEs. 17 got pembrolizumab and 5 (35.2%) had 7 irAEs. Majority of the irAEs were grade I (n=10, 35.7%) or grade II (n=11, 39.2%), while 6 (21.4%) grade III and only 1 (3.5%) grade IV irAE was observed. Median time to appearance of irAEs was 2 cycles. Immunotherapy was continued in 12, temporarily held in 7 and permanently discontinued only in 4 patients. No death was attributed to irAEs. Six patients developed diarrhea, 4 hepatitis, 6 skin rash, 5 thyroid issues and 3 pneumonitis. Rare irAEs included cardiac tamponade (grade IV), uveitis (grade II), central adrenal insufficiency and mild neutropenia in one patient each. 2 patients had pre-existing autoimmune conditions (rheumatoid arthritis and chronic dermatitis), both had transient flares though immunotherapy was continued. Of note, only 3 patients received PDL-1 inhibitors and 1 developed grade II polymyalgia rheumatica and hypothyroidism.

Using multivariate logistic regression, we found no significant association between irAEs and age, body mass index, derived neutrophil to lymphocyte ratio, chronic kidney disease or environmental/medical allergies.

CONCLUSIONS: ICPIs were generally well tolerated in our population, though prompt recognition of rare and severe irAEs is essential. Larger studies are needed to investigate the predictive risk factors for irAEs.

INTRODUCTION: American Society of Clinical Oncology (ASCO) has developed guidelines on the management of immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICPIs). However, many irAEs are under-reported and the studies to investigate predictive factors are limited with variable results.

METHODS: A total of 66 patients who received ICPIs at Stratton VAMC Albany between January 2015 to December 2018 were studied. Computerized Patient Record System (CPRS) was used to do a retrospective chart review to identify irAEs and related parameters. IRB approval was obtained.

RESULTS: Sixty-three patients received PD-1 inhibitors (62 males). Our study included 39 patients with lung, 10 renal, 6 head and neck, 4 skin (melanoma), and 2 bladder cancers, and 1 metastatic cancer with unknown primary. Median age of patients with irAEs was 69.5 years versus 66.7 years for patients without irAEs. 23 (36.5%) patients experienced 28 irAEs. 45 patients received nivolumab, 18 (40%) of which had 21 irAEs. 17 got pembrolizumab and 5 (35.2%) had 7 irAEs. Majority of the irAEs were grade I (n=10, 35.7%) or grade II (n=11, 39.2%), while 6 (21.4%) grade III and only 1 (3.5%) grade IV irAE was observed. Median time to appearance of irAEs was 2 cycles. Immunotherapy was continued in 12, temporarily held in 7 and permanently discontinued only in 4 patients. No death was attributed to irAEs. Six patients developed diarrhea, 4 hepatitis, 6 skin rash, 5 thyroid issues and 3 pneumonitis. Rare irAEs included cardiac tamponade (grade IV), uveitis (grade II), central adrenal insufficiency and mild neutropenia in one patient each. 2 patients had pre-existing autoimmune conditions (rheumatoid arthritis and chronic dermatitis), both had transient flares though immunotherapy was continued. Of note, only 3 patients received PDL-1 inhibitors and 1 developed grade II polymyalgia rheumatica and hypothyroidism.

Using multivariate logistic regression, we found no significant association between irAEs and age, body mass index, derived neutrophil to lymphocyte ratio, chronic kidney disease or environmental/medical allergies.

CONCLUSIONS: ICPIs were generally well tolerated in our population, though prompt recognition of rare and severe irAEs is essential. Larger studies are needed to investigate the predictive risk factors for irAEs.