AVAHO

Background: Palliative radiotherapy plays an important role in metastatic lung cancer (LC) treatment. Of VHA LC patients, 46% present with metastatic disease. The American Society for Radiation Oncology (ASTRO) has developed evidenced-based guidelines regarding management of metastatic LC.

Methods: In May 2016, an electronic survey of 84 VHA Radiation Oncologists (ROs) was conducted to assess metastatic LC management. Information on years in practice, employment status, academic appointment, board certification, and familiarity with ASTRO lung cancer guidelines was obtained. Two clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/ against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or YAG laser technology. Survey results were assessed for concordance with ASTRO guidelines.

Results: The survey response rate was 64%. Among respondents, 96% were board certified, 90% held academic appointments, 85% were full-time employees, 11% were part-time employees, and 3% were employed on contract. When asked about use of palliative radiotherapy for lung cancer, 88% were familiar with ASTRO guidelines, 13% had used Stereotactic Body Radiotherapy (SBRT) for palliation, and 26% referred to outside centers for EBB.

Clinical Scenarios: Case 1 – Metastatic (M1b) disease with local chest wall pain and 3 month life expectancy: All respondents recommended palliative radiotherapy, and most (98%) did not recommend concurrent chemotherapy. The fractionation schemes most often used were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%).

Case 2 – Metastatic (M1a) disease with endobronchial tumor blockage: 87% of the respondents would use conventional radiotherapy for symptoms such as hemoptysis, intractable cough, and pain, and the remainder would use SBRT. Almost half of respondents (49%) recommended EBB or YAG lung re-expansion before external beam radiotherapy.

Conclusion: In our study of VHA ROs and their knowledge of management of advanced (M1a/M1b) lung cancer, we found no distinction in clinical decisions based on demographic profiles. Almost all reported knowledge of evidence-based treatment guidelines for palliative radiotherapy of lung cancer and most recommended treatment according to current guidelines.”

Background: Palliative radiotherapy plays an important role in metastatic lung cancer (LC) treatment. Of VHA LC patients, 46% present with metastatic disease. The American Society for Radiation Oncology (ASTRO) has developed evidenced-based guidelines regarding management of metastatic LC.

Methods: In May 2016, an electronic survey of 84 VHA Radiation Oncologists (ROs) was conducted to assess metastatic LC management. Information on years in practice, employment status, academic appointment, board certification, and familiarity with ASTRO lung cancer guidelines was obtained. Two clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/ against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or YAG laser technology. Survey results were assessed for concordance with ASTRO guidelines.

Results: The survey response rate was 64%. Among respondents, 96% were board certified, 90% held academic appointments, 85% were full-time employees, 11% were part-time employees, and 3% were employed on contract. When asked about use of palliative radiotherapy for lung cancer, 88% were familiar with ASTRO guidelines, 13% had used Stereotactic Body Radiotherapy (SBRT) for palliation, and 26% referred to outside centers for EBB.

Clinical Scenarios: Case 1 – Metastatic (M1b) disease with local chest wall pain and 3 month life expectancy: All respondents recommended palliative radiotherapy, and most (98%) did not recommend concurrent chemotherapy. The fractionation schemes most often used were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%).

Case 2 – Metastatic (M1a) disease with endobronchial tumor blockage: 87% of the respondents would use conventional radiotherapy for symptoms such as hemoptysis, intractable cough, and pain, and the remainder would use SBRT. Almost half of respondents (49%) recommended EBB or YAG lung re-expansion before external beam radiotherapy.

Conclusion: In our study of VHA ROs and their knowledge of management of advanced (M1a/M1b) lung cancer, we found no distinction in clinical decisions based on demographic profiles. Almost all reported knowledge of evidence-based treatment guidelines for palliative radiotherapy of lung cancer and most recommended treatment according to current guidelines.”

Background: Palliative radiotherapy plays an important role in metastatic lung cancer (LC) treatment. Of VHA LC patients, 46% present with metastatic disease. The American Society for Radiation Oncology (ASTRO) has developed evidenced-based guidelines regarding management of metastatic LC.

Methods: In May 2016, an electronic survey of 84 VHA Radiation Oncologists (ROs) was conducted to assess metastatic LC management. Information on years in practice, employment status, academic appointment, board certification, and familiarity with ASTRO lung cancer guidelines was obtained. Two clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/ against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or YAG laser technology. Survey results were assessed for concordance with ASTRO guidelines.

Results: The survey response rate was 64%. Among respondents, 96% were board certified, 90% held academic appointments, 85% were full-time employees, 11% were part-time employees, and 3% were employed on contract. When asked about use of palliative radiotherapy for lung cancer, 88% were familiar with ASTRO guidelines, 13% had used Stereotactic Body Radiotherapy (SBRT) for palliation, and 26% referred to outside centers for EBB.

Clinical Scenarios: Case 1 – Metastatic (M1b) disease with local chest wall pain and 3 month life expectancy: All respondents recommended palliative radiotherapy, and most (98%) did not recommend concurrent chemotherapy. The fractionation schemes most often used were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%).

Case 2 – Metastatic (M1a) disease with endobronchial tumor blockage: 87% of the respondents would use conventional radiotherapy for symptoms such as hemoptysis, intractable cough, and pain, and the remainder would use SBRT. Almost half of respondents (49%) recommended EBB or YAG lung re-expansion before external beam radiotherapy.

Conclusion: In our study of VHA ROs and their knowledge of management of advanced (M1a/M1b) lung cancer, we found no distinction in clinical decisions based on demographic profiles. Almost all reported knowledge of evidence-based treatment guidelines for palliative radiotherapy of lung cancer and most recommended treatment according to current guidelines.”

Background: The Comprehensive Cancer Program held a community Colorectal Cancer Awareness Fair on March 5, 2019 at the VAMC. The goal was to increase awareness of Colorectal Cancer and to engage veterans in educational opportunities about Colorectal Cancer.

Methods: The VAMC purchased an in atable “Megacolon” for veterans to walk through guided by nurses from the GI department. Cubicles were set-up for nursing education sessions, a provider station, a scheduling station, and a colonoscope table. A video loop “Before and After Colonoscopy” by Mechanisms in Medicine, Inc. (Thornhill, Ontario, Canada) played continuously in the waiting area by the provider and nurse’s cubicles. Providers in the GI department offered 2 educational presentations: “How to Stop Colon Cancer Before It Starts” by Carol Macaron, MD; and “Colonoscopy: The Good, Bad, and Ugly” by Edith Ho, MD. Additional education information was provided at staffed tables from VA General Surgery, GI, MOVE! Nutrition & Food Services, and Smoking Cessation. Also, in attendance were Crohn’s and Colitis Foundation, and the American Cancer Society. External Affairs advertised the fair on Facebook and Twitter. Medical Media created publicity posters and event flyers.

Results: The event was attended by 244 people—68 veterans, 170 employees, and 6 guests. Six colonoscopies were scheduled onsite. At least 7 veterans had questions regarding their colonoscopy surveillance in which reminder dates were given.

Background: The Comprehensive Cancer Program held a community Colorectal Cancer Awareness Fair on March 5, 2019 at the VAMC. The goal was to increase awareness of Colorectal Cancer and to engage veterans in educational opportunities about Colorectal Cancer.

Methods: The VAMC purchased an in atable “Megacolon” for veterans to walk through guided by nurses from the GI department. Cubicles were set-up for nursing education sessions, a provider station, a scheduling station, and a colonoscope table. A video loop “Before and After Colonoscopy” by Mechanisms in Medicine, Inc. (Thornhill, Ontario, Canada) played continuously in the waiting area by the provider and nurse’s cubicles. Providers in the GI department offered 2 educational presentations: “How to Stop Colon Cancer Before It Starts” by Carol Macaron, MD; and “Colonoscopy: The Good, Bad, and Ugly” by Edith Ho, MD. Additional education information was provided at staffed tables from VA General Surgery, GI, MOVE! Nutrition & Food Services, and Smoking Cessation. Also, in attendance were Crohn’s and Colitis Foundation, and the American Cancer Society. External Affairs advertised the fair on Facebook and Twitter. Medical Media created publicity posters and event flyers.

Results: The event was attended by 244 people—68 veterans, 170 employees, and 6 guests. Six colonoscopies were scheduled onsite. At least 7 veterans had questions regarding their colonoscopy surveillance in which reminder dates were given.

Background: The Comprehensive Cancer Program held a community Colorectal Cancer Awareness Fair on March 5, 2019 at the VAMC. The goal was to increase awareness of Colorectal Cancer and to engage veterans in educational opportunities about Colorectal Cancer.

Methods: The VAMC purchased an in atable “Megacolon” for veterans to walk through guided by nurses from the GI department. Cubicles were set-up for nursing education sessions, a provider station, a scheduling station, and a colonoscope table. A video loop “Before and After Colonoscopy” by Mechanisms in Medicine, Inc. (Thornhill, Ontario, Canada) played continuously in the waiting area by the provider and nurse’s cubicles. Providers in the GI department offered 2 educational presentations: “How to Stop Colon Cancer Before It Starts” by Carol Macaron, MD; and “Colonoscopy: The Good, Bad, and Ugly” by Edith Ho, MD. Additional education information was provided at staffed tables from VA General Surgery, GI, MOVE! Nutrition & Food Services, and Smoking Cessation. Also, in attendance were Crohn’s and Colitis Foundation, and the American Cancer Society. External Affairs advertised the fair on Facebook and Twitter. Medical Media created publicity posters and event flyers.

Results: The event was attended by 244 people—68 veterans, 170 employees, and 6 guests. Six colonoscopies were scheduled onsite. At least 7 veterans had questions regarding their colonoscopy surveillance in which reminder dates were given.

Background: Multidisciplinary tumor boards (MTBs) have been shown to positively impact the assessment and treatment of cancer patients (Pillay et al, 2016) and increase referrals to specialty services present at the meetings (eg genetic testing in breast cancer, Cohen et al, 2016). However, no research to date has explored the impact of involvement of psychosocial providers on MTBs. The following two cases are presented as examples of multidisciplinary cancer care that was facilitated by psychology/social work involvement in the Head and Neck Cancer MTB at VAPAHCS.

Case Report 1: Mr. T is an 86-year-old veteran who was referred to the Oncology and ENT services in May 2017 for a recurrent squamous cell carcinoma in the neck, presumably from prior lip primary. The patient evaluated by Oncology, KC, and ENT who recommended surgical resection. The veteran consented but later cancelled his surgery due to beliefs that God would cure him. The MTB reviewed his case, and the veteran agreed to return for a visit to the Oncology clinic. SD met with the veteran first, and then accompanied him to a meeting with the Oncologist who arranged a same day appointment with an ENT surgeon and an anesthesiologist. SD integrated the veteran’s belief systems (eg, that God would cure his cancer) to help facilitate his decisions. The veteran’s surgery was expedited and completed 3 days later. At present, he has no evidence of recurrent disease.

Case Report 2: Mr. M is a 62-year-old veteran who was referred to the ENT and Oncology Services in October 2017 for squamous cell carcinoma of base of tongue. He was first seen by ENT, discussed in MTB, then seen by KC and BA. Significant psychosocial issues were identified that could complicate his care, including homelessness and PTSD symptoms that directly impacted his ability to stay in VA housing and interact with the medical system. A multidisciplinary treatment plan was created to meet the veteran’s housing/ hygiene needs and provide interventions to assist him in managing PTSD symptoms enough to proceed through treatment. The veteran was able to complete treatment, has no evidence of recurrent disease, and has returned to his goal of hiking the Pacific Crest.

Background: Multidisciplinary tumor boards (MTBs) have been shown to positively impact the assessment and treatment of cancer patients (Pillay et al, 2016) and increase referrals to specialty services present at the meetings (eg genetic testing in breast cancer, Cohen et al, 2016). However, no research to date has explored the impact of involvement of psychosocial providers on MTBs. The following two cases are presented as examples of multidisciplinary cancer care that was facilitated by psychology/social work involvement in the Head and Neck Cancer MTB at VAPAHCS.

Case Report 1: Mr. T is an 86-year-old veteran who was referred to the Oncology and ENT services in May 2017 for a recurrent squamous cell carcinoma in the neck, presumably from prior lip primary. The patient evaluated by Oncology, KC, and ENT who recommended surgical resection. The veteran consented but later cancelled his surgery due to beliefs that God would cure him. The MTB reviewed his case, and the veteran agreed to return for a visit to the Oncology clinic. SD met with the veteran first, and then accompanied him to a meeting with the Oncologist who arranged a same day appointment with an ENT surgeon and an anesthesiologist. SD integrated the veteran’s belief systems (eg, that God would cure his cancer) to help facilitate his decisions. The veteran’s surgery was expedited and completed 3 days later. At present, he has no evidence of recurrent disease.

Case Report 2: Mr. M is a 62-year-old veteran who was referred to the ENT and Oncology Services in October 2017 for squamous cell carcinoma of base of tongue. He was first seen by ENT, discussed in MTB, then seen by KC and BA. Significant psychosocial issues were identified that could complicate his care, including homelessness and PTSD symptoms that directly impacted his ability to stay in VA housing and interact with the medical system. A multidisciplinary treatment plan was created to meet the veteran’s housing/ hygiene needs and provide interventions to assist him in managing PTSD symptoms enough to proceed through treatment. The veteran was able to complete treatment, has no evidence of recurrent disease, and has returned to his goal of hiking the Pacific Crest.

Background: Multidisciplinary tumor boards (MTBs) have been shown to positively impact the assessment and treatment of cancer patients (Pillay et al, 2016) and increase referrals to specialty services present at the meetings (eg genetic testing in breast cancer, Cohen et al, 2016). However, no research to date has explored the impact of involvement of psychosocial providers on MTBs. The following two cases are presented as examples of multidisciplinary cancer care that was facilitated by psychology/social work involvement in the Head and Neck Cancer MTB at VAPAHCS.

Case Report 1: Mr. T is an 86-year-old veteran who was referred to the Oncology and ENT services in May 2017 for a recurrent squamous cell carcinoma in the neck, presumably from prior lip primary. The patient evaluated by Oncology, KC, and ENT who recommended surgical resection. The veteran consented but later cancelled his surgery due to beliefs that God would cure him. The MTB reviewed his case, and the veteran agreed to return for a visit to the Oncology clinic. SD met with the veteran first, and then accompanied him to a meeting with the Oncologist who arranged a same day appointment with an ENT surgeon and an anesthesiologist. SD integrated the veteran’s belief systems (eg, that God would cure his cancer) to help facilitate his decisions. The veteran’s surgery was expedited and completed 3 days later. At present, he has no evidence of recurrent disease.

Case Report 2: Mr. M is a 62-year-old veteran who was referred to the ENT and Oncology Services in October 2017 for squamous cell carcinoma of base of tongue. He was first seen by ENT, discussed in MTB, then seen by KC and BA. Significant psychosocial issues were identified that could complicate his care, including homelessness and PTSD symptoms that directly impacted his ability to stay in VA housing and interact with the medical system. A multidisciplinary treatment plan was created to meet the veteran’s housing/ hygiene needs and provide interventions to assist him in managing PTSD symptoms enough to proceed through treatment. The veteran was able to complete treatment, has no evidence of recurrent disease, and has returned to his goal of hiking the Pacific Crest.

Background: Malnutrition in cancer patients has a significant correlation with disability, dysfunction and death, as well as increased patient care costs, neutropenia, reduced quality of life, fall risk, fractures, nosocomial infections, and longer treatment durations 1-3. Registered dietitian (RD) involvement early on may increase recognition of malnutrition for at-risk patients. Guidelines for nutrition staffing in cancer centers is illdefined in the literature, with few existing recommendations.

Methods: In Phase 1, a survey of RDs across VHA was conducted to determine current referral and staffing practices surrounding nutrition care and services in outpatient oncology clinics. The survey was administered to RDs who devote some or all of their time to oncology nutrition in the outpatient setting and participate on 1 of 2 popular VHA listservs: a nutrition support listserv, and an oncology nutrition listserv.

Phase 2 will be a multi-site, retrospective, chart analysis among 20 VA facilities who treat cancer patients in the outpatient setting. Site investigators, divided into proactive vs. reactive nutrition practices based on Phase 1 survey results, will be instructed to obtain a list of patients diagnosed with high nutrition risk cancers during 2016 and 2017.

Primary outcomes measured will include weight loss, percent maximum weight change over speci ed timeframes, diagnosis of malnutrition, and reported breaks in treatment. Secondary outcomes include overall survival and disease-free survival. For all comparisons, P < 0.05 will be considered statistically signifcant.

Discussion: The data from 46 sites completing the national survey show that RD staffing practices vary widely across VA cancer centers. Few centers staff full time or dedicated oncology RDs independent of patient caseload, with the median oncology dedicated RD FTE being 0.5. Consult and referral practices dictating nutrition intervention were found to be reported as 17% proactive, 25% reactive, and 58% a combination of both practices. Phase 2 results seek to compare patient outcomes with RD staffing and nutrition care practices to determine much needed guidelines for effective nutrition delivery in VHA cancer centers across the U.S.

Background: Malnutrition in cancer patients has a significant correlation with disability, dysfunction and death, as well as increased patient care costs, neutropenia, reduced quality of life, fall risk, fractures, nosocomial infections, and longer treatment durations 1-3. Registered dietitian (RD) involvement early on may increase recognition of malnutrition for at-risk patients. Guidelines for nutrition staffing in cancer centers is illdefined in the literature, with few existing recommendations.

Methods: In Phase 1, a survey of RDs across VHA was conducted to determine current referral and staffing practices surrounding nutrition care and services in outpatient oncology clinics. The survey was administered to RDs who devote some or all of their time to oncology nutrition in the outpatient setting and participate on 1 of 2 popular VHA listservs: a nutrition support listserv, and an oncology nutrition listserv.

Phase 2 will be a multi-site, retrospective, chart analysis among 20 VA facilities who treat cancer patients in the outpatient setting. Site investigators, divided into proactive vs. reactive nutrition practices based on Phase 1 survey results, will be instructed to obtain a list of patients diagnosed with high nutrition risk cancers during 2016 and 2017.

Primary outcomes measured will include weight loss, percent maximum weight change over speci ed timeframes, diagnosis of malnutrition, and reported breaks in treatment. Secondary outcomes include overall survival and disease-free survival. For all comparisons, P < 0.05 will be considered statistically signifcant.

Discussion: The data from 46 sites completing the national survey show that RD staffing practices vary widely across VA cancer centers. Few centers staff full time or dedicated oncology RDs independent of patient caseload, with the median oncology dedicated RD FTE being 0.5. Consult and referral practices dictating nutrition intervention were found to be reported as 17% proactive, 25% reactive, and 58% a combination of both practices. Phase 2 results seek to compare patient outcomes with RD staffing and nutrition care practices to determine much needed guidelines for effective nutrition delivery in VHA cancer centers across the U.S.

Background: Malnutrition in cancer patients has a significant correlation with disability, dysfunction and death, as well as increased patient care costs, neutropenia, reduced quality of life, fall risk, fractures, nosocomial infections, and longer treatment durations 1-3. Registered dietitian (RD) involvement early on may increase recognition of malnutrition for at-risk patients. Guidelines for nutrition staffing in cancer centers is illdefined in the literature, with few existing recommendations.

Methods: In Phase 1, a survey of RDs across VHA was conducted to determine current referral and staffing practices surrounding nutrition care and services in outpatient oncology clinics. The survey was administered to RDs who devote some or all of their time to oncology nutrition in the outpatient setting and participate on 1 of 2 popular VHA listservs: a nutrition support listserv, and an oncology nutrition listserv.

Phase 2 will be a multi-site, retrospective, chart analysis among 20 VA facilities who treat cancer patients in the outpatient setting. Site investigators, divided into proactive vs. reactive nutrition practices based on Phase 1 survey results, will be instructed to obtain a list of patients diagnosed with high nutrition risk cancers during 2016 and 2017.

Primary outcomes measured will include weight loss, percent maximum weight change over speci ed timeframes, diagnosis of malnutrition, and reported breaks in treatment. Secondary outcomes include overall survival and disease-free survival. For all comparisons, P < 0.05 will be considered statistically signifcant.

Discussion: The data from 46 sites completing the national survey show that RD staffing practices vary widely across VA cancer centers. Few centers staff full time or dedicated oncology RDs independent of patient caseload, with the median oncology dedicated RD FTE being 0.5. Consult and referral practices dictating nutrition intervention were found to be reported as 17% proactive, 25% reactive, and 58% a combination of both practices. Phase 2 results seek to compare patient outcomes with RD staffing and nutrition care practices to determine much needed guidelines for effective nutrition delivery in VHA cancer centers across the U.S.

Background: A commonly voiced concern of oncologists, regarding the introduction of palliative care, is that patients might be immediately steered to hospice care and away from oncology care.

Objective: To assess the impact of oncology-palliative care collaboration on trends of referrals to palliative and hospice care.

Methods: In January 2015, we implemented an integrated oncology-palliative care clinic model with the following elements:

1. Pre-clinic “huddle” among palliative care and oncology staff to identify palliative care needs for patients;
2. Shared palliative care and oncology clinic appointments;
3. Introduction of palliative care for every new oncology clinic patient, for advance care planning;
4. Concurrent oncology and palliative care follow-up for all high-risk patients (aggressive histology, progressing disease, etc.) for goals of care discussions and symptom management; and
5. Palliative care and oncology staff co-managing oncology patients enrolled in hospice care.

Measurements: We examined the following metrics for FY15, FY16, FY17, and FY18.

1. Total number of palliative care consults;
2. Number of palliative care consults from oncology;
3. Percentage palliative care consults from oncology [(item 2 × 100) / item 1];
4. Total number of referrals to hospice care;
5. Number of referrals to hospice care from oncology; and
6. Percentage hospice care referrals from oncology [(item 5 × 100) / item 4].

Results: During the period of FY15 to FY18, there was a consistent increase in total palliative care consults (355, 394, 549, and 570 respectively). There also was a consistent increase in percentage palliative care consults from oncology (24%, 34%, 38%, and 40% respectively) without an increase in percentage hospice care referrals from oncology.

Conclusion: A common concern is that palliative care in oncology care will result in patients being immediately steered to hospice care and away from continued oncology care. Although it was limited to a single clinical setting, our intervention resulted in increased palliative care consults from oncology without a proportionate increase in hospice care referrals from oncology during the same time-period, suggesting that earlier access to palliative care did not result in immediate transition to hospice care. Palliative care offers opportunities for goals of care conversations and symptom management in oncology care, prior to transition to hospice care. Future implications include robust studies to further test these findings, review of structure and training of oncology-palliative care teams, and systems redesign to develop dyad or shared clinic models.

Background: A commonly voiced concern of oncologists, regarding the introduction of palliative care, is that patients might be immediately steered to hospice care and away from oncology care.

Objective: To assess the impact of oncology-palliative care collaboration on trends of referrals to palliative and hospice care.

Methods: In January 2015, we implemented an integrated oncology-palliative care clinic model with the following elements:

1. Pre-clinic “huddle” among palliative care and oncology staff to identify palliative care needs for patients;
2. Shared palliative care and oncology clinic appointments;
3. Introduction of palliative care for every new oncology clinic patient, for advance care planning;
4. Concurrent oncology and palliative care follow-up for all high-risk patients (aggressive histology, progressing disease, etc.) for goals of care discussions and symptom management; and
5. Palliative care and oncology staff co-managing oncology patients enrolled in hospice care.

Measurements: We examined the following metrics for FY15, FY16, FY17, and FY18.

1. Total number of palliative care consults;
2. Number of palliative care consults from oncology;
3. Percentage palliative care consults from oncology [(item 2 × 100) / item 1];
4. Total number of referrals to hospice care;
5. Number of referrals to hospice care from oncology; and
6. Percentage hospice care referrals from oncology [(item 5 × 100) / item 4].

Results: During the period of FY15 to FY18, there was a consistent increase in total palliative care consults (355, 394, 549, and 570 respectively). There also was a consistent increase in percentage palliative care consults from oncology (24%, 34%, 38%, and 40% respectively) without an increase in percentage hospice care referrals from oncology.

Conclusion: A common concern is that palliative care in oncology care will result in patients being immediately steered to hospice care and away from continued oncology care. Although it was limited to a single clinical setting, our intervention resulted in increased palliative care consults from oncology without a proportionate increase in hospice care referrals from oncology during the same time-period, suggesting that earlier access to palliative care did not result in immediate transition to hospice care. Palliative care offers opportunities for goals of care conversations and symptom management in oncology care, prior to transition to hospice care. Future implications include robust studies to further test these findings, review of structure and training of oncology-palliative care teams, and systems redesign to develop dyad or shared clinic models.

Background: A commonly voiced concern of oncologists, regarding the introduction of palliative care, is that patients might be immediately steered to hospice care and away from oncology care.

Objective: To assess the impact of oncology-palliative care collaboration on trends of referrals to palliative and hospice care.

Methods: In January 2015, we implemented an integrated oncology-palliative care clinic model with the following elements:

1. Pre-clinic “huddle” among palliative care and oncology staff to identify palliative care needs for patients;
2. Shared palliative care and oncology clinic appointments;
3. Introduction of palliative care for every new oncology clinic patient, for advance care planning;
4. Concurrent oncology and palliative care follow-up for all high-risk patients (aggressive histology, progressing disease, etc.) for goals of care discussions and symptom management; and
5. Palliative care and oncology staff co-managing oncology patients enrolled in hospice care.

Measurements: We examined the following metrics for FY15, FY16, FY17, and FY18.

1. Total number of palliative care consults;
2. Number of palliative care consults from oncology;
3. Percentage palliative care consults from oncology [(item 2 × 100) / item 1];
4. Total number of referrals to hospice care;
5. Number of referrals to hospice care from oncology; and
6. Percentage hospice care referrals from oncology [(item 5 × 100) / item 4].

Results: During the period of FY15 to FY18, there was a consistent increase in total palliative care consults (355, 394, 549, and 570 respectively). There also was a consistent increase in percentage palliative care consults from oncology (24%, 34%, 38%, and 40% respectively) without an increase in percentage hospice care referrals from oncology.

Conclusion: A common concern is that palliative care in oncology care will result in patients being immediately steered to hospice care and away from continued oncology care. Although it was limited to a single clinical setting, our intervention resulted in increased palliative care consults from oncology without a proportionate increase in hospice care referrals from oncology during the same time-period, suggesting that earlier access to palliative care did not result in immediate transition to hospice care. Palliative care offers opportunities for goals of care conversations and symptom management in oncology care, prior to transition to hospice care. Future implications include robust studies to further test these findings, review of structure and training of oncology-palliative care teams, and systems redesign to develop dyad or shared clinic models.

Background: Malignant melanoma is an aggressive malignancy that can present as a poorly differentiated neoplasm. Loss of S100 and melanA antigenicity can make pathologic identification difficult, especially in those patients who lack a cutaneous primary lesion. Immunostaining with SOX10, a key nuclear transcription factor in the differentiation of neural crest progenitor cells to melanocytes, has a high reported sensitivity and specificity for pathologic identification of melanoma in difficult cases.

Case Report: A 69-year-old male with a history of heavy tobacco use presented to the otolaryngology clinic with a left parotid mass. He underwent a parotid gland biopsy, which was significant for a high grade, poorly differentiated malignancy of unclear primary source. A staging PET/CT demonstrated localized hypermetabolic activity in the draining left cervical lymph node basins. He underwent a left modified radical neck dissection and parotidectomy. Pathologic assessment demonstrated a 3.9 × 1.6 × 1.6 cm3 poorly differentiated carcinoma with perineural invasion and 8/85 lymph nodes involved. Morphologically, it had features of a high grade epithelioid tumor with spindle cell features. Immunohistochemical (IHC) stains were negative for epithelial markers (AE1/3, EMA, CK5/6, CAM5.2), smooth muscle actin, CD34, S100, and melanA. Given the concern for a spindle cell melanoma that lost its antigenicity for S100 and melanA, a SOX10 IHC stain was performed.

The SOX10 immunostain demonstrated strong, diffuse positivity which secured the diagnosis of malignant melanoma. Molecular testing for BRAF and KIT mutations was negative. The  nal diagnosis was a stage IVA (pT2pN2bM0) malignant melanoma of the parotid gland without a cutaneous primary lesion. The patient received a course of adjuvant radiation to a total dose of 66Gy and will complete one year of adjuvant immunotherapy with Nivolumab.

Conclusion: Malignant melanoma can present as a poorly differentiated malignancy and may be difficult to diagnose by providers, especially in the absence of a typical clinical history and a primary cutaneous lesion. In cases where the standard melanoma immunostains are negative, IHC staining with SOX10 can help secure the diagnosis with high sensitivity and specificity.

Background: Malignant melanoma is an aggressive malignancy that can present as a poorly differentiated neoplasm. Loss of S100 and melanA antigenicity can make pathologic identification difficult, especially in those patients who lack a cutaneous primary lesion. Immunostaining with SOX10, a key nuclear transcription factor in the differentiation of neural crest progenitor cells to melanocytes, has a high reported sensitivity and specificity for pathologic identification of melanoma in difficult cases.

Case Report: A 69-year-old male with a history of heavy tobacco use presented to the otolaryngology clinic with a left parotid mass. He underwent a parotid gland biopsy, which was significant for a high grade, poorly differentiated malignancy of unclear primary source. A staging PET/CT demonstrated localized hypermetabolic activity in the draining left cervical lymph node basins. He underwent a left modified radical neck dissection and parotidectomy. Pathologic assessment demonstrated a 3.9 × 1.6 × 1.6 cm3 poorly differentiated carcinoma with perineural invasion and 8/85 lymph nodes involved. Morphologically, it had features of a high grade epithelioid tumor with spindle cell features. Immunohistochemical (IHC) stains were negative for epithelial markers (AE1/3, EMA, CK5/6, CAM5.2), smooth muscle actin, CD34, S100, and melanA. Given the concern for a spindle cell melanoma that lost its antigenicity for S100 and melanA, a SOX10 IHC stain was performed.

The SOX10 immunostain demonstrated strong, diffuse positivity which secured the diagnosis of malignant melanoma. Molecular testing for BRAF and KIT mutations was negative. The  nal diagnosis was a stage IVA (pT2pN2bM0) malignant melanoma of the parotid gland without a cutaneous primary lesion. The patient received a course of adjuvant radiation to a total dose of 66Gy and will complete one year of adjuvant immunotherapy with Nivolumab.

Conclusion: Malignant melanoma can present as a poorly differentiated malignancy and may be difficult to diagnose by providers, especially in the absence of a typical clinical history and a primary cutaneous lesion. In cases where the standard melanoma immunostains are negative, IHC staining with SOX10 can help secure the diagnosis with high sensitivity and specificity.

Background: Malignant melanoma is an aggressive malignancy that can present as a poorly differentiated neoplasm. Loss of S100 and melanA antigenicity can make pathologic identification difficult, especially in those patients who lack a cutaneous primary lesion. Immunostaining with SOX10, a key nuclear transcription factor in the differentiation of neural crest progenitor cells to melanocytes, has a high reported sensitivity and specificity for pathologic identification of melanoma in difficult cases.

Case Report: A 69-year-old male with a history of heavy tobacco use presented to the otolaryngology clinic with a left parotid mass. He underwent a parotid gland biopsy, which was significant for a high grade, poorly differentiated malignancy of unclear primary source. A staging PET/CT demonstrated localized hypermetabolic activity in the draining left cervical lymph node basins. He underwent a left modified radical neck dissection and parotidectomy. Pathologic assessment demonstrated a 3.9 × 1.6 × 1.6 cm3 poorly differentiated carcinoma with perineural invasion and 8/85 lymph nodes involved. Morphologically, it had features of a high grade epithelioid tumor with spindle cell features. Immunohistochemical (IHC) stains were negative for epithelial markers (AE1/3, EMA, CK5/6, CAM5.2), smooth muscle actin, CD34, S100, and melanA. Given the concern for a spindle cell melanoma that lost its antigenicity for S100 and melanA, a SOX10 IHC stain was performed.

The SOX10 immunostain demonstrated strong, diffuse positivity which secured the diagnosis of malignant melanoma. Molecular testing for BRAF and KIT mutations was negative. The  nal diagnosis was a stage IVA (pT2pN2bM0) malignant melanoma of the parotid gland without a cutaneous primary lesion. The patient received a course of adjuvant radiation to a total dose of 66Gy and will complete one year of adjuvant immunotherapy with Nivolumab.

Conclusion: Malignant melanoma can present as a poorly differentiated malignancy and may be difficult to diagnose by providers, especially in the absence of a typical clinical history and a primary cutaneous lesion. In cases where the standard melanoma immunostains are negative, IHC staining with SOX10 can help secure the diagnosis with high sensitivity and specificity.

Justification: A diagnosis of malignancy is of great relevance to the patient and sets in motion numerous activities. How long is it reasonable to wait for a pathologic diagnosis on a biopsy obtained for suspected cancer?

Methods: To address this question, we analyzed our turn-around-time (TAT) for biopsies and cytologies obtained for initial diagnosis of malignancy and compared it to relevant literature. Another goal was to evaluate the influence of special stains on TAT. We obtained from VISTA TAT on surgical pathology and cytopathology specimens in which an initial diagnosis of malignancy was made (excluding non-melanoma skin cancer, GYN, and urine cytologies) between January 2016 and August 2018. We analyzed the impact of histochemical and immunohistochemical stains performed on TAT.

Results and Discussion: During this period, 2014 new malignancies were diagnosed among 31,407 biopsies (6.41%). Average TAT for all biopsies was 1.48 days; average TAT for biopsies with initial diagnosis of malignancy was 2.2 days. 149 new diagnoses of malignancy were made by cytology, with an average TAT of 1.49 days, compared with 1.63 days TAT for all cytologies. Performance of special stains had no statistical impact on TAT when compared with cases with no special stains.

Remarkably, no guidelines have been promulgated by institutions or accrediting bodies for TAT on specimens obtained for initial diagnosis of malignancy. Likewise, such data is not available in the literature; it is unclear how many institutions monitor this. The College of American Pathologists indicates that 90% of routine biopsies should be  nalized within 2 working days; the Association of Directors of Anatomic and Surgical Pathology indicates that at least 80% of routine biopsies should be  nalized in 3 days. However, guidelines for specimens obtained for initial diagnosis of malignancy, which frequently require special handling/ancillary testing (deeper sections, histo/immunohistochemistry, molecular studies, consultation) are not available.

Recommendations: Institutions should develop practices that prioritize study of specimens obtained to rule out malignancy and should monitor their TAT. All institutions and accrediting bodies (CAP, Commission on Cancer, etc.) should develop guidelines for TAT for initial diagnosis of malignancy and audit this information.

Justification: A diagnosis of malignancy is of great relevance to the patient and sets in motion numerous activities. How long is it reasonable to wait for a pathologic diagnosis on a biopsy obtained for suspected cancer?

Methods: To address this question, we analyzed our turn-around-time (TAT) for biopsies and cytologies obtained for initial diagnosis of malignancy and compared it to relevant literature. Another goal was to evaluate the influence of special stains on TAT. We obtained from VISTA TAT on surgical pathology and cytopathology specimens in which an initial diagnosis of malignancy was made (excluding non-melanoma skin cancer, GYN, and urine cytologies) between January 2016 and August 2018. We analyzed the impact of histochemical and immunohistochemical stains performed on TAT.

Results and Discussion: During this period, 2014 new malignancies were diagnosed among 31,407 biopsies (6.41%). Average TAT for all biopsies was 1.48 days; average TAT for biopsies with initial diagnosis of malignancy was 2.2 days. 149 new diagnoses of malignancy were made by cytology, with an average TAT of 1.49 days, compared with 1.63 days TAT for all cytologies. Performance of special stains had no statistical impact on TAT when compared with cases with no special stains.

Remarkably, no guidelines have been promulgated by institutions or accrediting bodies for TAT on specimens obtained for initial diagnosis of malignancy. Likewise, such data is not available in the literature; it is unclear how many institutions monitor this. The College of American Pathologists indicates that 90% of routine biopsies should be  nalized within 2 working days; the Association of Directors of Anatomic and Surgical Pathology indicates that at least 80% of routine biopsies should be  nalized in 3 days. However, guidelines for specimens obtained for initial diagnosis of malignancy, which frequently require special handling/ancillary testing (deeper sections, histo/immunohistochemistry, molecular studies, consultation) are not available.

Recommendations: Institutions should develop practices that prioritize study of specimens obtained to rule out malignancy and should monitor their TAT. All institutions and accrediting bodies (CAP, Commission on Cancer, etc.) should develop guidelines for TAT for initial diagnosis of malignancy and audit this information.

Justification: A diagnosis of malignancy is of great relevance to the patient and sets in motion numerous activities. How long is it reasonable to wait for a pathologic diagnosis on a biopsy obtained for suspected cancer?

Methods: To address this question, we analyzed our turn-around-time (TAT) for biopsies and cytologies obtained for initial diagnosis of malignancy and compared it to relevant literature. Another goal was to evaluate the influence of special stains on TAT. We obtained from VISTA TAT on surgical pathology and cytopathology specimens in which an initial diagnosis of malignancy was made (excluding non-melanoma skin cancer, GYN, and urine cytologies) between January 2016 and August 2018. We analyzed the impact of histochemical and immunohistochemical stains performed on TAT.

Results and Discussion: During this period, 2014 new malignancies were diagnosed among 31,407 biopsies (6.41%). Average TAT for all biopsies was 1.48 days; average TAT for biopsies with initial diagnosis of malignancy was 2.2 days. 149 new diagnoses of malignancy were made by cytology, with an average TAT of 1.49 days, compared with 1.63 days TAT for all cytologies. Performance of special stains had no statistical impact on TAT when compared with cases with no special stains.

Remarkably, no guidelines have been promulgated by institutions or accrediting bodies for TAT on specimens obtained for initial diagnosis of malignancy. Likewise, such data is not available in the literature; it is unclear how many institutions monitor this. The College of American Pathologists indicates that 90% of routine biopsies should be  nalized within 2 working days; the Association of Directors of Anatomic and Surgical Pathology indicates that at least 80% of routine biopsies should be  nalized in 3 days. However, guidelines for specimens obtained for initial diagnosis of malignancy, which frequently require special handling/ancillary testing (deeper sections, histo/immunohistochemistry, molecular studies, consultation) are not available.

Recommendations: Institutions should develop practices that prioritize study of specimens obtained to rule out malignancy and should monitor their TAT. All institutions and accrediting bodies (CAP, Commission on Cancer, etc.) should develop guidelines for TAT for initial diagnosis of malignancy and audit this information.

Purpose: Nivolumab is a fully human IgG4 programmed death 1 immune checkpoint inhibitor (ICI) antibody that has anti-tumor activity by selectively blocking the interaction of the programmed death 1 receptor with its two known programmed death ligands PD-L1 and PD-L2. In doing so, this immune checkpoint inhibitor removes the negative signal stifling T cell activation and proliferation within the tumor microenvironment and demonstrates favorable antitumor activity.

Case Report: We report an interesting case of immune checkpoint inhibitor-induced primary hypothyroidism with associated hypothyroid myopathy in a young patient with surgically resected stage IIIB melanoma receiving adjuvant nivolumab. He presented 12 weeks into therapy with severe myalgias, arthralgias, and intermittent disequilibrium of unclear etiology. Laboratory evaluation demonstrated a significant elevation in thyroid stimulating hormone and creatine kinase with an undetectable free T4 with standard laboratory measurement. With thyroid hormone replacement therapy alone, he had rapid improvement in his musculoskeletal symptoms and laboratory parameters over a threeweek period.

Discussion: This case emphasizes the serious nature of endocrine immune-related adverse events in patients receiving immune checkpoint inhibitors. Additionally, it highlights that unlike most other immunerelated adverse events, endocrine immune-related adverse events can generally be managed with adequate hormone replacement alone with swift improvements in symptoms. This allows patients to continue immune checkpoint inhibitors safely without immunosuppression which may dampen the anti-tumor activity of these agents.

Conclusion: This case highlights the importance of early recognition and the appropriate management of endocrine immune-related adverse events to maximize patient safety and good outcomes.

Purpose: Nivolumab is a fully human IgG4 programmed death 1 immune checkpoint inhibitor (ICI) antibody that has anti-tumor activity by selectively blocking the interaction of the programmed death 1 receptor with its two known programmed death ligands PD-L1 and PD-L2. In doing so, this immune checkpoint inhibitor removes the negative signal stifling T cell activation and proliferation within the tumor microenvironment and demonstrates favorable antitumor activity.

Case Report: We report an interesting case of immune checkpoint inhibitor-induced primary hypothyroidism with associated hypothyroid myopathy in a young patient with surgically resected stage IIIB melanoma receiving adjuvant nivolumab. He presented 12 weeks into therapy with severe myalgias, arthralgias, and intermittent disequilibrium of unclear etiology. Laboratory evaluation demonstrated a significant elevation in thyroid stimulating hormone and creatine kinase with an undetectable free T4 with standard laboratory measurement. With thyroid hormone replacement therapy alone, he had rapid improvement in his musculoskeletal symptoms and laboratory parameters over a threeweek period.

Discussion: This case emphasizes the serious nature of endocrine immune-related adverse events in patients receiving immune checkpoint inhibitors. Additionally, it highlights that unlike most other immunerelated adverse events, endocrine immune-related adverse events can generally be managed with adequate hormone replacement alone with swift improvements in symptoms. This allows patients to continue immune checkpoint inhibitors safely without immunosuppression which may dampen the anti-tumor activity of these agents.

Conclusion: This case highlights the importance of early recognition and the appropriate management of endocrine immune-related adverse events to maximize patient safety and good outcomes.

Purpose: Nivolumab is a fully human IgG4 programmed death 1 immune checkpoint inhibitor (ICI) antibody that has anti-tumor activity by selectively blocking the interaction of the programmed death 1 receptor with its two known programmed death ligands PD-L1 and PD-L2. In doing so, this immune checkpoint inhibitor removes the negative signal stifling T cell activation and proliferation within the tumor microenvironment and demonstrates favorable antitumor activity.

Case Report: We report an interesting case of immune checkpoint inhibitor-induced primary hypothyroidism with associated hypothyroid myopathy in a young patient with surgically resected stage IIIB melanoma receiving adjuvant nivolumab. He presented 12 weeks into therapy with severe myalgias, arthralgias, and intermittent disequilibrium of unclear etiology. Laboratory evaluation demonstrated a significant elevation in thyroid stimulating hormone and creatine kinase with an undetectable free T4 with standard laboratory measurement. With thyroid hormone replacement therapy alone, he had rapid improvement in his musculoskeletal symptoms and laboratory parameters over a threeweek period.

Discussion: This case emphasizes the serious nature of endocrine immune-related adverse events in patients receiving immune checkpoint inhibitors. Additionally, it highlights that unlike most other immunerelated adverse events, endocrine immune-related adverse events can generally be managed with adequate hormone replacement alone with swift improvements in symptoms. This allows patients to continue immune checkpoint inhibitors safely without immunosuppression which may dampen the anti-tumor activity of these agents.

Conclusion: This case highlights the importance of early recognition and the appropriate management of endocrine immune-related adverse events to maximize patient safety and good outcomes.