AVAHO

Purpose/Background

Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.

Methods

A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.

Results

Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.

Implications/Significance

This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.

Purpose/Background

Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.

Methods

A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.

Results

Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.

Implications/Significance

This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.

Purpose/Background

Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.

Methods

A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.

Results

Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.

Implications/Significance

This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.

Background

In December of 2023, a workgroup at VA Connecticut Healthcare System (“VACHS”) initiated a quality improvement project to use the weekly GI Tumor Board meeting to identify patients who would benefit from PHASER testing. The PHASER panel includes two genes that are involved in the metabolism of two commonly used chemotherapy drugs in this patient population. Our goal was to identify patients with potentially impaired metabolism of 5FU and/or irinotecan prior to initiating treatment so that the doses of the appropriate drugs could be adjusted, leading to less toxicity for patients while on treatment and fewer lingering side-effects from treatment.

Results

Here we report outcomes based on 12 months of data. We reviewed the charts of all patients who received 5-FU or irinotecan during the period 1/1/24-12/31/24 based on pharmacy records. We separately identified all VACHS patients with newly diagnosed GI cancers in 2024 using data generated by the Tumor Registrar. 39 patients met criteria for PHASER testing. Of those, 37/39 (95%) patients got the testing. The 2 additional patients who were identified during our data analysis will be offered PHASER testing. Of the 37 patients who were tested, 7 patients (19%) had a genetic variant that could potentially impact chemotherapy dosing. 3 of these 7 patients were treated with chemotherapy and did require dose-adjustment. Of note, 100% of patients diagnosed with a new GI malignancy at VA Connecticut in 2024 whose treatment plan included possible chemotherapy with 5FU or Irinotecan got PHASER testing. In one year, this best practice is now our standard procedure.

Conclusions

Despite access to pharmacogenomic testing at VA, there can be variations between VA sites in terms of uptake of this new testing. VA Connecticut’s PHASER testing initiative for patients with GI malignancies is a model that can be replicated throughout VA. This initiative is part of a broader focus at VACHS on “pre-habilitation” and pre-treatment testing that is designed to reduce toxicity of treatment and improve quality of life for cancer survivors.

Background

In December of 2023, a workgroup at VA Connecticut Healthcare System (“VACHS”) initiated a quality improvement project to use the weekly GI Tumor Board meeting to identify patients who would benefit from PHASER testing. The PHASER panel includes two genes that are involved in the metabolism of two commonly used chemotherapy drugs in this patient population. Our goal was to identify patients with potentially impaired metabolism of 5FU and/or irinotecan prior to initiating treatment so that the doses of the appropriate drugs could be adjusted, leading to less toxicity for patients while on treatment and fewer lingering side-effects from treatment.

Results

Here we report outcomes based on 12 months of data. We reviewed the charts of all patients who received 5-FU or irinotecan during the period 1/1/24-12/31/24 based on pharmacy records. We separately identified all VACHS patients with newly diagnosed GI cancers in 2024 using data generated by the Tumor Registrar. 39 patients met criteria for PHASER testing. Of those, 37/39 (95%) patients got the testing. The 2 additional patients who were identified during our data analysis will be offered PHASER testing. Of the 37 patients who were tested, 7 patients (19%) had a genetic variant that could potentially impact chemotherapy dosing. 3 of these 7 patients were treated with chemotherapy and did require dose-adjustment. Of note, 100% of patients diagnosed with a new GI malignancy at VA Connecticut in 2024 whose treatment plan included possible chemotherapy with 5FU or Irinotecan got PHASER testing. In one year, this best practice is now our standard procedure.

Conclusions

Despite access to pharmacogenomic testing at VA, there can be variations between VA sites in terms of uptake of this new testing. VA Connecticut’s PHASER testing initiative for patients with GI malignancies is a model that can be replicated throughout VA. This initiative is part of a broader focus at VACHS on “pre-habilitation” and pre-treatment testing that is designed to reduce toxicity of treatment and improve quality of life for cancer survivors.

Background

In December of 2023, a workgroup at VA Connecticut Healthcare System (“VACHS”) initiated a quality improvement project to use the weekly GI Tumor Board meeting to identify patients who would benefit from PHASER testing. The PHASER panel includes two genes that are involved in the metabolism of two commonly used chemotherapy drugs in this patient population. Our goal was to identify patients with potentially impaired metabolism of 5FU and/or irinotecan prior to initiating treatment so that the doses of the appropriate drugs could be adjusted, leading to less toxicity for patients while on treatment and fewer lingering side-effects from treatment.

Results

Here we report outcomes based on 12 months of data. We reviewed the charts of all patients who received 5-FU or irinotecan during the period 1/1/24-12/31/24 based on pharmacy records. We separately identified all VACHS patients with newly diagnosed GI cancers in 2024 using data generated by the Tumor Registrar. 39 patients met criteria for PHASER testing. Of those, 37/39 (95%) patients got the testing. The 2 additional patients who were identified during our data analysis will be offered PHASER testing. Of the 37 patients who were tested, 7 patients (19%) had a genetic variant that could potentially impact chemotherapy dosing. 3 of these 7 patients were treated with chemotherapy and did require dose-adjustment. Of note, 100% of patients diagnosed with a new GI malignancy at VA Connecticut in 2024 whose treatment plan included possible chemotherapy with 5FU or Irinotecan got PHASER testing. In one year, this best practice is now our standard procedure.

Conclusions

Despite access to pharmacogenomic testing at VA, there can be variations between VA sites in terms of uptake of this new testing. VA Connecticut’s PHASER testing initiative for patients with GI malignancies is a model that can be replicated throughout VA. This initiative is part of a broader focus at VACHS on “pre-habilitation” and pre-treatment testing that is designed to reduce toxicity of treatment and improve quality of life for cancer survivors.

Background

Early palliative care (PC) has been shown to improve cancer patients’ quality of life, symptom control, disease knowledge, psychological and spiritual health, end-of-life care, and survival, as well as reduce hospital admissions and emergency visits. The American Society of Clinical Oncology and the World Health Organization recommend that every patient with advanced cancer should be treated by a multidisciplinary palliative care team early in the course of the disease and in conjunction with anticancer treatment. Despite the documented benefits and the recommendations, early PC is still not often offered in clinical practice.

Results

Through a retrospective data review from July, August, and September 2023, a low percentage of early PC referrals were identified among Veterans with pancreatic, head and neck, and stage IV lung cancer in the Infusion Clinic. Only 48.5% had an early PC referral, which is a referral made within 8 weeks from the time of diagnosis and 3 or more months before death. A survey conducted among oncology providers suggests that the lack of provider knowledge about the scope of PC, the lack of set criteria/protocol to initiate a referral, and provider discomfort in referring patients were thought to hinder early referrals or cause late or/lack of referrals.

Discussion

This quality improvement project aimed to increase the early PC referral rate among advanced cancer patients in the infusion clinic to improve patient outcomes. An early PC referral toolkit was implemented consisting of (a) provider education about the scope of PC, (b) a script to help providers introduce PC as part of the comprehensive care team, (c) a PC brochure for reference, and (d) an Evidence-Based Five-item Screening Checklist to identify patients needing PC.

Conclusions

Nine months of data monitoring and analysis post-implementation revealed a 100% (n=12) early PC referral rate, and 80% (n=12) of providers reported feeling comfortable referring their patients. The project fostered a culture of comprehensive cancer care while empowering providers to make early referrals that improve patients’ multidimensional outcomes. The toolkit remains available to oncology providers and is shared upon request with other VA centers, as it is replicable in most VA settings that offer PC.

Background

Early palliative care (PC) has been shown to improve cancer patients’ quality of life, symptom control, disease knowledge, psychological and spiritual health, end-of-life care, and survival, as well as reduce hospital admissions and emergency visits. The American Society of Clinical Oncology and the World Health Organization recommend that every patient with advanced cancer should be treated by a multidisciplinary palliative care team early in the course of the disease and in conjunction with anticancer treatment. Despite the documented benefits and the recommendations, early PC is still not often offered in clinical practice.

Results

Through a retrospective data review from July, August, and September 2023, a low percentage of early PC referrals were identified among Veterans with pancreatic, head and neck, and stage IV lung cancer in the Infusion Clinic. Only 48.5% had an early PC referral, which is a referral made within 8 weeks from the time of diagnosis and 3 or more months before death. A survey conducted among oncology providers suggests that the lack of provider knowledge about the scope of PC, the lack of set criteria/protocol to initiate a referral, and provider discomfort in referring patients were thought to hinder early referrals or cause late or/lack of referrals.

Discussion

This quality improvement project aimed to increase the early PC referral rate among advanced cancer patients in the infusion clinic to improve patient outcomes. An early PC referral toolkit was implemented consisting of (a) provider education about the scope of PC, (b) a script to help providers introduce PC as part of the comprehensive care team, (c) a PC brochure for reference, and (d) an Evidence-Based Five-item Screening Checklist to identify patients needing PC.

Conclusions

Nine months of data monitoring and analysis post-implementation revealed a 100% (n=12) early PC referral rate, and 80% (n=12) of providers reported feeling comfortable referring their patients. The project fostered a culture of comprehensive cancer care while empowering providers to make early referrals that improve patients’ multidimensional outcomes. The toolkit remains available to oncology providers and is shared upon request with other VA centers, as it is replicable in most VA settings that offer PC.

Background

Early palliative care (PC) has been shown to improve cancer patients’ quality of life, symptom control, disease knowledge, psychological and spiritual health, end-of-life care, and survival, as well as reduce hospital admissions and emergency visits. The American Society of Clinical Oncology and the World Health Organization recommend that every patient with advanced cancer should be treated by a multidisciplinary palliative care team early in the course of the disease and in conjunction with anticancer treatment. Despite the documented benefits and the recommendations, early PC is still not often offered in clinical practice.

Results

Through a retrospective data review from July, August, and September 2023, a low percentage of early PC referrals were identified among Veterans with pancreatic, head and neck, and stage IV lung cancer in the Infusion Clinic. Only 48.5% had an early PC referral, which is a referral made within 8 weeks from the time of diagnosis and 3 or more months before death. A survey conducted among oncology providers suggests that the lack of provider knowledge about the scope of PC, the lack of set criteria/protocol to initiate a referral, and provider discomfort in referring patients were thought to hinder early referrals or cause late or/lack of referrals.

Discussion

This quality improvement project aimed to increase the early PC referral rate among advanced cancer patients in the infusion clinic to improve patient outcomes. An early PC referral toolkit was implemented consisting of (a) provider education about the scope of PC, (b) a script to help providers introduce PC as part of the comprehensive care team, (c) a PC brochure for reference, and (d) an Evidence-Based Five-item Screening Checklist to identify patients needing PC.

Conclusions

Nine months of data monitoring and analysis post-implementation revealed a 100% (n=12) early PC referral rate, and 80% (n=12) of providers reported feeling comfortable referring their patients. The project fostered a culture of comprehensive cancer care while empowering providers to make early referrals that improve patients’ multidimensional outcomes. The toolkit remains available to oncology providers and is shared upon request with other VA centers, as it is replicable in most VA settings that offer PC.

Background

Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).

Methods

Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.

Results

A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.

Conclusions

Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.

Background

Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).

Methods

Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.

Results

A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.

Conclusions

Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.

Background

Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).

Methods

Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.

Results

A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.

Conclusions

Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.

Purpose/Background

The purpose of this project was to understand how implementing a consult template could optimize hematology E-consult evaluation. At the Tampa VA, providers can submit hematology E-consults for interpretation of lab abnormalities and management recommendations that do not require an in-person hematology evaluation. Previously, submission of an E-consult did not require prerequisite labs or imaging or for lab parameters to be met, leading to an increased number of hematology E-consults and subsequently, lower efficiency for hematologists.

Methods

A hematology E-consult template was created through collaboration between the hematology/ oncology and ambulatory care sections, which lists specific diagnoses and required parameters/workup needed for each diagnosis prior to submission of the E-consult. If those criteria were not met, the consult was cancelled. A representative sample of one month pre- and post-implementation data was analyzed.

Results

The E-consult template was implemented in September 2024. From April to August 2024, the average number of E-consults per month was 243, averaging at 11.0 per day, while from October 2024 to February 2025, the average number of E-consults per month was 146.4, averaging at 6.6 per day. In August 2024, the leading reasons for consult were anemia (77), leukocytosis (26), and thrombocytopenia (24). That month, there were 15 consult cancellations, with the primary reason being the patient was established in clinic (9). In October 2024, the leading reasons for consult were anemia (39), leukocytosis (14), and thrombocytopenia (13). That month, there were 34 consult cancellations, with the primary reason being that hematology advised a clinic consultation rather than an E-consult (10).

Implications/Significance

These data reveal that the hematology E-consult template was associated with a decreased number of E-consults per day and per month. Implementation of the hematology E-consult template allows the hematology consultants to focus on interpretation of lab results and providing management recommendations, as opposed to providing standard of care diagnostic recommendations. It also serves as an educational tool to referring providers, to understand appropriate indications for hematology E-consultation. Lastly, the template has created increased efficiency in providing hematology recommendations and ultimately, improved timely care for our veterans.

Purpose/Background

The purpose of this project was to understand how implementing a consult template could optimize hematology E-consult evaluation. At the Tampa VA, providers can submit hematology E-consults for interpretation of lab abnormalities and management recommendations that do not require an in-person hematology evaluation. Previously, submission of an E-consult did not require prerequisite labs or imaging or for lab parameters to be met, leading to an increased number of hematology E-consults and subsequently, lower efficiency for hematologists.

Methods

A hematology E-consult template was created through collaboration between the hematology/ oncology and ambulatory care sections, which lists specific diagnoses and required parameters/workup needed for each diagnosis prior to submission of the E-consult. If those criteria were not met, the consult was cancelled. A representative sample of one month pre- and post-implementation data was analyzed.

Results

The E-consult template was implemented in September 2024. From April to August 2024, the average number of E-consults per month was 243, averaging at 11.0 per day, while from October 2024 to February 2025, the average number of E-consults per month was 146.4, averaging at 6.6 per day. In August 2024, the leading reasons for consult were anemia (77), leukocytosis (26), and thrombocytopenia (24). That month, there were 15 consult cancellations, with the primary reason being the patient was established in clinic (9). In October 2024, the leading reasons for consult were anemia (39), leukocytosis (14), and thrombocytopenia (13). That month, there were 34 consult cancellations, with the primary reason being that hematology advised a clinic consultation rather than an E-consult (10).

Implications/Significance

These data reveal that the hematology E-consult template was associated with a decreased number of E-consults per day and per month. Implementation of the hematology E-consult template allows the hematology consultants to focus on interpretation of lab results and providing management recommendations, as opposed to providing standard of care diagnostic recommendations. It also serves as an educational tool to referring providers, to understand appropriate indications for hematology E-consultation. Lastly, the template has created increased efficiency in providing hematology recommendations and ultimately, improved timely care for our veterans.

Purpose/Background

The purpose of this project was to understand how implementing a consult template could optimize hematology E-consult evaluation. At the Tampa VA, providers can submit hematology E-consults for interpretation of lab abnormalities and management recommendations that do not require an in-person hematology evaluation. Previously, submission of an E-consult did not require prerequisite labs or imaging or for lab parameters to be met, leading to an increased number of hematology E-consults and subsequently, lower efficiency for hematologists.

Methods

A hematology E-consult template was created through collaboration between the hematology/ oncology and ambulatory care sections, which lists specific diagnoses and required parameters/workup needed for each diagnosis prior to submission of the E-consult. If those criteria were not met, the consult was cancelled. A representative sample of one month pre- and post-implementation data was analyzed.

Results

The E-consult template was implemented in September 2024. From April to August 2024, the average number of E-consults per month was 243, averaging at 11.0 per day, while from October 2024 to February 2025, the average number of E-consults per month was 146.4, averaging at 6.6 per day. In August 2024, the leading reasons for consult were anemia (77), leukocytosis (26), and thrombocytopenia (24). That month, there were 15 consult cancellations, with the primary reason being the patient was established in clinic (9). In October 2024, the leading reasons for consult were anemia (39), leukocytosis (14), and thrombocytopenia (13). That month, there were 34 consult cancellations, with the primary reason being that hematology advised a clinic consultation rather than an E-consult (10).

Implications/Significance

These data reveal that the hematology E-consult template was associated with a decreased number of E-consults per day and per month. Implementation of the hematology E-consult template allows the hematology consultants to focus on interpretation of lab results and providing management recommendations, as opposed to providing standard of care diagnostic recommendations. It also serves as an educational tool to referring providers, to understand appropriate indications for hematology E-consultation. Lastly, the template has created increased efficiency in providing hematology recommendations and ultimately, improved timely care for our veterans.

Background

The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.

Methods

In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.

Results

TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).

Conclusions

Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.

Background

The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.

Methods

In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.

Results

TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).

Conclusions

Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.

Background

The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.

Methods

In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.

Results

TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).

Conclusions

Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.

Purpose/Objectives

Radiation oncology treatment planning and delivery systems are predominantly designed as silos, centered around the care of individual patients and generally disconnected from the broader health record. This poses significant challenges for cohort or population scale research, particularly when trying to analyze the nuances and details of treatments. The National Radiation Oncology Program (NROP) sought to design, develop, and implement a platform-agnostic tool to extract clinically meaningful treatment details from DICOM-RT data and applied this in a pilot initiative to centralize data from several VA distinct treatment facilities and merge the resulting dataset with the broader electronic health record to support research and clinical operations.

Methods

Leveraging NROP’s Health Information Gateway Exchange (HINGE) system, we developed the capability to analyze DICOM-RT datasets and output detailed and clinically meaningful radiation treatment information including but not limited to structure-specific dose volume histogram data, individual beam-level treatment details, and verified delivered fraction data. We applied this to historical data from VA facilities participating in NROP’s initial pilot and linked the resulting data with the broader electronic health record on an individual patient level, constituting the Granular Radiotherapy Information Database (GRID).

Results

We demonstrate successful export of clinically meaningful treatment details from a large real-world cohort of VA patients treated between 2012-2024. This constitutes a novel source of authoritative radiation oncology data within the VA CDW. We confirmed the ability to arbitrarily query these cohorts based on both the intrinsic data export as well as its linkages to the broader electronic health record.

Conclusions

This is a proof-of-principle study demonstrating the ability to extract and integrate detailed radiotherapy data with the broader health record, as well as enable unprecedented arbitrary queries at population scale and broad reuse in the VA research and clinical operations.

Purpose/Objectives

Radiation oncology treatment planning and delivery systems are predominantly designed as silos, centered around the care of individual patients and generally disconnected from the broader health record. This poses significant challenges for cohort or population scale research, particularly when trying to analyze the nuances and details of treatments. The National Radiation Oncology Program (NROP) sought to design, develop, and implement a platform-agnostic tool to extract clinically meaningful treatment details from DICOM-RT data and applied this in a pilot initiative to centralize data from several VA distinct treatment facilities and merge the resulting dataset with the broader electronic health record to support research and clinical operations.

Methods

Leveraging NROP’s Health Information Gateway Exchange (HINGE) system, we developed the capability to analyze DICOM-RT datasets and output detailed and clinically meaningful radiation treatment information including but not limited to structure-specific dose volume histogram data, individual beam-level treatment details, and verified delivered fraction data. We applied this to historical data from VA facilities participating in NROP’s initial pilot and linked the resulting data with the broader electronic health record on an individual patient level, constituting the Granular Radiotherapy Information Database (GRID).

Results

We demonstrate successful export of clinically meaningful treatment details from a large real-world cohort of VA patients treated between 2012-2024. This constitutes a novel source of authoritative radiation oncology data within the VA CDW. We confirmed the ability to arbitrarily query these cohorts based on both the intrinsic data export as well as its linkages to the broader electronic health record.

Conclusions

This is a proof-of-principle study demonstrating the ability to extract and integrate detailed radiotherapy data with the broader health record, as well as enable unprecedented arbitrary queries at population scale and broad reuse in the VA research and clinical operations.

Purpose/Objectives

Radiation oncology treatment planning and delivery systems are predominantly designed as silos, centered around the care of individual patients and generally disconnected from the broader health record. This poses significant challenges for cohort or population scale research, particularly when trying to analyze the nuances and details of treatments. The National Radiation Oncology Program (NROP) sought to design, develop, and implement a platform-agnostic tool to extract clinically meaningful treatment details from DICOM-RT data and applied this in a pilot initiative to centralize data from several VA distinct treatment facilities and merge the resulting dataset with the broader electronic health record to support research and clinical operations.

Methods

Leveraging NROP’s Health Information Gateway Exchange (HINGE) system, we developed the capability to analyze DICOM-RT datasets and output detailed and clinically meaningful radiation treatment information including but not limited to structure-specific dose volume histogram data, individual beam-level treatment details, and verified delivered fraction data. We applied this to historical data from VA facilities participating in NROP’s initial pilot and linked the resulting data with the broader electronic health record on an individual patient level, constituting the Granular Radiotherapy Information Database (GRID).

Results

We demonstrate successful export of clinically meaningful treatment details from a large real-world cohort of VA patients treated between 2012-2024. This constitutes a novel source of authoritative radiation oncology data within the VA CDW. We confirmed the ability to arbitrarily query these cohorts based on both the intrinsic data export as well as its linkages to the broader electronic health record.

Conclusions

This is a proof-of-principle study demonstrating the ability to extract and integrate detailed radiotherapy data with the broader health record, as well as enable unprecedented arbitrary queries at population scale and broad reuse in the VA research and clinical operations.

Purpose/Background

Oncology clinical pharmacist practitioners (CPP) play a critical role in optimizing drug therapy, managing side effects, and ensuring medication adherence. As a specialized clinical area, specific training is needed to ensure quality of care. Oncology pharmacy training programs are commercially available but pose a financial burden and are not specific to the Veterans Health Administration (VHA). A comprehensive, virtual Oncology Bootcamp series was implemented to upskill new oncology pharmacists (or pharmacists seeking to further their understanding of oncology practice), with didactic materials and clinical tools to enhance and standardize quality care delivery.

Methods

This program was comprised of an online platform of 23 one hour-long continuing education accredited sessions, delivered by leading subject matter experts. Pharmacists from two Veteran Integrated Service Networks (VISNs) were invited for the first year of the bootcamp. The curriculum encompassed fundamentals of oncology practice, patient care assessment, chemotherapy protocol review, practice management, and supportive care. Participants also received in-depth training on managing various cancer types, including but not limited to prostate, lung, gastrointestinal and hematologic malignancies. VHA specific information, including utilization of Oncology Clinical Pathways to promote standardized care was included where applicable. The interactive nature of the virtual sessions provided opportunities for real-time discussion and immediate feedback. To measure the impact of this program, a pre and post program evaluation of participants was conducted.

Results

Over the course of the program, more than 40 pharmacists across two VISNs participated in the bootcamp series. Results of the program evaluation showed an increase in self-reported comfort and skill levels in all criteria that were assessed (oncology pharmacotherapy, solid tumor malignancies, hematologic malignancies and oral anti-cancer therapy management). Additionally, 85% of respondents stated the series met their overall goals and over 90% of respondents stated they were either satisfied or very satisfied with the content, speakers and organization of the course.

Implications/Significance

This initiative has established the viability and significance of a highly accessible, VHA pathway specific and Veteran centric platform for oncology pharmacy professional development. Future directions for the program include a broader nationwide audience, increased content coverage and self-paced learning options.

Purpose/Background

Oncology clinical pharmacist practitioners (CPP) play a critical role in optimizing drug therapy, managing side effects, and ensuring medication adherence. As a specialized clinical area, specific training is needed to ensure quality of care. Oncology pharmacy training programs are commercially available but pose a financial burden and are not specific to the Veterans Health Administration (VHA). A comprehensive, virtual Oncology Bootcamp series was implemented to upskill new oncology pharmacists (or pharmacists seeking to further their understanding of oncology practice), with didactic materials and clinical tools to enhance and standardize quality care delivery.

Methods

This program was comprised of an online platform of 23 one hour-long continuing education accredited sessions, delivered by leading subject matter experts. Pharmacists from two Veteran Integrated Service Networks (VISNs) were invited for the first year of the bootcamp. The curriculum encompassed fundamentals of oncology practice, patient care assessment, chemotherapy protocol review, practice management, and supportive care. Participants also received in-depth training on managing various cancer types, including but not limited to prostate, lung, gastrointestinal and hematologic malignancies. VHA specific information, including utilization of Oncology Clinical Pathways to promote standardized care was included where applicable. The interactive nature of the virtual sessions provided opportunities for real-time discussion and immediate feedback. To measure the impact of this program, a pre and post program evaluation of participants was conducted.

Results

Over the course of the program, more than 40 pharmacists across two VISNs participated in the bootcamp series. Results of the program evaluation showed an increase in self-reported comfort and skill levels in all criteria that were assessed (oncology pharmacotherapy, solid tumor malignancies, hematologic malignancies and oral anti-cancer therapy management). Additionally, 85% of respondents stated the series met their overall goals and over 90% of respondents stated they were either satisfied or very satisfied with the content, speakers and organization of the course.

Implications/Significance

This initiative has established the viability and significance of a highly accessible, VHA pathway specific and Veteran centric platform for oncology pharmacy professional development. Future directions for the program include a broader nationwide audience, increased content coverage and self-paced learning options.

Purpose/Background

Oncology clinical pharmacist practitioners (CPP) play a critical role in optimizing drug therapy, managing side effects, and ensuring medication adherence. As a specialized clinical area, specific training is needed to ensure quality of care. Oncology pharmacy training programs are commercially available but pose a financial burden and are not specific to the Veterans Health Administration (VHA). A comprehensive, virtual Oncology Bootcamp series was implemented to upskill new oncology pharmacists (or pharmacists seeking to further their understanding of oncology practice), with didactic materials and clinical tools to enhance and standardize quality care delivery.

Methods

This program was comprised of an online platform of 23 one hour-long continuing education accredited sessions, delivered by leading subject matter experts. Pharmacists from two Veteran Integrated Service Networks (VISNs) were invited for the first year of the bootcamp. The curriculum encompassed fundamentals of oncology practice, patient care assessment, chemotherapy protocol review, practice management, and supportive care. Participants also received in-depth training on managing various cancer types, including but not limited to prostate, lung, gastrointestinal and hematologic malignancies. VHA specific information, including utilization of Oncology Clinical Pathways to promote standardized care was included where applicable. The interactive nature of the virtual sessions provided opportunities for real-time discussion and immediate feedback. To measure the impact of this program, a pre and post program evaluation of participants was conducted.

Results

Over the course of the program, more than 40 pharmacists across two VISNs participated in the bootcamp series. Results of the program evaluation showed an increase in self-reported comfort and skill levels in all criteria that were assessed (oncology pharmacotherapy, solid tumor malignancies, hematologic malignancies and oral anti-cancer therapy management). Additionally, 85% of respondents stated the series met their overall goals and over 90% of respondents stated they were either satisfied or very satisfied with the content, speakers and organization of the course.

Implications/Significance

This initiative has established the viability and significance of a highly accessible, VHA pathway specific and Veteran centric platform for oncology pharmacy professional development. Future directions for the program include a broader nationwide audience, increased content coverage and self-paced learning options.

This transcript has been edited for clarity.

Hi, I’m Doctor Monty Pal, and I’m a medical oncologist at City of Hope Comprehensive Cancer Center.

I run the kidney cancer program there, and it’s really been amazing to see the tidal wave of new therapies that we’ve developed for kidney cancer over the years.

What I will say is that most of the treatments that we have, the doublet therapies and adjuvant treatments, really pertain to the most dominant subset of kidney cancer, and that’s clear cell; that really represents about 75%-80% of all cases of kidney cancer.

Having said that, I’d like to focus on perhaps a less dominant subset of kidney cancer known as papillary. This represents about 15%-20% of cases.

To be fair, there are other rare subtypes and those certainly warrant focus as well: Chromophobe represents about 5% of all diseases; translocation, unclassified, a percentage point or 2.

But papillary really is a setting in which we can do — and as I’ll demonstrate, have done — clinical trials.

Now papillary kidney cancer is similar in terms of its demographics to clear cell renal cell carcinoma (RCC). There still tends to be a male predominance. It may have a slightly lower age of initial presentation, but otherwise there’s many commonalities.

I do think one of the areas where it differs, and this is critical, is in the context of biology: We think that papillary RCC is really driven by the MET proto-oncogene amongst other things. With that in mind, there have been a whole host of therapies directed at the MET proto-oncogene, and we’ll discuss that in just a moment.

I wanted to first talk about management of localized papillary kidney cancer. This management doesn’t differ significantly from what we would perhaps consider in the context of localized clear cell kidney cancer. For stage 1 through 3 disease, patients still receive surgery as the mainstay, and I would argue that, in the context of stage 4 disease, we should still really consider aggressive local definitive therapies if at all possible.

Having said that, the role of adjuvant therapy is a bit unclear in this context. I would suggest that in the context of adjuvant therapy for papillary kidney cancer, it’s a bit of a no go until we have greater data in this setting. Therapies like pembrolizumab and sunitinib really were only tested in the context of clear cell disease.

And with that background, I wanted to move into metastatic disease. For patients with stage 4 papillary kidney cancer, therapy may or may not resemble the treatments that we use for clear cell kidney cancer.

There have been trials in yesteryear with really creative names, ASPEN and ESPN for instance, that actually juxtaposed older therapies against one another. Sunitinib against everolimus, for instance, was common to both of those studies. And it really suggested perhaps that sunitinib was the preferred choice between those two targeted therapies. Sunitinib then became a bit of a standard when it came to randomized trials, and in fact, it still remains something that’s incorporated as a base regimen at phase 3 clinical trials.

I’ll show you that in the PAPMET clinical trial, which was a randomized phase 2 experience, we were able to compare sunitinib to cabozantinib, crizotinib, and savolitinib. The latter three drugs are all so-called MET inhibitors. And what’s quite interesting about this study is that cabozantinib, the dual VEGF/MET inhibitor, really is the one that seemed to win out.

When you look at median progression-free survival (PFS), in sunitinib in that study was around 6 months. When you look at cabozantinib, it was around 9 months.

Having said that, with cabozantinib, there was no overall survival advantage, and I will say that the PFS benefit is modest. So, we still need more in the way of clinical trials.

To that end, there’s a number of single arm studies supporting cabozantinib-based regimens, cabozantinib/atezolizumab and cabozantinib/nivolumab, with healthy response rates. For papillary kidney cancer, the response rate with those regimens is around 43%-47%.

In the context of lenvatinib and pembrolizumab, we actually see the response rate augmented to approximately 53%.

So, with those numbers in mind, I definitely think that doublet therapy is promising, but as we always tell our fellows in the clinic, randomization is really king.

So, we do have two phase 3 clinical trials, STELLAR-304, which is a study that I’m running, and the second study is known as SAMETA. Both evaluate papillary patients, but in very different ways.

STELLAR-304 includes patients with papillary, translocation, and unclassified kidney cancer and randomizes to sunitinib vs zanzalintinib, a novel TKI, with nivolumab.

In contrast, SAMETA takes the very interesting approach of actually selecting out patients with MET abnormalities and randomizing them to sunitinib vs savolitinib.

There are other approaches. For instance, the SUNNIFORECAST study recently assessed nivolumab and ipilimumab. There are randomized phase 2 studies looking at axitinib and pembrolizumab or perhaps axitinib and, sorry, cabozantinib with atezolizumab.

But I do think these phase 3 studies, SAMETA and STELLAR-304, are the ones that are really poised to change the landscape of therapy for papillary kidney cancer.

Sumanta K. Pal, MD, Professor, Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California, has disclosed the following relevant financial relationships: Received travel from: CRISPR; Ipsen. A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Hi, I’m Doctor Monty Pal, and I’m a medical oncologist at City of Hope Comprehensive Cancer Center.

I run the kidney cancer program there, and it’s really been amazing to see the tidal wave of new therapies that we’ve developed for kidney cancer over the years.

What I will say is that most of the treatments that we have, the doublet therapies and adjuvant treatments, really pertain to the most dominant subset of kidney cancer, and that’s clear cell; that really represents about 75%-80% of all cases of kidney cancer.

Having said that, I’d like to focus on perhaps a less dominant subset of kidney cancer known as papillary. This represents about 15%-20% of cases.

To be fair, there are other rare subtypes and those certainly warrant focus as well: Chromophobe represents about 5% of all diseases; translocation, unclassified, a percentage point or 2.

But papillary really is a setting in which we can do — and as I’ll demonstrate, have done — clinical trials.

Now papillary kidney cancer is similar in terms of its demographics to clear cell renal cell carcinoma (RCC). There still tends to be a male predominance. It may have a slightly lower age of initial presentation, but otherwise there’s many commonalities.

I do think one of the areas where it differs, and this is critical, is in the context of biology: We think that papillary RCC is really driven by the MET proto-oncogene amongst other things. With that in mind, there have been a whole host of therapies directed at the MET proto-oncogene, and we’ll discuss that in just a moment.

I wanted to first talk about management of localized papillary kidney cancer. This management doesn’t differ significantly from what we would perhaps consider in the context of localized clear cell kidney cancer. For stage 1 through 3 disease, patients still receive surgery as the mainstay, and I would argue that, in the context of stage 4 disease, we should still really consider aggressive local definitive therapies if at all possible.

Having said that, the role of adjuvant therapy is a bit unclear in this context. I would suggest that in the context of adjuvant therapy for papillary kidney cancer, it’s a bit of a no go until we have greater data in this setting. Therapies like pembrolizumab and sunitinib really were only tested in the context of clear cell disease.

And with that background, I wanted to move into metastatic disease. For patients with stage 4 papillary kidney cancer, therapy may or may not resemble the treatments that we use for clear cell kidney cancer.

There have been trials in yesteryear with really creative names, ASPEN and ESPN for instance, that actually juxtaposed older therapies against one another. Sunitinib against everolimus, for instance, was common to both of those studies. And it really suggested perhaps that sunitinib was the preferred choice between those two targeted therapies. Sunitinib then became a bit of a standard when it came to randomized trials, and in fact, it still remains something that’s incorporated as a base regimen at phase 3 clinical trials.

I’ll show you that in the PAPMET clinical trial, which was a randomized phase 2 experience, we were able to compare sunitinib to cabozantinib, crizotinib, and savolitinib. The latter three drugs are all so-called MET inhibitors. And what’s quite interesting about this study is that cabozantinib, the dual VEGF/MET inhibitor, really is the one that seemed to win out.

When you look at median progression-free survival (PFS), in sunitinib in that study was around 6 months. When you look at cabozantinib, it was around 9 months.

Having said that, with cabozantinib, there was no overall survival advantage, and I will say that the PFS benefit is modest. So, we still need more in the way of clinical trials.

To that end, there’s a number of single arm studies supporting cabozantinib-based regimens, cabozantinib/atezolizumab and cabozantinib/nivolumab, with healthy response rates. For papillary kidney cancer, the response rate with those regimens is around 43%-47%.

In the context of lenvatinib and pembrolizumab, we actually see the response rate augmented to approximately 53%.

So, with those numbers in mind, I definitely think that doublet therapy is promising, but as we always tell our fellows in the clinic, randomization is really king.

So, we do have two phase 3 clinical trials, STELLAR-304, which is a study that I’m running, and the second study is known as SAMETA. Both evaluate papillary patients, but in very different ways.

STELLAR-304 includes patients with papillary, translocation, and unclassified kidney cancer and randomizes to sunitinib vs zanzalintinib, a novel TKI, with nivolumab.

In contrast, SAMETA takes the very interesting approach of actually selecting out patients with MET abnormalities and randomizing them to sunitinib vs savolitinib.

There are other approaches. For instance, the SUNNIFORECAST study recently assessed nivolumab and ipilimumab. There are randomized phase 2 studies looking at axitinib and pembrolizumab or perhaps axitinib and, sorry, cabozantinib with atezolizumab.

But I do think these phase 3 studies, SAMETA and STELLAR-304, are the ones that are really poised to change the landscape of therapy for papillary kidney cancer.

Sumanta K. Pal, MD, Professor, Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California, has disclosed the following relevant financial relationships: Received travel from: CRISPR; Ipsen. A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Hi, I’m Doctor Monty Pal, and I’m a medical oncologist at City of Hope Comprehensive Cancer Center.

I run the kidney cancer program there, and it’s really been amazing to see the tidal wave of new therapies that we’ve developed for kidney cancer over the years.

What I will say is that most of the treatments that we have, the doublet therapies and adjuvant treatments, really pertain to the most dominant subset of kidney cancer, and that’s clear cell; that really represents about 75%-80% of all cases of kidney cancer.

Having said that, I’d like to focus on perhaps a less dominant subset of kidney cancer known as papillary. This represents about 15%-20% of cases.

To be fair, there are other rare subtypes and those certainly warrant focus as well: Chromophobe represents about 5% of all diseases; translocation, unclassified, a percentage point or 2.

But papillary really is a setting in which we can do — and as I’ll demonstrate, have done — clinical trials.

Now papillary kidney cancer is similar in terms of its demographics to clear cell renal cell carcinoma (RCC). There still tends to be a male predominance. It may have a slightly lower age of initial presentation, but otherwise there’s many commonalities.

I do think one of the areas where it differs, and this is critical, is in the context of biology: We think that papillary RCC is really driven by the MET proto-oncogene amongst other things. With that in mind, there have been a whole host of therapies directed at the MET proto-oncogene, and we’ll discuss that in just a moment.

I wanted to first talk about management of localized papillary kidney cancer. This management doesn’t differ significantly from what we would perhaps consider in the context of localized clear cell kidney cancer. For stage 1 through 3 disease, patients still receive surgery as the mainstay, and I would argue that, in the context of stage 4 disease, we should still really consider aggressive local definitive therapies if at all possible.

Having said that, the role of adjuvant therapy is a bit unclear in this context. I would suggest that in the context of adjuvant therapy for papillary kidney cancer, it’s a bit of a no go until we have greater data in this setting. Therapies like pembrolizumab and sunitinib really were only tested in the context of clear cell disease.

And with that background, I wanted to move into metastatic disease. For patients with stage 4 papillary kidney cancer, therapy may or may not resemble the treatments that we use for clear cell kidney cancer.

There have been trials in yesteryear with really creative names, ASPEN and ESPN for instance, that actually juxtaposed older therapies against one another. Sunitinib against everolimus, for instance, was common to both of those studies. And it really suggested perhaps that sunitinib was the preferred choice between those two targeted therapies. Sunitinib then became a bit of a standard when it came to randomized trials, and in fact, it still remains something that’s incorporated as a base regimen at phase 3 clinical trials.

I’ll show you that in the PAPMET clinical trial, which was a randomized phase 2 experience, we were able to compare sunitinib to cabozantinib, crizotinib, and savolitinib. The latter three drugs are all so-called MET inhibitors. And what’s quite interesting about this study is that cabozantinib, the dual VEGF/MET inhibitor, really is the one that seemed to win out.

When you look at median progression-free survival (PFS), in sunitinib in that study was around 6 months. When you look at cabozantinib, it was around 9 months.

Having said that, with cabozantinib, there was no overall survival advantage, and I will say that the PFS benefit is modest. So, we still need more in the way of clinical trials.

To that end, there’s a number of single arm studies supporting cabozantinib-based regimens, cabozantinib/atezolizumab and cabozantinib/nivolumab, with healthy response rates. For papillary kidney cancer, the response rate with those regimens is around 43%-47%.

In the context of lenvatinib and pembrolizumab, we actually see the response rate augmented to approximately 53%.

So, with those numbers in mind, I definitely think that doublet therapy is promising, but as we always tell our fellows in the clinic, randomization is really king.

So, we do have two phase 3 clinical trials, STELLAR-304, which is a study that I’m running, and the second study is known as SAMETA. Both evaluate papillary patients, but in very different ways.

STELLAR-304 includes patients with papillary, translocation, and unclassified kidney cancer and randomizes to sunitinib vs zanzalintinib, a novel TKI, with nivolumab.

In contrast, SAMETA takes the very interesting approach of actually selecting out patients with MET abnormalities and randomizing them to sunitinib vs savolitinib.

There are other approaches. For instance, the SUNNIFORECAST study recently assessed nivolumab and ipilimumab. There are randomized phase 2 studies looking at axitinib and pembrolizumab or perhaps axitinib and, sorry, cabozantinib with atezolizumab.

But I do think these phase 3 studies, SAMETA and STELLAR-304, are the ones that are really poised to change the landscape of therapy for papillary kidney cancer.

Sumanta K. Pal, MD, Professor, Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California, has disclosed the following relevant financial relationships: Received travel from: CRISPR; Ipsen. A version of this article appeared on Medscape.com.

Objective

To assess the impact of virtual reality on the distress and pain levels of oncology patients in a VA outpatient infusion clinic.

Background

It is known that distress in cancer care leads to several problems including decreased survival, decreased treatment adherence, and inability to make treatment decisions. Virtual reality (VR) has proven to be beneficial to Veterans suffering from stress, anxiety, and other mental health ailments. This VA Oncology Infusion clinic is assessing the impact of VR on its Veterans’ distress and pain levels.

Methods

The pilot phase will last from 3/5/25- 9/5/25. Prior to each VR session, Veterans are administered an NCCN cancer distress screening tool and a numerical pain assessment. Post-VR session, Veterans are reassessed for distress and pain. The veterans are asked the following questions after each session: 1) Would you recommend VR to other veterans? and 2) Was the VR headset easy to use? Each VR session is approximately 10-15 minutes long, and the Veterans choose to engage in mindfulness activities, breathing exercises, or view scenery of their choice.

Results

Preliminary results indicate receptiveness and positive experiences amongst Veterans. 66% of Veterans who have used the VR headset have demonstrated a decrease in Cancer Distress by at least 2 points after a 10–15-minute VR session. 92% of Veterans that have used the VR headset report that it is easy to use and that they would recommend it to other Veterans.

Feasibility

The VA has created the Extended Reality Network (XR) to support the implementation of VR at the local site level. Resources and training are widely available to ensure program success.

Sustainability and Impact

A clearly developed standard of work and protocol that is tailored to the local site’s workflow, including a VR champion is needed to ensure sustainability. Preliminary data shows that veterans are engaged and responding positively to this innovative approach to cancer distress management, as evidenced by decreased distress levels and anxiety.

Objective

To assess the impact of virtual reality on the distress and pain levels of oncology patients in a VA outpatient infusion clinic.

Background

It is known that distress in cancer care leads to several problems including decreased survival, decreased treatment adherence, and inability to make treatment decisions. Virtual reality (VR) has proven to be beneficial to Veterans suffering from stress, anxiety, and other mental health ailments. This VA Oncology Infusion clinic is assessing the impact of VR on its Veterans’ distress and pain levels.

Methods

The pilot phase will last from 3/5/25- 9/5/25. Prior to each VR session, Veterans are administered an NCCN cancer distress screening tool and a numerical pain assessment. Post-VR session, Veterans are reassessed for distress and pain. The veterans are asked the following questions after each session: 1) Would you recommend VR to other veterans? and 2) Was the VR headset easy to use? Each VR session is approximately 10-15 minutes long, and the Veterans choose to engage in mindfulness activities, breathing exercises, or view scenery of their choice.

Results

Preliminary results indicate receptiveness and positive experiences amongst Veterans. 66% of Veterans who have used the VR headset have demonstrated a decrease in Cancer Distress by at least 2 points after a 10–15-minute VR session. 92% of Veterans that have used the VR headset report that it is easy to use and that they would recommend it to other Veterans.

Feasibility

The VA has created the Extended Reality Network (XR) to support the implementation of VR at the local site level. Resources and training are widely available to ensure program success.

Sustainability and Impact

A clearly developed standard of work and protocol that is tailored to the local site’s workflow, including a VR champion is needed to ensure sustainability. Preliminary data shows that veterans are engaged and responding positively to this innovative approach to cancer distress management, as evidenced by decreased distress levels and anxiety.

Objective

To assess the impact of virtual reality on the distress and pain levels of oncology patients in a VA outpatient infusion clinic.

Background

It is known that distress in cancer care leads to several problems including decreased survival, decreased treatment adherence, and inability to make treatment decisions. Virtual reality (VR) has proven to be beneficial to Veterans suffering from stress, anxiety, and other mental health ailments. This VA Oncology Infusion clinic is assessing the impact of VR on its Veterans’ distress and pain levels.

Methods

The pilot phase will last from 3/5/25- 9/5/25. Prior to each VR session, Veterans are administered an NCCN cancer distress screening tool and a numerical pain assessment. Post-VR session, Veterans are reassessed for distress and pain. The veterans are asked the following questions after each session: 1) Would you recommend VR to other veterans? and 2) Was the VR headset easy to use? Each VR session is approximately 10-15 minutes long, and the Veterans choose to engage in mindfulness activities, breathing exercises, or view scenery of their choice.

Results

Preliminary results indicate receptiveness and positive experiences amongst Veterans. 66% of Veterans who have used the VR headset have demonstrated a decrease in Cancer Distress by at least 2 points after a 10–15-minute VR session. 92% of Veterans that have used the VR headset report that it is easy to use and that they would recommend it to other Veterans.

Feasibility

The VA has created the Extended Reality Network (XR) to support the implementation of VR at the local site level. Resources and training are widely available to ensure program success.

Sustainability and Impact

A clearly developed standard of work and protocol that is tailored to the local site’s workflow, including a VR champion is needed to ensure sustainability. Preliminary data shows that veterans are engaged and responding positively to this innovative approach to cancer distress management, as evidenced by decreased distress levels and anxiety.