Purpose: This study sought to characterize the incidence of cisplatin-induced hearing change by cancer location and aspects of the treatment regimen in a sample of Veterans undergoing chemotherapy at the VA Portland HCS. An additional goal was to characterize the severity of hearing loss prior to treatment and the contributions of cisplatin-induced hearing loss in relation to the need for auditory rehabilitation.

Background: Between 2008 and 2014, 17,173 Veterans were treated with cisplatin chemotherapy. Many began treatment with pre-existing hearing loss and up to half likely sustained ototoxicity. Even minor shifts in hearing, left untreated, can constrain effective provider-Veteran treatment partnerships, family and workplace communication, and can significantly limit optimal quality of life following cancer.

Methods: Serial hearing testing and medical records data were obtained prospectively from 2011-2016 in N = 87 cancer patients. Baseline hearing tests were completed within 24 hours of the first cisplatin treatment, during and after treatment. The primary outcome was a shift in the audiogram based on the NCI Common Terminology Criteria for Adverse Events (CTCAE) Grades 1-4 and American Speech-Language-Hearing Association (ASHA) guidelines for a significant ototoxic shift. Hearing shifts that met criteria for CTCAE Grade 1 were further evaluated in relation to cisplatin cumulative dose, initial dose, concurrent radiation and cancer location.

Data Analysis: Descriptive statistics characterize the severity of pre-existing hearing loss and ototoxic changes. Effects of cisplatin dose, cancer location, and radiation on the risks for CTCAE Grade 1 ototoxic event were estimated using hierarchical logistic regression.

Results: Ototoxicity meeting CTCAE grade 3 were found at a rate of 19% for head and neck cancers. This group warrants priority surveillance. Less severe (Grade 1) shifts were found at high rates across other cancer locations assessed in this study. CTCAE Grade 1 ototoxicity is associated with cancer location, starting dose, and concurrent radiation. Importantly, Grade 1 exceeds the magnitude of an ASHA-significant hearing shift by definition. These Veterans are a high priority group for hearing monitoring and rehabilitation service provision by Audiology.

Implications: CTCAE Grade 1 ototoxicity is a commonly occurring toxicity that may limit Veteran-provider communication and quality of life.

Purpose: This study sought to characterize the incidence of cisplatin-induced hearing change by cancer location and aspects of the treatment regimen in a sample of Veterans undergoing chemotherapy at the VA Portland HCS. An additional goal was to characterize the severity of hearing loss prior to treatment and the contributions of cisplatin-induced hearing loss in relation to the need for auditory rehabilitation.

Background: Between 2008 and 2014, 17,173 Veterans were treated with cisplatin chemotherapy. Many began treatment with pre-existing hearing loss and up to half likely sustained ototoxicity. Even minor shifts in hearing, left untreated, can constrain effective provider-Veteran treatment partnerships, family and workplace communication, and can significantly limit optimal quality of life following cancer.

Methods: Serial hearing testing and medical records data were obtained prospectively from 2011-2016 in N = 87 cancer patients. Baseline hearing tests were completed within 24 hours of the first cisplatin treatment, during and after treatment. The primary outcome was a shift in the audiogram based on the NCI Common Terminology Criteria for Adverse Events (CTCAE) Grades 1-4 and American Speech-Language-Hearing Association (ASHA) guidelines for a significant ototoxic shift. Hearing shifts that met criteria for CTCAE Grade 1 were further evaluated in relation to cisplatin cumulative dose, initial dose, concurrent radiation and cancer location.

Data Analysis: Descriptive statistics characterize the severity of pre-existing hearing loss and ototoxic changes. Effects of cisplatin dose, cancer location, and radiation on the risks for CTCAE Grade 1 ototoxic event were estimated using hierarchical logistic regression.

Results: Ototoxicity meeting CTCAE grade 3 were found at a rate of 19% for head and neck cancers. This group warrants priority surveillance. Less severe (Grade 1) shifts were found at high rates across other cancer locations assessed in this study. CTCAE Grade 1 ototoxicity is associated with cancer location, starting dose, and concurrent radiation. Importantly, Grade 1 exceeds the magnitude of an ASHA-significant hearing shift by definition. These Veterans are a high priority group for hearing monitoring and rehabilitation service provision by Audiology.

Implications: CTCAE Grade 1 ototoxicity is a commonly occurring toxicity that may limit Veteran-provider communication and quality of life.

Purpose: This study sought to characterize the incidence of cisplatin-induced hearing change by cancer location and aspects of the treatment regimen in a sample of Veterans undergoing chemotherapy at the VA Portland HCS. An additional goal was to characterize the severity of hearing loss prior to treatment and the contributions of cisplatin-induced hearing loss in relation to the need for auditory rehabilitation.

Background: Between 2008 and 2014, 17,173 Veterans were treated with cisplatin chemotherapy. Many began treatment with pre-existing hearing loss and up to half likely sustained ototoxicity. Even minor shifts in hearing, left untreated, can constrain effective provider-Veteran treatment partnerships, family and workplace communication, and can significantly limit optimal quality of life following cancer.

Methods: Serial hearing testing and medical records data were obtained prospectively from 2011-2016 in N = 87 cancer patients. Baseline hearing tests were completed within 24 hours of the first cisplatin treatment, during and after treatment. The primary outcome was a shift in the audiogram based on the NCI Common Terminology Criteria for Adverse Events (CTCAE) Grades 1-4 and American Speech-Language-Hearing Association (ASHA) guidelines for a significant ototoxic shift. Hearing shifts that met criteria for CTCAE Grade 1 were further evaluated in relation to cisplatin cumulative dose, initial dose, concurrent radiation and cancer location.

Data Analysis: Descriptive statistics characterize the severity of pre-existing hearing loss and ototoxic changes. Effects of cisplatin dose, cancer location, and radiation on the risks for CTCAE Grade 1 ototoxic event were estimated using hierarchical logistic regression.

Results: Ototoxicity meeting CTCAE grade 3 were found at a rate of 19% for head and neck cancers. This group warrants priority surveillance. Less severe (Grade 1) shifts were found at high rates across other cancer locations assessed in this study. CTCAE Grade 1 ototoxicity is associated with cancer location, starting dose, and concurrent radiation. Importantly, Grade 1 exceeds the magnitude of an ASHA-significant hearing shift by definition. These Veterans are a high priority group for hearing monitoring and rehabilitation service provision by Audiology.

Implications: CTCAE Grade 1 ototoxicity is a commonly occurring toxicity that may limit Veteran-provider communication and quality of life.

Purpose: Describe symptom burden and distress among Veteran cancer survivors.

Background: Survivorship is an important component of cancer care as patients transition from treatment to surveillance and cope with long-term effects of therapy. Veterans receiving care at the VA are quite different from those described in existing survivorship literature, with lower income and health literacy, poorer physical andmental health, and more comorbidities compared to the general population. Survivorship needs have not been well defined in this population.

Methods: Veterans are referred or recruited to survivorship clinic after completing definitive therapy. An NCCN distress thermometer (DT) is completed in survivorship clinic as part of routine clinical care.

Data Analysis: This analysis was restricted to cancer survivors meeting Commission on Cancer guidance for survivorship care eligibility. Descriptive statistics summarized findings from the DT. To place symptom burden in context, a comparison group was selected consisting of Veterans with comparable cancer site and stage who completed a DT at their first treatment appointment. Reported symptoms were compared to those from survivors with chi-square analysis.

Results: The DT was completed by 47 lung, colorectal, anal, and head and neck cancer survivors between February 2015 and April 2016. Most were white males, with an average age of 66. Of 39 practical, family, emotional, and physical problems included on the DT, survivors reported an average of 9.2 issues (range 0-22). The most common problems were dyspnea (64%), fatigue (60%), pain (57%), sleep (45%), worry (43%), and depression (40%). The average distress score was 3.6 (range 0-9).

The comparison group contained 147 Veterans; they reported an average of 7.4 issues as sources of distress.

Survivors were significantly more likely to report difficulty with breathing, constipation, depression, anhedonia, sadness, sleep concerns, and tingling in the hands and feet. The only issues more common in patients at the start of treatment compared to survivors were nervousness and transportation concerns. There was no difference in concerns regarding treatment decisions, pain, or finances.

Implications: Veteran cancer survivors reported significant symptom burden, particularly concerning mental health and side effects of treatment. Cancer survivorship clinic can play an important role in identifying and addressing the significant symptom burden. A multidisciplinary approach, particularly one including mental health services, is very important.

Purpose: Describe symptom burden and distress among Veteran cancer survivors.

Background: Survivorship is an important component of cancer care as patients transition from treatment to surveillance and cope with long-term effects of therapy. Veterans receiving care at the VA are quite different from those described in existing survivorship literature, with lower income and health literacy, poorer physical andmental health, and more comorbidities compared to the general population. Survivorship needs have not been well defined in this population.

Methods: Veterans are referred or recruited to survivorship clinic after completing definitive therapy. An NCCN distress thermometer (DT) is completed in survivorship clinic as part of routine clinical care.

Data Analysis: This analysis was restricted to cancer survivors meeting Commission on Cancer guidance for survivorship care eligibility. Descriptive statistics summarized findings from the DT. To place symptom burden in context, a comparison group was selected consisting of Veterans with comparable cancer site and stage who completed a DT at their first treatment appointment. Reported symptoms were compared to those from survivors with chi-square analysis.

Results: The DT was completed by 47 lung, colorectal, anal, and head and neck cancer survivors between February 2015 and April 2016. Most were white males, with an average age of 66. Of 39 practical, family, emotional, and physical problems included on the DT, survivors reported an average of 9.2 issues (range 0-22). The most common problems were dyspnea (64%), fatigue (60%), pain (57%), sleep (45%), worry (43%), and depression (40%). The average distress score was 3.6 (range 0-9).

The comparison group contained 147 Veterans; they reported an average of 7.4 issues as sources of distress.

Survivors were significantly more likely to report difficulty with breathing, constipation, depression, anhedonia, sadness, sleep concerns, and tingling in the hands and feet. The only issues more common in patients at the start of treatment compared to survivors were nervousness and transportation concerns. There was no difference in concerns regarding treatment decisions, pain, or finances.

Implications: Veteran cancer survivors reported significant symptom burden, particularly concerning mental health and side effects of treatment. Cancer survivorship clinic can play an important role in identifying and addressing the significant symptom burden. A multidisciplinary approach, particularly one including mental health services, is very important.

Purpose: Describe symptom burden and distress among Veteran cancer survivors.

Background: Survivorship is an important component of cancer care as patients transition from treatment to surveillance and cope with long-term effects of therapy. Veterans receiving care at the VA are quite different from those described in existing survivorship literature, with lower income and health literacy, poorer physical andmental health, and more comorbidities compared to the general population. Survivorship needs have not been well defined in this population.

Methods: Veterans are referred or recruited to survivorship clinic after completing definitive therapy. An NCCN distress thermometer (DT) is completed in survivorship clinic as part of routine clinical care.

Data Analysis: This analysis was restricted to cancer survivors meeting Commission on Cancer guidance for survivorship care eligibility. Descriptive statistics summarized findings from the DT. To place symptom burden in context, a comparison group was selected consisting of Veterans with comparable cancer site and stage who completed a DT at their first treatment appointment. Reported symptoms were compared to those from survivors with chi-square analysis.

Results: The DT was completed by 47 lung, colorectal, anal, and head and neck cancer survivors between February 2015 and April 2016. Most were white males, with an average age of 66. Of 39 practical, family, emotional, and physical problems included on the DT, survivors reported an average of 9.2 issues (range 0-22). The most common problems were dyspnea (64%), fatigue (60%), pain (57%), sleep (45%), worry (43%), and depression (40%). The average distress score was 3.6 (range 0-9).

The comparison group contained 147 Veterans; they reported an average of 7.4 issues as sources of distress.

Survivors were significantly more likely to report difficulty with breathing, constipation, depression, anhedonia, sadness, sleep concerns, and tingling in the hands and feet. The only issues more common in patients at the start of treatment compared to survivors were nervousness and transportation concerns. There was no difference in concerns regarding treatment decisions, pain, or finances.

Implications: Veteran cancer survivors reported significant symptom burden, particularly concerning mental health and side effects of treatment. Cancer survivorship clinic can play an important role in identifying and addressing the significant symptom burden. A multidisciplinary approach, particularly one including mental health services, is very important.

Purpose: To evaluate the utilization of national drug Criteria for Use documents for oncologic drugs in VHA.

Background: VHA National Pharmacy Benefits Management (PBM) has been developing Criteria for Use (CFU) documents for oncologic therapies since 2001. There is no formalized mechanism to track the utilization of these documents.

Methods: A sample of clinical oncology pharmacy specialists participated in an online survey of five questions regarding recollection of CFU use. A total of 23 active CFU documents were included: 11 for oral and 12 for injectable drugs. 5 questions focused on pharmacist’s recollection of the following: 1) general use of CFU documents as a reference in the past month; 2) use of particular CFU document(s) in the past month; 3) useful document(s); 4) useless document(s); and 5) specific subsections of outdated CFU that need to be updated.

Results: Nineteen pharmacists were surveyed. Responses were provided by 11 for a response rate of 58%. The majority (70%) recall using the ibrutinib CFU in the past month, followed by use of the abiraterone CFU (60%). On average, 36% recall referring to national CFU documents 3-5 times when evaluating drug orders, and 18% recall referring to them more than 5 times. The abiraterone CFU were considered to be useful by 50% of those surveyed. Both abiraterone and enzalutamide were ranked as useful documents (Q#3, n = 10) by 50%, followed by regorafenib and ibrutinib (each 40%). Aprepitant and capecitabine documents were considered to be no longer useful (Q#4, n = 6). When asked about specific areas of the CFU that are in need of update, the overwhelming majority of question responders (Q#5, n = 5) agreed that both Inclusion Criteria (100%) and Exclusion Criteria (80%) were the areas on which to focus. CFU documents for oral therapies were used more often, compared to the injectable therapies (34 vs 15%).

Implications: This pilot highlights variance in utilization and perceived usefulness of CFU documents. Expansion of this pilot with a larger sample size can help direct improvements to increase utilization.

Purpose: To evaluate the utilization of national drug Criteria for Use documents for oncologic drugs in VHA.

Background: VHA National Pharmacy Benefits Management (PBM) has been developing Criteria for Use (CFU) documents for oncologic therapies since 2001. There is no formalized mechanism to track the utilization of these documents.

Methods: A sample of clinical oncology pharmacy specialists participated in an online survey of five questions regarding recollection of CFU use. A total of 23 active CFU documents were included: 11 for oral and 12 for injectable drugs. 5 questions focused on pharmacist’s recollection of the following: 1) general use of CFU documents as a reference in the past month; 2) use of particular CFU document(s) in the past month; 3) useful document(s); 4) useless document(s); and 5) specific subsections of outdated CFU that need to be updated.

Results: Nineteen pharmacists were surveyed. Responses were provided by 11 for a response rate of 58%. The majority (70%) recall using the ibrutinib CFU in the past month, followed by use of the abiraterone CFU (60%). On average, 36% recall referring to national CFU documents 3-5 times when evaluating drug orders, and 18% recall referring to them more than 5 times. The abiraterone CFU were considered to be useful by 50% of those surveyed. Both abiraterone and enzalutamide were ranked as useful documents (Q#3, n = 10) by 50%, followed by regorafenib and ibrutinib (each 40%). Aprepitant and capecitabine documents were considered to be no longer useful (Q#4, n = 6). When asked about specific areas of the CFU that are in need of update, the overwhelming majority of question responders (Q#5, n = 5) agreed that both Inclusion Criteria (100%) and Exclusion Criteria (80%) were the areas on which to focus. CFU documents for oral therapies were used more often, compared to the injectable therapies (34 vs 15%).

Implications: This pilot highlights variance in utilization and perceived usefulness of CFU documents. Expansion of this pilot with a larger sample size can help direct improvements to increase utilization.

Purpose: To evaluate the utilization of national drug Criteria for Use documents for oncologic drugs in VHA.

Background: VHA National Pharmacy Benefits Management (PBM) has been developing Criteria for Use (CFU) documents for oncologic therapies since 2001. There is no formalized mechanism to track the utilization of these documents.

Methods: A sample of clinical oncology pharmacy specialists participated in an online survey of five questions regarding recollection of CFU use. A total of 23 active CFU documents were included: 11 for oral and 12 for injectable drugs. 5 questions focused on pharmacist’s recollection of the following: 1) general use of CFU documents as a reference in the past month; 2) use of particular CFU document(s) in the past month; 3) useful document(s); 4) useless document(s); and 5) specific subsections of outdated CFU that need to be updated.

Results: Nineteen pharmacists were surveyed. Responses were provided by 11 for a response rate of 58%. The majority (70%) recall using the ibrutinib CFU in the past month, followed by use of the abiraterone CFU (60%). On average, 36% recall referring to national CFU documents 3-5 times when evaluating drug orders, and 18% recall referring to them more than 5 times. The abiraterone CFU were considered to be useful by 50% of those surveyed. Both abiraterone and enzalutamide were ranked as useful documents (Q#3, n = 10) by 50%, followed by regorafenib and ibrutinib (each 40%). Aprepitant and capecitabine documents were considered to be no longer useful (Q#4, n = 6). When asked about specific areas of the CFU that are in need of update, the overwhelming majority of question responders (Q#5, n = 5) agreed that both Inclusion Criteria (100%) and Exclusion Criteria (80%) were the areas on which to focus. CFU documents for oral therapies were used more often, compared to the injectable therapies (34 vs 15%).

Implications: This pilot highlights variance in utilization and perceived usefulness of CFU documents. Expansion of this pilot with a larger sample size can help direct improvements to increase utilization.

Purpose: To determine the effect of Chemotherapy Review Subcommittee on cost savings at the ONCVAMC.

Background: Oncology costs have dramatically increased secondary to newly approved cancer drugs. To reduce or avoid the costs of cancer care, more Veterans are seeking treatment through the VA. ONCVAMC cancer patients under treatment have increased ~15%/year for 10 years. Antineoplastic medications are the most expensive component of the pharmacy IV budget. To reduce costs, ONCVAMC oncology providers have implemented cost savings initiatives (CSI).

Methods: CSI for oncology medications included: dose rounding to nearest available vial size; excluding antibody therapy from using actual body surface calculation in obese patients; grouping patients receiving the same drug to appointments on the same day; using multi-dose vials; purchasing generic or lower priced contract drugs. When appropriate, oral agents with comparable effectiveness were substituted for IV pre and post chemotherapy symptom management. Savings are reported as percentage of IV oncology drug expenditures. Cost savings were tracked and reported monthly to the subcommittee.

Data Analysis: Dose rounding to nearest commercially available vial- 58%; excluding antibody therapy from using actual body surface calculation in obese patients- 17%; rounding to nearest vial size- 8.1%; purchasing generic or lower cost contract drugs- 6.6%; grouping patients receiving the same drug to appointments on the same day- 4.9%; multi-dose vial drug formulations- 4.8%; switching to oral agents for pre and post chemotherapy management- 0.6% (implemented 4/2016).

Results: Savings from 10/2015 through 5/2016 were greater than 3% of the total IV oncology drug expenditures. By extrapolation 2016 cost savings will be ~5%. The overall cost savings from 10/1/2015 to 5/31/2016 was $97,061.

Implications: CSI by oncology providers resulted in significant cost savings. CPRS based chemotherapy order sets, implemented 4/2016, will further increase cost savings. However, since newer, more efficacious antineoplastics are more expensive and the ONCVAMC Veterans receiving treatment increase ~15%/year, CSI will not reduce the oncology related costs, but will reduce the rate of increase. Oncology CSI will lead to more efficient use of ONCVAMC expenditures.

Purpose: To determine the effect of Chemotherapy Review Subcommittee on cost savings at the ONCVAMC.

Background: Oncology costs have dramatically increased secondary to newly approved cancer drugs. To reduce or avoid the costs of cancer care, more Veterans are seeking treatment through the VA. ONCVAMC cancer patients under treatment have increased ~15%/year for 10 years. Antineoplastic medications are the most expensive component of the pharmacy IV budget. To reduce costs, ONCVAMC oncology providers have implemented cost savings initiatives (CSI).

Methods: CSI for oncology medications included: dose rounding to nearest available vial size; excluding antibody therapy from using actual body surface calculation in obese patients; grouping patients receiving the same drug to appointments on the same day; using multi-dose vials; purchasing generic or lower priced contract drugs. When appropriate, oral agents with comparable effectiveness were substituted for IV pre and post chemotherapy symptom management. Savings are reported as percentage of IV oncology drug expenditures. Cost savings were tracked and reported monthly to the subcommittee.

Data Analysis: Dose rounding to nearest commercially available vial- 58%; excluding antibody therapy from using actual body surface calculation in obese patients- 17%; rounding to nearest vial size- 8.1%; purchasing generic or lower cost contract drugs- 6.6%; grouping patients receiving the same drug to appointments on the same day- 4.9%; multi-dose vial drug formulations- 4.8%; switching to oral agents for pre and post chemotherapy management- 0.6% (implemented 4/2016).

Results: Savings from 10/2015 through 5/2016 were greater than 3% of the total IV oncology drug expenditures. By extrapolation 2016 cost savings will be ~5%. The overall cost savings from 10/1/2015 to 5/31/2016 was $97,061.

Implications: CSI by oncology providers resulted in significant cost savings. CPRS based chemotherapy order sets, implemented 4/2016, will further increase cost savings. However, since newer, more efficacious antineoplastics are more expensive and the ONCVAMC Veterans receiving treatment increase ~15%/year, CSI will not reduce the oncology related costs, but will reduce the rate of increase. Oncology CSI will lead to more efficient use of ONCVAMC expenditures.

Purpose: To determine the effect of Chemotherapy Review Subcommittee on cost savings at the ONCVAMC.

Background: Oncology costs have dramatically increased secondary to newly approved cancer drugs. To reduce or avoid the costs of cancer care, more Veterans are seeking treatment through the VA. ONCVAMC cancer patients under treatment have increased ~15%/year for 10 years. Antineoplastic medications are the most expensive component of the pharmacy IV budget. To reduce costs, ONCVAMC oncology providers have implemented cost savings initiatives (CSI).

Methods: CSI for oncology medications included: dose rounding to nearest available vial size; excluding antibody therapy from using actual body surface calculation in obese patients; grouping patients receiving the same drug to appointments on the same day; using multi-dose vials; purchasing generic or lower priced contract drugs. When appropriate, oral agents with comparable effectiveness were substituted for IV pre and post chemotherapy symptom management. Savings are reported as percentage of IV oncology drug expenditures. Cost savings were tracked and reported monthly to the subcommittee.

Data Analysis: Dose rounding to nearest commercially available vial- 58%; excluding antibody therapy from using actual body surface calculation in obese patients- 17%; rounding to nearest vial size- 8.1%; purchasing generic or lower cost contract drugs- 6.6%; grouping patients receiving the same drug to appointments on the same day- 4.9%; multi-dose vial drug formulations- 4.8%; switching to oral agents for pre and post chemotherapy management- 0.6% (implemented 4/2016).

Results: Savings from 10/2015 through 5/2016 were greater than 3% of the total IV oncology drug expenditures. By extrapolation 2016 cost savings will be ~5%. The overall cost savings from 10/1/2015 to 5/31/2016 was $97,061.

Implications: CSI by oncology providers resulted in significant cost savings. CPRS based chemotherapy order sets, implemented 4/2016, will further increase cost savings. However, since newer, more efficacious antineoplastics are more expensive and the ONCVAMC Veterans receiving treatment increase ~15%/year, CSI will not reduce the oncology related costs, but will reduce the rate of increase. Oncology CSI will lead to more efficient use of ONCVAMC expenditures.

Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.

Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.

Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.

Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.

Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.

Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.

Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.

Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.

Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.

Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.

Purpose: Palliative Care is essential to Oncology. The purpose of this abstract is to describe the AVAHO Palliative Care Research subcommittee, its objectives, and evidence of its productive multi-disciplinary and inter-institutional collaboration.

Background: The American Society of Clinical Oncology (ASCO) recommends Palliative Care for all patients with metastatic lung cancer and other symptomatic advanced malignancies. VA mandates Palliative Care inpatient consult teams for all medical facilities. It is not clearly known how Palliative Care is integrated into standard VA outpatient Oncology practice. In addition, questions remain regarding the optimal way(s) to provide Palliative Oncology Care. The AVAHO Palliative Care Research subcommittee was established in 2015 and currently has 7 members from 7 VA institutions. The mission of the subcommittee is to develop partnerships among VA clinicians, pharmacists, social workers, researchers, and VA leadership with the shared goal of providing optimal Palliative Oncology Care within the VA. In laying the groundwork for productive collaboration, we have identified a need to better understand the current interface between VA Oncology Clinics and Palliative Care teams. In particular, we seek to review the evidence for providing on-site Palliative Care to patients with advanced malignancies, and we seek to understand the current availability of outpatient Palliative Care within VA outpatient Oncology clinics.

Methods: We have identified 2 initial approaches to address these questions. First, we have submitted a proposal to the VA Evidence-Based Synthesis Program (ESP) to review the evidence regarding optimal Palliative Care delivery methods for patients with advanced malignancies and
the feasibility of providing on-site Palliative Care embedded into VA Oncology clinics. Second, we plan to survey current VA Oncology providers to understand their Palliative Care referral patterns, available on-site resources, and barriers to providing optimal Palliative Care for their patients.

Analysis/Results: At the AVAHO 2016 meeting, we will provide updated information on the ESP proposal and the Palliative Care in Oncology Survey.

Conclusion: The AVAHO Palliative Care Research subcommittee represents a multidisciplinary and inter-institutional collaboration with a common goal of optimizing VA Palliative Oncology Care. This subcommittee is a model of how AVAHO can foster productive collaborations. We welcome new members.

Purpose: To evaluate failure rates of patients from a single institution who underwent salvage and adjuvant radiation therapy (RT) following radical retropubic prostatectomy for adenocarcinoma of the prostate.

Methods: Between 2002 and 2015, 62 patients were treated with Intensity Modulated Radiation Therapy following Radical Retropubic Prostatectomy (RRP). Of these, 45 (72.6%) patients received salvage therapy, all of whom had a Prostate Specific Antigen (PSA) of > 0.2; while 17 (27.4%) patients underwent adjuvant RT at a median of 5 months following RRP, due to having either positive extracapsular extension (ECE) (65%), seminal vesicle invasion (SVI) (29%), and/or positive margins (65%). The median dose delivered to the prostate fossa, as per the Radiation Therapy Oncology Group guidelines for post-prostatectomy radiation therapy, was 6600c Gy at 180-200 cGy a fraction. In the salvage group, 9 patients ended up receiving androgen deprivation therapy (ADT) at some point following RRP, while 7 patients were prescribed ADT in the adjuvant group.

Results: With the median follow-up of 62 months, the median disease free survival rates were 10.8 and 4.3 years (P < 0.011) for the salvage and adjuvant groups, respectively. Biochemical progression free survival (bPFS) for the adjuvant groups was statistically significant (78.9%), when compared to 40% in the salvage group (P < 0.011). The patterns of failure in the salvage group were 9 patients had local failure (LF), 2 distant metastases (DM), and 3 patients had both LF and DM in the salvage group. On the other hand, in the adjuvant treatment group there was 1 patient with LF, 1 with DM and 1 patient with both LF and DM. Of those who failed following RT, the median time to failure was 25 and 99 months in the salvage and adjuvant groups, respectively. No patient experienced any sort of grade 3 toxicity following RT in either of the groups, per the CTCAE v3.0 criteria.

Conclusion: A retrospective review of 62 patients who received radiation therapy in either the salvage or adjuvant setting following prostatectomy revealed that adjuvant patients were with superior local control rates than salvage patients. We conclude that patients with high-risk features following prostatectomy receive adjuvant therapy and not delay radiation therapy until there is biochemical failure.

Purpose: To evaluate failure rates of patients from a single institution who underwent salvage and adjuvant radiation therapy (RT) following radical retropubic prostatectomy for adenocarcinoma of the prostate.

Methods: Between 2002 and 2015, 62 patients were treated with Intensity Modulated Radiation Therapy following Radical Retropubic Prostatectomy (RRP). Of these, 45 (72.6%) patients received salvage therapy, all of whom had a Prostate Specific Antigen (PSA) of > 0.2; while 17 (27.4%) patients underwent adjuvant RT at a median of 5 months following RRP, due to having either positive extracapsular extension (ECE) (65%), seminal vesicle invasion (SVI) (29%), and/or positive margins (65%). The median dose delivered to the prostate fossa, as per the Radiation Therapy Oncology Group guidelines for post-prostatectomy radiation therapy, was 6600c Gy at 180-200 cGy a fraction. In the salvage group, 9 patients ended up receiving androgen deprivation therapy (ADT) at some point following RRP, while 7 patients were prescribed ADT in the adjuvant group.

Results: With the median follow-up of 62 months, the median disease free survival rates were 10.8 and 4.3 years (P < 0.011) for the salvage and adjuvant groups, respectively. Biochemical progression free survival (bPFS) for the adjuvant groups was statistically significant (78.9%), when compared to 40% in the salvage group (P < 0.011). The patterns of failure in the salvage group were 9 patients had local failure (LF), 2 distant metastases (DM), and 3 patients had both LF and DM in the salvage group. On the other hand, in the adjuvant treatment group there was 1 patient with LF, 1 with DM and 1 patient with both LF and DM. Of those who failed following RT, the median time to failure was 25 and 99 months in the salvage and adjuvant groups, respectively. No patient experienced any sort of grade 3 toxicity following RT in either of the groups, per the CTCAE v3.0 criteria.

Conclusion: A retrospective review of 62 patients who received radiation therapy in either the salvage or adjuvant setting following prostatectomy revealed that adjuvant patients were with superior local control rates than salvage patients. We conclude that patients with high-risk features following prostatectomy receive adjuvant therapy and not delay radiation therapy until there is biochemical failure.

Purpose: To evaluate failure rates of patients from a single institution who underwent salvage and adjuvant radiation therapy (RT) following radical retropubic prostatectomy for adenocarcinoma of the prostate.

Methods: Between 2002 and 2015, 62 patients were treated with Intensity Modulated Radiation Therapy following Radical Retropubic Prostatectomy (RRP). Of these, 45 (72.6%) patients received salvage therapy, all of whom had a Prostate Specific Antigen (PSA) of > 0.2; while 17 (27.4%) patients underwent adjuvant RT at a median of 5 months following RRP, due to having either positive extracapsular extension (ECE) (65%), seminal vesicle invasion (SVI) (29%), and/or positive margins (65%). The median dose delivered to the prostate fossa, as per the Radiation Therapy Oncology Group guidelines for post-prostatectomy radiation therapy, was 6600c Gy at 180-200 cGy a fraction. In the salvage group, 9 patients ended up receiving androgen deprivation therapy (ADT) at some point following RRP, while 7 patients were prescribed ADT in the adjuvant group.

Results: With the median follow-up of 62 months, the median disease free survival rates were 10.8 and 4.3 years (P < 0.011) for the salvage and adjuvant groups, respectively. Biochemical progression free survival (bPFS) for the adjuvant groups was statistically significant (78.9%), when compared to 40% in the salvage group (P < 0.011). The patterns of failure in the salvage group were 9 patients had local failure (LF), 2 distant metastases (DM), and 3 patients had both LF and DM in the salvage group. On the other hand, in the adjuvant treatment group there was 1 patient with LF, 1 with DM and 1 patient with both LF and DM. Of those who failed following RT, the median time to failure was 25 and 99 months in the salvage and adjuvant groups, respectively. No patient experienced any sort of grade 3 toxicity following RT in either of the groups, per the CTCAE v3.0 criteria.

Conclusion: A retrospective review of 62 patients who received radiation therapy in either the salvage or adjuvant setting following prostatectomy revealed that adjuvant patients were with superior local control rates than salvage patients. We conclude that patients with high-risk features following prostatectomy receive adjuvant therapy and not delay radiation therapy until there is biochemical failure.

Linden Spital, NP, a psychiatric mental-health nurse practitioner, staffs the Psychiatric Consultation Liaison Service at the University of Michigan in Ann Arbor. Nearly every hospital larger than about 200 beds, she says, could benefit from a similar service, and hospitalists could play an important role in creating it.

I wrote about the idea for a generally similar service in my April 2015 column, but at the time, I didn’t know of an institution that had something like this in place.

Along with her hospitalist colleagues, Anupama (Anu) Goyal, MBChB, and Rob Chang, MD, Linden has launched a service to provide assistance to bedside caregivers dealing with very difficult patients (eg, those who are verbally or physically threatening to staff, unreasonably demanding and angry, have bizarre behavior, etc.).

Sample Cases

Two recent cases illustrate the role of the service. A female patient in her 60s had several admissions characterized by what many caregivers agreed were unreasonably precise demands regarding how her care should be delivered. She was verbally abusive of caregivers, especially those who were young or of a different race, and her family member tended to reinforce these maladaptive behaviors. Staff found it very stressful to care for her and had concerns that her care suffered as a result.

Linden served as a resource and support for staff, plus worked with providers to set limits on the patient and family behavior and to separate patient behaviors that were and weren’t modifiable. Linden’s efforts helped clarify the goals for the patient’s care and reduced staff distress. Even though the patient’s behavior didn’t change significantly, staff anecdotally reported less distress and concern that the patient’s care suffered as a result.

Another case involved a man in his 50s who had a progressive neurodegenerative disease and was admitted because of increasingly aggressive behavior in his skilled-nursing facility (SNF). Providers at the SNF attributed the poor behavior to changes in medications. His behavior was very difficult to manage, and staff asked for Linden’s help. She worked with the patient and realized much of his difficult behavior stemmed from his frustration with communicating verbally because of his neurologic disease. Rather than pursue increasing psychotropics, Linden promoted efforts to develop a system of hand signals the patient could use to communicate needs. His behavior improved, presumably by reducing his own frustration and improving his autonomy.

Atypical Consults

This psychiatric consultation liaison service has some overlap with traditional inpatient psychiatry services, but it is configured so that the caregiver is essentially embedded on the medical units of the hospital and assists in the care of patients who wouldn’t typically be appropriate for a psychiatry consult. For example, patients and/or families who act out because of anger over being on observation status are appropriate for this service but would usually not be appropriate for a psychiatry consult. The two examples above aren’t ideal cases for a standard psychiatry consult; however, the attending hospitalist needed help nonetheless.

Operational Details

The liaison service started with a successful trial on two hospital units in 2013. Linden began serving as the sole clinician on the service in January 2015. She is available during the daytime on weekdays, and any staff can request her participation in the care of a patient. Her visits are billed when appropriate, but many aren’t billed (for example, if her primary work was to conference with staff regarding management of a patient).

Consults can be requested by anyone (nurses, etc., as well as physicians, though only the latter would be billable) via an electronic health record entry that helps ensure whether the request is for this service versus the inpatient psychiatry service. The order includes a standard list of potential reasons for consult that can be selected and amplified with free text comments. She also receives verbal consult requests as she moves through the hospital.

Linden’s position is budgeted through the psychiatry department and funded by the hospital with only modest professional fee collections.

An Idea That Is Catching On?

Anu Goyal made me aware of a study from 2004 that summarized findings from experience with a similar service at Washington University in St. Louis, but the service was cancelled after a short time due to its cost.1 She also found a few studies from the 1990s and a 2001 study from Australia that report on a similar service.

But maybe the idea is catching on again, at least a little.

On April 25, The Wall Street Journal published an article titled “Hospitals Test Putting Psychiatrists on Medical Wards.”2 It described programs at Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore, and NewYork-Presbyterian/Columbia University Medical Center in New York City. They share some similarities with the service at the University of Michigan. However, according to the article, the three big-city programs tilt more toward a traditional consultation model than what Linden does.

I think every hospital should be thinking about a service other than traditional consult psychiatry that could help with challenging patient behavior. The University of Michigan model or similar ones seem like a good place to start. TH

Reference

1. Yakimo R, Kurlowicz L, Murray R. Evaluation of outcomes in psychiatric consultation-liaison nursing practice. Arch Psychiatr Nurs. 2004;18(6):215-227.

   2. Ladnado L. Hospitals test putting psychiatrists on medical wards. The Wall Street Journal website. Accessed July 3, 2016.

Linden Spital, NP, a psychiatric mental-health nurse practitioner, staffs the Psychiatric Consultation Liaison Service at the University of Michigan in Ann Arbor. Nearly every hospital larger than about 200 beds, she says, could benefit from a similar service, and hospitalists could play an important role in creating it.

I wrote about the idea for a generally similar service in my April 2015 column, but at the time, I didn’t know of an institution that had something like this in place.

Along with her hospitalist colleagues, Anupama (Anu) Goyal, MBChB, and Rob Chang, MD, Linden has launched a service to provide assistance to bedside caregivers dealing with very difficult patients (eg, those who are verbally or physically threatening to staff, unreasonably demanding and angry, have bizarre behavior, etc.).

Sample Cases

Two recent cases illustrate the role of the service. A female patient in her 60s had several admissions characterized by what many caregivers agreed were unreasonably precise demands regarding how her care should be delivered. She was verbally abusive of caregivers, especially those who were young or of a different race, and her family member tended to reinforce these maladaptive behaviors. Staff found it very stressful to care for her and had concerns that her care suffered as a result.

Linden served as a resource and support for staff, plus worked with providers to set limits on the patient and family behavior and to separate patient behaviors that were and weren’t modifiable. Linden’s efforts helped clarify the goals for the patient’s care and reduced staff distress. Even though the patient’s behavior didn’t change significantly, staff anecdotally reported less distress and concern that the patient’s care suffered as a result.

Another case involved a man in his 50s who had a progressive neurodegenerative disease and was admitted because of increasingly aggressive behavior in his skilled-nursing facility (SNF). Providers at the SNF attributed the poor behavior to changes in medications. His behavior was very difficult to manage, and staff asked for Linden’s help. She worked with the patient and realized much of his difficult behavior stemmed from his frustration with communicating verbally because of his neurologic disease. Rather than pursue increasing psychotropics, Linden promoted efforts to develop a system of hand signals the patient could use to communicate needs. His behavior improved, presumably by reducing his own frustration and improving his autonomy.

Atypical Consults

This psychiatric consultation liaison service has some overlap with traditional inpatient psychiatry services, but it is configured so that the caregiver is essentially embedded on the medical units of the hospital and assists in the care of patients who wouldn’t typically be appropriate for a psychiatry consult. For example, patients and/or families who act out because of anger over being on observation status are appropriate for this service but would usually not be appropriate for a psychiatry consult. The two examples above aren’t ideal cases for a standard psychiatry consult; however, the attending hospitalist needed help nonetheless.

Operational Details

The liaison service started with a successful trial on two hospital units in 2013. Linden began serving as the sole clinician on the service in January 2015. She is available during the daytime on weekdays, and any staff can request her participation in the care of a patient. Her visits are billed when appropriate, but many aren’t billed (for example, if her primary work was to conference with staff regarding management of a patient).

Consults can be requested by anyone (nurses, etc., as well as physicians, though only the latter would be billable) via an electronic health record entry that helps ensure whether the request is for this service versus the inpatient psychiatry service. The order includes a standard list of potential reasons for consult that can be selected and amplified with free text comments. She also receives verbal consult requests as she moves through the hospital.

Linden’s position is budgeted through the psychiatry department and funded by the hospital with only modest professional fee collections.

An Idea That Is Catching On?

Anu Goyal made me aware of a study from 2004 that summarized findings from experience with a similar service at Washington University in St. Louis, but the service was cancelled after a short time due to its cost.1 She also found a few studies from the 1990s and a 2001 study from Australia that report on a similar service.

But maybe the idea is catching on again, at least a little.

On April 25, The Wall Street Journal published an article titled “Hospitals Test Putting Psychiatrists on Medical Wards.”2 It described programs at Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore, and NewYork-Presbyterian/Columbia University Medical Center in New York City. They share some similarities with the service at the University of Michigan. However, according to the article, the three big-city programs tilt more toward a traditional consultation model than what Linden does.

I think every hospital should be thinking about a service other than traditional consult psychiatry that could help with challenging patient behavior. The University of Michigan model or similar ones seem like a good place to start. TH

Reference

1. Yakimo R, Kurlowicz L, Murray R. Evaluation of outcomes in psychiatric consultation-liaison nursing practice. Arch Psychiatr Nurs. 2004;18(6):215-227.

   2. Ladnado L. Hospitals test putting psychiatrists on medical wards. The Wall Street Journal website. Accessed July 3, 2016.

Linden Spital, NP, a psychiatric mental-health nurse practitioner, staffs the Psychiatric Consultation Liaison Service at the University of Michigan in Ann Arbor. Nearly every hospital larger than about 200 beds, she says, could benefit from a similar service, and hospitalists could play an important role in creating it.

I wrote about the idea for a generally similar service in my April 2015 column, but at the time, I didn’t know of an institution that had something like this in place.

Along with her hospitalist colleagues, Anupama (Anu) Goyal, MBChB, and Rob Chang, MD, Linden has launched a service to provide assistance to bedside caregivers dealing with very difficult patients (eg, those who are verbally or physically threatening to staff, unreasonably demanding and angry, have bizarre behavior, etc.).

Sample Cases

Two recent cases illustrate the role of the service. A female patient in her 60s had several admissions characterized by what many caregivers agreed were unreasonably precise demands regarding how her care should be delivered. She was verbally abusive of caregivers, especially those who were young or of a different race, and her family member tended to reinforce these maladaptive behaviors. Staff found it very stressful to care for her and had concerns that her care suffered as a result.

Linden served as a resource and support for staff, plus worked with providers to set limits on the patient and family behavior and to separate patient behaviors that were and weren’t modifiable. Linden’s efforts helped clarify the goals for the patient’s care and reduced staff distress. Even though the patient’s behavior didn’t change significantly, staff anecdotally reported less distress and concern that the patient’s care suffered as a result.

Another case involved a man in his 50s who had a progressive neurodegenerative disease and was admitted because of increasingly aggressive behavior in his skilled-nursing facility (SNF). Providers at the SNF attributed the poor behavior to changes in medications. His behavior was very difficult to manage, and staff asked for Linden’s help. She worked with the patient and realized much of his difficult behavior stemmed from his frustration with communicating verbally because of his neurologic disease. Rather than pursue increasing psychotropics, Linden promoted efforts to develop a system of hand signals the patient could use to communicate needs. His behavior improved, presumably by reducing his own frustration and improving his autonomy.

Atypical Consults

This psychiatric consultation liaison service has some overlap with traditional inpatient psychiatry services, but it is configured so that the caregiver is essentially embedded on the medical units of the hospital and assists in the care of patients who wouldn’t typically be appropriate for a psychiatry consult. For example, patients and/or families who act out because of anger over being on observation status are appropriate for this service but would usually not be appropriate for a psychiatry consult. The two examples above aren’t ideal cases for a standard psychiatry consult; however, the attending hospitalist needed help nonetheless.

Operational Details

The liaison service started with a successful trial on two hospital units in 2013. Linden began serving as the sole clinician on the service in January 2015. She is available during the daytime on weekdays, and any staff can request her participation in the care of a patient. Her visits are billed when appropriate, but many aren’t billed (for example, if her primary work was to conference with staff regarding management of a patient).

Consults can be requested by anyone (nurses, etc., as well as physicians, though only the latter would be billable) via an electronic health record entry that helps ensure whether the request is for this service versus the inpatient psychiatry service. The order includes a standard list of potential reasons for consult that can be selected and amplified with free text comments. She also receives verbal consult requests as she moves through the hospital.

Linden’s position is budgeted through the psychiatry department and funded by the hospital with only modest professional fee collections.

An Idea That Is Catching On?

Anu Goyal made me aware of a study from 2004 that summarized findings from experience with a similar service at Washington University in St. Louis, but the service was cancelled after a short time due to its cost.1 She also found a few studies from the 1990s and a 2001 study from Australia that report on a similar service.

But maybe the idea is catching on again, at least a little.

On April 25, The Wall Street Journal published an article titled “Hospitals Test Putting Psychiatrists on Medical Wards.”2 It described programs at Brigham and Women’s Hospital in Boston, Johns Hopkins Hospital in Baltimore, and NewYork-Presbyterian/Columbia University Medical Center in New York City. They share some similarities with the service at the University of Michigan. However, according to the article, the three big-city programs tilt more toward a traditional consultation model than what Linden does.

I think every hospital should be thinking about a service other than traditional consult psychiatry that could help with challenging patient behavior. The University of Michigan model or similar ones seem like a good place to start. TH

Reference

1. Yakimo R, Kurlowicz L, Murray R. Evaluation of outcomes in psychiatric consultation-liaison nursing practice. Arch Psychiatr Nurs. 2004;18(6):215-227.

   2. Ladnado L. Hospitals test putting psychiatrists on medical wards. The Wall Street Journal website. Accessed July 3, 2016.

An 88-year-old male with locally advanced basal-cell carcinoma (BCC) of the scalp who had received multiple resections, stem cell graft, and amniotic allograft continued to progress with severe ulcerations that extended into the dura. Patient was initiated on vismodegib 150 mg daily and subsequently developed a diffuse maculopapular rash within 14 days of treatment. The rash resolved with topical triamcinolone 0.1% and discontinuation of vismodegib. Loratadine 10 mg daily was concurrently administered for rash prophylaxis upon vismodegib re-initiation. Within 7 days of therapy, the rash returned, and subsequently vismodegib was discontinued and oral prednisone taper was initiated. Given limited effective treatment options, vismodegib was continued at a modified schedule of 150 mg daily for 2 weeks then 1 week off with prednisone 5 mg daily. To date, patient has completed 2 years of treatment with no return of rash or disease progression.

BCC occurs in 2 million patients annually in the US. Fortunately, most of these cases are responsive to local therapy with rare metastatic progression. The emergence of novel Hedgehog pathway inhibitors (vismodegib, sonidegib) provide effective options for advanced BCC. Although vismodegib has been reported to cause Grade 3-4 adverse events in 25% of patients, there are no reports of vismodegib-induced rash nor recommendations regarding management.

For many novel targeted therapies, the appropriate management of toxicities has not been well described. This case study presents a patient that continues to respond to therapy with a novel modified dosing scheme in addition to low-dose prednisone. We present this case report to offer a potential treatment option in patients who experience a vismodegib-induced rash.

An 88-year-old male with locally advanced basal-cell carcinoma (BCC) of the scalp who had received multiple resections, stem cell graft, and amniotic allograft continued to progress with severe ulcerations that extended into the dura. Patient was initiated on vismodegib 150 mg daily and subsequently developed a diffuse maculopapular rash within 14 days of treatment. The rash resolved with topical triamcinolone 0.1% and discontinuation of vismodegib. Loratadine 10 mg daily was concurrently administered for rash prophylaxis upon vismodegib re-initiation. Within 7 days of therapy, the rash returned, and subsequently vismodegib was discontinued and oral prednisone taper was initiated. Given limited effective treatment options, vismodegib was continued at a modified schedule of 150 mg daily for 2 weeks then 1 week off with prednisone 5 mg daily. To date, patient has completed 2 years of treatment with no return of rash or disease progression.

BCC occurs in 2 million patients annually in the US. Fortunately, most of these cases are responsive to local therapy with rare metastatic progression. The emergence of novel Hedgehog pathway inhibitors (vismodegib, sonidegib) provide effective options for advanced BCC. Although vismodegib has been reported to cause Grade 3-4 adverse events in 25% of patients, there are no reports of vismodegib-induced rash nor recommendations regarding management.

For many novel targeted therapies, the appropriate management of toxicities has not been well described. This case study presents a patient that continues to respond to therapy with a novel modified dosing scheme in addition to low-dose prednisone. We present this case report to offer a potential treatment option in patients who experience a vismodegib-induced rash.

An 88-year-old male with locally advanced basal-cell carcinoma (BCC) of the scalp who had received multiple resections, stem cell graft, and amniotic allograft continued to progress with severe ulcerations that extended into the dura. Patient was initiated on vismodegib 150 mg daily and subsequently developed a diffuse maculopapular rash within 14 days of treatment. The rash resolved with topical triamcinolone 0.1% and discontinuation of vismodegib. Loratadine 10 mg daily was concurrently administered for rash prophylaxis upon vismodegib re-initiation. Within 7 days of therapy, the rash returned, and subsequently vismodegib was discontinued and oral prednisone taper was initiated. Given limited effective treatment options, vismodegib was continued at a modified schedule of 150 mg daily for 2 weeks then 1 week off with prednisone 5 mg daily. To date, patient has completed 2 years of treatment with no return of rash or disease progression.

BCC occurs in 2 million patients annually in the US. Fortunately, most of these cases are responsive to local therapy with rare metastatic progression. The emergence of novel Hedgehog pathway inhibitors (vismodegib, sonidegib) provide effective options for advanced BCC. Although vismodegib has been reported to cause Grade 3-4 adverse events in 25% of patients, there are no reports of vismodegib-induced rash nor recommendations regarding management.

For many novel targeted therapies, the appropriate management of toxicities has not been well described. This case study presents a patient that continues to respond to therapy with a novel modified dosing scheme in addition to low-dose prednisone. We present this case report to offer a potential treatment option in patients who experience a vismodegib-induced rash.

Purpose: In 2015, the New Mexico VA Health Care System completion of colorectal cancer screening fell below the national VA average of 82%. The facility Healthcare Effectiveness Data and Information Set (HEDIS) mean aggregated data for Colorectal Cancer Screening was 74.14%. This presents an alarming truth: the failure to screen 25% of the Veteran population served.

The projects purpose stands to improve quality outcomes through the early detection and prevention of colorectal cancer by increasing provider and Veteran awareness.

Relevant Background/Problem: Colorectal cancer is the third leading cause of cancer deaths and remains preventable through appropriate and timely screening. In 2012, 134,784 people in the United States were diagnosed with colorectal cancer, of which 51,516 people died.

Barriers leading to low screening compliance include knowledge deficits, fear, access, and common myths and misconceptions. Providers and Veterans fail to understand the difference of recommended screening anddiagnostic guidelines; available prevention/ detection options/ personal risk factors; ultimately neglecting screening completion due to lack of symptoms.

Methods: We held an Outreach Colorectal Cancer Awareness Fair for the community. A 20-foot long inflatable colon, depicting various stages of abnormalities was brought in. Attendees completed screening questionnaires, focusing on risk factors/ history/ symptoms. These were reviewed on site with providers, and appropriate care was ordered: colonoscopy or FIT testing. Various educational booths served to provide education using evidence-based data. Follow-up letters and calls after the event served to increase Veteran compliance. The local news station showcased the VAMC in a positive light.

Results: We had 355 attendees. 104 Veterans completed screening. 71% of Veterans were identified as needing further diagnostic testing based on provider assessment. 6 Veterans were given FIT packets on that day; an additional 17 were later identified based on review of forms (total 22%). Initial return rate of FIT cards was 83%, exceeding facility norm, and 51 Veterans were scheduled for colonoscopy (49%).

Implications: The overall outcome from this event has been to greatly improve attitudes from the level of the patient and employee volunteers to the community and upper management: improving the overall awareness to screening and diagnostic modalities for colorectal cancer.

Purpose: In 2015, the New Mexico VA Health Care System completion of colorectal cancer screening fell below the national VA average of 82%. The facility Healthcare Effectiveness Data and Information Set (HEDIS) mean aggregated data for Colorectal Cancer Screening was 74.14%. This presents an alarming truth: the failure to screen 25% of the Veteran population served.

The projects purpose stands to improve quality outcomes through the early detection and prevention of colorectal cancer by increasing provider and Veteran awareness.

Relevant Background/Problem: Colorectal cancer is the third leading cause of cancer deaths and remains preventable through appropriate and timely screening. In 2012, 134,784 people in the United States were diagnosed with colorectal cancer, of which 51,516 people died.

Barriers leading to low screening compliance include knowledge deficits, fear, access, and common myths and misconceptions. Providers and Veterans fail to understand the difference of recommended screening anddiagnostic guidelines; available prevention/ detection options/ personal risk factors; ultimately neglecting screening completion due to lack of symptoms.

Methods: We held an Outreach Colorectal Cancer Awareness Fair for the community. A 20-foot long inflatable colon, depicting various stages of abnormalities was brought in. Attendees completed screening questionnaires, focusing on risk factors/ history/ symptoms. These were reviewed on site with providers, and appropriate care was ordered: colonoscopy or FIT testing. Various educational booths served to provide education using evidence-based data. Follow-up letters and calls after the event served to increase Veteran compliance. The local news station showcased the VAMC in a positive light.

Results: We had 355 attendees. 104 Veterans completed screening. 71% of Veterans were identified as needing further diagnostic testing based on provider assessment. 6 Veterans were given FIT packets on that day; an additional 17 were later identified based on review of forms (total 22%). Initial return rate of FIT cards was 83%, exceeding facility norm, and 51 Veterans were scheduled for colonoscopy (49%).

Implications: The overall outcome from this event has been to greatly improve attitudes from the level of the patient and employee volunteers to the community and upper management: improving the overall awareness to screening and diagnostic modalities for colorectal cancer.

Purpose: In 2015, the New Mexico VA Health Care System completion of colorectal cancer screening fell below the national VA average of 82%. The facility Healthcare Effectiveness Data and Information Set (HEDIS) mean aggregated data for Colorectal Cancer Screening was 74.14%. This presents an alarming truth: the failure to screen 25% of the Veteran population served.

The projects purpose stands to improve quality outcomes through the early detection and prevention of colorectal cancer by increasing provider and Veteran awareness.

Relevant Background/Problem: Colorectal cancer is the third leading cause of cancer deaths and remains preventable through appropriate and timely screening. In 2012, 134,784 people in the United States were diagnosed with colorectal cancer, of which 51,516 people died.

Barriers leading to low screening compliance include knowledge deficits, fear, access, and common myths and misconceptions. Providers and Veterans fail to understand the difference of recommended screening anddiagnostic guidelines; available prevention/ detection options/ personal risk factors; ultimately neglecting screening completion due to lack of symptoms.

Methods: We held an Outreach Colorectal Cancer Awareness Fair for the community. A 20-foot long inflatable colon, depicting various stages of abnormalities was brought in. Attendees completed screening questionnaires, focusing on risk factors/ history/ symptoms. These were reviewed on site with providers, and appropriate care was ordered: colonoscopy or FIT testing. Various educational booths served to provide education using evidence-based data. Follow-up letters and calls after the event served to increase Veteran compliance. The local news station showcased the VAMC in a positive light.

Results: We had 355 attendees. 104 Veterans completed screening. 71% of Veterans were identified as needing further diagnostic testing based on provider assessment. 6 Veterans were given FIT packets on that day; an additional 17 were later identified based on review of forms (total 22%). Initial return rate of FIT cards was 83%, exceeding facility norm, and 51 Veterans were scheduled for colonoscopy (49%).

Implications: The overall outcome from this event has been to greatly improve attitudes from the level of the patient and employee volunteers to the community and upper management: improving the overall awareness to screening and diagnostic modalities for colorectal cancer.

Background: Peripherally Inserted Central Catheter (PICC) is an intravenous line placed into the patient’s upper arm to safely administer chemotherapy. For years, many patients receiving chemotherapy through a PICC line in the Outpatient Chemotherapy Clinic developed skin irritation and dermatitis at the insertion site. Interventions included, but were not limited to, corticosteroid spray, anti-histamine, occlusive dressing change, and covering the PICC site with gauze. Sometimes, replacement was needed for severe irritation or infection. These complications can lead to chronic discomfort, hospitalization, and delayed treatment.

Purpose: The purpose of this project was to reduce the incidence of PICC line skin irritation and dermatitis in patients receiving outpatient chemotherapy.

Methods: Nursing procedure required the PICC line dressing to be changed weekly. The site was cleansed with chlorhexidine, dried, and a chlorhexidine-soaked sponge was applied at the catheter exit site. The catheter was then secured with a catheter stabilization device and covered with a transparent occlusive dressing. The revised method added Cavilon No-Sting Barrier Film. The film was applied except to the area around the catheter exit site after the chlorhexidine was dried to create a barrier between the skin and the occlusive dressing. Skin condition was measured using the International Contact Dermatitis Research Group Scoring Scale.

Results: Results were evaluated through retrospective chart review. During the 3-months pre-implementation, 33 PICC lines were placed, 5 were replaced, and 32% had documented skin irritation. During the 3-months post-implementation, 28 PICC lines were placed, 3 were replaced, and 4% had documented skin irritation.

Conclusion: The results demonstrate a significant reduction of skin irritation incidence and support the use of Cavilon No-Sting Barrier Film as part of the PICC line dressing change. Evaluation in different settings with different PICC line populations is needed to fully evaluate efficacy.

Background: Peripherally Inserted Central Catheter (PICC) is an intravenous line placed into the patient’s upper arm to safely administer chemotherapy. For years, many patients receiving chemotherapy through a PICC line in the Outpatient Chemotherapy Clinic developed skin irritation and dermatitis at the insertion site. Interventions included, but were not limited to, corticosteroid spray, anti-histamine, occlusive dressing change, and covering the PICC site with gauze. Sometimes, replacement was needed for severe irritation or infection. These complications can lead to chronic discomfort, hospitalization, and delayed treatment.

Purpose: The purpose of this project was to reduce the incidence of PICC line skin irritation and dermatitis in patients receiving outpatient chemotherapy.

Methods: Nursing procedure required the PICC line dressing to be changed weekly. The site was cleansed with chlorhexidine, dried, and a chlorhexidine-soaked sponge was applied at the catheter exit site. The catheter was then secured with a catheter stabilization device and covered with a transparent occlusive dressing. The revised method added Cavilon No-Sting Barrier Film. The film was applied except to the area around the catheter exit site after the chlorhexidine was dried to create a barrier between the skin and the occlusive dressing. Skin condition was measured using the International Contact Dermatitis Research Group Scoring Scale.

Results: Results were evaluated through retrospective chart review. During the 3-months pre-implementation, 33 PICC lines were placed, 5 were replaced, and 32% had documented skin irritation. During the 3-months post-implementation, 28 PICC lines were placed, 3 were replaced, and 4% had documented skin irritation.

Conclusion: The results demonstrate a significant reduction of skin irritation incidence and support the use of Cavilon No-Sting Barrier Film as part of the PICC line dressing change. Evaluation in different settings with different PICC line populations is needed to fully evaluate efficacy.

Background: Peripherally Inserted Central Catheter (PICC) is an intravenous line placed into the patient’s upper arm to safely administer chemotherapy. For years, many patients receiving chemotherapy through a PICC line in the Outpatient Chemotherapy Clinic developed skin irritation and dermatitis at the insertion site. Interventions included, but were not limited to, corticosteroid spray, anti-histamine, occlusive dressing change, and covering the PICC site with gauze. Sometimes, replacement was needed for severe irritation or infection. These complications can lead to chronic discomfort, hospitalization, and delayed treatment.

Purpose: The purpose of this project was to reduce the incidence of PICC line skin irritation and dermatitis in patients receiving outpatient chemotherapy.

Methods: Nursing procedure required the PICC line dressing to be changed weekly. The site was cleansed with chlorhexidine, dried, and a chlorhexidine-soaked sponge was applied at the catheter exit site. The catheter was then secured with a catheter stabilization device and covered with a transparent occlusive dressing. The revised method added Cavilon No-Sting Barrier Film. The film was applied except to the area around the catheter exit site after the chlorhexidine was dried to create a barrier between the skin and the occlusive dressing. Skin condition was measured using the International Contact Dermatitis Research Group Scoring Scale.

Results: Results were evaluated through retrospective chart review. During the 3-months pre-implementation, 33 PICC lines were placed, 5 were replaced, and 32% had documented skin irritation. During the 3-months post-implementation, 28 PICC lines were placed, 3 were replaced, and 4% had documented skin irritation.

Conclusion: The results demonstrate a significant reduction of skin irritation incidence and support the use of Cavilon No-Sting Barrier Film as part of the PICC line dressing change. Evaluation in different settings with different PICC line populations is needed to fully evaluate efficacy.