267 Background: Chemotherapy accelerates the natural decline of ovarian reserve. Women with a new cancer diagnosis commonly experience psychosocial distress around anticipated fertility loss. Fertility preservation via oocyte cryopreservation or temporary ovarian suppression with GnRH agonists may address this concern. ASCO guidelines recommend early discussion of fertility, preservation methods, psychosocial distress counseling, and referral to a fertility specialist. Disparities have been shown in fertility counseling rates based on patient age, race and cancer type. We sought to identify patterns in fertility preservation practices at Lifespan Cancer Institute. Methods: We retrospectively reviewed the medical record of female patients aged 18-45 years at time of solid tumor or lymphoma diagnosis in the years 2014-2019 who received chemotherapy. We compared documented fertility discussions and referrals across patient demographics and provider characteristics. Generalized mixed effects modeling was used with a logit link or a log link (negative binomial or zero inflated truncated Poisson distribution). Results: Among 181 patients who met eligibility criteria, the median age was 38 years with 140 (77.3%) White and 23 (12.7%) Hispanic. Only 112 patients (61.9%) had a conversation about fertility documented by a medical oncologist. Overall, 42 (23.2%) were referred to a fertility specialist and 28 (15.5%) received fertility preservation. Older patients and patients with higher parity were less likely to have a conversation about fertility with their oncologist (parity: OR = 0.33, p = 0.0020; age: OR = 0.64, p = 0.0439) or to be referred to a fertility specialist (parity: OR = 0.87, p = < 0.0001; age: OR = 0.97, p < 0.0001). Male providers were less likely to refer patients to a specialist (OR = 0.85, p = 0.0155) or discuss fertility (OR = 0.02, p = 0.0164). On average, male providers had much shorter conversations about fertility (Cohen’s d = 1.01, p = 0.0007). Male providers were slightly more likely to refer patients of color to a fertility specialist than White patients (OR = 1.26, p = 0.0684). Patients with breast cancer were more likely to have discussions about fertility than patients with other cancers ( p < 0.0001). Conclusions: We found disparities among patient age, parity, cancer type and provider sex in fertility preservation practices at our institution. Though not statistically significant, we also found disparities among patient race. Nearly all breast cancer providers at our institution are female and use a note template that includes fertility preservation. Providers in other cancer subtypes may be less accustomed to addressing fertility based on their patient populations. A major limitation is that we were only able to capture explicitly documented conversations. This needs assessment supports implementation of a systematic approach to promote fertility preservation as a quality measure across all cancer types.
The Centers for Disease Control and Prevention (CDC) is currently investigating a nationwide outbreak of e- cigarette, or vaping, associated lung injury (EVALI). The objective of this case report is to review a suspected case of EVALI in Rhode Island and discuss how to identify and manage this condition.
The success of a facilitator-based model for advance care planning (ACP) in LaCrosse, Wisconsin, has inspired health systems to aim for widespread documentation of advance directives, but limited resources impair efforts to replicate this model. One promising strategy is the development of interactive, Internet-based tools that might increase access to individualized ACP at minimal cost. However, widespread adoption and implementation of Internet-based ACP efforts has yet to be described.We describe our early experiences in building a systematic, population-based ACP initiative focused on health system-wide deployment of an Internet-based tool as an adjunct to a facilitator-based model.With the sponsorship of our healthcare system's population health leadership, we engaged a diverse group of clinical stakeholders as champions to design an Internet-based ACP tool and facilitate local practice change. We describe how we simultaneously began to train clinicians in ACP conversations, engage patients and health system employees in thinking about ACP, redesign clinic workflows to accommodate ACP discussions, and integrate the Internet-based tool into the electronic medical record (EMR).Over 18 months, our project engaged two subspecialty clinics in a systematic ACP process and began work with a large primary care practice with a large Medicare Accountable Care Organization at-risk population. Overall, 807 people registered at the Internet site and 85% completed ACPs.We learned that changing culture and systems to promote ACP requires a comprehensive vision with simultaneous, interconnected strategies targeting patient education, clinician training, EMR documentation, and community awareness.
Sarcoidosis is a granulomatous disease that commonly presents with lung or lymphatic system manifestations. Diagnosis is often delayed due to variable clinical presentation. This is a case of a patient with metastatic clear cell ovarian cancer who developed disease reoccurence after definitive treatment with surgery and adjuvant chemotherapy. She was treated with multiple lines of therapy, including investigational agents. During this time, she developed mediastinal lymphadenopathy and hypercalcaemia. Due to suspicion that her presentation was not a manifestation of her malignancy, she underwent two lymph node biopsies revealing granulomatous disease. She was initiated on prednisone for management of sarcoidosis, which led to radiologic, laboratory and symptomatic improvement. Although the precipitating factor for this patient’s sarcoidosis cannot be definitively determined, nivolumab is a possible culprit. This case highlights the importance of a broad differential diagnosis when a patient undergoing antineoplastic treatment develops mediastinal lymphadenopathy or hypercalcaemia.
e21116 Background: For patients with unresectable stage III non-small cell lung cancer (NSCLC), chemoradiation followed by 1 year of durvalumab is standard of care. Treatment-induced pneumonitis can be life-threatening. Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic immune inflammation index (SII, defined as platelet x neutrophil / lymphocyte counts) are calculated from the CBC and have been studied as inflammatory biomarkers in a variety of settings. This study assessed trends in these indices among patients treated for stage III NSCLC. Methods: We reviewed medical records of adults with stage III NSCLC who completed chemoradiation and durvalumab from 1/2017 to 9/2021 as part of routine care. Patients who developed non-pneumonitis immune toxicity were excluded. NLR, PLR and SII were calculated at dates of first and last radiation dose and first durvalumab dose. For patients who developed pneumonitis, indices were also calculated at each of 8 weeks leading up to pneumonitis onset, defined as the first diagnostic CT scan and graded as 1-5 based on CTCAE criteria. Indices were compared between the pneumonitis and no pneumonitis group using rank-sum test. P values < 0.05 were considered statistically significant without adjustment for multiple testing. The slope of linear trend for each index was examined via log-gamma generalized linear regression model using a random intercept for each patient and robust standard error. Results: Of 65 patients who received chemoradiation followed by durvalumab, 2 were excluded because they were on clinical trial and 28 were excluded for non-pneumonitis immune toxicity. Among the 35 patients eligible for analysis, median age was 67 years; 20 (57%) were female; 6 (17%) were current smokers; 15 (43%) had COPD; and 17 (49%) developed pneumonitis (2 G1; 11 G2; 3 G3; 0 G4; 1 G5). In the pneumonitis group, NLR (p = 0.022), PLR (p = 0.007) and SII (p = 0.001) showed a statistically significant linear increase in the 5 weeks preceding pneumonitis onset. There were no differences in clinical characteristics, SII, NLR or PLR between the pneumonitis and no pneumonitis groups at the 3 time points examined. Conclusions: In this exploratory analysis, patients who developed pneumonitis showed a linear increase in inflammatory indices for 5 weeks before pneumonitis onset, suggesting information hidden in routine blood tests can anticipate development of a life-threatening complication. Our hypothesis-generating study will need validation in a larger prospective analysis with a control group. Future directions may also include examination of selected acute phase reactants or cytokines.
Gastroesophageal junction (GEJ) cancer is a highly morbid disease with a poor prognosis. While uncommon in the United States, globally it is ranked as the sixth or seventh most common cancer depending on survey tool. GEJ cancer presents a unique and challenging symptom profile for patients at all disease stages, regardless of histology. Even patients with early stage disease experience debilitating cancer-related symptoms and treatment side effects. The heavy symptom burden associated with this disease includes dysphagia, nausea and vomiting, pain, anxiety, depression and malnutrition. These symptoms require a multidisciplinary approach involving local therapies including radiation and stent placement, systemic cancer-directed therapy, nutritional support, and supportive medical management. This review aims to examine the unique symptom burden experienced by patients with GEJ cancer and provide an updated overview of symptom management techniques. A PubMed search was conducted using the terms "gastroesophageal junction cancer AND palliative care". Articles published from 2008 to 2022 with a primary focus on supportive care for patients with GEJ cancers were reviewed. A total of 119 articles were identified and screened in our database search. Of these, 22 full text articles met inclusion criteria and were reviewed. Seventeen articles addressed technical interventions for the alleviation of dysphagia, 1 article focused on nutrition, 1 article described the impact of multidisciplinary tumor boards, 1 article presented the effect of home nurse visits, 1 article described the use of antiemetics, and 1 article was a narrative review of supportive care. In this narrative review, we examine specific supportive care needs in the GEJ cancer population. While the predominant symptom addressed in the literature is dysphagia, patients with GEJ cancer carry a complex symptom burden from diagnosis, through cancer-directed therapy to end-of-life care. Early referral to specialty palliative care should be considered for all patients with GEJ cancer to foster symptom management and delivery of goal concordant care.
Existing data do not clearly define the role of Osimertinib in the treatment of resected EGFR-mutated lung cancer. We present the case of a patient with stage IIIA EGFR exon 19 deletion positive NSCLC whose disease was pathologically down staged by neoadjuvant chemoradiation. Future trials should include such patients to inform decisions about adjuvant treatment with respect to survival benefit and toxicity.
Cholangiocarcinoma is a malignancy of the bile ducts that is often associated with late diagnosis, poor overall survival, and limited treatment options. The standard of care therapy for cholangiocarcinoma has been cytotoxic chemotherapy with modest improvements in overall survival with the addition of immune checkpoint inhibitors. The discovery of actionable mutations has led to the advent of targeted therapies against FGFR and IDH-1, which has expanded the treatment landscape for this patient population. Significant efforts have been made in the pre-clinical space to explore novel immunotherapeutic approaches, as well as antibody–drug conjugates. This review provides an overview of the current landscape of treatment options, as well as promising future therapeutic targets.
