Abstract P4-10-04: EMBRACE (Ending metastatic breast cancer for everyone): A comprehensive approach to improve the care of patients with metastatic breast cancer

Background: In contrast to early stage breast cancer, the quality of care for patients with metastatic breast cancer (MBC) has been relatively understudied, as have interventions to improve care in the real-world setting. Patients with MBC face a variety of unique needs related to their disease, treatment options, and supportive care. Little attention has been focused on leveraging the strengths of academic and community-based settings to provide optimal care for these patients. To address these critical issues, we have designed and implemented a comprehensive program that combines clinical care, clinical research, physician engagement and patient education to optimize the care of MBC patients.

Methods: We developed a consistent and comprehensive intake process and follow-up approach for MBC patients who were seen at least once in the Breast Oncology Clinic (BOC) at Dana-Farber Cancer Institute (DFCI). A key component of our approach is the EMBRACE coordinator who meets with each MBC patient at the first clinic visit to review the clinical program, available educational and supportive resources, and consents to research studies. Each coordinator supports the DFCI-based oncologist and follows a discrete patient panel longitudinally, for whom they are responsible for facilitating referrals to supportive care resources, identifying potential candidates for trial prescreening, tracking availability of results from molecular testing for clinical trial matching, facilitating communication between DFCI-based providers and referring providers and organizing re-consultation visits when clinically appropriate. The coordinator contacts patients every 3 months to inquire about the patient's overall health and needs and provides updates on upcoming educational and supportive care activities at our institution. Educational offerings have been expanded to include a bi-annual newsletter, quarterly email updates, webcasts and an annual educational patient forum. Results: The program was fully implemented in the BOC across 27 oncologists in August 2016, after the start of a pilot in July 2015. On average, the program enrolls 30 to 40 new MBC patients per month at their initial visit. The EMBRACE coordinators currently support the DFCI-based oncologists in the care of approximately 1500 new and existing MBC patients and facilitate collaborations with 350 referring providers.

Conclusions: The EMBRACE program has made a tangible improvement in the quality of care for patients with MBC in our clinic. We have successfully established the infrastructure of the coordinator role and a robust tracking system to support the patient, DFCI-based provider, and referring provider. While the program has been solely based at DFCI, we believe that our approach has the potential for impact beyond our institution and ultimately serve as a model for enhanced academic-community-patient partnership.

Citation Format: Hughes ME, Frank ES, Merrill MS, Santiago RA, Kuhnly N, Crowley LM, Gupta G, Winer EP, Lin NU. EMBRACE (Ending metastatic breast cancer for everyone): A comprehensive approach to improve the care of patients with metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-04.

Consumptive hypothyroidism: an unusual paraneoplastic manifestation of a gastric gastrointestinal stromal tumor

A 42-year-old hypothyroid shepherd presented with a progressive abdominal lump accompanied by nausea and abdominal fullness. In addition, he had worsening hypothyroidism, despite supranormal doses of thyroxine. Computed tomography of the abdomen was suggestive of a mass lesion in relation to the stomach. A resection of the mass was done and the histopathology was suggestive of gastrointestinal stromal tumor. After surgery, the patient became euthyroid. We believe the patient had consumptive hypothyroidism due to the tumor.

Real Time Central Assessment of Kidney Transplant Indication Biopsies by Microarrays: The INTERCOMEX Study

The authors conducted a prospective trial to assess the feasibility of real time central molecular assessment of kidney transplant biopsy samples from 10 North American or European centers. Biopsy samples taken 1 day to 34 years posttransplantation were stabilized in RNAlater, sent via courier overnight at ambient temperature to the central laboratory, and processed (29 h workflow) using microarrays to assess T cell- and antibody-mediated rejection (TCMR and ABMR, respectively). Of 538 biopsy samples submitted, 519 (96%) were sufficient for microarray analysis (average length, 3 mm). Automated reports were generated without knowledge of histology and HLA antibody, with diagnoses assigned based on Molecular Microscope Diagnostic System (MMDx) classifier algorithms and signed out by one observer. Agreement between MMDx and histology (balanced accuracy) was 77% for TCMR, 77% for ABMR, and 76% for no rejection. A classification tree derived to provide automated sign-outs predicted the observer sign-outs with >90% accuracy. In 451 biopsy samples where feedback was obtained, clinicians indicated that MMDx more frequently agreed with clinical judgment (87%) than did histology (80%) (p = 0.0042). In 81% of feedback forms, clinicians reported that MMDx increased confidence in management compared with conventional assessment alone. The authors conclude that real time central molecular assessment is feasible and offers a useful new dimension in biopsy interpretation. ClinicalTrials.gov NCT#01299168.

A proposed scoring system for assessing the severity of actinic keratosis on the head: actinic keratosis area and severity index

BACKGROUND

Actinic keratosis (AK) severity is currently evaluated by subjective assessment of patients.

OBJECTIVES

To develop and perform an initial pilot validation of a new easy-to-use quantitative tool for assessing AK severity on the head.

METHODS

The actinic keratosis area and severity index (AKASI) for the head was developed based on a review of other severity scoring systems in dermatology, in particular the psoriasis area and severity index (PASI). Initial validation was performed by 13 physicians assessing AK severity in 18 AK patients and two controls using a physician global assessment (PGA) and AKASI. To determine an AKASI score, the head was divided into four regions (scalp, forehead, left/right cheek ear, chin and nose). In each region, the percentage of the area affected by AKs was estimated, and the severities of three clinical signs of AK were assessed: distribution, erythema and thickness.

RESULTS

There was a strong correlation between AKASI and PGA scores (Pearson correlation coefficient: 0.86). AKASI was able to discriminate between different PGA categories: mean (SD) AKASI increased from 2.88 (1.18) for 'light' to 5.33 (1.48) for 'moderate', 8.28 (1.89) for 'severe', and 8.73 (3.03) for 'very severe' PGA classification. The coefficient of variation for AKASI scores was low and relatively constant across all PGA categories.

CONCLUSIONS

Actinic keratosis area and severity index is proposed as a new quantitative tool for assessing AK severity on the head. It may be useful in the future evaluation of new AK treatments in clinical studies and the management of AK in daily practice.

Inpatient care of small and sick newborns in healthcare facilities

Neonatal units in teaching and non-teaching hospitals both in public and private hospitals have been increasing in number in the country since the sixties. In 1994, a District Newborn Care Programme was introduced as a part of the Child Survival and Safe Motherhood Programme (CSSM) in 26 districts. Inpatient care of small and sick newborns in the public health system got a boost under National Rural Health Mission with the launch of the national programme on facility-based newborn care (FBNC). This has led to a nationwide creation of Newborn Care Corners (NBCC) at every point of child birth, newborn stabilization units (NBSUs) at First Referral Units (FRUs) and special newborn care units (SNCUs) at district hospitals. Guidelines and toolkits for standardized infrastructure, human resources and services at each level have been developed and a system of reporting data on FBNC created. Till March 2015, there were 565 SNCUs, 1904 NBSUs and 14 163 NBCCs operating in the country. There has been considerable progress in operationalizing SNCUs at the district hospitals; however establishing a network of SNCUs, NBSUs and NBCCs as a composite functional unit of newborn care continuum at the district level has lagged behind. NBSUs, the first point of referral for the sick newborn, have not received the desired attention and have remained a weak link in most districts. Other challenges include shortage of physicians, and hospital beds and absence of mechanisms for timely repair of equipment. With admission protocols not being adequately followed and a weak NBSU system, SNCUs are faced with the problem of admission overload and poor quality of care. Applying best practices of care at SNCUs, creating more NBSU linkages and strengthening NBCCs are important steps toward improving quality of FBNC. This can be further improved with regular monitoring and mentoring from experienced pediatricians, and nurses drawn from medical colleges and the private sector. In addition there is a need to further increase such units to address the unmet need of facility-based care.

Nafion-stabilised bimetallic Pt-Cr nanoparticles as electrocatalysts for proton exchange membrane fuel cells (PEMFCs)

The current study investigated the unique combination of alloying (Pt with Cr) and Nafion stabilisation to reap the benefits of catalyst systems with enhanced catalytic activity and improved durability in PEMFCs.

The current study investigated the unique combination of alloying (Pt with Cr) and Nafion stabilisation to reap the benefits of catalyst systems with enhanced catalytic activity and improved durability in PEMFCs. Pt–Cr alloy nanoparticles stabilised with Nafion were chosen in the current study owing to their higher stability in acidic and oxidising media at high temperatures compared to other Pt-transition metal alloys (e.g. Pt–Ni, Pt–Co). Two different precursor : reducing agent (1 : 10 and 1 : 20) ratios were used in order to prepare two different alloys, denoted as Pt–Cr 10 and Pt–Cr 20. The Pt–Cr 20 alloy system (with composition Pt₈₀Cr₂₀) demonstrated higher electrocatalytic activity for the oxygen reduction reaction compared to commercial Pt/C (TKK) catalysts. Accelerated stress tests and single cell tests revealed that Nafion stabilised alloy catalyst systems displayed significantly enhanced durability (only ∼20% loss of ECSA) compared with Pt/C (50% loss of ECSA) due to improved catalyst–ionomer interaction. Furthermore, the Pt–Cr 20 alloy system demonstrated a current density comparable to that of Pt/C making them promising potential electrocatalysts for proton exchange membrane fuel cells.

Comparison between single stage and two stage bilateral total hip replacement- our results and review of literature

Bilateral total hip replacement (THR) is a common procedure nowdays. Staging of surgery is still a -matter of debate. We performed a study to compare single stage and two stage bilateral THR and discuss the peri-operative and post-operative advantages and complications. This was a retrospective study. 48 patients underwent single stage and 56 patients underwent two stage bilateral THR. The average follow up period was 64 months and 70 months respectively. The hospital stay was 5.6 days in single stage and 9.0 days in two stage bilateral THR. The total blood loss was 280 ml and 440 ml ; average blood trans-fusion was 1.6 units and 2.2 units and walk without support was started at 42 days and 58 days respectively. No difference in complication rate was seen. Single staged bilateral THR is a safe procedure. The definite benefits are short hospital stay, lower cost and early rehabilitation.

The prevalence of unsuspected onychomycosis and its causative organisms in a multicentre Canadian sample of 30 000 patients visiting physicians' offices

BACKGROUND

Onychomycosis is difficult to treat and a concern for many patients. Prevalence estimates of onychomycosis in North American clinic samples have been higher than what has been reported for general populations.

OBJECTIVE

A large, multicentre study was conducted to estimate the prevalence of toenail onychomycosis in the Canadian population.

METHODS

Patients were recruited from the offices of three dermatologists and one family physician in Ontario, Canada. Nail samples for mycological testing were obtained from normal and abnormal-looking nails. This sample of 32 193 patients includes our previous published study of 15 000 patients.

RESULTS

Abnormal nails were observed in 4350 patients. Of these, the prevalence of culture-confirmed toenail onychomycosis was estimated to be 6.7% (95% CI, 6.41-6.96%). Following sex and age adjustments for the general population, the estimated prevalence of toenail onychomycosis in Canada was 6.4% (95% CI, 6.12%-6.65%). The distribution of fungal organisms in culture-confirmed onychomycosis was 71.9% dermatophytes, 20.4% non-dermatophyte moulds and 7.6% yeasts. Toenail onychomycosis was four times more prevalent in those over the age of 60 years than below the age of 60 years.

CONCLUSION

The present data highlights that onychomycosis may be a growing medical concern among ageing patients.

Weekly versus Three-Weekly Cisplatin-based Concurrent Chemoradiotherapy as definitive treatment in Head and Neck Cancer- Where do we stand?

PURPOSE

To compare toxicity, compliance, and early response of weekly and 3-weekly cisplatin administration concurrent with radiotherapy as definitive treatment in locally advanced squamous cell carcinoma head and neck.

MATERIALS AND METHODS

Patients with histologically proven stage III - IV B head and neck carcinoma presenting from June 2013 to March 2014 were randomly assigned to weekly (35 mg/m2, 6 cycles; arm A) and 3 weekly (100 mg/m2, 3 cycles; arm B) cisplatin with concurrent radiotherapy.

RESULTS

60 patients were randomly assigned to treatment, 30 in each arm. Median follow-up was 8 months (range 4-13). There was no significant difference in grade 3 mucositis between the two arms (75.9% vs 70%, p = 0.20). Grade 3 neutropenia was more frequent in arm B (55.2% vs 26.7%, p = 0.01). Hypomagnesemia was the commonest electrolyte imbalance and it was significantly higher in arm B (60% vs 20%, p = 0.001). Completion rate of scheduled chemotherapy cycles was higher for patients receiving weekly regimen. Response at 3 months was similar for all the patients {Complete Response (66.7% vs 62.1%), p = 0.200}. Our data suggested that there is a reduced need of hospitalization and supportive care measures for patients receiving weekly cisplatin with RT (p = 0.05).

CONCLUSIONS

Weekly cisplatin 35 mg/m2 chemotherapy concurrent with radiotherapy is equally effective and less toxic in terms of neutropenia, hypomagnesemia and need for supportive measures than the conventional 3 weekly cisplatin 100 mg/m2 regimen.

Tavaborole 5% Solution: A Novel Topical Treatment for Toenail Onychomycosis

Onychomycosis is a stubborn fungal infection of the nails that can be difficult to effectively manage. One of the challenges with topical therapies is penetrating the nail plate to reach the site of infection. As the first antifungal in a boron-containing class of drugs with a novel mechanism of action, tavaborole is able to penetrate the nail plate more effectively than ciclopirox and amorolfine lacquers. In Phase II/III clinical trials, tavaborole was shown to be safe and clinically effective. Tavaborole 5% solution was approved by the US FDA for the treatment of toenail onychomycosis in July 2014 and is an important addition to the topical treatment arsenal against this stubborn infection.

Safe Conversion From Tacrolimus to Belatacept in High Immunologic Risk Kidney Transplant Recipients With Allograft Dysfunction

There is no literature on the use of belatacept for sensitized patients or regrafts in kidney transplantation. We present our initial experience in high immunologic risk kidney transplant recipients who were converted from tacrolimus to belatacept for presumed acute calcineurin inhibitor (CNI) toxicity and/or interstitial fibrosis/tubular atrophy. Six (mean age = 40 years) patients were switched from tacrolimus to belatacept at a median of 4 months posttransplant. Renal function improved significantly from a peak mean estimated glomerular filtration rate (eGFR) of 23.8 ± 12.9 mL/min/1.73 m(2) prior to the switch to an eGFR of 42 ± 12.5 mL/min/1.73 m(2) (p = 0.03) at a mean follow-up of 16.5 months postconversion. No new rejection episodes were diagnosed despite a prior history of rejection in 2/6 (33%) patients. Surveillance biopsies performed in 5/6 patients did not show subclinical rejection. No development of donor-specific antibodies (DSA) was noted. In this preliminary investigation, we report improved kidney function without a concurrent increase in risk of rejection and DSA in six sensitized patients converted from tacrolimus to belatacept. Improvement in renal function was noted even in patients with chronic allograft fibrosis without evidence of acute CNI toxicity. Further studies with protocol biopsies are needed to ensure safety and wider applicability of this approach.

Ivermectin 1% cream for rosacea

The etiology of papulopustular rosacea (PPR) is not well understood yet appears to involve both the innate and adaptive immune response in addition to possible infestation with Demodex mites. Current treatments for PPR consist mainly of antibiotics. Ivermectin cream 1%, a new topical treatment for PPR, possesses both anti-inflammatory and anti-parasitic properties. After 12 weeks of treatment, subjects treated with ivermectin cream 1% had significantly greater reductions in PPR symptoms and enhanced diseaserelated quality of life improvements compared to subjects who received vehicle. Furthermore, PPR symptoms continued to improve with prolonged treatment (40 weeks). Ivermectin cream 1% offers a multi-pronged approach to combat the complex pathophysiology of rosacea.