Perfusion MRI-Based Fractional Tumor Burden Differentiates between Tumor and Treatment Effect in Recurrent Glioblastomas and Informs Clinical Decision-Making

BACKGROUND AND PURPOSE

Fractional tumor burden better correlates with histologic tumor volume fraction in treated glioblastoma than other perfusion metrics such as relative CBV. We defined fractional tumor burden classes with low and high blood volume to distinguish tumor from treatment effect and to determine whether fractional tumor burden can inform treatment-related decision-making.

MATERIALS AND METHODS

Forty-seven patients with high-grade gliomas (primarily glioblastoma) with recurrent contrast-enhancing lesions on DSC-MR imaging were retrospectively evaluated after surgical sampling. Histopathologic examination defined treatment effect versus tumor. Normalized relative CBV thresholds of 1.0 and 1.75 were used to define low, intermediate, and high fractional tumor burden classes in each histopathologically defined group. Performance was assessed with an area under the receiver operating characteristic curve. Consensus agreement among physician raters reporting hypothetic changes in treatment-related decisions based on fractional tumor burden was compared with actual real-time treatment decisions.

RESULTS

Mean lower fractional tumor burden, high fractional tumor burden, and relative CBV of the contrast-enhancing volume were significantly different between treatment effect and tumor (P = .002, P < .001, and P < .001), with tumor having significantly higher fractional tumor burden and relative CBV and lower fractional tumor burden. No significance was found with intermediate fractional tumor burden. Performance of the area under the receiver operating characteristic curve was the following: high fractional tumor burden, 0.85; low fractional tumor burden, 0.7; and relative CBV, 0.81. In comparing treatment decisions, there were disagreements in 7% of tumor and 44% of treatment effect cases; in the latter, all disagreements were in cases with scattered atypical cells.

CONCLUSIONS

High fractional tumor burden and low fractional tumor burden define fractions of the contrast-enhancing lesion volume with high and low blood volume, respectively, and can differentiate treatment effect from tumor in recurrent glioblastomas. Fractional tumor burden maps can also help to inform clinical decision-making.

Outcomes of Early Use of an End of Range Axilla Orthotic in Children Following Burn Injury

Scar contracture is a significant complication of burn injury. This study aimed to describe outcomes of early axilla orthotic use at end of range abduction in children, following a burn to the axilla region. A retrospective review of 76 children (mean age 3.9 years [SD 3.6]) treated at a tertiary children's hospital from 2006 to 2016 was conducted. No child developed axilla contracture for the duration of the 2-year study follow-up with no adverse events recorded. If orthotic use was ceased <60 days post-burn, it was considered not an essential intervention to maintain range of movement, leaving 49 children using the orthotic ≥60 days. Compared with the children who ceased orthotic use in <60 days, children who required the orthotic ≥60 days had a significantly higher frequency of deep-dermal burn (59 vs 25%, p = .01), flame mechanism (25 vs 5%, p = .03), and burn injury distribution involving the anterior trunk, flank, and arm (18 vs 3%, p = .03). Early signs of contracture, considered loss of full axilla range or significant banding, developed in nine children within 3 months post-burn. With intensive therapy, all returned to full axilla range by 9 months post-burn. Children with skin tension at end of range shoulder movement at the 1-month clinical assessment were 11 times more likely to develop early signs of contracture (95% confidence interval [CI]: 1.9-62.1, p = .007). Intensive orthotic use at end of range shoulder abduction in children with axilla burns is well tolerated. When undertaken with ongoing therapist review, full axilla range can be maintained.

Dendritic cells, T cells and their interaction in rheumatoid arthritis

Dendritic cells (DCs) are the key professional antigen-presenting cells which bridge innate and adaptive immune responses, inducing the priming and differentiation of naive to effector CD4+ T cells, the cross-priming of CD8+ T cells and the promotion of B cell antibody responses. DCs also play a critical role in the maintenance of immune homeostasis and tolerance. DC-T cell interactions underpin the generation of an autoimmune response in rheumatoid arthritis (RA). Here we describe the function of DCs and review evidence for DC and T cell involvement in RA pathogenesis, in particular through the presentation of self-peptide by DCs that triggers differentiation and activation of autoreactive T cells. Finally, we discuss the emerging field of targeting the DC-T cell interaction for antigen-specific immunotherapy of RA.

Could shared decision making affect staying in hospital? A cross-sectional pilot study

Background

Shared Decision Making (SDM) is an approach where clinicians and patients share the best available evidence to make decision and where patients opinions are considered. This approach provides benefits for patients, clinicians and health care system. The aim of the present study is to investigate the patients’ perception of their participation in treatment choices and to identify the possible influences of variables in decision aids and therapeutic choices. Furthermore the present study evaluates the impact of SDM on the length of hospital stay and the health expenditure in Piemonte, an Italian region.

Methods

A cross-sectional study was performed in 2016. The patients were selected after hospitalization to clinical and surgical units at the Rivoli and Susa Hospital. Data were collected through the questionnaire and the Hospital Discharge Registers. STROBE guidelines for observational studies were used. A descriptive analysis was conducted. Frequencies and percentages of the categorical variables were reported. Statistical analyses were performed using t-test, chi-square test and Mann-Whitney test.

Results

The final sample was made of 174 subjects. More than half of the sample reported a SDM approach. Female gender (p = 0.027) and lower age (p = 0.047) are associated with an increased possibility to report SDM. Receiving “good” or “excellent” information, having their own request fulfilled and their opinions took into account by healthcare professionals, were all found to be predictors for an approach recognized as SDM (p ≤ 0.05). The perception that healthcare professionals spent a proper amount of time with the patients and used an understendable language are factors increase the chance of a “shared” decision process (p ≤ 0.05). The patients trust in the information given by the healthcare professional is not affecting their perception about the decision making process (P = 0.195). No significant difference where recorded in length of stay and hospital expenditure.

Conclusions

The data show the role played by different dimension of the patients-clinician relationship and that the strongest determinant of a perceived shared decision making approach are healthcare professional-depending.

Secondary breast angiosarcoma: A multicentre retrospective survey by the national Italian association of Breast Surgeons (ANISC)

BACKGROUND

Breast angiosarcoma is a malignant mesenchymal neoplasm, which accounts for approximately 2% of all soft tissue sarcomas. Secondary breast angiosarcoma (SBA) may be related to chronic lymphedema after a mastectomy with lymph node dissection (Stewart Treves syndrome) and previous radiotherapy for complications from breast radiation treatment. It is a very rare condition; therefore, diagnosis and management are still a challenge.

METHODS

The ANISC collected SBA data by means of a survey sent to all Italian breast centres in the ANISC. The clinicopathological characteristics and the management of this disease were analysed.

RESULTS

Twenty-four centres participated in this survey in which 112 cases of SBA were analysed. The median age of the women with SBA was 68.9 years and it appeared approximately 90 months after the first irradiation for breast cancer. In 92% of cases, a mastectomy was performed without axillary dissection for those patients having a high grade of SBA (74.2%). The prognosis was worse in the high-grade cases (overall survival-OS: 36 months) as compared with the low-grade cases (OS: 48 months). After a follow-up of 5 years, 50.5% of the patients were still alive. Disease-free survival (DFS) was 35 months, and there were no differences between the groups of patients with either high- or low-grade histology.

CONCLUSIONS

Secondary breast angiosarcoma is a very aggressive disease associated with a short survival outcome. The surgical approach still remains an important step in the course of treatment; furthermore, an accurate histological examination is helpful in establishing the prognosis of the patient. A mastectomy is mandatory. A longer OS was observed in patients with low-grade angiosarcoma as compared to high-grade angiosarcoma (C.I. 40-57 vs. 31-41 months).

Abstract PD6-12: Evaluating racial disparities in breast cancer referrals for hereditary risk assessment

Background: There is a pronounced onco-racial disparity in Washington, D.C., which had the highest national incidence of breast cancer in African Americans (AA) patients in between 2010-2015 and the worst outcomes (American Cancer Society). Recent data indicates a higher incidence of deleterious BRCA1 [and BRCA2] mutations and variants of uncertain significance (VUS) in AA patients compared to Caucasian (C) patients when controlled for patients of Ashkenazi Jewish (AJ) populations (Hall 2009). Despite this, AA women meeting National Comprehensive Cancer Network (NCCN) criteria for genetic testing are less likely to complete such testing compared to C women nationally. Studies have investigated psycho-social drivers of minority patient aversion to genetic testing. We hypothesize that lack of physician referral for cancer genetic counseling and testing for AA women contributes to this disparity.

Methods: The George Washington Cancer Center (GWCC) Registry was used to identify non-Hispanic African Americans (BNH) and non-Hispanic whites (WNH) treated for breast cancer between 2014-2018. Of those individuals selected for inclusion were those who met select NCCN criteria for referral for genetic evaluation including breast cancer diagnosis under age 50, triple negative breast cancer (TNBC) under age 60, and two primary breast cancers. Only BNH and WNH individuals were included. Excluded patients were those who were not BNH or WNH or who did not meet the NCCN criteria listed above. Patients were then stratified by race according to who underwent genetic evaluation, whether at our Ruth Paul Cancer Genetics and Prevention Service (RPCGPS) or elsewhere, by reviewing GWCC, RPCGPS, and patient clinic records for genetic testing results from outside institutions. Patient charts were used to identify individuals who received a physician referral over the course of their cancer care.

Results: 1180 patients were treated at the GWCC for breast cancer (both in situ and invasive carcinoma) between 2014–2018. Of those, BNH n=502; WNH n=435. Twenty-seven percent of BNH and WNH patients met the study criteria for referral for genetic evaluation (n=252; BNH n=115, WNH n=137), including breast cancer diagnosis under age 50 (BNH n=76; WNH n=108), TNBC under age 60 (BNH n=14; WNH n=5), and two primary breast cancers (BNH n=18, WNH n=16). Several patients identified met two or more criteria for referral (BNH n=7, WNH n=8). Physician referral rates differed significantly by race (BNH 76%, n=87 and WNH 91%; n=125; χ2=11.4, p-value&lt;0.001). Of referred patients, there was no significant difference in those who followed-up at RPCGPS by race (BNH 93%, n=81; WNH= 93%, n=116, χ2 =0.0072, p-value=0.93).

Conclusions: Low genetic testing rates for AA breast cancer patients are an impediment to resolving the prominent onco-racial breast cancer disparities. This study identified physician referral as a potential contributor to racial disparity in the utilization of cancer genetics services. Potential reasons for the discrepancy in referral may include lag in physician education on the topic of hereditary risk and barriers in physician-patient communication. These findings need to be confirmed and explored at other sites to help improve the identification of at-risk women in the AA community.

Citation Format: Pepin A, Peterson J, Thomas R, Johnson K, Stark E, Biagi T, Kaltman R. Evaluating racial disparities in breast cancer referrals for hereditary risk assessment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-12.

E-tools for hospital management: An overview of smartphone applications for health professionals

BACKGROUND

Commonly, management of the main hospital activities is organized by different software packages that run on desktop computers, which may not always allow fast and practical use by health operators. This problem could be alleviated by combining these software packages with mobile health. The aim of this study is to provide an overview of smartphone and tablet applications used for hospital management and administration in order to evaluate their features and analyze them according to their content, number of downloads and field of application.

METHODS

Researchers performed the survey on the two main application stores available on the Internet: iTunes for Apple devices and Google Play for Android devices. Using specific keywords, 47 apps that met the inclusion criteria were identified.

RESULTS

Most of the applications were designed for health operators and patient management (76.6%); 12.8% of the apps were focused on the organization and setting of hospital resources, and 10.6% of the apps could help hospital administrators perform self-evaluations of their structures, processes and outcomes. The large majority of apps (80.7%) counted less than 1000 downloads. Most of them (87.5%) were in English and free to download (93.6%).

DISCUSSION

The results of the first attempt to provide an overview of this emerging topic showed that, despite the existence of several applications for hospital management purposes, these tools appear to be not very widespread. In our opinion, there is a strong need to further assess the quality of these applications; thus, it may be worth continuing to monitor this field in order to analyze eventual improvements in the design and distribution of these apps.

How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Advertisement of electronic cigarettes in Italy: characteristics of online videos and the most popular promotional messages

Given the increasing popularity of electronic cigarettes (ECs) and a lack of regulation of EC advertising, this study aimed to analyse online videos promoting ECs to assess the main marketing messages that could influence consumers' perceptions of associated risks and benefits. A web search of EC advertising videos was performed on YouTube by using keywords related to EC promotion. An evaluation grid was used to analyse promotional messages contained in each video. The most frequent promotional messages were related to health benefits (67.7%) and to the possibility of quitting smoking (57.4%). Messages that could also be appealing to adolescents and young adults, such as those promoting the multiple flavors available and the technological improvement of ECs, were present in 41.2% and 42.7% of the videos respectively. ECs similar to traditional cigarettes in appearance were included in 52.9% of the videos. EC promotional videos address messages not only to smokers who want to quit or decrease tobacco consumption but also to nonsmokers, especially young people. The use of ECs similar to traditional cigarettes may be a gateway to tobacco cigarette use. Since EC use may represent an important public health concern, regulatory policies on EC advertising should be established.