Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma with Intra-atrial Tumor Extension: Imaging Response and Oncologic Outcomes

To evaluate outcomes in patients with right atrial (RA) hepatocellular carcinoma extension treated with transarterial chemoembolization. Eight patients were retrospectively reviewed. Follow-up visits occurred at 4-6 weeks; transarterial chemoembolization was repeated if residual tumor persisted. After transarterial chemoembolization, RA tumor volume reduction was 86% ± 19; α-fetoprotein level showed a reduction of 95%. From RA tumor diagnosis, 3-, 6-, and 12-month overall survival was 100% ± 0, 100% ± 0, and 67% ± 29, respectively. In patients with hepatocellular carcinoma invading the right atrium, transarterial chemoembolization alone or in combination with systemic therapy yields an improved imaging response and may be associated with improved survival.

Better Than You Think—Appropriate Use of Implantable Cardioverter-Defibrillators at a Single Academic Center: A Retrospective Review

Background: Implantable cardioverter-defibrillators (ICDs) can be life-saving devices, although they are expensive and may cause complications. In 2013, several professional societies published joint appropriate use criteria (AUC) assessing indications for ICD implantation. Data evaluating the clinical application of AUC are limited. Previous registry-based studies estimated that 22.5% of primary prevention ICD implantations were “non-evidence-based” implantations. On the basis of AUC, we aimed to determine the prevalence of “rarely appropriate” ICD implantation at our institution for comparison with previous estimates.Methods: We reviewed 286 patients who underwent ICD implantation between 2013 and 2016. Appropriateness of each ICD implantation was assessed by independent review and rated on the basis of AUC.Results: Of 286 ICD implantations, two independent reviewers found that 89.5% and 89.2%, respectively, were appropriate, 5.6% and 7.3% may be appropriate, and 1.8% and 2.1% were rarely appropriate. No AUC indication was found for 3.5% and 3.4% of ICD implantations, respectively. Secondary prevention ICD implantations were more likely rarely appropriate (2.6% vs. 1.2% and 3.6% vs. 1.1%) or unrated (6.0% vs. 1.2% and 2.7% vs. 0.6%). The reviewers found 3.5% and 3.4% of ICD implantations, respectively, were non-evidence-based implantations. The difference in rates between reviewers was not statistically significant.Conclusion: Compared with prior reports, our prevalence of rarely appropriate ICD implantation was very low. The high appropriate use rate could be explained by the fact that AUC are based on current clinical practice. The AUC could benefit from additional secondary prevention indications. Most importantly, clinical judgement and individualized care should determine which patients receive ICDs irrespective of guidelines or criteria.

Surgical Residents as Certified Bilingual Speakers: A Quality Improvement Initiative

BACKGROUND

The objective of this quality improvement initiative was to identify general surgery residents proficient in a non-English language and have each attempt the Clinician Cultural and Linguistic Assessment (CCLA) to become qualified bilingual staff speakers.

METHODS

General surgery house staff were asked to self-identify as proficient in a language other than English. Fees for the certification examination were waived, and each resident was excused from clinical duties to complete the exam. McNemar's test was used for statistical analysis.

RESULTS

All residents responded to the initial survey, with 18/65 reporting a non-English language proficiency. Of the 12 residents who sat for the CCLA exam, 9 (75.0%) passed, with 5 certifying in the most commonly spoken non-English languages at this institution. The number of certified residents increased from 1 to 10 (1.5 % to 15.4%, p = 0.004).

CONCLUSION

Language barriers result in health care disparities for patients with limited English proficiency. This reproducible quality improvement initiative significantly increased the number of qualified bilingual speakers, while 25.0% of self-described proficient speakers did not demonstrate adequate language proficiency. These newly certified providers allow for increased language concordant care, which may be associated with improved outcomes.

Rectal cancer patients younger than 50 years lack a survival benefit from NCCN guideline-directed treatment for stage II and III disease

BACKGROUND

The incidence of rectal cancer in patients younger than 50 years is increasing. To test the hypothesis that the biology in this younger cohort may differ, this study compared survival patterns, stratifying patients according to National Comprehensive Cancer Network (NCCN) guideline-driven care and age.

METHODS

The National Cancer Data Base was queried for patients treated with curative-intent transabdominal resections with negative surgical margins for stage I to III rectal cancer between 2004 and 2014. Outcomes and overall survival for patients younger than 50 years and patients 50 years old or older were compared by subgroups based on NCCN guideline-driven care.

RESULTS

A total of 43,106 patients were analyzed. Younger patients were more likely to be female and minorities, to be diagnosed at a higher stage, and to have travelled further to be treated at academic/integrated centers. Short- and long-term outcomes were significantly better for patients younger than 50 years, with age-specific survival rates calculated. Younger patients were more likely to receive radiation treatment outside NCCN guidelines for stage I disease. In younger patients, the administration of neoadjuvant chemoradiation for stage II and III disease was not associated with an overall survival benefit.

CONCLUSIONS

Age-specific survival data for patients with rectal cancer treated with curative intent do not support an overall survival benefit from NCCN guideline-driven therapy for stage II and III patients younger than 50 years. These data suggest that early-onset disease may differ biologically and in its response to multimodality therapy.

Implementing pregnancy screening prior to chemotherapy: A quality improvement initiative

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Background: ASCO’s QOPI sets standards for excellence in oncologic care. One standard is screening appropriate female patients for pregnancy prior to chemotherapy. No guidelines exist regarding screening protocols or timing. Prior data collection at our institution from 2012-2014 revealed that 35% of women of childbearing potential were screened prior to chemo, with medical oncology performing only 7% of screening. Less than half (48%) of those tests were ordered within 14 days prior to treatment start. Methods: A quality improvement (QI) intervention was implemented at UF Health outpatient infusion center on 8/15/16 based on the above data. A checkbox was added to the pre-chemo checklist used by infusion nurses. For eligible patients (women ages 18-55 without prior tubal ligation or hysterectomy), a point of care pregnancy test, included in standing orders, was recommended. We reviewed data for women who received outpatient chemo during 9/16-11/16 to determine rates of pregnancy screening (PS) after intervention. Results: 49 women, ages 18-55, of childbearing potential were identified and presented for 174 chemo cycles from 9/1/16 to 11/30/16. Of these, 15 (30.6%) received PS before chemo. Fifty pregnancy tests were ordered during this period; all were negative. Of the 50 tests, 42 (84%) were ordered by medical oncology, 3 (6%) by a surgical oncology, 3 (6%) by radiation oncology, and 1 (2%) by emergency medicine. Of the PS tests ordered by medical oncology, 64.2% were within 14 days of chemotherapy. Conclusions: In three months of QI intervention, PS prior to chemo increased from 7% to 30.6%. Screening was 13% in women older than 45, but higher in women age 25-34 (60%) and 35-44 (67%). Although the screening rate improved, it remains below our goal of 80%. Possible explanations for low rates are inclusion of postmenopausal women and those older than 50. Excluding these patients could reduce screening burden while identifying appropriate patients. [Table: see text]

Pregnancy screening prior to chemotherapy initiation: A retrospective review

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Background: ASCO’s Quality Oncology Practice Initiative (QOPI) sets site standards to promote excellence in oncology care. One standard is screening appropriate female patients for pregnancy prior to chemotherapy. However, no formal guidelines exist regarding pregnancy screening protocols or timing of screening. We believe that women are inconsistently being screened for pregnancy prior to chemotherapy. Methods: A retrospective chart review was conducted using the UF Health (UFH) tumor registry and electronic health record (Epic) to identify women ages 18-55 who received chemotherapy or endocrine therapy by a medical oncologist between January 1, 2012 and December 31, 2014. Exclusions were prior hysterectomy or tubal ligation, known pregnancy, or treatment outside of UFH. The following data was collected: age, race, diagnosis date, cancer type, pregnancy screening test (urine or blood β-HCG) and date, specialty of ordering provider, name of chemotherapy or endocrine agent, and participation in interventional clinical trial. Results: Our search identified 501 potentially eligible women. Of these, 204 were excluded, 96% due to prior hysterectomy or tubal ligation. Of the remaining 297 eligible women, 103 (35%) received pregnancy testing prior to chemotherapy. Three screening tests were positive of the 103 pregnancy tests ordered. Follow up testing revealed 2 were true positives and 1 was a false positive. Of the 103 pregnancy tests, 23 (22%) were ordered by medical oncology, 51 (50%) were ordered by a surgery or anesthesia, and 16 (16%) were ordered by emergency medicine. 48% of the pregnancy tests were performed within 14 days prior to treatment start date. Conclusions: At our institution, pregnancy screening rates in women of childbearing potential were just 35%, and less than half of the women who were screened received pregnancy testing within 14 days of treatment start. Based on this data, a quality improvement project has been initiated in the outpatient medical oncology clinic and infusion center to improve pregnancy screening in this population. [Table: see text]