A cluster of three extrapulmonary Mycobacterium abscessus infections linked to well-maintained water-based heater-cooler devices

BACKGROUND

Various water-based heater-cooler devices (HCDs) have been implicated in nontuberculous mycobacteria outbreaks. Ongoing rigorous surveillance for healthcare-associated M. abscessus (HA-Mab) put in place following a prior institutional outbreak of M. abscessus alerted investigators to a cluster of 3 extrapulmonary M. abscessus infections among patients who had undergone cardiothoracic surgery.

METHODS

Investigators convened a multidisciplinary team and launched a comprehensive investigation to identify potential sources of M. abscessus in the healthcare setting. Adherence to tap water avoidance protocols during patient care and HCD cleaning, disinfection, and maintenance practices were reviewed. Relevant environmental samples were obtained. Patient and environmental M. abscessus isolates were compared using multilocus-sequence typing and pulsed-field gel electrophoresis. Smoke testing was performed to evaluate the potential for aerosol generation and dispersion during HCD use. The entire HCD fleet was replaced to mitigate continued transmission.

RESULTS

Clinical presentations of case patients and epidemiologic data supported intraoperative acquisition. M. abscessus was isolated from HCDs used on patients and molecular comparison with patient isolates demonstrated clonality. Smoke testing simulated aerosolization of M. abscessus from HCDs during device operation. Because the HCD fleet was replaced, no additional extrapulmonary HA-Mab infections due to the unique clone identified in this cluster have been detected.

CONCLUSIONS

Despite adhering to HCD cleaning and disinfection strategies beyond manufacturer instructions for use, HCDs became colonized with and ultimately transmitted M. abscessus to 3 patients. Design modifications to better contain aerosols or filter exhaust during device operation are needed to prevent NTM transmission events from water-based HCDs.

Advances in rectal cancer: Real-world evidence suggests limited gains in prognosis for elderly patients

BACKGROUND

Rectal cancer treatment has improved considerably due to the introduction of total meso-rectal excision, radio-chemotherapy, and high-resolution imaging. The aim of this observational cohort study was to quantify the effectiveness of these advances using high-quality data from a representative cohort of patients.

METHODS

20 281 non-metastasized cases retrieved from the Munich Cancer Registry database were divided into three time periods corresponding to before (1988-1997), partial (1998-2007), and full implementation (2008-2019) of clinical advances. Early-onset (<50 yrs.), middle-aged, elderly patient subgroups (> 70 yrs.) were compared. The overall effectiveness of evidence-based guideline adherence was also examined.

RESULTS

Median survival improved by 1.5 yrs. from the first to the last time period. Relative survival increased from 74.9% (5-yr 95%CI[73.3 - 76.6]) to 79.2% (95%CI[77.8 - 80.5]). The incidence of locoregional recurrences was reduced dramatically by more than half (5-yr 17.7% (95%CI[16.5 - 18.8]); 6.7% (95%CI[6.1 - 7.3])). Gains in 5-yr relative survival were limited to early-onset and middle-aged patients with no significant improvement seen in elderly patients (Female 68.6% [63.9 - 73.3] to 67.6% [64.0 - 71.2]; Male 71.7% [65.9 - 77.4] to 74.0% [70.8 - 77.2]).

CONCLUSIONS

Real-world evidence suggests that recent treatment advances have lead to an increase in prognosis for rectal cancer patients. However, more effort should be made to improve the implementation of new developments in elderly patients. Especially considering, that these cases represent a growing majority of diagnosed patients.

A Quality Improvement Project to Decrease CLABSIs in Non-ICU Settings

BACKGROUND AND OBJECTIVES

Central line-associated bloodstream infections (CLABSIs) are a common, preventable healthcare-associated infection. In our 3-hospital health system, CLABSI rates in non-intensive care unit (ICU) settings were above the internal target rate of zero. A robust quality improvement (QI) project to reduce non-ICU CLABSIs was undertaken by a team of Doctor of Nursing Practice (DNP)-prepared nurse leaders enrolled in a post-DNP Quality Implementation Scholars program and 2 QI experts. Based on a review of the literature and local root cause analyses, the QI team implemented the evidence-based practice of using 2% chlorhexidine gluconate (CHG) cloths for daily bathing for non-ICU patients with a central line.

METHODS

A pre-post-design was used for this QI study. CHG bathing was implemented using multifaceted educational strategies that included an e-learning module, printed educational materials, educational outreach, engagement of unit-based CLABSI champions, and an electronic reminder in the electronic health record. Generalized linear mixed-effects models were used to assess the change in CLABSI rates before and after implementation of CHG bathing. CLABSI rates were also tracked using statistical process control (SPC) charts to monitor stability over time. CHG bathing documentation compliance was audited as a process measure. These audit data were provided to unit-based leadership (nurse managers and clinical team leaders) on a monthly basis. A Qualtrics survey was also disseminated to nursing leadership to evaluate their satisfaction with the CHG bathing implementation processes.

RESULTS

Thirty-four non-ICU settings participated in the QI study, including general medical/surgical units and specialty areas (oncology, neurosciences, cardiac, orthopedic, and pediatrics). While the change in CLABSI rates after the intervention was not statistically significant ( b = -0.35, P = .15), there was a clinically significant CLABSI rate reduction of 22.8%. Monitoring the SPC charts demonstrated that CLABSI rates remained stable after the intervention at all 3 hospitals as well as the health system. CHG bathing documentation compliance increased system-wide from 77% (January 2020) to 94% (February 2021). Overall, nurse leaders were satisfied with the CHG bathing implementation process.

CONCLUSIONS

To sustain this practice change in non-ICU settings, booster sessions will be completed at least on an annual basis. This study provides further support for using CHG cloths for daily patient bathing in the non-ICU setting.

Using an Electromagnetic Guidance System for Placement of Small-Bowel Feeding Tubes to Reduce Feeding Start Times

BACKGROUND

Cardiothoracic surgery patients have an increased risk for aspiration and may require enteral access for nutrition.

LOCAL PROBLEM

In a cardiothoracic intensive care unit, feeding start times were delayed because of scheduling conflicts with support services. An electromagnetic device (Cortrak 2 Enteral Access System, Avanos Medical) was introduced to allow advanced practice providers (nurse practitioners and physician assistants) to independently establish postpyloric access and reduce dependence on ancillary services.

METHODS

A quality improvement study was performed. Pre- and postimplementation data included order time, service arrival, tube placement time, tube positioning, and feeding start times for 207 placements. Pre- and postimplementation surveys were conducted to evaluate advanced practice provider satisfaction with enteral tube placement practices.

RESULTS

Feeding start time for initial placement decreased by 35.5% (15.6 hours to 10 hours); for subsequent placement, by 55.2% (15.5 hours to 7.0 hours). Assistance by support services decreased by 80.4% (before implementation, 100 of 100 placements [100%]; after implementation, 21 of 107 placements [19.6%]; P < .001; ϕ = 0.815). Overall, advanced practice provider satisfaction increased. Most participants said that using the electromagnetic device was faster, nutrition was delivered sooner, and implementation was a valuable practice change.

CONCLUSIONS

Using an electromagnetic device decreased feeding start times, reduced the need for support services, and increased advanced practice provider satisfaction with small-bowel feeding tube placement practices.

Moving nursing innovation to prime time through the use of creative partnerships

Nurses are well-positioned to solve many problems in healthcare through engagement in innovation. Support from healthcare organizations to facilitate creative partnerships may accelerate nurses' ability to innovate and improve job satisfaction. The value of creative partnerships is rooted in the diversity of experiences and skillsets of each project team member. While nurses may be content experts and key stakeholders, they often lack experience with project management, information technology, product development, and other important skills. We describe the use of co-creation approaches in creative partnerships with diverse stakeholders to enhance the ability of nurse-led project teams to build valuable and sustainable products or services.

A153 STRATEGIES TO DISTINGUISH PERIANAL FISTULAS RELATED TO CROHN’S DISEASE FROM CRYPTOGLANDULAR DISEASE: SYSTEMATIC REVIEW WITH META-ANALYSIS

Background

Differentiating between perianal fistulas related to cryptoglandular disease (CGD) and Crohn’s disease (CD) is essential to guide disease specific management.

Aims

We aimed to assess the ability of diagnostic strategies to differentiate between CD from CGD in patients with perianal fistulas.

Methods

We performed a diagnostic accuracy systematic review and meta-analysis. Electronic databases (MEDLINE, Embase, Web of Science, CENTRAL) were systematically searched from inception through February 2021 for studies that assessed a diagnostic test’s ability to distinguish fistula types. We calculated weighted summary estimates with 95% confidence intervals for sensitivity and specificity by bivariate analysis, using fixed effects models when data was available from two or more studies. The QUADAS tool was used to assess study quality.

Results

Twenty-one studies were identified and included: clinical symptoms (2 studies; n = 154 patients), MRI characteristics (3 studies; n = 296 patients), ultrasound characteristics (7 studies; n = 1003 patients), video capsule endoscopy (2 studies; n = 44 patients), fecal calprotectin (1 study; n = 56 patients) and various biomarkers (8 studies; n = 440 patients). MRI and ultrasound characteristics had the most robust data. Rectal inflammation, multiple-branched fistula tracts and abscesses on pelvic MRI, and the Crohn’s Ultrasound Fistula Sign, fistula debris and bifurcated fistulas on pelvic ultrasonography had high specificity (range, 80–95% vs. 89–96%) but poor sensitivity (range, 17–37% vs. 31–63%), respectively. Fourteen of twenty-one studies had risk of bias on at least one of the QUADAS domains.

Conclusions

Limited high-quality evidence suggest that imaging characteristics may help discriminate CD from CGD in patients with perianal fistulas. Larger, prospective studies are needed to confirm these findings and to evaluate if combining multiple diagnostic tests can improve diagnostic sensitivity.

Funding Agencies

None

Public Opinion Leadership in Nursing Practice: A Rogerian Concept Analysis

In the Dutch nursing context, work remains in strengthening the voice of nurses serving as frontline health care providers and board members alike. Conceptual clarity of Public Opinion Leadership (POL) in nursing practice is needed to provide attributes, antecedents and consequences for nurses and nurse leaders so they can contribute in the public debate and policy making processes. Using Rodgers’ method of evolutionary concept analysis and the key words “POL,” “lobbying” and “public affairs,” we searched PubMed (including MEDLINE), CINAHL, PsycINFO and Cochrane Library for articles written in English, published between January 1999 and May 2020, which resulted in a final selection of seven studies. In addition, transcripts of an expert panel discussion regarding POL were analyzed. Attributes of POL are credibility, accessibility, altruism, dynamic networking and sense of systemness. Antecedents are a clinical background, authentic authority, policy and political awareness and strategic skills. The main consequences of POL entail influencing those who are involved in policy making processes, a new generation of public opinion leaders, and the raising of bottom-up political leaders. POL is a relatively new concept for nursing, with increasing interest given the need to ensure quality of care by increasing the use of evidence in clinical practice. POL in nursing practice is defined as the action of influencing public debate regarding policy making processes by maintaining dynamic (social) networks, having a high sense of systemness, and being (clinically) credible, altruistic and accessible to peers and a wide variety of stakeholders.

Prevention of breast&ovarian cancer in women with BRCA-1/2 mutations - A decision-analytic evaluation

Background

Women who have inherited BRCA-1/2 mutations have substantially elevated lifetime risks for developing breast and/or ovarian cancer and may develop these cancers around age 30. Therefore, breast and ovarian cancer prevention should be administered relatively early in life for those women. We systematically evaluate the long-term effectiveness and cost-effectiveness of different breast and ovarian cancer prevention strategies in women with BRCA-1/2 mutations in Germany.

Methods

A decision-analytic Markov model simulating lifetime breast and ovarian cancer development in BRCA-1/2 carriers was developed to evaluate different strategies including intensified surveillance (IS), prophylactic bilateral mastectomy (PBM), and prophylactic bilateral oophorectomy (PBSO) alone or in combination at different ages. German clinical, epidemiological and cost (in 2018 Euro) data were used. Outcomes included cancer incidences, mortality, life years (LYs), quality-adjusted life years (QALYs), and discounted incremental cost-effectiveness ratios (ICER).

Results

All intervention strategies are more effective and less costly than IS alone. Prevention with PBM plus PBSO at age 30 maximizes life expectancy with 6.3 LYs gained, whereas PBM at age 30 with delayed PBSO at age 35 improves quality of life with 11.1 QALYs gained, when compared to IS alone. Both strategies are cost effective with ICER significantly below 10,000 EUR/LY or QALY gained.

Conclusions

Based on our results, PBM at age 30 plus PBSO between age 30 and 40 prolongs life and is cost effective in women with BRCA-1/2 mutations in Germany. Serial preventive surgeries with delayed PBSO potentially improve quality of life for women. We therefore suggest that efforts should be directed to carefully and thoroughly inform women with BRCA-1/2 mutations about their options to prevent breast and ovarian cancer.

Key messages

Prophylactic mastectomy at age 30 combined with prophylactic oophorectomy between age 30 and 40 may prolong lives and be cost effective in German women with BRCA- 1/2 mutations. Women’s quality of life might be improved by a delayed prophylactic oophorectomy after a prophylactic mastectomy.

Evaluation of a proactive hiring model to achieve workforce stability in the intensive care unit

AIM

The purpose was to evaluate an innovative Prospective Hiring Equation to determine registered nurse hiring needs.

BACKGROUND

The American Organization for Nursing Leadership identifies human resource management as a competency for nurse managers, yet calculations to determine when and how many registered nurses to hire are not readily available.

METHODS

We implemented an educational intervention to teach nurse mangers the Prospective Hiring Equation. We evaluated the processes (adoption and confidence) and outcomes (vacancy rates) using a pre-evaluation/postevaluation design in a single cohort of nurse managers (n = 9). We used a statistical process control chart to depict mean differences in vacancy rate at baseline and 6-month postimplementation.

RESULTS

Participants (n = 9) were on average 43 years' old, female, and had 2.94 (SD = 2.66) years' of nurse manager experience. Following implementation of the intervention, the combined vacancy rates of the intensive care units improved by 11.8% (SD = 7), and use of agency nurses decreased by 42.5% (premedian = 7.2, interquartile ratio = 3.6, 10.8; postmedian = 1.8, interquartile ratio 0.9, 8.55).

CONCLUSIONS

The Prospective Hiring Equation may be a useful tool to improve nurse managers human resource management competencies.

IMPLICATIONS FOR NURSING MANAGEMENT

The Prospective Hiring Equation may help nurse managers improve accuracy when evaluating hiring needs.

Outcome of breast cancer patients with low hormone receptor positivity: analysis of a 15-year population-based cohort

BACKGROUND

Guideline recommendations for the treatment of breast cancer with low hormone receptor (HR) expression (1%-9%) are ambiguous and several studies showed more similarities with HR-negative tumors than with HR strongly positive tumors (≥10%). We used a population-based 15-year cohort to compare patient characteristics and outcome of HR low positive tumors with HR-negative and HR strongly positive tumors, respectively.

PATIENTS AND METHODS

A total of 38  560 women diagnosed with early invasive breast cancer between 2004 and 2018 within the scope of the Munich Cancer Registry with 4.9 million inhabitants were included. Descriptive analyses of prognostic factors, treatment, and outcome analyses using the Kaplan-Meier method; cumulative incidence in consideration of competing risks; and multivariate analyses (Cox regression and Fine-Gray model) were conducted. Endpoints were time to local recurrence (TTLR), time to lymph node recurrence (TTLNR), time to metastasis (TTM), overall survival (OS), and relative survival (RS).

RESULTS

A total of 861 patients (2%) had HR low positive, 4862 (13%) HR-negative, and 32  837 (85%) HR strongly positive tumors. Within the HER2-negative cohort (n = 33  366), survival of HR low positive tumors was significantly worse than that of HR strongly positive tumors [OS hazard ratio 0.66 (95% confidence interval 0.55-0.78)], whereas between HR low positive and HR-negative tumors no significant survival difference could be detected [OS hazard ratio 0.93 (95% confidence interval 0.78-1.11)]. TTLR, TTLNR, and TTM showed similar results. By contrast, within the HER2-positive cohort (n = 5194), no statistically significant differences between the three HR groups could be detected in multivariate analyses.

CONCLUSION

Current definitions for HR positivity and its clinical relevance should be reconsidered. Patients with HR low positive/HER2-negative tumors could be regarded and treated similar to patients with triple-negative tumors.

Coupled-Cluster Calculations of Neutrinoless Double-β Decay in ^{48}Ca

We use coupled-cluster theory and nuclear interactions from chiral effective field theory to compute the nuclear matrix element for the neutrinoless double-β decay of ^{48}Ca. Benchmarks with the no-core shell model in several light nuclei inform us about the accuracy of our approach. For ^{48}Ca we find a relatively small matrix element. We also compute the nuclear matrix element for the two-neutrino double-β decay of ^{48}Ca with a quenching factor deduced from two-body currents in recent ab initio calculation of the Ikeda sum rule in ^{48}Ca [Gysbers et al., Nat. Phys. 15, 428 (2019)NPAHAX1745-247310.1038/s41567-019-0450-7].

Gamow-Teller Strength in ^{48}Ca and ^{78}Ni with the Charge-Exchange Subtracted Second Random-Phase Approximation

We develop a fully self-consistent subtracted second random-phase approximation for charge-exchange processes with Skyrme energy-density functionals. As a first application, we study Gamow-Teller excitations in the doubly magic nucleus ^{48}Ca, the lightest double-β emitter that could be used in an experiment, and in ^{78}Ni, the single-beta-decay rate of which is known. The amount of Gamow-Teller strength below 20 or 30 MeV is considerably smaller than in other energy-density-functional calculations and agrees better with experiment in ^{48}Ca, as does the beta-decay rate in ^{78}Ni. These important results, obtained without ad hoc quenching factors, are due to the presence of two-particle-two-hole configurations. Their density progressively increases with excitation energy, leading to a long high-energy tail in the spectrum, a fact that may have implications for the computation of nuclear matrix elements for neutrinoless double-β decay in the same framework.

How to Start an Enhanced Recovery After Surgery Cardiac Program

In this review the authors introduce a practical approach to guide the initiation of an enhanced recovery after surgery (ERAS) cardiac surgery program. The first step in implementation is organizing a dedicated multidisciplinary ERAS cardiac team composed of representatives from nursing, surgery, anesthesiology, and other relevant allied health groups. Identifying a program coordinator or navigator who will have responsibilities for developing and implementing educational initiatives, troubleshooting, monitoring progress and setbacks, and data collection is also vital for success. An institution-specific protocol is then developed by leveraging national guidelines and local expertise.

Ab Initio Treatment of Collective Correlations and the Neutrinoless Double Beta Decay of ^{48}Ca

Working with Hamiltonians from chiral effective field theory, we develop a novel framework for describing arbitrary deformed medium-mass nuclei by combining the in-medium similarity renormalization group with the generator coordinate method. The approach leverages the ability of the first method to capture dynamic correlations and the second to include collective correlations without violating symmetries. We use our scheme to compute the matrix element that governs the neutrinoless double beta decay of ^{48}Ca to ^{48}Ti, and find it to have the value 0.61, near or below the predictions of most phenomenological methods. The result opens the door to ab initio calculations of the matrix elements for the decay of heavier nuclei such as ^{76}Ge, ^{130}Te, and ^{136}Xe.

Sexual cues alter working memory performance and brain processing in men with compulsive sexual behavior

Pornography has been repeatedly at the centre of public attention and has been controversially discussed for a long time. However, little is known about the connection between pornographic stimuli and individual (neuronal) processing of attention and memory. Here, the impact and neural underpinnings of pornographic pictures on working memory processes in a sample of subjects with compulsive sexual behaviour was investigated. Therefore, whilst using functional magnetic resonance imaging (fMRI), a letter n-back task with neutral or pornographic pictures in the background was employed in 38 patients and 31 healthy controls. On the behavioural level, patients were slowed down by pornographic material depending on their pornography consumption in the last week, which was reflected by a higher activation in the lingual gyrus. In addition, the lingual gyrus showed a higher functional connectivity to the insula during processing of pornographic stimuli in the patient group. In contrast, healthy subjects showed faster responses when confronted with pornographic pictures only with high cognitive load. Also, patients showed a better memory for pornographic pictures in a surprise recognition task compared to controls, speaking for a higher relevance of pornographic material in the patient group. These findings are in line with the incentive salience theory of addiction, especially the higher functional connectivity to the salience network with the insula as a key hub and the higher lingual activity during processing of pornographic pictures depending on recent pornography consumption.

Critical comparison of methods for fault diagnosis in metabolomics data

Platforms like metabolomics provide an unprecedented view on the chemical versatility in biomedical samples. Many diseases reflect themselves as perturbations in specific metabolite combinations. Multivariate analyses are essential to detect such combinations and associate them to specific diseases. For this, usually targeted discriminations of samples associated to a specific disease from non-diseased control samples are used. Such targeted data interpretation may not respect the heterogeneity of metabolic responses, both between diseases and within diseases. Here we show that multivariate methods that find any set of perturbed metabolites in a single patient, may be employed in combination with data collected with a single metabolomics technology to simultaneously investigate a large array of diseases. Several such untargeted data analysis approaches have been already proposed in other fields to find both expected and unexpected perturbations, e.g. in Statistical Process Control. We have critically compared several of these approaches for their sensitivity and their correct identification of the specifically perturbed metabolites. Also a new approach is introduced for this purpose. The newly introduced Sparse Mean approach, which we find here as most sensitive and best able to identify the specifically perturbed metabolites, turns metabolomics into an untargeted diagnostic platform. Aside from metabolomics, the proposed approach may greatly benefit fault diagnosis with untargeted analyses in many other fields, such as Industrial Process Control, food Adulteration Detection, and Intrusion Detection.

Observation of the Self-Modulation Instability via Time-Resolved Measurements

Self-modulation of an electron beam in a plasma has been observed. The propagation of a long (several plasma wavelengths) electron bunch in an overdense plasma resulted in the production of multiple bunches via the self-modulation instability. Using a combination of a radio-frequency deflector and a dipole spectrometer, the time and energy structure of the self-modulated beam was measured. The longitudinal phase space measurement showed the modulation of a long electron bunch into three bunches with an approximately 200  keV/c amplitude momentum modulation. Demonstrating this effect is a breakthrough for proton-driven plasma accelerator schemes aiming to utilize the same physical effect.

Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation

Background

Nontuberculous mycobacteria (NTM) commonly colonize municipal water supplies and cause healthcare-associated outbreaks. We investigated a biphasic outbreak of Mycobacterium abscessus at a tertiary care hospital.

Methods

Case patients had recent hospital exposure and laboratory-confirmed colonization or infection with M. abscessus from January 2013 through December 2015. We conducted a multidisciplinary epidemiologic, field, and laboratory investigation.

Results

The incidence rate of M. abscessus increased from 0.7 cases per 10000 patient-days during the baseline period (January 2013-July 2013) to 3.0 cases per 10000 patient-days during phase 1 of the outbreak (August 2013-May 2014) (incidence rate ratio, 4.6 [95% confidence interval, 2.3-8.8]; P < .001). Thirty-six of 71 (51%) phase 1 cases were lung transplant patients with positive respiratory cultures. We eliminated tap water exposure to the aerodigestive tract among high-risk patients, and the incidence rate decreased to baseline. Twelve of 24 (50%) phase 2 (December 2014-June 2015) cases occurred in cardiac surgery patients with invasive infections. Phase 2 resolved after we implemented an intensified disinfection protocol and used sterile water for heater-cooler units of cardiopulmonary bypass machines. Molecular fingerprinting of clinical isolates identified 2 clonal strains of M. abscessus; 1 clone was isolated from water sources at a new hospital addition. We made several water engineering interventions to improve water flow and increase disinfectant levels.

Conclusions

We investigated and mitigated a 2-phase clonal outbreak of M. abscessus linked to hospital tap water. Healthcare facilities with endemic NTM should consider similar tap water avoidance and engineering strategies to decrease risk of NTM infection.

Current Status of Companion and Complementary Diagnostics: Strategic Considerations for Development and Launch

US Food and Drug Administration (FDA)‐approved diagnostic assays play an increasingly common role in managing patients to prolong lifespan while also enhancing quality of life. Diagnostic assays can be essential for the safe and effective use of therapeutics (companion diagnostic), or may inform on improving the benefit/risk ratio without restricting drug access (complementary diagnostic). This tutorial reviews strategic considerations for drug and assay development resulting in FDA‐approved companion or complementary diagnostic status.

[Clinical and epidemiological cancer registration in Germany]

OBJECTIVE

Function and funding of detailed clinical cancer registries (CCRs) is defined by German Social Code Book V (SGB V) and shall be implemented by the end of 2017.

CONTENT

Cancer registration according to regionally defined catchment areas, feedback of results and quality assurance are the basis which determines principles of operation and use of data. Each clinical department delivers only its own findings and therapy, while compilation by the clinical cancer registry describes the patients' way through the regional network of medical care. In this way, oncological centers are not burdened by troublesome documentation of data which originate from other clinics.

CONCLUSION

After successful implementation of CCRs, interested physicians and clinics are able to spend time for analysis and use of meaningful data with the objective of improving quality of care within the region, implementing innovative therapies and presenting their results, and generating new hypotheses to stimulate research.

Abstract P4-11-13: Cancer-specific distress, life satisfaction and parenting concerns in young breast cancer survivors

Introduction

It is known that young breast cancer (BC) patients tend to suffer more psychological stress and have lower quality of life than older women, are less sexually active and have more body image issues than healthy women of the same age. They may also be challenged by reproductive concerns. To our knowledge, no data exist about the effect of the disease on the life satisfaction of premenopausal BC patients. This study tries to elucidate life satisfaction in several aspects of daily life in this special cohort as well as aspects of cancer-specific distress and parenting concerns in order to improve our support strategies.

Materials and methods

In a cross-sectional study design, all patients with &lt; 40 years at primary BC diagnosis treated at Breast Center, CCC LMU Munich (Germany) between 2006 and 2013 were eligible for participation. Standardized questionnaires assessing life satisfaction (Life Satisfaction Questionnaire; Fahrenberg et al, 2000) and cancer-specific distress (Questionnaire on Stress in Cancer patients; Herschbach et al, 2003), as well as a self-developed questionnaire on partnership, employment situation, family planning, demographic and medical data were mailed in 2014.

Results

88 patients responded (55%). Compared with population data stratified for age and sex, patients showed significantly less satisfaction in the domains of health (p&lt;0.001) and sexuality (p=0.002) but not in any other domains or overall life satisfaction. The patients' most pronounced cancer-specific problems were fear of cancer recurrence and fear of further hospital stays, diminished sexual activity, and psychosomatic problems like nervousness, fatigue and insomnia. Of those patients who retrospectively evaluated their decision for or against fertility preservation, 76.4% were satisfied with their choice. Current desire to have children was reported by 45.8% of patients and another 15.6% were uncertain, but only 21.7% actually planned to have children. The most frequently reported reasons to refrain from childbearing were shortened life expectancy, negative impact of pregnancy on prognosis, and treatment-related infertility.

Discussion

In our cohort, the general life satisfaction of young breast cancer survivors showed no difference from women without cancer, but these patients were not satisfied with their general health status and with their sexuality. Also, cancer-related fears and psychosomatic problems considerably stress young patients and thus need to be addressed by supportive care programs. There is also a need for counselling regarding childbearing after BC treatment. In contrast, fertility preservation seems to be well established in medical consultations. In conclusion, tailored supportive care programs have to be realized to respond the unique needs of young BC patients.

Citation Format: Burgmann M, Hermelink K, Farr A, Heiduschka A, van Meegen F, Engel J, Harbeck N, Wuerstlein R. Cancer-specific distress, life satisfaction and parenting concerns in young breast cancer survivors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-11-13.

Abstract P3-07-09: Quantitative p95HER2 protein expression is predictive of trastuzumab response in HER2-positive metastatic breast cancer

Background: Expression of p95HER2 (p95), a truncated form of the HER2 receptor that lacks the trastuzumab binding site but retains kinase activity, has been reported as a prognostic biomarker for poor outcome in trastuzumab-treated HER2-positive metastatic breast cancer (MBC). However, the ability of p95 to predict trastuzumab benefit has not been demonstrated due to the difficulty in obtaining the appropriate control group, namely HER2+ MBC patients not treated with trastuzumab. In the current study, the predictive value of p95 expression was tested in a cohort comprised of HER2-positive MBC patients treated before the availability of trastuzumab and trastuzumab-treated HER2-positive MBC patients.

Methods: The current cohort was derived from 206 HER2-positive MBC patients in the Munich Cancer Registry with a median follow up of 64 months. Cases were divided between those that received trastuzumab (n=115) and those that were treated before the availability of trastuzumab (n=91). Quantitative p95 protein expression was measured in formalin-fixed paraffin-embedded samples using the p95 VeraTag® assay (Monogram Biosciences), which is specific for the active M611 form of p95. Quantitative total HER2 protein expression was measured using the HERmark® assay (Monogram Biosciences). p95 and HERmark cutoffs were pre-specified (Duchnowska, Clin Cancer Res, 20:2805, 2014 and Huang, Am J Clin Pathol, 134:303, 2010). Analyses with p95 were restricted to samples with confirmed HER2 overexpression by HERmark. All hazard ratios (HR) were stratified by estrogen receptor status and grade.

Results: Consistent with previous training (Sperinde, Clin Cancer Res, 16:4226, 2010) and validation (Duchnowska, Clin Cancer Res, 20:2805, 2014) datasets, subjects treated with trastuzumab experienced a shorter time to progression (TTP) when p95 expression levels were above the cutoff versus below the cutoff (HR = 3.8, p = 0.019). However, only a trend was observed between p95 expression levels and overall survival (HR = 2.2, p = 0.20), possibly due to a lower frequency of events and relatively small sample size. The predictive value of p95 was assessed by determining the benefit of adding trastuzumab to chemotherapy treatment in subsets below and above the p95 cutoff. As expected, patients with p95 below the cutoff experienced significant benefit in TTP from adding trastuzumab (HR = 0.13, p&lt;0.001), whereas patients with p95 above the cutoff experienced less benefit (HR = 0.70, p=0.47). p95 expression level was predictive of trastuzumab response with an interaction p-value of 0.015. The results for OS were similar, however trastuzumab benefit was less distinct between the two groups (interaction p = 0.18); HR = 0.23, p = 0.0013 below the p95 cutoff versus HR = 0.50, p = 0.14 above the p95 cutoff.

Conclusions: In this dataset, quantitative p95 expression was predictive of trastuzumab treatment benefit in MBC. Patients with high p95 expression may be particularly good candidates for dual HER2 blockade, as reported in the NeoALTTO trial (Scaltriti, Clin Cancer Res, 21:569, 2015), or other additional therapies.

Citation Format: Sperinde J, Bachmeier B, Weidler JM, Lie Y, Chenna A, Winslow J, Engel J, Schubert-Fritschle G, Sommerhoff C, Petropoulos C, Bates M, Huang W, Nerlich A. Quantitative p95HER2 protein expression is predictive of trastuzumab response in HER2-positive metastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-09.

Abstract P3-13-02: Surcigal management of ipsilateral breast tumor recurrence

PURPOSE

Approximately 10-15% of breast cancer patients treated by breast conserving surgery (BCS) and adjuvant radiotherapy (RT) will develop ipsilateral breast tumor recurrence (IBTR).

International guidelines suggest total mastectomy as treatment of choice for IBTR following lumpectomy and RT. Nevertheless, there is evidence that second BCS might be equally sufficient.

PATIENTS AND METHODS

Patients with IBTR diagnosed between 1990 and 2014 after BCS and RT were included (n=170).

34.1% women underwent secondary BCS, whereas 65.9% were treated by mastectomy. We determined predictive factors for time to local progression (TTP), disease free survival (DFS), and overall survival (OS) comparing these two groups.

RESULTS

Median follow-up after primary IBTR was 49 months (59 months for patients still alive at time of analysis). Five-year IBTR-free rate after secondary BCS was 77.6% (SD±6.1%) and 75.0% (SD±4.5%) for patients after mastectomy. Five-year DFS was 57.3% (SD±8.2%), and 61.9% (SD±5.5%), five-year OS was 84.7% (SD±5.8%), and 72.6% (SD±5.1%), respectively.

Prior adjuvant systemic therapy, muscular invasion, and skin infiltration were independent significant risk factors for a shorter TTP.

Additionally, lymphovascular infiltration (LVI) in the IBTR increased the risk for a shorter DFS.

LVI, muscular invasion, and skin infiltration were identified as independent significant risk factors for a shorter OS.

CONCLUSION

No significant difference in local control, DFS, and OS was seen between IBTR patients treated either by secondary BCS or mastectomy. Our data suggest that secondary BCS for IBTR patients after initial BCS and RT is feasible in selected patients.

Citation Format: Kolben T, Schwarz TM, Goess C, Blume C, Degenhardt T, Engel J, Wuerstlein R, Ditsch N, Harbeck N, Kahlert S. Surcigal management of ipsilateral breast tumor recurrence. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-02.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Data quality issues impede comparability of hospital treatment delay performance indicators

Aim

To assess the comparability of five performance indicator scores for treatment delay among patients diagnosed with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention in relation to the quality of the underlying data.

Methods

Secondary analyses were performed on data from 1017 patients in seven Dutch hospitals. Data were collected using standardised forms for patients discharged in 2012. Comparability was assessed as the number of occasions the indicator threshold was reached for each hospital.

Results

Hospitals recorded different time points based on different interpretations of the definitions. This led to substantial differences in indicator scores, ranging from 57 to 100 % of the indictor threshold being reached. Some hospitals recorded all the required data elements for calculating the performance indicators but none of the data elements could be retrieved in a fully automated way. Moreover, recording accessibility and completeness of time points varied widely within and between hospitals.

Conclusion

Hospitals use different definitions for treatment delay and vary greatly in the extent to which the necessary data are available, accessible and complete, impeding comparability between hospitals. Indicator developers, users and hospitals providing data should be aware of these issues and aim to improve data quality in order to facilitate comparability of performance indicators.

Regularized MANOVA (rMANOVA) in untargeted metabolomics

Many advanced metabolomics experiments currently lead to data where a large number of response variables were measured while one or several factors were changed. Often the number of response variables vastly exceeds the sample size and well-established techniques such as multivariate analysis of variance (MANOVA) cannot be used to analyze the data. ANOVA simultaneous component analysis (ASCA) is an alternative to MANOVA for analysis of metabolomics data from an experimental design. In this paper, we show that ASCA assumes that none of the metabolites are correlated and that they all have the same variance. Because of these assumptions, ASCA may relate the wrong variables to a factor. This reduces the power of the method and hampers interpretation. We propose an improved model that is essentially a weighted average of the ASCA and MANOVA models. The optimal weight is determined in a data-driven fashion. Compared to ASCA, this method assumes that variables can correlate, leading to a more realistic view of the data. Compared to MANOVA, the model is also applicable when the number of samples is (much) smaller than the number of variables. These advantages are demonstrated by means of simulated and real data examples. The source code of the method is available from the first author upon request, and at the following github repository: https://github.com/JasperE/regularized-MANOVA.