Coupling gamified continuing education with confidence-based assessment to address knowledge gaps and assess attitudes towards liquid biopsy for cancer screening among primary care providers

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Background: Blood-based liquid biopsy assays offer a simplified approach to detect cancer early, guide clinical decision making, and predict treatment success. Given their novelty, primary care providers need education to improve knowledge and confidence regarding their use. The use of gamification in continuing medical education (CME) has been shown to increase engagement and knowledge transfer, and confidence-based learning can improve the educational experience by identified areas in which learners lack comfort. Methods: We provided a gamified CME activity based on the principles of confidence-based learning designed to educate primary care providers (PCPs) on the latest advances regarding the use of liquid biopsy for cancer screening. The game coupled knowledge questions with self-assessment of confidence to gage awareness of these topics. Pre- and post-test was used to quantify the impact of the education. The CE activity was available for credit from March 31, 2021 to March 31, 2022. Results: As of January 2022, 389 PCPs have participated. Overall, participants scored an average 76% on gaming questions related to the rationale behind the use of cell free DNA (cfDNA) for cancer screening and the benefits of liquid biopsy over tissue biopsy, demonstrating relatively high baseline knowledge on these topics. Self-reported confidence among those who answered correctly, however, was only 3.4 out of 5.0, suggesting a lack of comfort with the concepts despite answering correctly. On topics related to specific studies that demonstrated the clinical utility of liquid biopsy, participants scored only 59% and confidence scored averaged 3.17 out of 5.0, demonstrating a lack of knowledge and comfort on these topics. Across all topics, providers scored a 61% on a pre-test. Post-learning, providers scored 89%, highlighting the impact of the education on knowledge gaps. Moreover, while 52% of participants had never ordered a liquid biopsy for cancer screening prior to the education, 69% report being likely or extremely likely to do so because of the education provided. Conclusions: Integration of gamified and confidence-based learning into CE activities is an impactful way to identify and address knowledge gaps while also informing the need for future education. In this study, while self-report of confidence generally correlated with knowledge scores, confidence scores were only average even among those who answered correctly, demonstrating the need for skills-based learning that may improve comfort with liquid biopsy in the clinical setting.

Engaging continuing medical education in evaluating knowledge gaps and preferences in advanced BRAF+ melanoma

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Background: Given the rapid evolution of treatments for advanced melanoma, oncology providers are challenged to stay current on evidence-based recommendations for optimal patient care. Integrating practice-based polling into continuing medical education (CME) activities is a proven way to increase engagement, address knowledge gaps, and assess attitudes on specific topics. Methods: We provided a CME activity designed to educate oncology and dermatology providers on the latest advances regarding the management of advanced BRAFmut+ melanoma. Interspersed engagement opportunities further assessed practice preferences and elucidated persisting educational needs. The CE activity was available for credit from December 31, 2020 to December 30, 2021. Results: 305 medical oncology or dermatology providers who each see an average of 25 patients with melanoma per month participated. These providers scored an average 38% on pretest topics related to the use of triple therapy and patient and/or tumor characteristics that guide clinical decision-making. Post-learning, providers scored 84%, highlighting the impact of the education on knowledge gaps. Notably, while 51% of these providers indicated that they were guessing on the pre-test, the percentage of those who were confident and correct on the post-test rose from 3% to 28%, demonstrating a rise in confidence among participants. While 50% of participants noted a positive perception of triple therapy (BRAF inhibitor + MEK inhibitor + anti-PD1) in the front-line setting, case-based polling questions showed that providers lack consensus regarding the use of combinations of treatments in other clinical scenarios. While 45% would recommend triple therapy in the first-line setting, dual checkpoint inhibitor (CPI)-based treatment is preferred after progression on a first-line CPI or dual-targeted therapy. Conclusions: CME is a useful method to address knowledge gaps regarding evolving treatment options. As data regarding the use of triple therapy for patients with BRAF+ melanoma emerges, oncology and dermatology providers will require further education on how to apply these options in practice.[Table: see text]

Cervical Cancer, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

Cervical cancer is a malignant epithelial tumor that forms in the uterine cervix. Most cases of cervical cancer are preventable through human papilloma virus (HPV) vaccination, routine screening, and treatment of precancerous lesions. However, due to inadequate screening protocols in many regions of the world, cervical cancer remains the fourth-most common cancer in women globally. The complete NCCN Guidelines for Cervical Cancer provide recommendations for the diagnosis, evaluation, and treatment of cervical cancer. This manuscript discusses guiding principles for the workup, staging, and treatment of early stage and locally advanced cervical cancer, as well as evidence for these recommendations. For recommendations regarding treatment of recurrent or metastatic disease, please see the full guidelines on NCCN.org.

Soft Tissue Sarcoma, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology

Soft tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin that display a heterogenous mix of clinical and pathologic characteristics. STS can develop from fat, muscle, nerves, blood vessels, and other connective tissues. The evaluation and treatment of patients with STS requires a multidisciplinary team with demonstrated expertise in the management of these tumors. The complete NCCN Guidelines for STS provide recommendations for the diagnosis, evaluation, and treatment of extremity/superficial trunk/head and neck STS, as well as intra-abdominal/retroperitoneal STS, gastrointestinal stromal tumors, desmoid tumors, and rhabdomyosarcoma. This portion of the NCCN Guidelines discusses general principles for the diagnosis, staging, and treatment of STS of the extremities, superficial trunk, or head and neck; outlines treatment recommendations by disease stage; and reviews the evidence to support the guidelines recommendations.

Uterine Neoplasms, Version 1.2018, NCCN Clinical Practice Guidelines in Oncology

Endometrial carcinoma is a malignant epithelial tumor that forms in the inner lining, or endometrium, of the uterus. Endometrial carcinoma is the most common gynecologic malignancy. Approximately two-thirds of endometrial carcinoma cases are diagnosed with disease confined to the uterus. The complete NCCN Guidelines for Uterine Neoplasms provide recommendations for the diagnosis, evaluation, and treatment of endometrial cancer and uterine sarcoma. This manuscript discusses guiding principles for the diagnosis, staging, and treatment of early-stage endometrial carcinoma as well as evidence for these recommendations.

Management of Immunotherapy-Related Toxicities, Version 1.2019, NCCN Clinical Practice Guidelines in Oncology

The aim of the NCCN Guidelines for Management of Immunotherapy-Related Toxicities is to provide guidance on the management of immune-related adverse events resulting from cancer immunotherapy. The NCCN Management of Immunotherapy-Related Toxicities Panel is an interdisciplinary group of representatives from NCCN Member Institutions and ASCO, consisting of medical and hematologic oncologists with expertise in a wide array of disease sites, and experts from the fields of dermatology, gastroenterology, neuro-oncology, nephrology, emergency medicine, cardiology, oncology nursing, and patient advocacy. Several panel representatives are members of the Society for Immunotherapy of Cancer (SITC). The initial version of the NCCN Guidelines was designed in general alignment with recommendations published by ASCO and SITC. The content featured in this issue is an excerpt of the recommendations for managing toxicity related to immune checkpoint blockade and a review of existing evidence. For the full version of the NCCN Guidelines, including recommendations for managing toxicities related to chimeric antigen receptor T-cell therapy, visitNCCN.org.

NCCN Framework for Resource Stratification: A Framework for Providing and Improving Global Quality Oncology Care

More than 14 million new cancer cases and 8.2 million cancer deaths are estimated to occur worldwide on an annual basis. Of these, 57% of new cancer cases and 65% of cancer deaths occur in low- and middle-income countries. Disparities in available resources for health care are enormous and staggering. The WHO estimates that the United States and Canada have 10% of the global burden of disease, 37% of the world's health workers, and more than 50% of the world's financial resources for health; by contrast, the African region has 24% of the global burden of disease, 3% of health workers, and less than 1% of the world's financial resources for health. This disparity is even more extreme with cancer. NCCN has developed a framework for stratifying the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) to help health care systems in providing optimal care for patients with cancer with varying available resources. This framework is modified from a method developed by the Breast Health Global Initiative. The NCCN Framework for Resource Stratification (NCCN Framework) identifies 4 resource environments: basic resources, core resources, enhanced resources, and NCCN Guidelines, and presents the recommendations in a graphic format that always maintains the context of the NCCN Guidelines. This article describes the rationale for resource-stratified guidelines and the methodology for developing the NCCN Framework, using a portion of the NCCN Cervical Cancer Guideline as an example.

NCCN Guidelines Insights: Bone Cancer, Version 2.2017

The NCCN Guidelines for Bone Cancer provide interdisciplinary recommendations for treating chordoma, chondrosarcoma, giant cell tumor of bone, Ewing sarcoma, and osteosarcoma. These NCCN Guidelines Insights summarize the NCCN Bone Cancer Panel's guideline recommendations for treating Ewing sarcoma. The data underlying these treatment recommendations are also discussed.

Palliative Care Version 1.2016

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. The NCCN Guidelines are intended to provide guidance to the primary oncology team on the integration of palliative care into oncology. The NCCN Palliative Care Panel's recommendations seek to ensure that each patient experiences the best quality of life possible throughout the illness trajectory. Accordingly, the NCCN Guidelines outline best practices for screening, assessment, palliative care interventions, reassessment, and after-death care.

Uterine Sarcoma, Version 1.2016: Featured Updates to the NCCN Guidelines

The NCCN Guidelines for Uterine Neoplasms provide interdisciplinary recommendations for treating endometrial carcinoma and uterine sarcomas. These NCCN Guidelines Insights summarize the NCCN Uterine Neoplasms Panel's 2016 discussions and major guideline updates for treating uterine sarcomas. During this most recent update, the panel updated the mesenchymal tumor classification to correspond with recent updates to the WHO tumor classification system. Additionally, the panel revised its systemic therapy recommendations to reflect new data and collective clinical experience. These NCCN Guidelines Insights elaborate on the rationale behind these recent changes.

Impact of cannabis use during stabilization on methadone maintenance treatment

BACKGROUND AND OBJECTIVES

Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals and has the potential to impact treatment in a negative manner.

METHODS

To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance.

RESULTS

Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

Unraveling glutamate-opioid receptor interactions using high-resolution electron microscopy: implications for addiction-related processes

Adaptive responses in glutamate and opioid receptor systems in limbic circuits are emerging as a critical component of the neural plasticity induced by chronic use of abused substances. The present commentary reviews findings from neuroanatomical studies, with superior spatial resolution, that support a cellular basis for prominent interactions of glutamate and opioid receptor systems in preclinical models of drug addiction. The review begins by highlighting the advantages of high-resolution electron microscopic immunohistochemistry for unraveling receptor interactions at the synapse. With an emphasis on a recent publication describing the anatomical relationship between the μ-opioid receptor (MOR) and the AMPA-GluR2 subunit (Beckerman, M. A., and Glass, M. J., 2011. Ultrastructural relationship between the AMPA-GluR2 receptor subunit and the mu-opioid receptor in the mouse central nucleus of the amygdala. Exp Neurol), we review the anatomical evidence for opioid-induced neural plasticity of glutamate receptors in selected brain circuits that are key integrative substrates in the brain's motivational system. The findings stress the importance of glutamate-opioid interactions as important neural mediators of adaptations to chronic use of abused drugs, particularly within the amygdaloid complex.

Characterization of cannabinoid-1 receptors in the locus coeruleus: relationship with mu-opioid receptors

The locus coeruleus (LC)-norepinephrine system is a target of both cannabinoid and opioid actions. The present study investigated the anatomical distribution of cannabinoid-1 receptor (CB1r) in the LC and its association with mu-opioid receptor (MOR). Immunoreactivity for CB1r was localized to pre- and postsynaptic cellular profiles in the LC, 82% of which were dual-labeled for tyrosine hydroxylase (TH). Of the CB1r-immunoreactive structures, 66% were somatodendritic profiles, 22% were axon terminals, and the remaining 12% were associated with glial and small unmyelinated axon-like structures. CB1r immunoreactivity (-ir) in somatodendritic profiles was more often localized to the cytoplasm, whereas CB1r-ir located in axon terminals was more commonly localized on the plasma membrane. Somatodendritic profiles with CB1r-ir typically received input from axon terminals forming asymmetric-type synapses. In contrast, presynaptic profiles with CB1r-ir typically formed symmetric synaptic specializations. Anatomical studies confirmed the co-existence of MOR and CB1r-ir in common somatodendritic compartments of catecholaminergic neurons in the LC, and also revealed CB1r-positive axon terminals forming synaptic contact with MOR-containing dendrites. Our results provide evidence for a heterogeneous distribution of CB1r in the LC and demonstrate that CB1r and MOR co-exist in cellular profiles in this region. These data suggest important potential interactions between cannabinoid and opioid systems in LC neuronal profiles that may impact noradrenergic tone.

Mu-opioid receptor redistribution in the locus coeruleus upon precipitation of withdrawal in opiate-dependent rats

Administration of mu-opioid receptor (MOR) agonists is known to produce adaptive changes within noradrenergic neurons of the rat locus coeruleus (LC). Alterations in the subcellular distribution of MOR have been shown to occur in the LC in response to full agonists and endogenous peptides; however, there is considerable debate in the literature whether trafficking of MOR occurs after chronic exposure to the partial-agonist morphine. In the present study, we examined adaptations in MOR after chronic opioid exposure using immunofluorescence and electron microscopy (EM), using receptor internalization as a functional endpoint. MOR trafficking in LC neurons was characterized in morphine-dependent rats that were given naltrexone at a dose known to precipitate withdrawal. After chronic morphine exposure, a subtle redistribution of MOR immunoreactivity from the membrane to the cytosol was detected within dendrites of LC neurons. Interestingly, an acute injection of naltrexone in rats exposed to chronic morphine produced a robust internalization of MOR, whereas administration of naltrexone failed to do so in naïve animals. These findings provide anatomical evidence for modified regulation of MOR trafficking after chronic morphine treatment in brain noradrenergic neurons. Adaptations in the MOR signaling pathways that regulate internalization may occur as a consequence of chronic treatment and precipitation of withdrawal. Mechanisms underlying this effect might include differential MOR regulation in the LC, or downstream effects of withdrawal-induced enkephalin (ENK) release from afferents to the LC.