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Harris CE, Vijenthira A, Ong SY, Baden LR, Hicks LK, Baird JH. COVID-19 and Other Viral Infections in Patients With Hematologic Malignancies. Am Soc Clin Oncol Educ Book 2023; 43:e390778. [PMID: 37163714 DOI: 10.1200/edbk_390778] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
COVID-19 and our armamentarium of strategies to combat it have evolved dramatically since the virus first emerged in late 2019. Vaccination remains the primary strategy to prevent severe illness, although the protective effect can vary in patients with hematologic malignancy. Strategies such as additional vaccine doses and now bivalent boosters can contribute to increased immune response, especially in the face of evolving viral variants. Because of these new variants, no approved monoclonal antibodies are available for pre-exposure or postexposure prophylaxis. Patients with symptomatic, mild-to-moderate COVID-19 and risk features for developing severe COVID-19, who present within 5-7 days of symptom onset, should be offered outpatient therapy with nirmatrelvir/ritonavir (NR) or in some cases with intravenous (IV) remdesivir. NR interacts with many blood cancer treatments, and reviewing drug interactions is essential. Patients with severe COVID-19 should be managed with IV remdesivir, tocilizumab (or an alternate interleukin-6 receptor blocker), or baricitinib, as indicated based on the severity of illness. Dexamethasone can be considered on an individual basis, weighing oxygen requirements and patients' underlying disease and their perceived ability to clear infection. Finally, as CD19-targeted and B-cell maturation (BCMA)-targeted chimeric antigen receptor (CAR) T-cell therapies become more heavily used for relapsed/refractory hematologic malignancies, viral infections including COVID-19 are increasingly recognized as common complications, but data on risk factors and prophylaxis in this patient population are scarce. We summarize the available evidence regarding viral infections after CAR T-cell therapy.
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Affiliation(s)
- Courtney E Harris
- Brigham and Women's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Abi Vijenthira
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Shin Yeu Ong
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Lindsey Robert Baden
- Brigham and Women's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Lisa K Hicks
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Hematology/Oncology, St Michael's Hospital, Toronto, Canada
| | - John H Baird
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
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Gong IY, Vijenthira A, Powis M, Calzavara A, Patrikar A, Sutradhar R, Hicks LK, Wilton D, Singh S, Krzyzanowska MK, Cheung MC. Association of COVID-19 Vaccination With Breakthrough Infections and Complications in Patients With Cancer. JAMA Oncol 2023; 9:386-394. [PMID: 36580318 PMCID: PMC10020872 DOI: 10.1001/jamaoncol.2022.6815] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/21/2022] [Indexed: 12/30/2022]
Abstract
Importance Patients with cancer are known to have increased risk of COVID-19 complications, including death. Objective To determine the association of COVID-19 vaccination with breakthrough infections and complications in patients with cancer compared to noncancer controls. Design, Setting, and Participants Retrospective population-based cohort study using linked administrative databases in Ontario, Canada, in residents 18 years and older who received COVID-19 vaccination. Three matched groups were identified (based on age, sex, type of vaccine, date of vaccine): 1:4 match for patients with hematologic and solid cancer to noncancer controls (hematologic and solid cancers separately analyzed), 1:1 match between patients with hematologic and patients with solid cancer. Exposures Cancer diagnosis. Main Outcomes and Measures Outcomes occurring 14 days after receipt of second COVID-19 vaccination dose: primary outcome was SARS-CoV-2 breakthrough infection; secondary outcomes were emergency department visit, hospitalization, and death within 4 weeks of SARS-CoV-2 infection (end of follow-up March 31, 2022). Multivariable cumulative incidence function models were used to obtain adjusted hazard ratio (aHR) and 95% CIs. Results A total of 289 400 vaccinated patients with cancer (39 880 hematologic; 249 520 solid) with 1 157 600 matched noncancer controls were identified; the cohort was 65.4% female, and mean (SD) age was 66 (14.0) years. SARS-CoV-2 breakthrough infection was higher in patients with hematologic cancer (aHR, 1.33; 95% CI, 1.20-1.46; P < .001) but not in patients with solid cancer (aHR, 1.00; 95% CI, 0.96-1.05; P = .87). COVID-19 severe outcomes (composite of hospitalization and death) were significantly higher in patients with cancer compared to patients without cancer (aHR, 1.52; 95% CI, 1.42-1.63; P < .001). Risk of severe outcomes was higher among patients with hematologic cancer (aHR, 2.51; 95% CI, 2.21-2.85; P < .001) than patients with solid cancer (aHR, 1.43; 95% CI, 1.24-1.64; P < .001). Patients receiving active treatment had a further heightened risk for COVID-19 severe outcomes, particularly those who received anti-CD20 therapy. Third vaccination dose was associated with lower infection and COVID-19 complications, except for patients receiving anti-CD20 therapy. Conclusions and Relevance In this large population-based cohort study, patients with cancer had greater risk of SARS-CoV-2 infection and worse outcomes than patients without cancer, and the risk was highest for patients with hematologic cancer and any patients with cancer receiving active treatment. Triple vaccination was associated with lower risk of poor outcomes.
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Affiliation(s)
- Inna Y. Gong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abi Vijenthira
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre–University Health Network, Toronto, Ontario, Canada
| | - Melanie Powis
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre–University Health Network, Toronto, Ontario, Canada
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Andrew Calzavara
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Aditi Patrikar
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Rinku Sutradhar
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lisa K. Hicks
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Hematology/Oncology, St Michael’s Hospital–Unity Health, Toronto Ontario, Canada
| | - Drew Wilton
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Simron Singh
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Monika K. Krzyzanowska
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre–University Health Network, Toronto, Ontario, Canada
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Matthew C. Cheung
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Powis M, Sutradhar R, Patrikar A, Cheung M, Gong I, Vijenthira A, Hicks LK, Wilton D, Krzyzanowska MK, Singh S. Factors associated with timely COVID-19 vaccination in a population-based cohort of patients with cancer. J Natl Cancer Inst 2023; 115:146-154. [PMID: 36321960 PMCID: PMC9905967 DOI: 10.1093/jnci/djac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/21/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND In many jurisdictions, cancer patients were prioritized for COVID-19 vaccination because of increased risk of infection and death. To understand sociodemographic disparities that affected timely receipt of COVID-19 vaccination among cancer patients, we undertook a population-based study in Ontario, Canada. METHODS Patients older than 18 years and diagnosed with cancer January 2010 to September 2020 were identified using administrative data; vaccination administration was captured between approval (December 2020) up to February 2022. Factors associated with time to vaccination were evaluated using multivariable Cox proportional hazards regression. RESULTS The cohort consisted of 356 535 patients, the majority of whom had solid tumor cancers (85.9%) and were not on active treatment (74.1%); 86.8% had received at least 2 doses. The rate of vaccination was 25% lower in recent (hazard ratio [HR] = 0.74, 95% confidence interval [CI] = 0.72 to 0.76) and nonrecent immigrants (HR = 0.80, 95% CI = 0.79 to 0.81). A greater proportion of unvaccinated patients were from neighborhoods with a high concentration of new immigrants or self-reported members of racialized groups (26.0% vs 21.3%, standardized difference = 0.111, P < .001), residential instability (27.1% vs 23.0%, standardized difference = 0.094, P < .001), or material deprivation (22.1% vs 16.8%, standardized difference = 0.134, P < .001) and low socioeconomic status (20.9% vs 16.0%, standardized difference = 0.041, P < .001). The rate of vaccination was 20% lower in patients from neighborhoods with the lowest socioeconomic status (HR = 0.82, 95% CI = 0.81 to 0.84) and highest material deprivation (HR = 0.80, 95% CI = 0.78 to 0.81) relative to those in more advantaged neighborhoods. CONCLUSIONS Despite funding of vaccines and prioritization of high-risk populations, marginalized patients were less likely to be vaccinated. Differences are likely due to the interplay between systemic barriers to access and cultural or social influences affecting uptake.
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Affiliation(s)
- Melanie Powis
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre—University Health Network, Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre—University Health Network, Toronto, ON, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Aditi Patrikar
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Matthew Cheung
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Inna Gong
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Abi Vijenthira
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre—University Health Network, Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa K Hicks
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Hematology/Oncology, St. Michael’s Hospital—Unity Health, Toronto, ON, Canada
| | - Drew Wilton
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Monika K Krzyzanowska
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre—University Health Network, Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre—University Health Network, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Simron Singh
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Bodley T, Levi O, Chan M, Friedrich JO, Hicks LK. Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention. BMJ Qual Saf 2023:bmjqs-2022-015358. [PMID: 36657786 DOI: 10.1136/bmjqs-2022-015358] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Critically ill patients receive frequent routine and recurring blood tests, some of which are unnecessary. AIM To reduce unnecessary routine phlebotomy in a 30-bed tertiary medical-surgical intensive care unit (ICU) in Toronto, Ontario. METHODS This prospective quality improvement study included a 7-month preintervention baseline, 5-month intervention and 11-month postintervention period. Change strategies included education, ICU rounds checklists, electronic order set modifications, an electronic test add-on tool and audit and feedback. The primary outcome was mean volume of blood collected per patient-day. Secondary outcomes included the number blood tubes used and red cell transfusions. Balancing measures included the timing and types of blood tests, ICU length of stay and mortality. Outcomes were evaluated using process control charts and segmented regression. RESULTS Patient demographics did not differ between time periods; total number of patients: 2096, median age: 61 years, 60% male. Mean phlebotomy volume±SD decreased from 41.1±4.0 to 34.1±4.7 mL/patient-day. Special cause variation was met at 13 weeks. Segmental regression demonstrated an immediate postintervention decrease of 6.6 mL/patient-day (95% CI 1.8 to 11.4 p=0.009), which was sustained. Blood tube consumption decreased by 1.4 tubes/patient-day (95% CI 0.4 to 2.4, p=0.005) amounting to 13 276 tubes (95% CI 4602 to 22 127 tubes) saved over 11 months. Red blood cell transfusions decreased from 10.5±5.2 to 8.3±4.4 transfusions/100 patient-days (incident rate ratio 0.56, 95% CI 0.35 to 0.88, p=0.01). There was no impact on length of stay (2 days, IQR 1-5) and mortality (18.1%±2.0%). CONCLUSION Iterative improvement interventions targeting clinician test ordering behaviour can reduce ICU phlebotomy and may impact red cell transfusions. Frequent stakeholder consultation, incorporating stewardship into daily workflow, and audit and feedback are effective strategies.
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Affiliation(s)
- Thomas Bodley
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Olga Levi
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada.,Medical Surgical Intensive Care, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada
| | - Maverick Chan
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada.,Division of Hematology/Oncology, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Critical Care and Medicine Departments, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada
| | - Lisa K Hicks
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada.,Division of Hematology/Oncology, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada
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Suleman A, Liu J, Hicks LK, Drori AK, Crump M, Kridel R, Prica A, Berinstein N. Methotrexate cytarabine thiotepa rituximab (MATRix) chemoimmunotherapy for primary central nervous system lymphoma: a Toronto experience. Haematologica 2022; 108:1186-1189. [PMID: 36453110 PMCID: PMC10071115 DOI: 10.3324/haematol.2022.282014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Not available.
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Affiliation(s)
| | - Jiajia Liu
- Faculty of Medicine, University of Toronto
| | - Lisa K Hicks
- Faculty of Medicine, University of Toronto; Division of Medical Oncology and Hematology, St. Michael's Hospital
| | | | - Michael Crump
- Faculty of Medicine, University of Toronto; Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre
| | - Robert Kridel
- Faculty of Medicine, University of Toronto; Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre
| | - Anca Prica
- Faculty of Medicine, University of Toronto; Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre
| | - Neil Berinstein
- Faculty of Medicine, University of Toronto; Sunnybrook Health Sciences Centre, Odette Cancer Centre
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Powis ML, Sutradhar R, Patrikar A, Cheung M, Gong IY, Vijenthira A, Hicks LK, Wilton D, Krzyzanowska MK, Singh S. Factors associated with timely receipt of COVID vaccination in patients with cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
167 Background: In many jurisdictions patients with new hematological cancers, or those receiving hematopoietic stem cell transplant or immunosuppressive agents, were prioritized for COVID vaccination due to increased risk of infection and death. In Ontario, Canada those residing in congregate settings, or regions with high positivity rates or high proportions of essential workers were also prioritized. While vaccine inequities exist, it remains unclear whether they persisted amongst the prioritized cancer population. Methods: We undertook a retrospective, population-based study to evaluate factors associated with COVID vaccination in patients residing in Ontario, Canada, >18 years of age, and diagnosed with cancer between 01/2010 and 09/2020. Factors associated with time from vaccine approval to full vaccination (two doses) and third doses were evaluated using multivariable Cox proportional hazards regression models. Results: The cohort consisted of 356,535 patients; as of 30 January 2022 of which 86.8% had received at least two doses. Compared to patients with more remote diagnoses (> 1 year), newly diagnosed patients rate of vaccination was lower (HR: 0.89, 95%CI: 0.88-0.91, p < 0.01) and a greater proportion were unvaccinated (13.6% vs 11.8%; p < 0.01). Conversely, rate of vaccination was higher in patients treated with systemic therapy in the last 6 months (HR: 1.04, 95%CI: 1.03-1.05, p < 0.01). Rate of vaccination was 25% lower in recent (HR:0.74,95% CI: 0.72-0.76, p < 0.01) and non-recent immigrants (HR: 0.80, 95% CI: 0.79-0.81, p < 0.01), and a greater proportion remained unvaccinated, compared to those who were Canadian-born (20.1 and 16.6% vs 10.9%; p < 0.01). Compared to the most advantaged quintiles, quintiles with the lowest socioeconomic status (14.5% vs 9.4%; p < 0.01), or highest residential instability (13.3% vs 10.8%; p < 0.01), material deprivation (10.5% vs 9.6%; p < 0.01), or ethnic concentration quintiles (13.7% vs 10.4%; p < 0.01) had higher proportions of unvaccinated patients. Rate of vaccination was 20% lower in patients with the lowest socioeconomic status (HR: 0.83, 95% CI: 0.81-0.84, p < 0.01) and those with highest material deprivation (HR: 0.80, 95% CI: 0.79-0.82, p < 0.01) relative to more advantaged groups. Similar trends were observed for receipt of third doses in the eligible cohort. Conclusions: Despite direct government funding of COVID vaccines and distribution policies aimed a prioritizing high-risk populations marginalized patients with cancer were less likely to be vaccinated than other cancer patients. Differences in receipt of vaccination are likely due to the interplay between systemic barriers to access (low trust, transportation barriers, work schedules), and cultural/ social influences impacting uptake. Future efforts should work directly members of high-risk communities to understand how to improve vaccine delivery among these communities.
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Affiliation(s)
- Melanie Lynn Powis
- Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | - Matthew Cheung
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Lisa K. Hicks
- St. Michael's Hospital, Division of Hematology/Oncology; Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Simron Singh
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
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Dainty KN, Seaton MB, Estacio A, Hicks LK, Jamieson T, Ward S, Yu CH, Mosko JD, Kassardjian CD. Virtual Specialist Care during the COVID-19 Pandemic: A Multi-Method Study of Patient Experience. JMIR Med Inform 2022; 10:e37196. [PMID: 35482950 PMCID: PMC9239568 DOI: 10.2196/37196] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Transitioning nonemergency, ambulatory medical care to virtual visits in light of the COVID-19 global pandemic has been a massive shift in philosophy and practice that naturally came with a steep learning curve for patients, physicians, and clinic administrators. Objective We undertook a multimethod study to understand the key factors associated with successful and less successful experiences of virtual specialist care, particularly as they relate to the patient experience of care. Methods This study was designed as a multimethod patient experience study using survey methods, descriptive qualitative interview methodology, and administrative virtual care data collected by the hospital decision support team. Six specialty departments participated in the study (endoscopy, orthopedics, neurology, hematology, rheumatology, and gastroenterology). All patients who could speak and read English and attended a virtual specialist appointment in a participating clinic at St. Michael’s Hospital (Toronto, Ontario, Canada) between October 1, 2020, and January 30, 2021, were eligible to participate. Results During the study period, 51,702 virtual specialist visits were conducted in the departments that participated in the study. Of those, 96% were conducted by telephone and 4% by video. In both the survey and interview data, there was an overall consensus that virtual care is a satisfying alternative to in-person care, with benefits such as reduced travel, cost, time, and SARS-CoV-2 exposure, and increased convenience. Our analysis further revealed that the specific reason for the visit and the nature and status of the medical condition are important considerations in terms of guidance on where virtual care is most effective. Technology issues were not reported as a major challenge in our data, given that the majority of “virtual” visits reported by our participants were conducted by telephone, which is an important distinction. Despite the positive value of virtual care discussed by the majority of interview participants, 50% of the survey respondents still indicated they would prefer to see their physician in person. Conclusions Patient experience data collected in this study indicate a high level of satisfaction with virtual specialty care, but also signal that there are nuances to be considered to ensure it is an appropriate and sustainable part of the standard of care.
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Affiliation(s)
- Katie N Dainty
- North York General Hospital, 4001 Leslie StreetLE-140, Toronto, CA
| | - M Bianca Seaton
- North York General Hospital, 4001 Leslie StreetLE-140, Toronto, CA
| | | | - Lisa K Hicks
- Unity Health - St. Michael's Hospital, Toronto, CA
| | | | - Sarah Ward
- Unity Health - St. Michael's Hospital, Toronto, CA
| | | | - Jeff D Mosko
- Unity Health - St. Michael's Hospital, Toronto, CA
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Gong IY, Vijenthira A, Betschel SD, Hicks LK, Cheung MC. COVID-19 vaccine response in patients with hematologic malignancy: A systematic review and meta-analysis. Am J Hematol 2022; 97:E132-E135. [PMID: 35007350 PMCID: PMC9011569 DOI: 10.1002/ajh.26459] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/25/2021] [Accepted: 01/03/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Inna Y. Gong
- Department of Medicine University of Toronto Toronto Ontario Canada
| | - Abi Vijenthira
- Department of Medicine University of Toronto Toronto Ontario Canada
- Division of Medical Oncology and Hematology Princess Margaret Cancer Centre Toronto Ontario Canada
| | - Stephen D. Betschel
- Department of Medicine University of Toronto Toronto Ontario Canada
- Division of Allergy and Immunology St. Michael's Hospital Toronto Ontario Canada
| | - Lisa K. Hicks
- Department of Medicine University of Toronto Toronto Ontario Canada
- Division of Hematology/Oncology St. Michael's Hospital Toronto Ontario Canada
| | - Matthew C. Cheung
- Department of Medicine University of Toronto Toronto Ontario Canada
- Division of Medical Oncology and Hematology Sunnybrook Health Sciences Centre Toronto Ontario Canada
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Desai A, Mohammed TJ, Duma N, Garassino MC, Hicks LK, Kuderer NM, Lyman GH, Mishra S, Pinato DJ, Rini BI, Peters S, Warner JL, Whisenant JG, Wood WA, Thompson MA. COVID-19 and Cancer: A Review of the Registry-Based Pandemic Response. JAMA Oncol 2021; 7:1882-1890. [PMID: 34473192 PMCID: PMC8805603 DOI: 10.1001/jamaoncol.2021.4083] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Importance The COVID-19 pandemic has had consequences for patients with cancer worldwide and has been associated with delays in diagnosis, interruption of treatment and follow-up care, and increases in overall infection rates and premature mortality. Observations Despite the challenges experienced during the pandemic, the global oncology community has responded with an unprecedented level of investigation, collaboration, and technological innovation through the rapid development of COVID-19 registries that have allowed an increased understanding of the natural history, risk factors, and outcomes of patients with cancer who are diagnosed with COVID-19. This review describes 14 major registries comprising more than 28 500 patients with cancer and COVID-19; these ongoing registry efforts have provided an improved understanding of the impact and outcomes of COVID-19 among patients with cancer. Conclusions and Relevance An initiative is needed to promote active collaboration between different registries to improve the quality and consistency of information. Well-designed prospective and randomized clinical trials are needed to collect high-level evidence to guide long-term epidemiologic, behavioral, and clinical decision-making for this and future pandemics.
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Affiliation(s)
- Aakash Desai
- Division of Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Turab J. Mohammed
- Department of Medicine, University of Connecticut, Farmington, CT, USA
| | - Narjust Duma
- Department of Medicine, Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, WI, USA
| | | | - Lisa K. Hicks
- Division of Hematology/Oncology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Gary H. Lyman
- Fred Hutchinson Cancer Research Center/University of Washington/Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Sanjay Mishra
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David J. Pinato
- Department of Surgery & Cancer, Imperial College London, London, UK
- Division of Oncology, Department of Translational Medicine, Piemonte Orientale University, Novara, Italy
| | - Brian I. Rini
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jeremy L. Warner
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer G. Whisenant
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William A. Wood
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kahale LA, Matar CF, Tsolakian I, Hakoum MB, Yosuico VE, Terrenato I, Sperati F, Barba M, Hicks LK, Schünemann H, Akl EA. Antithrombotic therapy for ambulatory patients with multiple myeloma receiving immunomodulatory agents. Cochrane Database Syst Rev 2021; 9:CD014739. [PMID: 34582035 PMCID: PMC8477647 DOI: 10.1002/14651858.cd014739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Multiple myeloma is a malignant plasma cell disorder characterised by clonal plasma cells that cause end-organ damage such as renal failure, lytic bone lesions, hypercalcaemia and/or anaemia. People with multiple myeloma are treated with immunomodulatory agents including lenalidomide, pomalidomide, and thalidomide. Multiple myeloma is associated with an increased risk of thromboembolism, which appears to be further increased in people receiving immunomodulatory agents. OBJECTIVES (1) To systematically review the evidence for the relative efficacy and safety of aspirin, oral anticoagulants, or parenteral anticoagulants in ambulatory patients with multiple myeloma receiving immunomodulatory agents who otherwise have no standard therapeutic or prophylactic indication for anticoagulation. (2) To maintain this review as a living systematic review by continually running the searches and incorporating newly identified studies. SEARCH METHODS We conducted a comprehensive literature search that included (1) a major electronic search (14 June 2021) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE via Ovid, and Embase via Ovid; (2) hand-searching of conference proceedings; (3) checking of reference lists of included studies; and (4) a search for ongoing studies in trial registries. As part of the living systematic review approach, we are running continual searches, and we will incorporate new evidence rapidly after it is identified. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the benefits and harms of oral anticoagulants such as vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC), anti-platelet agents such as aspirin (ASA), and parenteral anticoagulants such as low molecular weight heparin (LMWH)in ambulatory patients with multiple myeloma receiving immunomodulatory agents. DATA COLLECTION AND ANALYSIS Using a standardised form, we extracted data in duplicate on study design, participants, interventions, outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and minor bleeding. For each outcome we calculated the risk ratio (RR) with its 95% confidence interval (CI) and the risk difference (RD) with its 95% CI. We then assessed the certainty of evidence at the outcome level following the GRADE approach (GRADE Handbook). MAIN RESULTS We identified 1015 identified citations and included 11 articles reporting four RCTs that enrolled 1042 participants. The included studies made the following comparisons: ASA versus VKA (one study); ASA versus LMWH (two studies); VKA versus LMWH (one study); and ASA versus DOAC (two studies, one of which was an abstract). ASA versus VKA One RCT compared ASA to VKA at six months follow-up. The data did not confirm or exclude a beneficial or detrimental effect of ASA relative to VKA on all-cause mortality (RR 3.00, 95% CI 0.12 to 73.24; RD 2 more per 1000, 95% CI 1 fewer to 72 more; very low-certainty evidence); symptomatic DVT (RR 0.57, 95% CI 0.24 to 1.33; RD 27 fewer per 1000, 95% CI 48 fewer to 21 more; very low-certainty evidence); PE (RR 1.00, 95% CI 0.25 to 3.95; RD 0 fewer per 1000, 95% CI 14 fewer to 54 more; very low-certainty evidence); major bleeding (RR 7.00, 95% CI 0.36 to 134.72; RD 6 more per 1000, 95% CI 1 fewer to 134 more; very low-certainty evidence); and minor bleeding (RR 6.00, 95% CI 0.73 to 49.43; RD 23 more per 1000, 95% CI 1 fewer to 220 more; very low-certainty evidence). One RCT compared ASA to VKA at two years follow-up. The data did not confirm or exclude a beneficial or detrimental effect of ASA relative to VKA on all-cause mortality (RR 0.50, 95% CI 0.05 to 5.47; RD 5 fewer per 1000, 95% CI 9 fewer to 41 more; very low-certainty evidence); symptomatic DVT (RR 0.71, 95% CI 0.35 to 1.44; RD 22 fewer per 1000, 95% CI 50 fewer to 34 more; very low-certainty evidence); and PE (RR 1.00, 95% CI 0.25 to 3.95; RD 0 fewer per 1000, 95% CI 14 fewer to 54 more; very low-certainty evidence). ASA versus LMWH Two RCTs compared ASA to LMWH at six months follow-up. The pooled data did not confirm or exclude a beneficial or detrimental effect of ASA relative to LMWH on all-cause mortality (RR 1.00, 95% CI 0.06 to 15.81; RD 0 fewer per 1000, 95% CI 2 fewer to 38 more; very low-certainty evidence); symptomatic DVT (RR 1.23, 95% CI 0.49 to 3.08; RD 5 more per 1000, 95% CI 11 fewer to 43 more; very low-certainty evidence); PE (RR 7.71, 95% CI 0.97 to 61.44; RD 7 more per 1000, 95% CI 0 fewer to 60 more; very low-certainty evidence); major bleeding (RR 6.97, 95% CI 0.36 to 134.11; RD 6 more per 1000, 95% CI 1 fewer to 133 more; very low-certainty evidence); and minor bleeding (RR 1.42, 95% CI 0.35 to 5.78; RD 4 more per 1000, 95% CI 7 fewer to 50 more; very low-certainty evidence). One RCT compared ASA to LMWH at two years follow-up. The pooled data did not confirm or exclude a beneficial or detrimental effect of ASA relative to LMWH on all-cause mortality (RR 1.00, 95% CI 0.06 to 15.89; RD 0 fewer per 1000, 95% CI 4 fewer to 68 more; very low-certainty evidence); symptomatic DVT (RR 1.20, 95% CI 0.53 to 2.72; RD 9 more per 1000, 95% CI 21 fewer to 78 more; very low-certainty evidence); and PE (RR 9.00, 95% CI 0.49 to 166.17; RD 8 more per 1000, 95% CI 1 fewer to 165 more; very low-certainty evidence). VKA versus LMWH One RCT compared VKA to LMWH at six months follow-up. The data did not confirm or exclude a beneficial or detrimental effect of VKA relative to LMWH on all-cause mortality (RR 0.33, 95% CI 0.01 to 8.10; RD 3 fewer per 1000, 95% CI 5 fewer to 32 more; very low-certainty evidence); symptomatic DVT (RR 2.32, 95% CI 0.91 to 5.93; RD 36 more per 1000, 95% CI 2 fewer to 135 more; very low-certainty evidence); PE (RR 8.96, 95% CI 0.49 to 165.42; RD 8 more per 1000, 95% CI 1 fewer to 164 more; very low-certainty evidence); and minor bleeding (RR 0.33, 95% CI 0.03 to 3.17; RD 9 fewer per 1000, 95% CI 13 fewer to 30 more; very low-certainty evidence). The study reported that no major bleeding occurred in either arm. One RCT compared VKA to LMWH at two years follow-up. The data did not confirm or exclude a beneficial or detrimental effect of VKA relative to LMWH on all-cause mortality (RR 2.00, 95% CI 0.18 to 21.90; RD 5 more per 1000, 95% CI 4 fewer to 95 more; very low-certainty evidence); symptomatic DVT (RR 1.70, 95% CI 0.80 to 3.63; RD 32 more per 1000, 95% CI 9 fewer to 120 more; very low-certainty evidence); and PE (RR 9.00, 95% CI 0.49 to 166.17; RD 8 more per 1000, 95% CI 1 fewer to 165 more; very low-certainty evidence). ASA versus DOAC One RCT compared ASA to DOAC at six months follow-up. The data did not confirm or exclude a beneficial or detrimental effect of ASA relative to DOAC on DVT, PE, and major bleeding and minor bleeding (minor bleeding: RR 5.00, 95% CI 0.31 to 79.94; RD 4 more per 1000, 95% CI 1 fewer to 79 more; very low-certainty evidence). The study reported that no DVT, PE, or major bleeding events occurred in either arm. These results did not change in a meta-analysis including the study published as an abstract. AUTHORS' CONCLUSIONS The certainty of the available evidence for the comparative effects of ASA, VKA, LMWH, and DOAC on all-cause mortality, DVT, PE, or bleeding was either low or very low. People with multiple myeloma considering antithrombotic agents should balance the possible benefits of reduced thromboembolic complications with the possible harms and burden of anticoagulants. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Lara A Kahale
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Charbel F Matar
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Ibrahim Tsolakian
- Department of Obstertrics and Gynaecology, University of Toledo College of Medicine and Life Sciences, Ohio, USA
| | - Maram B Hakoum
- Department of Family Medicine, Cornerstone Care Teaching Health Center, Mount Morris, Pennsylvania, USA
| | | | - Irene Terrenato
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesca Sperati
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maddalena Barba
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Lisa K Hicks
- Medicine, St. Michael's Hospital and the University of Toronto, Toronto, Canada
| | - Holger Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Elie A Akl
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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11
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O'Brien SH, Badawy SM, Rotz SJ, Shah MD, Makarski J, Bercovitz RS, Hogan MJS, Luchtman-Jones L, Panepinto JA, Priola GM, Witmer CM, Wolfson JA, Yee M, Hicks LK. The ASH-ASPHO Choosing Wisely Campaign: 5 hematologic tests and treatments to question. Pediatr Blood Cancer 2021; 68:e28967. [PMID: 34047047 DOI: 10.1002/pbc.28967] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Choosing Wisely is a medical stewardship and quality-improvement initiative led by the American Board of Internal Medicine Foundation in collaboration with leading medical societies in the United States. The American Society of Hematology (ASH) has been an active participant in the Choosing Wisely project. In 2019, ASH and the American Society of Pediatric Hematology/Oncology (ASPHO) formed a joint task force to solicit, evaluate, and select items for a pediatric-focused Choosing Wisely list. By using an iterative process and an evidence-based method, the ASH-ASPHO Task Force identified 5 hematologic tests and treatments that health care providers and patients should question because they are not supported by evidence, and/or they involve risks of medical and financial costs with low likelihood of benefit. The ASH-ASPHO Choosing Wisely recommendations are as follows: (1) avoid routine preoperative hemostatic testing in an otherwise healthy child with no previous personal or family history of bleeding, (2) avoid platelet transfusion in asymptomatic children with a platelet count 10 × 103 /μL unless an invasive procedure is planned, (3) avoid thrombophilia testing in children with venous access-associated thrombosis and no positive family history, (4) avoid packed red blood cells transfusion for asymptomatic children with iron deficiency anemia and no active bleeding, and (5) avoid routine administration of granulocyte colony-stimulating factor for prophylaxis of children with asymptomatic autoimmune neutropenia and no history of recurrent or severe infections. We recommend that health care providers carefully consider the anticipated risks and benefits of these identified tests and treatments before performing them.
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Key Words
- COAGULATION/coagulation, COAGULATION/venous thromboembolism prophylaxis, diagnosis, and treatment, PLATELETS/disorders of platelets, PHAGOCYTES/neutrophils, RED CELLS/anemia
- clinical: nutritional
- iron, cobalamin, folate, anemia, autoimmune neutropenia, iron deficiency, platelets, pre-operative coagulation, thrombophilia
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Affiliation(s)
- Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Mona D Shah
- Division of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Julie Makarski
- Independent consultant methodologist, Hamilton, ON, Canada
| | - Rachel S Bercovitz
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mary-Jane S Hogan
- Department of Pediatrics, Section of Hematology and Oncology, Yale School of Medicine, New Haven, CT
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Julie A Panepinto
- Division of Pediatric Hematology/Oncology, Children's Wisconsin/Medical College of Wisconsin, Milwaukee, WI
| | - Ginna M Priola
- Division of Pediatric Hematology/Oncology, Mission Children's Hospital, Asheville, NC
| | - Char M Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Julie A Wolfson
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama, Birmingham, AL
| | - Marianne Yee
- Division of Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, GA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Lisa K Hicks
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
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12
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DeAngelo DJ, Reiter A, Radia D, Deininger MW, George TI, Panse J, Vannucchi AM, Jentzsch M, Alvarez-Twose I, Mital A, Hermine O, Dybedal I, Hexner EO, Hicks LK, Span L, Mesa R, Bose P, Pettit KM, Heaney ML, Oh S, Sen J, Lin HM, Mar BG, Gotlib J. Abstract CT023: PATHFINDER: Interim analysis of avapritinib (ava) in patients (pts) with advanced systemic mastocytosis (AdvSM). Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-ct023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Systemic mastocytosis is a clonal, hematologic neoplasm driven by KIT D816V mutation in >90% of cases, with limited treatment options. In a phase I study, ava, a potent inhibitor of KIT D816V, induced durable responses which deepened over time in pts with AdvSM, regardless of prior therapy or AdvSM subtype. PATHFINDER (NCT03580655) is a pivotal open-label, single-arm phase II study of ava in pts with AdvSM. Methods: Pts were aged ≥18 years with centrally confirmed diagnosis of an AdvSM subtype. Primary endpoint was overall response rate (ORR) by modified International Working Group-Myeloproliferative Neoplasms Research and Treatment and European Competence Network on Mastocytosis criteria. This pre-specified interim analysis included 32 response-evaluable pts. Secondary endpoints included mean baseline change in AdvSM-Symptom Assessment Form Total Symptom Score (TSS) (Gotlib J et al. ASH 2018) and safety. Results: At June 23, 2020, 62 pts with AdvSM received ava primarily at 200 mg orally once daily (QD). Median age was 69 years (range 31-88), 31% had ECOG PS 2-3, and 68% had prior systemic treatment (55% with midostaurin). At 10.4 months median follow-up, 52/62 (84%) pts remained on treatment. ORR was 75% (95% CI 57-89; P=1.6×10-9) in 32 response-evaluable pts. Complete remission with full or partial hematologic recovery occurred in 19% of pts. Median time to response was 2 months; responses deepened over time. Median overall survival (OS) was not reached; estimated 12-month OS was 87%. There were ≥50% reductions from baseline serum tryptase (87%; n=54), marrow mast cell aggregates (71%; n=44), and KIT D816V allele fraction (53%; n=33). Mean TSS at baseline (n=56) was 18.3; fatigue, spots, itching, flushing, and abdominal pain were the most severe symptoms. Mean change in TSS was -7.7 (1-sided P<0.001) after 6 months of treatment (n=36). Common (≥25%) adverse events (AEs; all grade, Grade ≥3) were peripheral (50%, 3%) and periorbital (35%, 3%) edema, thrombocytopenia (32%, 8%), and anemia (29%,16%). Overall, 5% of pts discontinued due to a treatment-related AE and 5% due to disease progression. There were 3 (5%) deaths, all unrelated to treatment. Seven (11%) pts had cognitive effect AEs (all Grade 1-2). One pt with pre-treatment severe thrombocytopenia (platelets <50×109/L) had Grade 4 subdural hematoma. Subsequent pts with pre-treatment severe thrombocytopenia were excluded, platelet monitoring was intensified, and dose interruption for severe thrombocytopenia was recommended; no intracranial bleeding events occurred in 57 pts without pre-treatment severe thrombocytopenia. Conclusions: The pivotal PATHFINDER study showed that ava 200 mg QD induced rapid responses, which deepened over the course of treatment, and improved symptoms in pts with AdvSM. Ava was generally well tolerated with a manageable safety profile, including effective thrombocytopenia risk mitigation.
Citation Format: Daniel J. DeAngelo, Andreas Reiter, Deepti Radia, Michael W. Deininger, Tracy I. George, Jens Panse, Alessandro M. Vannucchi, Madlen Jentzsch, Iván Alvarez-Twose, Andrzej Mital, Olivier Hermine, Ingunn Dybedal, Elizabeth O. Hexner, Lisa K. Hicks, Lambert Span, Ruben Mesa, Prithviraj Bose, Kristen M. Pettit, Mark L. Heaney, Stephen Oh, Jayita Sen, Hui-Min Lin, Brenton G. Mar, Jason Gotlib. PATHFINDER: Interim analysis of avapritinib (ava) in patients (pts) with advanced systemic mastocytosis (AdvSM) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT023.
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Affiliation(s)
| | - Andreas Reiter
- 2Department of Hematology and Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Deepti Radia
- 3Guy's & St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Michael W. Deininger
- 4Division of Hematology and Hematologic Malignancies, University of Utah, Huntsman Cancer Institute, Salt Lake City, UT
| | | | - Jens Panse
- 6Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital Aachen, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Alessandro M. Vannucchi
- 7Center for Research and Innovation of Myeloproliferative Neoplasms – CRIMM, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Madlen Jentzsch
- 8Medical Clinic I – Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | - Iván Alvarez-Twose
- 9Institute of Mastocytosis Studies of Castilla-La Mancha, Spanish Reference Center of Mastocytosis, Toledo, Spain
| | - Andrzej Mital
- 10Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Olivier Hermine
- 11Necker–Enfants Malades Hospital and Imagine Institute, CEREMAST, Paris, France
| | - Ingunn Dybedal
- 12Department of Hematology, Oslo University Hospital, Oslo, Norway
| | | | - Lisa K. Hicks
- 14Division of Hematology/Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lambert Span
- 15Department of Hematology, University Medical Center Groningen, Groningen, Netherlands
| | - Ruben Mesa
- 16Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX
| | - Prithviraj Bose
- 17The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Stephen Oh
- 20Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO
| | - Jayita Sen
- 21Blueprint Medicines Corporation, Cambridge, MA
| | - Hui-Min Lin
- 21Blueprint Medicines Corporation, Cambridge, MA
| | | | - Jason Gotlib
- 22Division of Hematology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, CA
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13
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Mohammed-Ali Z, Bhandarkar S, Tahir S, Handford C, Yip D, Beriault D, Hicks LK. Implementing effective test utilization via team-based evaluation and revision of a family medicine laboratory test requisition. BMJ Open Qual 2021; 10:bmjoq-2020-001219. [PMID: 33731485 PMCID: PMC7978073 DOI: 10.1136/bmjoq-2020-001219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/16/2021] [Accepted: 02/28/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Zahraa Mohammed-Ali
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Seema Bhandarkar
- Department of Family and Community Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Shafqat Tahir
- Department of Laboratory Medicine, Unity HealthToronto, Toronto, Ontario, Canada
| | - Curtis Handford
- Department of Family and Community Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Drake Yip
- Department of Laboratory Medicine, Unity HealthToronto, Toronto, Ontario, Canada
| | - Daniel Beriault
- Department of Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, Unity HealthToronto, Toronto, Ontario, Canada
| | - Lisa K Hicks
- Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Abstract
Overutilization of tests and treatments is a widespread problem in contemporary heath care, and laboratory medicine is no exception. It is estimated that 10-70% of laboratory tests may be unnecessary, with estimates in the literature varying depending on the situation and the laboratory test. Inappropriate use of laboratory tests can lead to further unnecessary testing, adverse events, inaccurate diagnoses, and inappropriate treatments. Altogether, this increases the risk of harm to a patient, which can be physical, psychological, or financial in nature. Overutilization in healthcare is driven by complex factors including care delivery models, litigious practice environments, and medical and patient culture. Quality improvement (QI) methods can help to tackle overutilization. In this review, we outline the global healthcare problem of laboratory overutilization, particularly in the developed world, and describe how an understanding of and application of quality improvement principles can help to address this challenge.
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Affiliation(s)
- Daniel R Beriault
- Department of Laboratory Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Julie A Gilmour
- Division of Endocrinology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa K Hicks
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Hematology and Oncology, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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15
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 371] [Impact Index Per Article: 123.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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16
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Bodley T, Chan M, Levi O, Clarfield L, Yip D, Smith O, Friedrich JO, Hicks LK. Patient harm associated with serial phlebotomy and blood waste in the intensive care unit: A retrospective cohort study. PLoS One 2021; 16:e0243782. [PMID: 33439871 PMCID: PMC7806151 DOI: 10.1371/journal.pone.0243782] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background Intensive care unit (ICU) patients are at high risk of anemia, and phlebotomy is a potentially modifiable source of blood loss. Our objective was to quantify daily phlebotomy volume for ICU patients, including blood discarded as waste during vascular access, and evaluate the impact of phlebotomy volume on patient outcomes. Methods This was a retrospective observational cohort study between September 2014 and August 2015 at a tertiary care academic medical-surgical ICU. A prospective audit of phlebotomy practices in March 2018 was used to estimate blood waste during vascular access. Multivariable logistic regression was used to evaluate phlebotomy volume as a predictor of ICU nadir hemoglobin < 80 g/L, and red blood cell transfusion. Results There were 428 index ICU admissions, median age 64.4 yr, 41% female. Forty-four patients (10%) with major bleeding events were excluded. Mean bedside waste per blood draw (144 draws) was: 3.9 mL from arterial lines, 5.5 mL central venous lines, and 6.3 mL from peripherally inserted central catheters. Mean phlebotomy volume per patient day was 48.1 ± 22.2 mL; 33.1 ± 15.0 mL received by the lab and 15.0 ± 8.1 mL discarded as bedside waste. Multivariable regression, including age, sex, admission hemoglobin, sequential organ failure assessment score, and ICU length of stay, showed total daily phlebotomy volume was predictive of hemoglobin <80 g/L (p = 0.002), red blood cell transfusion (p<0.001), and inpatient mortality (p = 0.002). For every 5 mL increase in average daily phlebotomy the odds ratio for nadir hemoglobin <80 g/L was 1.18 (95% CI 1.07–1.31) and for red blood cell transfusion was 1.17 (95% CI 1.07–1.28). Conclusion A substantial portion of daily ICU phlebotomy is waste discarded during vascular access. Average ICU phlebotomy volume is independently associated with ICU acquired anemia and red blood cell transfusion which supports the need for phlebotomy stewardship programs.
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Affiliation(s)
- Thomas Bodley
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Maverick Chan
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Olga Levi
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Lauren Clarfield
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Drake Yip
- Division of Laboratory Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Orla Smith
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Jan O. Friedrich
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Lisa K. Hicks
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Division of Hematology/Oncology, St. Michael’s Hospital, Toronto, Ontario, Canada
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May JE, Irelan PC, Boedeker K, Cahill E, Fein S, Garcia DA, Hicks LK, Lawson J, Lim MY, Morton CT, Rajasekhar A, Shanbhag S, Zumberg MS, Plovnick RM, Connell NT. Systems-based hematology: highlighting successes and next steps. Blood Adv 2020; 4:4574-4583. [PMID: 32960959 PMCID: PMC7509880 DOI: 10.1182/bloodadvances.2020002947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 12/21/2022] Open
Abstract
Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - David A Garcia
- Division of Hematology, University of Washington, Seattle, WA
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Ming Y Lim
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT
| | - Colleen T Morton
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Anita Rajasekhar
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | - Satish Shanbhag
- Cancer Specialists of North Florida, Fleming Island, FL; and
| | - Marc S Zumberg
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | | | - Nathan T Connell
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Veloce N, Chan M, Seemangal J, Zwolinski A, Al Saleh AS, Garcia L, Habib LA, Jayakar J, Kimpton M, Batt J, Hicks LK. Increasing screening for latent tuberculosis in patients with hematologic malignancy: A quality improvement project. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
264 Background: Latent tuberculosis infection (LBTI) affects about one quarter of the world population. Treating LTBI is the most effective way of preventing active TB. Patients with hematologic malignancy (HM) and LTBI are at heightened risk (2-40 times baseline) of progressing to active TB. Universal TB screening is recommended for this population. In 2016, a patient receiving chemotherapy for myeloma at our center developed active TB. This triggered an intensive contact tracing investigation involving local public health units, infection control, and specialists. Over 800 patients had one or more exposures to the index case. No cases of secondary TB were identified; however, the contact tracing was resource intensive and stressful for patients and staff. This project aims to prevent future incidents by developing a standardized process for completing and documenting TBSTs, ensuring LTBIs are identified and managed prior to systemic therapy for HM. We aimed to complete and document TBSTs in ≥85% of patients starting systemic therapy for HM by Feb 2018. Methods: Baseline data was determined via retrospective review of 25 patients receiving chemotherapy for HM Jul-Nov 2017. An order set, work flow process map and standard operating procedure were created over a series of plan-do-study act cycles. TBST was added to a pre-existing “ready for treatment” checklist employed by pharmacists at our site. When pharmacists could find no record of a TBST result prior to treatment, the treating physician was notified. The go-live date was Aug 15, 2018. The impact of change was evaluated via chart review of patients who started chemotherapy for HM between Aug 27, 2018-Feb 27, 2019. Results: Prior to implementation of the standardized process, 3/25 patients (12%) had documentation of prior TBST. Following implementation of the standardized process, 14/30 patients (47%) had documentation of TBST prior to starting systemic therapy for HM. All 14 patients had negative TBSTs. Conclusions: Developing a standardized process for ordering, completing, and documenting TBST for patients starting systemic therapy for HM is feasible and effective. Additional revisions of the process are required to meet our target.
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Affiliation(s)
- Nicole Veloce
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON, Canada
| | - Maverick Chan
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON, Canada
| | - Julie Seemangal
- St. Michael's Hospital, Respirology/Tuberculosis, Toronto, ON, Canada
| | - Andrea Zwolinski
- St. Michael's Hospital, Hematology/Oncology, Toronto, ON, Canada
| | | | - Luciana Garcia
- University of Toronto, Faculty of Medicine, Toronto, ON, Canada
| | | | - Jai Jayakar
- University of Toronto, Faculty of Medicine, Newmarket, ON, Canada
| | - Miriam Kimpton
- University of Toronto, Faculty of Medicine, Toronto, ON, Canada
| | - Jane Batt
- St. Michael's Hospital, Respirology/Tuberculosis, Toronto, ON, Canada
| | - Lisa K. Hicks
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON; Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Abdulrehman J, Lausman A, Tang GH, Nisenbaum R, Petrucci J, Pavenski K, Hicks LK, Sholzberg M. Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study. PLoS Med 2019; 16:e1002867. [PMID: 31430296 PMCID: PMC6701755 DOI: 10.1371/journal.pmed.1002867] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Iron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities. METHODS AND FINDINGS In order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael's Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%-14.11%]; post-intervention 10.6% [95% CI 9.6%-11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group. CONCLUSIONS The introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.
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Affiliation(s)
- Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University Health Network, Toronto, Canada
| | - Andrea Lausman
- Department of Obstetrics and Gynecology, St. Michael’s Hospital, University of Toronto, Canada
| | - Grace H. Tang
- Hematology Oncology Clinical Research Group, St. Michael’s Hospital, Toronto, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Applied Health Research Centre, MAP Centre for Urban Health Solutions, St. Michael’s Hospital, University of Toronto, Canada
| | - Jessica Petrucci
- Hematology Oncology Clinical Research Group, St. Michael’s Hospital, Toronto, Canada
| | - Katerina Pavenski
- Division of Hematology/Oncology, Department of Medicine and Department of Laboratory Medicine, St. Michael’s Hospital, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, St. Michael’s Hospital, University of Toronto, Canada
| | - Lisa K. Hicks
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Division of Hematology/Oncology, Department of Medicine and Department of Laboratory Medicine, St. Michael’s Hospital, Toronto, Canada
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Division of Hematology/Oncology, Department of Medicine and Department of Laboratory Medicine, St. Michael’s Hospital, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, St. Michael’s Hospital, University of Toronto, Canada
- * E-mail:
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Affiliation(s)
- Amanda Li
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa K Hicks
- Division of Hematology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Parsons JA, Greenspan NR, Baker NA, McKillop C, Hicks LK, Chan O. Treatment preferences of patients with relapsed and refractory multiple myeloma: a qualitative study. BMC Cancer 2019; 19:264. [PMID: 30909874 PMCID: PMC6434792 DOI: 10.1186/s12885-019-5467-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 03/13/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Multiple myeloma is a haematological malignancy characterized by significant morbidity and mortality. This study sought to develop an in-depth understanding of patients' lived experiences of relapsed or refractory multiple myeloma (RRMM) and its treatment, and to identify which features of treatment were most important to them. METHODS Qualitative interviews and focus groups (FGs) were conducted with 32 people living with RRMM across Canada. In Phase 1, interviews focused on participants' accounts of their experiences with the disease and its treatment and laid the groundwork for the FGs (Phase 2). The FGs developed a deeper understanding of patients' treatment priorities. Interview and FG transcripts were coded for emergent themes and patterns. RESULTS The interviews identified important side effects that had significant impacts on patients' lives, including physical, cognitive, and psychological/emotional side effects. Participants also identified specific treatment features (attributes) that were important to them. These were compiled into a list and used in the FGs to understand patients' priorities. Higher prioritized attributes were: life expectancy, physical and cognitive side effects, and financial impact. Mode of administration, treatment intervals, psychological side effects, and sleep/mood effects were identified as lower priorities. CONCLUSIONS RRMM and its treatments impact importantly on patients' quality-of-life across a range of domains. Patients prioritized treatment features that could enhance life expectancy, minimize side effects and offset financial burdens. IMPLICATIONS FOR CANCER SURVIVORS A clear articulation of patient priorities can contribute to efforts to design treatment with patients' concerns in mind, thereby promoting a more patient-centered approach to care.
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Affiliation(s)
- Janet A Parsons
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada. .,Department of Physical Therapy and the Rehabilitation Sciences Institute, University of Toronto, 160-500 University Ave., Toronto, ON, M5G 1V7, Canada.
| | | | - Natalie A Baker
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Chris McKillop
- Turalt, Inc., Suite 2201, 250 Yonge St., Toronto, Canada
| | - Lisa K Hicks
- Division Hematology/Oncology St. Michael's Hospital, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, Canada
| | - Olivia Chan
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada
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22
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Longmore A, Veloce N, Mercado M, Dainty K, Hicks LK. Understanding what drives patients with cancer to visit the emergency department: A qualitative study. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
173 Background: Visits to the emergency department (ED) are common among patients with cancer (PWCs). Previous research suggests that few ED visits are precipitated by true oncologic emergencies (Diaz-Couselo 2004). Designing initiatives to reduce ED visits requires a rich understanding of factors that drive PWCs to visit the ED. Methods: Standardized interviews were conducted with 12 oncology clinicians at an academic oncology clinic in Toronto, Canada. Interviews were also conducted with 10 PWCs. Interviews explored factors that may drive ED visits, and interviewees’ insights into interventions to prevent ED visits. Interviews were audio recorded and transcribed. Transcriptions were qualitatively analyzed by two independent reviewers using the constant comparison method (Strauss and Corbin 1998). Results: Ten themes were identified as factors that may drive ED visits, with little overlap between themes identified by clinicians versus those identified by PWCs. Clinicians identified low socioeconomic status, lack of social support, advanced age, comorbidities, anxiety and non-adherence as important factors. In contrast, PWCs focused on the severity and expectedness of symptoms, lack of access to afterhours oncology advice and care, and adherence with medical and non-medical advice as drivers of ED visits. Regarding potential interventions, there was broad agreement between clinicians and PWCs regarding what might be helpful. Both groups identified improved access to expert cancer advice/care, improved coordination of care between clinics and ancillary health services, and patient education as important interventions. Clinicians also believed increasing community supports would help prevent ED visits. PWCs emphasized that some ED visits are not preventable. Conclusions: Clinicians and PWCs have different views on what drives ED visits. Despite identifying different drivers, clinicians and PWCs identified common solutions for reducing ED visits.
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Affiliation(s)
- Avery Longmore
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON; Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicole Veloce
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON, Canada
| | - Marck Mercado
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON; Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katie Dainty
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Lisa K. Hicks
- St. Michael's Hospital, Division of Hematology/Oncology, Toronto, ON; Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Hicks LK, O'Brien P, Sholzberg M, Veloce N, Trafford A, Sinclair D. Tackling overutilization of hospital tests and treatments: Lessons learned from a grassroots approach. Healthc Manage Forum 2018; 31:186-190. [PMID: 30133329 DOI: 10.1177/0840470418781172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Recent data suggest unnecessary medical testing and treatment is relatively common in Canada. A number of harms to patients can arise as a result of unnecessary tests and treatments. In addition to patient harm, unnecessary tests and treatments add to the cost of medical care. Inspired by the Choosing Wisely campaign, St. Michael's Hospital in Toronto, Ontario, developed a hospital-wide program to address many different forms of overutilization at our hospital. The program prioritizes harm reduction over cost-containment and aims to create sustainable change through grassroots clinician engagement. This article will review important lessons learned from the St. Michael's experience.
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Affiliation(s)
- Lisa K Hicks
- 1 St. Michael's Hospital, Toronto, Ontario, Canada
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Michelle Sholzberg
- 1 St. Michael's Hospital, Toronto, Ontario, Canada
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Doug Sinclair
- 1 St. Michael's Hospital, Toronto, Ontario, Canada
- 2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Sholzberg M, Teitel J, Hicks LK. The authors respond to “Is referral necessary for abnormal bleeding?”. CMAJ 2017; 189:E1369. [DOI: 10.1503/cmaj.733365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Sholzberg M, Teitel J, Hicks LK. A 24-year-old woman with heavy menstrual bleeding. CMAJ 2017; 189:E779-E780. [DOI: 10.1503/cmaj.161469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Fralick M, Hicks LK, Chaudhry H, Goldberg N, Ackery A, Nisenbaum R, Sholzberg M. REDucing Unnecessary Coagulation Testing in the Emergency Department (REDUCED). BMJ Qual Improv Rep 2017; 6:bmjquality_uu221651.w8161. [PMID: 28469907 PMCID: PMC5411723 DOI: 10.1136/bmjquality.u221651.w8161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 12/31/2016] [Indexed: 11/17/2022]
Abstract
The PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time) were tests developed in the early 20th century for specific and unique indications. Despite this, they are often ordered together routinely. The objective of this study was to determine if a multimodal intervention could reduce PT/INR and aPTT testing in the emergency department (ED). This was a prospective multi-pronged quality improvement study at St. Michael's Hospital. The initiative involved stakeholder engagement, uncoupling of PT/INR and aPTT testing, teaching, and most importantly a revision to the ED order panels. After changes to order panels, weekly rates of PT/INR and aPTT testing per 100 ED patients decreased (17.2 vs 38.4, rate ratio=0.45 (95% CI 0.43-0.47), p<0.001; 16.6 vs 37.8, rate ratio=0.44 (95% CI 0.42-0.46), p<0.001, respectively). Rate of creatinine testing per 100 ED patients, our internal control, increased during the same period (54.0 vs 49.7, rate ratio=1.09 (95% CI 1.06-1.12); p<0.0001) while the weekly rate per 100 ED patients receiving blood transfusions slightly decreased (0.5 vs 0.7, rate ratio=0.66 (95% CI 0.49-0.87), p=0.0034). We found that a simple process change to order panels was associated with meaningful reductions in coagulation testing without obvious adverse effects.
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Affiliation(s)
- Michael Fralick
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lisa K Hicks
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
| | - Hina Chaudhry
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nicola Goldberg
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
| | - Alun Ackery
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada
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Prica A, Baldassarre F, Hicks LK, Imrie K, Kouroukis T, Cheung M. Rituximab in Lymphoma and Chronic Lymphocytic Leukaemia: A Practice Guideline. Clin Oncol (R Coll Radiol) 2016; 29:e13-e28. [PMID: 27746042 DOI: 10.1016/j.clon.2016.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/20/2016] [Accepted: 07/05/2016] [Indexed: 11/25/2022]
Abstract
Rituximab is the first monoclonal antibody to be approved for use by the US Food and Drug Administration in cancer. Its role in the treatment of non-Hodgkin lymphoma, including chronic lymphocytic leukaemia (CLL), has evolved significantly. We aimed to systematically review and update the literature on rituximab in lymphoma and CLL, and provide evidence-based consensus guidelines for its rational use. Validated methodology from the Cancer Care Ontario Program in Evidence-based Care was used. A comprehensive literature search was completed by a methodologist from the Hematology Disease Site Group of Cancer Care Ontario. Data were extracted from randomised controlled trials of rituximab-containing chemotherapy regimens for patients with lymphoma or CLL. Fifty-six primary randomised controlled trials were retrievable and met all inclusion criteria. Clinically important benefits in progression-free survival or overall survival were seen in the following settings: (i) addition of rituximab to combination chemotherapy for initial treatment of aggressive B-cell lymphomas, including diffuse large B-cell lymphoma, Burkitt lymphoma and HIV-related lymphoma with CD4 count ≥50/mm3; (ii) addition of rituximab to combination chemotherapy for initial and subsequent treatment of follicular lymphoma and other indolent B-cell lymphomas; (iii) use of rituximab maintenance in patients with indolent B-cell lymphomas who have responded to chemoimmunotherapy; (iv) addition of rituximab to fludarabine-based chemotherapy or chlorambucil for initial treatment of CLL. The consensus opinion of the Hematology Disease Site Group is that rituximab is recommended for these indications.
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Affiliation(s)
- A Prica
- Princess Margaret Hospital, Toronto, Ontario, Canada
| | - F Baldassarre
- Program in Evidence-based Care, Cancer Care Ontario, McMaster University, Hamilton, Ontario, Canada.
| | - L K Hicks
- St. Michael Hospital, Toronto, Ontario, Canada
| | - K Imrie
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - T Kouroukis
- Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - M Cheung
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Hicks LK, Rajasekhar A, Bering H, Carson KR, Kleinerman J, Kukreti V, Ma A, Mueller BU, O'Brien SH, Panepinto JA, Pasquini MC, Sarode R, Wood WA. Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology. Am J Hematol 2016; 91:787-92. [PMID: 27152483 DOI: 10.1002/ajh.24412] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/26/2016] [Accepted: 05/03/2016] [Indexed: 01/03/2023]
Abstract
Choosing Wisely (CW) is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. In an effort to learn from and leverage the work of others, the American Society of Hematology CW Task Force developed a method to identify and prioritize CW recommendations from other medical societies of high relevance and importance to patients with blood disorders and their physicians. All 380 CW recommendations were reviewed and assessed for relevance and importance. Relevance was assessed using the MORE(TM) relevance scale. Importance was assessed with regard to six guiding principles: harm avoidance, evidence, aggregate cost, relevance, frequency and impact. Harm avoidance was considered the most important principle. Ten highly relevant and important recommendations were identified from a variety of professional societies. Recommendations focused on decreasing unnecessary imaging, blood work, treatments and transfusions, as well as on increasing collaboration across disciplines and considering value when recommending treatments. Many CW recommendations have relevance beyond the society of origin. The methods developed by the ASH CW Task Force could be easily adapted by other Societies to identify additional CW recommendations of relevance and importance to their fields. Am. J. Hematol. 91:787-792, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Lisa K. Hicks
- St. Michael's Hospital; University of Toronto; Toronto Ontario Canada
| | | | - Harriet Bering
- Harvard Vanguard Medical Associates; Beverly Massachusetts
| | | | | | - Vishal Kukreti
- University of Toronto, University Health Network; Toronto Ontario
| | - Alice Ma
- University of North Carolina; Chapel Hill North Carolina
| | | | | | - Julie A. Panepinto
- Medical College of Wisconsin/Children's Hospital of Wisconsin; Milwaukee Wisconsin
| | | | - Ravi Sarode
- UT Southwestern Medical Center; Dallas Texas
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Hicks LK, Lien K, Chan KKW. ASCO Provisional Clinical Opinion for Hepatitis B Virus Screening Before Cancer Therapy: Are These the Right Tests in the Right Patients? J Oncol Pract 2016; 11:e490-4. [PMID: 26188049 DOI: 10.1200/jop.2015.004945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Lisa K Hicks
- St Michael's Hospital, University of Toronto; and Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelly Lien
- St Michael's Hospital, University of Toronto; and Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- St Michael's Hospital, University of Toronto; and Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Acuna SA, Fernandes KA, Daly C, Hicks LK, Sutradhar R, Kim SJ, Baxter NN. Cancer Mortality Among Recipients of Solid-Organ Transplantation in Ontario, Canada. JAMA Oncol 2016; 2:463-9. [DOI: 10.1001/jamaoncol.2015.5137] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sergio A. Acuna
- Institute of Health Policy, Management and Education, University of Toronto, Toronto, Ontario, Canada2Department of Surgery, Li Ki Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Corinne Daly
- Department of Surgery, Li Ki Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Lisa K. Hicks
- Division of Hematology/Oncology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada5Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - S. Joseph Kim
- Institute of Health Policy, Management and Education, University of Toronto, Toronto, Ontario, Canada3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada6Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Nancy N. Baxter
- Institute of Health Policy, Management and Education, University of Toronto, Toronto, Ontario, Canada2Department of Surgery, Li Ki Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada3Institute for Clinical Evaluative Sciences, Toron
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Hicks LK, Feld JJ, Saluja R, Truong J, Haynes AE, Chan KK. Hepatitis B reactivation in patients with solid tumors: A systematic review and meta-analysis. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.7_suppl.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
138 Background: Hepatitis B virus (HBV) affects over 250 million people worldwide. Most people with chronic HBV (HBsAg positive) have no signs or symptoms of infection. However, when exposed to immunosuppression they are at risk of HBV reactivation which can cause hepatitis, liver failure and death. The risk of HBV reactivation in patients receiving chemotherapy for solid tumors, the efficacy of antiviral prophylaxis, and the clinical impact of HBV reactivation in this setting are uncertain. Primary Aim: To estimate the risk of clinical HBV reactivation (increased HBV DNA + transaminitis) among HBsAg-positive patients administered chemotherapy for a solid tumor. Secondary Aims: To estimate the efficacy of anti-viral prophylaxis and the risk of death from HBV reactivation in patients receiving chemotherapy for solid tumors. Methods: A systematic review and meta-analysis of the English language literature on HBV reactivation was completed (OVID Medline, 1946 to Aug 2013). All citations were reviewed by two or more authors. Data from patients with hematologic malignancies were excluded. Pooled probabilities of HBV reactivation risk, death from HBV reactivation, and odds ratio for the impact of anti-viral prophylaxis were estimated with a random effects model. Results: 2,667 citations were identified; 19 were eligible for inclusion. The pooled estimate for clinical HBV reactivation in HBsAg-positive patients receiving chemotherapy for a solid tumor was 21.9% (95% CI; 16.5% to 27.3%) in those not receiving anti-viral prophylaxis, and 2.4% (95% CI 0.7% to 4.2%) in those receiving anti-viral prophylaxis. The odds ratio for clinical HBV reactivation with antiviral prophylaxis compared to no prophylaxis was 0.12 (95% CI 0.06 to 0.25). In the absence of viral prophylaxis, the risk of dying from HBV reactivation in HBsAg-positive solid tumor patients was estimated at 1.3% with a 95% CI of 0.3% to 2.3%. Conclusions: Patients with chronic HBV who are administered chemotherapy for a solid tumor appear to be at substantial risk of clinical HBV reactivation; this risk may be mitigated by anti-viral prophylaxis. In the absence of anti-viral therapy, patients may experience a small but important risk of dying from HBV reactivation.
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Affiliation(s)
| | - Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ronak Saluja
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Judy Truong
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Kelvin K. Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
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Mozessohn L, Chan KKW, Feld JJ, Hicks LK. Hepatitis B reactivation in HBsAg-negative/HBcAb-positive patients receiving rituximab for lymphoma: a meta-analysis. J Viral Hepat 2015; 22:842-9. [PMID: 25765930 DOI: 10.1111/jvh.12402] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/11/2015] [Indexed: 12/18/2022]
Abstract
Patients with chronic hepatitis B (HBsAg-positive) are at risk of viral reactivation if rituximab is administered without antiviral treatment, a potentially fatal complication of treatment. Patients with so-called 'resolved hepatitis B virus infection' (HBsAg-negative/cAb-positive) may also be at risk. We performed a systematic review of the English and Chinese language literature to estimate the risk of hepatitis B virus (HBV) reactivation in HBsAg-negative/cAb-positive patients receiving rituximab for lymphoma. A pooled risk estimate was calculated for HBV reactivation. The impact of HBsAb status and study design on reactivation rates was explored. Data from 578 patients in 15 studies were included. 'Clinical HBV reactivation', (ALT >3 × normal and either an increase in HBV DNA from baseline or HBsAg seroreversion), was estimated at 6.3% (I(2) = 63%, P = 0.006). Significant heterogeneity was detected. Reactivation rates were higher in prospective vs retrospective studies (14.2% vs 3.8%; OR = 4.39, 95% CI 0.83-23.28). Exploratory analyses found no effect of HBsAb status on reactivation risk (OR = 0.083; P = 0.151). Our meta-analysis confirms a measurable and potentially substantial risk of HBV reactivation in HBsAg-negative/cAb-positive patients exposed to rituximab. However, heterogeneity in the existing literature limits the generalizability of our findings. Large, prospective studies, with uniform definitions of HBV reactivation, are needed to clarify the risk of HBV reactivation in HBsAg-negative/cAb-positive patients.
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Affiliation(s)
- L Mozessohn
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
| | - K K W Chan
- Division of Hematology/Oncology, Sunnybrook Odette Cancer Centre, Toronto, ON, Canada
| | - J J Feld
- Toronto Centre for Liver Disease, Toronto Western Hospital Liver Centre, Toronto, ON, Canada
| | - L K Hicks
- Division of Hematology/Oncology, St. Michael's Hospital, Toronto, ON, Canada
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Wong WWL, Hicks LK, Tu HA, Krahn M, Pritchard KI, Feld JJ, Chan KK. Hepatitis B virus screening before adjuvant chemotherapy in patients with early stage breast cancer: A cost-effectiveness analysis. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.6617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Hong-Anh Tu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Murray Krahn
- THETA, University of Toronto, Toronto, ON, Canada
| | | | - Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kelvin K. Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
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Abstract
The author proposes a shift away from economic arguments toward a focus on patient-level harms caused by overuse, arguing that by focusing on how overuse affects our patients, we may begin to alter the practice.
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Affiliation(s)
- Lisa K. Hicks
- St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Visram A, Chan KKW, McGee P, Boro J, Hicks LK, Feld JJ. Poor recognition of risk factors for hepatitis B by physicians prescribing immunosuppressive therapy: a call for universal rather than risk-based screening. PLoS One 2015; 10:e0120749. [PMID: 25875198 PMCID: PMC4398053 DOI: 10.1371/journal.pone.0120749] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/06/2015] [Indexed: 02/07/2023] Open
Abstract
Background Reactivation of hepatitis B virus (HBV) during immunosuppressive therapy (IST) can lead to severe and even fatal hepatitis but can be largely prevented with prophylactic antiviral therapy. Screening for HBV prior to starting IST is recommended. Both risk-based and universal screening have been recommended by different societies. For effective risk-based screening, physicians must be aware of risk factors for chronic HBV infection. Methods The HBV screening practices prior to starting IST of rheumatologists, medical and hematological oncologists were evaluated by survey and chart review. Country of origin, the primary risk factor for HBV exposure, was determined in all patients. Results Of 140 rheumatology, 79 medical oncology and 53 hematology patients reviewed, 81%, 11% and 81% were deemed to be at high risk of HBV reactivation by their physicians respectively, however only 27%, 6% and 62% (p<0.0001) were actually screened for HBV prior to starting IST. For patients from HBV-endemic regions, more hematology patients (53%) were correctly identified by their physicians as being at high risk of reactivation than rheumatology patients (2.4%, p=0.0001) or medical oncology patients (15%, p=0.009). However actual screening rates were not increased in patients from endemic regions. A total of 81 patients were screened for HBsAg; 2 were positive. Of the 33 patients screened for anti-HBc, 10 (30%) were positive. Conclusions Hematologists, rheumatologists and medical oncologists had low rates of screening for HBV prior to prescribing IST, largely due to poor identification of those at risk for infection. Risk-based screening strategies are unlikely to be effective and should be replaced by universal screening.
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Affiliation(s)
- Alissa Visram
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
- * E-mail:
| | - Kelvin K. W. Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | | | - Jordana Boro
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Lisa K. Hicks
- St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
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Hicks LK, Bering H, Carson KR, Haynes AE, Kleinerman J, Kukreti V, Ma A, Mueller BU, O'Brien SH, Panepinto JA, Pasquini MC, Rajasekhar A, Sarode R, Wood WA. Five hematologic tests and treatments to question. Hematology Am Soc Hematol Educ Program 2014; 2014:599-603. [PMID: 25696917 DOI: 10.1182/asheducation-2014.1.599] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Choosing Wisely® is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. The American Society of Hematology (ASH) released its first Choosing Wisely® list in 2013. Using the same evidence-based methodology as in 2013, ASH has identified 5 additional tests and treatments that should be questioned by clinicians and patients under specific, indicated circumstances. The ASH 2014 Choosing Wisely® recommendations include: (1) do not anticoagulate for more than 3 months in patients experiencing a first venous thromboembolic event in the setting of major, transient risk factors for venous thromboembolism; (2) do not routinely transfuse for chronic anemia or uncomplicated pain crises in patients with sickle cell disease; (3) do not perform baseline or surveillance computed tomography scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia; (4) do not test or treat for heparin-induced thrombocytopenia if the clinical pretest probability of heparin-induced thrombocytopenia is low; and (5) do not treat patients with immune thrombocytopenia unless they are bleeding or have very low platelet counts.
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Affiliation(s)
- Lisa K Hicks
- University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | | | | | | | - Vishal Kukreti
- University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Alice Ma
- University of North Carolina, Chapel Hill, NC
| | | | | | - Julie A Panepinto
- Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
| | | | | | - Ravi Sarode
- University of Texas Southwestern Medical Center, Dallas, TX
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Hicks LK, Feld JJ, Juan J, Truong J, Zurawska U, Giotis A, Chan KK. An electronic prompt to improve hepatitis B virus screening prior to cancer treatment. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.30_suppl.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
169 Background: Hepatitis B virus (HBV) reactivation is a potentially fatal complication of cancer therapy that is almost entirely preventable. Despite this, HBV screening rates remain low at many centers. We evaluated the effectiveness of an electronic prompt on HBV screening rates and compared this strategy with education alone. Methods: An education session on HBV reactivation was delivered to all oncology staff at two large, academic oncology centers in the fall of 2010. At one center (study center) an electronic prompt was also introduced. The electronic prompt reminded physicians to screen for HBV when booking a new patient’s first chemotherapy and automatically trigged an electronic order for HBsAg if the physician assented. The prompt was not implemented at the second (control) center. The primary endpoint was the rate of HBV screening. Actual HBV screening rates were determined in both centers for 10 months prior to and for 12 months following the interventions. HBV screening rates were assessed and compared with process control charts (p-charts); 3-sigma limits were employed to define special cause variation. Results: 6,116 new patients received their first chemotherapy during the study period (2,095 study center; 4,021 control center). In the pre-prompt period, the screening rate was stable at 16% at the study center and 25% in the control center. In the prompt period, the screening rate increased to 62% at the study center and was unchanged at 25% in the control center. Special cause variation suggesting a non-random improvement in HBV screening rate was detected at the Study Center two months after the introduction of the electronic prompt. Conclusions: An electronic prompt increased the rate of HBV screening, however screening rates remained relatively low. Education sessions did not appear to improve the HBV screening rate.
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Affiliation(s)
- Lisa K. Hicks
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Joshua Juan
- University Health Network, Toronto, ON, Canada
| | - Judy Truong
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Angie Giotis
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin K. Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Wong WWL, Hicks LK, Tu HA, Krahn M, Pritchard KI, Feld JJ, Chan KK. HBV screening before adjuvant chemotherapy in patients with early breast cancer: A cost-effectiveness analysis. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.30_suppl.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11 Background: The seroprevalence of hepatitis B virus (HBV) infection among Canadian was 0.4%, and 1.6% among immigrants. Most infected individuals have clinically silent disease. Cytotoxic chemotherapy causes reactivation in 30% of the HBV infected patients. This can be severe and fatal, may also lead to interruption of chemotherapy. HBV screening before adjuvant chemotherapy (ADJ) for breast cancer (BC) seems to be a plausible strategy. Our objective is to estimate the health and economic effects of HBV screening strategies. Methods: We developed a state transition microsimulation model to examine the cost effectiveness of 3 strategies for 55 year old BC patients undergoing ADJ: (1) No screen; (2) Screen Imm: Screen immigrant only and treat; (3) Screen all: Screen all and treat; with antiviral therapies. In the model, health states were constructed to reflect the natural history of BC and HBV. Model data were obtained from published literature. We used a payer perspective, a lifetime time horizon, and used a 5% discount rate. Results: Screen all would prevent 43 severe reactivations (SR), 9 deaths from reactivation (DR), 22 chemotherapy interruptions (CI), 36 decompensated cirrhosis (DC), 48 HCCs, and 67 HBV deaths per 100,000 persons screened over the lifetime of the cohort. Screen Imm would prevent 34 SR, 4 DR, 20 CI, 30 DC, 41 HCCs, and 52 HBV deaths. Screen all was associated with an increase of at least 0.00368 quality adjusted life years (QALY) and cost C$116 more per person, translating to an incremental cost effectiveness ratio (ICER) of C$31,518-51,276/QALY gained compared with No screen, depends on different antiviral therapies. Screen all was the most cost effective, while Screen Imm was ruled out due to extended dominance (ED) by No Screen and Screen all. Conclusions: HBV screening before ADJ for BC patients would prevent a significant number of reactivations, and is likely be cost effective. [Table: see text]
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Affiliation(s)
- William W. L. Wong
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON, Canada
| | - Lisa K. Hicks
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Hong-Anh Tu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Murray Krahn
- THETA, University of Toronto, Toronto, ON, Canada
| | | | - Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kelvin K. Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Feld JJ, Hicks LK, Juan J, Judy T, Zurawska U, Giotis A, Chan KK. An electronic prompt prior to myelosuppressive therapy to improve hepatitis B virus screening. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.6627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
| | - Lisa K. Hicks
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Joshua Juan
- University Health Network, Toronto, ON, Canada
| | - Truong Judy
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Angie Giotis
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin K. Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Uppal N, Tobin S, Cape J, Muller M, Hicks LK. Feasibility and utility of influenza vaccination in hematology/oncology clinics. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
166 Background: Seasonal influenza vaccination is recommended for cancer patients. However, many cancer clinics do not routinely offer flu shots. Early in January, 2013, Toronto experienced widespread influenza activity. Approximately 25% of hospitalizations on the hematology/oncology ward at St. Michael's Hospital (SMH) during this time were for suspected influenza. A large number of patients were noted to be unvaccinated. In-response, influenza vaccination was organized in parallel with regular hematology/oncology clinics at SMH. Aims: To determine the feasibility and utility of influenza vaccination in a cancer clinic. Methods: All patients seen in the SMH hematology/oncology clinic between January 14 and February 1, 2013, were eligible for influenza vaccination. A brief survey was administered to obtain vaccination history, willingness to receive flu vaccination, and beliefs about flu vaccination. Information regarding diagnosis, treatment, and family physician was obtained from the medical record. Univariate testing was completed with the Chi-squared and Fisher’s exact tests as appropriate. Results: 555 patients were seen during the period of interest; 206 completed the survey (37% response rate). Median age of respondents was 63 years, 42% were male, and 81% had cancer. 107(52%) of respondents had not received seasonal influenza vaccination of whom 41 (38%) accepted vaccination when offered. Among vaccinated patients, most received the flu shot from a family physician (70%). Reasons for not receiving the flu shot were personal preference (24%), belief that it was not necessary (19%), inconvenience (14%), concerns about side effects (8%), believe that it was contraindicated during chemotherapy (7%) and a perception that a medical practitioner advised against it (7%). Patients without a registered family physician were less likely to have received the seasonal flu shot (p=0.03). Patients with a malignant diagnosis and patients receiving IV chemotherapy tended to have lower rates of seasonal flu vaccination (p=0.09 and p=0.12 respectively). Conclusions: Administering influenza vaccination during hematology/oncology clinics is feasible and may address a care gap in this population.
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Hicks LK, Leung P, Cape J. Screening for hepatitis B virus prior to chemotherapy: A quality improvement project. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
158 Background: Hepatitis B virus (HBV) reactivation is a well-recognized and serious complication of chemotherapy which can be prevented with prophylactic antiviral therapy. St. Michael’s Hospital (SMH) is an academic hospital in Toronto, Canada, serving an inner city population. The prevalence of chronic HBV in populations such as ours is estimated to be > 8%, compared to 2% of all Canadians. In this context, surveillance for HBV prior to chemotherapy is very important. Aim: To increase the HBV screening rate among patients starting IV chemotherapy at SMH to greater than 90% by December 2013. Methods: Repeated plan-do-study-act (PDSA) cycles targeting HBV screening in our chemotherapy unit were initiated in January 2013 and are on-going. Appropriate HBV screening was defined as at least one HBsAg test up to 3 months prior to, or 3 weeks after starting chemotherapy. Interventions included education sessions, posters, standardized HBV lab order sets, and pharmacist review of lab data prior to first chemotherapy with reminders to physicians when HBV testing was absent. Pre and post-intervention HBV screening rates were compared using process control charting. Results: Between January 1, 2012, and June 15, 2013, 407 unique patients started IV chemotherapy at SMH. Prior to our interventions a stable HBV screening rate of approximately 30% was observed. Sequential process improvements were introduced in January and April 2013. Process control charting demonstrated the presence of special cause variation subsequent to our interventions with a significant improvement in the HBV testing rate (post-intervention rate of 70%). The HBV testing rate began to improve in January 2013 and met criteria for special cause variation by February 2013. Conclusions: It is possible to dramatically increase the rate of HBV testing prior to chemotherapy through relatively simple, low tech process improvements. Further improvements are necessary to reach our goal of a 90% HBV screening rate prior to IV chemotherapy. Additional planned interventions include individualized physician report cards on HBV screening rates using achievable benchmark criteria and an education campaign directed at empowering patients to ask about HBV testing.
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Mozessohn L, Chan KK, Feld JJ, Hicks LK. Hepatitis B reactivation in patients with lymphoma: A meta-analysis. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
228 Background: Patients with hepatitis B virus (HBV) who are HBsAg+ are at risk of HBV reactivation if rituximab is administered in the absence of antiviral treatment. Recently, it has been reported that patients with so-called “resolved HBV infection”(HBsAg-/cAb+) may also be at risk; however, the degree of risk is not known. Methods: We performed a systematic review of the English and Chinese language literature in Medline (1996 to June week 3 2013) and Embase (1996 to 2013 week 26) using the MeSH terms “lymphoma” and “hepatitis B”. Eligible studies were limited to those reporting primary data on HBV reactivation rates in HBsAg-/cAb+ patients receiving rituximab. We excluded case series with less than 5 patients. Pooled estimates were calculated for HBV reactivation and the impact of HBsAb status on HBV reactivation rate was explored. We also examined reactivation in HBsAg+ patients receiving rituximab by performing a systematic review of the English language literature in PubMed (1997 to June 21, 2013) using the terms “hepatitis B virus”, “reactivation” and “lymphoma”. Results: Data from 550 HBsAg-/cAb+ patients in 12 studies were included. Using a standardized definition of HBV reactivation, (increase in HBV DNA from baseline or HBsAg seroreversion +/- ALT >3 x upper limit of normal), the pooled estimate for the risk of HBV reactivation in HBsAg-/cAb+ patients was 8.1% (I2 = 55%, P = 0.007). Significant heterogeneity was apparent. Exploratory analyses suggested that patients were less likely to reactivate if they were HBsAb+ (OR = 0.32; 95% CI 0.12-0.85, P = 0.0285). In HBsAg+ patients we meta-analyzed prospective, controlled studies. Without antiviral prophylaxis, the reactivation rate for HBsAg+ lymphoma patients was 51.0% (I2 = 0%, P = 0.93). Conclusions: Our meta-analyses confirm that there is a risk of HBV reactivation in HBsAg-/cAb+ patients exposed to rituximab. HBsAb+ patients may be at lower risk than those who are HBsAb-. However, heterogeneity in the risk estimates limits their generalizability. Without prophylaxis, significant reactivation in HBsAg+ patients exists. Large prospective studies are needed to clarify the risk of HBV reactivation in HBsAg-/cAb+ patients and to inform decisions about best practice.
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Affiliation(s)
| | - Kelvin K. Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
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Tobin S, Fenuta J, Kruchowski J, Hicks LK. High-needs hematology/oncology patients: A quality improvement project. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
197 Background: St. Michael’s Hospital (SMH) is an academic, inner-city hospital in Toronto, Canada. In the hematology/oncology (hem/onc) program, a small number of patients appeared to contribute disproportionately to hospital admissions and emergency department (ED) visits. We hypothesized that high needs hem/onc patients could be recognized early in their care and that ED visit and admission rates among these patients could be decreased through targeted interventions. Methods: Members of the hem/onc team were interviewed regarding characteristics, which they felt predicted higher needs and greater liklihood for hospital admission/ED visit. A list of high risk features was generated. ED visit and admission rates for a prospectively identified high needs cohort were compared to rates for the entire hem/onc clinic. An intervention targeting high needs hem/onc patients is on-going. Pre and post-intervention ED visit and admission rates will be compared. Results: Interviews with 3 nurses, 1 social worker, 1 discharge planner, and 4 physicians identified 10 factors that the hem/onc team believed were predictive of higher needs and subsequent higher ED visit and admission rates. Between December 1, 2012, and February 28, 2013, 42 high needs hem/onc out-patients were prospectively identified. The ED visit and admission rates for this cohort were retrospectively compared to those of the entire hem/onc clinic and found to be dramatically higher (Table). Begininng in June 2013, hem/onc patients identified as “high needs” were offered enrollment in a NP-based program offering telephone assessments following ED visits, hospital admissions or discharges. Assessment of the impact of this intervention is ongoing. Conclusions: It is possible to prospectively identify hem/onc patients who are at risk of higher than usual ED visit and admission rates. Identifying this population may provide an opportunity to decrease their ED visit and admission rates. An evaluation of an intervention targeting high needs hem/onc patients is ongoing. Preliminary data will be presented. [Table: see text]
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Mozessohn L, Chan KK, Feld JJ, Hicks LK. Hepatitis B reactivation in HBsAg-/cAb+ patients receiving rituximab: A meta-analysis. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6592 Background: Patients with hepatitis B virus (HBV) who are HBsAg+ are recognized to be at risk of HBV reactivation if rituximab is administered in the absence of antiviral treatment. Recently, it has been reported that patients with so-called “resolved HBV infection”(HBsAg-/cAb+) may also be at risk; however, the degree of risk is not known. Methods: We performed a systematic review of the English and Chinese language literature in Medline (1996 to July week 2 2012) and Embase (1996 to 2012 week 29) using the MeSH terms “lymphoma” and “hepatitis B”. Eligible studies were limited to those reporting primary data on HBV reactivation rates in HBsAg-/cAb+ patients receiving rituximab. We excluded case series with less than 5 patients. Pooled estimates were calculated for HBV reactivation and the impact of HBsAb status on HBV reactivation rate was explored. Results: Data from 445 patients in 12 studies were included. Using a standardized definition of HBV reactivation, (ALT >3 x upper limit of normal AND either an increase in HBV DNA from baseline OR HBsAg seroreversion), the pooled estimate for the risk of HBV reactivation in HBsAg-/cAb+ patients was 5.4% (I2 = 63%, P = 0.009). Significant heterogeneity was apparent. Exploratory analyses suggested that patients were less likely to reactivate if they were HBsAb+ (OR = 0.32; 95% CI 0.12-0.85, P = 0.0285). Conclusions: Our meta-analysis confirms that there is a measurable risk of HBV reactivation in HBsAg-/cAb+ patients exposed to rituximab HBsAb+ patients may be at lower risk than those who are HBsAb-. However, heterogeneity in the risk estimates limits their generalizability. Large prospective studies are needed to clarify the risk of HBV reactivation in HBsAg-/cAb+ patients and to inform decisions about best practice.
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Affiliation(s)
| | | | - Jordan J. Feld
- University Health Network, University of Toronto, Toronto, ON, Canada
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Lee RS, Bell CM, Singh JM, Hicks LK. Hepatitis B screening before chemotherapy: a survey of practitioners' knowledge, beliefs, and screening practices. J Oncol Pract 2012; 8:325-8, 1 p following 328. [PMID: 23598840 PMCID: PMC3500474 DOI: 10.1200/jop.2012.000597] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2012] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with medication, provided that asymptomatic HBV carriers are identified. We explored the knowledge, beliefs, and practices of Canadian oncologists/hematologists regarding HBV screening before chemotherapy. METHODS A novel questionnaire was mailed to all practicing hematologists/oncologists, where publicly accessible online physician registries facilitated identification of these specialists (71% of the Canadian physician population). RESULTS Of 504 potentially eligible practitioners, 311 (62%) responded, of whom 246 indicated that they administered chemotherapy and were thus included in final analyses. Respondents tended to underestimate the risk of HBV reactivation, and recognition of the major risk factor for HBV carriage (ie, birth in an endemic area) was low. Forty percent of respondents reported rarely or never testing for HBV before chemotherapy, and 36% reported screening only those patients with HBV risk factors. In multivariate analysis, having a predominantly hematologic practice, practitioner experience with HBV reactivation, ability to correctly estimate the risk of HBV reactivation, fewer years in practice, and female sex were independently associated with an increased likelihood of screening for HBV. CONCLUSION Canadian oncologists and hematologists tend to underestimate the risk of HBV reactivation and report relatively low HBV screening rates. Among those practitioners who do screen, the favored strategy is selective screening of patients with HBV risk factors. However, oncologists'/hematologists' knowledge regarding risk factors for HBV carriage seems to be low, potentially undermining the success of a selective screening strategy.
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Affiliation(s)
- Ronita S.M. Lee
- University of Toronto; University Health Network; and St Michael's Hospital, Toronto, Ontario, Canada
| | - Chaim M. Bell
- University of Toronto; University Health Network; and St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey M. Singh
- University of Toronto; University Health Network; and St Michael's Hospital, Toronto, Ontario, Canada
| | - Lisa K. Hicks
- University of Toronto; University Health Network; and St Michael's Hospital, Toronto, Ontario, Canada
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Zurawska U, Hicks LK, Woo G, Bell CM, Krahn M, Chan KK, Feld JJ. Hepatitis B Virus Screening Before Chemotherapy for Lymphoma: A Cost-Effectiveness Analysis. J Clin Oncol 2012; 30:3167-73. [DOI: 10.1200/jco.2011.40.7510] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Hepatitis B virus (HBV) reactivation is a potentially fatal complication of chemotherapy that can be largely prevented with antiviral prophylaxis. It remains unclear whether HBV screening is cost effective. Methods A decision model was developed to compare the clinical outcomes, costs, and cost effectiveness of three HBV screening strategies for patients with lymphoma before R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy: screen all patients for hepatitis B surface antigen (HBsAg; Screen-All), screen patients identified as being at high risk for HBV infection (Screen-HR), and screen no one (Screen-None). Patients testing positive were administered antiviral therapy until 6 months after completion of chemotherapy. Those not screened were initiated on antiviral therapy only if HBV hepatitis occurred. Probabilities of HBV and lymphoma outcomes were derived from systematic literature review. A third-party payer perspective was adopted, costs were expressed in 2011 Canadian dollars, and a 1-year time horizon was used. Results Screen-All was the dominant strategy. It was least costly at $32,589, compared with $32,598 for Screen-HR and $32,657 for Screen-None. It was also associated with the highest 1-year survival rate at 84.99%, compared with 84.96% for Screen-HR and 84.86% for Screen-None. The analysis was sensitive to the prevalence of HBsAg positivity in the low-risk population, with Screen-HR becoming least costly when this value was ≤ 0.20%. Conclusion In patients receiving R-CHOP for lymphoma, screening all patients for HBV reduces the rate of HBV reactivation (10-fold) and is less costly than screening only high-risk patients or screening no patients.
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Affiliation(s)
- Urszula Zurawska
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Lisa K. Hicks
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Gloria Woo
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Chaim M. Bell
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Murray Krahn
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Kelvin K. Chan
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
| | - Jordan J. Feld
- Urszula Zurawska, Lisa K. Hicks, Gloria Woo, Chaim M. Bell, Kelvin K. Chan and Jordan J. Feld, University of Toronto; Lisa K. Hicks and Chaim M. Bell, St Michael's Hospital; and Kelvin K. Chan, Princess Margaret Hospital and Sunnybrook Odette Cancer Centre; Lisa K. Hicks and Chaim M. Bell, Keenan Research Centre, Li Ka Shing Knowledge Institute; Gloria Woo and Murray Krahn, Toronto Health Economics and Technology Assessment; Jordan J. Feld, Toronto Western Hospital Sandra Rotman Centre for Global Health,
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Moayedi Y, Venos ES, Ghaffar H, Gough KA, Hicks LK. Paying more than lip service to an oral lesion: a case of plasmablastic lymphoma. BMJ Case Rep 2012; 2012:bcr-2012-006452. [PMID: 22802569 DOI: 10.1136/bcr-2012-006452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Plasmablastic lymphoma (PBL) is a variant of lymphoma originally described in the oral cavity of patients with advanced HIV. Our patient developed PBL despite well-controlled HIV and a CD4 count greater than 800 cells/µl. A drug interaction with an inhaled corticosteroid and ritonavir likely contributed to the development of this malignancy through increased immune suppression.
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Affiliation(s)
- Yasbanoo Moayedi
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Ezzat HM, Cheung MC, Hicks LK, Boro J, Montaner JSG, Lima VD, Harris M, Leitch HA. Incidence, predictors and significance of severe toxicity in patients with human immunodeficiency virus-associated Hodgkin lymphoma. Leuk Lymphoma 2012; 53:2390-6. [DOI: 10.3109/10428194.2012.697560] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Lee R, Vu K, Bell CM, Hicks LK. Screening for hepatitis B surface antigen before chemotherapy: current practice and opportunities for improvement. ACTA ACUST UNITED AC 2011; 17:32-8. [PMID: 21151407 DOI: 10.3747/co.v17i6.653] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Hepatitis B virus (hbv) reactivation is a recognized complication of chemotherapy. The U.S. Centers for Disease Control and Prevention recommend that all patients be screened for the hbv surface antigen (hbsag) before chemotherapy. We sought to determine the frequency of hbsag testing before chemotherapy at our hospital and to increase the frequency of testing to more than 90% of patients starting chemotherapy. METHODS Using a retrospective electronic chart review, we identified the frequency of hbsag testing for patients initiated on intravenous chemotherapy at out institution between March 2006 and March 2007. The frequency of left ventricular function testing in the subgroup of patients receiving potentially cardiotoxic chemotherapy was identified as a comparator. An educational intervention was developed and delivered to the multidisciplinary oncology team. The frequency of hbsag testing was determined post intervention. Qualitative interviews were conducted with the members of the oncology team to identify risk perception and barriers to testing. RESULTS Of 208 patients started on intravenous chemotherapy between March 2006 and March 2007, only 28 (14%) were tested for hbsag. All 138 patients scheduled for cardiotoxic chemotherapy (100%) underwent left ventricular function testing. In the post-intervention phase, of 74 patients started on intravenous chemotherapy, 24 (31%) underwent hbsag testing, with 1 patient testing positive. CONCLUSIONS The frequency of testing for hbsag before chemotherapy was very low at our institution. An educational intervention resulted in only a modest improvement. Potential barriers to routine screening include lack of awareness about existing guidelines, controversy about the evidence that supports hbsag testing guidelines, and a perception by physicians that hbv reactivation does not occur with solid tumours.
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Affiliation(s)
- R Lee
- Department of Medicine, University of Toronto, Toronto, ON
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Cheung MC, Hicks LK, Leitch HA. Excessive Neurotoxicity With ABVD When Combined With Protease Inhibitor–Based Antiretroviral Therapy in the Treatment of AIDS-Related Hodgkin Lymphoma. Clinical Lymphoma Myeloma and Leukemia 2010; 10:E22-5. [DOI: 10.3816/clml.2010.n.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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