Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus: a retrospective analysis

BACKGROUND

 Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE).

METHODS

 This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval.

RESULTS

 In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 - 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 - 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 - 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 - 29 months) than the recommended interval.

CONCLUSION

 Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Abstract P3-05-10: Impact of neoadjuvant systemic therapy on sTIL in breast cancer

Background

Multiple studies have shown a correlation between the presence of stromal tumor infiltrating lymphocytes (sTIL) and breast cancer outcomes. Higher sTIL are associated with higher rates of pCR, DFS, and OS. These findings have been primarily observed in TNBC and in HER2+ rather than in HR+, which overall has lower sTIL. Despite this growing body of prognostic evidence, there is little data comparing sTIL at diagnosis to sTIL after neoadjuvant systemic treatment. Understanding the impact of treatment on sTIL may lead to novel techniques to increase host immune response in the tumor microenvironment. The objective of this study was to correlate sTIL in paired samples before and after standard neoadjuvant systemic therapy, and then to identify the direction and magnitude of change in sTIL along with any associated features.

Methods

Institutional pathology database was queried for invasive breast carcinoma with “yp” in staging designation. From July 2013 to September 2016, there were 122 cases identified. When cases were excluded due to unavailable biopsy slides, there were 61 cases remaining. Needle biopsy and finalsurgical specimens were evaluated using International TIL Working Group 2014 guidelines and reported as a whole number percentage. In specimens with pCR, where there are no applicable guidelines, sTIL were determined by estimating the lymphoplasmacytic infiltrate in the tumor bed. Additional information gathered from the electronic medical record included patient age, clinical TNM stage, breast cancer subtype (HR+, HER2+, TNBC), neoadjuvant systemic therapy regimen (anthracycline, nonanthracycline, Trastuzumab-containing, endocrine), and response to treatment (pCR, residual invasive disease). A negative binomial generalized linear mixed model was used for analysis.

Results

Overall the sTIL declined from biopsy to surgery by about 36% (β = -0.448, S.E. = 0.223, pvalue = 0.045). However, there were 19/61 patients who had an increase in sTIL with neoadjuvant systemic therapy. For this group, the mean biopsy sTIL was 9.7% while the mean surgery sTIL was 28.7%, significantly higher than the mean biopsy (p-value &lt; 0.001). This group was not associated with age, stage, breast cancer subtype, or regimen. We examined our results in the 37/61 patients who did not achieve pCR. In all breast cancer subtypes, this group had an increase from biopsy to surgery in sTIL, with no significant difference between treatment regimens. Increasing age was significantly associated with lower sTIL in both biopsy and surgery specimens (p-value = 0.033). For every decade increase in age, sTIL decreased by about 37%.

Discussion

Overall the sTIL declined from biopsy to surgery. In the group of patients with an increase in sTIL, there was no significant correlation with systemic treatment regimen. There was a nonsignificant trend towards increasing sTIL and residual disease at surgery. We hypothesize that the host immune response declined after tumor eradication in pCR and remained active when residual disease was present. Increasing age was significantly associated with lower sTIL. Further work to identify additional factors associated with sTIL is needed to guide efforts to alter the immune response for improved breast cancer outcomes.

Citation Format: Armaghani A, Asirvatham R, Mramba L, Daily K. Impact of neoadjuvant systemic therapy on sTIL in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-10.

Characteristics of circulating tumor cells in newly diagnosed metastatic pancreatic adenocarcinoma

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Background: Circulating tumor cells (CTCs) represent real time dissemination of solid tumors. Historically, CTC enumeration has been challenging to perform successfully in pancreatic cancer (PCa). Using a previously published microfluidic device designed to increase cell capture, we analyzed CTC characteristics in a cohort of newly diagnosed patients with metastatic PCa. Methods: After provision of informed consent, blood samples (7-10mL) were collected within 1 month of treatment initiation. Specimens were processed within 6 hours of collection. A UF developed microfluidic device was used to capture and identify EpCam+ CTCs. Isolated cells were verified as CTCs consistent with FDA-approved definitions (cytokeratin+, DAPI+, CD45-). Statistical analysis was performed using Scheffe’s method along with analysis of variance to test interactions between the clinical demographics and groups. The study was approved by the UF IRB. Results: A cohort of 27 patients had CTC determination at treatment onset with multi-agent chemotherapy for metastatic PCa. Cohort characteristics included: median age 65 (range 29-76), 63% male, 92% white, 85% with intact primary pancreatic tumor, pancreatic tumor location: head (n = 12), body (n = 5), tail (n = 6), number of sites of metastasis: 1 (n = 18), 2 (n = 7), 3 (n = 2), and median albumin 3.9 g/dl. Median CTC for the entire cohort was 7/mL of blood (range 2-12). CTCs were detected and quantified in all patients analyzed. In those with intact primary tumors, there were no significant differences in CTCs based on age (≥65), sex, albumin (≥3.5 g/dl), or number of metastatic organ sites (1, 2, or 3). However, primary tumor location in the head vs. tail was different (mean 7.7 vs. 4.3/mL; p = 0.02; CI -5.78 – [-] 0.41). Conclusions: This analysis demonstrates the feasibility of measuring CTCs in patients with metastatic PCa. CTC amount does not appear impacted by systemic tumor burden or demographic differences. However, anatomic differences in primary tumor location may be important in CTC studies. Further analysis of a larger and more diverse patient data set is planned.

A growth reference for mid upper arm circumference for age among school age children and adolescents, and validation for mortality: growth curve construction and longitudinal cohort study

Objectives To construct growth curves for mid-upper-arm circumference (MUAC)-for-age z score for 5-19 year olds that accord with the World Health Organization growth standards, and to evaluate their discriminatory performance for subsequent mortality.Design Growth curve construction and longitudinal cohort study.Setting United States and international growth data, and cohorts in Kenya, Uganda, and Zimbabwe.Participants The Health Examination Survey (HES)/National Health and Nutrition Examination Survey (NHANES) US population datasets (age 5-25 years), which were used to construct the 2007 WHO growth reference for body mass index in this age group, were merged with an imputed dataset matching the distribution of the WHO 2006 growth standards age 2-6 years. Validation data were from 685 HIV infected children aged 5-17 years participating in the Antiretroviral Research for Watoto (ARROW) trial in Uganda and Zimbabwe; and 1741 children aged 5-13 years discharged from a rural Kenyan hospital (3.8% HIV infected). Both cohorts were followed-up for survival during one year.Main outcome measures Concordance with WHO 2006 growth standards at age 60 months and survival during one year according to MUAC-for-age and body mass index-for-age z scores.Results The new growth curves transitioned smoothly with WHO growth standards at age 5 years. MUAC-for-age z scores of -2 to -3 and less than-3, compared with -2 or more, was associated with hazard ratios for death within one year of 3.63 (95% confidence interval 0.90 to 14.7; P=0.07) and 11.1 (3.40 to 36.0; P<0.001), respectively, among ARROW trial participants; and 2.22 (1.01 to 4.9; P=0.04) and 5.15 (2.49 to 10.7; P<0.001), respectively, among Kenyan children after discharge from hospital. The AUCs for MUAC-for-age and body mass index-for-age z scores for discriminating subsequent mortality were 0.81 (95% confidence interval 0.70 to 0.92) and 0.75 (0.63 to 0.86) in the ARROW trial (absolute difference 0.06, 95% confidence interval -0.032 to 0.16; P=0.2) and 0.73 (0.65 to 0.80) and 0.58 (0.49 to 0.67), respectively, in Kenya (absolute difference in AUC 0.15, 0.07 to 0.23; P=0.0002).Conclusions The MUAC-for-age z score is at least as effective as the body mass index-for-age z score for assessing mortality risks associated with undernutrition among African school aged children and adolescents. MUAC can provide simplified screening and diagnosis within nutrition and HIV programmes, and in research.

"When you give birth you will not be without your mother" A mixed methods study of advice on breastfeeding for first-time mothers in rural coastal Kenya

Background

Exclusive breastfeeding for the first 6 months of life is currently recommended by the World Health Organization, but mixed feeding earlier than this commonly occurs in rural coastal Kenya. Mothers may receive conflicting advice on breastfeeding from various sources including health workers, relatives and community members. We aimed to find out how first-time mothers learn to breastfeed, who advises them on infant feeding and what advice they obtain in case of any breastfeeding problems.

Methods

To identify advisers, a questionnaire on socio-demographic status, place of delivery, household members, education and help received on breastfeeding, breastfeeding problems, name of advisers and their relationship to the mothers was administered to 50 new first-time mothers in Jaribuni, Kilifi (population approximately 18,000). Summary statistics were obtained using frequencies, medians and interquartile ranges (IQR). Focus group discussions (FGDs) were held amongst 4 groups of mothers who had answered questionnaires; 4 groups of their named advisers; and 1 group of community health workers in order to explore breastfeeding practices, problems and advice given. FGDs were analysed by thematic framework analysis.

Results

First-time mothers were young (median age 18, IQR 17–21, range 14–26 years) and 42 % were single. Living in extended families was the norm and married women lived with their husband’s family. All had a female family member or neighbour helping with childcare in the perinatal period. The main advisers on breastfeeding were their mother or older female members of their husband’s family. Married first-time mothers felt obliged to follow their mother-in-law’s advice to maintain good relationships and show respect within the household. Breastfeeding problems were reported by 80 % of respondents. Nipple pain (56 %) was the most reported problem, then breast engorgement (48 %) and insufficient milk supply (38 %). Most problems were treated at home without consultation with health workers. Concerns were raised about co-sleeping, breastfeeding whilst lying down, and insufficient milk supply. Advisers would like more information on breastfeeding in order to help mothers.

Conclusions

Interventions to increase knowledge of, and facilitate optimal breastfeeding practices in first-time mothers should include those family members who advise and assist with childcare around the time of delivery.

Electronic supplementary material

The online version of this article (doi:10.1186/s13006-016-0069-6) contains supplementary material, which is available to authorized users.