Chemotherapy Treatment Plans Research Articles

Photobiomodulation in the treatment of palmar–plantar erythrodysesthesia: a randomised controlled clinical study protocol

IntroductionHand–foot syndrome, also known as palmar–plantar erythrodysesthesia (PPE), is a complication caused by chemotherapy. Clinically, it manifests as erythema and oedema on the palms of the hands and feet, dry...

Personalized Versus Precision Nanomedicine for Treatment of Ovarian Cancer.

The response to treatment is substantially varied between individual patients with ovarian cancer. However, chemotherapy treatment plans rarely pay sufficient attention to the mentioned factors. Instead, standardized treatment protocols are usually employed for most ovarian cancer patients. Variations in an individual's sensitivity to drugs significantly limit the effectiveness of treatment in some patients and lead to severe toxicities in others. In the present investigation, a nanotechnology-based approach for personalized treatment of ovarian carcinoma (the most lethal type of gynecological cancer) constructed on the individual genetic profile of the patient's tumor is developed and validated. The expression of predefined genes and proteins is analyzed for each patient sample. Finally, a mixture of the complex nanocarrier-based targeted delivery system containing drug(s)/siRNA(s)/targeted peptide is selected from the pre-synthesized bank and tested in vivo on murine cancer model using cancer cells isolated from tumors of each patient. Based on the results of the present study, an innovative approach and protocol for personalized treatment of ovarian cancer are suggested and evaluated. The results of the present study clearly show the advantages and perspectives of the proposed individual treatment approach.

PATH-26. A RARE CASE OF EXOPHYTIC PILOCYTIC ASTROCYTOMA DIAGNOSED VIA MOLECULAR TESTING

Abstract INTRODUCTION Pilocytic astrocytoma (PA) is a WHO grade 1 neoplasm that can share histological and radiological features with more malignant entities, including high grade astrocytoma with piloid features. In cases where the differential remains broad after histopathological examination, DNA methylation analysis and next generation sequencing can contribute significantly to making an accurate diagnosis. Machine learning has also played a role in developing multiple classifying algorithms which group tumors by their methylation status. CASE We report a case of an exophytic left frontal mass with adjacent bone erosion that preoperatively was favored to be a meningioma. Intraoperatively, the mass was found to be cortically based. With histopathologic review at two centers, the diagnosis remained IDH wildtype low-grade glioma not otherwise specified. The clinical treatment team interpreted the post-operative increase in T2 signal as radiographic progression consistent with high grade glioma and planned to proceed with chemoradiation. Patient elected for further evaluation; methylation array profiling and next generation sequencing identified a KIAA1549::BRAF fusion, consistent with a final diagnosis of pilocytic astrocytoma, a WHO Grade 1 Glioma. Given the favorable prognosis following gross total resection, the patient was recommended active surveillance and radiation and chemotherapy treatment planning was stopped. DISCUSSION This is a rare case of an exophytic pilocytic astrocytoma in which the tumor’s atypical histologic and radiographic appearance increased the likelihood of diagnostic errors. This case illustrates the clinical importance of utilizing methylation array profiling and next-generation sequencing to confirm a diagnosis.

Chemo-Toxicity Calculator use in shared decision-making for chemotherapy treatment planning.

403 Background: Chemotherapy related symptoms and toxicities are frequent among cancer patients, especially those ≥ 65 years old. These symptoms and toxicities can contribute to patients having a decreased quality of life and unmet treatment outcomes. The modified CARG, Chemo-Toxicity Calculator, is an assessment of function, comorbidity, cognition, psychological state, social activity/support and nutrition. The goal of using the calculator, was to improve shared decision-making between the physician, patient and caregiver. Discussions focused on treatment, modifying treatment regimens and other alternatives such as palliative or hospice. Methods: Rocky Mountain Cancer Centers introduced the modified CARG, Chemo-Toxicity Calculator, in 2022 as part of cancer patient workflow for 10 physicians. In 2022, 156 patients completed the Chemo-Toxicity Calculator to identify and predict the risk of initiation or continuation of chemotherapy treatment in patients ≥ 65 years old. Using the CARG assessment allowed the physician and patient to have open discussions about the pros and cons of initiation or continuation of chemotherapy treatment or if they should pursue alternative treatment. 27 of these patients (17.3%) elected to receive hospice care in lieu of traditional treatment. The Chemo-Toxicity Calculator link was added in the electronic health record (EHR) for access at the point of care. Process: 1. Review patients at the time of initial treatment and subsequent lines of therapy. 2. CARG assessment completed for patients ≥ 65 years old. 3. Shared decision-making discussion including the voice of the patient. 4. Psychosocial interventions and care coordination. Results: As of May 2023,10 providers administered the modified CARG assessment on 244 patients. The tool identified patients that would not benefit from treatment and instances where cycle one dose reduction would be appropriate to reduce toxicity risk. Of the 244 patients who completed the assessment, 47 (19.2%) elected alternative treatment. Conclusions: The Chemo-Toxicity Calculator is a functional, practical first step toward the inclusion of a geriatric assessment for all patients ≥ 65 years old. Patients understand it, and it sets the stage for shared decision-making discussions. This valued intervention aids subsequent discussions about dose reduction and ongoing risks of treatment. Actions taken based on the results of the Chemo-Toxicity Calculator, reduced toxicity by dose reductions and helped patients choose an alternative to chemotherapy.

Standardization of pregnancy screening prior to chemotherapy: A quality improvement project.

467 Background: Administering chemotherapy during pregnancy is considered a serious adverse event, especially during the first trimester. NCCN and QOPI Certification program standards require assessing and documenting pregnancy status for women of childbearing age before first administration of a new chemotherapy regimen. However, guidelines and policies lack standardization on patient selection. We aimed to understand and address barriers to pregnancy testing prior to initiation of chemotherapy at a large regional cancer center. Methods: An institutional guideline was developed recommending a qualitative serum beta hCG test prior to each chemotherapy cycle (21 days apart) for females55 years with an intact uterus and ovaries who are not postmenopausal. A retrospective systematic sample between 1/2022 and 6/2022 demonstrated that 17% (5/30) of eligible patients underwent pregnancy testing within 7 days of starting chemotherapy. Staff education was sent out 08/2022 to multidisciplinary team members. An automated nudge in the electronic health record (EHR, Epic) was added to prompt guideline concordant pregnancy testing at the time of chemotherapy treatment plan ordering. The EHR was set to assess guideline parameters and automatically add pregnancy testing to the labs section of each cycle if criteria met. A systematic sample of 20 eligible patients was assessed monthly for compliance. Results: Among 20 assessed eligible patients per month, an average of 16 pregnancy tests were administered, an increase from baseline 17% compliance to 80% sustained over a 8 month period. Of the 160 cases abstracted, no pregnancies were detected. Conclusions: Electronic health record nudge in conjunction with institutional guideline and education, led to an increase in appropriate pregnancy testing prior to initiation of chemotherapy. The Quality Department will continue with Pregnancy Testing audits quarterly as a quality assurance activity, and rates of compliance will continue to be reported through the Hem/Onc Quality Committee. This approach demonstrates feasibility of achieving NCCN and QOPI standards while tailoring the intervention to patients of childbearing potential.[Table: see text]

Correlation between Lymph Node Regression Grading and Tumor Regression Grading after Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer

This study aimed to determine the relationship between tumor regression grading (TRG) and lymph node regression grading (LRG) after neoadjuvant chemoradiotherapy (nCRT) for locally advanced rectal cancer (LARC). The study was a retrospective analysis of the clinical data of LARC patients who underwent preoperative nCRT at one institution. A total of 101 rectal cancer patients who received nCRT and underwent total rectal mesenteric excision (TME) were included. Pathologists independently assessed the pathological response of the primary tumor and lymph nodes (LN) to nCRT using TRG and LRG, respectively. The highest LRG score for each patient was defined as LRGmax, and LRGsum was the overall tumor burden of all LNs in the specimen. The study included 101 LARC patients who underwent nCRT and TME. The patient population consisted of 65 males and 36 females with an average age of 54.86 years (range 20-81 years), of which 68 were aged 60 years or younger and 33 were older than 60. The radiotherapy treatment plan consisted of 1.8-2Gy per dose, administered 5 times per week for a total dose of 45-50.4Gy, along with oral capecitabine chemotherapy (825 mg/m2, bid) on the day of radiation therapy. The chemotherapy treatment plan included XELOX, mFOLFOX6, and FOLFOX4. The cTNM stage of the tumor before surgery was cT2 in 2 cases, cT3 in 63 cases, and cT4 in 36 cases. Eight cases were cN0 and 93 were cN+. After surgery, the ypTNM stage was T0 in 19 cases, T1 in 4 cases, T2 in 27 cases, T3 in 45 cases, and T4 in 6 cases. The N stage was N0 in 76 cases, N1 in 20 cases, and N2 in 5 cases. TRG was 0 in 17 cases (16.8%), 1 in 15 cases (14.9%), 2 in 61 cases (60.4%), and 3 in 8 cases (7.9%). LRGmax scores were 0 in 66 cases (65.3%), 1 in 17 cases (16.8%), 2 in 5 cases (5.0%), 3 in 3 cases (3.0%), 4 in 5 cases (5.0%), and 5 in 5 cases (5.0%). LRGsum scores were ≤3 in 85 cases (84.2%), 4-9 in 11 cases (10.9%), and ≥10 in 5 cases (5.0%). Correlation analysis showed that LRGmax was significantly correlated with TRG, ypT, and ypN (P = 0.038, P = 0.015, P < 0.01), with correlation coefficients of 0.184, 0.212, and 0.626, respectively. There was no significant correlation between LRGmax and cT and cN+. Similarly, LRGsum was significantly correlated with TRG, ypT, and ypN (P = 0.022, P = 0.002, P < 0.01) with correlation coefficients of 0.212, 0.276, and 0.707, respectively. There was no significant correlation between LRGsum and cT and cN. The results of our study indicate a significant correlation between LRG and TRG (P = 0.022). Additionally, LRG was found to be positively correlated with the ypT and ypN stages of the primary tumor and lymph nodes post-surgery, with correlation coefficients of 0.276 and 0.707, respectively (P = 0.002 and P<0.01). No significant correlations were observed between LRG and cT and cN+ stages. Our findings demonstrate a significant association between LRG and TRG, as well as a positive correlation between LRG and the ypT and ypN stages of the primary tumor and lymph nodes following surgery.

Standardization of pregnancy screening prior to chemotherapy: A quality improvement project.

e18702 Background: Administering chemotherapy during pregnancy is considered a serious adverse event, especially during the first trimester. NCCN and QOPI Certification program standards require assessing and documenting pregnancy status for women of childbearing age before first administration of a new chemotherapy regimen. However, guidelines and policies lack standardization on patient selection. We aimed to understand and address barriers to pregnancy testing prior to initiation of chemotherapy at a large regional cancer center. Methods: An institutional guideline was developed recommending a qualitative serum beta hCG test prior to each chemotherapy cycle (≥21 days apart) for females ≤ 55 years with an intact uterus and ovaries who are not postmenopausal. A retrospective chart review between 1/2022 and 6/2022 using systematic sampling and the above algorithm revealed a baseline compliance of 17% (5/30) of patients undergoing a pregnancy test within 7 days of starting chemotherapy. In an effort to improve compliance, the guideline and educational email was sent out 08/2022 to medical oncologists, nurse educators, nurse navigators, and pharmacists. An automated nudge in the electronic health record (Epic) was added to prompt guideline concordant pregnancy testing at the time of chemotherapy treatment plan ordering. Assessments were conducted at the end of each month by systematic sampling of 20 eligible patients. Compliance was determined according to institutional guideline. Results: Among 20 assessed eligible patients per month, an average of 15.75 pregnancy tests were administered, an increase from baseline 17% compliance to 76% sustained over a 5 month period. Of the 100 cases abstracted, no pregnancies were detected. Conclusions: Electronic health record nudge in conjunction with institutional guideline and education, led to an increase in appropriate pregnancy testing prior to initiation of chemotherapy. This approach demonstrates feasibility of achieving NCCN and QOPI standards while tailoring the intervention to patients of childbearing potential. [Table: see text]

Development and validation of prognostic models for colon adenocarcinoma based on combined immune-and metabolism-related genes.

The heterogeneity of tumor tissue is one of the reasons for the poor effect of tumor treatment, which is mainly affected by the tumor immune microenvironment and metabolic reprogramming. But more research is needed to find out how the tumor microenvironment (TME) and metabolic features of colon adenocarcinoma (COAD) are related. We obtained the transcriptomic and clinical data information of COAD patients from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) databases. Consensus clustering analysis was used to identify different molecular subtypes, identify differentially expressed genes (DEGs) associated with immune-and metabolism-related genes (IMRGs) prognosis. Univariate and multivariable Cox regression analysis and Lasso regression analysis were applied to construct the prognostic models based on the IMRG risk score. The correlations between risk scores and TME, immune cell infiltration, and immune checkpoint genes were investigated. Lastly, potential appropriate drugs related to the risk score were screened by drug sensitivity analysis. By consensus clustering analysis, we identified two distinct molecular subtypes. It was also found that the multilayered IMRG subtypes were associated with the patient's clinicopathological characteristics, prognosis, and TME cell infiltration characteristics. Meanwhile, a prognostic model based on the risk score of IMRGs was constructed and its predictive power was verified internally and externally. Clinicopathological analysis and nomogram give it better clinical guidance. The IMRG risk score plays a key role in immune microenvironment infiltration. Patients in the high-risk groups of microsatellite instability (MSI) and tumor mutational burden (TMB) were found to, although with poor prognosis, actively respond to immunotherapy. Furthermore, IMRG risk scores were significantly associated with immune checkpoint gene expression. The potential drug sensitivity study helps come up with and choose a chemotherapy treatment plan. Our comprehensive analysis of IMRG signatures revealed a broad range of regulatory mechanisms affecting the tumor immune microenvironment (TIME), immune landscape, clinicopathological features, and prognosis. And to explore the potential drugs for immunotherapy. It will help to better understand the molecular mechanisms of COAD and provide new directions for disease treatment.

The impact of COVID-19 on autologous stem cell transplantation in multiple myeloma: A single-centre, qualitative evaluation study

Autologous stem cell transplantation (ASCT) is standard of care in biologically fit, newly diagnosed multiple myeloma (MM) patients, offering better therapeutic outcomes and improved quality of life (QoL). However, with the UK’s 1st national lockdown on 23/03/2020, several guidelines recommended deferring ASCT due to risks of infection, with resource limitations forcing some units to suspend ASCT entirely. Such changes to patients’ treatment plans inevitably altered their lived experience during these uncertain times with expected impact on QoL. We conducted a qualitative study using semi-structured interviews to gain insight into MM patients’ understanding of their disease, initial therapy and ASCT, and their response to therapy changes. A clinical snapshot of how COVID-19 affected the MM ASCT service in a single UK institution is also provided, including changes to chemotherapy treatment plans, timing, and prioritisation of ASCT. Framework analysis identified 6 overarching themes: (1) beliefs about ASCT, (2) perceptions of information provided about MM and ASCT, (3) high levels of fear and anxiety due to COVID-19, (4) feelings about ASCT disruption or delay due to COVID-19, (5) perceptions of care, and (6) importance of social support. Example subthemes were beliefs that ASCT would provide a long-remission/best chance of normality including freedom from chemotherapy and associated side-effects, disappointment, and devastation at COVID-related treatment delays (despite high anxiety about infection) and exceptionally high levels of trust in the transplant team. Such insights will help us adjust our service and counselling approaches to be more in tune with patients’ priorities and expectations.

HGG-38. Gliomatosis cerebri/Glioblastoma with discordant histological and molecular profiles - treatment and outcome of a pediatric patient

Gliomatosis cerebri is no longer recognized as a distinctive pathological diagnosis, but a manifestation of diffuse glioma involving at least three cerebral lobes. Lack of understanding in this manifestation of CNS neoplasms limits treatment for this aggressive disease. Here we present a case of stabilization of disease in a pediatric patient with unusual molecular profiles normally associated with aggressive tumor behavior. A nine-year-old male presented with acute onset of right-sided vision changes, headache and numbness of the left arm and leg for one day. He also had a three-month history of an asymptomatic bump on the right temporal skull bone. MRI of the brain was significant for diffuse thickening of the cortex of the entire right hemisphere (temporal>frontal>parietal lobes). No specific enhancing lesion or restricted diffusion was noted. Histologically, the tissue had findings of diffuse low-grade astrocytoma. Molecular genetic testing was notable for TERT and EGFR mutations which are more consistent with adult type high-grade astrocytic tumors. MGMT promoter methylation array was negative. Final diagnosis was glioblastoma, IDH and H3 wildtype. All the molecular features of this tumor were high-grade with an average progression free survival of less than 12 months. Despite the lack of methylation, we opted to include alkylating agents in a maintenance chemotherapy treatment plan following radiation therapy with concurrent temozolomide. Despite poor prognostic factors, the patient is alive without signs of progression 2.5 years post-diagnosis. Targeted agents were not used in upfront treatment for this patient. This is a rare case of stabilization of disease with conventional treatment in a very aggressive tumor. This case is a rare constellation of an ‘adult-type’ molecular profile in a pediatric patient with a low grade, less aggressive behavior profile, and highlights the need to better understand this rare subtype of tumors in children.

Results of an online, globally-available survey to determine modes of cancer treatment education used by patients with cancer.

e18523 Background: Many patients with cancer (PwC) possess a suboptimal understanding of their chemotherapy treatment plan.1 Accordingly, PwC may seek information regarding both the disease and its treatment from other resources. Purpose: A freely-accessible website was curated by oncology pharmacists to provide evidence-based educational material on chemotherapy treatment plans. Objective: To use the website to deploy an online survey assessing other modes of education routinely accessed by PwC. Methods: Between February 2020 and January 2021, PwC completed an anonymous, English language survey via www.chemoexperts.com. Results: A total of 1,036 self-identified patient users began the survey. The majority were from North America (75%). Most respondents (65%) were female. PwC were asked: “If you received education from a health care professional (HCP), what type of education did you receive?” Multiple responses were allowed. Of the 820 patients who responded to this question, 77.4% (n = 635) were given printed material, 52.3% (n = 429) were taught in clinic, 8% (n = 66) were shown videos, 5.7% (n = 47) participated in an educational class outside of clinic, and 4% (n = 33) were given magazines. Roughly 37% were directed to an internet site (n = 304; 92 to chemoexperts.com, 212 to other internet sites) by a HCP. Patients also reported using blogs (12.7%; n = 111/873 respondents), websites other than chemoexperts (85%; n = 742/873), support groups (28.4%; n = 248/873), and YouTube (15.1%; n = 132/873). Discussion: In-person teaching sessions are vital to understanding treatment plans. While the ongoing COVID-19 pandemic may have lowered the percentage of PwC who are offered teaching, some PwC may still not absorb or retain all there is to know during in-person sessions and seek other resources to bolster their understanding of treatment. Although the majority of users reported receiving printed material, this too may be limited in its ability to meet the needs of all individuals. Knowing PwC may seek varying modes of education, HCPs should direct patients to resources they are familiar with. Conclusions: To our knowledge, this is the first global survey to examine modes of education utilized by PwC. Although PwC may receive teaching in person, many still seek a variety of educational resources outside of clinic. Relying solely on printed material will not meet the needs of some PwC. When educating PwC in clinic, HCPs concerned about the validity of outside materials should direct patients to resources they are familiar with and trust. Reference: Almalki H, Absi A, Alghamdi A, Alsalmi M, Khan M. Analysis of Patient-Physician Concordance in the Understanding of Chemotherapy Treatment Plans Among Patients With Cancer. JAMA Netw Open. 2020 Mar 2;3(3):e200341.

Impact of preauthorization review on oncology drug and radiation costs.

e18829 Background: Preauthorization review (PR) is designed to ensure that patients receive evidence-based medicine (EBM) treatment but also affects costs. We estimated changes in chemotherapy and radiation costs when PR found treatments to deviate from EBM. Methods: We identified chemotherapy and radiation treatment plans reviewed by Eviti Connect in 2020 found to contain medically unjustified deviations from EBM after a request for peer-to-peer discussion. We calculated the cost difference in antineoplastic and supportive drugs and radiation procedures between deviating plans and any approved replacements. We assumed completion of curative drug regimens and 4 months duration for non-curative treatments. Results: We report net change in treatment costs for all patients with plans reviewed. Of 13,370 patients with reviewed plans, 1-4 deviating plans were identified for 1899 patients (14.2%), or 2160 deviating plans. Mean savings were $38,242 (95%CI $35,354 - $41,118) per patient with a deviating plan, $33,097 (95%CI $30,851- $35,343) per deviating plan, and $5,348 per patient with a plan reviewed. Inflation-adjusted per patient savings were 27% greater than we reported in 2012. Total savings were $71,497,374. Applying these results to a covered population of 1 million, assuming 0.3% undergo PR annually, would save $16,041,000. Provider appeals were submitted for 2.2% of cases found deviating and 0.3% were upheld. Conclusions: PR directly ensures EBM cancer care by identifying deviating treatments and reduces treatment costs. This analysis likely underestimates realized savings because it includes only drug and radiation procedure costs; noncurative treatments often extend beyond 4 months; and provider experience with PR may deter submitting treatments previously determined to be deviating.

ESyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems.

Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available. As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes. eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts. eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

Search for ways to improve the effectiveness of treatment of pulmonary tuberculosis patients with multiple resistance of mycobacterium tuberculosis to anti-tuberculosis drugs

Aim. To conduct a comparative study of the effectiveness of treatment of MDR-TB patients by using short-term and individual chemotherapy regimens and including the drug Cholecalciferol in the treatment complex.Material and methods. The group of MDR-TB patients with a short-term treatment regimen included 40 patients, and 40 patients were included in the group of MDR-TB patients with an individual treatment regimen. Both observation groups were divided into two subgroups of patients with MDR-TB of the lungs (20 people from each group). In one group treatment included Cholecalciferol 300,000 U intramuscularly weekly (6-8 times in total) in the complex of the above treatment; comparison groups: patients with MDR-TB of the lungs (20 people from each group) received a complex of the above chemotherapy without the drug Cholecalciferol.Results. In the group of patients with the inclusion of Cholecalciferol in a short-term treatment regimen, a favorable treatment outcome was noted in 100% of cases, while in the group of patients without Cholicalciferol - in 80% of cases. With an individual treatment regimen in the group of patients with the inclusion of Cholecalciferol, conversion by sputum culture also occurred in 100% of cases, while in the group of patients without Cholicalciferol - in 70% of patients.Conclusion. Thus, the introduction of a new short-term chemotherapy regimen for MDR-TB patients has increased the effectiveness of their treatment. In two subgroups of MDR-TB patients with different chemotherapy regimens, who received injections of Cholecalciferol in the chemotherapy treatment plan, the effectiveness of treatment based on the results of the timing of the development of conversion by sputum culture was assessed as significantly higher than in the subgroups that did not receive vitamin D3.

Local Recurrence of Primary Cardiac Leiomyosarcoma After Resection: A Rare Case

Introduction: Leiomyosarcoma (LMS) is a fatal tumor, though primary cardiac is very rarely encountered. In this report, we evaluated the surgical and medical management of primary cardiac LMS, which is a sporadic tumor.Case Presentation: A 60-year-old female patient was examined for pulmonary edema after penicillin allergy in May 2019, while transthoracic echocardiography (ECHO) revealed an appearance compatible with a 5x3.5 cm mass in the right atrium. In addition, transesophageal ECHO showed a 7x4.6 cm foreground mass compatible with a myxoma in the right atrium (RA). The patient was then operated on emergency. Besides, an adjuvant ifosfamide-mesna-doxorubicine (IMA) protocol was planned to be given to the patient after local radiotherapy.Conclusions: In this report presented, we made RT and chemotherapy treatment plans in the case of recurrence without R0 surgery. Recurrence rates of up to 50% can occur in LMS, and systemic chemotherapy can be applied after relapse

An ASP-based Solution to the Chemotherapy Treatment Scheduling problem

AbstractThe problem of scheduling chemotherapy treatments in oncology clinics is a complex problem, given that the solution has to satisfy (as much as possible) several requirements such as the cyclic nature of chemotherapy treatment plans, maintaining a constant number of patients, and the availability of resources, for example, treatment time, nurses, and drugs. At the same time, realizing a satisfying schedule is of upmost importance for obtaining the best health outcomes. In this paper we first consider a specific instance of the problem which is employed in the San Martino Hospital in Genova, Italy, and present a solution to the problem based on Answer Set Programming (ASP). Then, we enrich the problem and the related ASP encoding considering further features often employed in other hospitals, desirable also in S. Martino, and/or considered in related papers. Results of an experimental analysis, conducted on the real data provided by the San Martino Hospital, show that ASP is an effective solving methodology also for this important scheduling problem.

COMBINED TREATMENT OF OPERABLE RECTAL CANCER WITH NEGATIVE PROGNOSIS FACTORS: A PROSPECTIVE STUDY

Introduction. Neoadjuvant chemotherapy (nact) is a potential alternative to chemoradiation therapy (crt) for rectal cancer and may allow early prevention of distant metastasis.Objective: to study the safety and efficacy of nact for patients with rectal cancer without damage to the mesorectal fascia.Material and methods. From 2016 to 2019, patients with cancer of the upper ampullar (сmrt2-t4an+m0, cmrt4an0m0), medium ampullar (cmrt3сn0m0, cmrt2n+m0) rectal regions were included in the pilot prospective study. All patients underwent nact according to the capox 4 scheme. Evaluation of the effect was carried out on the basis of mri of the small pelvis. In the case of regression or stabilization, surgery was performed, and in the case of progression, crt was followed by surgery. After surgery, all patients were scheduled for adjuvant chemotherapy for a total duration of 6 months. The primary endpoint was the rate of pathological complete response (mandard trg 1). Secondary endpoints included disease progression, toxicity (nci-ctc v. 5.0), postoperative complications (clavien-dindo), chemotherapy regimen, and long-term treatment outcomes.Results. 136 patients were included into the study. Of 130 (11 %) patients, who underwent only nact prior to surgery, 15 had pathological complete response. 99 patients (72.8 %) received a full course of chemotherapy for 6 months (nact + adjuvant pct). 6 (4.3 %) patients after neoadjuvant chemotherapy were treated with crt, 5 (3.67 %) of them due to local progression according to mri data, 1 (0.7 %) due to grade 3 toxicity during 1 course of pct and inability to continue chemotherapy treatment plan. Radiation therapy resulted in partial tumor regression in all patients. Systemic progression was not observed in any patient. Grade iii–iv toxicity was observed in 7 (5.1 %) patients, including bronchospasm (n=2, 1.4 %), thrombocytopenia (n=1, 0.7 %), neutropenia (n=1, 0.7 %), peripheral neuropathy (n=1, 0.7 %), cardiotoxicity (n=1, 0.7 %), diarrhea (n=1, 0.7 %). Grade v toxicity (acute myocardial infarction) was observed in 1 (0.7 %) patient. R0 resection was performed in all cases. Grade iiia postoperative complications occurred in 6 (4.4 %) patients, iiib complications in 5 (3.7 %) patients, and death due to sepsis after postoperative pneumonia in 1 (0.7 %) patient. The frequency of anastomotic leak was 3.6 % (n=5). The median follow-up was 31.4 months, the overall survival (os) and disease-free survival (dfs) rates were 94 % and 92.8 %.Conclusion. Neoadjuvant chemotherapy is a promising treatment option for rectal cancer patients with negative prognostic factors.

Multi-stage appointment scheduling for outpatient chemotherapy unit: a case study

This paper deals with a multi stage hybrid flow-shop problem (HFSP) that arises in a privately Chemotherapy clinic. It aims to optimize the makespan of the daily chemotherapy activity. Each patient must respect the cyclic nature of chemotherapy treatment plans made by his referent on- cologist while taking into account the high variability in resource requirements (treatment time, nurse time, pharmacy time). The problem requires the assignment of chemotherapy patients to oncologists, pharmacists, chemotherapy beds or chairs and nurses over a 1-day period. We provided a Mixed Integer Program (MIP) to model this issue, which can be considered as a five-stage hybrid flow-shop scheduling problem with additional resources, dedicated machines, and no-wait constraints. Since this problem is known to be NP-hard, we provided a lower bound expression and developed an approximated solving algorithm: a tabu search inspired metaheuristic based on a constructive heuristic that can quickly reach satisfying results. To assess the empirical performance of the proposed approach, we conducted experi- ments on randomly generated instances based on real-world data of a Tunisian private clinic: Clinique Ennasr. Computational experiments show the efficiency of the proposed procedures: The mathematical model provided optimal solutions in reasonable computational time only for small instances (up to 10 patients). Meta-heuristic’s results demonstrate, also, that the proposed approach offers good results in terms of solution quality and computational times with an average relative gap to the MIP solution equal to 3.13% and to the lower bound equal to 5.37% for small instances (up to 15 patients). The same gap to the lower bound increases to 25% for medium and large size instances (20–50 patients).

Design of eSyM: An ePRO-based symptom management tool fully integrated in the electronic health record (Epic) to foster patient/clinician engagement, sustainability, and clinical impact.

164 Background: Chemotherapy and surgery can cause distressing symptoms, which can be a burden for health systems to address. Programs that directly engage patients, including electronic tracking of patient-reported outcomes (ePROs), can improve symptom control and decrease the need for acute care. Previous ePRO programs have relied on third party vendors with limited EHR integration, constraining their clinical utility and scalability. An integrated solution could offer distinct advantages. Methods: As part of NCI’s Moonshot-funded IMPACT consortium, 6 health systems and Epic built an electronic symptom management program (eSyM) based on the PRO-CTCAE questionnaire that is fully integrated into the EHR. The agile, user-centered design process engaged patients, clinicians, and institutions. The core functional components include: 1) symptom surveys in the postoperative period or between chemotherapy visits, 2) self-management tip sheets, 3) clinician alerts, and 4) dashboards for population management. Critical points of integration with supporting EHR functions and workflow impacts were identified; and major challenges of integration and implementation were described. Results: eSyM, which was implemented at two health systems (Baptist Memorial in Tennessee and Mississippi and West Virginia University Health) in the fall of 2019, required multiple supporting EHR functions: 1) access a secure, HIPPA-compliant patient portal/messaging system (MyChart); 2) record diagnosis, procedure and chemotherapy treatment plan data; 3) identify target populations and track metrics/events; 4) define and execute autonomous logic-based workflow rules; 5) generate reports for clinicians/patients; and 6) documentation. Major challenges included: 1) working within pre-existing EHR system standards and capabilities, which limited the ability to customize interfaces and workflows specifically for the eSyM use case; and 2) adapting to different EHR configurations and polices across multiple health systems. Conclusions: The eSyM build leveraged many existing EHR capabilities and overcame regulatory hurdles; but it required design and workflow compromise. Integration of ePRO-based symptom management programs into the EHR could help overcome barriers, consolidate clinical workflows, and foster scalability/sustainability. Ongoing efforts include launching eSyM at four more sites and evaluating its adoption, usability, and impact on clinical outcomes.

Evaluating compliance of NCCN cancer and chemotherapy-induced anemia guidelines in a community healthcare setting.

16 Background: The National Comprehensive Cancer Network has released guidelines for management of cancer- and chemotherapy-induced anemia which are defined as Hb less than 11g/dL or a greater than 2g/dL decrease from baseline. The myelosuppressive effects of cancer, chemotherapy and associated treatments, can accumulate with each cycle leading to severe and worsening anemia. It is important to properly identify and treat anemia in cancer patients in a timely manner. This project evaluates the degree to which NCCN guidelines are followed within a multi-site community healthcare setting. Methods: Obtained patient medical records within Hartford Healthcare system in a 4 month period (Nov. 2019-Feb. 2020), who were started on new cancer chemotherapy treatment plans. Patients on single agent immunotherapy or hormone therapy only plans were excluded. Reviewed patient’s medical records to identify who met criteria for cancer- and chemotherapy-induced anemia and who received recommended work up and treatment based on NCCN guidelines. Age, sex, disease, renal function, and goals of treatment were also recorded. Results: A total of 869 patient records were obtained. 598 patients met the inclusion criteria. 452 patients (75.6%) met criteria for cancer- and chemotherapy-induced anemia. 235 patients (52%) had anemia appropriately documented in the physician medical record. 111 patients with anemia (24.6%) had an iron panel performed and 29 patients (6.4%) had a reticulocyte count resulted. For those eligible by NCCN criteria for anemia specific interventions 27 patients (40%) received appropriate iron supplementation, 95 patients (85.6%) received appropriate blood transfusions and 10 patients (7.7%) received appropriate EPO. Conclusions: It is apparent that based on NCCN guidelines, monitoring, evaluation, and treatment of anemia is not being appropriately performed in this healthcare setting. Based on this data a quality improvement project for proper documentation, workup, and treatment of anemia is being developed. [Table: see text]