Expert Treatment Recommendations Research Articles

Comparison of expert treatment recommendations versus community healthcare providers: Analysis from an online decision support tool for metastatic breast cancer.

1053 Background: Management of metastatic breast cancer (MBC) is quickly evolving. Beyond hormone receptor (HR) status, a growing list of molecular markers are used to refine individualized systemic treatment (Tx). However, the number of options increases the complexity of Tx decision-making for healthcare professionals (HCPs). Here, we report an analysis of discordance between expert Tx recommendations vs HCPs from an online Interactive Decision Support Tool (IDST). Methods: Five breast cancer experts provided Tx recommendations for 59 unique MBC case scenarios where systemic therapy was indicated. Case scenarios were defined by key characteristics, including HR status, previous Tx, prior duration of response, and actionable biomarkers. After HCPs (n = 91) selected specific patient (pt) criteria and their intended Tx, the IDST showed the breast cancer experts’ recommendations, and HCPs were then asked whether seeing the recommendations changed their intended Tx plan. Experts’ recommendations were compared with that of HCPs to assess for concordance or discordance. Results: For first-line (1L) HR+/HER2- MBC, all experts (100%) recommended endocrine therapy with CDK4/6 inhibitor vs 38% of HCPs. For 1L HER2+ MBC, 62.5% concordance was observed with HCPs selecting expert recommended docetaxel, trastuzumab, and pertuzumab (THP). For 1L therapy for triple negative breast cancer (TNBC) based on BRCA1/2mutation and/or PD-L1 status, 44% of HCPs indicated they were uncertain of optimal Tx. Discordant findings were also observed for pretreated pts. For pretreated HR+/HER2- MBC, <50% of HCPs selected expert-recommended elacestrant for ESR1 mutant disease and chemotherapy (CT) if <12 months of prior response to 1L Tx vs 100% of experts. Moreover, 2 out of 5 HCPs agreed with experts in recommending T-DXd in pretreated HER2-low MBC. In pretreated HER2+ MBC, 100% of experts chose T-DXd vs 60% of HCPs if previous THP and no brain metastases, and 60% of experts vs 40% of HCPs chose T-DXd if brain metastases. In recurrent TNBC with no actionable biomarkers and ≥2 previous systemic CT, 7% of HCPs selected sacituzumab govitecan vs all experts selecting this Tx or CT not previously received. Overall, 50% and 29% of HCPs indicated expert recommendations changed or confirmed their practice, respectively. Conclusions: Data from an online IDST demonstrate discordance of expert recommendations and community HCPs Tx selection in MBC, which is made challenging by a number of variables that that must be assessed during the care continuum. Expert recommendations in the IDST often reinforced or changed HCP’s Tx plan, highlighting the need for ongoing education and the potential of an online tool to improve optimal Tx decisions for MBC, particularly when HCPs must consider current guidelines and tumor-specific biomarkers across multiple tumor types they may see.

Contemporary Multiple Myeloma Treatment Patterns Among HCPs and Concordance with Expert Recommendations: Analysis of an Interactive Online Decision Support Tool

Background: The management of multiple myeloma (MM) continues to evolve with the emergence of new classes of therapy, most recently including BCMA-targeted therapies. Considering the expanding MM treatment armamentarium, we sought to identify contemporary practice patterns among healthcare professionals (HCPs) for MM and compare them with those of experts using an online decision support tool. Methods: An online decision support tool was developed with input from 5 experts providing therapy recommendations for 192 unique patient case scenarios based on considerations including disease setting, treatment history, access to therapy, and specific comorbidities. HCP tool users entered specific patient criteria to define a case along with their intended management for that case. The tool then showed the 5 expert recommendations for that same case scenario, and users were asked if the recommendations impacted their intended approach. An analysis of expert recommendations and user-selected therapy was performed. Results: Between April 2023 and July 2023, 207 patient cases were entered by 144 participating HCPs. HCP and expert treatment recommendations were frequently discordant, regardless of treatment setting (Table). The highest concordance between HCP and expert recommendations (47%; P <.0001) was in the induction setting (n = 111). In this setting, experts were more likely to recommend quadruplet regimens compared with HCPs (62% vs 27%, respectively; P <.0001). Treatment selection concordance was lower in the maintenance (n = 17; 24%; P <.0001) and relapsed/refractory settings (n = 79; 20%; P <.0001). The lowest concordance (10%; P <.0001) between HCP and expert treatment recommendations was noted in the relapsed/refractory setting specifically among patients who were refractory to earlier lines of therapy (n = 41; P <.0001). For patients who are refractory to earlier lines of therapy, experts were more likely to recommend an anti-CD38-based combination regimen compared with HCPs (81% vs 32; P <.0001). When recommending treatment for patients with triple- or penta-refractory disease, experts were significantly more likely to recommend BCMA-targeted agents (83% vs 39%; P <.0001). For HCPs whose treatment plan did not match expert recommendations in these scenarios, 53% of respondents indicated that expert recommendations confirmed or changed their intended therapy, but 31% indicated that there were barriers to implementing those recommendations. Conclusions: These data suggest ongoing challenges with incorporating the newest therapies and combinations across the spectrum of MM into patient care, particularly multidrug regimens in the induction and maintenance settings and BCMA-targeted therapies in those with triple- or penta-refractory disease. Continued education and development of resources for HCPs, including online decision support tools, may be increasingly important as the treatment of MM continues to grow in complexity.

A Novel Online Decision Support Tool to Determine Practice Patterns and Concordance with Experts in the Treatment of Patients with Immune Thrombocytopenia

Background: Immune thrombocytopenia (ITP) is a complex disease involving dysregulation of the immune system with inadequate platelet production and increased platelet destruction. When treatment is warranted, corticosteroids are frequently used as first-line therapy. Steroid-refractory patients eventually require alternative treatments, of which there are several approved and well-studied options. However, these second-line treatments have not been rigorously compared in clinical trials. To assist healthcare professionals (HCPs) in managing patients with ITP, we developed an online interactive decision support tool to provide expert recommendations for treatment. Here we report an analysis of practice patterns among HCPs and experts for ITP cases after initial therapy failure and the impact of expert recommendations on HCP decisions. Methods: An online tool was developed with 4 experts providing recommendations on management of 332 unique patient cases based on patient- and disease-specific factors that the experts considered relevant to making treatment decisions. HCPs entered patient case details including age, treatment setting, platelet count, current presentation, and presence of risk factors for bleeding, along with their intended management approach, before being shown the expert recommendations for their specific scenario. Results: Between October 2022 and July 2023, 311 patient cases were entered by 256 HCPs, including 194 (62.4%) cases of treatment-exposed patients (Table). Of the treatment-exposed cases, 72.1% were submitted by physicians, and 23.2% were submitted by HCPs in North America. There was strong alignment between HCP treatment selection and at least 1 expert recommendation (69%; P = .0001). There was consensus among experts for 94.4% of cases with patients ≥21 years of age who were treatment exposed. In these cases, experts recommended thrombopoietin receptor agonists (TPO-RA) for 83.5% of cases in contrast to HCPs recommending them in 38.2% of cases. Alternatives for TPO-RA chosen by HCPs in cases with patients ≥21 years of age who were treatment exposed included rituximab (29.6%), immunoglobulin (23.5%), fostamatinib (12.5%), splenectomy (9.8%), observation (8.6%), or unsure (16%). There was consensus among experts for 72% of cases with patients <21 years of age who were treatment exposed. For cases with patients <21 of age who were treatment exposed, HCPs chose immunoglobulin (28.6%), observation (28.6%), rituximab (14.3%), splenectomy (4.7%), or unsure (23.8%). In 47.6% of cases where HCPs indicated an alternative selection, they indicated that expert recommendations changed their treatment choice. HCPs indicated there were barriers to implementation in 7% of indicated cases. Conclusion: Based on our analysis of an online treatment decision tool, practice patterns for the management of patients with ITP aligned between HCPs and at least 1 tool expert in 69% of treatment-experienced cases. For previously treated patients, HCPs were less likely to choose a TPO-RA compared with tool experts, although very few identified barriers to implementation. Although specific treatment utilization patterns differed between HCPs and experts based on data from this tool, HCPs appeared amenable to practice changes based on expert recommendations. Online decision support tools can offer opportunities for HCPs to receive education and expert guidance in choosing optimal treatment regimens for ITP, a condition where treatment guidelines may not address every unique patient scenario.

State-of-the-art management of HER2-negative early breast cancer: Treatment patterns among healthcare professionals and concordance with expert recommendations.

553 Background: The management of high-risk HER2-negative early-stage breast cancer (EBC) has recently evolved with the addition of newer agents including abemaciclib, olaparib, and pembrolizumab as (neo)adjuvant therapy options for appropriate patients. To aid healthcare professionals (HCPs) in the recommended implementation of these agents, we developed an online treatment decision support tool providing case-specific treatment guidance from 5 breast cancer experts. Here, we report an analysis of cases entered into the tool by HCPs, comparing their planned treatment with expert recommendations. Methods: Expert therapy recommendations for 10 case scenarios in high-risk HER2-negative EBC based on 3 pivotal clinical trials (KEYNOTE-522, OlympiA, and monarchE) were obtained in March 2022. Patient and disease characteristics included hormone receptor (HR) status, BRCA mutational status, lymph node positivity, presence of residual disease after resection, and additional criteria based on the 3 practice-changing trials. HCPs entered specific patient and disease factors into the tool along with their intended treatment plan and were shown 5 individual expert treatment recommendations for the unique case scenario. Results: From June 2022 to January 2023, 547 HCPs entered 982 patient case scenarios into the tool. A comparison of treatment recommendations by experts and HCPs showed divergence for several case scenarios. For patients with high-risk HR-positive/HER2-negative EBC and no BRCA mutation, all 5 experts recommended adjuvant abemaciclib plus endocrine therapy. By contrast, 64% of HCPs’ therapy choices were discordant with the experts, with 49% choosing chemotherapy followed by endocrine therapy. For patients with triple-negative breast cancer (TNBC) who received neoadjuvant chemotherapy and have no residual disease, all 5 experts recommended observation, whereas 36% of HCPs recommended additional adjuvant therapy. In the setting of BRCA-mutated TNBC with residual disease after neoadjuvant pembrolizumab plus chemotherapy, 4 of 5 experts recommended adjuvant pembrolizumab plus olaparib, but just 33% of HCPs chose this combination. One third of HCPs who initially selected treatment options that diverged from expert recommendations or who were uncertain about treatment choice intend to change their therapy selection to align with the experts. Conclusions: Analysis of data from this tool suggests differences in clinical practice between experts and HCPs for multiple case scenarios of high-risk EBC, including examples of potential overtreatment. Moreover, our data demonstrate that this decision support tool may lead to better alignment of HCP treatment choices with experts, with the potential to improve clinical management of patients.

Variance in Practice between Experts and Oncology Healthcare Professionals for Follicular Lymphoma: Analysis of an Online Treatment Decision Tool

Variance in Practice between Experts and Oncology Healthcare Professionals for Follicular Lymphoma: Analysis of an Online Treatment Decision Tool

Ultrasound-based evaluation of the prevalence of abdominal cystic echinococcosis in the Turkestan region of Kazakhstan

Human cystic echinococcosis (CE) is a zoonotic disease caused by Echinococcus granulosus sensu lato. CE is known to be endemic in some parts of Central Asia. We present findings from an ultrasound-based survey to estimate the prevalence of CE in the Turkestan oblast of Kazakhstan. In October 2019, six villages were chosen based on records from a national surveillance dataset. Inhabitants aged 5-90 y were invited to undergo a free abdominal ultrasound to screen for CE cysts. All identified cysts were staged according to the WHO-endorsed classification for CE cysts. A total of 2252 individuals underwent ultrasound screening. Twenty-two (0.98%) individuals had CE, with a combined total of 33 cysts: 25 (75.7%) inactive (14 CE4, 11 CE5) and 8 (24.3%) active/transitional (2 CE1, 1 CE2, 3 CE3a, 2 CE3b). One patient had a postsurgical cavity. Sixty-eight patients (3.0%) reported CE prior to surgical treatment. In 25 (36.8%) previously diagnosed patients, albendazole prophylaxis was not used. CE is endemic in the study region, with ongoing transmission. The number of surgically treated CE patients suggests an underestimation of the disease burden by the current surveillance system. Further studies on local CE epidemiology and the implementation of expert treatment recommendations are needed.

Evolving Treatment Patterns of Healthcare Providers (HCPs) and Multiple Myeloma (MM) Experts from 2013-2017: Analysis of an Annually Updated Online Treatment Decision Tool

BackgroundExpanding availability of novel agents for treating MM has transformed management strategies, particularly for relapsed/refractory (R/R) disease. Since 2013, experienced MM physicians from leading academic institutions and cancer centers (experts) have annually updated an online tool designed to provide HCPs with treatment recommendations for specific patient cases. Previous reports from our tool analyses have shown yearly changes in treatment patterns among experts but a multiyear delay by HCPs in the adoption of many expert-recommended treatment strategies into their practice.MethodsTo develop the tool, 5 MM experts provided treatment recommendations for hundreds of case scenarios across induction, maintenance, and R/R disease settings. To use the tool, HCPs seeking treatment consultation entered patient and disease factors with a planned treatment for that specific patient using dropdown menus and received 5 expert recommendations for their case. HCPs were asked to indicate the impact of expert recommendations on their planned treatment. This report includes analysis and comparison of intended treatment of HCPs for 790 cases entered into the 2017 iteration of tool with expert recommendations for those patient cases. Treatment trends observed in 2017 will also be compared with those from previous years.ResultsConsensus (≥ 3 of 5 experts choosing the same treatment) among experts has been increasing for induction therapy since 2013. In ASCT-eligible patients, regardless of any other factors, experts recommended bortezomib/lenalidomide/dexamethasone (VRd) in 75% of tool cases in 2017, up from 58% in 2016 and 45% in 2013 and 2014. By comparison, HCPs used VRd for 44% of ASCT-eligible patient cases in 2017 and only 19% in 2016. Expert recommendation of VRd for 66% (vs 48% of HCPs) of ASCT-ineligible cases in 2017 also increased from 38% (vs 18% of HCPs) in 2016. Expert recommendations for induction therapy changed most for cases with varying comorbidities, and data from the 2017 tool are shown in the figure below. In patients without specific comorbidities or with cardiac dysfunction only, experts recommended VRd for 87% to 90% of these cases (vs 41% to 44% of HCPs). In cases involving peripheral neuropathy, experts recommended carfilzomib/lenalidomide/dexamethasone (KRd) for 60% and VRd for 30% compared with HCPs selecting KRd for 10% and VRd for 71% of those cases.In the R/R setting, the novelty and broad range of available regimens are reflected in the lack of consensus in treatment recommendations by both the experts as well as the planned treatment of HCPs. In 304 R/R case scenarios, only 36 cases (12%) had an exact expert treatment consensus and 63 cases (21%) had 2 pairs of experts agreeing on the same treatment recommendations. However, overall treatment strategies were similar among experts, with use of triplet regimens including novel agents increasing in 2017. Experts recommended Kd or daratumumab monotherapy for 40% of cases refractory to lenalidomide in 2016. In 2017, experts no longer recommended monotherapy or doublet therapy for R/R cases in this setting. In 2017, the experts recommended triplet regimen therapy for 87% to 97% of cases involving bortezomib-refractory or lenalidomide/bortezomib-refractory patients, and each of the recommendations included either carfilzomib, ixazomib, daratumumab, or elotuzumab compared with only 55% to 60% of their recommendations including triplet therapy with one of these agents in 2016. Again, variation was observed in the intended treatment of HCPs compared with the expert recommendations for R/R cases. In 2017, the intended treatment of HCPs did not match any of the experts' recommendations for 45% of the R/R cases entered into the tool.ConclusionsAnalysis of cases entered into our expert-developed treatment decision tool shows that a wide gap remains between expert treatment recommendations and the intended treatment plans of HCPs for many of the same MM case scenarios. Experts had nearly full consensus on choice of induction therapy; however, differences between expert recommendations in R/R MM are due to availability of multiple triplet-based treatment options in this setting. In addition, newly approved therapies continue to have a strong impact on experts' recommendations as they quickly integrate new agents into their treatment approaches. A detailed analysis of expert and HCP MM practice trends will be presented. [Display omitted] DisclosuresKumar:Celgene, Millennium, BMS, Onyx, Janssen, Noxxon, AbbVie, Amgen, Merck, Oncopeptides, Skyline Diagnostics, Takeda: Consultancy; Skyline: Honoraria; Celgene, Millennium/Takeda, Onyx, AbbVie, Janssen, Sanofi, Novartis, Amgen, Genentech, Merck, Oncopeptides, Roche, Skyline Diagnostics: Research Funding. Lentzsch:Caelum Biosciences: Other: leadership position and stock; BMS: Consultancy; Amgen: Consultancy. Anderson:Gilead Sciences: Membership on an entity's Board of Directors or advisory committees; Oncopep: Other: scientific founder; C4 Therapeutics: Other: scientific founder; Millenium Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees; MedImmune: Membership on an entity's Board of Directors or advisory committees.

Variance between Experts and Oncology Healthcare Providers in Managing Polycythemia Vera and Myelofibrosis: Analysis of an Online Treatment Decision Support Tool

BackgroundThe management of patients with the Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) polycythemia vera (PV) and myelofibrosis (MF) is evolving. US clinical practice guidelines for MF were published for the first time in late 2016, and those for PV (and essential thrombocythemia) are in development. Clinicians still face substantial challenges in selecting therapy for patients with PV and MF. To assist with patient care and to help healthcare providers (HCPs) make informed decisions in this complex treatment landscape, an online treatment decision support tool was developed. Here we report data comparing expert treatment recommendations from the tool with the intended treatment entered by HCPs using the tool.MethodsIn February 2017, 5 experts in MPN patient care provided specific treatment recommendations for numerous distinct PV and MF case scenarios. These scenarios were defined by key patient and disease characteristics, including the presence of disease symptoms or anemia, previous response to treatment, and eligibility for transplantation and other therapeutic modalities. To use the tool, participating HCPs entered specific patient and disease factors along with their intended treatment plan for their case. When the case entry was completed, the expert treatment recommendations for that specific patient case were shown, followed by a short survey designed to determine if the expert recommendations had changed the HCP's planned course of treatment.ResultsFrom March 20, 2017, to June 9, 2017, 369 patient cases (n = 172 for PV; n = 197 for MF) were entered into the tool by 270 HCPs (83% MDs). Although there was expert consensus (≥ 3 of 5 experts choosing the same treatment course) for the majority of PV and MF cases (table), variance among the experts did exist in select areas: for example, the treatment of anemic patients with intermediate-2-risk/high-risk MF who had significant disease symptoms or splenomegaly but were not candidates for transplantation. A comparison of expert and tool user treatment choices showed substantial variability for several different patient case scenarios (table). For example, compared with expert recommendations for the PV cases, many tool users would potentially overtreat patients at low risk for thrombosis and underuse peginterferon (pegIFN) and ruxolitinib for high-risk patients. Approximately one half of the PV cases entered into the tool involved patients with prior intolerance/inadequate response to hydroxyurea (HU), and the intended treatment for these patients indicated by the majority of HCPs did not match consensus expert recommendations. Compared with expert recommendations for the MF cases, many tool users would potentially overtreat asymptomatic low-risk/intermediate-1-risk patients and underuse ruxolitinib for higher-risk patients. Among the HCPs who reported that their intended treatment plan differed from the experts, 73% indicated that the recommendations provided by the tool would change their previous management plans.ConclusionsAnalysis of cases and intended treatment plans entered into an online PV/MF treatment decision support tool indicated variance in expert and HCP treatment choices for many case scenarios. Expert recommendations in this online tool changed the intended treatment plan of many HCPs and, as such, suggest that online treatment decision tools developed by respected experts can help optimize the care of patients with PV and MF. A full analysis of all cases entered into the tool-including a detailed report of expert and HCP practice trends for PV and MF management-will be presented. [Display omitted] DisclosuresDeininger:Ariad Pharmaceuticals, Bristol Myers Squibb, CTI BioPharma Corp, Gilead, Incyte, Novartis, Pfizer, Celgene, Blue Print, Galena: Consultancy, Membership on an entity's Board of Directors or advisory committees; Gilead: Research Funding; ARIAD: Consultancy; Incyte: Consultancy; Celgene: Research Funding; Novartis: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Pfizer: Consultancy. Mascarenhas:Promedior: Research Funding; Incyte: Other: Clinical Trial Steering Committee , Research Funding; CTI Biopharma: Research Funding; Janssen: Research Funding; Merck: Research Funding; Novartis: Other: DSMB member , Research Funding. Mesa:Incyte Corporation: Research Funding; Ariad: Consultancy; Promedico: Research Funding; Celgene Corporation: Research Funding; Galena Biopharma, Inc.: Consultancy; Gilead Sciences, Inc.: Research Funding; CTI BioPharma Corp.: Research Funding; Novartis Pharmaceuticals Corporation: Consultancy. Stein:Incyte: Consultancy. Verstovsek:Lilly Oncology: Research Funding; Promedior: Research Funding; Astrazeneca: Research Funding; Pfizer: Research Funding; Incyte: Research Funding; Bristol Myers Squibb: Research Funding; Pfizer: Research Funding; Gilead: Research Funding; Roche: Research Funding; Astrazeneca: Research Funding; NS Pharma: Research Funding; Galena BioPharma: Research Funding; CTI BioPharma Corp: Research Funding; Bristol Myers Squibb: Research Funding; Seattle Genetics: Research Funding; Gilead: Research Funding; NS Pharma: Research Funding; Celgene: Research Funding; Promedior: Research Funding; Roche: Research Funding; Seattle Genetics: Research Funding; CTI BioPharma Corp: Research Funding; Lilly Oncology: Research Funding; Genentech: Research Funding; Celgene: Research Funding; Genentech: Research Funding; Blueprint Medicines Corp: Research Funding; Blueprint Medicines Corp: Research Funding; Galena BioPharma: Research Funding; Incyte: Research Funding.

Analysis of Healthcare Provider Practice Patterns from Individual Patient Cases Entered into an Online Treatment Decision Tool for Chronic Lymphocytic Leukemia (CLL)

BackgroundNew agent approvals and indications in CLL have changed treatment approaches and increased the complexity of managing CLL. Healthcare providers (HCPs), particularly those practicing in community settings with limited experience in caring for patients with CLL, can be challenged to make informed treatment decisions in this evolving treatment landscape. We report on an analysis of current CLL treatment patterns of HCPs using an online treatment decision tool developed by experienced CLL physicians from leading academic institutions and cancer centers (experts) to assist HCPs in their practice.MethodsSince 2016, CLL experts have developed and then twice updated (early 2016, late 2016, and 2017) an online treatment decision tool designed to provide specific recommendations for patient case scenarios entered by HCPs. For each iteration of the tool, 5 experts provided their treatment recommendations for hundreds of case variations based on key factors defined by the experts as those that guide treatment choices in their practice. Factors for newly diagnosed CLL included age, fitness (based on ECOG PS, CIRS, and renal function), cytogenetic abnormalities, and IGHV mutation status. Additional variables for patients with relapsed/refractory disease after first-line treatment included previous treatment, response duration, reason for switching therapy, burden of comorbidities, and disease-related symptoms. To use the tool, participating HCPs entered patient and disease factors along with their intended treatment plan for that case. When the entry of the case into the tool was completed, the 5 expert treatment recommendations for that specific patient case were shown, followed by a short survey designed to determine if the expert recommendations changed the HCPs' planned course of treatment. Our analysis includes a comparison of intended treatment of HCPs for 2198 cases entered into the tool (early 2016, n = 883; late 2016, n = 562; 2017, n = 753) with the expert recommendations for those patient cases.ResultsAlthough there was consensus among the experts (≥ 3 of 5 experts choosing the same treatment course) for 87% of cases included in the 2017 tool, there was substantial variation between the expert recommendations and the intended treatment of HCPs using the tool. In treatment-naive patients with del(17p) CLL in all 3 tool iterations, experts recommended ibrutinib as first-line therapy for 100% of cases regardless of any other variable, whereas only approximately 40% of HCPs planned to use ibrutinib for these patients.For young (< 65 years of age), fit patients with non-del(17p) CLL, the addition of IGHV mutation status as a factor in the late 2016 and 2017 tools changed expert recommendations. Experts recommended FCR for 60% (vs HCPs at 68%) and ibrutinib for 40% (vs HCPs at 14%) of cases with IGHV mutations. For cases without IGHV mutations, experts recommended FCR for 0% (vs HCPs at 53%), ibrutinib for 80% (vs HCPs at 18%), and BR for 20% (vs HCPs at 21%) of the cases. Similar treatment patterns are also seen with older or unfit patients with non-del(17p) CLL, where the expert recommended use of ibrutinib increased from early 2016 to 2017 (21% to > 65% of cases), whereas HCP use of ibrutinib remained consistent (15% to 20%).In patients with del(17p) CLL who progressed on first-line therapy, the approval of venetoclax changed treatment patterns among both experts and HCPs in the late 2016 and 2017 tools. In patient cases with del(17p) CLL who were discontinuing ibrutinib, experts consistently recommended venetoclax in 93% of cases (7% idelalisib + R for cases with intolerance to ibrutinib) vs HCPs using venetoclax for 59% and 69% of cases in late 2016 and 2017, respectively. For HCPs whose intended treatment differed from experts, 50% indicated that their treatment plan would change after using the tool (36% no/undecided and 14% reported barriers to change).ConclusionsPractice patterns between experts and HCPs differed substantially in their use of novel therapy for routine clinical practice. Expert recommendations in this online tool changed the intended treatment plan of HCPs using the tool and suggests that online treatment decision tools developed by respected experts can help optimize the care of patients with CLL. A full analysis of all cases entered into the tool, including a detailed report of expert and HCP practice trends, will be presented. DisclosuresCoutre:Gilead: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Janssen: Consultancy; Pharmacyclics LLC, an AbbVie Company: Consultancy, Research Funding; Celgene: Consultancy, Research Funding. Sharman:Novartis: Research Funding; Genentech: Research Funding; Gilead Sciences, Inc.: Consultancy, Honoraria, Research Funding, Speakers Bureau. Zelenetz:Amgen: Consultancy; Celgene: Consultancy.

The multisystem inflammatory syndrome in children and its association to SARS-CoV-2.

Multisystem inflammatory syndrome in children (MIS-C)/pediatric inflammatory multisystem syndrome (PIMS) is a new and serious disease that occurs in temporal association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We describe the clinical presentation, diagnosis, and treatment recommendations. To date, no randomized prospective studies have been published; recommendations are based on some observational studies, case reports, and expert opinions. The article provides an overview of the most important publications, presents the current results of the German Registry for PIMS and expert recommendations for treatment. MIS-C PIMS is a new syndrome that is associated with a variety of virus infections, and also with SARS-CoV-2. The main characteristics are fever, multiple organ dysfunction due to a hyper-inflammatory state. In particular, cardiac dysfunction and severe shock. A high proportion of patients require intensive medical care, but the absolute number of children with SARS-CoV-2 MIS-C is low. Medical therapy is based on pathophysiologic considerations and is not evidence-based. Immunoglobulins, steroids and biologics are used and lead to effective treatment. Therefore, the mortality rate is very low. Patients usually recover within days, sequelae are reported only in a minority of cases.

Development of expert recommendations for the treatment of PTSD with comorbid substance use disorder

Background: PTSD and substance use disorder (SUD) frequently co-occur. Estimates of life time PTSD amongst SUD patients range from 26% to 52%, with estimates of current PTSD between 15% and 42%. Amongst individual diagnosed with PTSD estimates of comorbid substance abuse range from 19% to 35% and comorbid alcohol abuse from 36% to 52% (Roberts, Roberts, Jones, & Bisson, 2016). PTSD-SUD comorbidity presents many clinical challenges for treating clinicians. Individuals with PTSD-SUD present with a more severe clinical profile, tend to have poorer functioning and wellbeing, and inferior treatment outcomes. Clinicians view this comorbidity to be substantially more difficult to treat than either disorder alone (Schäfer & Lotzin, 2018). There are now a number of well-established psychological therapies for PTSD. These include prolonged exposure, cognitive therapy, cognitive processing therapy and EMDR (Bisson et al., 2019). However, patients with PTSD-SUD comorbidity are often excluded from clinical trials of psychological intervention. Clinicians are therefore often uncertain about how best to implement effective treatment, and traditionally, patients with this comorbidity have been offered treatment sequentially. This normally involves referral for to PTSD treatment only after completion of treatment for addiction (Roberts, Back, Mueser, & Murray, 2020). However, there are concerns about whether this approach causes some patients to ‘fall through the cracks’ between services and there is debate about whether integrated or simultaneous approaches might be more effective. A number of integrated treatment approaches have been developed. These are often grouped into past focused treatments, which include components of exposure-based trauma processing; and present focused treatments, which focus more on improving current coping skills (see Roberts et al., 2020). Recent reviews have tended to report more support for exposure-based approaches, particularly in relation to PTSD outcomes (Roberts et al., 2020), although findings have been based on a small number of studies and high drop-out from treatment has been noted as a problem across different approaches. Most recent guidelines (e.g. ISTSS 2018 – see NICE 2018; Bisson et al., 2019) have not included scoping questions to address issues of comorbidity, and there are no widely accepted guidelines about how to deliver optimal care and treatment for such individuals. Objectives and methodology: To describe the work of a task force which has been established to develop expert recommendations for the psychological treatment of this comorbidity for ESTSS, following principles used in guideline development through two stages. Stage 1. Update of a systematic review and meta-analysis (Roberts et al., 2016) of RCTs of psychological interventions aimed at treating comorbid PTSD and SUD, with the aim of establishing the current evidence base for a number of approaches including: Trauma focused CBT trauma focused treatments plus treatment as usual for SUD, such as COPE Present focused treatments such as Seeking Safety plus treatment as usual for SUD Integrated cognitive restructuring-based interventions plus treatment as usual for SUD EMDR plus treatment as usual for SUD. The working group also seeks to investigate whether there is evidence for different models of treatment delivery: i.e. sequential treatments, vs. integrated treatments delivered by the same therapist vs simultaneous treatments delivered by different therapists. Treatment recommendations will be based on the strength and quality of the findings addressing which will be evaluated through the GRADE approach. Stage 2. It is anticipated that many of the challenges faced in clinical practice are unlikely to be addressed through the Stage 1 process, where there is limited high-quality evidence to make evidence-based recommendations. Stage 2 will involve the collation good practice/consensus point recommendations made in trusted methodologically rigorous treatment guidelines and expert guidance publications. Findings and Recommendations: This project is currently ongoing. The presentation will provide an update of the progress of the working group, share preliminary findings where these are available and make recommendations for future research.

Evolving Treatment Patterns in Chronic Lymphocytic Leukemia Among Experts and Community Practitioners: Analysis of an Online Decision Support Tool

Evolving Treatment Patterns in Chronic Lymphocytic Leukemia Among Experts and Community Practitioners: Analysis of an Online Decision Support Tool

Abstract P4-14-07: Treatment patterns for metastatic hormone receptor-positive breast cancer: Comparing expert and community practice

Abstract Background Endocrine therapies and CDK4/6 inhibitors have dramatically improved outcomes for patients with hormone receptor-positive (HR+) metastatic breast cancer (MBC). To help inform treatment decisions among healthcare providers (HCPs) caring for patients with MBC, we have developed and regularly updated an online treatment decision support tool that provides recommendations from multiple breast cancer experts for specifically defined patient scenarios. Here we report data for HR+/HER2- MBC cases entered into the tool since 2016, capturing self-reported practice trends from HCPs compared with matched treatment recommendations from experts. Methods For the most recent MBC treatment tool (published October 2018), 5 breast cancer experts provided treatment consultation for 549 unique MBC case scenarios based on a simplified set of variables: disease phenotype, previous systemic therapy, visceral crisis (yes/no), rate of disease progression, and the presence or absence of germline BRCA1/2 mutations. HCPs used selection menus to enter patient and disease factors based on these variables along with their intended treatment plan. When completed, the experts’ treatment recommendations for that specific patient case were shown to the HCPs at which time they were asked to indicate if the expert recommendations changed their planned treatment. Results From October 2018 through June 2019, 603 HCPs entered 1127 patient case scenarios, including 581 HR+/HER2- MBC cases, in the most recent online tool. A comparison of expert and HCP treatment choices for select HR+/HER2- MBC case scenarios from the October 2016 and October 2018 tool is shown in the Table. In the setting of HR+/HER2- MBC, among those HCPs whose planned treatment differed from the consensus expert recommendation, 55% indicated that they would change their original choice of treatment. Conclusions CDK4/6 inhibitors have had a large impact on expert treatment recommendations for patients with HR+/HER2- MBC. However, data from this online treatment decision support tool suggest ongoing differences in practice between experts and community HCPs in this setting. For many cases entered into the tool, the practice of the majority of HCPs differed from expert consensus (Table). Consensus expert recommendations in this online tool changed the intended treatment plan of many using it and, therefore, can help optimize the care of patients with MBC. A detailed analysis of overall community practice trends for HR+/HER2- MBC along with a comparison of expert and HCP practice for different case scenarios will be presented. HR+/HER2- MBC Case Scenarios (no visceral crisis)Expert Consensus Recommendation (%)Expert Consensus Recommendation (%)HCP Practice Matched Expert Consensus Recommendation, % (n)HCP Practice Matched Expert Consensus Recommendation, % (n)2016201820162018de novoCDK4/6i + AI (100)CDK4/6i + AI (100)23 (111)32 (188)Previous (neo)adjuvant AICDK4/6i + FULV (92)CDK4/6i + FULV (90)22 (54)17 (77)Previous CDK4/6i + AIFULV (82)FULV ± EVE (92)0 (14)18 (40)Previous AI and CDK4/6i + FulvEVE + EXE (87)EVE + EXE (73)63 (19)28 (18) Citation Format: Timothy Quill, Sara Hurvitz, Kathy D. Miller, Ruth O'Regan, Tiffany A. Traina, Rachael Andrie, Kevin L. Obholz, Mohammad Jahanzeb. Treatment patterns for metastatic hormone receptor-positive breast cancer: Comparing expert and community practice [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-14-07.

Evolution in Practice Patterns and Differences Among Experts and Community Healthcare Providers in the Treatment of Patients with Chronic Lymphocytic Leukemia

Evolution in Practice Patterns and Differences Among Experts and Community Healthcare Providers in the Treatment of Patients with Chronic Lymphocytic Leukemia

Analysis of an Online Treatment Decision Tool Reveals Variances in Practice between Experts and Oncology Healthcare Providers for Newly Diagnosed Follicular Lymphoma

Analysis of an Online Treatment Decision Tool Reveals Variances in Practice between Experts and Oncology Healthcare Providers for Newly Diagnosed Follicular Lymphoma

Utility of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions in the adult and paediatric population

Introduction Primary care provider (PCP) competency in dermatology is inadequate despite the high volume of patients with skin conditions. Better education and access to dermatology expertise is vital to improve patient care. We present a comprehensive case-based evaluation of Dermatology Extension for Community Healthcare Outcomes (ECHO) sessions, an innovative videoconferencing educational model, by determining the diagnostic and treatment accuracy of dermatological conditions by PCPs over a 2-year period. Methods This is a retrospective cross-sectional study evaluating the use and impact of Dermatology ECHO over a 2-year period. Outcomes assessed include patient demographics, PCPs’ diagnostic accuracy, and expert treatment impact. Results were analysed using summary statistics and Pearson’s chi-square test to describe the adult and paediatric populations. Results One hundred and sixty-seven adult cases and 56 paediatric cases were presented in 2016–2017. Among the 223 cases, 137 adult and 44 paediatric cases were complete and eligible for analysis. The mean lesion duration was 3.3 years in adults and 2.9 years in children prior to presentation. Upon case presentation, almost half (43.8%) of the adult cases were incorrectly diagnosed by their PCP with 18.8% receiving a partially correct diagnosis. PCPs had greater diagnostic accuracy in children (45% correct diagnosis, 27.5% partially correct, 27.5% incorrect). Expert treatment recommendations benefited 83.6% of adult cases and 72.5% of paediatric cases. Discussion This study highlights the need for better dermatology access and teaching opportunities among PCPs in Missouri. Dermatology ECHO provides a platform for didactic learning and case presentations to improve dermatology competency among PCPs.

Abstract P5-16-02: Variance between experts and community practitioners in treatment of metastatic breast cancer

Abstract Background New treatment options continue to improve outcomes for patients with metastatic breast cancer (MBC). However, clinicians' lack of clinical experience using new agents, a complex treatment landscape, and the broad treatment recommendations in available guidelines can make the choice of an optimal treatment for individual patients with MBC challenging. An online treatment decision support tool was developed to overcome these challenges and provide recommendations from multiple experts for specific MBC patient scenarios. Here we report data comparing expert treatment recommendations with the intended treatment indicated by clinicians using the tool. Methods In October 2016, 5 breast cancer experts provided treatment consultation for 492 unique MBC case scenarios based on a simplified set of variables: disease phenotype, previous systemic therapy, visceral crisis (yes/no), and rate of disease progression. These patient and disease characteristics along with expert treatment consultation were used to develop the treatment decision tool. Clinicians used drop-down menus to enter patient and disease factors along with their intended treatment plan. When completed, the experts' treatment recommendations for that specific patient case were shown to the clinicians, at which point the users were asked to indicate if the expert recommendations changed their planned treatment. Results From December 2016 through April 2017, 619 healthcare providers entered 1018 patient case scenarios in the online MBC tool representing the following phenotypes: HR+/HER2- (53%), HR-/HER2+ (10%), HR+/HER2+ (14%), and triple-negative breast cancer (23%). A comparison of expert and community oncologist treatment choices in select patient case scenarios with expert consensus is shown in the table. Among participating oncologists whose initial intended treatment of MBC differed from the experts, 51% indicated that they would change their choice of therapy. Conclusions MBC therapy continues to evolve with new agents having a large impact on how experts treat MBC. Data from the online MBC treatment decision support tool indicate variance in expert and oncologist treatment choices for many case scenarios. Moreover, consensus expert recommendations in this online tool changed the intended treatment plan of many using it and, therefore, can help optimize the care of patients with MBC. A detailed analysis of self-identified practice trends among those using the online tool, along with a comparison of expert and participating oncologist treatment choices for different MBC case scenarios, will be presented. MBC Case ScenarioMajority Consensus Recommendation Among Experts, %Tool Cases Where Oncologist Intended Treatment Matched the Expert Consensus Recommendation, %HR+/HER2- (no visceral crisis)•De novoPalbociclib + letrozole: 10023•Previous (neo)adjuvant AIPalbociclib + fulvestrant: 9219•Previous palbociclib + letrozoleFulvestrant: 820•Previous palbociclib + fulvestrantEverolimus + exemestane: 8750HR-/HER2+•De novoTHP: 10068•Previous pertuzumabT-DM1: 10066Triple-negative breast cancer•Visceral crisisCombination CT: 9139•No visceral crisis, fast progressionSingle-agent CT: 7250AI, aromatase inhibitor; CT, chemotherapy. Citation Format: Quill TA, Blackwell KL, Hurvitz S, Miller KD, Robert N, Obholz KL, Jahanzeb M. Variance between experts and community practitioners in treatment of metastatic 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 P5-16-02.

Cost Of Hospital Treatment For Severe And Moderate-To-Severe Influenza In Russia

Respiratory viral infection (RVI) both in children and adults is one of the leading causes of hospitalizations in Russia every year. Presently the Russian mandatoty medical insurance system (MMIS) defines low tariffs for RVI hospitalization (€401.37-€575.22) and a lot of cases are thought to be eligible for out-patient care. Still some influenza patients may need expensive hospital care, but the cost has never been calculated. The aim of this study was to estimate the cost of hospital treatment for severe and moderate-to-severe influenza in adult patients. The list of recourses used in severe and moderate-to-severe influenza hospital treatment was made by experts - clinical practitioners in the field of infectious diseases. Pharmacotherapy and laboratory tests for identifying influenza virus by polymerase chain reaction (PCR) were considered to be cost drivers by experts, when use of other resources was considered to be equal to routine care in an infectious ward. The drug costs were calculated on the basis of registered maximal manufacture’s prices. The cost of PCR was submitted by regional hospitals. Other medical costs were calculated based on average cost per inpatient-day in the infectious ward of the regional hospitals (excluding drugs) and average length of hospital stay of influenza patients with different degree of severity. The cost of drugs is €1,605.48 and €129.12 per patient with severe and moderate-to-severe influenza, respectively. The total cost of hospitalization is €2,300.87 for a severe influenza case and €664.28 for moderate-to-severe patient. 1st place in the drug costs structure belongs to antibiotics for bacterial complications (56 % of drug costs) in moderate-to-severe influenza, and to plasma protease inhibitors (38%) in severe flu. PCR makes a small share in total costs. Cost of severe and moderate-to-severe influenza calculated based on expert treatment recommendations is much higher than defined tariff in Russian MMIS.

Impact of an Interactive On-line Tool on Therapeutic Decision-Making for Patients with Advanced Non-Small-Cell Lung Cancer

Treatment guidelines provide recommendations but cannot account for the wide variability in patient-tumor characteristics in individual patients. We developed an on-line interactive decision tool to provide expert recommendations for specific patient scenarios in the first-line and maintenance settings for advanced non-small-cell lung cancer. We sought to determine how providing expert feedback would influence clinical decision-making. Five lung cancer experts selected treatment for 96 different patient cases based on patient and/or tumor-specific features. These data were used to develop an on-line decision tool. Participant physicians entered variables for their patient scenario with treatment choices, and then received expert treatment recommendations for that scenario. To determine the impact on decision-making, users were asked whether the expert feedback impacted their original plan. A total of 442 individual physicians, of which 88% were from outside the United States, entered 653 cases, with report on impact in 389 cases. Expert feedback affected treatment choice in 73% of cases (23% changed and 50% confirmed decisions). For cases with epidermal growth factor receptor (EGFR) mutation or anaplastic lymphoma kinase (ALK) fusion, all experts selected targeted therapy whereas 51% and 58% of participants did not. Greater variability was seen between experts and participants for cases involving EGFR or ALK wild-type tumors. Participants were 2.5-fold more likely to change to expert recommended therapy for ALK fusions than for EGFR mutations (p = 0.017). This online tool for treatment decision-making resulted in a positive influence on clinician's decisions. This approach offers opportunities for improving quality of care and meets an educational need in application of new therapeutic paradigms.

THE AMERICAN SOCIETY OF CLINICAL PSYCHOPHARMACOLOGY SURVEY OF PSYCHOPHARMACOLOGISTS' PRACTICE PATTERNS FOR THE TREATMENT OF MOOD DISORDERS.

Optimal successive treatment decisions are not well established after an initial medication nonresponse in major depressive disorder or bipolar disorder. While practice guidelines offer consensus-based expert treatment recommendations, little is known about "real world" pharmacology decision making by practicing psychopharmacologists. We surveyed via Internet the national membership of the American Society of Clinical Psychopharmacology (ASCP) to study preferred pharmacotherapy strategies and factors that influence medication choices for patients with mood disorders. Surveys were returned by 154/752 ASCP members (21%). After nonresponse to a serotonin reuptake inhibitor in major depressive disorder, participants equally favored switching within or across antidepressant classes. After a partial response, adjunctive bupropion was the preferred intervention, followed by changing antidepressant classes. Atypical antipsychotic augmentation was only a fourth-line consideration, even though moderate or marked efficacy was perceived in most instances with olanzapine, aripiprazole, and quetiapine. Respondents favored avoiding antidepressants in bipolar I patients with mixed/cycling features or prior antidepressant-associated mania/hypomania. In rapid cyclers, they advocated antidepressant cessation and preferred the use of atypical antipsychotics and lamotrigine. Participating psychopharmacologists treating adults with mood disorders report prescribing medications that largely mirror the evidence base with only a few notable exceptions, in consideration of the characteristics of definable clinical subpopulations.