Influence Treatment Selection Research Articles

Optical Nanomotion Detection to Rapidly Discriminate between Fungicidal and Fungistatic Effects of Antifungals on Single-Cell Candida albicans.

Candida albicans is an emerging pathogen that poses a significant challenge due to its multidrug-resistant nature. There are two types of antifungal agents, fungicidal and fungistatic, with distinct mechanisms of action against fungal pathogens. Fungicidal agents kill fungal pathogens, whereas fungistatic agents inhibit their growth. The growth can be restored once the agent is removed and favorable conditions are established. Recognizing this difference is crucial as it influences treatment selection and infection prognosis. We present a technique based on optical nanomotion detection (ONMD) (i.e., observing the movement of the cells using an optical microscope) to discriminate rapidly between fungicidal (caspofungin) and fungistatic (fluconazole) drugs. The technique is based on the change in a yeast cell's nanomotion as a function of time during a two-hour treatment with the antifungal of interest followed by a one-hour growth period. The cells are entrapped in microwells in a microfluidic chip, which allows a quick exchange of growth medium and antifungal agent, enabling ONMD measurements on the same individual cells before and after treatment. This procedure permits to discriminate between fungicidal and fungistatic antifungals in less than 3 h, with single-cell resolution by observing if the nanomotion recovers after removing the treatment and reintroducing growth medium (YPD), or continues to drop. The simplicity of the approach holds promise for further development into a user-friendly device for rapid antifungal susceptibility testing (AFST), potentially being implemented in hospitals and medical centers worldwide in developed and developing countries.

Internal Mammary Lymphadenopathy Does Not Impact Oncologic Outcomes in Patients Treated with Neoadjuvant Chemotherapy: Results from the I-SPY2 Clinical Trial.

Internal mammary lymphadenopathy (IML) plays a role in breast cancer stage and prognosis. We aimed to evaluate method of IML detection, how IML impacts response to neoadjuvant chemotherapy (NAC), and oncologic outcomes. We evaluated patients enrolled in the I-SPY-2 clinical trial from 2010 to 2022. We captured the radiographic method of IML detection (magnetic resonance imaging [MRI], positron emission tomography/computed tomography [PET/CT], or both) and compared patients with IML with those without. Rates of locoregional recurrence (LRR), distant recurrence (DR) and event-free survival (EFS) were compared by bivariate analysis. Of 2095 patients, 198 (9.5%) had IML reported on pretreatment imaging. The method of IML detection was 154 (77.8%) MRI only, 11 (5.6%) PET/CT only, and 33 (16.7%) both. Factors associated with IML were younger age (p=0.001), larger tumors (p<0.001), and higher tumor grade (p=0.027). Pathologic complete response (pCR) was slightly higher in the IML group (41.4% vs. 34.0%; p=0.03). There was no difference in breast or axillary surgery (p=0.41 and p=0.16), however IML patients were more likely to undergo radiation (68.2% vs. 54.1%; p<0.001). With a median follow up of 3.72 years (range 0.4-10.2), there was no difference between IM+ versus IM- in LRR (5.6% vs. 3.8%; p=0.25), DR (9.1% vs. 7.9%; p=0.58), or EFS (61.6% vs. 57.2%; p=0.48). This was true for patients with and without pCR. In this large cohort of patients treated with NAC, outcomes were not negatively impacted by IML. We demonstrated that IML influences treatment selection but is not a poor prognostic indicator when treated with modern NAC and multidisciplinary disease management.

Single-Center Insights into Cesarean Scar Pregnancy: Treatment Strategies and Determinants

Background: This study aimed to evaluate the effectiveness of different treatments for cesarean scar pregnancy (CSP) and to identify key factors influencing treatment selection, in order to help standardize CSP management. Methods: We retrospectively analyzed data from 220 CSP patients at the Family Planning Department of the Women’s Hospital, School of Medicine, Zhejiang University, from January 2019 to December 2019, adhering to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. Treatment methods included dilation and curettage (D&amp;C), curettage after uterine artery embolization (UAE+C), hysteroscopy plus curettage (H/S+C), H/S+C following UAE (UAE+H/S+C), and hysteroscopy combined with laparoscopic resection (L/S+H/S). We assessed treatment outcomes by evaluating the normalization of serum β-human chorionic gonadotropin (β-hCG) levels, disappearance of the isthmic mass, and the occurrence of complications. Results: No significant difference in treatment success rates was found among the groups (p &gt; 0.05). Larger gestational sac diameter (GSD) and thinner myometrial thickness were significant factors in choosing uterine artery embolization (UAE) (p &lt; 0.05), while thinner myometrial thickness alone was a predictor for selecting H/S+C (p &lt; 0.05). The presence of a fetal heartbeat and the subtype of CSP also influenced the choice of UAE and surgical treatment (p &lt; 0.05). Conclusions: This study highlights the need for personalized treatment plans for CSP, considering factors like GSD, myometrial thickness, heartbeat, and CSP subtype. Although no treatment method proved superior, the study identifies important considerations for treatment selection, emphasizing the importance of individualized care in CSP management. The use of STROBE guidelines ensured comprehensive reporting and analysis, offering valuable insights for CSP treatment.

Treatment selection and real-world analysis of immunotherapy with or without chemotherapy in PD-L1-high metastatic non-small cell lung cancer.

Lung cancer is the leading cause of cancer death in Australia. Immunotherapy has improved outcomes in patients with metastatic non-small cell lung cancer (NSCLC). Pembrolizumab is approved in first-line treatment as single-agent immunotherapy (SAI) or combination chemoimmunotherapy (CIT). In metastatic NSCLC programmed death-ligand 1 (PD-L1) ≥50% either regimen may be used. We aim to identify patient and tumour characteristics that influence treatment selection. This is a retrospective observational study. Pharmacy records identified patients with metastatic/recurrent NSCLC receiving pembrolizumab at two metropolitan centres in Victoria, Australia, since 2018. Demographics, tumour characteristics, Charlson Comorbidity Index (CCI) and treatment data were collected. Descriptive and multivariate analyses were performed. Sixty-one patients had metastatic NSCLC PD-L1 ≥50% and received pembrolizumab with median age of 65.6 years, Eastern Cooperative Oncology Group 0-1 in 82%. CIT was administered to 23% (14) with no difference in rate of delivery between centres (P = 0.808). CCI mean score differed (3.38 SAI vs 2.36 CIT, P = 0.042). Patients with high CCI score (≥2) were less likely to receive CIT (OR = 0.15, P = 0.003, 95% confidence interval (CI) 0.04-0.57). Primary tumours over 5 cm were more likely to receive CIT (OR = 3.74, P = 0.043, 95% CI = 1.04-13.42). Site-specific metastases of liver, brain and pericardial effusion were not associated with CIT. Patients with higher comorbidity score were less likely to receive CIT, suggesting chemotherapy avoidance in comorbid patients. Larger tumours are associated with CIT use, indicating that oncologists may use tumour size as a surrogate of disease burden. Limitations include small sample size and data cut-off. Future prospective studies could incorporate comorbid status and a validated disease burden score to stratify patients.

Commercial Versus Medicaid Insurance and Use of High-Priced Anticancer Treatments.

Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents.

A tale of two pathways: Review of immune checkpoint inhibitors in DNA mismatch repair-deficient and microsatellite instability-high endometrial cancers.

The DNA mismatch repair (MMR) pathway is critical for correcting DNA mismatches generated during DNA replication. MMR-deficiency (MMR-D) leads to microsatellite instability (MSI) associated with an increased mutation rate, driving cancer development. This is particularly relevant in endometrial cancer (EC) as 25%-30% of tumors are of MMR-D/MSI-high (MSI-H) phenotype. Comprehensive assessment using immunohistochemistry (IHC) and sequencing-based techniques are necessary to fully evaluate ECs given the importance of molecular subtyping in staging and prognosis. This also influences treatment selection as clinical trials have demonstrated survival benefits for immune checkpoint inhibitors (ICIs) alone and in combination with chemotherapy for MMR-D/MSI-H EC patients in various treatment settings. As a portion of MMR-D/MSI-H ECs are driven by Lynch syndrome, an inherited cancer predisposition syndrome that is also associated with colorectal cancer, this molecular subtype also prompts germline assessment that can affect at-risk family members. Additionally, heterogeneity in the tumor immune microenvironment and tumor mutation burden (TMB) have been described by MMR mechanism, meaning MLH1 promoter hypermethylation versus germline/somatic MMR gene mutation, and this may affect response to ICI therapies. Variations by ancestry in prevalence and mechanism of MMR-D/MSI-H tumors have also been reported and may influence health disparities given observed differences in tumors of Black compared to White patients which may affect ICI eligibility. These observations highlight the need for additional prospective studies to evaluate the nuances regarding MMR-D heterogeneity as well as markers of resistance to inform future trials of combination therapies to further improve outcomes for patients with EC.

Medication-based Comorbidity Measures and Prostate Cancer Treatment Selection

IntroductionWe aimed to assess the association between comorbidities and prostate cancer management. Patients and methodsWe studied 12,603 South Australian men diagnosed with prostate cancer between 2003 and 2019. Comorbidity was measured one year prior to prostate cancer diagnosis using a medication-based comorbidity index (Rx-Risk). Binomial logistic regression analyses were used to assess the association between comorbidities and primary treatment selection (active surveillance, radical prostatectomy (RP), external beam radiotherapy (EBRT) with or without androgen deprivation therapy (ADT), brachytherapy, ADT alone, and watchful waiting (WW)). Certain common comorbidities within Rx-Risk (cardiac disorders, diabetes, chronic airway diseases, depression and anxiety, thrombosis, and chronic pain) were also assessed. All models were adjusted for sociodemographic and tumor characteristics. ResultsLikelihood of receiving RP was lower among men with Rx-Risk score ≥3 (odds ratio (OR) 0.62, 95%CI:0.56-0.69) and Rx-Risk 2 (OR 0.80, 95%CI:0.70-0.92) compared with no comorbidity (Rx-Risk ≤0). Men with high comorbidity (Rx-Risk ≥3) were more likely to have received ADT alone (OR 1.76, 95%CI:1.40-2.21), EBRT (OR 1.30, 95%CI:1.17-1.45) or WW (OR 1.49, 95%CI:1.19-1.88) compared with Rx-Risk ≤0. Pre-existing cardiac and respiratory disorders, thrombosis, diabetes, depression and anxiety, and chronic pain were associated with lower likelihood of selecting RP and higher likelihood of EBRT (except chronic airway disease) or WW (except diabetes and depression and anxiety). Cardiac disorders and thrombosis were associated with higher likelihood of selecting ADT alone. Furthermore, age had greater effect on treatment choice than the level of comorbidity. ConclusionHigh comorbidity burden was associated with primary treatment choice, with significantly less RP and more EBRT, WW and ADT alone among men with higher levels of comorbidity. Each of the individual comorbid conditions also influenced treatment selection.

Efficacy of Microneedling and CO2 Laser for Acne Scar Remodelling: A Comprehensive Review.

Acne scarring is a prevalent issue affecting millions worldwide, with significant psychological and social implications. Microneedling and CO2 laser therapy have emerged as promising modalities for acne scar remodelling. Microneedling induces controlled micro-injuries to stimulate collagen production, while CO2 laser therapy precisely ablates scar tissue. This comprehensive review evaluates the efficacy, safety, and comparative benefits of microneedling and CO2 laser therapy. Literature synthesis reveals both modalities to improve acne scars, albeit with different mechanisms and risks. Factors influencing treatment selection and the role of combination therapy are discussed. Future directions include optimising protocols and exploring novel techniques. Overall, microneedling and CO2 laser therapy offer valuable options for acne scar management, empowering individuals to address the physical and emotional burden of scarring.

Patient experiences in making PTSD treatment decisions.

Although there is a range of effective posttraumatic stress disorder (PTSD) treatments, the number of patients who receive those treatments is disappointingly low (Finley et al., 2015; Maguen et al., 2018). Very little research has examined the patient experience of deciding on a PTSD treatment option and how that experience influences treatment preference and selection. In a sample of 12 veterans and 10 providers, we recorded the sessions in which providers discussed PTSD treatment options with their patients and then interviewed patients to ask their impressions of those same sessions. Specifically, using qualitative analysis, we sought to understand (a) patient preferences and experiences of choosing a PTSD treatment option, (b) what information patients retain from treatment planning sessions, and (c) why patients chose a given treatment. Almost all the patients in this sample chose an evidence-based psychotherapy but could remember little about the options afterward. Patients reported that providers presented options neutrally and that they made shared decisions with their providers. Most could talk through their reasons for coming to a decision and felt comfortable with the decision, but decisions were often made heuristically rather than deliberatively. Surprisingly, a few patients had a hard time explaining why they chose a specific treatment, were not conscious of their exact reasons for choosing a treatment, or seemed unable to remember why they chose a treatment. We also noticed subtle ways in which providers' discussions influenced treatment choice. Implications for practice are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise.

Worldwide, many people who would benefit from osteoporosis drugs are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate treatment regimens for prevention of osteoporotic fractures. A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered from a large programme of related research studies about bisphosphonate regimens and from recent published international clinical guidelines. Clinical and public stakeholders refined the list of uncertainties into research questions. The third step prioritised the questions using a modified nominal group technique. In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. The top 10 includes questions relating to which people should be offered intravenous bisphosphonates first line (1); optimal duration of treatment (2); the role of bone turnover markers in treatment breaks (3); support patient need for medicine optimisation (4); support primary care practitioner need regarding bisphosphonates (5); comparing zoledronate given in community vs hospital settings (6); ensuring quality standards are met (7); the long-term model of care (8); best bisphosphonate for people aged under 50 (9); and supporting patient decision-making about bisphosphonates (10). This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. These findings have implications for research into implementation to address the care gap and education of healthcare professionals. Using James Lind Alliance methodology, this study reports prioritised topics of importance to stakeholders in the research of bisphosphonate treatment in osteoporosis. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care.

Recommandations pour la pratique clinique Nice/Saint-Paul-de-Vence 2022–2023 : Diagnostic histomoléculaire des carcinomes de l'endomètre

French recommendations for clinical practice Nice-Saint-Paul de Vence 2022-2023: histomolecular diagnosis of endometrial carcinomas The characterisation of endometrial carcinomas has been recently modified and enriched by molecular classification, the integration of which now impacts therapeutic decisions on whether adjuvant therapy should be administered or not in localized tumors, and influences treatment selection in advanced disease. Mandatory information includes histological type according to WHO 2020 classification, histological grade, hormone receptors status and molecular classification, the main new elements to provide being analysis of MMR proteins, p53 status and POLE status in selected cases. Sampling and preparation of material must be performed adequately to allow complete analysis. Numerous markers can be used to better define histological type, distinguish between primary lesion or metastases, or provide prognostic information. Determination of MMR/MSI profile is complex but well defined by guidelines that precisely describe techniques to be used and interpretation rules. Knowledge of POLE status is useful to guide therapeutic strategy, especially to consider de-escalation in stages I and II, in particular in case of high grade and/or p53 mutated tumors. This is why indications of POLE determination must be well defined. Finally, oncogenetics consultation is recommended in dMMR tumors (except in case or MLH1 promoter methylation) and in patients with evocative familial history.

P082 Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise

Abstract Background/Aims Worldwide, many people who would benefit from osteoporosis treatment are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate regimens for the treatment of osteoporosis. Methods A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered (Step 1) from recent published international clinical guidelines and a large programme of related research studies about bisphosphonate regimens: the ‘Bisphosphonate aLternAtive regimenS for the prevenTion of Osteoporotic Fragility Fractures’ (Blast Off) study, which consisted of six discrete individual research studies conducted between May 2019 and February 2022, relating to the experience, effectiveness and cost-effectiveness of different bisphosphonate regimens. Clinical and public stakeholders refined the list of uncertainties into research questions (step 2) and then prioritised the questions using a modified nominal group technique (step 3) in two, day-long online workshops. Results In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. Twenty nine stakeholders were involved in refining uncertainties and prioritisation, including 16 public contributors, 2 Allied Health Professionals, 3 GPs and 8 Consultants. The top 10 questions are shown in Table 1. Conclusion This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care. These findings have implications for research into implementation to address the care gap and education of healthcare professionals in the treatment of osteoporosis. Disclosure Z. Paskins: None. A. Moult: None. N. Corp: None. A. Bastounis: None. S. Davis: Grants/research support; Grant from Roche Diagnostics to her employing insitution to fund research into the cost-effectiveness of using a biomarker to monitor response to treatment with antifracture medication. M. Narayanasamy: None. J. Griffin: None. N. Gittoes: None. J. Leonardi-Bee: None. T. Langley: None. S. Bishop: None. O. Sahota: None.

PCR124 First-Line Treatment Patterns Among Patients With Locally Advanced or Metastatic Urothelial Cancer (la/mUC): A Systematic Literature Review

The outcomes of patients with la/mUC are poor; however, systemic treatments (STs) including chemotherapy sequenced by maintenance immunotherapy (IO) are available to extend survival. First-line (1L) treatment patterns and reasons for no receipt of ST (NST) are not well known. We aimed to characterize 1L treatment patterns, NST, attrition rates across line of therapy, and factors influencing treatment selection for patients with la/mUC.

Gonadotropin-releasing hormone analog therapies for children with central precocious puberty in the United States.

Gonadotropin-releasing hormone agonists (GnRHa's) are the standard treatment for children with central precocious puberty (CPP). We aim to present data on available GnRHa options with an easy-to-review table and discuss factors that influence treatment selection. Five GnRHa's are currently FDA-approved and prescribed in the US and published data suggest similar safety and efficacy profiles over the first year of treatment. One- and 3-month intramuscular (IM) leuprolide acetate (LA) have long-term safety and efficacy data and allow for flexible dosing. Six-month IM triptorelin pamoate offers a longer duration of treatment, but without long-term efficacy and outcome data. Six-month subcutaneous (SQ) LA combines a SQ route of injection and long duration of action but lacks long-term efficacy and outcome data. The 12-month SQ histrelin acetate implant avoids injections and offers the longest duration of action, but requires a minor surgical procedure with local or general anesthesia. Factors in treatment selection include route of administration, needle size, injection volume, duration of action, and cost. The current GnRHa landscape provides options with varying benefits and risks, allowing physicians and caregivers to select the most appropriate therapy based on the specific needs and concerns of the child and the caregiver. Agents have different advantages and disadvantages for use, with no one agent displaying superiority.

Superior effects of natalizumab versus other DMTs on patient-reported outcomes in people with multiple sclerosis

BackgroundLittle is known about the comparative effectiveness of multiple sclerosis (MS) disease-modifying therapies (DMTs) on patient-reported outcomes in MS. We compared the effects of natalizumab to other DMTs in relation...

HSD7 Does Clinical Evidence of Heterogeneity Influence Treatment Selection? a Case Study of Abiraterone Acetate for Metastatic Castration-Sensitive Prostate Cancer

Two pivotal clinical trials, both published in June 2017, have demonstrated that abiraterone acetate (AA) combined with androgen deprivation therapy (ADT) significantly extends the survival of metastatic castration-sensitive prostate cancer (mCSPC) patients compared to ADT alone. Yet, the benefits may be pronounced for younger compared with older patients. We aimed to assess whether the publication of the trials’ results was associated with differential AA utilization between age groups.

The Incidence, Prevalence, and Associated Costs of Anemia, Malignancy, Venous Thromboembolism, Major Adverse Cardiovascular Events, and Infections in Rheumatoid Arthritis Patients by Treatment History in the United States.

ObjectiveComorbidities in rheumatoid arthritis (RA) can influence treatment selection, impact treatment persistency, and increase health care costs. This study assessed the magnitude of comorbidity burden via epidemiology (incidence and prevalence) and associated costs of select comorbidities in RA patients: anemia, malignancy, venous thromboembolism (VTE), major adverse cardiovascular events (MACE), and infections, stratified by history of disease‐modifying antirheumatic drug (DMARD) exposure.MethodsFrom the IQVIA PharMetrics® Plus database, we selected adult patients with RA (2 or more RA diagnostic codes at least 30 days apart) at initiation of a new DMARD (DMARD‐naïve), after the first conventional synthetic DMARD (csDMARD) or after the first biologic DMARD (bDMARD). We assessed pre‐index prevalence (percentage) and on‐treatment incidence (per 100 patient‐years [P100PY]) of the aforementioned comorbidities. For patients with versus without incident conditions, we compared total all‐cause health care costs as unadjusted and adjusted for baseline characteristics and health care costs.ResultsPrior to initiating a new treatment, among DMARD‐naïve patients (N = 28,201), csDMARD switchers (N = 7,816), or bDMARD switchers (N = 4,656), the overall prevalence ranged from 14.1% to 16.2% (anemia), from 1.3% to 5.2% (malignancy, evaluated in csDMARD and bDMARD switchers), from 1.5% to 2.1% (VTE), from 1.8% to 2.9% (MACE), and from 66.6% to 76.1% (infections). Once on index treatment, overall incidence (P100PY) among the cohorts ranged from 6.9 to 8.9 (anemia), from 2.0 to 2.3 (malignancy), from 0.7 to 0.9 (VTE), from 1.6 to 2.0 (MACE), and from 77.4 to 87.7 (infections). The incident comorbidities (except herpes zoster) were associated with increased adjusted health care costs.ConclusionAnemia, malignancy, VTE, MACE, and infections affect patients with RA at all stages of their treatment journey and are associated with increased health care costs.

Esthetic Rehabilitation of Anterior Dentition with Different Types of Ceramic Restorations: Two Case Reports.

All-ceramic systems represent an excellent restorative alternative for fixed dental prostheses, single crowns, and veneers in the anterior dentition. With respect to improved mechanical properties, lithium disilicate ceramic material provide a broad range of indications, and extended veneers can serve as an alternative to full crowns. Although ceramic veneers represent a more conservative approach compared to crowns, the correct indication is essential to achieving the ideal outcome. The following case reports describe two types of fixed restorations of the anterior dentition: extended lithium disilicate ceramic veneers and lithium disilicate full crowns. Factors influencing treatment selection for each type of restorations are presented.

Association between nuclear grade of renal cell carcinoma and the aorta-lesion-attenuation-difference

Several features noted on renal mass biopsy (RMB) can influence treatment selection including tumor histology and nuclear grade. However, there is poor concordance between renal cell carcinoma (RCC) nuclear grade on RMB compared to nephrectomy specimens. Here, we evaluate the association of nuclear grade with aorta-lesion-attenuation-difference (ALAD) values determined on preoperative CT scan. A retrospective review of preoperative CT scans and surgical pathology was performed on patients undergoing nephrectomy for solid renal masses. ALAD was calculated by measuring the difference in Hounsfield units (HU) between the aorta and the lesion of interest on the same image slice on preoperative CT scan. The discriminative ability of ALAD to differentiate low-grade (nuclear grade 1 and 2) and high-grade (nuclear grade 3 and 4) tumors was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) using ROC analysis. Sub-group analysis by histologic sub-type was also performed. A total of 368 preoperative CT scans in patients with RCC on nephrectomy specimen were reviewed. Median patient age was 61years (IQR 52-68). The majority of patients were male, 66% (243/368). Tumor histology was chromophobe RCC in 7.6%, papillary RCC in 15.5%, and clear cell RCC in 76.9%. The majority, 69.3% (253/365) of tumors, were stage T1a. Nuclear grade was grade 1 in 5.46% (19/348), grade 2 in 64.7% (225/348), grade 3 in 26.2% (91/348), and grade 4 in 3.2% (11/348). Nephrographic ALAD values for grade 1, 2, 3, and 4 were 73.7, 46.5, 36.4, and 43.1, respectively (p = 0.0043). Nephrographic ALAD was able to differentiate low-grade from high-grade RCC with a sensitivity of 32%, specificity of 89%, PPV of 86%, and NPV of 36%. ROC analysis demonstrated the predictive utility of nephrographic ALAD to predict high- versus low-grade RCC with an AUC of 0.60 (95% CI 0.51-0.69). ALAD was significantly associated with nuclear grade in our nephrectomy series. Strong specificity and PPV for the nephrographic phrase demonstrate a potential role for ALAD in the pre-operative setting that may augment RMB findings in assessing nuclear grade of RCC. Although this association was statistically significant, the clinical utility is limited at this time given the results of the statistical analysis (relatively poor ROC analysis). Sub-group analysis by histologic subtype yielded very similar diagnostic performance and limitations of ALAD. Further studies are necessary to evaluate this relationship further.

Real-world practice patterns in treatment of metastatic breast cancer in Washington State.

e13038 Background: Evidence-based, national guidelines for the management of metastatic breast cancer (MBC) recommend numerous treatment options that do not capture the nuances of real-world practice. Disparities may exist across Washington State with financial implications for patients and health systems. The objective of this study was to assess practice patterns around treatment of ER+/HER2- MBC in actual clinical practice. Methods: We collaborated with Hutchinson Institute for Cancer Outcomes Research (HICOR) to link enrollment and insurance claims records with Washington State cancer registries from 2008-2017. Our cohort comprised of women &gt;18 years old with de novo ER+/HER2- MBC who met enrollment criteria in one of four payors (Premera, Regence, Medicare, or Medicaid). We identified receipt of first line treatment, categorized as CDK4/6 inhibitors plus endocrine therapy (CDKi+ET), chemotherapy (CT), or endocrine therapy alone (ET). We examined factors influencing treatment selection using Fisher's and Kruskal-Wallis tests. Total costs (defined as costs from inpatient and outpatient claims one year after diagnosis) was estimated for patients and payors. Results: We identified 140 patients with de novo ER+/HER2- MBC with median age of 64 (range 28-95). The majority of the cohort were Caucasian (90%) with the rest comprising of Asian, Black, American Indian, and Hispanic patients. Based on the Rural Urban Commuting Area (RUCA) classification, patients predominantly lived in metropolitan neighborhoods (96%). Over 20% of patients lived in areas of high deprivation (area of deprivation index, ADI, 8-10). Patients had either Commercial (40.7%), Medicaid/Medicare (43.6%) or multiple (15.7%) insurance. Our data show that 17 patients (12%) received first line therapy with CDKi + ET, 64 patients (46%) with CT, and 59 patients (42%) with ET alone. Factors influencing treatment selection include age, co-morbidity score, and payor type. Older patients (&gt;65 years old) were more likely to receive ET alone compared to younger patients (56% vs 44%, p value &lt;0.001). Patients with high co-morbidity score were more likely to receive ET (30%) compared to CT (5%) or CDKi + ET (23%), p value &lt;0.001. Patients with commercial insurance made up over 50% of patients in our cohort who received CDKi +ET, while Medicare-insured patients were most likely to receive ET alone (p value &lt;0.001). We estimated the mean cost of receiving first line therapy with CDKi +ET ($20,368 and $175,932), CT ($10,624 and $117,847) and ET alone ($13,292 and $60,338) for patients and payors, respectively (costs inflated to December 2019). Conclusions: Our study shows substantial variation across Washington state in treatment selection and costs for patients with metastatic breast cancer in the first-line setting. Our findings demonstrate the need for initiatives to standardize quality of care relative to clinical guidelines in metastatic breast cancer care.