Mortality In Oncology Patients Research Articles

Quantifying febrile neutropenia rates using electronic medical records in a large integrated delivery network.

e18298 Background: Febrile neutropenia (FN) is a key driver of morbidity and mortality in oncology patients receiving myelotoxic chemotherapy. Identification and prophylaxis per guidelines can result in a substantial reduction of FN risk and is a key oncology quality of care measure. This project evaluated the feasibility of using electronic medical records (EMR) to quantify FN rates and characterize patients at risk for FN. Methods: Search algorithm was used in EMR to identify patients initiating oncologic care between 1/1/2016 and 12/1/2017 at the Masonic Cancer Clinic, University of Minnesota—Fairview Health System, for a lymphoid, gastrointestinal, breast, female genital, or thoracic malignancy. FN event was identified using a diagnosis of neutropenia (ICD-10: D70.x) with associated fever (ICD-10: R50.2-R50.9) or infection (ICD-10: A40.x, A41.x, B95.0-B95.8, B96.0-B96.8, T80.21-T80.29) during the myelotoxic chemotherapy course. FN rates were evaluated overall and by cancer type, disease status, prior chemotherapy use, select comorbidities, age, curative or palliative intent, and treatment plan FN risk. Results: A total of 1,123 patients receiving 1,663 myelotoxic chemotherapy plans were identified. Patients were predominately female (60%) with a mean age of 61 years (SD: 14.1). A total of 66 patients experienced 79 FN events. Of these events, 70 (88.6%) resulted in a hospitalization. The FN rate during the study period was 5.9% (95% CI: 2.3%-10.2%). Factors associated with the highest FN rates were: lymphoid malignancy (9.9%), non-metastatic disease (7.2%), no prior chemotherapy (6.5%), ≥ 3 comorbidities. Conclusions: Our findings indicate it is feasible to estimate FN rates using a search algorithm with a known FN definition in the EMR of a large integrated delivery network. While additional analyses are planned to account for concomitant patient characteristics to fully understand the occurrence of FN, the current project nevertheless demonstrates the ability of estimating FN rates to both measure care quality and allow pursuing quality improvement (QI) initiatives for appropriate FN prophylaxis. The results also have the potential to serve as a benchmark for similar QI projects in other large healthcare systems.

Subjective global assessment against other anthropometric and functional parameters as predictor of hospital length of stay and mortality in oncologic patients

Subjective global assessment against other anthropometric and functional parameters as predictor of hospital length of stay and mortality in oncologic patients

Microbiology and clinical characteristics of viridans group streptococci in patients with cancer

This study assessed the microbiology, clinical syndromes, and outcomes of oncologic patients with viridans group streptococci isolated from blood cultures between January 1st, 2013 and December 31st, 2016 in a referral hospital in Mexico using the Bruker MALDI Biotyper. Antimicrobial sensitivity was determined using BD Phoenix 100 according to CLSI M100 standards. Clinical information was obtained from medical records and descriptive analysis was performed.Forty-three patients were included, 22 females and 21 males, aged 42 ± 17 years. Twenty (46.5%) patients had hematological cancer and 23 (53.5%) a solid malignancy. The viridans group streptococci isolated were Streptococcus mitis, 20 (46.5%); Streptococcus anginosus, 14 (32.6%); Streptococcus sanguinis, 7 (16.3%); and Streptococcus salivarius, 2 (4.7%). The main risk factors were pyrimidine antagonist chemotherapy in 22 (51.2%) and neutropenia in 19 (44.2%) cases, respectively. Central line associated bloodstream infection was diagnosed in 18 (41.9%) cases. Septic shock occurred in 20.9% of patients, with an overall mortality of 18.6%. Only four S. mitis revealed penicillin-resistance.Our results are similar to those of other series, identifying these bacteria as emerging pathogens with significant morbidity and mortality in oncologic patients. The MALDI-TOF system increased the rate of viridans group streptococci isolation in this population.

Effect of pneumocystis jirovecii pneumonia (PJP) on morbidity and mortality in oncology patients: A single centre experience.

e22088Background: Patients with malignancy are at high risk for PJP due to profound immunosuppression from their treatment. Diagnosis may be delayed as many patients present with fevers, respirator...

Association of pre-operative medication use with post-surgery mortality and morbidity in oncology patients receiving comprehensive geriatric assessment.

Comprehensive geriatric assessment (CGA) has become a predictor for elderly cancer patients in post-surgical complications, including post-discharge institutionalization and mortality. To determine whether pre-operative medication use is associated with post-operative morbidity and mortality in oncology patients receiving CGA. Patients aged 65years or older who were scheduled for cancer surgery and presented for CGA were included in the present study. Baseline characteristics of patients were collected from electrical medical records, and pre-operative medication review was performed. The primary outcome was death within 30days after surgery and post-discharge institutionalization. A total of 475 cancer patients were included. Among them, three patients died within 30days after surgery and 14 patients were discharged to another institution. All patients who died within 30days after surgery had polypharmacy with marginal significance (P = 0.087). Multivariate analysis models were constructed using significant factors for post-surgery institutionalization from univariate analysis: Model I (polypharmacy and transfusion), Model II (polypharmacy and infection), and Model III (polypharmacy, transfusion, and infection). Infection was the most significant factor. Its adjusted odds ratio was as large as 11.1 and attributable risk was almost 91%. In pre-surgery medication use, only polypharmacy showed significant association with post-discharge institutionalization. Attributable risk of polypharmacy was around 75%. It is possible that pre-operative medication use has impact on death and post-discharge institutionalization in geriatric oncology patients, further highlighting the importance of medication optimization for elderly patients with cancer surgery.

Abstract 3668: Oncolytic adenoviruses expressing OX40L or GITRL immune modulators show antitumor effect on immune-competent mouse breast cancer models

Abstract Metastasis of advanced stage cancers remains as the main cause of morbidity and mortality in oncologic patients. Metastatic cancers, especially those that metastasize to the brain, are generally resistant to conventional therapies. Thus, more innovative and efficacious therapies are urgently needed. Therapeutic goals are the specific targeting of malignant cells, shrinkage of stablished tumors, prevention and/or eradication of metastases and, ultimately, induction of a specific anti-tumor immune response. In this study we tested the efficiency of a treatment regimen consisting of oncolytic adenoviruses combined with specific immune regulators to prevent tumor progression and metastasis. In order to do so, mouse metastatic breast cancer cells 4T1 or 66c14, were orthotopically implanted in female BALB/c mice. The resulting primary tumors were treated with multiple doses of third generation adenoviruses targeting different immune checkpoints, such as, OX40/OX40L and GITR/GITRL pathways in the immune synapse. The treatment with these adenoviral constructs resulted in T cells activation and reduction of the metastases in 50% of the mice. In addition, the size and number of the metastases detected in lungs were significantly lower comparing with those observed in the control groups. Survival rates were also significantly different (P < 0.046) when compared to controls. FACS analysis of isolated tumor-infiltrating lymphocytes, as well as, splenocytes showed that OX40/OX40L or GITR/GITRL immune therapies were able to activate and increase the number of cytotoxic T cells and suppress tumor anergy. In summary, we demonstrated for the first time that Delta-24-RGDOX and Delta-24-GREAT, expressing OX40L and GITRL respectively, display antitumor effect on immune competent models of metastatic breast cancer. Citation Format: Francisco W. Puerta Martinez, Yisel A. Rivera, Teresa Nguyen, Xuejun Fan, Jared M. Henderson, Shifat Rehnuma, Mohammad B. Hossain, Hong Jiang, Juan Fueyo, Candelaria Gomez Manzano. Oncolytic adenoviruses expressing OX40L or GITRL immune modulators show antitumor effect on immune-competent mouse breast cancer models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3668. doi:10.1158/1538-7445.AM2017-3668

Diagnóstico y prevención de la cardiotoxicidad inducida por fármacos antineoplásicos: de la imagen a las tecnologías «ómicas»

Heart failure due to antineoplastic therapy remains a major cause of morbidity and mortality in oncological patients. These patients often have no prior manifestation of disease. There is therefore a need for accurate identification of individuals at risk of such events before the appearance of clinical manifestations. The present article aims to provide an overview of cardiac imaging as well as new “-omics” technologies, especially with regard to genomics and proteomics as promising tools for the early detection and prediction of cardiotoxicity and individual responses to antineoplastic drugs.Full English text available from:www.revespcardiol.org/en

Early Diagnosis and Prediction of Anticancer Drug-induced Cardiotoxicity: From Cardiac Imaging to “Omics” Technologies

Heart failure due to antineoplastic therapy remains a major cause of morbidity and mortality in oncological patients. These patients often have no prior manifestation of disease. There is therefore a need for accurate identification of individuals at risk of such events before the appearance of clinical manifestations. The present article aims to provide an overview of cardiac imaging as well as new “-omics” technologies, especially with regard to genomics and proteomics as promising tools for the early detection and prediction of cardiotoxicity and individual responses to antineoplastic drugs.

The Current and Future Treatment of Brain Metastases.

Brain metastases are the most common intracranial malignancy, accounting for significant morbidity and mortality in oncology patients. The current treatment paradigm for brain metastasis depends on the patient’s overall health status, the primary tumor pathology, and the number and location of brain lesions. Herein, we review the modern management options for these tumors, including surgical resection, radiotherapy, and chemotherapy. Recent operative advances, such as fluorescence, confocal microscopy, and brachytherapy, are highlighted. With an increased understanding of the pathophysiology of brain metastasis come increased future therapeutic options. Therapy targeted to specific tumor molecular pathways, such as those involved in blood–brain barrier transgression, cell–cell adhesion, and angiogenesis, are also reviewed. A personalized plan for each patient, based on molecular characterizations of the tumor that are used to better target radiotherapy and chemotherapy, is undoubtedly the future of brain metastasis treatment.

Rationale for setting up a cardio-oncology unit: our experience at Mayo Clinic

BackgroundThe diagnosis and management of cardiovascular complications have become a clinical concern for oncologists, cardiologists, surgeons, interventional radiologists, radiation therapy physicians, internists, nurses, pharmacists, administrators, and all the stakeholders involved in the care of cancer patients. Anticancer therapies have extended the lives of patients with cancer, but for some this benefit is attenuated by adverse cardiovascular effects.MethodsThis review article aims to provide an overview of the rationale of setting up a cardio-oncology unit and reflect on our own experience establishing this service, and conclude with some fundamental aspects of consideration for evaluation and management of patients with cancer and cardiovascular diseases.ResultsCardiotoxicity can lead to congestive heart failure and cardiac death. In fact, chemotherapy-related cardiac dysfunction may carry one of the worst prognoses of all types of cardiomyopathies, and has a profound impact on morbidity and mortality in oncology patients. Other complex clinical situations involve cancer patients who might benefit from a highly curative drug in terms of cancer survival but face limitations of its administration because of concomitant cardiovascular diseases. Indeed, the balance between the benefits and risks of the cancer therapy regimen in the context of the cardiovascular status of the individual patient can sometimes be extraordinarily challenging. A subspecialty with a multidisciplinary integrative approach between oncologists, hematologists, cardiologists, among others has thus emerged to address these issues, termed cardio-oncology. Cardio-oncology addresses the spectrum of prevention, detection, monitoring and treatment of cancer patients with cardiovascular diseases, or at risk for cardiotoxicity, in a multidisciplinary manner. In this field, cardiologists assist oncologists and hematologists with cardiovascular recommendations. This can be mediated through e-consultations or face-to-face evaluations.ConclusionCardio-oncology is a subspecialty that assists in the overall care of cancer patients with and without cardiovascular disease in an interdisciplinary fashion. We believe that this partnership of sharing responsibilities and experiences among health-care team members can potentially decrease cancer therapeutics-related cardiovascular complications and improve clinical outcomes.

An Analysis of VTE Prophylaxis Practice in Oncology Patients after Implementation of a Standardized Mandatory Computerized Clinical Decision Support Tool

▪Introduction: Venous thromboembolism (VTE) is an important cause of morbidity and mortality in oncology patients. Prophylaxis reduces the risk of VTE by 60% but many patients are not prescribed risk-appropriate VTE prophylaxis. We developed mandatory computerized clinical decision support-enabled, service-specific (CCDS) order sets to improve our institution’s VTE prophylaxis performance. The order sets require providers to complete short check lists to assess VTE risk factors and contraindications to pharmacologic prophylaxis. Based upon the answers to these questions, the order sets display the risk-appropriate VTE prophylaxis regimen for each individual patient. The purpose of this retrospective study is to evaluate VTE prophylaxis and events rates in hospitalized cancer patients admitted using a CCDS medical oncology VTE order set.Methods: Using electronic administrative records, we retrospectively collected prescription and clinical data on patients admitted to the solid tumor and hematologic malignancy services at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center (JHSKCCC) from October 17, 2010 (date of order set implementation) through June 30, 2014. A two-sided student’s t test or chi-square test were used for statistical analyses, as appropriate.Results: 7920 patients were admitted from 10/17/2010 to 6/30/14. The mean age was 57 years and 46% were female. The median length of stay was 4 days. Solid tumor service providers were more likely to prescribe risk-appropriate VTE prophylaxis (Table 1) and patients on the solid tumor service were more likely to be assessed as being at high risk for VTE (Table 2). Pharmacologic prophylaxis was more common on the solid tumor service while ambulation was the most common form of prophylaxis on the hematologic malignancy service. (Table 3) Risk-appropriate VTE prophylaxis was high on both services (Figure 1). Data on objectively-confirmed hospital-acquired VTE will be presented at the meeting.Conclusion: We report the largest analysis to date of VTE prophylaxis practices in hospitalized cancer patients. Significant differences in perceived VTE risk and prescribed prophylaxis were noted between services. Use of a computerized decision support-enabled VTE prophylaxis order set was associated with high rates of risk-appropriate VTE prophylaxis.Table 1:Patient Population CharacteristicsSolid TumorHeme MalignancyP-ValueTotal – no.49952925Mean Age – no. (SD)58.0 (13.2)56.1 (14.7)<0.001Female – no.2290 (46%)1303 (45%)Median length of stay (IQR)4 (3-6)5 (3-10.5)Risk Appropriate Prophylaxis4410 (88%)2474 (85%)<0.001Table 2:VTE Risk Assessment of Patient PopulationVTE Risk CategorySolid TumorHeme MalignancyP-valueHigh Risk – no. (%)4782 (96%)2338 (80%)<0.001High Risk w/ CI –no. (%)1222 (25%)1789 (61%)<0.001High Risk w/o CI - no. (%)3560 (71%)549 (19%)<0.001Moderate Risk – no. (%)213 (4%)587 (20%)<0.001Mod. Risk w/ CI – no. (%)41 (1%)506 (17%)<0.001Mod. Risk w/o CI – no. (%)172 (3%)81 (3%)<0.001CI= Contraindication to pharmacologic prophylaxisTable 3:VTE Prophylaxis OrdersMedical OncologyHeme MalignancyP-valuePharm Only – no. (%)2992 (69%)412 (15%)<0.001Mech Only – no. (%)700 (16%)563 (20%)Pharm + Mech – no. (%)388 (9%)87 (3%)Ambulation Only – no. (%)230 (5%)1699 (61%)<0.001Pharm= pharmacologic prophylaxis (i.e. unfractionated or low molecular weight heparin, fondaparinux), Mech= graduate compression stockings or sequential compression devices or both [Display omitted] DisclosuresStreiff:Boehringer-Ingelheim: Consultancy; Daiichi-Sankyo: Consultancy; Janssen Healthcare: Consultancy; Pfizer: Consultancy; Portola: Research Funding.

CTPA for clinically suspected pulmonary emboli in oncology patients

Aim Pulmonary embolism (PE) is a known cause of morbidity and mortality in oncology patients. Whilst much of the literature focuses on the detection of incidental PE in this cohort of patients (approximately 4%), little is written about the rate of positive CT Pulmonary Angiograms (CTPA) when PE is clinically suspected. We wanted to assess the rate of positive CTPA specifically amongst oncology patients with suspected PE in our teaching hospital.

Pulmonary embolism in oncologic patients: frequency and embolus burden of symptomatic and unsuspected events

Pulmonary embolism (PE) is a common cause of morbidity and mortality in oncologic patients. Furthermore, PE is an unsuspected finding in many cases. To determine the frequency and embolus burden of PE in a consecutive oncologic patient group including symptomatic as well as incidental and initially unreported events. In a retrospective, single-center study from June 2005 to January 2010 all patients with an oncologic disease (ICD-10 code C00 to C96) that received at least one contrast-enhanced computed tomography (CT) examination of the chest were reviewed. The study group included 3270 patients with 6780 examinations. A validated pulmonary artery obstruction index (Mastora score) was used to assess embolus burden. PE was found in 240 of 3270 (7.3%) oncologic patients. The frequency was highly variable among different malignancies ranging from 0% to 25%. In the present study about half of all PE were unsuspected. The mean embolus burden was significantly higher in symptomatic PE than in unsuspected PE (P <0.001). The risk of developing a PE was 1.5 times higher in patients with metastases compared to patients without metastases (P <0.005). Age and sex had no influence on PE risk and embolus burden. PE is a frequent unsuspected finding in staging examinations: particularly in patients with malignancies of the ovary, brain, and pancreas, and in patients with metastases. Therefore, the status of the pulmonary vasculature should be assessed in every staging examination that includes the chest. The effect of therapeutic actions on PE events and the unsuspected finding of PE in follow-up CT examinations require further prospective studies.

Vitamin D3 supplementation to improve fatigue in patients with advanced cancer.

9097 Background: Fatigue is one of the most common symptoms of patients diagnosed with cancer. Vitamin D deficiency has been associated with an increased risk of mortality in oncology patients. We conducted a prospective vitamin D (cholecalciferol) supplementation study to analyse the response to oral D3 supplementation on fatigue in this population of chemo-naïve patients. Methods: Eligibility critera included life expectancy ≥ 6 months, ECOG PS 0-3, low serum 25-hydroxyvitamin D3 at the time of diagnosis (using cutoff value of 32 ng/mL), and normal serum calcium level. Cancer related fatigue was measured with the Functional Assessment of Cancer Therapy Fatigue module (FACT-F). Patients were randomized to receive oral supplementation with 2,000 IU of Vitamin D3 daily for 3 months with standard cancer treatment or to continue standard treatment without vit D3 supplementation. Primary endpoint was changes in the FACT-F scale. Secondary endpoints was improvement of vitamin D serum levels and safety. Results: 69 vit D deficient patients enrolled in the this study between November 2009 and November 2011 returned a baseline FACT-F. The mean serum 25(OH)D levels were 18.7 ng/ml (SD = 7.4) at baseline. Patients in experimental arm showed marked improvement from baseline in fatigue (p&lt;0.05) and vitamin D serum levels after 3 months (p&lt;0.001). There were significant difference in fatigue score in patients with experimental arm and control arm after 3 months of treatment (p&lt; 0.001). Conclusions: Vitamin D supplementation resulted in a significant increase in Fatigue score and serum 25(OH)D levels in vitamin D deficient patients. Fatigue improve rapidly but remain worse in control arm. The safety profile of vitamin D in combination with chemotherapy or BSC was acceptable. [Table: see text]

124 Clostridium difficile infection does not cause higher mortality in oncology patients

124 Clostridium difficile infection does not cause higher mortality in oncology patients

Epidemiology, laboratory characteristics and outcome of blood stream infections in a regional oncology unit: Category: Lesson in Microbiology & Infection Control

Infection is a common cause of morbidity and mortality in oncology patients. The most important risk factor is neutropenia secondary to cytotoxic chemotherapy, although other treatment associated risk factors such as surgery, radiotherapy and use of invasive devices, as well as tumour associated risk factors are important. This immunocompromised group of patients are predisposed to severe, rapidly progressive infections often without development of concurrent inflammation. This, in conjunction with the constantly changing epidemiology of microorganisms, means it is crucial to ensure that locally appropriate empirical antibiotic therapy guidelines are in place.

Small increases in serum creatinine are associated with prolonged ICU stay and increased hospital mortality in critically ill patients with cancer

Declining kidney function has been associated with adverse hospital outcome in cancer patients. ICU literature suggests that small changes in serum creatinine are associated with poor outcome. We hypothesized that reductions in renal function previously considered trivial would predict a poor outcome in critically ill patients with malignant disease. We evaluated the effects on hospital mortality and ICU length of stay of small changes in creatinine following admission to the intensive care unit. We conducted a retrospective cohort study utilizing clinical, laboratory and pharmacy data collected from 3,795 patients admitted to the University of Texas M.D. Anderson Cancer Center's Intensive Care Unit. We conducted univariate and multivariate regression analysis to determine those factors associated with adverse ICU and hospital outcome. Increases in creatinine as small as 10% (0.2 mg/dl) were associated with prolonged ICU stay (5 days vs 6.6 days, p < 0.001) and increased mortality (14.6% vs 25.5%, p < 0.0001). Patients with a 25% rise in creatinine during the first 72 h of ICU admission were twice as likely to die in the hospital (14.3% vs 30.1%, p < 0.001). RIFLE criteria were accurate predictors of outcome, though they missed much of the risk of even smaller increases in creatinine. Even small rises in serum creatinine following admission to the ICU are associated with increased morbidity and mortality in oncologic patients. The poor outcome in those with rising creatinine could not be explained by severity of illness or other risk factors. These small changes in creatinine may not be trivial, and should be regarded as evidence of a decline in an individual patient's condition.

APACHE II and SOFA scores for intensive care and hospital outcome prediction in oncologic patients

The number of acute organ failures has been shown to be an important determinant of prognosis in critically ill cancer patients admitted to an ICU [1]. Although the SOFA score is useful in analyzing the number and the severity of acute organ failures related to ICU mortality, it is not validated to predict outcomes in the ICU. On the other hand, general prognostic models have failed to accurately predict outcomes in the oncologic population [2,3]. Given this, we propose to analyze the ability of the SOFA score compared with the APACHE II score in predicting ICU and inhospital mortality in oncologic patients.

Prophylaxis and treatment of venous thromboembolism in patients with cancer: an update

The close correlation between venous thromboembolism (VTE) and cancer has been known for some time, and numerous reports in the literature have highlighted the epidemiological significance. Moreover, VTE has a substantial impact on morbidity and mortality in oncological patients. The prevention and treatment of VTE are important aspects of the clinical management of patients with cancer. The presence of a tumour is often associated with thrombotic complications that are more difficult to diagnose, and sometimes make the treatment of VTE less effective and more likely to cause haemorrhages.

Skin and Wound Assessment and Care in Oncology

To present an in-depth overview of skin and wound assessment and care that will provide a solid foundation to better understand the effects of treatment and cancer on skin and wound care in oncology patients. Current research and published literature. Adequate skin and wound assessment and care are essential to maintaining adequate quality of life and decreasing morbidity and mortality in oncology patients. Any systematic changes in skin and wound care practices for patients with cancer will be led by oncology nurses. Thus, a broad understanding of skin and wounds is essential.