National Comprehensive Cancer Network Recommends Research Articles

Prevalence of anemia and compliance to the National Comprehensive Cancer Network guidelines for workup and treatment of anemia among patients with gynecologic malignancies.

32 Background: The National Comprehensive Cancer Network (NCCN) recommends prompt evaluation of anemic patients with hemoglobin (Hb) ≤ 11g/dL. There are a paucity of studies evaluating compliance with the NCCN guidelines. Our objective was to investigate the prevalence of anemia among patients diagnosed with gynecologic cancers and assess compliance with NCCN guidelines. Methods: We performed a retrospective cohort study of patients diagnosed and treated with gynecologic cancer at our institution from 2008-2018. Tumor-registry-confirmed cancer cases were identified using ICD codes from the Synthetic Derivative (SD) database which is a de-identified copy of our institution’s electronic medical record. Patients were included if they were between the ages of 18 and 89, had their initial care at our institution, and had a Hb within the first 6 months of diagnosis. Dual primaries were excluded. Anemia was defined as Hb ≤ 11g/dL. Anemia was graded using the CTCAE v.4.0. Absolute and possible iron deficiency were defined by NCCN Guidelines. Results: We identified 1031 patients who met our inclusion criteria. The median age was 61 years (range 20 - 86). The most common malignancy was uterine cancer 509 (49%) followed by ovarian 262 (25%), cervical 133 (13%), vulvar 107 (10%) and vaginal 20 (2%). Of the 1031 patients in our study, 662 (64%) were noted to be anemic within six months of diagnosis. Of these patients 128 (19%) were noted to have grade 1, 309 (47%) grade 2, and 225 (34%) grade 3 anemia. Of those who were anemic, 90 (14%) underwent any workup for anemia, of which 63 (10%) had iron studies performed. Of those with iron studies performed, 7 (1%) patients had absolute iron deficiency and 24 (4%) had possible iron deficiency. Despite the small percentage of individuals with anemia evaluation, 266 (34%) patients received treatment of anemia. Treatments included: oral iron 47 (7%), IV iron 6 (1%), and blood transfusion 213 (32%). Conclusions: Anemia is pervasive among gynecologic cancer patients, but compliance with NCCN guidelines is low. Our data suggest there are opportunities for improvement in evaluation and management of anemia among gynecologic cancers.

Evaluation of oncologic outcomes in head and neck cancer patients ≥80 years old based on adherence to NCCN guideline for postoperative adjuvant treatment

There is a paucity of literature characterizing outcomes in older adult patients with head and neck cancer (HNC). This study aims to describe patients from this group, their adherence to National Comprehensive Cancer Network (NCCN) adjuvant treatment guidelines, and the impact of guideline adherence on overall survival (OS). In this retrospective cohort study, we reviewed all patients ≥80 years old with HNC who underwent surgery with curative intent from 2008 to 2016. Adherence to NCCN guidelines was determined in blinded fashion, and quality metrics and OS were compared. One hundred fifty-nine patients met inclusion criteria. The majority of patients (n = 94, 59%) underwent treatment in accordance with NCCN recommendations while 65 (41%) deviated from NCCN guidelines. The two cohorts did not demonstrate a difference in 2-year OS (62% vs 66%, P = .50). Older adult patient outcomes were not different when treatment deviated from NCCN guidelines.

Consulting “Dr. Google” for Prostate Cancer Treatment Options: A Contemporary Worldwide Trend Analysis

BackgroundIn the era of digital data, the Internet has become the primary source from which individuals draw healthcare information. ObjectiveThe aim of the present study is to determine worldwide public interest in prostate cancer (PCa) treatments, their penetrance and variation, and how they compare over time. Design, setting, and participantsAn analysis of worldwide search-engine trends included electronic Google queries from people who searched PCa treatment options from January 2004 to August 2018, worldwide. Join-point regression was performed. Comparisons of annual relative search volume (ARSV), average annual percentage change (AAPC), and temporal patterns were analysed to assess loss or gain of interest. Outcome measurements and statistical analysisEvaluations were made regarding (1) interest in PCa treatments, (2) comparison of people’s interest, and (3) impact of the US Preventive Service Task Force (USPSTF) screening recommendation and National Comprehensive Cancer Network (NCCN) guideline endorsements on Internet searching for PCa treatments. Results and limitationsThe mean ARSV for “prostatectomy” was 73% in 2004 and decreased thereafter, reaching a nadir of 36% in 2014 (APC: –7.2%; 95% confidence interval [CI] –7.8, –6.7; p < 0.01). Similarly, decreased interest was recorded for radiation therapy (AAPC: –3.2%; p = 0.1), high-intensity focused ultrasound (AAPC: –2.3%; p = 0.1), hormonal therapy (AAPC: –11.6%; p < 0.01), ablation therapy (AAPC: –4.1%; p < 0.01), cryotherapy (AAPC: –9.9%; p < 0.01), and brachytherapy (AAPC: –8.3%; p < 0.01). A steep interest was found in active surveillance (AS) (AAPC: +14.2%; p < 0.01) and focal therapy (AAPC: +27.5%; p < 0.01). When trends were compared before and after NCCN and USPSTF recommendations, a consistent decrease of all the treatment options was found, while interest in focal therapy and AS showed an augmented mean ARSV (+19.6 and +31.6, respectively). ConclusionsPeople are increasingly searching the Internet for PCa treatment options. A parallel decrease of interest was found for the nonmonitoring treatments, except for focal therapy, while an important growth of appeal has been recorded for AS. Understanding people inquisitiveness together with their degree of knowledge could be supportive to guiding counselling in the decision-making process and putting effort in certifying patient information. Patient summaryIn the era of digital data, patients are increasingly searching the Internet for prostate cancer (PCa) treatment options. To safeguard patients’ knowledge, it is mandatory to understand how people seek healthcare information, guaranteeing certified and evidence-based information pertaining to PCa treatments options.

Evaluation of the utility of localized adjuvant radiation for node-negative primary cutaneous squamous cell carcinoma with clear histologic margins

Though the National Comprehensive Cancer Network recommends consideration of localized adjuvant radiation after clear-margin surgery for cutaneous squamous cell carcinoma (cSCC) with large-caliber (≥0.1-mm) nerve invasion (LCNI) and other high-risk features, only a single small study has compared surgery plus adjuvant radiation therapy (S+ART) to surgical monotherapy (SM) for cSCC. Compare S+ART to SM for primary cSCCs with LCNI and other risk factors. Matched retrospective cohort study of primary cSCCs (matched on sex, age, immune status, type of surgery, diameter, differentiation, depth, and LCNI) treated with S+ART versus SM. A subgroup analysis of cSCCs with LCNI was performed. In total, 62 cSCCs were included in matched analysis (31 S+ART and 31 SM) and 33 cSCCs in the LCNI analysis (16 S+ART and 17 SM). There were no significant differences in local recurrence, metastasis, or death from disease in either analysis. Risk of local recurrence was low (8%, 7/89), with 3 of the local recurrences being effectively treated upon recurrence. Single academic center and nonrandomized design. Adjuvant radiation did not improve outcomes compared with SM due to a low baseline risk of recurrence, although adjuvant radiation for named nerve invasion and LCNI of ≥3 nerves has been shown to improve outcomes in a prior study. Randomized studies are needed to define the subset of cSCC for whom adjuvant radiation has utility.

Magnetic resonance imaging findings of styloglossus and hyoglossus muscle invasion: Relationship to depth of invasion and clinical significance as a predictor of advisability of elective neck dissection in node negative oral tongue cancer

PurposeBy comparing styloglossus and hyoglossus muscle invasion (SHMI) of oral tongue squamous cell cancer (OTSCC) on MR imaging to pathological depth of invasion (DOI) and prognosis, we aimed to evaluate the clinical significance of MR imaging findings of SHMI. MethodForty-five, early stages and clinically N0 OTSCCs were retrospectively reviewed. Data included pathological DOI, DOI on MR imagings, two-year potential cervical lymph node positive, locoregional control, disease-free survival, and overall survival. Data were statistically compared between the groups with MR evidence of SHMI (SHMI+) and without MR evidence of SHMI (SHMI-). ResultsThere were 17 SHMI + and 28 SHMI-. Elective neck dissections performed on 13 cases revealed five node positive cases, all of which were SHMI + . Pathological DOI in SHMI + was significantly larger than SHMI- (average 9.0 vs 4.6 mm, p < 0.001). All SHMI + revealed pathological DOI larger than 4 mm. The two-year potential cervical lymph node positive rate of SHMI + was significantly higher than SHMI- (p = 0.01). Locoregional control rate and disease-free survival of SHMI+ were significantly lower than in SHMI- (p = 0.02). There was no significant difference in overall survival. Interobserver agreement in evaluation of SHMI on MR imaging was good (kappa value = 0.72, p < 0.001). ConclusionsPathological DOIs of SHMI + were all larger than 4 mm, which is the cut-off point that National Comprehensive Cancer Network recommends for neck dissection, and SHMI + had a worse prognosis than SHMI-. SHMI + can be used as a criterion for elective neck dissection.

PS1060 CO‐OCCURRENCE OF DNMT3A‐R882, FLT3 AND NPM1 MUTATIONS IDENTIFIES A SUBSET OF AML PATIENTS WITH ADVERSE PROGNOSIS

Background:DNMT3A mutations are found in approximately 22% of adult acute myeloid leukemia (AML) cases, occurring more commonly in a hotspot at codon 882. These mutations are an early event in leukemogenesis, causing impaired DNA methylation and aberrant gene expression. Previous studies have shown that isolated DNMT3A mutations may cause limited clonal hematopoiesis in healthy individuals, however, additional mutations in genes such as FLT3 or NPM1 are required for leukemic transformation. Despite its well‐recognized role in AML development, little is known about the prognostic repercussions of the interaction between these three genes.Aims:Here, we aimed to investigate i) the clinical and biological differences between #R882 (hotspot) and non‐R882 mutations in AML and ii) the impact of the synergism between DNMT3a, FLT3 and NPM1 mutations on patient survival.Methods:218 non‐selected adult AML patients (non‐AML M3) followed in a reference center in northeast Brazil were enrolled. Additionally, 180 patients from The Cancer Genome Atlas (TCGA) databank were evaluated as an independent cohort. Brazilian patients were treated according to the 7+3 chemotherapy protocol followed by consolidation with high doses of cytarabine, while patients from the TCGA cohort were treated according to the National Comprehensive Cancer Network recommendations. Screening for DNMT3a mutations was performed by direct Sanger Sequencing.Results:DNMT3A R882 mutations were associated with FAB monocytic AML subtypes (M4 and M5), higher leukocyte counts, normal karyotype and FLT3 and NPM1 mutations (more evident for FLT3/NPM1 double‐positivity), while non‐R882 mutations were associated with NRAS and IDH2 mutations. Analysis of TCGA patient's transcriptome data revealed that patients harboring concomitant DNMT3a, FLT3 and NPM1 mutations had different patterns of gene expression compared to their counterparts with isolated mutations. Next, to address whether the association between DNMT3a R882, FLT3 and NPM1 mutations is clinically relevant, we created a composite variable grouping patients harboring DNMT3a R882 mutations with at least one mutation in FLT3 or NPM1 (here referred to as R882/FLT3/NPM1). Strikingly, patients assigned to the R882/FLT3/NPM1 group had significantly poorer overall (Brazilian cohort: HR: 2.44, 95% CI: 1.35–4.44; P = 0.002 and TCGA cohort: HR: 1.83, 95% CI: 1.09–3.06; P = 0.022) and disease‐free survival rates (Brazilian cohort: HR: 1.94, 95% CI: 1.08–5.92; P = 0.027 and TCGA cohort: HR: 2.06, 95% CI: 1.11–3.81; P = 0.021) in both cohorts. Similar results were observed when analysis was restricted to the normal‐karyotype group. On the other hand, individual analysis of DNMT3a (or #R882 only) mutations showed only a tendency for shorter survival that did not reached statistical significance in both cohorts. Proportional hazards modeling showed that R882/FLT3/NPM1, but not single mutational status, remained independently predictive of poor outcomes (Brazilian cohort: HR: 1.97, 95% CI: 1.06–3.84; P = 0.048 and TCGA cohort: HR: 2.14, 95% CI: 1.24–3.68; P = 0.006).Summary/Conclusion:AML patients with R882 mutations have distinct clinical and molecular signatures from those with non‐R882. At the transcriptome level, triple positive‐mutated patients (DNMT3a‐R882, FLT3 and NPM1) cluster differently from the single positives ones, suggesting functional interaction between these mutations. By transposing these findings into a composite variable, we show that the synergism between DNMT3a, FLT3 and NPM1 mutations identifies a subset of AML with a particularly adverse prognosis.

Performance of Oncotype Dx test in patients with T1bN0, grade 1, hormone receptor-positive, HER2-negative breast cancer.

e12043 Background: NCCN (National comprehensive cancer network) recommends to consider Oncotype DX testing for patients diagnosed with T1bN0 stage 1A breast cancers that are hormone receptor positive and HER-2 negative. This study is a retrospective review of these patients diagnosed at Cone Health Cancer Center between 2012 and 2018 who had Oncotype DX testing. Methods: Patients with T1b hormone receptor positive and HER-2 negative breast cancers, who had Oncotype DX testing performed were queried from tumor registry from 2012 to 2018. Registry provided data on the patients ER/PR and Her 2 neu as well as whether they received chemotherapy. Patient charts were reviewed for grade, Ki 67 and their Oncotype Dx scores. Results: A total of 104 patients with T1b N0 (stage IA ) invasive breast cancers that were ER and PR positive and HER-2 negative between 2012 and 2018 had Oncotype DX test performed. Grade 1 tumors comprised 75 patients. Among these, four patients received adjuvant chemotherapy who had Oncotype scores of 22, 27, 29 and 38. Among patients with Ki 67 ≤ 10% and grade 1, only one patient out of 104 required chemotherapy. Conclusions: This retrospective analysis suggests that 97% of patients with T1b, grade 1, ER/PR positive, HER-2 negative breast cancers had Oncotype scores of less than 25. Hence Oncotype testing may be safely omitted for this group. Grade along with Ki 67 can identify a subset of T1bN0 ER/PR positive and Her 2 negative patients who do not need Oncotype testing.[Table: see text]

Surveillance for Hepatocellular Carcinoma: Current Best Practice and Future Direction.

Hepatocellular cancer (HCC) is the fourth leading cause of cancer-related deaths worldwide and the fastest growing cause of cancer deaths in the United States. The overall prognosis of HCC remains dismal, except for the subset of patients who are diagnosed at early stage and receive potentially curative therapies, such as surgical resection and liver transplantation. Given this, expert society guidelines recommend HCC surveillance every 6 months in at-risk individuals. Despite these recommendations, the effectiveness of HCC surveillance remains a subject of debate. We discuss current best practices for HCC surveillance and the evidence that support these recommendations. We also describe several initiatives that are underway to improve HCC surveillance and outline areas that may serve as high-yield targets for future research. Overall, we believe these efforts will help the field move toward precision surveillance, where surveillance tests and intervals are tailored to individual HCC risk. Doing so can maximize surveillance benefits, minimize surveillance harms, and optimize overall value for all patients.

Clinically node-negative head and neck mucosal melanoma: An analysis of current treatment guidelines & outcomes

ObjectivesTo analyze head and neck mucosal melanoma (MM) treatment patterns, and their association with survival, relative to National Comprehensive Cancer Network (NCCN) guidelines. Material & methodsAdult head and neck MM patients with clinically-staged T3/4aN0 disease were identified in a retrospective analysis of the National Cancer Database (2010–2014) and stratified into sinonasal cavity (SN) and oral cavity, oropharynx, larynx, or hypopharynx (non-SN) cohorts. ResultsWe identified 353 SN and 79 non-SN MM cases. The majority of patients were treated with surgery (SN: 92.4%; non-SN 84.8%), within NCCN guidelines. Treatment within the non-SN MM NCCN recommendation of elective neck dissection (END) was approximately 26.6%. END is not recommended for SN MM and was not performed in 91.5% of cases. Radiotherapy (RT) is recommended in both SN and non-SN MM and was utilized in 63.5% of SN patients and 46.8% of non-SN patients.END was not independently associated with OS compared to surgery alone (SN HR: 1.350 [95% CI: 0.733–2.485]; non-SN HR: 3.460 [95% CI: 0.912–13.125]). RT was independently associated with improved OS in SN MM cases (HR: 0.679 [95% CI: 0.479–0.963]), but not in non-SN MM cases (HR: 0.824 [95% CI: 0.331–2.051]). ConclusionThe majority of patients with head and neck MM are not treated within NCCN guidelines. The use of recommended END in non-SN patients is low. Similarly, adjuvant RT utilization is low. Our analysis shows that while greater use of RT may increase survival rates in this disease, the utility of END is unclear.

Abstract P4-03-04: Genetic testing contributes significantly to improved identification of women eligible for increased breast cancer screening compared to the Tyrer-Cuzick risk model

Abstract Background: Increased screening, including breast MRI, is recommended for women carrying pathogenic variants (PVs) in certain breast cancer risk genes, as well as women with an estimated remaining lifetime risk of breast cancer &amp;gt;20% based on risk models such as Tyrer-Cuzick (TC). We determined the extent to which genetic testing identifies women as candidates for increased screening who would not have been flagged using the TC model. Methods: We evaluated 100,318 women who underwent clinical genetic testing for suspicion of hereditary breast cancer risk between June 2017 and June 2018. Testing with a 28 gene pan-cancer panel included 5 established breast cancer risk genes for which there are National Comprehensive Cancer Network (NCCN) recommendations for increased screening including breast MRI (BRCA1, BRCA2, ATM, CHEK2, PALB2). A remaining lifetime breast cancer risk estimate was calculated using TC V 7.02, unless the woman was ineligible due to a breast cancer diagnosis, age over 85, or if the sample was submitted without any of the necessary TC data. Risk estimates were calculated entering the BRCA1/2 status as unknown. Results: 4,640 (4.6%) women were found to carry a PV in one of the five genes, with 57.0% of the PVs in BRCA1 or BRCA2, and 43.0% in ATM, CHEK2 or PALB2. Among the women with a PV, 1,479 (31.9%) had a diagnosis of breast cancer, and 407 (8.8%) were ineligible for TC for another reason. A TC risk estimate was calculated for 2,754 women, of whom 41.5% did not meet the 20% threshold using TC. Table 1 shows the breakdown for each gene by age at the time of testing. Women with PVs in BRCA1 were the least likely to have a TC score &amp;lt;20% and those with PVs in BRCA2 and ATM were the most likely to fall below the 20% threshold. Remaining lifetime risk declined with age in all groups. Table 1.Percentage of women carrying PVs in breast cancer risk genes with a remaining lifetime risk of breast cancer risk estimated at &amp;lt;20% by Tyrer-Cuzick.Age at time of testingBRCA1 (N=1215)BRCA2 (N=1432)ATM (N=609)CHEK2 (N=971)PALB2 (N=413)&amp;lt;2014.8%11.1%0.0%33.3% 20-2922.0%27.3%29.5%28.4%19.1%30-3928.7%38.1%30.3%36.4%22.6%40-4938.4%48.8%47.7%42.5%50.0%50-5949.4%62.7%64.3%52.3%44.4%60-6987.5%78.8%71.9%77.8%71.4%70-79--100.0%100.0%100.0%100.0%80+100.0%--------All ages33.6%45.7%46.3%42.6%37.4% Conclusions: Among the women included in this analysis, the TC model failed to identify approximately 40% of women eligible for high risk breast cancer screening due to PVs in breast cancer risk genes. This demonstrates that risk models based on clinical factors alone will fail to identify a significant fraction of women who are candidates for modified medical management. Additionally, it may be desirable to re-evaluate setting thresholds based on remaining lifetime risk, since this dramatically reduces the likelihood that high-risk women will be flagged for increased screening at older ages, when their immediate risk of a breast cancer diagnosis is likely to be highest. Citation Format: Gorringe HM, Rosenthal E, Morris B, Manley S. Genetic testing contributes significantly to improved identification of women eligible for increased breast cancer screening compared to the Tyrer-Cuzick risk model [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-03-04.

Determining optimal follow up for patients with anal cancer following chemoradiation.

689 Background: U.S. health care is increasingly defined by over expenditure and inefficiency. Optimizing patient follow-up is critical especially in cancers treated with high control rates. The objective of this study was to assess time to disease recurrence or toxicity in a cohort of patients with anal carcinoma in order to optimize patient care. Methods: 140 patients diagnosed with biopsy-proven, non-metastatic anal carcinoma, treated with chemoradiation utilizing IMRT, were identified from an institutional database at our high volume center. After IRB approval, a retrospective study was conducted that evaluated local recurrence (LR), distant metastasis (DM), overall survival (OS), and late ≥ grade three toxicity (LG3T) based on National Cancer Institute Common Terminology for Adverse Events version 4. Patients were followed post-treatment every three months for two years, every six months in years 3-5 then yearly thereafter with imaging per National Comprehensive Cancer Network recommendations. Results: Median age and follow up is 58 years and 27 months, respectively. Patients were staged based on AJCC 8th edition and 24 patients were stage I (17%), 55 stage II (39%) and 61 stage III (44%). The median radiation dose was 54 Gy (range: 40-62.5), and 11% of patients required a radiation break. The two year LC, DMFS, and OS were 93%, 94% and 89% and 5-year LC, DMFS, OS were 92%, 87% and 85% respectively. In total, there were 29 disease or treatment related events: LR occurred in nine patients, DM in 11 patients, and LG3T in nine patients. Overall, 62% of events occurred within year one and 77 % within two years. Stratified by event type, at two years 79% of LR, 64% of DM and 89% LG3T were identified. At the remaining follow-up points after 2 years there was an event incidence rate of 1.4%. Conclusions: The majority of recurrences/toxicities in patients diagnosed with non-metastatic anal carcinoma after chemoradiation occur within the first year, with 77% of any event occurring before year two. The data from individual time points suggest a reduction in follow-up during years 3-5 may provide adequate surveillance. Considering revisions of the current follow-up recommendations could maximize health care resources while also improving patient quality of life.

Population-based assessment of the national comprehensive cancer network recommendations for baseline imaging of hepatocellular carcinoma.

This analysis aims to evaluate the performance characteristics of alternative baseline imaging thresholds in a cohort of hepatocellular carcinoma (HCC) patients from the Surveillance, Epidemiology, and End Results (SEER) database. HCC patients within the SEER database (2010-2015) who had complete information on clinical T and N stages as well as complete information on metastatic sites were eligible for the current study. Various performance characteristics associated with baseline imaging were investigated, including specificity, sensitivity, positive likelihood ratio (LR), negative LR, number needed to investigate (NNI), negative predictive value (NPV), positive predictive value (PPV), and accuracy. A total of 27,201 HCC patients were included. Based on current recommendations that advocate for the use of cross-sectional chest imaging in all newly diagnosed cases of HCC, these recommendations would yield a PPV of 5.0% for the detection of lung metastases. This would translate to an NNI of 20.0. When T1N0 patients were excluded from routine chest or bone imaging, this resulted in a PPV of 6.8% for the identification of lung metastases and an NNI of 14.7. Likewise, this translated to a PPV of 4.6% for the identification of bone metastases and an NNI of 21.7. Similarly, when patients with T1N0 disease and normal alpha-fetoprotein (AFP) were excluded from routine imaging, this resulted in a PPV of 5.6% for the identification of lung metastases and an NNI of 17.8. Also, this translated to a PPV of 3.8% for the identification of bone metastases and an NNI of 26.3. The current study suggests that the omission of routine baseline chest imaging may be considered in selected patients with asymptomatic early-stage HCC and normal AFP.

Population-based validation of the National Comprehensive Cancer Networkrecommendations for baseline imaging for bladder cancer: a case for routine baseline bone scan?

This study aims at evaluating the performance of some of the imaging recommendations of the National Comprehensive Cancer Network (NCCN) for initial evaluation of bladder cancer. Surveillance, epidemiology and end results program (2010-2015) was queried and patients with clinically (T1-T4) bladder cancer and complete information about clinical T/N (tumor/nodal) stage and metastatic sites were extracted. The following characteristics were evaluated in the current analysis: sensitivity,specificity, number needed to investigate (NNI), positive predictive value (PPV), negative predictive value and accuracy. According to the current NCCN guidelines, PPV (for the recognition of lung metastases) is 4.7% and NNI to detect one case of lung metastasis is 21.2. Similarly, PPV (for the recognition of liver metastases) is 3.1% and NNI to detect one case of liver metastasis is 32.2. Using a different imaging threshold (i.e., routinely imaging all patients >T2N0), PPV (for the recognition of lung metastases) is 10.4% and NNI to detect one case of lung metastasis is 9.6. Similarly, PPV (for the recognition of liver metastases) is 7% and NNI to detect one case of liver metastasis is 14.2. The above two thresholds were also evaluated for routine bone scanning. PPV (for the detection of one case of bone metastasis) is 5.3% using the first threshold and 11.2% using the second threshold. Imaging per current NCCN guidelines results in few patients with undetected asymptomatic lung or liver metastases. A routine baseline bone scan should be additionally considered for some asymptomatic patients with muscle-invasive disease.

Opportunities for use of radiation therapy in penile cancer based on patterns of care in the United States from 2007 to 2013.

Background:Radiation therapy (RT) is an effective modality for the treatment of squamous cell carcinomas of the penis. The National Comprehensive Cancer Network recommends consideration of primary radiation for penile preservation, in surgically unresectable tumors, and as adjuvant therapy for positive margins, bulky groin nodes or pelvic nodes. We performed a population-based analysis to evaluate the usage of RT in penile cancer from 2007 to 2013.Methods:We used the Surveillance, Epidemiology and End Results (SEER) database to identify men diagnosed with squamous cell carcinoma of the penis from 2007 to 2013. Patients were grouped as early stage (T1–T2N0), locally advanced (T3–T4N0), node-positive (T1xN1–3) and metastatic. We used linear regression model to test for factors associated with adjuvant radiation in node-positive patients.Results:We identified 2200 men diagnosed with penile cancer between 2007 and 2013. Of these, 66.4% had early stage, 10.7% had locally advanced, 15.5% had node-positive, 3.2% had metastatic cancer. Among patient with early stage cancer, RT was used in 14 patients (1.0%) and postoperative radiation in an additional 45 patients (3.1%). Among 340 patients with node-positive cancer, 62.1% received surgery alone, 5.6% radiation alone, 21.8% surgery with adjuvant radiation, and 10.6% neither surgery nor radiation. Of patients who had surgery, 26.0% had adjuvant radiation. On univariate analysis, higher nodal stage (N2–3 versus N1) was associated with adjuvant radiation (p = 0.02), while there was a trend for higher T-stage (T3/T4 versus T1/T2) (p = 0.08) and history of prior malignancy (p = 0.06). On multivariate analysis, only higher nodal stage (N2–3 versus N1) was associated with use of adjuvant radiation [hazard ratio (HR) 1.94, p = 0.03].Conclusions:A small percentage of patient who are eligible for primary or adjuvant RT in the United States receive this treatment. Further work should be done to assess barriers to use of radiation in patients with penile cancer.

Influenza Vaccination Rates during the First Year after Diagnosis of Diffuse Large B Cell Lymphoma

Objective: Influenza infection is a significant cause of morbidity and mortality in patients with cancer, and thus the National Comprehensive Cancer Network (NCCN) recommends annual influenza vaccination for all individuals with cancer. We sought to examine the documentation rate of influenza vaccination administration, refusal, or discussion of vaccination in the first year after diagnosis of diffuse large B cell lymphoma (DLBCL) for patients across three hospitals in two healthcare systems.Methods: Medical records were reviewed for 114 patients with a new diagnosis of DLBCL between February 2015 and October 2017 who presented to either Emory St. Joseph Hospital (a community hospital setting), Winship Cancer Institute at Emory University (an academic medical center), or Grady Memorial Hospital (a county hospital). Documentation of administration, refusal, or discussion regarding influenza vaccination by physicians, advanced practice providers, or nursing staff during the period of influenza vaccine availability for the first influenza season after diagnosis was assessed.Results: Among 114 patients with newly diagnosed DLBCL, 54% were male, and 46% were over 60 years of age with a median age of 59 years (range 21-88 years). One patient was excluded from analysis as she was enrolled in hospice prior to influenza season. Documentation of influenza vaccination status within 1 year of diagnosis of DLBCL was performed for 56% (63/113) of patients. Nearly 75% (47/63) of documentation regarding vaccination was performed by inpatient nursing staff at time of admission. Documentation of influenza vaccination status was performed by the primary oncologist in 4% (5/113) of all cases and 8% of the documented cases respectively (5/63). The county hospital and the academic medical center had higher documentation of vaccination rates (62% [5/8] and 60% [27/45], respectively) compared with the community hospital (50% [5/10]). Of the patients with documentation of influenza vaccination status, vaccine refusal was documented for 41% (26/63) of patients, and counseling regarding the importance of vaccination was not documented for any patient.Conclusions: Our study shows that documentation of education and administration of influenza vaccination is suboptimal in these 2 healthcare systems. Although vaccinations that occurred outside of these healthcare systems by primary care providers, pharmacies, and other providers would not be recorded in this dataset unless the patient had a hospital admission, these data suggest a gap in patient care and education that could lead to increased risk of worse outcomes from influenza infection. Routine outpatient vaccination screening and counseling in oncology clinics will be explored to improve documentation of influenza vaccination and influenza vaccination rate. Additionally, strategies for sharing patient information about vaccination between providers in different healthcare systems could improve vaccination compliance in patients with lymphoma. Further work is needed to determine the effectiveness of routine influenza vaccination in patients receiving anti-cancer therapy. DisclosuresAllen:Merck: Research Funding; Bayer: Consultancy. Flowers:BeiGene: Research Funding; Burroughs Wellcome Fund: Research Funding; Pharmacyclics/ Janssen: Consultancy; Genentech/Roche: Consultancy; Bayer: Consultancy; Denovo Biopharma: Consultancy; Eastern Cooperative Oncology Group: Research Funding; Gilead: Research Funding; Spectrum: Consultancy; Celgene: Research Funding; Karyopharm: Consultancy; Genentech/Roche: Research Funding; Janssen Pharmaceutical: Research Funding; TG Therapeutics: Research Funding; OptumRx: Consultancy; Millennium/Takeda: Research Funding; National Cancer Institute: Research Funding; V Foundation: Research Funding; Acerta: Research Funding; Abbvie: Research Funding; Pharmacyclics: Research Funding; Gilead: Consultancy; Abbvie: Consultancy, Research Funding.

North American population-based validation of the National Comprehensive Cancer Network Practice Guideline Recommendations for locoregional lymph node and bone imaging in prostate cancer patients

BackgroundThe National Comprehensive Cancer Network (NCCN) guidelines provide recommendations for staging of prostate cancer patients in the objective regarding presence of locoregional lymph node metastases (LNM) and bone metastases. We tested the performance characteristics of these recommendations in a community setting.MethodsWithin the Surveillance, Epidemiology, and End Results database (2004–2014), we identified patients with available Gleason, clinical stage and prostatic specific antigen. Performance characteristics endpoints consisted of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NVP), overall accuracy and the number needed to image (NNI).ResultsTotally, 191,308 patients were assessable for the validation of the LNM staging recommendations. Sensitivity ranged from 80.6 to 86.3%, specificity from 74.7 to 79.3%, PPV from 7.8 to 8.0%, overall accuracy from 75.0 to 79.3% and NPV was 99.5%. The respective NNI values were 12.5 and 12.8. 197,408 patients were assessable for the validation of bone scan recommendations. These recommendations resulted in 90.8% sensitivity, 76.3% specificity, PPV of 5.7%, NPV of 99.8% and overall accuracy of 76.5%. The NNI was 17.5.ConclusionThe NCCN recommendations for locoregional LNM miss few patients with clinical LNM (0.3–0.4%) and provide a virtually perfect NPV of 99.5%. Also, the recommendations for bone scan miss a marginal number of patients with established bone metastases (0.14%) and yield a virtually perfect NPV of 99.8%.

Prophylactic mastectomy can save patients up to $50,000 compared to lifelong screening in BRCA 1 and BRCA 2 patients

Background: Awareness of value-based, quality carehas become an increasingly important issue for healthcare. Patients with a BRCAmutation have a lifetime risk of developing breast cancer up to 87% by age 70.The option of high-risk screening versus risk-reducing surgery is a physical,emotional, and financial decision. Given the significant expense associatedwith lifetime screening for BRCA 1 and 2 patients, surgery may not only be anoption to prevent cancer but may reduce healthcare cost as well. To date thereare no cost analysis of surgery versus screening from the patient perspective.We designed a study to compare the expense of lifelong screening versusprophylactic mastectomy with reconstruction for BRCA 1 and 2 patients toevaluate potential cost-saving benefits. Methods: We performed a projected cost analysisbased the on an estimate of lifelong, high-risk screening compared toprophylactic bilateral mastectomy with deep inferior epigastric perforator(DIEP) flap reconstruction. We utilized National Comprehensive Cancer Network(NCCN) recommendations to define lifelong high-risk breast screening. Thescreening included the cost of 1 additional office visit per year, an annualbreast magnetic resonance image (MRI), and an annual mammogram. Costs werecalculated from average expenses charged to patients as well estimates from thebilling hotline at our institution. The final estimates are after all discountshave been taken by the hospital and are representative of the final out ofpocket fee that is paid. The high-risk screening cost was compared to the cost ofa bilateral prophylactic mastectomy with DIEP flap reconstruction. Included inthis surgery cost was the operating room fees, plastic surgeon fees, anesthesiafees, and the hospital stay. The patient costs were estimated based on ahypothetical insurance plan with a deductible of $1,000 ,an 80/20 copay, and a$5,000 annual out of pocket maximum. Results: When comparing the totalexpenditures, we found that the estimated annual cost for screening is $2,611.The patient out of pocket cost is then calculated to be $1,322 annually. Thusif a patient has no events, biopsies, or cancers, high-risk screening will costan estimated $67,422 over the patient’s lifetime. The insurance company willpay an estimated $1,405/year with a lifetime total of $71,075. The totallifetime screening cost is $138,497 paid by both the patient and insurancecompany. The bilateral prophylactic mastectomy with DIEP reconstruction costaverage reimbursement was $94,733. Of this cost, the patient will pay her outof pocket maximum for the year, but will not have further charges associatedwith high-risk screening. If an insurance plan has an out of pocket maximum of$5,000 the patient has the potential of a lifetime savings of $62,422 with theadded benefit of a significant cancer risk-reduction. Additionally as the totalout of pocket for the patient is additive, it is most financially beneficialfor the patient to have surgery at a younger age. The insurance provider pays$71,075 for screening and $89,733 for prophylactic surgery. Although theinsurance provide ultimately pays more for surgery in this model, the benefitis in the reduction of cancer and its associated costs. Conclusions: Patients with a BRCA mutation will save morethan $50,000 over their lifetimes by choosing to undergo early risk-reducingprophylactic mastectomy with reconstruction. Therefore the surgery option notonly reduces cancer risk, but also has a significant lifetime cost savings.Patient cost perspectives have not previously been published and we feel that’swhat makes this novel and an asset to future patient conversations.

Evaluation of the impact of a multidisciplinary intervention to increase pneumococcal vaccination rates in patients with advanced lung cancer.

61 Background: National Comprehensive Cancer Network recommends pneumococcal vaccination for adults 19 years and older with cancer. Currently at Massachusetts General Hospital (MGH) pneumococcal vaccination is not part of routine cancer care. A vaccination quality improvement project was developed to increase pneumococcal vaccination in lung cancer patients. The primary objective of this evaluation is to assess the impact of a multidisciplinary intervention to increase pneumococcal vaccination in patients with advanced lung cancer receiving intravenous anticancer therapy. Methods: Thoracic oncology clinic schedule and patient electronic medical records were reviewed prospectively from 01/01/2018 to 05/31/2018 by the clinical pharmacist to identify patients with advanced lung cancer eligible for vaccination. Patients list along with recommended vaccine type and schedule was emailed by the clinical pharmacist to clinical team (oncologist, nurse practitioner and practice nurses). Practice nurses obtained immunization records for patients with non-MGH primary care providers. A designated thoracic oncology nurse practitioner ordered appropriate vaccines. Vaccinations were administered by infusion nurse. Results: 50 patients were identified as eligible for vaccination: 7 patients had history of receiving prevnar 13, and 9 patients had history of pnemovax 23. 34 patients had no prior vaccination history. Through this intervention, 10 patients completed vaccination with both prevnar 13 and pnemovax 23. 15 patients received one of the two recommended vaccines. 22 patients refused vaccination, and 3 patients died before their next scheduled infusion visit. Conclusions: Pneumococcal vaccination is recommended for patients with cancer prior to initiation or three months after completion of immunosuppressive therapies. However, it is not always feasible to vaccinate patients prior to start of therapy as delays in cancer care can lead to disease related complications. Incorporating multidisciplinary intervention to identify patients with advanced lung cancer who are candidate for pneumococcal vaccination can improve the adherence to the guidelines.

Impact of radiotherapy facility volume on the management and survival of patients with muscle-invasive bladder cancer receiving bladder-preserving therapy.

18 Background: Higher facility surgical volume predicts for improved survival in patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy. Here, we investigated the association between facility radiotherapy (RT) case volume and compliance with National Comprehensive Cancer Network (NCCN) guidelines as well as overall survival (OS) for patients with MIBC receiving radiation-based bladder preservation. Methods: The National Cancer Database (NCDB) was used to identify patients who were diagnosed with non-metastatic MIBC from 2004 to 2015 and received RT at the reporting institution. Patient, tumor, and treatment characteristics were recorded. Facility RT case volume was defined as the summed MIBC cases treated with RT during the study period. Facilities were divided into high or low volume groups at the 80th percentile of RT case volume. We compared compliance with NCCN guidelines regarding total RT dose of at least 55 Gy, use of TURBT prior to RT, and planned use of concurrent chemotherapy using the χ2 test. OS was assessed using Kaplan-Meier method. A Cox proportional hazard model was used to evaluate predictors of survival. Results: There were 7,562 included patients, and 3,816 (50.5%) were treated at a high-volume center. Median RT case volume was 21 for high-volume centers versus 8 cases for low-volume centers. Higher rates of compliance with all three NCCN recommendations were observed at high-volume centers (48% vs 41%, P&lt; .0001). Age, sex, tumor stage, nodal status, Charlson Comorbidity Index, insurance status, and use of a TURBT prior to RT were predictive of survival. Volume as a continuous variable was an independent predictor of OS ( P= .002). Treatment at a high-volume facility was associated with significantly greater OS for all patients (log-rank P= .001), including patients with a Charlson Comorbidity Index of 0 ( P= .012). Further division of facilities into quartiles revealed incremental improvement in OS with higher facility volume ( P= .001). Conclusions: Bladder preservation treatment at a high-volume facility is associated with greater guideline-concordant management and improved OS among patients with MIBC.

Lymph Node Size Predicts for Asymptomatic Brain Metastases in Patients With Non–small-cell Lung Cancer at Diagnosis

BackgroundWe questioned whether the National Comprehensive Cancer Network recommendations for brain magnetic resonance imaging (MRI) for patients with stage ≥ IB non–small-cell lung cancer (NSCLC) was high-yield compared with American College of Clinical Pharmacy and National Institute for Health and Care Excellence guidelines recommending stage III and above NSCLC. We present the prevalence and factors predictive of asymptomatic brain metastases at diagnosis in patients with NSCLC without extracranial metastases. Materials and MethodsA retrospective analysis of 193 consecutive, treatment-naïve patients with NSCLC diagnosed between January 2010 and August 2015 was performed. Exclusion criteria included no brain MRI staging, symptomatic brain metastases, or stage IV based on extracranial disease. Univariate and multivariate logistic regression was performed. ResultsThe patient characteristics include median age of 65 years (range, 36-90 years), 51% adenocarcinoma/36% squamous carcinoma, and pre-MRI stage grouping of 31% I, 22% II, 34% IIIA, and 13% IIIB. The overall prevalence of brain metastases was 5.7% (n = 11). One (2.4%) stage IA and 1 (5.6%) stage IB patient had asymptomatic brain metastases at diagnosis, both were adenocarcinomas. On univariate analysis, increasing lymph nodal stage (P = .02), lymph nodal size > 2 cm (P = .009), multi-lymph nodal N1/N2 station involvement (P = .027), and overall stage (P = .005) were associated with asymptomatic brain metastases. On multivariate analysis, increasing lymph nodal size remained significant (odds ratio, 1.545; P = .009). ConclusionOur series shows a 5.7% rate of asymptomatic brain metastasis for patients with stage I to III NSCLC. Increasing lymph nodal size was the only predictor of asymptomatic brain metastases, suggesting over-utilization of MRI in early-stage disease, especially in lymph node-negative patients with NSCLC. Future efforts will explore the utility of baseline MRI in lymph node-positive stage II and all stage IIIA patients.