Seattle Cancer Care Alliance Research Articles

418: An Educated Patient is a Safe Patient

The issues of limited medical literacy and patient anxiety are addressed in Seattle Cancer Care Alliance Patient and Family Education program for bone marrow transplant recipients and caregivers. Academic sophistication can not be a requirement for patient safety. Instead, the Patient Centered, Patient and Family Caregiver Education Program, utilizes a mix of teaching methods, learning opportunities, information sources, and communication approaches to facilitate caregiver role training and to impart patient knowledge.

Talking With Patients About the Cost of Cancer Care.

Talking With Patients About the Cost of Cancer Care.

Medullary Thyroid Cancer: Options for Systemic Therapy of Metastatic Disease?

Renato G. Martins, Division of Medical Oncology, Seattle Cancer Care Alliance, University of Washington, Seattle, WA Joseph G. Rajendran, Division of Nuclear Medicine, Seattle Cancer Care Alliance, University of Washington, Seattle, WA Peter Capell, Division of Endocrinology, Seattle Cancer Care Alliance, University of Washington, Seattle, WA David R. Byrd, Department of Surgery, Seattle Cancer Care Alliance, University of Washington, Seattle, WA David A. Mankoff, Divisions of Nuclear Medicine and Endocrinology, Seattle Cancer Care Alliance, University of Washington, Seattle, WA

The nursing role in the orientation and education for outpatient pre-HSCT patients, families, and caregivers at the seattle cancer care alliance

The nursing role in the orientation and education for outpatient pre-HSCT patients, families, and caregivers at the seattle cancer care alliance

Implementation of Electronic Self-Report Assessment-Cancer (ESRA-C): Symptom and quality of life screening/monitoring in Transplant Ambulatory Care

Significance: Patients may present with several significant problems in a transplant clinic visit and it is time consuming for care providers to perform full assessments and evaluate the patient’s concerns. The ESRA-C program provides the patient with means to easily report problems, and the care providers with quick review of the patient’s priorities. Purpose: To evaluate feasibility of the web-based, ESRA-C program and randomized trial in the Seattle Cancer Care Alliance ambulatory HSCT service.

Keratinocyte Dysplasia in Hematopoietic Stem Cell Transplant Recipients in the Day 28 to 84 Post Transplant Period.

Severe keratinocyte dysplasia (SKD) has been reported in the early post‐transplant period of hematopoietic stem cell transplant (HCST) patients, with a frequency as high as 47.4%. In the period less than 3 weeks post‐transplant it was associated with cyclophosphamide conditioning. The purpose of our study was to determine the prevalence of SKD in a later post‐transplant period, from 28 days to 84 days, and study the possible causes. The 2003 slide file (227 slides) of Seattle Cancer Care Alliance was examined for skin biopsies from patients who had undergone HCST. Twenty‐two cases (9.7%) showed SKD. A control group of 22 biopsies matched for days post‐transplant and age were selected from the remaining 205 biopsies. SKD was associated with a busulfan conditioning regimen, 72.7% in the SKD group and 36.3% in the control group (p = 0.016). SKD was not associated with cyclophosphamide (p = 0.174), fludarabin (p = 0.263) or total body irradiation (p = 0.50). Although active GVHD (grade 2 or 3) was more commonly seen in SKD group (45.5%) than the control group (22.2%), it did not show significant difference (p = 0.052). Our study showed that SKD developed in 9.7% of the skin biopsies from days 28 to 84 post‐transplant, and was associated with busulfan conditioning regimen.

Single Daily Dose of I.V. Busulfan (BU) in Pediatric Patients. Feasibility, Pharmacokinetics (PK) and Toxicity.

Administration of oral BU is a challenge in pediatric patients. The I.V preparation can improve compliance and eliminate variability in absorption. The metabolism and clearance of BU is age dependant. A prospective trial using a single daily dose of I.V. BU as part of a reduced Intensity Regimen was undertaken. Patients were enrolled after proper informed consent was signed... The regimen consisted of a test dose of BU (0.8mg/kg as a 2 hr infusion) on day -10, Fludarabine 25mg/m2/day from day-10 to -5, BU 3.2 mg/Kg/Day on days -5 ,-4.and rabbit ATG 2mg/kg daily on days -4 to-1. Cells were infused on day 0. The stem cell source were UCB (n=4), MUD (n=7) and MSD (n=1). PK samples (2, 4, 6,8,12 hrs) were obtained and submitted to the Seattle Cancer Care Alliance for determination of the Area Under the Curve (AUC) and clearance for BU. Twelve patients were enrolled (8F, 4M), median age 8 (0.5–16), median weight 22.6 kg (4.3–58.8) with the following diagnoses: Neuroblastoma (n=3), ALL (n=3), CML (n=2), Aplastic Anemia and X linked Lymphoprolipherative Disease, Ommen's syndrome, Severe Combined Immune Deficiency. An AUC of 800–1200 and 3200–4800 uMol*min were targeted for the test dose and the single daily dose respectively. The median AUC for the test dose was 1003 uMol*min (804–1315), and the median clearance was 3.1 (ml/min)/Kg (2.4–7.3). The median AUC for the single daily dose was 3512 uMol*min (1511–4097) and the clearance 3.4 (ml/min)/kg (2.8–6.8). After the test dose 4 patients had their dose adjusted (2 patients lower and 2 patients higher). In the very young patients (< 1 year of age) the AUC of the single daily dose could not be predicted due to abnormal clearance. No instances of VOD or seizures were observed. Full donor chimerism was achieved in 8 patients in a median of 23 days (14–53), 2 patients developed graft failure, 1 patient was not evaluable for engraftment due to early TRM from pre-existing CMV pneumonia and 1 patient is too early. In conclusion, a single daily dose of I.V. BU is feasible, a test dose can be a predictor of the single daily dose AUC except in the very young, No regimen related toxicity was observed and engraftment was prompt and complete in 8 evaluable patients.

Frequency and magnitude of dose adjustment of IV busulfan in targeted dosing strategy for pediatric allogeneic transplantation

Busulfan is an important therapuetic agent in pediatric allogeneic transplantation. The recent introduction of IV busulfan (IV Busulfex®, ESPpharma) has descreased the intra-and interpatient dose variations associated with oral absorption and allows for targeted therapy. Children have increased drug clearance and varying degrees of hepatic function both developmentally and associated with the underlying disorders for which they are being treated. Because of this variability, first dose pharmacokinetics were perfomed on all of our patients to ensure the targeted AUC was achieved. In a series of 85 consecutive children undergoing allogeneic transplant at Methodist Children’s Hospital/Texas Transplant Institute from June 2001 to October 2003, 45 children received myeloablative doses of busulfan (0.8 mg/kg for patients 3–10 kgs; 1 mg/kg for patients > 10 kgs till age 4 yrs; 0.8 mg/kg for patients > 4 yrs given every 6 hours for 16 doses) as part of a busulfan/cyclophosphamide, busulfan/melphalan or busulfan/fludarabine preparative regimen. 42/45 patients had their actual weight used for dosing calculations. Adjusted IBW was used in 3 patients. All patients received dilantin for seizure prophylaxis. First dose pharmcokinetics were performed by the Clinical Pharmokinetics Lab at Seattle Cancer Care Alliance, targetting an AUC of 900–1300 umol.min, with dose adjustments done starting with dose 7, if needed. Donor source was matched sibling donor bone marrow or cord blood in 10 and unrelated donor sources in 35 (2 marrow and 33 mismatched umbilical cord units). The median age was 4.7 yrs (range 1 month to 17 years). Patients underwent transplant for a variety of conditions: 12 AML, 5 CML, 1 JMML, 9 ALL, 1 lymphoma, 3 HLH, 10 primary immunodefiencies, 4 hematology disorders. No patients developed VOD. 32/33 patients of patients who received a fully myeloabalative preparative regimen engrafted. A targeted AUC (900–1300 umoles.min) was achieved with initial dosing in 50% of the patients. However, many children required dose adjustment to achieve the targeted AUC, mostly dose escalation (see table ). Given the variability of metabolism in children, first dose pharmacokintics are recommended. Additionally, the starting dose in infants is lower than the currently recommended dose.TableAge/ WeightStarting Dose (mg/kg)AUC μmol · min: Median (range)Final Dosing (mg/kg): Median (range)Percent of Patients Requiring Dose AdjustmentDose Increased/ Dose Decreased3–10 kg (n = 12)0.81167 (825–1869)0.93 (0.67–1.25)50%–6/12 pts4↑/2↓10 kg-4 years (n = 11)11142 (908–1518)1 (0.76–1.25)27%–3/112↑/1↓>4 years (n = 22)0.81089 (620–1827)0.82 (0.57–1.25)65%–15/2311↑/4↓ Open table in a new tab