Treatment Summary Research Articles

Understanding and Improving Survivorship Care for Adolescents and Young Adults with Cancer.

Purpose: To explore and highlight the opportunities and challenges that underlie the development of survivorship care for adolescent and young adult cancer. Methods: A multimethod approach was used, with perspectives of survivors, relatives, and health care professionals elicited through an online survey, focus group, and semistructured interviews. Results: Four themes were identified using thematic analysis: adjusting to life after cancer, transition to community-based care, ongoing change and reform of health care, and supporting survivorship services. Adolescents and young adults (AYAs) and their families struggled with the transition from active treatment, which was complicated by ongoing disease/treatment impacts and a collective dearth of knowledge and resources on how to support AYAs during this time. Limited confidence and communication in patient-general practitioner relationships complicated the transition to community-based care, with treatment summaries and survivorship care plans an underused resource. A growing movement toward integrated, holistic, and equitable survivorship care was identified, but progress has been fragmented and under-resourced. Further research, funding, and advocacy are needed to support ongoing survivorship initiatives. Conclusions: Although some survivorship concerns are common across age groups, others are specific to AYAs' developmental stage, emphasizing the need for integrated, age-appropriate, and targeted survivorship services for AYAs. The transition from active treatment to longer term survivorship presents challenges for ongoing clinical care and support; change is needed at individual, service, and system levels to provide quality, sustainable, and integrated care to AYA cancer survivors.

Functional Outcome of Elderly Patients Treated for Odontoid Fracture: A Multicenter Study.

Retrospective multicenter study. Analysis of impact of conservative and surgical treatments on functional outcome of geriatric odontoid fractures. Treatment of odontoid fractures in aged population is still debatable. One hundred fourty-seven consecutive odontoid fractures in elderly patients were classified according to Anderson-D'Alonzo and Roy-Camille classifications. Philadelphia type collar was always positioned and kept as a treatment whenever acceptable. Halo-vest, anterior screw fixation, C1-C2 posterior arthrodesis, and occipito-cervical fixation were the other treatments adopted. Conservative or surgical treatment strategy was more significantly influenced by antero-posterior displacement (< or >5 mm) and by surgeon decision. On admission ASA, modified Rankin scale (mRS-pre) and Charlson Comorbidity Index (CCI) were assessed. Modified Rankin scale (mRS-post), Neck Disability Index (NDI), and Smiley Webster Pain Scale (SWPS) were administered 12 to 15 months after treatment to estimate functional outcome in terms of general disability, neck-related disability, and ability to return to work/former activity. Risk of treatment crossover was calculated considering factors affecting outcome. Fracture healing process in terms of fusion-stability, no fusion-stability, no fusion-no stability was evaluated at 12 months through a cervical computed tomography (CT) scan. Dynamic cervical spine x-rays were obtained whether necessary. No fusion-stability was considered an adequate treatment goal in our geriatric population. Chi square/Fisher exact test and logistic regression were performed for statistical anal. Overall 67 patients were treated conservatively whereas 80 underwent surgery. Collar was adopted in 45 patients, while anterior odontoid fixation and C1-C2 posterior arthrodesis were preferred for 30 patients each. 79.8% of patients showed good outcomes according to NDI. No significant differences were observed between patients of 65 to 79 years and more than or equal to 80 years (P = 0.81). CCI greatly correlated with mRS-post, with higher indexes in 68.8% of cases characterized by good outcomes (P = 0.05). mRS-pre correlated with NDI (P < 0.000001) and mRS-post (P = 0.04). CCI, mRS-pre, and surgery were associated with worse NDI, while both C1-C2 posterior arthrodesis and occipito-cervical stabilization were associated with worse mRS-post, respectively in 40% and 30% of cases. Younger patients had a higher risk of treatment crossover. mRS-pre and CCI provided two independent predictive values respectively for functional outcome and post-treatment disability. Compared with conservative immobilizations, surgery revealed no advantages in the elderly in terms of functional outcome. 3.

Development and Implementation of Survivorship Tools to Enable Medical Follow-Up After Childhood Cancer Treatment in Southern Sweden.

PURPOSESurvival rates after childhood cancer have increased from 20% to 80% since the 1970s. The increased number of survivors emphasizes the importance of late effects and their monitoring. Late effects may have a strong impact on quality of life in survivors. The purpose of this study was to make key data in a quality registry available for direct clinical use, enabling health care professionals to perform efficient and appropriate long-term medical follow-up after childhood cancer treatment.METHODSThe population-based quality registry upon which this study is centered contains data on all individuals diagnosed with childhood cancer (diagnosed at 18 years of age or younger) in southern Sweden since January 1, 1970, and treatment data on 5-year survivors. Web tools, which were developed and implemented in a health care setting, generate a personalized treatment summary for each patient and enable risk group stratification of survivors.RESULTSGeneration of a personalized treatment summary and risk group stratification of survivors led to identification of women at risk for developing breast cancer as a consequence of childhood cancer treatment. Three novel cases of previously undiagnosed breast cancer were identified.CONCLUSIONThe registry, together with the developed tools, enabled health care professionals to perform medical follow-up in this at-risk patient population.

Survivorship care: Improving delivery of care plans for hematology patients at the Washington Cancer Institute (WCI).

6605 Background: Cancer and long-term sequalae of its treatment impact the future health and psychosocial wellness of these survivors. ASCO guidelines recommend providing survivorship care to cancer patients who have completed treatment with curative intent. The Commission on Cancer (COC) recommends that survivorship care including treatment summaries be delivered to 50% of eligible patients. In our ASCO Quality Training Program project, we aimed to achieve this COC goal of 50% for the year 2018. Methods: Baseline data collected from Jan 1, 2016 to June 30, 2018 indicated that 33% of hematologic malignancy survivors at WCI received treatment summaries and survivorship care. For the year 2018, there were 11 survivors of hematologic malignancy, and 4 of them (36%) had received survivorship care prior to initiation of the project. We surveyed 12 providers to obtain data for perceived challenges to deliver survivorship care. Large volume of patients, lack of resources, no standardized process and high no-show rates were identified as the most important barriers. A bi-monthly survivorship clinic run by hematology/oncology fellows was initiated in September 2018 to address some of these barriers. Patient referral forms were mounted in the clinic work rooms to assist providers with identifying patients that qualify for survivorship; a pathway for referrals to the survivorship clinic was created and providers were informed about the clinic. Information flyers regarding survivorship care and the clinic were placed in the waiting room to increase awareness amongst patients. Results: By November 30, 2018, 63% of hematological cancer survivors received survivorship care and treatment summaries. Compared to the average from the preceding two years, survivorship care delivery increased by 30%. Conclusions: Our institution was able to meet the COC requirement by delivering survivorship care to 63% of survivors of hematological malignancies through the intervention from this quality improvement study. We intend to extend this process to other tumor types to increase the delivery of consolidated survivorship care at the WCI.

Evaluation of a Multidisciplinary Team Approach for Generating Survivorship Care Plan Treatment Summaries in Patients With Breast Cancer.

The optimal structure for survivorship care plan (SCP) programs and methodology for generating treatment summaries (TSs) has not yet been defined, but the Commission on Cancer and the National Accreditation Program for Breast Centers both mandate that participating oncology programs implement SCP-TS processes for patients that have completed treatment. We used the Institute for Healthcare Improvement's Plan-Do-Study-Act model for conducting a quality improvement project evaluating two different SCP-TS programs implemented at the Henry Ford Health System/Henry Ford Cancer Institute's Breast Oncology Program in Detroit, Michigan. System I involved TSs drafted by nonspecialist breast clinic staff; System II involved TSs vetted through a multidisciplinary breast specialist conference approach. Accuracy of basic documentation entries related to dates and components of treatment were compared for the two approaches. Seventy-one System I and 93 System II documents were reviewed. Documentation was accurate in at least 90% of documents for both systems regarding delivery of chemotherapy and/or endocrine therapy and for documenting the identity of the various members of the cancer treatment team. Both systems had notable inaccuracies in documenting type of surgery performed, but System II had fewer inaccuracies than System I (33.78% v 51.67%, respectively; P = .05). System II, compared with System I, had fewer inaccuracies in documenting date of diagnosis (9.68% v 25.35%, respectively; P = .01) and had less missing information for dose of radiation delivered (9.33% v 33.9%, respectively; P < .01). A multidisciplinary team approach to drafting and reviewing SCP-TS documents improved content accuracy for our program, but ongoing education regarding documentation of various surgical procedures is warranted.

QIM19-135: The Quality Oncology Practice Initiative Program: Experience in Spain

Background: Patient quality care is a discipline that has acquired enormous relevance in today’s healthcare. The Quality Oncology Practice Initiative (QOPI) is a referral worldwide in terms of quality for oncology practices. The ECO Foundation is a foundation of experts representing the major Spanish hospitals involved in the treatment of cancer patients. ECO reached an agreement with ASCO to involve Spanish hospitals in the QOPI program. Methods: 6 rounds of data collection have taken place (Fall 2015 to Round 1 2018). Practices had to register online and submit data into the QOPI platform, and the ECO Foundation offered all centers the necessary support. 17 Spanish hospitals have participated in the 6 rounds, and 7 of them have repeated participation. Core and lung cancer modules were completed. Results: During the 6 rounds, 1,877 charts were submitted by the Spanish practices. In most of the rounds, the highest scores were: pathology report confirming malignancy; number of chemotherapy cycles documented; patient consent for chemotherapy; and 5 measures of the lung cancer module. The lowest scores were: chemotherapy treatment summary provided to patient within 3 months of chemotherapy end; chemotherapy treatment summary provided or communicated to practitioner(s) within 3 months of chemotherapy end; smoking/tobacco use cessation counselling recommended to smokers/tobacco users in past year; and tobacco cessation counselling administered or patient referred in past year. The percentage of participating practices that presented results higher than 70% was successively 64%, 50%, 75%, and 100% in the last 3 rounds. For the 7 hospitals that repeated participation, 3 reported an improvement of their global scores. Regarding QOPI Certification, 3 Spanish hospitals received this accreditation in September 2017 and one in June 2018. Conclusions: These preliminary results are a good starting point for the continued implementation of the QOPI program in Spain, thus providing a well-structured approach to analyze cancer care. The ECO Foundation will continue pursuing excellence and quality with further activities like the QOPI Certification program and Quality Training Program, these being performed for the first time in Spain in 2017 and 2018, respectively.

Bridging the Radiation Oncology and Diagnostic Radiology Communication Gap: A Survey to Determine Usefulness and Optimal Presentation of Radiotherapy Treatment Plans for Radiologists

Rationale and ObjectivesWe hypothesized that providing visual-spatial information to radiologists on where radiation has been delivered in an easily accessible way may improve the accuracy of image interpretation and thereby improve quality of patient care. We present a national representation of radiologists’ opinions regarding the usefulness and optimal approach for implementing a system to promote access to radiotherapy (RT) plans. MethodsAn anonymous survey was sent to the members of the Association of University Radiologists. Descriptive statistics were performed. ResultsQuestionnaires were returned by 95 of 1383 members. Demographics comprised of 76% attendings with 94% practicing within an academic setting. Only 40% of radiologists reported that they knew most of the time whether a patient has received RT in the field scanned. A large majority of respondents (88%) felt that a history of prior radiation in a cancer patient was at least an occasional barrier that affected the ability to interpret imaging findings in a clinically useful way. The following types of information was considered helpful when interpreting a scan: screenshots of the radiation plan (85%), scrollable DICOM data on planning CT showing delivered RT dose lines (54%), and written text RT treatment summary (47%). Nearly all (89%) desired DICOM data within the clinical radiology Picture Archiving and Communication System system. Radiologists expected the ease of accessibility to RT plans to result in increased efficiency (76%) and accuracy (88%). ConclusionDiagnostic radiologists desire improved access and integration of radiotherapy plans into the diagnostic radiology clinical workup in the form of visual-spatial data.

Abstract P4-14-12: Outcomes in hormone receptor positive, invasive lobular cancer in the era of endocrine monotherapy

Abstract Background:Invasive lobular carcinoma (ILC) accounts for up to 15% of all breast cancers and is clinically and biologically distinct from invasive ductal carcinoma (IDC). Despite that, women with early stage ILC are often treated similarly to IDC. However, several retrospective studies suggest that patients (pts) with ILC may not derive survival benefit from the addition of chemotherapy to endocrine therapy relative to pts with IDC. The purpose of our study was to compare outcomes of pts with ILC treated with chemotherapy with those who received endocrine monotherapy. Methods: A retrospective review of pts with ILC or pleomorphic lobular carcinoma treated at the Ohio State University James Cancer Center from 2004-2014 was performed. Clinico-pathologic characteristics, treatment summary and clinical outcomes were collected. Distant disease-free survival (DDFS) was defined as time from diagnosis to the first distant metastases or death and overall survival (OS) was the time from diagnosis to death or last known follow up. DDFS and OS curves were created using Kaplan-Meier methods and compared using log-rank tests. Cox proportional hazard models were used to calculate univariate and multi variable hazard ratios (HR) for OS and DDFS. Results: We identified 379 pts with early stage ILC (stage I: 43% (162/379), stage II: 34% (127/379), stage III: 22% (84/379), unknown: 1% (6/379)). The majority of pts were post-menopausal (79%), Caucasian (92%) and ER+/PR+ (87%) and HER2 negative (96%). One hundred seventy six pts (46%) received chemotherapy and 189 (50%) pts received endocrine therapy alone. Pts who received chemotherapy had stage II or III disease, positive lymph nodes and grade 2 or 3 tumors; while pts who received endocrine monotherapy had stage I disease, negative lymph nodes and grade 1 or 2 tumors. We found a 51% decrease in chemotherapy (from 63% to 31%) and an increase in endocrine monotherapy use (from 34% to 65%) between 2004-2010 and 2011-2014. One hundred thirty two pts were evaluated with Oncotype DX, of which 76% (100/132) were node negative with the majority having a low recurrence score (low: 64%; intermediate: 33%; high: 3%). The use of Oncotype DX increased from 21.1% in 2004-2010 to 47.9% in 2011-2014. We found that 112 of 149 pts with at least 5 years follow up (75.2%) successfully completed five or more years of endocrine therapy. Univariate cox models showed worse DDFS HRs for type of therapy and node status (HR: 2.36, p=0.005, HR: 4.16, p&amp;lt;0.001, respectively). However, the HR for therapy was no longer significant when adjusting for age, grade, and nodal involvement (HR = 1.19, 95% CI: 0.56 – 2.52, p=0.646). Nodal involvement remained significant (HR= 3.56, 95% CI: 1.64-7.70, p=0.001) after adjusting for therapy, age and grade. No significant difference in OS was found between endocrine monotherapy and chemotherapy (p=0.426, log-rank test). Conclusion: We found no difference in DDFS between endocrine monotherapy and chemotherapy after adjusting for age, grade, and nodal involvement in pts with early stage ILC. This supports the hypothesis that ILC may not derive a significant benefit from the addition of chemotherapy. We need more prospective clinical trials considering histology to better understand how best to treat ILC. Citation Format: Williams N, Liu J, Stephens J, Palettas M, Boutrid H, Sardesai S, Reinbolt R, Stover D, VanDeusen J, Noonan A, Wesolowski R, Lustberg M, Ramaswamy B. Outcomes in hormone receptor positive, invasive lobular cancer in the era of endocrine monotherapy [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 P4-14-12.

Survivor and Clinician Assessment of Survivorship Care Plans for Hematopoietic Stem Cell Transplantation Patients: An Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

The long-term care of hematopoietic stem cell transplantation (HSCT) survivors poses special challenges owing to a myriad of possible chronic and/or late complications. Survivorship care plans (SCPs) have been proposed as tools to communicate information on the late effects of treatment and recommended follow-up care to clinicians and survivors. The primary aims of this study were to determine SCP content and format, as well as to assess the preferred timing of SCP provision following HSCT. HSCT survivors and nontransplantation clinicians (oncologists and primary care physicians) were invited to participate in a survey evaluating the usefulness and utility of a sample HSCT-specific SCP with a treatment summary generated by autopopulation from an electronic health record (EHR). All participating HSCT survivors (n = 29) and clinicians (n = 18) indicated a desire to receive an SCP. More than 85% of the participants perceived information about treatments received, recommended follow-up and health maintenance including vaccinations, survivor and clinician resources, and graft-versus-host disease and other late/chronic side effects to be useful. The majority of survivors also believed that care team contact information was useful. In addition, >85% of survivors and clinicians agreed that the SCP increased their understanding of treatments and chronic/late side effects, improved health care provided, and were satisfied with the SCP and found it understandable and easy to use. The majority of survivors indicated that additional information should be added to the SCP, whereas some clinicians deemed the SCP too long. Survivors preferred to receive the SCP as a paper document at the end of a regular follow-up visit and review it with a cancer clinician, whereas clinicians preferred to receive the SCP through the EHR. These findings will help improve the design of future SCPs for use by HSCT survivors and clinicians. Future work will include leveraging the EHR to ease the burden of creating user-centered documents.

Implementing Recommended Long Term Follow up Screening and Preventive Practices in an Allogeneic Hematopoietic Cell Transplant Survivorship Clinic

The number of allogeneic hematopoietic cell transplantation (HCT) survivors is projected to increase and guidelines for screening and management of late effects have been established. Although the value of a systematic process for the long-term care of HCT survivors and screening of late effects is increasingly recognized, best practices for the implementation of survivorship care delivery has not been well described. In October 2016, we established a Survivorship Clinic for allogeneic HCT recipients in our Blood and Marrow Transplant (BMT) Program. A consultative model aimed to augment care provided by the patient's primary transplant and primary care physician was felt to best fit our program's needs. Patients (pts) are seen by a Nurse Practitioner (NP) and social worker (SW) at day 100 and 1 year visits. Visits include a comprehensive history and physical, symptom assessment, and graft-versus-host disease evaluation, as well as review and provision of a treatment summary and care plan. 1-year recommended assessments include: bone density scan, vitamin D, TSH, lipid panel, HbA1c, Ferritin, pulmonary function tests (PFTs), ophthalmic exam, and mammogram and pelvic exam (women). We performed a formal review of follow up with recommended screening guidelines among pts seen in our Survivorship Clinic from 2016-2018. Since its establishment, 161 pts received allogeneic HCT in our Program, of whom 131 pts have been seen at day 100 and 42 have been seen at 1-year. Patients not seen at day 100 were due to relapse, death or acute illness where they were not able to attend the clinic visit. Among pts seen at day 100 but not at 1 year, 7 were international, 2 were deferred due to relapse, 12 died prior to one year follow up, one transferred care to another facility and 67 have not reached their 1-year follow up. Of 42 pts seen at 1 year, all have received a complete treatment summary and care plan at both day 100 and 1 year. 35 pts had an evaluation and follow up with their transplant SW for psychosocial assessment. 41 pts had a bone density scan completed. All 42 pts completed a screening TSH, vitamin D, lipid panel, HbA1c, Ferritin, and PFTs. 36 saw ophthalmology for a yearly exam. Of the 20 women seen at 1 year, all 20 had mammograms done and 19 had gynecologic exams. In summary, this review of our NP run BMT survivorship clinic demonstrates feasibility and a high rate of adherence to recommended late effects screening practices for HCT survivors. As the survivorship program continues to grow, further integration of patient-reported outcomes and interventional research on late effects to improve the well-being of long-term survivors is planned.

Evaluating Survivorship Care Plans for Use By Hematopoietic Stem Cell Transplant Survivors and Non-Transplant Clinicians: An Engineering, Primary Care, and Oncology Collaborative for Survivorship Health

Background Survivors of hematopoietic stem cell transplants (HSCTs) face many chronic and late complications that pose challenges to future survivorship care. The provision and review of Survivorship Care Plans (SCPs) has been proposed as a method to improve knowledge of these complications as well as screening and treatment recommendations among survivors and their non-transplant clinicians. Creating SCPs can be work intensive, however, using the electronic health record (EHR) can reduce the time and personnel resources required to generate SCPs and complement efforts to discretely capture HSCT data. Objectives Our objectives were to determine what content should be included in HSCT-focused SCPs for these diverse users as well as format and preferred timing of SCP provision. Results will be used to create HSCT-focused SCP templates generated by and integrated with an EHR. Methods Eligible HSCT survivors were ≥18 years and received a HSCT > 12 months ago. Non-transplant primary care and oncology clinicians were eligible if they provided care to HSCT patients. Those eligible were invited to complete a survey evaluating a HSCT-focused SCP with treatment summary data generated by an EHR. The usefulness of content, format and utility of the document, and timing of provision were considered especially pertinent. The survey utilized both 5-point Likert scales and open-ended questions. Results Survey response rate exceeded 80% (n=29/36 survivors; n=18/22 clinicians). Our survivor respondents were a median age of 59 (range 32-73), White (100%), mostly female (52%) and educated (52% held an associate degree or higher). Clinician respondents were predominately female (67%), White (78%) and providing primary care (56%). Over 85% of survivors and clinicians perceived information about treatments received, recommended follow-up and health maintenance including vaccinations, survivor and clinician resources, graft versus host disease and other late/chronic side effects to be useful or very useful. The majority of survivors also found care team contact information useful or very useful. Additionally, over 85% of survivors and clinicians agreed or strongly agreed that the SCP would improve follow-up care and increase their understanding of treatments and chronic/late side effects. Overall, 88% were satisfied with the SCP and found it understandable and easy to use. All respondents indicated a desire to receive SCPs. Survivors (93%) prefer to receive the SCP as a paper document at the end of a regular follow-up, and most would like to receive the SCP immediately after transplant (70%) or two to three months after transplant (67%). Clinicians (89%) would prefer to receive the SCP through the EHR. Conclusion These results will help improve future HSCT-focused SCP templates to meet the needs of these users. Future work will include leveraging the EHR for creation and provision of SCPs with ease.

Surgical Treatment of Developmental Spondylolisthesis: Contemporary Series With a Two-Surgeon Team

Study DesignRetrospective case series. ObjectivesTo report operative outcomes of contemporary surgical treatment of spondylolisthesis in the pediatric population. Summary of Background DataSurgical treatment of developmental spondylolisthesis is controversial, with limited data on complication and reoperation rates. MethodsA retrospective study followed pediatric patients with either L5–S1 high-grade spondylolisthesis (HGS) or L5–S1 symptomatic low-grade spondylolisthesis (LGS) for a minimum of two years. All patients underwent a contemporary, single-stage decompression, partial reduction, and posterior instrumented fusion (DRPF) or in situ stabilization by a combined orthopedic and neurosurgeon team at a single institution during 2005–2015. Clinical examination and radiographic data were collected preoperatively and at discharge, 1 year, 2 years, and terminal visit (defined as the last follow-up at >2 years). ResultsThirty-four patients (79% HGS), mean (±standard deviation) age at surgery 13.5 (±3.3) years, were followed for 4.8 (±2.3) years. The patients who underwent DRPF (n = 26) had mean lumbosacral angle increase from 79.8° (±20.8) to 92.5° (±16.1) (p < .001) and mean listhesis reduce from 63.2% (±21.9) to 26.0% (±20.1) (p < .001). Preoperatively, 18 (53%) had neurologic symptoms. At one- and two-year follow-up, new or residual neurologic symptoms were present in four patients (12%) (p < .001). Postoperative symptoms were not significantly related to amount of reduction. Sixteen (47%) underwent reoperation at an average of 24.8 months, 10 for planned prominent instrumentation removal, and 6 for true complications. ConclusionsSurgical reduction and decompression of spondylolisthesis in the pediatric population restores spinopelvic alignment. We found no evidence that a greater amount of reduction was associated with a higher incidence of postoperative complications. However, patients should be advised that prominent instrumentation may require future removal. Although previous reports suggest complication rates and permanent neurologic sequelae in up to 20% after operative treatment of spondylolisthesis, our results suggest that a contemporary approach with a two-surgeon team may provide improved results. Level of EvidenceLevel IV.

Ability of the Global Alignment and Proportion Score to Predict Mechanical Failure Following Adult Spinal Deformity Surgery—Validation in 149 Patients With Two-Year Follow-up

Study DesignRetrospective analysis of prospectively collected data. ObjectivesTo validate the Global Alignment and Proportion (GAP) score in a single-center cohort of adult spinal deformity (ASD) patients. Summary of Background DataSurgical treatment for ASD is associated with a high risk of mechanical failure and consequent revision surgery. To improve prediction of mechanical complications, the GAP score was developed with promising results. Development was based on the assumption that not all patients would benefit from the same fixed radiographic targets as pelvic incidence is an individual, morphological parameter that greatly influences the sagittal curves of the spine. MethodsIn a validation study of the GAP score, patients undergoing ASD surgery with four or more levels of instrumentation were consecutively included at a tertiary spine unit. Patients were followed for a minimum of two years. Pre- and postoperative GAP score and categories were calculated for all patients, and the association with mechanical failure and revision surgery was analyzed. ResultsA total of 149 patients with a mean age of 57.4 years were included. Overall, the rates of mechanical failure and revision surgery were 51% and 35% respectively. The area under the curve (AUC) using receiver operating characteristic was classified as “no or low discriminatory power” for the GAP score in predicting either outcome (AUC = 0.50 and 0.49, respectively). Similarly, there were no significant associations between GAP categories and the occurrence of mechanical failure or revision surgery when using Cochran-Armitage test of trend (p = .28 for mechanical failure and p = .58 for revision surgery). ConclusionsIn a consecutive series of surgically treated ASD patients, we found no significant association between postoperative GAP score and mechanical failure or revision surgery. Despite minor limitations in similarities to the original study cohort, further validation studies or adjustments to the original scoring system are proposed. Level of EvidenceLevel II.

Neighborhood Characteristics and Colorectal Cancer Survivors' Quality of Care.

Purpose: Quality cancer care entails receipt of a Survivorship Care Plan (SCP). The purpose of this study was to determine differences in SCP delivery by patient-level and neighborhood characteristics.Methods: We obtained California cancer registry data on individuals who were diagnosed with stage I, II, or III colorectal cancer (CRC) between 2012 and 2015 and resided in predetermined geographic areas. We then mailed them a questionnaire, which queried about receipt of a SCP and its content. SCP was defined by content, as summary of cancer treatment, cancer surveillance recommendations, and/or an individualized preventive care. Using logistic regression modeling, each measure of SCP, as well as the summary measure (none vs. any), was evaluated by person-level characteristics. Subsequently, neighborhood-level characteristics were added to the model to explore their additional value.Results: Overall 80% of CRC survivors received a SCP. Receipt of SCPs was associated with person-level characteristics, while neighborhood characteristics did not make an additional contribution. Young, male employed survivors and those with more recent diagnoses or later cancer stages had greater odds of receiving a SCP.Conclusion: When providing SCPs, health care providers prioritize patient groups who they may perceive as vulnerable or likely to benefit from SCPs.

Bridging the Gap: A Pilot Program to Understand and Meet the Needs of Pediatric Patients and Families as They Transition Off Cancer-Directed Therapy.

Background: With improved curative therapies, over 80% of children and adolescent/young adults diagnosed with cancer are expected to live into adulthood. This population is at risk for increased morbidity and early mortality and requires ongoing health care and surveillance for late effects of treatment. This pilot study assessed the acceptability of a structured medical visit at the completion of cancer-directed therapy as well as patient/family's knowledge of diagnosis and other aspects of care. Method: Patients/families who were 0 to 6 months from completion of cancer-directed therapy attended a one-time transition visit during which they completed a series of questionnaires assessing knowledge about diagnosis, treatment, potential late effects, and duration of ongoing care. They were then given treatment summaries, a plan for follow-up care, information about care after treatment as well as late effects. They completed a questionnaire to assess their satisfaction with this visit. Results: The majority of patients/families knew their diagnosis and treatment modalities. Less knew that their treatment put them at risk for cardiac toxicity or problems with future fertility. A significant number thought follow-up care would continue for only 5 years. Overall participants were satisfied with the visit. Conclusion: The transition period from on to off therapy may be a critical time point to provide patients with cancer and their families with information regarding treatment, follow-up care and testing, and potential late effects. Future studies should assess if this intervention improves compliance with recommended care and surveillance, and improved outcomes.

CARs, CRS and neurotoxicity: severe complications after administration of immunotherapy : Essentials for intensivists

The development of chimeric antigen receptor (CAR) T‑cells has shown promising results in relapsed/refractory B‑cell acute lymphoblastic leukemia/lymphoma (B-ALL) and diffuse large cell B‑cell lymphoma. Complications, especially cytokine release syndrome (CRS) and CAR T‑cell related encephalopathy syndrome (CRES), can be life threatening. The management of both plays akey role in CAR T‑cell therapy. Diagnosis, clinical presentation and development of complications in the treatment with CAR T‑cells. Summary of incidence, mortality and treatment of severe complications after administration of CAR T‑cells referring to current studies and therapy recommendations. Complications after administration of CAR T‑cells, especially CRS and CRES, can be life threatening. The timely identification of side effects and their appropriate treatment usually leads to complete recovery. Using atherapy algorithm in the treatment with CAR T‑cells allows safe management of toxicities and can be helpful in recognizing them in time.

Randomized controlled trial of individualized treatment summary and survivorship care plans for hematopoietic cell transplantation survivors.

Survivorship Care Plans (SCPs) may facilitate long-term care for cancer survivors, but their effectiveness has not been established in hematopoietic cell transplantation recipients. We evaluated the impact of individualized SCPs on patient-reported outcomes among transplant survivors. Adult (≥18 years at transplant) survivors who were 1-5 years post transplantation, proficient in English, and without relapse or secondary cancers were eligible for this multicenter randomized trial. SCPs were developed based on risk-factors and treatment exposures using patient data routinely submitted by transplant centers to the Center for International Blood and Marrow Transplant Research and published guidelines for long-term follow up of transplant survivors. Phone surveys assessing patient-reported outcomes were conducted at baseline and at 6 months. The primary end point was confidence in survivorship information, and secondary end points included cancer and treatment distress, knowledge of transplant exposures, health care utilization, and health-related quality of life. Of 495 patients enrolled, 458 completed a baseline survey and were randomized (care plan=231, standard care=227); 200 (87%) and 199 (88%) completed the 6-month assessments, respectively. Patients’ characteristics were similar in the two arms. Participants on the care plan arm reported significantly lower distress scores at 6 months and an increase in the Mental Component Summary quality of life score assessed by the Short Form 12 (SF-12) instrument. No effect was observed on the end point of confidence in survivorship information or other secondary outcomes. Provision of individualized SCPs generated using registry data was associated with reduced distress and improved mental domain of quality of life among 1-5 year hematopoietic cell transplantation survivors. Trial registered at clinicaltrials.gov 02200133.

Automating Treatment Summary Development Using Electronic Billing Information: A Pilot Study of Survivors of Head and Neck Cancer.

Although the provision of a treatment summary (TS) is a quality indicator in oncology, routine delivery of TSs remains challenging. Automatic TS generation could facilitate use, but data on accuracy are lacking in complex cancers such as head and neck cancer (HNC). We developed and evaluated an electronic platform to automate TS generation for HNC. The algorithms autopopulated TSs using data from billing records and an institutional cancer registry. A nurse practitioner used the medical record to verify the accuracy of the information and made corrections electronically. Inaccurate and missing data were considered errors. We described and investigated reasons for errors in the automatically generated TSs. We enrolled a heterogeneous population of 43 survivors of HNC. Using billing data, the information on primary site, lymph node status, radiation, and chemotherapy use was accurate in 93%, 95%, 93%, and 95% of patients, respectively. Billing data captured surgery accurately in 77% of patients; once an omitted billing code was identified, accuracy increased to 98%. Chemotherapies were captured in 90% of patients. Using the cancer registry, month and year of diagnosis were accurate in 91% of cases; stage was accurate in 28% of cases. Reprogramming the algorithm to ascertain clinical stage when pathologic stage was unavailable resulted in 100% accuracy. The algorithms inconsistently identified radiation receipt and treating physicians from billing data. It is feasible to automatically and accurately generate most components of TSs for HNC using billing and cancer registry data, although clinical review is necessary in some cases.

New Directions in Treatments Targeting Stroke Recovery.

Stroke is the leading cause of neurological disability in the U.S. and worldwide. Remarkable advances have been made over the last 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in treatments to enhance neurological recovery after stroke. However, a number of promising research directions have been identified for treatments targeting stroke recovery and are the focus of the current review (Figure 1). Open in a separate window Figure 1. Summary of current experimental treatments for stroke recovery and their readiness for incorporation into clinical practice based on synthesis of current evidence. Readiness for clinical application ranges from preclinical development (i.e. in animal studies only, red) to broad clinical application (green).

Survivorship care planning and implementation in neuro-oncology.

Survivorship has become a significant topic within oncologic care. The tools and means by which the provision of survivorship care can be implemented and delivered are in development and are the focus of significant research oncology-wide. These tools and methods include innovations of survivorship care delivery, survivorship care plans, and improving communication among all stakeholders in an individual patient's care as the means to elevate health-related quality of life. The merits of these survivorship care provisions in the field of neuro-oncology and its patients' exigent need for more patient-centric care focused on living with their illness are discussed. Since 2014 there has been a mandate within the United States for adult cancer patients treated with curative intent to receive survivorship care plans, comprising a treatment summary and a follow-up plan, intended to facilitate patients' care after initial diagnosis and upfront treatment. Several cancer-specific survivorship care plans have been developed and endorsed by health care professional organizations and patient advocacy groups. A survivorship care plan specific for neuro-oncology has been collaboratively developed by a multidisciplinary and interprofessional committee; it is endorsed by the Society for Neuro-Oncology Guidelines Committee. It is available as open access for download from the Society for Neuro-Oncology website under "Resources": https://www.soc-neuro-onc.org/SNO/Resources/Survivorship_Care_Plan.aspx. Survivorship care offers an opportunity to begin directly addressing the range of issues patients navigate throughout their illness trajectory, an oncology initiative to which neuro-oncology patients both need and deserve equitable access.