User login
Assessment of Barriers to Cancer Care
Purpose: The purpose of this quality improvement project was to determine barriers to cancer care in an urban, largely African-American veteran sample at the Washington DC Veterans Affairs Medical Center (DCVA). The DCVA veteran population has several characteristics associated with challenges in accessing cancer care, including a large African-American population and patients with mental health diagnoses.
Methods: Veterans completed an anonymous survey assess barriers to care as part of a larger survey examining veteran needs in cancer care. Descriptive statistics were conducted on the current responders (n = 128) with an ongoing recruitment goal of 150 survey completers.
Results indicated both logistical and psychosocial barriers, with trouble with transportation or parking (32%) and nancial dif culties (20%) most frequently reported. Nearly half of the sample (45%, n = 55) reported having a psychiatric or mental health diagnosis. A signi cant percentage of this subsample reported that their mental health symptoms caused them to avoid or delay cancer screening (18%), stop cancer treatment (13%), or delay follow-up visits after nishing cancer treatment (17%). Moreover, 62% of this sub-sample stated their mental health symptoms were worsened by their cancer care. The most common reported exacerbators were undergoing imaging (eg, MRI or PET scan) (35%), radiation therapy (33%), and attending follow-up visits (33%).
Conclusion: Logistical barriers are currently being addressed through expanding provider knowledge of transportation resources and opening of an expanded parking garage. Findings of transportation and parking barriers likely reflect specific construction projects at the DCVA and may not be generalizable to other settings. Further quality improvement work based on the results of this project include incorporating screening for mental health diagnoses and targeted interventions for patients identifying concerns related to mental health symptom stressors with the goal of increasing timeliness of care.
Purpose: The purpose of this quality improvement project was to determine barriers to cancer care in an urban, largely African-American veteran sample at the Washington DC Veterans Affairs Medical Center (DCVA). The DCVA veteran population has several characteristics associated with challenges in accessing cancer care, including a large African-American population and patients with mental health diagnoses.
Methods: Veterans completed an anonymous survey assess barriers to care as part of a larger survey examining veteran needs in cancer care. Descriptive statistics were conducted on the current responders (n = 128) with an ongoing recruitment goal of 150 survey completers.
Results indicated both logistical and psychosocial barriers, with trouble with transportation or parking (32%) and nancial dif culties (20%) most frequently reported. Nearly half of the sample (45%, n = 55) reported having a psychiatric or mental health diagnosis. A signi cant percentage of this subsample reported that their mental health symptoms caused them to avoid or delay cancer screening (18%), stop cancer treatment (13%), or delay follow-up visits after nishing cancer treatment (17%). Moreover, 62% of this sub-sample stated their mental health symptoms were worsened by their cancer care. The most common reported exacerbators were undergoing imaging (eg, MRI or PET scan) (35%), radiation therapy (33%), and attending follow-up visits (33%).
Conclusion: Logistical barriers are currently being addressed through expanding provider knowledge of transportation resources and opening of an expanded parking garage. Findings of transportation and parking barriers likely reflect specific construction projects at the DCVA and may not be generalizable to other settings. Further quality improvement work based on the results of this project include incorporating screening for mental health diagnoses and targeted interventions for patients identifying concerns related to mental health symptom stressors with the goal of increasing timeliness of care.
Purpose: The purpose of this quality improvement project was to determine barriers to cancer care in an urban, largely African-American veteran sample at the Washington DC Veterans Affairs Medical Center (DCVA). The DCVA veteran population has several characteristics associated with challenges in accessing cancer care, including a large African-American population and patients with mental health diagnoses.
Methods: Veterans completed an anonymous survey assess barriers to care as part of a larger survey examining veteran needs in cancer care. Descriptive statistics were conducted on the current responders (n = 128) with an ongoing recruitment goal of 150 survey completers.
Results indicated both logistical and psychosocial barriers, with trouble with transportation or parking (32%) and nancial dif culties (20%) most frequently reported. Nearly half of the sample (45%, n = 55) reported having a psychiatric or mental health diagnosis. A signi cant percentage of this subsample reported that their mental health symptoms caused them to avoid or delay cancer screening (18%), stop cancer treatment (13%), or delay follow-up visits after nishing cancer treatment (17%). Moreover, 62% of this sub-sample stated their mental health symptoms were worsened by their cancer care. The most common reported exacerbators were undergoing imaging (eg, MRI or PET scan) (35%), radiation therapy (33%), and attending follow-up visits (33%).
Conclusion: Logistical barriers are currently being addressed through expanding provider knowledge of transportation resources and opening of an expanded parking garage. Findings of transportation and parking barriers likely reflect specific construction projects at the DCVA and may not be generalizable to other settings. Further quality improvement work based on the results of this project include incorporating screening for mental health diagnoses and targeted interventions for patients identifying concerns related to mental health symptom stressors with the goal of increasing timeliness of care.
Severe Autoimmune Pancytopenia: An Unusual Presentation of Chronic Lymphocytic Leukemia (CLL)
Case Report: A 61-year-old African American man presented to his PCP complaining of severe weakness and dyspnea with minimal exertion. The symptoms had begun about 6 weeks prior to the visit and had slowly worsened. The patient denied any bleeding, fever chills or sweats. He had a past, presumed history of ulcerative colitis, inactive, on no medications, as well as benign prostatic hypertrophy (BPH) without therapy. He denied any use of OTC’s; no drug or alcohol use. No risk factors for HIV. In the office he was noticed to be severely anemic with a Hgb of 2.5, on repeat was 2.7 gm/dL. Platelet count was 10 000/uL, confirmed on repeat CBC and examination of the smear. WBC was 4,500 with about 80% normal appearing lymphocytes. LDH was 143(wnl). A B12 level was low at 208, with an elevated MMA of 829. The patient was admitted for evaluation and transfusions. There were no petechiae or echymoses in the visible areas of the skin. The patient initially refused physical exam or any diagnostic procedures. A subsequent flow cytometric assay of his blood was consistent with CLL. Eventually a bone marrow aspirate and biopsy were performed. It showed a hypercellular bone marrow, with major decrease in all myeloid, erythroid and megakaryocytic elements which were replaced by population of mature, small lymphocytes, consistent with the diagnosis of CLL. In particular, histology was characterized by almost complete absence of megakaryocytes, leading to suspicion of an auto-immune component driving disease. The patient was started on pulse dexamethasone vitamin B12, and administered weekly anti-CD20 (Rituximab) for 4 doses. He was also started on eltrombopag and a BTK inhibitor (Ibrutinib) both of which he continues to take to date. His counts have slowly risen, and the patient continues to improve.
Discussion: Severe pancytopenia as a presentation of CLL is uncommon, perhaps in contrast to autoimmune cytopenias which are relatively common events during the lifecycle of patients with CLL and are thought to arise from antibody production by the normal BCells, in this setting of T-cell dysregulation. Given recent trends in the treatment of CLL with BTK inhibitors, which have been both used to treat, as well as believed to have caused auto-immune CLL complications it’s important to review the occurrence of cytopenias and how to manage them in this setting.
Case Report: A 61-year-old African American man presented to his PCP complaining of severe weakness and dyspnea with minimal exertion. The symptoms had begun about 6 weeks prior to the visit and had slowly worsened. The patient denied any bleeding, fever chills or sweats. He had a past, presumed history of ulcerative colitis, inactive, on no medications, as well as benign prostatic hypertrophy (BPH) without therapy. He denied any use of OTC’s; no drug or alcohol use. No risk factors for HIV. In the office he was noticed to be severely anemic with a Hgb of 2.5, on repeat was 2.7 gm/dL. Platelet count was 10 000/uL, confirmed on repeat CBC and examination of the smear. WBC was 4,500 with about 80% normal appearing lymphocytes. LDH was 143(wnl). A B12 level was low at 208, with an elevated MMA of 829. The patient was admitted for evaluation and transfusions. There were no petechiae or echymoses in the visible areas of the skin. The patient initially refused physical exam or any diagnostic procedures. A subsequent flow cytometric assay of his blood was consistent with CLL. Eventually a bone marrow aspirate and biopsy were performed. It showed a hypercellular bone marrow, with major decrease in all myeloid, erythroid and megakaryocytic elements which were replaced by population of mature, small lymphocytes, consistent with the diagnosis of CLL. In particular, histology was characterized by almost complete absence of megakaryocytes, leading to suspicion of an auto-immune component driving disease. The patient was started on pulse dexamethasone vitamin B12, and administered weekly anti-CD20 (Rituximab) for 4 doses. He was also started on eltrombopag and a BTK inhibitor (Ibrutinib) both of which he continues to take to date. His counts have slowly risen, and the patient continues to improve.
Discussion: Severe pancytopenia as a presentation of CLL is uncommon, perhaps in contrast to autoimmune cytopenias which are relatively common events during the lifecycle of patients with CLL and are thought to arise from antibody production by the normal BCells, in this setting of T-cell dysregulation. Given recent trends in the treatment of CLL with BTK inhibitors, which have been both used to treat, as well as believed to have caused auto-immune CLL complications it’s important to review the occurrence of cytopenias and how to manage them in this setting.
Case Report: A 61-year-old African American man presented to his PCP complaining of severe weakness and dyspnea with minimal exertion. The symptoms had begun about 6 weeks prior to the visit and had slowly worsened. The patient denied any bleeding, fever chills or sweats. He had a past, presumed history of ulcerative colitis, inactive, on no medications, as well as benign prostatic hypertrophy (BPH) without therapy. He denied any use of OTC’s; no drug or alcohol use. No risk factors for HIV. In the office he was noticed to be severely anemic with a Hgb of 2.5, on repeat was 2.7 gm/dL. Platelet count was 10 000/uL, confirmed on repeat CBC and examination of the smear. WBC was 4,500 with about 80% normal appearing lymphocytes. LDH was 143(wnl). A B12 level was low at 208, with an elevated MMA of 829. The patient was admitted for evaluation and transfusions. There were no petechiae or echymoses in the visible areas of the skin. The patient initially refused physical exam or any diagnostic procedures. A subsequent flow cytometric assay of his blood was consistent with CLL. Eventually a bone marrow aspirate and biopsy were performed. It showed a hypercellular bone marrow, with major decrease in all myeloid, erythroid and megakaryocytic elements which were replaced by population of mature, small lymphocytes, consistent with the diagnosis of CLL. In particular, histology was characterized by almost complete absence of megakaryocytes, leading to suspicion of an auto-immune component driving disease. The patient was started on pulse dexamethasone vitamin B12, and administered weekly anti-CD20 (Rituximab) for 4 doses. He was also started on eltrombopag and a BTK inhibitor (Ibrutinib) both of which he continues to take to date. His counts have slowly risen, and the patient continues to improve.
Discussion: Severe pancytopenia as a presentation of CLL is uncommon, perhaps in contrast to autoimmune cytopenias which are relatively common events during the lifecycle of patients with CLL and are thought to arise from antibody production by the normal BCells, in this setting of T-cell dysregulation. Given recent trends in the treatment of CLL with BTK inhibitors, which have been both used to treat, as well as believed to have caused auto-immune CLL complications it’s important to review the occurrence of cytopenias and how to manage them in this setting.
High Risk Breast Cancer Screening Pilot Program in Accordance With National Guidelines
Purpose: Assess breast cancer (BC) risk, lifestyle factors, post-traumatic stress disorder (PTSD) status, chemoprevention and genetic consultations in women Veterans.
Background/Rationale: By 2020, women using Veterans Affairs Medical Centers (VAMC) will rise to 15%. For US women at high risk of BC, national guidelines (ASCO/USPSTF) recommend chemoprevention and genetic counseling for which fewer than 10% accept.
Methods: A pilot program was conducted at two VAMCs in the Bronx, NY and Washington, DC. Participants were enrolled at women’s health visits or education/awareness events. A questionnaire included the Gail Breast Cancer Risk Assessment Tool (BCRAT), the Breast Cancer Genetics Referral Screening Tool (B-RST), and lifestyle questions. Body mass index (BMI) and PTSD status were determined. Chemoprevention was recommended based on 5-year BCRAT > 1.66%; the B-RST was used for genetic counseling referrals. Chemoprevention candidates were given pre- and post-consultation knowledge questions.
Results: 99 women Veterans aged > 35 years with no personal history of BC, average age 54 years, participated between 2015-2018. Of these 35 (35%) had a Gail score of > 1.66%. Of this subset, 46% had prior breast biopsies and 86% had a positive family history. PTSD was present in 31%. Twenty-six (74%) accepted consultations for chemoprevention; 19% accepted chemoprevention; 37% patients were referred for genetic counseling; and 85% increased their awareness of chemoprevention. Among all participants, 79% had overweight or obese BMIs; 58% exercise weekly; 51% drink alcohol; 14% were smokers and 21% consumed 3-4 servings of fruits/vegetables daily.
Conclusions/Implications: Our study demonstrated that three times as many women Veterans are at increased risk of BC compared to the general population, based on a high rate of prior breast biopsies or positive family history. PTSD rates were nearly 3 times the national average and are implicated in poor adherence to medical advice. Chemoprevention utilization was nearly twice the national average. Lifestyle factors were similar to general population rates and unlikely to impact risk levels. Limitations included self-referrals and the large percentage of patients with a family history of BC, making them more likely to seek screening. As the number of Women Veterans increases, chemoprevention options should follow national guidelines.
Purpose: Assess breast cancer (BC) risk, lifestyle factors, post-traumatic stress disorder (PTSD) status, chemoprevention and genetic consultations in women Veterans.
Background/Rationale: By 2020, women using Veterans Affairs Medical Centers (VAMC) will rise to 15%. For US women at high risk of BC, national guidelines (ASCO/USPSTF) recommend chemoprevention and genetic counseling for which fewer than 10% accept.
Methods: A pilot program was conducted at two VAMCs in the Bronx, NY and Washington, DC. Participants were enrolled at women’s health visits or education/awareness events. A questionnaire included the Gail Breast Cancer Risk Assessment Tool (BCRAT), the Breast Cancer Genetics Referral Screening Tool (B-RST), and lifestyle questions. Body mass index (BMI) and PTSD status were determined. Chemoprevention was recommended based on 5-year BCRAT > 1.66%; the B-RST was used for genetic counseling referrals. Chemoprevention candidates were given pre- and post-consultation knowledge questions.
Results: 99 women Veterans aged > 35 years with no personal history of BC, average age 54 years, participated between 2015-2018. Of these 35 (35%) had a Gail score of > 1.66%. Of this subset, 46% had prior breast biopsies and 86% had a positive family history. PTSD was present in 31%. Twenty-six (74%) accepted consultations for chemoprevention; 19% accepted chemoprevention; 37% patients were referred for genetic counseling; and 85% increased their awareness of chemoprevention. Among all participants, 79% had overweight or obese BMIs; 58% exercise weekly; 51% drink alcohol; 14% were smokers and 21% consumed 3-4 servings of fruits/vegetables daily.
Conclusions/Implications: Our study demonstrated that three times as many women Veterans are at increased risk of BC compared to the general population, based on a high rate of prior breast biopsies or positive family history. PTSD rates were nearly 3 times the national average and are implicated in poor adherence to medical advice. Chemoprevention utilization was nearly twice the national average. Lifestyle factors were similar to general population rates and unlikely to impact risk levels. Limitations included self-referrals and the large percentage of patients with a family history of BC, making them more likely to seek screening. As the number of Women Veterans increases, chemoprevention options should follow national guidelines.
Purpose: Assess breast cancer (BC) risk, lifestyle factors, post-traumatic stress disorder (PTSD) status, chemoprevention and genetic consultations in women Veterans.
Background/Rationale: By 2020, women using Veterans Affairs Medical Centers (VAMC) will rise to 15%. For US women at high risk of BC, national guidelines (ASCO/USPSTF) recommend chemoprevention and genetic counseling for which fewer than 10% accept.
Methods: A pilot program was conducted at two VAMCs in the Bronx, NY and Washington, DC. Participants were enrolled at women’s health visits or education/awareness events. A questionnaire included the Gail Breast Cancer Risk Assessment Tool (BCRAT), the Breast Cancer Genetics Referral Screening Tool (B-RST), and lifestyle questions. Body mass index (BMI) and PTSD status were determined. Chemoprevention was recommended based on 5-year BCRAT > 1.66%; the B-RST was used for genetic counseling referrals. Chemoprevention candidates were given pre- and post-consultation knowledge questions.
Results: 99 women Veterans aged > 35 years with no personal history of BC, average age 54 years, participated between 2015-2018. Of these 35 (35%) had a Gail score of > 1.66%. Of this subset, 46% had prior breast biopsies and 86% had a positive family history. PTSD was present in 31%. Twenty-six (74%) accepted consultations for chemoprevention; 19% accepted chemoprevention; 37% patients were referred for genetic counseling; and 85% increased their awareness of chemoprevention. Among all participants, 79% had overweight or obese BMIs; 58% exercise weekly; 51% drink alcohol; 14% were smokers and 21% consumed 3-4 servings of fruits/vegetables daily.
Conclusions/Implications: Our study demonstrated that three times as many women Veterans are at increased risk of BC compared to the general population, based on a high rate of prior breast biopsies or positive family history. PTSD rates were nearly 3 times the national average and are implicated in poor adherence to medical advice. Chemoprevention utilization was nearly twice the national average. Lifestyle factors were similar to general population rates and unlikely to impact risk levels. Limitations included self-referrals and the large percentage of patients with a family history of BC, making them more likely to seek screening. As the number of Women Veterans increases, chemoprevention options should follow national guidelines.
Breast Cancer Risk Assessment and Chemoprevention Use Among VA Primary Care
Background: Despite recommended guidelines and available medications to reduce breast cancer risk by up to 50-65%, < 5% of the 10 million eligible women are offered chemoprevention in the U.S. The comfort level, practice patterns, and barriers to breast cancer risk assessment and chemoprevention use within the VA have not been reported.
Methods: We assessed VA primary care providers using a REDcap survey. We obtained provider demographics, use and comfort level with breast cancer risk models and chemoprevention, and knowledge about chemoprevention. Data was analyzed with Fisher exact or chi-square tests.
Results: Of the 200 survey respondents, 167 were included for analysis. Overall, 30% used the Gail model monthly or more often, and 1.5% prescribed chemoprevention in the past 2 years. Fewer than 30% correctly answered chemoprevention knowledge questions. Designated women’s
health providers were more comfortable with risk assessment and chemoprevention (P < .046, P < .004) and used risk models more often (P < .045). 63% expressed interest in education about breast cancer prevention.
Conclusions: Breast cancer risk assessment and chemoprevention use by VA primary care is limited by lack of comfort and familiarity. Women‘s health providers are more comfortable and knowledgeable about breast cancer risk models and chemoprevention, offering an opportunity for partnership with high-risk oncologists to improve breast cancer risk assessment and chemoprevention use among female Veterans.
Background: Despite recommended guidelines and available medications to reduce breast cancer risk by up to 50-65%, < 5% of the 10 million eligible women are offered chemoprevention in the U.S. The comfort level, practice patterns, and barriers to breast cancer risk assessment and chemoprevention use within the VA have not been reported.
Methods: We assessed VA primary care providers using a REDcap survey. We obtained provider demographics, use and comfort level with breast cancer risk models and chemoprevention, and knowledge about chemoprevention. Data was analyzed with Fisher exact or chi-square tests.
Results: Of the 200 survey respondents, 167 were included for analysis. Overall, 30% used the Gail model monthly or more often, and 1.5% prescribed chemoprevention in the past 2 years. Fewer than 30% correctly answered chemoprevention knowledge questions. Designated women’s
health providers were more comfortable with risk assessment and chemoprevention (P < .046, P < .004) and used risk models more often (P < .045). 63% expressed interest in education about breast cancer prevention.
Conclusions: Breast cancer risk assessment and chemoprevention use by VA primary care is limited by lack of comfort and familiarity. Women‘s health providers are more comfortable and knowledgeable about breast cancer risk models and chemoprevention, offering an opportunity for partnership with high-risk oncologists to improve breast cancer risk assessment and chemoprevention use among female Veterans.
Background: Despite recommended guidelines and available medications to reduce breast cancer risk by up to 50-65%, < 5% of the 10 million eligible women are offered chemoprevention in the U.S. The comfort level, practice patterns, and barriers to breast cancer risk assessment and chemoprevention use within the VA have not been reported.
Methods: We assessed VA primary care providers using a REDcap survey. We obtained provider demographics, use and comfort level with breast cancer risk models and chemoprevention, and knowledge about chemoprevention. Data was analyzed with Fisher exact or chi-square tests.
Results: Of the 200 survey respondents, 167 were included for analysis. Overall, 30% used the Gail model monthly or more often, and 1.5% prescribed chemoprevention in the past 2 years. Fewer than 30% correctly answered chemoprevention knowledge questions. Designated women’s
health providers were more comfortable with risk assessment and chemoprevention (P < .046, P < .004) and used risk models more often (P < .045). 63% expressed interest in education about breast cancer prevention.
Conclusions: Breast cancer risk assessment and chemoprevention use by VA primary care is limited by lack of comfort and familiarity. Women‘s health providers are more comfortable and knowledgeable about breast cancer risk models and chemoprevention, offering an opportunity for partnership with high-risk oncologists to improve breast cancer risk assessment and chemoprevention use among female Veterans.
Double-Expressor Lymphoma (DEL) in Veterans at DC VAMC
Purpose: To identify DEL amongst veteran patients with diffuse large B cell lymphoma (DLBCL) and its outcome.
Background: Molecular profile determines prognosis in DLBCL. Activated B-cell (ABC), a subtype of DLBCL, is associated with poor outcome compared to germinal center Bcell (GCB). Poor response to standard chemotherapy is seen with double-hit lymphomas as detected by FISH (5% -10% of DLBCL) and DELs that express both MYC and BCL-2 as detected by immunohistochemistry (IHC) (cutoffs—30% MYC, 40% BCL-2), with a median overall survival of <12 months.
Methods: Sixty-nine DLBCL patients diagnosed at DC VAMC from 1/1996-4/2016 were identified utilizing cancer registry. IHC stains were reviewed for CD3, CD10, CD20, BCL-2, BCL-6, C-MYC, MUM-1, MIB1, and p53. DLBCL were sub-classified as GCB and ABC based on CD10, BCL6 and MUM1 stains. Demographic data, diagnosis, treatment and outcome in terms of relapse and death are analyzed and will be presented at the meeting.
Results: Of the 69 DLBCL cases, only 37 met inclusion criteria; 32 were excluded due to unavailable blocks (20, mostly sent to outside institutions), tissue exhaustion with incomplete IHC data (6), T-cell rich B cell lymphoma (5) and pending (1). 20 cases are GCB and 17 ABC. All cases are CD20 positive with high mib1. MYC is positive in 17 cases (46%) and 15 of them double positive for BCL-2 (40%).
Implications/Future Directions: DLBCL veterans at the DC VAMC have a high percentage of double expressors when compared to the literature. It will be important to examine clinical data, treatment, and outcome to develop better treatment guidelines for double-expressor DLBCL. Future studies are in plan to compare double hit lymphomas to double expressors.
Purpose: To identify DEL amongst veteran patients with diffuse large B cell lymphoma (DLBCL) and its outcome.
Background: Molecular profile determines prognosis in DLBCL. Activated B-cell (ABC), a subtype of DLBCL, is associated with poor outcome compared to germinal center Bcell (GCB). Poor response to standard chemotherapy is seen with double-hit lymphomas as detected by FISH (5% -10% of DLBCL) and DELs that express both MYC and BCL-2 as detected by immunohistochemistry (IHC) (cutoffs—30% MYC, 40% BCL-2), with a median overall survival of <12 months.
Methods: Sixty-nine DLBCL patients diagnosed at DC VAMC from 1/1996-4/2016 were identified utilizing cancer registry. IHC stains were reviewed for CD3, CD10, CD20, BCL-2, BCL-6, C-MYC, MUM-1, MIB1, and p53. DLBCL were sub-classified as GCB and ABC based on CD10, BCL6 and MUM1 stains. Demographic data, diagnosis, treatment and outcome in terms of relapse and death are analyzed and will be presented at the meeting.
Results: Of the 69 DLBCL cases, only 37 met inclusion criteria; 32 were excluded due to unavailable blocks (20, mostly sent to outside institutions), tissue exhaustion with incomplete IHC data (6), T-cell rich B cell lymphoma (5) and pending (1). 20 cases are GCB and 17 ABC. All cases are CD20 positive with high mib1. MYC is positive in 17 cases (46%) and 15 of them double positive for BCL-2 (40%).
Implications/Future Directions: DLBCL veterans at the DC VAMC have a high percentage of double expressors when compared to the literature. It will be important to examine clinical data, treatment, and outcome to develop better treatment guidelines for double-expressor DLBCL. Future studies are in plan to compare double hit lymphomas to double expressors.
Purpose: To identify DEL amongst veteran patients with diffuse large B cell lymphoma (DLBCL) and its outcome.
Background: Molecular profile determines prognosis in DLBCL. Activated B-cell (ABC), a subtype of DLBCL, is associated with poor outcome compared to germinal center Bcell (GCB). Poor response to standard chemotherapy is seen with double-hit lymphomas as detected by FISH (5% -10% of DLBCL) and DELs that express both MYC and BCL-2 as detected by immunohistochemistry (IHC) (cutoffs—30% MYC, 40% BCL-2), with a median overall survival of <12 months.
Methods: Sixty-nine DLBCL patients diagnosed at DC VAMC from 1/1996-4/2016 were identified utilizing cancer registry. IHC stains were reviewed for CD3, CD10, CD20, BCL-2, BCL-6, C-MYC, MUM-1, MIB1, and p53. DLBCL were sub-classified as GCB and ABC based on CD10, BCL6 and MUM1 stains. Demographic data, diagnosis, treatment and outcome in terms of relapse and death are analyzed and will be presented at the meeting.
Results: Of the 69 DLBCL cases, only 37 met inclusion criteria; 32 were excluded due to unavailable blocks (20, mostly sent to outside institutions), tissue exhaustion with incomplete IHC data (6), T-cell rich B cell lymphoma (5) and pending (1). 20 cases are GCB and 17 ABC. All cases are CD20 positive with high mib1. MYC is positive in 17 cases (46%) and 15 of them double positive for BCL-2 (40%).
Implications/Future Directions: DLBCL veterans at the DC VAMC have a high percentage of double expressors when compared to the literature. It will be important to examine clinical data, treatment, and outcome to develop better treatment guidelines for double-expressor DLBCL. Future studies are in plan to compare double hit lymphomas to double expressors.
A Multidisciplinary, Multicenter Partnership Model for Breast Health Care in Women Veterans
Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.
Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.
Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.
Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.
Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.
Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.
Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.
Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.
Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.
Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.
Purpose: To demonstrate Lean Process Improvement methodologies in a multidisciplinary, multicenter model to screen for increased risk of breast cancer in Women Veterans. We strive to deliver a team-based, cross-functional model that meets the unique healthcare needs of female Veterans and results in a Veteran-centric delivery of care.
Relevant Background/ Problem: Women are the fastest growing veterans population seeking care at the VA Health Administration (VHA). There is also an increased risk of breast cancer in Women Veterans. Based on national guidelines we are developing tools to promote the use of screening for high risk breast cancer and its prevention as well as other breast health issues.
Methods: A 9 institution, multidisciplinary team including oncology, surgery, nursing, pharmacy, biostatistics, genetic counseling, mental health, and health systems engineering was launched at the 2014 AVAHO annual meeting. Since then, the group has met every 2 weeks by conference call and has developed subcommittees focusing on International Review Board approval, data collection, grant writing, survey design, and strategic planning. We have developed tools to collect data, CPRS research notes, and a multiple choice questionnaire.
Results: As a result of combined efforts, currently 5 studies are being conducted: Know your breast cancer risk factors and prevention options-pilot program currently enrolling patients at 2 sites. The preliminary data will be presented at AVAHO. Chemoprevention in VHA system: A VINCI data review from 2000-2015 VINCI data review of prophylactic mastectomies at VHA from 2000-2015. Survey for Primary Care physicians regarding awareness of increased risk breast cancer screening and prevention options. Lean Process Improvement project to roll out a program to increase the use of CVT so that VAMCs may offer screening and primary prevention for high risk breast cancer. Additionally, we are offering genetic counseling and plan to improve adherence to chemoprevention through the use of CVT.
Implications/Future Directions: Lean Process Improvement may be an effective method to coordinate clinical care in high risk breast cancer screening and awareness. This process should be considered as a model throughout the VHA system to offer care in accordance with national guidelines for our Women Veterans.
Breast Cancer Risk Assessment and Utilization of Prevention Options Among Female Veterans: A Feasibility Pilot Study
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Purpose: To increase the appropriate breast cancer risk quantification, utilization of chemoprevention, and genetic counseling among Women Veterans at high risk for breast
cancer in accordance with national guidelines.
Background/Rationale: There are over 2 million women who constitute the fastest growing segment of eligible veterans within the VHA. The number of women diagnosed with breast cancer has more than tripled from 1995 to 2012. Chemoprevention reduces the risk of breast cancer by 50-62% in high risk patients. An estimated 10 million women in the U.S. may be eligible, but fewer than 5% of high risk women are offered chemoprevention.
Methods: This is an ongoing feasibility pilot study being conducted at 2 VAMCs (“VAMC 1” and “VAMC 2”) with plans for expansion to 7 more VAMCs. Participants were enrolled at the time of their regular visit to Women’s Health Clinics. Eligibility criteria includes: women age ≥ 35 with no history of breast cancer. After completing a 20 multiple choice questionnaire, 5-year and lifetime risk of invasive breast cancer is calculated using the Gail risk tool (BCRAT). A woman is considered high risk and eligible for chemoprevention if her 5-year risk is ≥ 1.67% or her lifetime risk is ≥ 20%. Eligibility for genetic counseling is based on the Breast Cancer Referral Screening Tool (B-RST), which includes a personal or family history of breast or ovarian cancer and Jewish ancestry.
Results: 72 females (42 at “VAMC 1” and 30 at “VAMC 2”) were enrolled and completed the questionnaire. Of these patients, 17/42 (40%) and 6/30 (20%) had Gail score of > 1.66 and were considered high risk for breast cancer. All 23 females at both facilities had Oncology clinic consultations for chemoprevention. Only 1 female at each center accepted chemoprevention with tamoxifen (“VAMC 1”) and anastrazole (“VAMC 2”). Six patients had telehealth genetic counseling consults.
Implications/Future Directions: Increasing awareness of breast cancer risk status and utilization of prevention options is a critical element in our program to increase screening and provide chemoprevention according to national guidelines in the VHA. Future directions include tool development and national spread of screening efforts.
Gender Disparity in Breast Cancer: A Veteran Population Based Comparison
Introduction: Male breast cancer (MBC) comprises < 1% of all cancers in men and continues to rise. Because of MBC rarity, there is paucity in the literature. Management of MBC is generalized from female breast cancer (FBC). The Veterans Affairs Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare and contrast the characteristics and outcomes of MBC with FBC in the VA population.
Methods: VACCR data from 153 VAMCs were used to analyze the database of VA patients who had breast cancer diagnosed between 1998 and 2013. Primary site codes were identified for breast cancer (50.0-50.9). Data were entered and analyzed using biostatistical software (SAS 9.3).
Results: In total, 6,443 patient records were reviewed, and 1,123 MBC patients were compared with 5,320 FBC patients. The mean age at diagnosis was 70 years for MBS and 57 years for FBC (P < .0001). In patients aged > 50 years, higher numbers of MBC diagnosis (95%) were made compared with FBC diagnosis (72%). Seventy-five percent of patients with breast cancer were white in both genders. More MBC patients (40% in men vs 24% in women) presented with higher disease stage (3 and 4) compared with FBC (21% had ductal carcinoma in situ and 53% stage 1). The dominant histology was ductal carcinoma. No difference in laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Forty-five percent and 36% of patients with MBC or FBC, respectively, received hormonal treatment as first course, but fewer MBC patients received chemotherapy and radiation. The mean follow up time was 754 days. As of December 2013, 355 (32%) MBC and 791 (15%) FBC patients died during the course of the study. Males had higher odds of death compared with that of females, but when adjusted for age, race, stage, and grade, survival was better among males.
Conclusions: To the authors’ knowledge, this is the largest series of MBC and FBC completed to date in the veteran population. The results suggested that males were older at presentation and had higher stage of breast cancer compared with that of FBC. The higher mortality rate in MBC may be due to higher stage and/or tumor biology.
Introduction: Male breast cancer (MBC) comprises < 1% of all cancers in men and continues to rise. Because of MBC rarity, there is paucity in the literature. Management of MBC is generalized from female breast cancer (FBC). The Veterans Affairs Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare and contrast the characteristics and outcomes of MBC with FBC in the VA population.
Methods: VACCR data from 153 VAMCs were used to analyze the database of VA patients who had breast cancer diagnosed between 1998 and 2013. Primary site codes were identified for breast cancer (50.0-50.9). Data were entered and analyzed using biostatistical software (SAS 9.3).
Results: In total, 6,443 patient records were reviewed, and 1,123 MBC patients were compared with 5,320 FBC patients. The mean age at diagnosis was 70 years for MBS and 57 years for FBC (P < .0001). In patients aged > 50 years, higher numbers of MBC diagnosis (95%) were made compared with FBC diagnosis (72%). Seventy-five percent of patients with breast cancer were white in both genders. More MBC patients (40% in men vs 24% in women) presented with higher disease stage (3 and 4) compared with FBC (21% had ductal carcinoma in situ and 53% stage 1). The dominant histology was ductal carcinoma. No difference in laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Forty-five percent and 36% of patients with MBC or FBC, respectively, received hormonal treatment as first course, but fewer MBC patients received chemotherapy and radiation. The mean follow up time was 754 days. As of December 2013, 355 (32%) MBC and 791 (15%) FBC patients died during the course of the study. Males had higher odds of death compared with that of females, but when adjusted for age, race, stage, and grade, survival was better among males.
Conclusions: To the authors’ knowledge, this is the largest series of MBC and FBC completed to date in the veteran population. The results suggested that males were older at presentation and had higher stage of breast cancer compared with that of FBC. The higher mortality rate in MBC may be due to higher stage and/or tumor biology.
Introduction: Male breast cancer (MBC) comprises < 1% of all cancers in men and continues to rise. Because of MBC rarity, there is paucity in the literature. Management of MBC is generalized from female breast cancer (FBC). The Veterans Affairs Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare and contrast the characteristics and outcomes of MBC with FBC in the VA population.
Methods: VACCR data from 153 VAMCs were used to analyze the database of VA patients who had breast cancer diagnosed between 1998 and 2013. Primary site codes were identified for breast cancer (50.0-50.9). Data were entered and analyzed using biostatistical software (SAS 9.3).
Results: In total, 6,443 patient records were reviewed, and 1,123 MBC patients were compared with 5,320 FBC patients. The mean age at diagnosis was 70 years for MBS and 57 years for FBC (P < .0001). In patients aged > 50 years, higher numbers of MBC diagnosis (95%) were made compared with FBC diagnosis (72%). Seventy-five percent of patients with breast cancer were white in both genders. More MBC patients (40% in men vs 24% in women) presented with higher disease stage (3 and 4) compared with FBC (21% had ductal carcinoma in situ and 53% stage 1). The dominant histology was ductal carcinoma. No difference in laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Forty-five percent and 36% of patients with MBC or FBC, respectively, received hormonal treatment as first course, but fewer MBC patients received chemotherapy and radiation. The mean follow up time was 754 days. As of December 2013, 355 (32%) MBC and 791 (15%) FBC patients died during the course of the study. Males had higher odds of death compared with that of females, but when adjusted for age, race, stage, and grade, survival was better among males.
Conclusions: To the authors’ knowledge, this is the largest series of MBC and FBC completed to date in the veteran population. The results suggested that males were older at presentation and had higher stage of breast cancer compared with that of FBC. The higher mortality rate in MBC may be due to higher stage and/or tumor biology.