AVAHO

Background: Oncologists are often not aware of the symptom burden their patients experience. Patient reported outcome (PRO) assessments are tools to measure symptoms. Higher symptom burden is associated with worse quality of life (QOL) and shorter survival, and implementation of PRO assessments is associated with improved QOL and longer survival. The Veteran Symptom Assessment Scale (VSAS) is a PRO template that is incorporated into the Veteran Administration’s (VA) computer patient record system. It is used by health care team members to record patient symptoms and is consistent and reproducible. However, as VSAS is administered at patient visits, it cannot measure between-visit symptoms. Thus, we sought to develop a platform by which veterans receiving hematology- oncology care can directly report their symptoms at any time.

Description: VA Office of Connected Care developed a text messaging platform called “Annie” which includes different disease-based assessment and automated management tools. Annie is named after Lieutenant Annie G. Fox, Chief Nurse in the Army Nurse Corps at Hickman Field, Pearl Harbor and the first woman to receive the Purple Heart for combat.

We developed an oncology symptom module in Annie that incorporates the VSAS symptoms, with a rating scale of 1 – 10 (1 = least severe, 10 = most severe). Veterans signed up for the oncology module receive weekday reminders to report symptoms, but may report symptoms on any day and time, even multiple times a day. After reporting a symptom and severity, a message with advice is texted to the veteran. This text is provided for self-help purposes, and does not replace individualized advice provided by an oncology nurse or provider. The Annie oncology module is available throughout the VA.

Implications: The Annie oncology module may improve implementation of VSAS at VA facilities, by removing the necessity for nurse administration. Using Annie will help VA facilities meet quality of care goals recommended by the American Society of Clinical Oncology and American College of Surgeon and will improve measurement of cancer related symptoms, a first step to developing symptom management tools for VA providers.

Background: Oncologists are often not aware of the symptom burden their patients experience. Patient reported outcome (PRO) assessments are tools to measure symptoms. Higher symptom burden is associated with worse quality of life (QOL) and shorter survival, and implementation of PRO assessments is associated with improved QOL and longer survival. The Veteran Symptom Assessment Scale (VSAS) is a PRO template that is incorporated into the Veteran Administration’s (VA) computer patient record system. It is used by health care team members to record patient symptoms and is consistent and reproducible. However, as VSAS is administered at patient visits, it cannot measure between-visit symptoms. Thus, we sought to develop a platform by which veterans receiving hematology- oncology care can directly report their symptoms at any time.

Description: VA Office of Connected Care developed a text messaging platform called “Annie” which includes different disease-based assessment and automated management tools. Annie is named after Lieutenant Annie G. Fox, Chief Nurse in the Army Nurse Corps at Hickman Field, Pearl Harbor and the first woman to receive the Purple Heart for combat.

We developed an oncology symptom module in Annie that incorporates the VSAS symptoms, with a rating scale of 1 – 10 (1 = least severe, 10 = most severe). Veterans signed up for the oncology module receive weekday reminders to report symptoms, but may report symptoms on any day and time, even multiple times a day. After reporting a symptom and severity, a message with advice is texted to the veteran. This text is provided for self-help purposes, and does not replace individualized advice provided by an oncology nurse or provider. The Annie oncology module is available throughout the VA.

Implications: The Annie oncology module may improve implementation of VSAS at VA facilities, by removing the necessity for nurse administration. Using Annie will help VA facilities meet quality of care goals recommended by the American Society of Clinical Oncology and American College of Surgeon and will improve measurement of cancer related symptoms, a first step to developing symptom management tools for VA providers.

Background: Oncologists are often not aware of the symptom burden their patients experience. Patient reported outcome (PRO) assessments are tools to measure symptoms. Higher symptom burden is associated with worse quality of life (QOL) and shorter survival, and implementation of PRO assessments is associated with improved QOL and longer survival. The Veteran Symptom Assessment Scale (VSAS) is a PRO template that is incorporated into the Veteran Administration’s (VA) computer patient record system. It is used by health care team members to record patient symptoms and is consistent and reproducible. However, as VSAS is administered at patient visits, it cannot measure between-visit symptoms. Thus, we sought to develop a platform by which veterans receiving hematology- oncology care can directly report their symptoms at any time.

Description: VA Office of Connected Care developed a text messaging platform called “Annie” which includes different disease-based assessment and automated management tools. Annie is named after Lieutenant Annie G. Fox, Chief Nurse in the Army Nurse Corps at Hickman Field, Pearl Harbor and the first woman to receive the Purple Heart for combat.

We developed an oncology symptom module in Annie that incorporates the VSAS symptoms, with a rating scale of 1 – 10 (1 = least severe, 10 = most severe). Veterans signed up for the oncology module receive weekday reminders to report symptoms, but may report symptoms on any day and time, even multiple times a day. After reporting a symptom and severity, a message with advice is texted to the veteran. This text is provided for self-help purposes, and does not replace individualized advice provided by an oncology nurse or provider. The Annie oncology module is available throughout the VA.

Implications: The Annie oncology module may improve implementation of VSAS at VA facilities, by removing the necessity for nurse administration. Using Annie will help VA facilities meet quality of care goals recommended by the American Society of Clinical Oncology and American College of Surgeon and will improve measurement of cancer related symptoms, a first step to developing symptom management tools for VA providers.

Background: A substantial percentage of veterans receiving chemotherapy in our infusion room reported some degree of feelings of distress. Distress can lead to patient dissatisfaction and an overall negative patient care experience.

Methods: We utilized the NCCN Distress Thermometer tool (scale 1-10) to gauge veterans self-reported level of distress after being seated in the infusion room. Of 88 veterans surveyed, 86% reported varying degrees of distress. Forty-two percent had scores of 4 or higher, and 18% with scores considered moderate to severe. Veterans reported that the fear of not knowing what to expect when starting treatment was a major contributor.

We created an informational video for veterans to view prior to their  rst infusion room appointment. The video depicts a walk through the veterans shoes as they check into clinic, undergo a chemotherapy clearance appointment, access a peripheral vein or port, then ends with introducing the team of infusion nurses. Additionally, we have implemented chair-side service to veterans in the infusion room with physicians, volunteers and members of leadership rotating to offer coffee/tea, DVD players, electronic tablets, magazines, card games, and warm blankets.

Results: After implementation of this veteran centered initiative, there has been a reduction in overall distress levels. After implementation, 31% of scores were a 4 or higher, showing a decrease by 11%. Additionally, there were lower numbers of scores in the severe distress range, 4.4% compared to 6% before the intervention.

Conclusion: Helping veterans to understand what to expect with initiation of chemotherapy can help reduce distress and start their cancer journey on a positive note. Bringing members of the clinical team and leadership to the chair-side to serve our veterans creates a patient centric environment and supports the mission to enhance veterans’ experience.

Background: A substantial percentage of veterans receiving chemotherapy in our infusion room reported some degree of feelings of distress. Distress can lead to patient dissatisfaction and an overall negative patient care experience.

Methods: We utilized the NCCN Distress Thermometer tool (scale 1-10) to gauge veterans self-reported level of distress after being seated in the infusion room. Of 88 veterans surveyed, 86% reported varying degrees of distress. Forty-two percent had scores of 4 or higher, and 18% with scores considered moderate to severe. Veterans reported that the fear of not knowing what to expect when starting treatment was a major contributor.

We created an informational video for veterans to view prior to their  rst infusion room appointment. The video depicts a walk through the veterans shoes as they check into clinic, undergo a chemotherapy clearance appointment, access a peripheral vein or port, then ends with introducing the team of infusion nurses. Additionally, we have implemented chair-side service to veterans in the infusion room with physicians, volunteers and members of leadership rotating to offer coffee/tea, DVD players, electronic tablets, magazines, card games, and warm blankets.

Results: After implementation of this veteran centered initiative, there has been a reduction in overall distress levels. After implementation, 31% of scores were a 4 or higher, showing a decrease by 11%. Additionally, there were lower numbers of scores in the severe distress range, 4.4% compared to 6% before the intervention.

Conclusion: Helping veterans to understand what to expect with initiation of chemotherapy can help reduce distress and start their cancer journey on a positive note. Bringing members of the clinical team and leadership to the chair-side to serve our veterans creates a patient centric environment and supports the mission to enhance veterans’ experience.

Background: A substantial percentage of veterans receiving chemotherapy in our infusion room reported some degree of feelings of distress. Distress can lead to patient dissatisfaction and an overall negative patient care experience.

Methods: We utilized the NCCN Distress Thermometer tool (scale 1-10) to gauge veterans self-reported level of distress after being seated in the infusion room. Of 88 veterans surveyed, 86% reported varying degrees of distress. Forty-two percent had scores of 4 or higher, and 18% with scores considered moderate to severe. Veterans reported that the fear of not knowing what to expect when starting treatment was a major contributor.

We created an informational video for veterans to view prior to their  rst infusion room appointment. The video depicts a walk through the veterans shoes as they check into clinic, undergo a chemotherapy clearance appointment, access a peripheral vein or port, then ends with introducing the team of infusion nurses. Additionally, we have implemented chair-side service to veterans in the infusion room with physicians, volunteers and members of leadership rotating to offer coffee/tea, DVD players, electronic tablets, magazines, card games, and warm blankets.

Results: After implementation of this veteran centered initiative, there has been a reduction in overall distress levels. After implementation, 31% of scores were a 4 or higher, showing a decrease by 11%. Additionally, there were lower numbers of scores in the severe distress range, 4.4% compared to 6% before the intervention.

Conclusion: Helping veterans to understand what to expect with initiation of chemotherapy can help reduce distress and start their cancer journey on a positive note. Bringing members of the clinical team and leadership to the chair-side to serve our veterans creates a patient centric environment and supports the mission to enhance veterans’ experience.

Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).

Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.

Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).

Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.

Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).

Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.

Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).

Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.

Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).

Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.

Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).

Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.

Purpose: Approximately 10% of patients with stage I non-small cell lung cancer (NSCLC) are managed without definitive therapy. We therefore investigated whether this rate is similar among veterans cared for by the Veterans Health Administration (VHA), and explored the outcomes and factors associated with under- utilization of these standard of care management strategies.

Methods: The Veterans Affairs (VA) Corporate Data Warehouse (CDW) was queried for all patients diagnosed with NSCLC between 2003 and 2016. Receipt of definitive therapy was determined using VHA cancer registry data, CPT codes and ICD-9/ICD-10 procedure codes within a year after diagnosis. We also captured receipt of chemotherapy as the primary course of treatment, whenever this was the case. Vital status data were assessed using the Kaplan-Meier method.

Results: A total of 19,971 veterans were diagnosed with biopsy-proven clinical stage I NSCLC. The primary treatment for 13,080 (65.5%), 4,889 (24.5%), and 2,002 (10.0%) patients was surgery, RT, or no documented surgery or RT, respectively. The 5-year overall survival for these 3 groups was 53.1%, 19.7%, and 8.9%, respectively. The proportion of patients without documentation of definitive therapy was highest in 2004 at 16.9%, decreasing to 6.3% by 2016. Patients treated at a VA medical center with an on-site radiation oncology service were more likely to receive definitive therapy (chi-square P<0.01). However, this difference was driven by higher utilization of surgery instead of radiation therapy. Among patients without documentation of definitive therapy, 17.4% received systemic chemotherapy as their first reported treatment course.

Conclusion: The proportion of patients without documentation of definitive surgery or RT was similar to previous publications. The rate of no definitive therapy has declined by more than 50% over the past decade, and is coincident with the increased availability of onsite radiotherapy services, as well as minimally invasive thoracic surgery and stereotactic radiotherapy within and outside the VHA. Future investigations of this dataset are likely to increase our understanding about the reasons for treatment delay or avoidance, and its consequences for patients with a highly curable stage I NSCLC.

Purpose: Approximately 10% of patients with stage I non-small cell lung cancer (NSCLC) are managed without definitive therapy. We therefore investigated whether this rate is similar among veterans cared for by the Veterans Health Administration (VHA), and explored the outcomes and factors associated with under- utilization of these standard of care management strategies.

Methods: The Veterans Affairs (VA) Corporate Data Warehouse (CDW) was queried for all patients diagnosed with NSCLC between 2003 and 2016. Receipt of definitive therapy was determined using VHA cancer registry data, CPT codes and ICD-9/ICD-10 procedure codes within a year after diagnosis. We also captured receipt of chemotherapy as the primary course of treatment, whenever this was the case. Vital status data were assessed using the Kaplan-Meier method.

Results: A total of 19,971 veterans were diagnosed with biopsy-proven clinical stage I NSCLC. The primary treatment for 13,080 (65.5%), 4,889 (24.5%), and 2,002 (10.0%) patients was surgery, RT, or no documented surgery or RT, respectively. The 5-year overall survival for these 3 groups was 53.1%, 19.7%, and 8.9%, respectively. The proportion of patients without documentation of definitive therapy was highest in 2004 at 16.9%, decreasing to 6.3% by 2016. Patients treated at a VA medical center with an on-site radiation oncology service were more likely to receive definitive therapy (chi-square P<0.01). However, this difference was driven by higher utilization of surgery instead of radiation therapy. Among patients without documentation of definitive therapy, 17.4% received systemic chemotherapy as their first reported treatment course.

Conclusion: The proportion of patients without documentation of definitive surgery or RT was similar to previous publications. The rate of no definitive therapy has declined by more than 50% over the past decade, and is coincident with the increased availability of onsite radiotherapy services, as well as minimally invasive thoracic surgery and stereotactic radiotherapy within and outside the VHA. Future investigations of this dataset are likely to increase our understanding about the reasons for treatment delay or avoidance, and its consequences for patients with a highly curable stage I NSCLC.

Purpose: Approximately 10% of patients with stage I non-small cell lung cancer (NSCLC) are managed without definitive therapy. We therefore investigated whether this rate is similar among veterans cared for by the Veterans Health Administration (VHA), and explored the outcomes and factors associated with under- utilization of these standard of care management strategies.

Methods: The Veterans Affairs (VA) Corporate Data Warehouse (CDW) was queried for all patients diagnosed with NSCLC between 2003 and 2016. Receipt of definitive therapy was determined using VHA cancer registry data, CPT codes and ICD-9/ICD-10 procedure codes within a year after diagnosis. We also captured receipt of chemotherapy as the primary course of treatment, whenever this was the case. Vital status data were assessed using the Kaplan-Meier method.

Results: A total of 19,971 veterans were diagnosed with biopsy-proven clinical stage I NSCLC. The primary treatment for 13,080 (65.5%), 4,889 (24.5%), and 2,002 (10.0%) patients was surgery, RT, or no documented surgery or RT, respectively. The 5-year overall survival for these 3 groups was 53.1%, 19.7%, and 8.9%, respectively. The proportion of patients without documentation of definitive therapy was highest in 2004 at 16.9%, decreasing to 6.3% by 2016. Patients treated at a VA medical center with an on-site radiation oncology service were more likely to receive definitive therapy (chi-square P<0.01). However, this difference was driven by higher utilization of surgery instead of radiation therapy. Among patients without documentation of definitive therapy, 17.4% received systemic chemotherapy as their first reported treatment course.

Conclusion: The proportion of patients without documentation of definitive surgery or RT was similar to previous publications. The rate of no definitive therapy has declined by more than 50% over the past decade, and is coincident with the increased availability of onsite radiotherapy services, as well as minimally invasive thoracic surgery and stereotactic radiotherapy within and outside the VHA. Future investigations of this dataset are likely to increase our understanding about the reasons for treatment delay or avoidance, and its consequences for patients with a highly curable stage I NSCLC.

Purpose: To evaluate the clinical impact of biweekly liver function tests (LFTs) during the first 3 months of abiraterone therapy in veterans with prostate cancer.

Background: Abiraterone monitoring recommendations include biweekly LFTs for 3 months, then monthly based on concerns of early hepatoxicity in a limited number of patients. Veterans at the Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC) appear to tolerate abiraterone without clinically significant hepatoxicity despite stringent monitoring. There appears to be an opportunity to improve patient satisfaction/ quality of life and decrease cost to the healthcare system.

Methods: Patients were included in this retrospective chart review if abiraterone was initiated through the RLRVAMC between May 2014 and July 2018. Exclusion criteria were discontinuation within three months due to rising prostate-specific antigen or adverse drug events unrelated to hepatotoxicity, prior abiraterone exposure, and management outside RLRVAMC. Primary outcome was incidence and severity of LFT changes. Secondary outcomes included incidence and cause of dose reduction and death. Descriptive statistics analyzed outcomes. Severity of toxicity was classified according to common terminology criteria for adverse events (CTCAE) version 5.

Results: Ninety patients were included. Across three months of treatment, 24 (26.7%), 2 (2.2%), 0, and 2 (2.2%) patients experienced maximum CTCAE grade 1, 2, 3, and 4 LFT changes, respectively. Two patients experienced grade 3 or 4 LFT changes, both with previous therapy modifications due to grade 1 or 2 LFT changes and acute illness. Therapy modifications for any reason occurred in 4.4% of patients, all due to acute illness, general tolerability concerns, or grade 1 or 2 LFT changes. Four patients experienced death. No deaths were considered directly related to abiraterone.

Implications: Need for week 10 laboratory monitoring may be determined based on patient specific criteria. Reduction in laboratory monitoring may increase patient satisfaction/quality of life and decrease unnecessary costs to the healthcare system. Patients initiated on abiraterone through the RLRVAMC will receive monthly monitoring starting at week eight in the absence of baseline risk factors for hepatoxicity, grade 2 or worsening grade 1 changes during the first two months of therapy, or new grade 1 changes identified at week eight of therapy

Purpose: To evaluate the clinical impact of biweekly liver function tests (LFTs) during the first 3 months of abiraterone therapy in veterans with prostate cancer.

Background: Abiraterone monitoring recommendations include biweekly LFTs for 3 months, then monthly based on concerns of early hepatoxicity in a limited number of patients. Veterans at the Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC) appear to tolerate abiraterone without clinically significant hepatoxicity despite stringent monitoring. There appears to be an opportunity to improve patient satisfaction/ quality of life and decrease cost to the healthcare system.

Methods: Patients were included in this retrospective chart review if abiraterone was initiated through the RLRVAMC between May 2014 and July 2018. Exclusion criteria were discontinuation within three months due to rising prostate-specific antigen or adverse drug events unrelated to hepatotoxicity, prior abiraterone exposure, and management outside RLRVAMC. Primary outcome was incidence and severity of LFT changes. Secondary outcomes included incidence and cause of dose reduction and death. Descriptive statistics analyzed outcomes. Severity of toxicity was classified according to common terminology criteria for adverse events (CTCAE) version 5.

Results: Ninety patients were included. Across three months of treatment, 24 (26.7%), 2 (2.2%), 0, and 2 (2.2%) patients experienced maximum CTCAE grade 1, 2, 3, and 4 LFT changes, respectively. Two patients experienced grade 3 or 4 LFT changes, both with previous therapy modifications due to grade 1 or 2 LFT changes and acute illness. Therapy modifications for any reason occurred in 4.4% of patients, all due to acute illness, general tolerability concerns, or grade 1 or 2 LFT changes. Four patients experienced death. No deaths were considered directly related to abiraterone.

Implications: Need for week 10 laboratory monitoring may be determined based on patient specific criteria. Reduction in laboratory monitoring may increase patient satisfaction/quality of life and decrease unnecessary costs to the healthcare system. Patients initiated on abiraterone through the RLRVAMC will receive monthly monitoring starting at week eight in the absence of baseline risk factors for hepatoxicity, grade 2 or worsening grade 1 changes during the first two months of therapy, or new grade 1 changes identified at week eight of therapy

Purpose: To evaluate the clinical impact of biweekly liver function tests (LFTs) during the first 3 months of abiraterone therapy in veterans with prostate cancer.

Background: Abiraterone monitoring recommendations include biweekly LFTs for 3 months, then monthly based on concerns of early hepatoxicity in a limited number of patients. Veterans at the Richard L. Roudebush Veterans Affairs Medical Center (RLRVAMC) appear to tolerate abiraterone without clinically significant hepatoxicity despite stringent monitoring. There appears to be an opportunity to improve patient satisfaction/ quality of life and decrease cost to the healthcare system.

Methods: Patients were included in this retrospective chart review if abiraterone was initiated through the RLRVAMC between May 2014 and July 2018. Exclusion criteria were discontinuation within three months due to rising prostate-specific antigen or adverse drug events unrelated to hepatotoxicity, prior abiraterone exposure, and management outside RLRVAMC. Primary outcome was incidence and severity of LFT changes. Secondary outcomes included incidence and cause of dose reduction and death. Descriptive statistics analyzed outcomes. Severity of toxicity was classified according to common terminology criteria for adverse events (CTCAE) version 5.

Results: Ninety patients were included. Across three months of treatment, 24 (26.7%), 2 (2.2%), 0, and 2 (2.2%) patients experienced maximum CTCAE grade 1, 2, 3, and 4 LFT changes, respectively. Two patients experienced grade 3 or 4 LFT changes, both with previous therapy modifications due to grade 1 or 2 LFT changes and acute illness. Therapy modifications for any reason occurred in 4.4% of patients, all due to acute illness, general tolerability concerns, or grade 1 or 2 LFT changes. Four patients experienced death. No deaths were considered directly related to abiraterone.

Implications: Need for week 10 laboratory monitoring may be determined based on patient specific criteria. Reduction in laboratory monitoring may increase patient satisfaction/quality of life and decrease unnecessary costs to the healthcare system. Patients initiated on abiraterone through the RLRVAMC will receive monthly monitoring starting at week eight in the absence of baseline risk factors for hepatoxicity, grade 2 or worsening grade 1 changes during the first two months of therapy, or new grade 1 changes identified at week eight of therapy

Background: High lifetime counts of pre-cancerous polyps, termed “adenomas,” are associated with increased risk for colorectal cancer (CRC). Given that a genetic predisposition to adenomas may increase susceptibility to CRC, further studies are needed to characterize low-penetrance germline factors in those with increased cumulative adenoma counts.

Purpose: To investigate if known CRC or adenomarisk single nucleotide polymorphisms (SNPs) are associated with increasing cumulative adenoma counts in a prospective screening cohort of veterans.

Data Analysis: The CSP #380 screening colonoscopy cohort includes a biorepository of selected individuals with baseline advanced neoplasia and matched individuals without neoplasia (n=612). Blood samples were genotyped using the Illumina Infinium Omni2.5-8 GWAS chip and associated cumulative adenoma counts were summed over 10 years. A corrected Poisson regression (adjusted for age at last colonoscopy, gender, and race) was used to evaluate associations between higher cumulative adenoma counts and 43 pre-specified CRC-risk SNPs or a subset of these SNPs shown also to be associated with adenomas in published literature. SNPs were evaluated singly or combined in a Genetic Risk Score (GRS). The GRS was constructed from only the eight adenomarisk SNPs and calculated based on the total number of present risk alleles (0-2) summed across all SNPs per individual (both weighted for published effect size and unweighted).

Results: Four CRC-risk SNPs were associated with increasing mean adenoma counts (P<0.05): rs12241008 (gene: VTI1A), rs2423279 (BMP2/HAO1), rs3184504 (SH2B3), and rs961253 (FERMT1/BMP2), with risk allele risk ratios (RR) of 1.31, 1.29, 1.24, and 1.23, respectively. Only one known adenoma-risk SNP was significant in our dataset (rs961253; OR 1.23 per risk allele; P=0.01). An increasing weighted GRS was associated with increased cumulative adenoma counts (weighted RR 1.58, P=0.03; unweighted RR 1.03, P=0.39).

Implications: In this CRC screening cohort, four known CRC-risk SNPs were found to be associated with increasing cumulative adenoma counts. Additionally, an increasing burden of adenoma-risk SNPs, as measured by a weighted GRS, was associated with higher cumulative adenoma counts. Future work will evaluate predictive tools based on a precancerous, adenoma GRS to better risk stratify patients during CRC screening, and compare to current CRC genetic risk scores.

Background: High lifetime counts of pre-cancerous polyps, termed “adenomas,” are associated with increased risk for colorectal cancer (CRC). Given that a genetic predisposition to adenomas may increase susceptibility to CRC, further studies are needed to characterize low-penetrance germline factors in those with increased cumulative adenoma counts.

Purpose: To investigate if known CRC or adenomarisk single nucleotide polymorphisms (SNPs) are associated with increasing cumulative adenoma counts in a prospective screening cohort of veterans.

Data Analysis: The CSP #380 screening colonoscopy cohort includes a biorepository of selected individuals with baseline advanced neoplasia and matched individuals without neoplasia (n=612). Blood samples were genotyped using the Illumina Infinium Omni2.5-8 GWAS chip and associated cumulative adenoma counts were summed over 10 years. A corrected Poisson regression (adjusted for age at last colonoscopy, gender, and race) was used to evaluate associations between higher cumulative adenoma counts and 43 pre-specified CRC-risk SNPs or a subset of these SNPs shown also to be associated with adenomas in published literature. SNPs were evaluated singly or combined in a Genetic Risk Score (GRS). The GRS was constructed from only the eight adenomarisk SNPs and calculated based on the total number of present risk alleles (0-2) summed across all SNPs per individual (both weighted for published effect size and unweighted).

Results: Four CRC-risk SNPs were associated with increasing mean adenoma counts (P<0.05): rs12241008 (gene: VTI1A), rs2423279 (BMP2/HAO1), rs3184504 (SH2B3), and rs961253 (FERMT1/BMP2), with risk allele risk ratios (RR) of 1.31, 1.29, 1.24, and 1.23, respectively. Only one known adenoma-risk SNP was significant in our dataset (rs961253; OR 1.23 per risk allele; P=0.01). An increasing weighted GRS was associated with increased cumulative adenoma counts (weighted RR 1.58, P=0.03; unweighted RR 1.03, P=0.39).

Implications: In this CRC screening cohort, four known CRC-risk SNPs were found to be associated with increasing cumulative adenoma counts. Additionally, an increasing burden of adenoma-risk SNPs, as measured by a weighted GRS, was associated with higher cumulative adenoma counts. Future work will evaluate predictive tools based on a precancerous, adenoma GRS to better risk stratify patients during CRC screening, and compare to current CRC genetic risk scores.

Background: High lifetime counts of pre-cancerous polyps, termed “adenomas,” are associated with increased risk for colorectal cancer (CRC). Given that a genetic predisposition to adenomas may increase susceptibility to CRC, further studies are needed to characterize low-penetrance germline factors in those with increased cumulative adenoma counts.

Purpose: To investigate if known CRC or adenomarisk single nucleotide polymorphisms (SNPs) are associated with increasing cumulative adenoma counts in a prospective screening cohort of veterans.

Data Analysis: The CSP #380 screening colonoscopy cohort includes a biorepository of selected individuals with baseline advanced neoplasia and matched individuals without neoplasia (n=612). Blood samples were genotyped using the Illumina Infinium Omni2.5-8 GWAS chip and associated cumulative adenoma counts were summed over 10 years. A corrected Poisson regression (adjusted for age at last colonoscopy, gender, and race) was used to evaluate associations between higher cumulative adenoma counts and 43 pre-specified CRC-risk SNPs or a subset of these SNPs shown also to be associated with adenomas in published literature. SNPs were evaluated singly or combined in a Genetic Risk Score (GRS). The GRS was constructed from only the eight adenomarisk SNPs and calculated based on the total number of present risk alleles (0-2) summed across all SNPs per individual (both weighted for published effect size and unweighted).

Results: Four CRC-risk SNPs were associated with increasing mean adenoma counts (P<0.05): rs12241008 (gene: VTI1A), rs2423279 (BMP2/HAO1), rs3184504 (SH2B3), and rs961253 (FERMT1/BMP2), with risk allele risk ratios (RR) of 1.31, 1.29, 1.24, and 1.23, respectively. Only one known adenoma-risk SNP was significant in our dataset (rs961253; OR 1.23 per risk allele; P=0.01). An increasing weighted GRS was associated with increased cumulative adenoma counts (weighted RR 1.58, P=0.03; unweighted RR 1.03, P=0.39).

Implications: In this CRC screening cohort, four known CRC-risk SNPs were found to be associated with increasing cumulative adenoma counts. Additionally, an increasing burden of adenoma-risk SNPs, as measured by a weighted GRS, was associated with higher cumulative adenoma counts. Future work will evaluate predictive tools based on a precancerous, adenoma GRS to better risk stratify patients during CRC screening, and compare to current CRC genetic risk scores.

Background: Nivolumab (Opdivo) was initially FDAapproved at a dose of 3mg/kg by intravenous infusion over 60 minutes every 2 weeks. In September 2016, nivolumab’s FDA approved dosing was changed from 3mg/kg to a 240mg flat dose. In January 2018, nivolumab’s FDA approved dosing was updated to reflect a decreased infusion time of 30 minutes. In March 2018, nivolumab’s FDA approved dosing was again modified from 240mg every 2 weeks to 480mg every 4 weeks. The VA Northeast Ohio Healthcare System (VANEOHS) adopted the 480mg every 4 weeks regimen in March 2018. The increased nivolumab dose and shortened infusion time raised some concern regarding immune-mediated toxicities which was the rationale behind this medication use evaluation (MUE).

Methods: This retrospective chart review was completed to compare the incidence of toxicity between the every 2 week and the every 4 week dosing schedules and evaluate the adoption of every 4 week dosing regimen by VANEOHS prescribers. Patients newly initiated on nivolumab between 10/1/17 and 9/30/18 were reviewed for the occurrence of immune-mediated adverse events (AEs) within the first 3 months of treatment.

Results: Sixty-five patients were included in the MUE, with 21 (46%) initiated on 240mg every 2 weeks and 25 (54%) initiated on 480mg every 4 weeks. All patients initiated on 240mg every 2 weeks were either converted to 480mg every 4 weeks, or nivolumab therapy was discontinued prior to VANEOHS adoption of the 4 week dosing regimen. Immune-mediated AEs potentially related to nivolumab therapy were documented in 8 (32%) patients receiving 480mg, and 4 (36%) patients receiving 240mg. Of patients who switched from nivolumab 240mg to 480mg, 3 (30%) experienced an AE while receiving 240mg, and 1 (10%) while receiving 480mg.

Conclusion: The nivolumab 480mg every 4 week dosing regimen was readily adopted by oncology providers at VANEOHS and the rate of patients experiencing AEs with nivolumab 480mg every 4 weeks compared to 240mg every 2 weeks, was similar between treatment groups. The results of this MUE support continued prescribing of the nivolumab 480mg every 4 week dosing regimen with close monitoring for adverse reactions.

Background: Nivolumab (Opdivo) was initially FDAapproved at a dose of 3mg/kg by intravenous infusion over 60 minutes every 2 weeks. In September 2016, nivolumab’s FDA approved dosing was changed from 3mg/kg to a 240mg flat dose. In January 2018, nivolumab’s FDA approved dosing was updated to reflect a decreased infusion time of 30 minutes. In March 2018, nivolumab’s FDA approved dosing was again modified from 240mg every 2 weeks to 480mg every 4 weeks. The VA Northeast Ohio Healthcare System (VANEOHS) adopted the 480mg every 4 weeks regimen in March 2018. The increased nivolumab dose and shortened infusion time raised some concern regarding immune-mediated toxicities which was the rationale behind this medication use evaluation (MUE).

Methods: This retrospective chart review was completed to compare the incidence of toxicity between the every 2 week and the every 4 week dosing schedules and evaluate the adoption of every 4 week dosing regimen by VANEOHS prescribers. Patients newly initiated on nivolumab between 10/1/17 and 9/30/18 were reviewed for the occurrence of immune-mediated adverse events (AEs) within the first 3 months of treatment.

Results: Sixty-five patients were included in the MUE, with 21 (46%) initiated on 240mg every 2 weeks and 25 (54%) initiated on 480mg every 4 weeks. All patients initiated on 240mg every 2 weeks were either converted to 480mg every 4 weeks, or nivolumab therapy was discontinued prior to VANEOHS adoption of the 4 week dosing regimen. Immune-mediated AEs potentially related to nivolumab therapy were documented in 8 (32%) patients receiving 480mg, and 4 (36%) patients receiving 240mg. Of patients who switched from nivolumab 240mg to 480mg, 3 (30%) experienced an AE while receiving 240mg, and 1 (10%) while receiving 480mg.

Conclusion: The nivolumab 480mg every 4 week dosing regimen was readily adopted by oncology providers at VANEOHS and the rate of patients experiencing AEs with nivolumab 480mg every 4 weeks compared to 240mg every 2 weeks, was similar between treatment groups. The results of this MUE support continued prescribing of the nivolumab 480mg every 4 week dosing regimen with close monitoring for adverse reactions.

Background: Nivolumab (Opdivo) was initially FDAapproved at a dose of 3mg/kg by intravenous infusion over 60 minutes every 2 weeks. In September 2016, nivolumab’s FDA approved dosing was changed from 3mg/kg to a 240mg flat dose. In January 2018, nivolumab’s FDA approved dosing was updated to reflect a decreased infusion time of 30 minutes. In March 2018, nivolumab’s FDA approved dosing was again modified from 240mg every 2 weeks to 480mg every 4 weeks. The VA Northeast Ohio Healthcare System (VANEOHS) adopted the 480mg every 4 weeks regimen in March 2018. The increased nivolumab dose and shortened infusion time raised some concern regarding immune-mediated toxicities which was the rationale behind this medication use evaluation (MUE).

Methods: This retrospective chart review was completed to compare the incidence of toxicity between the every 2 week and the every 4 week dosing schedules and evaluate the adoption of every 4 week dosing regimen by VANEOHS prescribers. Patients newly initiated on nivolumab between 10/1/17 and 9/30/18 were reviewed for the occurrence of immune-mediated adverse events (AEs) within the first 3 months of treatment.

Results: Sixty-five patients were included in the MUE, with 21 (46%) initiated on 240mg every 2 weeks and 25 (54%) initiated on 480mg every 4 weeks. All patients initiated on 240mg every 2 weeks were either converted to 480mg every 4 weeks, or nivolumab therapy was discontinued prior to VANEOHS adoption of the 4 week dosing regimen. Immune-mediated AEs potentially related to nivolumab therapy were documented in 8 (32%) patients receiving 480mg, and 4 (36%) patients receiving 240mg. Of patients who switched from nivolumab 240mg to 480mg, 3 (30%) experienced an AE while receiving 240mg, and 1 (10%) while receiving 480mg.

Conclusion: The nivolumab 480mg every 4 week dosing regimen was readily adopted by oncology providers at VANEOHS and the rate of patients experiencing AEs with nivolumab 480mg every 4 weeks compared to 240mg every 2 weeks, was similar between treatment groups. The results of this MUE support continued prescribing of the nivolumab 480mg every 4 week dosing regimen with close monitoring for adverse reactions.

Background: Poor adherence to oral anticancer medications (OAMs) is a well-recognized problem in oncology, however adherence to OAMs among veterans is largely unknown. Medication cost is often mitigated, however higher rates of comorbidities within the veteran population may contribute to impaired adherence. Additionally veterans living outside local catchments may be at increased risk for non-adherence or inadequate follow up due to geographic burden.

Cancer rates nationwide are projected to increase over the next 10-20 years. The Veterans Health Administration is the largest integrated health care system in the US, and characterizing OAM adherence and any potential barriers is valuable in improving veterans’ care.

Project Description: The purpose of this study is to investigate and characterize adherence to OAMs and recommend safety monitoring studies among US veterans enrolled at the VAPORHCS, as part of a fellowship quality improvement program initiative. This is a retrospective chart review of all veterans followed within the VAPORHCS hematology/oncology fellows’ clinic, who were taking OAMs from March 1, 2018 to March 1, 2019. Fellows reviewed their own panels, with an internal medicine faculty member performing an independent review on a portion of the charts. Information collected includes adherence to medications as well as recommended monitoring, as determined by provider notes, pharmacy records, and lab and imaging records. Additional information collected includes demographics, co-morbidities, polypharmacy, and service connection.

Results: Primary co-objectives of this project will be determining adherence to both medications and recommended routine monitoring studies (ie labs, imaging, and follow-up appointments). Secondary objectives will be characterizing adherence in relation to other patient factors, such as age, geographic location, primary malignancy, co-morbidities, polypharmacy, and service connection. This project was initiated in fall of 2018. The data has currently been all collected and is undergoing review and analysis. Full results should be available by end of July 2019.

Data Analysis: Initial data processing and univariate analysis is currently ongoing. We currently have plans to pursue multivariate analysis of the results through the Oregon Health and Science University Biostatics Shared Resource (BSR) Department.

Background: Poor adherence to oral anticancer medications (OAMs) is a well-recognized problem in oncology, however adherence to OAMs among veterans is largely unknown. Medication cost is often mitigated, however higher rates of comorbidities within the veteran population may contribute to impaired adherence. Additionally veterans living outside local catchments may be at increased risk for non-adherence or inadequate follow up due to geographic burden.

Cancer rates nationwide are projected to increase over the next 10-20 years. The Veterans Health Administration is the largest integrated health care system in the US, and characterizing OAM adherence and any potential barriers is valuable in improving veterans’ care.

Project Description: The purpose of this study is to investigate and characterize adherence to OAMs and recommend safety monitoring studies among US veterans enrolled at the VAPORHCS, as part of a fellowship quality improvement program initiative. This is a retrospective chart review of all veterans followed within the VAPORHCS hematology/oncology fellows’ clinic, who were taking OAMs from March 1, 2018 to March 1, 2019. Fellows reviewed their own panels, with an internal medicine faculty member performing an independent review on a portion of the charts. Information collected includes adherence to medications as well as recommended monitoring, as determined by provider notes, pharmacy records, and lab and imaging records. Additional information collected includes demographics, co-morbidities, polypharmacy, and service connection.

Results: Primary co-objectives of this project will be determining adherence to both medications and recommended routine monitoring studies (ie labs, imaging, and follow-up appointments). Secondary objectives will be characterizing adherence in relation to other patient factors, such as age, geographic location, primary malignancy, co-morbidities, polypharmacy, and service connection. This project was initiated in fall of 2018. The data has currently been all collected and is undergoing review and analysis. Full results should be available by end of July 2019.

Data Analysis: Initial data processing and univariate analysis is currently ongoing. We currently have plans to pursue multivariate analysis of the results through the Oregon Health and Science University Biostatics Shared Resource (BSR) Department.

Background: Poor adherence to oral anticancer medications (OAMs) is a well-recognized problem in oncology, however adherence to OAMs among veterans is largely unknown. Medication cost is often mitigated, however higher rates of comorbidities within the veteran population may contribute to impaired adherence. Additionally veterans living outside local catchments may be at increased risk for non-adherence or inadequate follow up due to geographic burden.

Cancer rates nationwide are projected to increase over the next 10-20 years. The Veterans Health Administration is the largest integrated health care system in the US, and characterizing OAM adherence and any potential barriers is valuable in improving veterans’ care.

Project Description: The purpose of this study is to investigate and characterize adherence to OAMs and recommend safety monitoring studies among US veterans enrolled at the VAPORHCS, as part of a fellowship quality improvement program initiative. This is a retrospective chart review of all veterans followed within the VAPORHCS hematology/oncology fellows’ clinic, who were taking OAMs from March 1, 2018 to March 1, 2019. Fellows reviewed their own panels, with an internal medicine faculty member performing an independent review on a portion of the charts. Information collected includes adherence to medications as well as recommended monitoring, as determined by provider notes, pharmacy records, and lab and imaging records. Additional information collected includes demographics, co-morbidities, polypharmacy, and service connection.

Results: Primary co-objectives of this project will be determining adherence to both medications and recommended routine monitoring studies (ie labs, imaging, and follow-up appointments). Secondary objectives will be characterizing adherence in relation to other patient factors, such as age, geographic location, primary malignancy, co-morbidities, polypharmacy, and service connection. This project was initiated in fall of 2018. The data has currently been all collected and is undergoing review and analysis. Full results should be available by end of July 2019.

Data Analysis: Initial data processing and univariate analysis is currently ongoing. We currently have plans to pursue multivariate analysis of the results through the Oregon Health and Science University Biostatics Shared Resource (BSR) Department.

Background: Tele-palliative care is an effective method of providing care for patients who wish to receive their care locally. In an effort to provide care to veterans that live remotely the Palliative Care program at the Pittsburgh VAMC created a Palliative Care Telemedicine clinic. The clinic provides a patient centered approach by working with primary care and subspecialists to manage symptoms, establish patient’s expectations with treatment and to determine what the patient is willing to endure to reach his/her goals. Patient focused care provides better quality of care and may result in a decrease in unwanted and inappropriate admissions, readmissions, tests, procedures and transfers to a higher level of care that may not align with the patient’s goals of care.

Methods: In 2018 the Palliative Care program partnered with Oncology to provide comprehensive patient care by CVT. Patients who requested that their chemotherapy/ immunotherapy be done at the local VA were seen by Oncology in Pittsburgh with subsequent visits and treatment done in the infusion clinic at the local VA. Patients were seen by Oncology by CVT prior to each treatment, Patients with stage IV disease or who had extensive symptom burden were referred for telepalliative care and were seen on the same day that they were seen by their Oncologist.

Results: Since 2018, 51 patients with the diagnosis of cancer were referred for both Oncology and Palliative Care CVT. There were a total of 211 clinic visits. Patents were primarily referred for symptom management and goals of care. Since January 2018, 22 patients are alive, 24 patients have died and 5 patients are currently receiving hospice care. 21 patients died at home or in a CLC—1 died in the hospital and 2 sites of death are unknown.

Conclusion: Preliminary data suggests that tele-palliative care can provide effective symptom management and may reduce deaths in an acute care setting. The palliative care program plans to expand tele-palliative care by offering this service to other facilities in the VISN as well as partnering with home hospice agencies to provide VVC for patients that are on hospice.

Background: Tele-palliative care is an effective method of providing care for patients who wish to receive their care locally. In an effort to provide care to veterans that live remotely the Palliative Care program at the Pittsburgh VAMC created a Palliative Care Telemedicine clinic. The clinic provides a patient centered approach by working with primary care and subspecialists to manage symptoms, establish patient’s expectations with treatment and to determine what the patient is willing to endure to reach his/her goals. Patient focused care provides better quality of care and may result in a decrease in unwanted and inappropriate admissions, readmissions, tests, procedures and transfers to a higher level of care that may not align with the patient’s goals of care.

Methods: In 2018 the Palliative Care program partnered with Oncology to provide comprehensive patient care by CVT. Patients who requested that their chemotherapy/ immunotherapy be done at the local VA were seen by Oncology in Pittsburgh with subsequent visits and treatment done in the infusion clinic at the local VA. Patients were seen by Oncology by CVT prior to each treatment, Patients with stage IV disease or who had extensive symptom burden were referred for telepalliative care and were seen on the same day that they were seen by their Oncologist.

Results: Since 2018, 51 patients with the diagnosis of cancer were referred for both Oncology and Palliative Care CVT. There were a total of 211 clinic visits. Patents were primarily referred for symptom management and goals of care. Since January 2018, 22 patients are alive, 24 patients have died and 5 patients are currently receiving hospice care. 21 patients died at home or in a CLC—1 died in the hospital and 2 sites of death are unknown.

Conclusion: Preliminary data suggests that tele-palliative care can provide effective symptom management and may reduce deaths in an acute care setting. The palliative care program plans to expand tele-palliative care by offering this service to other facilities in the VISN as well as partnering with home hospice agencies to provide VVC for patients that are on hospice.

Background: Tele-palliative care is an effective method of providing care for patients who wish to receive their care locally. In an effort to provide care to veterans that live remotely the Palliative Care program at the Pittsburgh VAMC created a Palliative Care Telemedicine clinic. The clinic provides a patient centered approach by working with primary care and subspecialists to manage symptoms, establish patient’s expectations with treatment and to determine what the patient is willing to endure to reach his/her goals. Patient focused care provides better quality of care and may result in a decrease in unwanted and inappropriate admissions, readmissions, tests, procedures and transfers to a higher level of care that may not align with the patient’s goals of care.

Methods: In 2018 the Palliative Care program partnered with Oncology to provide comprehensive patient care by CVT. Patients who requested that their chemotherapy/ immunotherapy be done at the local VA were seen by Oncology in Pittsburgh with subsequent visits and treatment done in the infusion clinic at the local VA. Patients were seen by Oncology by CVT prior to each treatment, Patients with stage IV disease or who had extensive symptom burden were referred for telepalliative care and were seen on the same day that they were seen by their Oncologist.

Results: Since 2018, 51 patients with the diagnosis of cancer were referred for both Oncology and Palliative Care CVT. There were a total of 211 clinic visits. Patents were primarily referred for symptom management and goals of care. Since January 2018, 22 patients are alive, 24 patients have died and 5 patients are currently receiving hospice care. 21 patients died at home or in a CLC—1 died in the hospital and 2 sites of death are unknown.

Conclusion: Preliminary data suggests that tele-palliative care can provide effective symptom management and may reduce deaths in an acute care setting. The palliative care program plans to expand tele-palliative care by offering this service to other facilities in the VISN as well as partnering with home hospice agencies to provide VVC for patients that are on hospice.

Background: In the US, Lung cancer is the second most common malignancy, but the most common cause of cancer deaths. In 2010, the National Lung Screening Trial described a 20.3% reduction in lung cancer mortality in high-risk patients screened by low-dose spiral CT (LDCT). In 2012, multiple groups established screening guidelines. The National Comprehensive Cancer Network recommended yearly screening for patients aged 55 to 75 years, ≥30 packyears of smoking, or smoking cessation within 15 years. In late 2013, LDCT screening for lung cancer was initiated at the Providence VA Medical Center. It was anticipated that over time there would be a rise in early stage cancers and decrease in late stage cancers. We submitted preliminary data at AVAHO in 2015 with increased earlier detection as anticipated. We have now completed 5 years of screening and are presenting data from 2014 through 2018.

Results: The number of screening CTs has increased almost every year (1929, 1875, 1916, 2201, 2336 respectively), and the number with cancer decreased from 1.34% (2014) to 0.008% (2018). The majority of NSCLCs found have been early stage, but with Small Cell Lung Cancer, 50% had limited and 50% extensive disease. Yearly screening is not likely to increase early detection of Small Cell Lung Cancer. Percentages of stage I & II for NSCLC prior to screening were 30% and 27% in 2012 and 2013 respectively. In 2014 – 2018 percentages were 69%, 60%, 50%, 83% and 50%. In 2016 and 2018, several veterans came to the VA to establish care with a known nodule, or had their first screening CT here, and they were found to have late stage disease. When we subtracted those first time screens the percentages of stage I & II were 69%, 60%, 78%, 83%, and 56%.

Discussion: As expected, for NSCLC yearly LDCT screening increased “pickup” of early stage disease. Unanswered questions include: How long should annual screening continue; What is the financial, emotional and radiation exposure impact of frequent screening, especially for those who need to be followed at more frequent intervals.

Background: In the US, Lung cancer is the second most common malignancy, but the most common cause of cancer deaths. In 2010, the National Lung Screening Trial described a 20.3% reduction in lung cancer mortality in high-risk patients screened by low-dose spiral CT (LDCT). In 2012, multiple groups established screening guidelines. The National Comprehensive Cancer Network recommended yearly screening for patients aged 55 to 75 years, ≥30 packyears of smoking, or smoking cessation within 15 years. In late 2013, LDCT screening for lung cancer was initiated at the Providence VA Medical Center. It was anticipated that over time there would be a rise in early stage cancers and decrease in late stage cancers. We submitted preliminary data at AVAHO in 2015 with increased earlier detection as anticipated. We have now completed 5 years of screening and are presenting data from 2014 through 2018.

Results: The number of screening CTs has increased almost every year (1929, 1875, 1916, 2201, 2336 respectively), and the number with cancer decreased from 1.34% (2014) to 0.008% (2018). The majority of NSCLCs found have been early stage, but with Small Cell Lung Cancer, 50% had limited and 50% extensive disease. Yearly screening is not likely to increase early detection of Small Cell Lung Cancer. Percentages of stage I & II for NSCLC prior to screening were 30% and 27% in 2012 and 2013 respectively. In 2014 – 2018 percentages were 69%, 60%, 50%, 83% and 50%. In 2016 and 2018, several veterans came to the VA to establish care with a known nodule, or had their first screening CT here, and they were found to have late stage disease. When we subtracted those first time screens the percentages of stage I & II were 69%, 60%, 78%, 83%, and 56%.

Discussion: As expected, for NSCLC yearly LDCT screening increased “pickup” of early stage disease. Unanswered questions include: How long should annual screening continue; What is the financial, emotional and radiation exposure impact of frequent screening, especially for those who need to be followed at more frequent intervals.

Background: In the US, Lung cancer is the second most common malignancy, but the most common cause of cancer deaths. In 2010, the National Lung Screening Trial described a 20.3% reduction in lung cancer mortality in high-risk patients screened by low-dose spiral CT (LDCT). In 2012, multiple groups established screening guidelines. The National Comprehensive Cancer Network recommended yearly screening for patients aged 55 to 75 years, ≥30 packyears of smoking, or smoking cessation within 15 years. In late 2013, LDCT screening for lung cancer was initiated at the Providence VA Medical Center. It was anticipated that over time there would be a rise in early stage cancers and decrease in late stage cancers. We submitted preliminary data at AVAHO in 2015 with increased earlier detection as anticipated. We have now completed 5 years of screening and are presenting data from 2014 through 2018.

Results: The number of screening CTs has increased almost every year (1929, 1875, 1916, 2201, 2336 respectively), and the number with cancer decreased from 1.34% (2014) to 0.008% (2018). The majority of NSCLCs found have been early stage, but with Small Cell Lung Cancer, 50% had limited and 50% extensive disease. Yearly screening is not likely to increase early detection of Small Cell Lung Cancer. Percentages of stage I & II for NSCLC prior to screening were 30% and 27% in 2012 and 2013 respectively. In 2014 – 2018 percentages were 69%, 60%, 50%, 83% and 50%. In 2016 and 2018, several veterans came to the VA to establish care with a known nodule, or had their first screening CT here, and they were found to have late stage disease. When we subtracted those first time screens the percentages of stage I & II were 69%, 60%, 78%, 83%, and 56%.

Discussion: As expected, for NSCLC yearly LDCT screening increased “pickup” of early stage disease. Unanswered questions include: How long should annual screening continue; What is the financial, emotional and radiation exposure impact of frequent screening, especially for those who need to be followed at more frequent intervals.