AVAHO

Background: Esophageal cancer continues to affect US veterans as the risk factors for esophageal adenocarcinoma and squamous cell carcinoma are highly prevalent in this patient population. While localized esophageal cancer can be cured with a tri-modality approach that includes neoadjuvant chemoradiation followed by esophagectomy, only those patients who achieve a pathologic complete remission to neoadjuvant chemoradiation have a 50% five-year overall survival. Those who do not achieve a pathologic complete remission or those with metastatic disease have a worse prognosis. Thus, there is a need to develop novel molecularly targeted agents for the treatment of esophageal
cancer. We have found that the Hedgehog signaling pathway, required for normal esophageal embryogenesis but silenced in the adult esophagus, is reactivated in both histologic subtypes of esophageal cancer.

Results: Using immunohistochemistry for the pathway ligand Sonic hedgehog or in situ hybridization for either Sonic hedgehog or the pathway target gene Gli1 on esophageal cancer tissue microarrays, we found that 206/346 (60%) cases were Hedgehog pathway active while normal squamous esophagus was negative. The anti-fungal agent itraconazole has previously been shown to inhibit Hedgehog signaling, and we were able to inhibit cell proliferation (cell number), Hedgehog pathway activity (quantitative real-time PCR), and VEGFR2 phosphorylation (Western blot) in vitro in OE33 esophageal adenocarcinoma cells. In a novel intraperitoneal xenograft model of liver metastases, itraconazole significantly improved overall survival in mice injected intraperitoneally with OE33 cells.

Conclusions: Based on these results we are conducting a phase 0 clinical trial administering itraconazole 300 mg po bid for 14-17 days to patients with localized esophageal cancer before neoadjuvant chemoradiation. To date, we have treated 6 patients with itraconazole and demonstrated inhibition of Hedgehog signaling by quantitative real-time PCR. It is hoped that results from this early phase trial may lead to further study and development of itraconazole as a molecularly targeted agent for esophageal cancer.

Background: Esophageal cancer continues to affect US veterans as the risk factors for esophageal adenocarcinoma and squamous cell carcinoma are highly prevalent in this patient population. While localized esophageal cancer can be cured with a tri-modality approach that includes neoadjuvant chemoradiation followed by esophagectomy, only those patients who achieve a pathologic complete remission to neoadjuvant chemoradiation have a 50% five-year overall survival. Those who do not achieve a pathologic complete remission or those with metastatic disease have a worse prognosis. Thus, there is a need to develop novel molecularly targeted agents for the treatment of esophageal
cancer. We have found that the Hedgehog signaling pathway, required for normal esophageal embryogenesis but silenced in the adult esophagus, is reactivated in both histologic subtypes of esophageal cancer.

Results: Using immunohistochemistry for the pathway ligand Sonic hedgehog or in situ hybridization for either Sonic hedgehog or the pathway target gene Gli1 on esophageal cancer tissue microarrays, we found that 206/346 (60%) cases were Hedgehog pathway active while normal squamous esophagus was negative. The anti-fungal agent itraconazole has previously been shown to inhibit Hedgehog signaling, and we were able to inhibit cell proliferation (cell number), Hedgehog pathway activity (quantitative real-time PCR), and VEGFR2 phosphorylation (Western blot) in vitro in OE33 esophageal adenocarcinoma cells. In a novel intraperitoneal xenograft model of liver metastases, itraconazole significantly improved overall survival in mice injected intraperitoneally with OE33 cells.

Conclusions: Based on these results we are conducting a phase 0 clinical trial administering itraconazole 300 mg po bid for 14-17 days to patients with localized esophageal cancer before neoadjuvant chemoradiation. To date, we have treated 6 patients with itraconazole and demonstrated inhibition of Hedgehog signaling by quantitative real-time PCR. It is hoped that results from this early phase trial may lead to further study and development of itraconazole as a molecularly targeted agent for esophageal cancer.

Background: Esophageal cancer continues to affect US veterans as the risk factors for esophageal adenocarcinoma and squamous cell carcinoma are highly prevalent in this patient population. While localized esophageal cancer can be cured with a tri-modality approach that includes neoadjuvant chemoradiation followed by esophagectomy, only those patients who achieve a pathologic complete remission to neoadjuvant chemoradiation have a 50% five-year overall survival. Those who do not achieve a pathologic complete remission or those with metastatic disease have a worse prognosis. Thus, there is a need to develop novel molecularly targeted agents for the treatment of esophageal
cancer. We have found that the Hedgehog signaling pathway, required for normal esophageal embryogenesis but silenced in the adult esophagus, is reactivated in both histologic subtypes of esophageal cancer.

Results: Using immunohistochemistry for the pathway ligand Sonic hedgehog or in situ hybridization for either Sonic hedgehog or the pathway target gene Gli1 on esophageal cancer tissue microarrays, we found that 206/346 (60%) cases were Hedgehog pathway active while normal squamous esophagus was negative. The anti-fungal agent itraconazole has previously been shown to inhibit Hedgehog signaling, and we were able to inhibit cell proliferation (cell number), Hedgehog pathway activity (quantitative real-time PCR), and VEGFR2 phosphorylation (Western blot) in vitro in OE33 esophageal adenocarcinoma cells. In a novel intraperitoneal xenograft model of liver metastases, itraconazole significantly improved overall survival in mice injected intraperitoneally with OE33 cells.

Conclusions: Based on these results we are conducting a phase 0 clinical trial administering itraconazole 300 mg po bid for 14-17 days to patients with localized esophageal cancer before neoadjuvant chemoradiation. To date, we have treated 6 patients with itraconazole and demonstrated inhibition of Hedgehog signaling by quantitative real-time PCR. It is hoped that results from this early phase trial may lead to further study and development of itraconazole as a molecularly targeted agent for esophageal cancer.

Purpose: Lymph node yield is an independent prognostic factor for survival outcomes in patients receiving neck dissection for oral squamous cell carcinoma (SCC). This study investigates whether hospital case volume is associated with increased lymph node yield in neck dissection specimens.

Background: Guidelines recommending minimum number of lymph nodes that constitutes an adequate neck dissection have not been established. There is evidence that comprehensive neck dissections with improved lymph node yield ( 18 nodes) are associated with better survival outcomes. Recent studies have proposed this association to be a potential institutional-level quality metric. However, whetherinstitutional experience (reflected by case volume) influences the quality and comprehensiveness of neck dissection (reflected in node yield) remains unknown.

Methods: The National Cancer Database was used to identify 21,150 patients who underwent primary neck dissections for oral SCC diagnosed between 2004 and 2015. Average annual surgical volumes were calculated for each facility to stratify them into quartiles based on highest to lowest case volumes. A multivariable negative binomial mixed model was used to model the number of nodes examined at the patient level, which accommodated the clustering of hospitals and adjusted for clinical and demographic factors.

Results: The median lymph node yield for all hospitals was 27 (Interquartile Range [IQR] 16-40) nodes. Median lymph nodes examined for the quartile of highest volume hospitals was 29 (IQR 19-42). Compared to a lymph node yield of 18 (IQR 9-30) in the 3rd quartile, 17 (IQR 9-27) in the 2nd quartile, and 16 (IQR 8-26) in the lowest quartile. A Dwass, Steel, Critchlow-Fligner procedure indicated that the number of nodes were significantly different for all pairwise comparisons except between the lowest two quartiles.

Conclusions: These data suggest that for patients with oral SCC undergoing neck dissections, increase in hospital case volume is associated with higher lymph node yield. Institutions with greater experience and case volumes are more likely to consistently meet the cutoff value of lymph node yield ( 18 lymph nodes) in neck dissection specimens, that are shown to improve survival outcomes.

Purpose: Lymph node yield is an independent prognostic factor for survival outcomes in patients receiving neck dissection for oral squamous cell carcinoma (SCC). This study investigates whether hospital case volume is associated with increased lymph node yield in neck dissection specimens.

Background: Guidelines recommending minimum number of lymph nodes that constitutes an adequate neck dissection have not been established. There is evidence that comprehensive neck dissections with improved lymph node yield ( 18 nodes) are associated with better survival outcomes. Recent studies have proposed this association to be a potential institutional-level quality metric. However, whetherinstitutional experience (reflected by case volume) influences the quality and comprehensiveness of neck dissection (reflected in node yield) remains unknown.

Methods: The National Cancer Database was used to identify 21,150 patients who underwent primary neck dissections for oral SCC diagnosed between 2004 and 2015. Average annual surgical volumes were calculated for each facility to stratify them into quartiles based on highest to lowest case volumes. A multivariable negative binomial mixed model was used to model the number of nodes examined at the patient level, which accommodated the clustering of hospitals and adjusted for clinical and demographic factors.

Results: The median lymph node yield for all hospitals was 27 (Interquartile Range [IQR] 16-40) nodes. Median lymph nodes examined for the quartile of highest volume hospitals was 29 (IQR 19-42). Compared to a lymph node yield of 18 (IQR 9-30) in the 3rd quartile, 17 (IQR 9-27) in the 2nd quartile, and 16 (IQR 8-26) in the lowest quartile. A Dwass, Steel, Critchlow-Fligner procedure indicated that the number of nodes were significantly different for all pairwise comparisons except between the lowest two quartiles.

Conclusions: These data suggest that for patients with oral SCC undergoing neck dissections, increase in hospital case volume is associated with higher lymph node yield. Institutions with greater experience and case volumes are more likely to consistently meet the cutoff value of lymph node yield ( 18 lymph nodes) in neck dissection specimens, that are shown to improve survival outcomes.

Purpose: Lymph node yield is an independent prognostic factor for survival outcomes in patients receiving neck dissection for oral squamous cell carcinoma (SCC). This study investigates whether hospital case volume is associated with increased lymph node yield in neck dissection specimens.

Background: Guidelines recommending minimum number of lymph nodes that constitutes an adequate neck dissection have not been established. There is evidence that comprehensive neck dissections with improved lymph node yield ( 18 nodes) are associated with better survival outcomes. Recent studies have proposed this association to be a potential institutional-level quality metric. However, whetherinstitutional experience (reflected by case volume) influences the quality and comprehensiveness of neck dissection (reflected in node yield) remains unknown.

Methods: The National Cancer Database was used to identify 21,150 patients who underwent primary neck dissections for oral SCC diagnosed between 2004 and 2015. Average annual surgical volumes were calculated for each facility to stratify them into quartiles based on highest to lowest case volumes. A multivariable negative binomial mixed model was used to model the number of nodes examined at the patient level, which accommodated the clustering of hospitals and adjusted for clinical and demographic factors.

Results: The median lymph node yield for all hospitals was 27 (Interquartile Range [IQR] 16-40) nodes. Median lymph nodes examined for the quartile of highest volume hospitals was 29 (IQR 19-42). Compared to a lymph node yield of 18 (IQR 9-30) in the 3rd quartile, 17 (IQR 9-27) in the 2nd quartile, and 16 (IQR 8-26) in the lowest quartile. A Dwass, Steel, Critchlow-Fligner procedure indicated that the number of nodes were significantly different for all pairwise comparisons except between the lowest two quartiles.

Conclusions: These data suggest that for patients with oral SCC undergoing neck dissections, increase in hospital case volume is associated with higher lymph node yield. Institutions with greater experience and case volumes are more likely to consistently meet the cutoff value of lymph node yield ( 18 lymph nodes) in neck dissection specimens, that are shown to improve survival outcomes.

Purpose/Rationale: To examine HPV testing, positivity, smoking status, and clinical presentation in a national sample of veterans with oropharyngeal cancer.

Background: HPV positivity confers a favorable prognosis in patients with oropharyngeal cancer. Some data suggest that smoking may influence prognosis in HPV+ patients. However, much of our understanding of HPV+ disease originates from single institution academic centers, which may not be representative of the veteran population with respect to smoking status and other features. Multiple de-escalation trials have recently been designed for HPV+ patients, and it is important to understand disease epidemiology in veterans to determine whether the findings will be generalizable to them.

Methods: We used the Veterans Affairs Central Cancer Registry to identify patients diagnosed with oropharyngeal cancer from 2010-2015. We quantified the frequency of HPV testing and positivity over time. We calculated smoking prevalence by HPV status. We then performed logistic regression to investigate associations between smoking status and presentation with T3/N2c or higher stage disease.

Results: For the 5,231 evaluable patients, rates of HPV testing increased from 20% in 2010 to 53% in 2015. Among the patients tested in 2015: 64% were high risk HPV+, 4% low risk HPV+, and 32% HPV−. Few patients were never smokers regardless of HPV status: 11% HPV− and 18% HPV+. Greater than one third (37%) of HPV+ and half (57%) of HPV− patients were current smokers. Current smoking was associated with an increased risk of presentation with American Joint Committee on Cancer 7 stage T3, N2c, or higher disease for both HPV+ (OR 1.48, P = .019) and HPV− patients (OR 2.14, P = .002).

Conclusions/Implications: HPV testing is increasing within the VA. Among tested patients, HPV positivity rates are comparable to that of the overall population. However, compared to a number of published trials that have established treatment outcomes in HPV+ patients, a larger proportion of veterans are current smokers. We found that smoking is associated with an increased risk of advanced primary tumor or nodal stage in veterans, regardless of HPV status. Efforts should be undertaken to increase HPV testing among veterans with oropharyngeal cancer in order to more reliably establish prognosis and understand the impact of smoking.

Purpose/Rationale: To examine HPV testing, positivity, smoking status, and clinical presentation in a national sample of veterans with oropharyngeal cancer.

Background: HPV positivity confers a favorable prognosis in patients with oropharyngeal cancer. Some data suggest that smoking may influence prognosis in HPV+ patients. However, much of our understanding of HPV+ disease originates from single institution academic centers, which may not be representative of the veteran population with respect to smoking status and other features. Multiple de-escalation trials have recently been designed for HPV+ patients, and it is important to understand disease epidemiology in veterans to determine whether the findings will be generalizable to them.

Methods: We used the Veterans Affairs Central Cancer Registry to identify patients diagnosed with oropharyngeal cancer from 2010-2015. We quantified the frequency of HPV testing and positivity over time. We calculated smoking prevalence by HPV status. We then performed logistic regression to investigate associations between smoking status and presentation with T3/N2c or higher stage disease.

Results: For the 5,231 evaluable patients, rates of HPV testing increased from 20% in 2010 to 53% in 2015. Among the patients tested in 2015: 64% were high risk HPV+, 4% low risk HPV+, and 32% HPV−. Few patients were never smokers regardless of HPV status: 11% HPV− and 18% HPV+. Greater than one third (37%) of HPV+ and half (57%) of HPV− patients were current smokers. Current smoking was associated with an increased risk of presentation with American Joint Committee on Cancer 7 stage T3, N2c, or higher disease for both HPV+ (OR 1.48, P = .019) and HPV− patients (OR 2.14, P = .002).

Conclusions/Implications: HPV testing is increasing within the VA. Among tested patients, HPV positivity rates are comparable to that of the overall population. However, compared to a number of published trials that have established treatment outcomes in HPV+ patients, a larger proportion of veterans are current smokers. We found that smoking is associated with an increased risk of advanced primary tumor or nodal stage in veterans, regardless of HPV status. Efforts should be undertaken to increase HPV testing among veterans with oropharyngeal cancer in order to more reliably establish prognosis and understand the impact of smoking.

Purpose/Rationale: To examine HPV testing, positivity, smoking status, and clinical presentation in a national sample of veterans with oropharyngeal cancer.

Background: HPV positivity confers a favorable prognosis in patients with oropharyngeal cancer. Some data suggest that smoking may influence prognosis in HPV+ patients. However, much of our understanding of HPV+ disease originates from single institution academic centers, which may not be representative of the veteran population with respect to smoking status and other features. Multiple de-escalation trials have recently been designed for HPV+ patients, and it is important to understand disease epidemiology in veterans to determine whether the findings will be generalizable to them.

Methods: We used the Veterans Affairs Central Cancer Registry to identify patients diagnosed with oropharyngeal cancer from 2010-2015. We quantified the frequency of HPV testing and positivity over time. We calculated smoking prevalence by HPV status. We then performed logistic regression to investigate associations between smoking status and presentation with T3/N2c or higher stage disease.

Results: For the 5,231 evaluable patients, rates of HPV testing increased from 20% in 2010 to 53% in 2015. Among the patients tested in 2015: 64% were high risk HPV+, 4% low risk HPV+, and 32% HPV−. Few patients were never smokers regardless of HPV status: 11% HPV− and 18% HPV+. Greater than one third (37%) of HPV+ and half (57%) of HPV− patients were current smokers. Current smoking was associated with an increased risk of presentation with American Joint Committee on Cancer 7 stage T3, N2c, or higher disease for both HPV+ (OR 1.48, P = .019) and HPV− patients (OR 2.14, P = .002).

Conclusions/Implications: HPV testing is increasing within the VA. Among tested patients, HPV positivity rates are comparable to that of the overall population. However, compared to a number of published trials that have established treatment outcomes in HPV+ patients, a larger proportion of veterans are current smokers. We found that smoking is associated with an increased risk of advanced primary tumor or nodal stage in veterans, regardless of HPV status. Efforts should be undertaken to increase HPV testing among veterans with oropharyngeal cancer in order to more reliably establish prognosis and understand the impact of smoking.

Purpose/Rationale: The purpose of this quality improvement project was three- fold; (1) To develop a cancer tracking dashboard that would replace a cumbersome and outdated paper-driven process; (2) To improve the cycle time to initiate treatment by one week; and (3) To decrease clinical time spent reviewing patient charts for timeliness.

Background: Bay Pines VA Healthcare System (BPVAHCS) established a Cancer Care Navigation Program (CCNP), specific to the head and neck cancer patient population. The nurse navigator is responsible for facilitating the Veteran’s progress through a complex healthcare system. The Veterans Health Administration system does not have one specific standard instrument to track the veteran across the cancer care continuum.

Methods: This project was limited to head and neck cancer cases who were to receive concurrent chemotherapy and radiation. Exclusions included surgical cases, adjuvant chemotherapy and/or radiation, and patients receiving care through the community. The cycle time is defined as: time pathology is signed to initiation of treatment. A retrospective chart review was conducted to calculate the cycle time for two fiscal quarters prior to implementation of the tool. We also documented daily the amount of time spent by the nurse in the Computerized Patient Record System (CPRS) to coordinate seamless cancer care. The data were then entered into an excel spread sheet and analyzed. As a result, this systems redesign project, an electronic tracking dashboard was designed and implemented. The exact data were extrapolated using the tool for the next two fiscal quarters.

Results: The quantitative data was a comparison of two samples; two quarters prior/after two quarters after implementation of the dashboard. The two sample unpaired t-test was utilized for analysis. Group one (n = 22) and group two (n = 23), the P value is < .0001 by conventional criteria; this difference is considered to be extremely statistically significant.

Conclusions/Implications: Utilizing the dashboard has rendered an additional 115 nursing hours dedicated to direct patient care and has improved by timeliness to treatment by five days. Current work includes building the dashboard to represent most cancers and the integration of the cancer tracking dashboard with CPRS enabling data to auto populate.

Purpose/Rationale: The purpose of this quality improvement project was three- fold; (1) To develop a cancer tracking dashboard that would replace a cumbersome and outdated paper-driven process; (2) To improve the cycle time to initiate treatment by one week; and (3) To decrease clinical time spent reviewing patient charts for timeliness.

Background: Bay Pines VA Healthcare System (BPVAHCS) established a Cancer Care Navigation Program (CCNP), specific to the head and neck cancer patient population. The nurse navigator is responsible for facilitating the Veteran’s progress through a complex healthcare system. The Veterans Health Administration system does not have one specific standard instrument to track the veteran across the cancer care continuum.

Methods: This project was limited to head and neck cancer cases who were to receive concurrent chemotherapy and radiation. Exclusions included surgical cases, adjuvant chemotherapy and/or radiation, and patients receiving care through the community. The cycle time is defined as: time pathology is signed to initiation of treatment. A retrospective chart review was conducted to calculate the cycle time for two fiscal quarters prior to implementation of the tool. We also documented daily the amount of time spent by the nurse in the Computerized Patient Record System (CPRS) to coordinate seamless cancer care. The data were then entered into an excel spread sheet and analyzed. As a result, this systems redesign project, an electronic tracking dashboard was designed and implemented. The exact data were extrapolated using the tool for the next two fiscal quarters.

Results: The quantitative data was a comparison of two samples; two quarters prior/after two quarters after implementation of the dashboard. The two sample unpaired t-test was utilized for analysis. Group one (n = 22) and group two (n = 23), the P value is < .0001 by conventional criteria; this difference is considered to be extremely statistically significant.

Conclusions/Implications: Utilizing the dashboard has rendered an additional 115 nursing hours dedicated to direct patient care and has improved by timeliness to treatment by five days. Current work includes building the dashboard to represent most cancers and the integration of the cancer tracking dashboard with CPRS enabling data to auto populate.

Purpose/Rationale: The purpose of this quality improvement project was three- fold; (1) To develop a cancer tracking dashboard that would replace a cumbersome and outdated paper-driven process; (2) To improve the cycle time to initiate treatment by one week; and (3) To decrease clinical time spent reviewing patient charts for timeliness.

Background: Bay Pines VA Healthcare System (BPVAHCS) established a Cancer Care Navigation Program (CCNP), specific to the head and neck cancer patient population. The nurse navigator is responsible for facilitating the Veteran’s progress through a complex healthcare system. The Veterans Health Administration system does not have one specific standard instrument to track the veteran across the cancer care continuum.

Methods: This project was limited to head and neck cancer cases who were to receive concurrent chemotherapy and radiation. Exclusions included surgical cases, adjuvant chemotherapy and/or radiation, and patients receiving care through the community. The cycle time is defined as: time pathology is signed to initiation of treatment. A retrospective chart review was conducted to calculate the cycle time for two fiscal quarters prior to implementation of the tool. We also documented daily the amount of time spent by the nurse in the Computerized Patient Record System (CPRS) to coordinate seamless cancer care. The data were then entered into an excel spread sheet and analyzed. As a result, this systems redesign project, an electronic tracking dashboard was designed and implemented. The exact data were extrapolated using the tool for the next two fiscal quarters.

Results: The quantitative data was a comparison of two samples; two quarters prior/after two quarters after implementation of the dashboard. The two sample unpaired t-test was utilized for analysis. Group one (n = 22) and group two (n = 23), the P value is < .0001 by conventional criteria; this difference is considered to be extremely statistically significant.

Conclusions/Implications: Utilizing the dashboard has rendered an additional 115 nursing hours dedicated to direct patient care and has improved by timeliness to treatment by five days. Current work includes building the dashboard to represent most cancers and the integration of the cancer tracking dashboard with CPRS enabling data to auto populate.

Background: Chondrosarcoma (CHS) is the second most common primary malignant solid bone tumor. Present management of CHS is based largely on case series from individual treatment centers. This study summarizes descriptive epidemiologic and prognostic characteristics associated with CHS patients utilizing the National Cancer Database (NCDB).

Methods: We identified 6,559 patients with CHS of the bone, joints, and/or articular cartilage in the NCDB from 2004-2015. Kaplan-Meier analyses were used to estimate 2- and 5-year survival, and median survival. Survival comparisons were made using log-rank tests.

Results: Median age at diagnosis was 53 years. 53.3% of cases were in males, and 86.4% were in white patients. 28.2% of cases were in lower limb long bones and associated joints. The most common NCDB analytic stage at presentation was stage I (60.5%). 6.4% of patients had known metastases at diagnosis. 86.6%, 7%, and 12.5% of patients received surgery, chemotherapy, and radiation, respectively. Overall probability of 5-year survival was 74.4%. Approximate 5-year survival for NCDB analytic stages I-IV was 86.2%, 53.1%, 52.4%, and 17.4%, respectively. The dedifferentiated subtype of CHS had the poorest 5-year survival (25.4%), while juxtacortical had the highest (93.4%). In 355 patients with high grade CHS, perioperative chemotherapy (33.7% 5-year survival) did not provide improved survival compared to surgery alone (51.2% 5-year survival).

Conclusions: To the best of our knowledge, this is the first NCDB study to evaluate survival by treatment type and stage in CHS, as well as to analyze epidemiologic and prognostic characteristics in all CHS subtypes. This study found CHS was most common in white patients, had a median age at diagnosis of 53 years, and was most frequently found in lower limb long bones and associated joints. The 5-year survival was much worse at stage IV compared to stages I, II, and III, as well as in dedifferentiated and mesenchymal tumor subtypes compared to conventional or other types of CHS. In high grade tumors, perioperative chemotherapy did not improve survival compared to surgery alone.

Background: Chondrosarcoma (CHS) is the second most common primary malignant solid bone tumor. Present management of CHS is based largely on case series from individual treatment centers. This study summarizes descriptive epidemiologic and prognostic characteristics associated with CHS patients utilizing the National Cancer Database (NCDB).

Methods: We identified 6,559 patients with CHS of the bone, joints, and/or articular cartilage in the NCDB from 2004-2015. Kaplan-Meier analyses were used to estimate 2- and 5-year survival, and median survival. Survival comparisons were made using log-rank tests.

Results: Median age at diagnosis was 53 years. 53.3% of cases were in males, and 86.4% were in white patients. 28.2% of cases were in lower limb long bones and associated joints. The most common NCDB analytic stage at presentation was stage I (60.5%). 6.4% of patients had known metastases at diagnosis. 86.6%, 7%, and 12.5% of patients received surgery, chemotherapy, and radiation, respectively. Overall probability of 5-year survival was 74.4%. Approximate 5-year survival for NCDB analytic stages I-IV was 86.2%, 53.1%, 52.4%, and 17.4%, respectively. The dedifferentiated subtype of CHS had the poorest 5-year survival (25.4%), while juxtacortical had the highest (93.4%). In 355 patients with high grade CHS, perioperative chemotherapy (33.7% 5-year survival) did not provide improved survival compared to surgery alone (51.2% 5-year survival).

Conclusions: To the best of our knowledge, this is the first NCDB study to evaluate survival by treatment type and stage in CHS, as well as to analyze epidemiologic and prognostic characteristics in all CHS subtypes. This study found CHS was most common in white patients, had a median age at diagnosis of 53 years, and was most frequently found in lower limb long bones and associated joints. The 5-year survival was much worse at stage IV compared to stages I, II, and III, as well as in dedifferentiated and mesenchymal tumor subtypes compared to conventional or other types of CHS. In high grade tumors, perioperative chemotherapy did not improve survival compared to surgery alone.

Background: Chondrosarcoma (CHS) is the second most common primary malignant solid bone tumor. Present management of CHS is based largely on case series from individual treatment centers. This study summarizes descriptive epidemiologic and prognostic characteristics associated with CHS patients utilizing the National Cancer Database (NCDB).

Methods: We identified 6,559 patients with CHS of the bone, joints, and/or articular cartilage in the NCDB from 2004-2015. Kaplan-Meier analyses were used to estimate 2- and 5-year survival, and median survival. Survival comparisons were made using log-rank tests.

Results: Median age at diagnosis was 53 years. 53.3% of cases were in males, and 86.4% were in white patients. 28.2% of cases were in lower limb long bones and associated joints. The most common NCDB analytic stage at presentation was stage I (60.5%). 6.4% of patients had known metastases at diagnosis. 86.6%, 7%, and 12.5% of patients received surgery, chemotherapy, and radiation, respectively. Overall probability of 5-year survival was 74.4%. Approximate 5-year survival for NCDB analytic stages I-IV was 86.2%, 53.1%, 52.4%, and 17.4%, respectively. The dedifferentiated subtype of CHS had the poorest 5-year survival (25.4%), while juxtacortical had the highest (93.4%). In 355 patients with high grade CHS, perioperative chemotherapy (33.7% 5-year survival) did not provide improved survival compared to surgery alone (51.2% 5-year survival).

Conclusions: To the best of our knowledge, this is the first NCDB study to evaluate survival by treatment type and stage in CHS, as well as to analyze epidemiologic and prognostic characteristics in all CHS subtypes. This study found CHS was most common in white patients, had a median age at diagnosis of 53 years, and was most frequently found in lower limb long bones and associated joints. The 5-year survival was much worse at stage IV compared to stages I, II, and III, as well as in dedifferentiated and mesenchymal tumor subtypes compared to conventional or other types of CHS. In high grade tumors, perioperative chemotherapy did not improve survival compared to surgery alone.

Purpose/Rationale: To examine national trends and predictors of annual surveillance prostate specific antigen (PSA attainment after radical prostatectomy among veterans with prostate cancer.

Background: Guidelines recommend men treated for prostate cancer undergo PSA surveillance at least annually, as salvage treatments exist when recurrence is detected early. Predictors of adherence are poorly understood. We therefore examined national trends in PSA surveillance after prostatectomy.

Methods: We used the Veterans Affairs Central Cancer Registry to identify 9,648 patients treated with radical prostatectomy from 2005-2008 with follow up through 2012. We defined guideline-concordant PSA surveillance as receipt of at least one PSA annually. We used multivariable logistic regression to examine associations between guideline concordance and demographic and clinical factors, including PSA values in the preceding year. We assessed facility predictors and variation using multilevel regression.

Results: We found decreasing annual concordance over time ( > 90% years 1-2, 80% year 7) and 69.7% five-year concordance. On multivariable analysis, guideline concordance was lower among those who were black, non-married, non-Hispanic, had PSA at diagnosis > 10 and  20, and had negative or unknown surgical margins (P < .05). Guideline concordance significantly increased once the PSA increased beyond 4 ng/ml. Controlling for facility level variation and covariates eliminated the disparity for black men. Facility-level guideline concordance ranged from 17-100% and was inversely related to urologist workforce (aOR 0.97 [FTE/patient], P = .009).

Conclusions: The majority of patients receive guideline concordant PSA surveillance after prostate cancer surgery, but wide facility level variation exists. Concordance sharply increases when PSA values increase past 4, suggesting that a lab threshold that is not relevant in the post-prostatectomy setting is providing false reassurance to providers and possibly contributing to missed opportunities to salvage men with curable disease. Racial disparities exist, which are related to facility-level variation. Better understanding risk stratification for surveillance and the impact of broad interventions (eg, survivorship care plans, electronic reminders, provider education) on guideline concordance appears warranted.

Purpose/Rationale: To examine national trends and predictors of annual surveillance prostate specific antigen (PSA attainment after radical prostatectomy among veterans with prostate cancer.

Background: Guidelines recommend men treated for prostate cancer undergo PSA surveillance at least annually, as salvage treatments exist when recurrence is detected early. Predictors of adherence are poorly understood. We therefore examined national trends in PSA surveillance after prostatectomy.

Methods: We used the Veterans Affairs Central Cancer Registry to identify 9,648 patients treated with radical prostatectomy from 2005-2008 with follow up through 2012. We defined guideline-concordant PSA surveillance as receipt of at least one PSA annually. We used multivariable logistic regression to examine associations between guideline concordance and demographic and clinical factors, including PSA values in the preceding year. We assessed facility predictors and variation using multilevel regression.

Results: We found decreasing annual concordance over time ( > 90% years 1-2, 80% year 7) and 69.7% five-year concordance. On multivariable analysis, guideline concordance was lower among those who were black, non-married, non-Hispanic, had PSA at diagnosis > 10 and  20, and had negative or unknown surgical margins (P < .05). Guideline concordance significantly increased once the PSA increased beyond 4 ng/ml. Controlling for facility level variation and covariates eliminated the disparity for black men. Facility-level guideline concordance ranged from 17-100% and was inversely related to urologist workforce (aOR 0.97 [FTE/patient], P = .009).

Conclusions: The majority of patients receive guideline concordant PSA surveillance after prostate cancer surgery, but wide facility level variation exists. Concordance sharply increases when PSA values increase past 4, suggesting that a lab threshold that is not relevant in the post-prostatectomy setting is providing false reassurance to providers and possibly contributing to missed opportunities to salvage men with curable disease. Racial disparities exist, which are related to facility-level variation. Better understanding risk stratification for surveillance and the impact of broad interventions (eg, survivorship care plans, electronic reminders, provider education) on guideline concordance appears warranted.

Purpose/Rationale: To examine national trends and predictors of annual surveillance prostate specific antigen (PSA attainment after radical prostatectomy among veterans with prostate cancer.

Background: Guidelines recommend men treated for prostate cancer undergo PSA surveillance at least annually, as salvage treatments exist when recurrence is detected early. Predictors of adherence are poorly understood. We therefore examined national trends in PSA surveillance after prostatectomy.

Methods: We used the Veterans Affairs Central Cancer Registry to identify 9,648 patients treated with radical prostatectomy from 2005-2008 with follow up through 2012. We defined guideline-concordant PSA surveillance as receipt of at least one PSA annually. We used multivariable logistic regression to examine associations between guideline concordance and demographic and clinical factors, including PSA values in the preceding year. We assessed facility predictors and variation using multilevel regression.

Results: We found decreasing annual concordance over time ( > 90% years 1-2, 80% year 7) and 69.7% five-year concordance. On multivariable analysis, guideline concordance was lower among those who were black, non-married, non-Hispanic, had PSA at diagnosis > 10 and  20, and had negative or unknown surgical margins (P < .05). Guideline concordance significantly increased once the PSA increased beyond 4 ng/ml. Controlling for facility level variation and covariates eliminated the disparity for black men. Facility-level guideline concordance ranged from 17-100% and was inversely related to urologist workforce (aOR 0.97 [FTE/patient], P = .009).

Conclusions: The majority of patients receive guideline concordant PSA surveillance after prostate cancer surgery, but wide facility level variation exists. Concordance sharply increases when PSA values increase past 4, suggesting that a lab threshold that is not relevant in the post-prostatectomy setting is providing false reassurance to providers and possibly contributing to missed opportunities to salvage men with curable disease. Racial disparities exist, which are related to facility-level variation. Better understanding risk stratification for surveillance and the impact of broad interventions (eg, survivorship care plans, electronic reminders, provider education) on guideline concordance appears warranted.

Purpose: Describe a shared medical visit approach used to orient Veterans and their caregivers to a new cancer diagnosis and cancer care processes.

Background: Veterans are referred to the Cancer Care Navigation Team (CCNT) by a health care provider when they have suspicion of cancer or new cancer diagnosis, as there is no onsite oncologist. Veterans indicate high levels of distress in this initial phase due to lack of information, uncertainty of next steps, lack of support system and other psychosocial issues.

Methods: A Cancer Orientation Clinic using a shared medical visit was developed for Veterans and their caregivers. The objectives of the visit are to decrease distress, increase understanding of the cancer journey, increase coping and self-care skills, proactively identify barriers to care and improve coordination of care. Veterans with a high suspicion of cancer or new cancer diagnosis are consulted to CCNT and scheduled into the Cancer Orientation Clinic. Visits are face-to-face and one hour in length, Veterans attend the appointment as a group of 3-5. Veterans are encouraged to bring a caregiver to their appointment. The CCNT multidisciplinary team including a registered nurse, social worker and nurse practitioner facilitate the visit. Educational information and cancer resources are presented in a group format to encourage sharing and support. Participants are introduced to the role of the CCNT and what to expect when traveling to VA tertiary centers for cancer care. There is educational content and discussion about cancer, their fears, and how they can improve/maintain their health to enhance cancer treatment outcomes. Veterans are assessed for distress and potential barriers; advance directives and release of information forms are completed. Each participant is given an individualized care plan by the nurse practitioner. Evaluation forms are completed by participants at the end of the visit.

Results: There were 10 Cancer Orientation Clinic visits completed for Veterans within the Spokane catchment areas between 3/14/18 and 5/30/18, for a total of 38 Veterans. The average level of distress reported at the visit was 6 (on a 1-10 scale). Evaluation forms have shown Veteran and caregiver satisfaction with the visit content and presentation.

Purpose: Describe a shared medical visit approach used to orient Veterans and their caregivers to a new cancer diagnosis and cancer care processes.

Background: Veterans are referred to the Cancer Care Navigation Team (CCNT) by a health care provider when they have suspicion of cancer or new cancer diagnosis, as there is no onsite oncologist. Veterans indicate high levels of distress in this initial phase due to lack of information, uncertainty of next steps, lack of support system and other psychosocial issues.

Methods: A Cancer Orientation Clinic using a shared medical visit was developed for Veterans and their caregivers. The objectives of the visit are to decrease distress, increase understanding of the cancer journey, increase coping and self-care skills, proactively identify barriers to care and improve coordination of care. Veterans with a high suspicion of cancer or new cancer diagnosis are consulted to CCNT and scheduled into the Cancer Orientation Clinic. Visits are face-to-face and one hour in length, Veterans attend the appointment as a group of 3-5. Veterans are encouraged to bring a caregiver to their appointment. The CCNT multidisciplinary team including a registered nurse, social worker and nurse practitioner facilitate the visit. Educational information and cancer resources are presented in a group format to encourage sharing and support. Participants are introduced to the role of the CCNT and what to expect when traveling to VA tertiary centers for cancer care. There is educational content and discussion about cancer, their fears, and how they can improve/maintain their health to enhance cancer treatment outcomes. Veterans are assessed for distress and potential barriers; advance directives and release of information forms are completed. Each participant is given an individualized care plan by the nurse practitioner. Evaluation forms are completed by participants at the end of the visit.

Results: There were 10 Cancer Orientation Clinic visits completed for Veterans within the Spokane catchment areas between 3/14/18 and 5/30/18, for a total of 38 Veterans. The average level of distress reported at the visit was 6 (on a 1-10 scale). Evaluation forms have shown Veteran and caregiver satisfaction with the visit content and presentation.

Purpose: Describe a shared medical visit approach used to orient Veterans and their caregivers to a new cancer diagnosis and cancer care processes.

Background: Veterans are referred to the Cancer Care Navigation Team (CCNT) by a health care provider when they have suspicion of cancer or new cancer diagnosis, as there is no onsite oncologist. Veterans indicate high levels of distress in this initial phase due to lack of information, uncertainty of next steps, lack of support system and other psychosocial issues.

Methods: A Cancer Orientation Clinic using a shared medical visit was developed for Veterans and their caregivers. The objectives of the visit are to decrease distress, increase understanding of the cancer journey, increase coping and self-care skills, proactively identify barriers to care and improve coordination of care. Veterans with a high suspicion of cancer or new cancer diagnosis are consulted to CCNT and scheduled into the Cancer Orientation Clinic. Visits are face-to-face and one hour in length, Veterans attend the appointment as a group of 3-5. Veterans are encouraged to bring a caregiver to their appointment. The CCNT multidisciplinary team including a registered nurse, social worker and nurse practitioner facilitate the visit. Educational information and cancer resources are presented in a group format to encourage sharing and support. Participants are introduced to the role of the CCNT and what to expect when traveling to VA tertiary centers for cancer care. There is educational content and discussion about cancer, their fears, and how they can improve/maintain their health to enhance cancer treatment outcomes. Veterans are assessed for distress and potential barriers; advance directives and release of information forms are completed. Each participant is given an individualized care plan by the nurse practitioner. Evaluation forms are completed by participants at the end of the visit.

Results: There were 10 Cancer Orientation Clinic visits completed for Veterans within the Spokane catchment areas between 3/14/18 and 5/30/18, for a total of 38 Veterans. The average level of distress reported at the visit was 6 (on a 1-10 scale). Evaluation forms have shown Veteran and caregiver satisfaction with the visit content and presentation.

Background: To best address the psychosocial concerns experienced by patients with cancer, the 2007 report of the IOM, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, described the importance of distress screening and identifying psychosocial needs to optimize the quality of the cancer care. This may be especially critical when treating the Veteran population, where psychosocial needs as a whole may be elevated compared to non-VA institutions. The NCCN distress thermometer screening tool is a commonly used, validated, and easily administered screen of distress (eg, Hoffman et al, 2004). However, challenges can arise in successful implementation, adherence, and responsiveness to the information gleaned from this screen (eg, Zebrack et al, 2015).

As an institution accredited by the commission on cancer, it is important to not only meet the distress screening standard (ie, assess and identify psychosocial needs) but to understand barriers to identifying psychosocial needs and to appropriately triage when psychosocial concerns are identified. Goals of this project were to understand challenges with distress screening, address barriers to distress screening, and improve quality of assessment and referrals following positive screens.

Results: At Hines VAMC, we rolled out distress screening in 2015 and 2016, with rates of screening administration increasing over the course of the first year. However, without continued monitoring and re-education, successful adherence decreased overtime. Additionally, of the 862 screens administered to date, 37% were found to be considered “positive.” We will discuss the various barriers and challenges associated with managing referrals to nonmedical providers.

Our team has identified several essential aspects of successful screening and follow-up including staff/nursing education, continued tracking and re-education over time, and establishing and maintaining relationships with psychosocial clinicians to best address these aspects of care and to optimize quality of cancer care overall. We will discuss the impact of the above interventions on adherence and responsiveness.

Background: To best address the psychosocial concerns experienced by patients with cancer, the 2007 report of the IOM, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, described the importance of distress screening and identifying psychosocial needs to optimize the quality of the cancer care. This may be especially critical when treating the Veteran population, where psychosocial needs as a whole may be elevated compared to non-VA institutions. The NCCN distress thermometer screening tool is a commonly used, validated, and easily administered screen of distress (eg, Hoffman et al, 2004). However, challenges can arise in successful implementation, adherence, and responsiveness to the information gleaned from this screen (eg, Zebrack et al, 2015).

As an institution accredited by the commission on cancer, it is important to not only meet the distress screening standard (ie, assess and identify psychosocial needs) but to understand barriers to identifying psychosocial needs and to appropriately triage when psychosocial concerns are identified. Goals of this project were to understand challenges with distress screening, address barriers to distress screening, and improve quality of assessment and referrals following positive screens.

Results: At Hines VAMC, we rolled out distress screening in 2015 and 2016, with rates of screening administration increasing over the course of the first year. However, without continued monitoring and re-education, successful adherence decreased overtime. Additionally, of the 862 screens administered to date, 37% were found to be considered “positive.” We will discuss the various barriers and challenges associated with managing referrals to nonmedical providers.

Our team has identified several essential aspects of successful screening and follow-up including staff/nursing education, continued tracking and re-education over time, and establishing and maintaining relationships with psychosocial clinicians to best address these aspects of care and to optimize quality of cancer care overall. We will discuss the impact of the above interventions on adherence and responsiveness.

Background: To best address the psychosocial concerns experienced by patients with cancer, the 2007 report of the IOM, Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, described the importance of distress screening and identifying psychosocial needs to optimize the quality of the cancer care. This may be especially critical when treating the Veteran population, where psychosocial needs as a whole may be elevated compared to non-VA institutions. The NCCN distress thermometer screening tool is a commonly used, validated, and easily administered screen of distress (eg, Hoffman et al, 2004). However, challenges can arise in successful implementation, adherence, and responsiveness to the information gleaned from this screen (eg, Zebrack et al, 2015).

As an institution accredited by the commission on cancer, it is important to not only meet the distress screening standard (ie, assess and identify psychosocial needs) but to understand barriers to identifying psychosocial needs and to appropriately triage when psychosocial concerns are identified. Goals of this project were to understand challenges with distress screening, address barriers to distress screening, and improve quality of assessment and referrals following positive screens.

Results: At Hines VAMC, we rolled out distress screening in 2015 and 2016, with rates of screening administration increasing over the course of the first year. However, without continued monitoring and re-education, successful adherence decreased overtime. Additionally, of the 862 screens administered to date, 37% were found to be considered “positive.” We will discuss the various barriers and challenges associated with managing referrals to nonmedical providers.

Our team has identified several essential aspects of successful screening and follow-up including staff/nursing education, continued tracking and re-education over time, and establishing and maintaining relationships with psychosocial clinicians to best address these aspects of care and to optimize quality of cancer care overall. We will discuss the impact of the above interventions on adherence and responsiveness.

Purpose: To inform VA stakeholders of the availability of Precision Oncology (PO) services for Veterans with advanced cancer.

Background: PO offers the promise of effective, lowtoxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A system-wide National PO Program (NPOP) including patients in rural areas launched in July 2016.

Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from NPOP records and cancer characteristics were extracted from NPOP and medical records. Drug use data was obtained from the VA Corporate Data Warehouse. NGS testing results and annotations were extracted from NPOP records.

Results: In all, 3,981 samples have been sent for NGS sequencing via NPOP. 3,036 samples were sequenced successfully and 597 failed (83.57% successful). Of the successful samples, 99 are liquid biopsies and 2,880 have Watson for Genomics treatment recommendations. Utilization of NPOP services has increased across VHA since the national rollout, from 4 participating facilities in NPOP’s first quarter (Q4 2016) to 51 facilities last quarter (Q3 2018). Average samples sent per month in 2018 is 182, up from 105 in 2017. Despite these increases, NGS testing is not yet systematically utilized at all participating facilities and 79 facilities did not participate last quarter. NPOP is servicing a large rural population (34% rural), which is similar to that of all VHA patients (33%) and more than twice the national rate (14%). The top diagnoses were lung (1,333: 917 adeno, 283 squamous, 133 non-small cell), colorectal (307), prostate (297), skin (154) and head and neck (75). 158 patients have been prescribed 225 of the recommended treatments before (130) and after (95) the NGS results date.

Conclusions: Utilization of NGS testing in the VHA population has grown significantly over the past year throughout most of the country. The higher volume has been facilitated through improvements in NPOP’s data infrastructure. Additional VHA patients can benefit from NGS gene panel testing to guide therapeutic decisionmaking.

Purpose: To inform VA stakeholders of the availability of Precision Oncology (PO) services for Veterans with advanced cancer.

Background: PO offers the promise of effective, lowtoxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A system-wide National PO Program (NPOP) including patients in rural areas launched in July 2016.

Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from NPOP records and cancer characteristics were extracted from NPOP and medical records. Drug use data was obtained from the VA Corporate Data Warehouse. NGS testing results and annotations were extracted from NPOP records.

Results: In all, 3,981 samples have been sent for NGS sequencing via NPOP. 3,036 samples were sequenced successfully and 597 failed (83.57% successful). Of the successful samples, 99 are liquid biopsies and 2,880 have Watson for Genomics treatment recommendations. Utilization of NPOP services has increased across VHA since the national rollout, from 4 participating facilities in NPOP’s first quarter (Q4 2016) to 51 facilities last quarter (Q3 2018). Average samples sent per month in 2018 is 182, up from 105 in 2017. Despite these increases, NGS testing is not yet systematically utilized at all participating facilities and 79 facilities did not participate last quarter. NPOP is servicing a large rural population (34% rural), which is similar to that of all VHA patients (33%) and more than twice the national rate (14%). The top diagnoses were lung (1,333: 917 adeno, 283 squamous, 133 non-small cell), colorectal (307), prostate (297), skin (154) and head and neck (75). 158 patients have been prescribed 225 of the recommended treatments before (130) and after (95) the NGS results date.

Conclusions: Utilization of NGS testing in the VHA population has grown significantly over the past year throughout most of the country. The higher volume has been facilitated through improvements in NPOP’s data infrastructure. Additional VHA patients can benefit from NGS gene panel testing to guide therapeutic decisionmaking.

Purpose: To inform VA stakeholders of the availability of Precision Oncology (PO) services for Veterans with advanced cancer.

Background: PO offers the promise of effective, lowtoxicity targeted therapies tailored to individual tumor genomics but is unequally available within VHA. A system-wide National PO Program (NPOP) including patients in rural areas launched in July 2016.

Methods: Patients tested with multigene next generation sequencing (NGS) tumor testing through 2 contracted vendors were identified from NPOP records and cancer characteristics were extracted from NPOP and medical records. Drug use data was obtained from the VA Corporate Data Warehouse. NGS testing results and annotations were extracted from NPOP records.

Results: In all, 3,981 samples have been sent for NGS sequencing via NPOP. 3,036 samples were sequenced successfully and 597 failed (83.57% successful). Of the successful samples, 99 are liquid biopsies and 2,880 have Watson for Genomics treatment recommendations. Utilization of NPOP services has increased across VHA since the national rollout, from 4 participating facilities in NPOP’s first quarter (Q4 2016) to 51 facilities last quarter (Q3 2018). Average samples sent per month in 2018 is 182, up from 105 in 2017. Despite these increases, NGS testing is not yet systematically utilized at all participating facilities and 79 facilities did not participate last quarter. NPOP is servicing a large rural population (34% rural), which is similar to that of all VHA patients (33%) and more than twice the national rate (14%). The top diagnoses were lung (1,333: 917 adeno, 283 squamous, 133 non-small cell), colorectal (307), prostate (297), skin (154) and head and neck (75). 158 patients have been prescribed 225 of the recommended treatments before (130) and after (95) the NGS results date.

Conclusions: Utilization of NGS testing in the VHA population has grown significantly over the past year throughout most of the country. The higher volume has been facilitated through improvements in NPOP’s data infrastructure. Additional VHA patients can benefit from NGS gene panel testing to guide therapeutic decisionmaking.

Background: Lung cancer is the second most common cancer diagnosis in Veterans. Although improvements in diagnostic tools and treatments have led to improved survival rates for all stages of lung cancer, it remains the leading cause of cancer death in both men and women and will account for an estimated one in four cancer deaths for 2017. The overall 5-year survival rate of patients with lung cancer remains poor with slow improving trend towards 20%. Early detection contributes to improved survival rates with a 5-year survival rate of 56.3% for earlier stage lung cancer compared to 4.7% survival rate for patients diagnosed at advanced stages, which still accounts for 57% of cases. It has been posited that delays in diagnosis and treatment of lung cancer have been associated with poor prognosis and survival.

Methods: At the Dayton VAMC, we sought to implement a fast track cancer care pathway for suspicious lung nodules utilizing a VA-designed web-based cancer care tracking system (CCTS), a nurse practitioner and the Chief of Pulmonary Medicine. Established guidelines were used to identify and track suspicious nodules. Suspicious nodules identified on a CAT scan were routed to the Chief of Pulmonary Medicine who assessed the imaging and orchestrated the diagnostic phase.

Results: Nurse navigators began using the CCTS application in the spring of 2017 and, by January 1, 2018, CCTS was fully operational. An Excel spreadsheet was developed to augment the reports from CCTS to document and monitor key metrics including timeliness of treatment and stage at diagnosis. Early data has been encouraging. In fiscal year 2016, the average time from suspicion to treatment was 110 days. The most current data that reflects that has been reduced to an average of 88 days punctuated by a consistent trend toward earlier stage diagnosis.

Conclusions: The diagnostic process for suspicious lung nodules can be complex and involve multiple disciplines and providers, so it is susceptible to delays, often both institutional and patient-driven. Using nurse navigators, a cancer tracking system, and fast tracking suspicious nodules may prevent patients from getting lost in the diagnostic maze resulting in improved timeliness of treatment.

Background: Lung cancer is the second most common cancer diagnosis in Veterans. Although improvements in diagnostic tools and treatments have led to improved survival rates for all stages of lung cancer, it remains the leading cause of cancer death in both men and women and will account for an estimated one in four cancer deaths for 2017. The overall 5-year survival rate of patients with lung cancer remains poor with slow improving trend towards 20%. Early detection contributes to improved survival rates with a 5-year survival rate of 56.3% for earlier stage lung cancer compared to 4.7% survival rate for patients diagnosed at advanced stages, which still accounts for 57% of cases. It has been posited that delays in diagnosis and treatment of lung cancer have been associated with poor prognosis and survival.

Methods: At the Dayton VAMC, we sought to implement a fast track cancer care pathway for suspicious lung nodules utilizing a VA-designed web-based cancer care tracking system (CCTS), a nurse practitioner and the Chief of Pulmonary Medicine. Established guidelines were used to identify and track suspicious nodules. Suspicious nodules identified on a CAT scan were routed to the Chief of Pulmonary Medicine who assessed the imaging and orchestrated the diagnostic phase.

Results: Nurse navigators began using the CCTS application in the spring of 2017 and, by January 1, 2018, CCTS was fully operational. An Excel spreadsheet was developed to augment the reports from CCTS to document and monitor key metrics including timeliness of treatment and stage at diagnosis. Early data has been encouraging. In fiscal year 2016, the average time from suspicion to treatment was 110 days. The most current data that reflects that has been reduced to an average of 88 days punctuated by a consistent trend toward earlier stage diagnosis.

Conclusions: The diagnostic process for suspicious lung nodules can be complex and involve multiple disciplines and providers, so it is susceptible to delays, often both institutional and patient-driven. Using nurse navigators, a cancer tracking system, and fast tracking suspicious nodules may prevent patients from getting lost in the diagnostic maze resulting in improved timeliness of treatment.

Background: Lung cancer is the second most common cancer diagnosis in Veterans. Although improvements in diagnostic tools and treatments have led to improved survival rates for all stages of lung cancer, it remains the leading cause of cancer death in both men and women and will account for an estimated one in four cancer deaths for 2017. The overall 5-year survival rate of patients with lung cancer remains poor with slow improving trend towards 20%. Early detection contributes to improved survival rates with a 5-year survival rate of 56.3% for earlier stage lung cancer compared to 4.7% survival rate for patients diagnosed at advanced stages, which still accounts for 57% of cases. It has been posited that delays in diagnosis and treatment of lung cancer have been associated with poor prognosis and survival.

Methods: At the Dayton VAMC, we sought to implement a fast track cancer care pathway for suspicious lung nodules utilizing a VA-designed web-based cancer care tracking system (CCTS), a nurse practitioner and the Chief of Pulmonary Medicine. Established guidelines were used to identify and track suspicious nodules. Suspicious nodules identified on a CAT scan were routed to the Chief of Pulmonary Medicine who assessed the imaging and orchestrated the diagnostic phase.

Results: Nurse navigators began using the CCTS application in the spring of 2017 and, by January 1, 2018, CCTS was fully operational. An Excel spreadsheet was developed to augment the reports from CCTS to document and monitor key metrics including timeliness of treatment and stage at diagnosis. Early data has been encouraging. In fiscal year 2016, the average time from suspicion to treatment was 110 days. The most current data that reflects that has been reduced to an average of 88 days punctuated by a consistent trend toward earlier stage diagnosis.

Conclusions: The diagnostic process for suspicious lung nodules can be complex and involve multiple disciplines and providers, so it is susceptible to delays, often both institutional and patient-driven. Using nurse navigators, a cancer tracking system, and fast tracking suspicious nodules may prevent patients from getting lost in the diagnostic maze resulting in improved timeliness of treatment.