Elevated serum CEA is associated with liver metastasis and distinctive circulating tumor DNA alterations in patients with castration-resistant prostate cancer.

BACKGROUND: Elevated serum carcinoembryonic antigen (CEA) is used to identify "treatment emergent" forms of castration-resistant prostate cancer (CRPC) such as aggressive variant prostate cancer (AVPC). However, its individual utility as a prognostic marker and the genetic alterations associated with its expression have not been extensively studied in CRPC. METHODS: This study retrospectively analyzed clinical outcomes and circulating tumor DNA profiles in 163 patients with CRPC and elevated or normal serum CEA. These same patients were then classified as AVPC or non-AVPC and compared to determine the uniqueness of CEA-associated gene alterations. RESULTS: Patients with elevated CEA demonstrated higher rates of liver metastasis (37.5% vs. 19.1%, p = 0.02) and decreased median overall survival from CRPC diagnosis (28.7 vs. 73.2 mo, p < 0.0001). In addition, patients with elevated CEA were more likely to harbor copy number amplifications (CNAs) in AR, PIK3CA, MYC, BRAF, CDK6, MET, CCNE1, KIT, RAF1, and KRAS. Based on variant allele frequency we also defined "clonal" single-nucleotide variants (SNVs) thought to be driving disease progression in each patient and found that CEA expression was negatively correlated with clonal AR SNVs and positively correlated with clonal TP53 SNVs. Of these genetic associations, only the increases in clonal TP53 SNVs and KRAS amplifications were recapitulated among patients with AVPC when compared to patients without AVPC. CONCLUSIONS: Together these findings suggest that CEA expression in CRPC is associated with aggressive clinical behavior and gene alterations distinct from those in AVPC.

Disparate Use of Chemoradiation in Elderly Patients With Localized Anal Cancer.

BACKGROUND: The incidence of squamous cell carcinoma of the anus (SCCA) is increasing, particularly among the elderly (age ≥65 years). We sought to compare patterns of care for the treatment of SCCA in elderly versus nonelderly patients. METHODS: Data for patients with stages I-III SCCA diagnosed from 2004 through 2015 were obtained from the National Cancer Database. Patients were categorized as having received standard-of-care (SOC) chemoradiation (CRT) with multiagent chemotherapy, non-SOC therapy, palliative therapy, or no treatment. Differences in treatment groups were tested using the chi-square test. We used logistic regression to identify predictors of SOC CRT and multiagent versus single-agent chemotherapy in patients receiving CRT. Propensity score matching was used to compare overall survival (OS) in elderly patients receiving multiagent versus single-agent chemotherapy for those receiving CRT. RESULTS: We identified 9,156 elderly and 17,640 nonelderly patients. A lower proportion of elderly versus nonelderly patients (54.5% vs 65.0%; P<.0001) received SOC CRT than other treatments or no treatment. In multivariate analysis, elderly patients were 38% less likely than nonelderly patients to receive SOC CRT (odds ratio, 0.62; 95% CI, 0.58-0.65; P<.0001). A higher proportion of the elderly were treated with single-agent versus multiagent chemotherapy (16.9% vs 11.8%; P<.0001), which resulted in a >1.5-fold increase in the likelihood of elderly patients receiving single-agent chemotherapy (odds ratio, 1.52; 95% CI, 1.39-1.66) in multivariate analysis. After propensity score matching, 3-year OS was higher in elderly patients who received CRT with multiagent versus single-agent chemotherapy (77.1% vs 67.5%; hazard ratio, 0.78; 95% CI, 0.68-0.89; P=.0002). CONCLUSIONS: In this comprehensive study of patients with stages I-III SCCA, elderly patients were less likely than nonelderly patients to receive SOC CRT. The low proportion of elderly patients receiving SOC CRT with multiagent chemotherapy for localized anal cancer suggests that the optimal treatment approach for this vulnerable population remains undefined.

Limited impact of clinician education on reducing inappropriate PF4 testing for heparin-induced thrombocytopenia.

A high frequency of PF4-ELISA testing in patients suspected to have heparin-induced thrombocytopenia (HIT) despite low 4T scores has been observed in multiple medical centers. Education of clinicians has been suggested to reduce inappropriate testing. We determined trends of PF4-ELISA testing in our institution after the introduction of a HIT education program for clinicians. A HIT Program was developed that included ongoing education, individual feedback, and continuous clinical audit of PF4-ELISA utilization. To assess the impact of education on PF4-ELISA testing trends, we conducted a prospective cohort review of all adult patients who had a PF4-ELISA ordered over a 3 month period (the last quarter of the academic year). 72 PF4-ELISA tests were ordered during the study period. Prospectively calculated 4T scores by investigators revealed 60 low-risk (83.3%), 9 intermediate-risk (12.5%), and 3 high-risk (4.16%). We observed divergent 4T scores with the ordering clinician calculating a higher 4T score compared to the Hematology Quality Improvement (QI) team. The majority of PF4-ELISA testing was ordered by the intensive care units (ICUs) (n = 32, 44.44%). Our study revealed that the frequency of calculation of 4T scores remains poor with the majority inappropriately performed in the ICU setting, with ordering clinicians calculating higher 4T scores than the Hematology QI team. This suggests that clinician education alone is insufficient. Introducing mandatory 4T score calculation prior to PF4-ELISA testing may not be helpful as ordering clinicians can bypass the restriction through inaccurate 4T score calculation.

A high-value cost conscious approach to minimize heparin induced thrombocytopenia antibody (HITAb) testing using the 4T score.

Heparin Induced Thrombocytopenia (HIT) is a serious complication from administration of heparin products. The 4T score is a validated pre-test probability tool to screen for HIT in hospitalized patients. As the negative predictive value (NPV) is very high further testing for HIT in patients with a low score can be avoided. Our objective was to determine trends at our hospital with respect to utilization of HIT antibody (HITAb) testing and evaluate economic burden from unnecessary HIT testing. A retrospective cohort review was performed on patients age 18 and above admitted to a tertiary care center from February 2013 to December 2014 who underwent HITAb testing. Surgical ICU patients were excluded. Patients were stratified into low, intermediate, and high risk for HIT based on the 4T model. Statistical analysis was performed using Chi square and regression models. Of 150 patients that underwent HITAb testing, 134 met inclusion criteria. 73 were male (54.47 %) and mean age was 55.50 ± 17.27 years. 81 patients had a low 4T score 0-3. Analysis of testing trends showed 60.44 % of patients were tested for HITAb despite being low risk using the 4T model. Only three patients with low 4T score were positive on confirmatory SRA testing (NPV 96.29 % CI 95 = 89.56-99.23 %). Expenditure due to inappropriate testing and treatment was estimated at $103,348.13. The majority of HITAb testing was found unnecessary based on the investigator calculated 4T score. We propose implementation of an electronic medical record (EMR) based calculator in order to reduce unneeded tests and reduce use of costlier alternative anticoagulants.

Mainstreaming germline genetic testing for patients with pancreatic cancer increases uptake.

Germline genetic testing is recommended for all patients with pancreatic cancer (PC) but uptake rates are low. We implemented a mainstreaming program in oncology clinics to increase testing for PC patients. Genetic counselors trained oncology providers to offer a standardized multigene panel and obtain informed consent using an educational video. Pre-test genetic counseling was available upon request. Otherwise, patients with identified pathogenic variants, strong family history, or questions regarding their results were referred for post-test genetic counseling. We measured rates of testing and genetic counseling visits. From September 2019 to April 2021, 245 patients with PC underwent genetic testing. This represents a 6.5-fold increase in germline testing volume (95% confidence interval 5.2-8.1) compared to previous years. At least one pathogenic or likely pathogenic variant (PV/LPV) was found in 34 (13.9%) patients, including 17 (6.9%) PV/LPVs in high or moderate risk genes and 18 (7.3%) in low risk or recessive genes. Five (2.0%) PVs had implications on treatment selection. 22 of the positive patients (64.7%) and an additional 8 PC patients (1 negative, 3 VUS, and 4 pre-test) underwent genetic counseling during the study period. Genetic counselors saw 2.0 PC patients/month prior to this project, 1.6 PC patients/month during this project, and would have seen 2.2 PC patients/month if all patients with pathogenic variants attended post-test counseling. Conclusions Mainstreaming genetic testing expands access for PC patients without overwhelming genetic counseling resources.

Cancer survivorship in hematologic malignancies: Lifestyle changes after diagnosis.

BACKGROUND: Studies show that patients make lifestyle changes soon after certain solid tumor diagnoses, suggesting that this may be a teachable moment to motivate and promote healthy behaviors. There is a paucity of data regarding changes made after a diagnosis of a hematologic malignancy. METHODS: A cross-sectional study of 116 patients at a community oncology center who completed anonymous questionnaires was performed. Questions addressed lifestyle choices made with respect to smoking, alcohol consumption, recreational drug use, diet, and exercise habits before and after diagnosis of a hematologic malignancy. Support systems utilized, including psychiatry services, were also assessed. RESULTS: Patients exhibited significant reduction in smoking behavior (Χ2  = 31.0, p < 0.001). 82.4% (n = 14) of one pack per day smokers quit between the time periods, with nearly all smokers showing a reduction after diagnosis. Alcohol use overall did not change significantly, however, 10.3% (n = 12) of patients reported quitting drinking completely between time periods. Changes in dietary intake and exercise were not statistically significant overall. Utilization of external support systems correlated with improved diet as well as decrease in total smoking years. CONCLUSIONS: This study demonstrates that patients exhibited significant lifestyle changes after being diagnosed with a hematologic malignancy. Clinicians should take advantage of this 'teachable moment' to educate patients about positive health behavior changes. Advances in cancer therapeutics have led to an increase in cancer survivors, this education is crucial in reducing the risk of developing chronic comorbidities as well as secondary malignancies.

Neurotoxic manifestations of high-dose intrathecal gadolinium administration for CT myelogram.

Use of intrathecal gadolinium for contrast-enhanced myelography and cisternography remains off-label and is currently not FDA-approved. We report a 70-year-old male who underwent CT myelogram utilizing off-label high-dose intrathecal gadolinium who developed altered mental status and bilateral hearing loss. Workup ruled out meningitis (infectious and aseptic), infectious encephalopathy, encephalitis, and hypothyroidism. MRI of the brain and lumbar spine without contrast displayed fluid collection in L4-5 interspace and diffuse cerebrospinal fluid (CSF) hyperdensity consistent with intrathecal gadolinium. The patient eventually improved with high-dose IV dexamethasone and supportive care and resolution of diffuse CSF hyperdensity was observed on repeat MRI. There are limited data demonstrating the safety of low-dose intrathecal gadolinium due to which usage remains off-label. Our case highlights the need for caution when using substances for off-label indications and reinforces the usage of less invasive and noninvasive diagnostic modalities when possible.