Are Biopsies Sufficient for Diagnosis Comparison of ESD and Forceps Biopsy Findings for Colon and Rectal Lesions

Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous colon and rectal lesions. For larger lesions ( .20mm) that are not amenable to endoscopic mucosal resection, superficial biopsies are typically taken prior to referral for ESD. The aim of this study was to evaluate the degree of concordance between superficial forceps biopsies and ESD pathology. Method(s): A retrospective medical record review was performed including consecutive patients who underwent ESD of colon and rectal lesions at a tertiary care center between 10/2018 and 11/2021. Pathology results from outside hospital and same institution pre-ESD superficial forceps biopsies were compared to ESD pathology results. The primary outcome was the number of patients found to have higher disease severity on ESD pathology compared with superficial forceps biopsies. Result(s): Of the 84 patients who underwent ESD of colon or rectal lesions, 72 had pre-ESD superficial forceps biopsies which were taken at an outside hospital (n=48) or at the same institution (n=36). The average length of time between outside hospital superficial forceps biopsies and ESD was 91 days compared to 75 days for those performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic prolonging time between procedures. Pathology findings after ESD differed from superficial forceps biopsies in 31/72 patients (43%) with 21 patients receiving upgraded disease severity and 6 patients receiving a new cancer diagnosis based on ESD pathology. Patients who received a new cancer diagnosis had more days between superficial forceps biopsies and ESD compared with the whole cohort (86 vs 75, respectively). Conclusion(s): While superficial forceps biopsies of colon and rectal lesions were typically concordant with ESD pathology, 29% of patients in this cohort received upgraded disease severity based on ESD pathology. This shows that while superficial forceps biopsies can aid in diagnosis, en bloc resection via ESD remains critical for accurate diagnosis of large colon and rectal lesions. These results also show that ESD is not only diagnostic but therapeutic given 75% of the patients in this cohort achieved R0 resection.

Prostate Cancer Screening during the Covid-19 Pandemic across Demographic Groups

INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic led to the delay of routine medical care, including cancer screening, beginning in March of 2020. While screening rates for several cancers, including prostate cancer, rapidly recovered after the first wave of the COVID-19 pandemic, the degree to which this recovery was realized in different populations remains unknown. We sought to determine the association of the COVID-19 pandemic with prostate cancer screening, particularly for traditionally underserved patients. METHOD(S): We performed a retrospective cohort study using electronic health records (EHR) data from the Optum EHR database for male patients between the ages of 55-69 eligible for prostate cancer screening from quarter 1 (Q1) of 2016 through Q2 of 2021. We excluded men with a prior diagnosis of prostate cancer. We performed multivariable analysis to estimate screening over time, adjusting for patient age, race, ethnicity, Census division of residence, and insurance status. RESULT(S): A total of 7,361,765 patients were included. After adjusting for patient demographics, the percentage of eligible patients with prostate cancer screening decreased from 2.2% in Q4 of 2019 to 1.3% in Q2 of 2020. There was a rebound in screening to 2.4% in Q3 of 2020, which is similar to baseline levels, and a subsequent decline to 1.6% in Q2 of 2021. This trend was seen even after stratifying based on age, race, ethnicity, division, and insurance status (Figure 1). CONCLUSION(S): A 40% decline in prostate cancer screening in Q2 of 2020 was observed during the first wave of the pandemic. This returned to baseline by Q3 of 2020. Subsequent decline was seen again through Q2 of 2021, which also coincides with the second wave of COVID-19. This trend was unaffected by patient characteristics, such as age, race, insurance status, or division of residence. While these data suggest that the peak of the pandemic impacted prostate cancer screening trends similarly across different patient demographic groups, further study is required to breakdown if this was due to social distancing, decreased clinic volumes, or other factors.

COMPARISON OF ESD AND SUPERFICIAL FORCEPS BIOPSY PATHOLOGY FOR ESOPHAGEAL LESIONS

DDW 2022 Author Disclosures: Daniel Scanlon: NO financial relationship with a commercial interest ;Brianna Shinn: NO financial relationship with a commercial interest ;Zachary Lieb: NO financial relationship with a commercial interest ;Brian Jacobs: NO financial relationship with a commercial interest ;Divya Chalikonda: NO financial relationship with a commercial interest ;Jason Ho: NO financial relationship with a commercial interest ;Abhishek Agnihotri: NO financial relationship with a commercial interest ;Anand Kumar: YES financial relationship with a commercial interest;Olympus:Consulting ;Anthony Infantolino: NO financial relationship with a commercial interest ;Christina Tofani: NO financial relationship with a commercial interest ;Alexander Schlachterman: NO financial relationship with a commercial interest Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive technique used for removal of superficial dysplastic or early cancerous esophageal lesions. Many of these lesions arise in a background of Barrett’s esophagus (BE) which is a known precursor of dysplasia and adenocarcinoma. Large lesions not amenable to endoscopic mucosal resection often have superficial forceps biopsies taken prior to referral for ESD. This study aims to evaluate the accuracy of superficial forceps biopsies compared with pathology from ESD. Methods: A retrospective medical record review was performed that included consecutive patients who underwent ESD for esophageal lesions at a tertiary care center between 6/2018 and 9/2021. Pathology results from outside hospital and same institution superficial forceps biopsies as well as ESD pathology reports were reviewed. The primary outcome measured was the number of patients found to have higher disease severity on ESD pathology compared with pre-ESD superficial forceps biopsies. Results: The 28 patients included in the study received superficial forceps biopsies at outside hospitals (n=9), the same institution (n=14), or both (n=5). An average of 99 days occurred between outside hospital superficial forceps biopsies and ESD compared with an average of 30 days between superficial forceps biopsies and ESD performed at the same institution. Delays between superficial forceps biopsies and ESD may be related to the COVID-19 pandemic leading to prolonged time between procedures. In the entire cohort, ESD pathology differed from superficial forceps biopsies in 13/28 patients (46%). 10 patients (36%) had their disease severity upgraded and 3 were newly diagnosed with cancer on ESD pathology. Findings were similar for patients with lesions arising in a background of BE (21/28) (Table 1). Of those with BE, 9/21 (43%) patients had ESD pathology that differed from superficial forceps biopsies with 6 patients (29%) receiving increased disease severity and 2 patients receiving a new cancer diagnosis on ESD pathology. Conclusion: Superficial forceps biopsies taken prior to resection of esophageal lesions via ESD were concordant with ESD pathology in the majority of cases, however 36% of patients received upgraded disease severity on ESD pathology. Findings were similar for patients with or without a background of Barrett’s esophagus. These results highlight the importance of en bloc resection not only for therapeutic benefit (60% of patients in this cohort achieved R0 resection), but for accurate staging of esophageal lesions. [Formula presented]

Telemedicine and Goals of Care Discussions: A Successful Combination in the Emergency Department

Study Objectives: There has been a long-standing need for emergency department (ED) clinicians to conduct goals of care (GOC) discussions in the ED despite the perceived barriers of constrained time and discomfort with these conversations. The COVID-19 pandemic led to rapid adoption and wider acceptance of telehealth. We developed a quality improvement project that evaluated having a dedicated clinician lead GOC discussions in the ED with support staffing by a virtual expert. Methods: A pre-project survey assessing ED resident, mid-level, and attending physician comfort with leading GOC discussions was performed. A senior emergency medicine (EM) resident was trained by a dual board-certified EM and palliative care physician to lead GOC discussions using a validated framework developed by VitalTalk. Over the course of a three-week elective, the resident was dedicated to performing GOC discussions in the ED with patients or surrogates of patients identified as being seriously ill, elderly and frail, having an acute exacerbation of serious chronic illness, or where the ED provider would not be surprised if the patient were to die within the next year. An EM or palliative care attending physician staffed all discussions in real-time using Zoom on an eye-level mounted iPad in each patient’s room. GOC discussions were documented as a procedure and participating patients completed a four-question telemedicine survey. Results: The pre-project survey found that 85.7% of respondents felt there was limited time to lead GOC discussions in the ED. Other perceived barriers included uncertainty in prognosis (60.7%) and preference for other providers to conduct the discussion (67.9%). 39.3% of providers reported leading 0 GOC discussions in the ED in the last month, while 42.9% estimated having led 1-3. Only 25% had consulted palliative care for any reason in the last month. A total of 23 GOC discussions were performed. Six patients' code statuses were identified as DNR/DNI. In one case, the discussion significantly altered the patient’s course: initial plans were to admit the patient to the intensive care unit but wishes for home hospice were identified instead. Most patients reported having had no prior GOC discussions. Problematic telemedicine issues included occasional connectivity malfunction, background noise, or the tele-provider missing subtle visual cues from patients. Silver linings included the unforeseen benefit of patients and surrogates virtually seeing each other despite COVID-19 visitor restrictions. Patients responded to the virtual visit with neutral to positive attitudes. 61.5% of patients surveyed had used telemedicine previously, and 61.5% felt talking to a doctor virtually was as satisfying as talking to a doctor in person. Conclusions: This project created an educational opportunity for residents to master the critical skill of leading GOC discussions and identified educational gaps. GOC discussions in the ED have the potential to dramatically alter the trajectory of patients' future care. The telemedicine platform provided a low cost, uncomplicated format to staff these discussions. Translation of this project into a resident elective may fortify GOC education and stimulate further research.

Trends in prostate cancer screening nationwide during the COVID-19 pandemic

INTRODUCTION AND OBJECTIVE: An important consequence of the COVID-19 pandemic was a precipitous decline in elective outpatient encounters such as cancer screening. It is particularly important to examine the effect of delays in cancer screening as a result of COVID-19-due to the potential for future morbidity, but as of yet, there have been no reports of cancer screening rates throughout the multiple waves of the pandemic on a nationwide level. We sought to examine monthly trends in prostate cancer screening during 2020 to better inform future clinical care. METHODS: To obtain prostate cancer screening rates, we queried the Healthjump dataset which provides outpatient encounter information for more than 40 million patients nationwide and is updated daily. This dataset was obtained through the COVID-19 Resesarch Database. Both encounter and laboratory test data for prostate cancer screening were collected from January 2019 to December 2020 using a combination of ICD-10 and CPT/HCPCS codes. We then analyzed these rates during three time periods: pre-pandemic (Jan 2019-Feb 2020), first wave (Mar 2020-May 2020), and postfirst wave (Jun 2020-Dec 2020). RESULTS: Prior to the pandemic (defined as March 2020) there were an average of 5731 screening visits, 2031 screening PSA labs, and 8173 total PSA labs (not specifically defined as screening) monthly. Between March and May 2020, these numbers declined to 3858, 1613, and 6237 monthly encounters, respectively (p<0.01). In April 2020, rates nadired at 50%, 66%, and 63%, respectively, of their pre-pandemic means. By June of 2020, prostate screening encounters returned to their pre-pandemic rates (Figure 1). CONCLUSIONS: Prostate cancer screening encounters quickly declined in the first 3 months of the COVID-19 pandemic but consistently returned to pre-pandemic rates between June and December 2020. Hopefully this is an indication that decreased prostate cancer screening due to COVID-19 was short-lived and will not lead to more advanced disease at diagnosis in the future. (Figure Presented).

Racial disparities in prostate cancer treatment in a multi-institutional regional collaborative

INTRODUCTION AND OBJECTIVE: Minority communities disproportionately shouldered poor COVID-19 outcomes, however the impact of the pandemic on prostate cancer (PCa) surgery is unknown. To that end, we sought to determine the racial impact on PCa care during the first wave of the pandemic. METHODS: Using a multi-institutional collaborative we evaluated practice patterns for Black and White patients with untreated non-metastatic PCa during the initial COVID-19 lockdown (March-May 2020) compared to prior (March-May 2019). Patient and practice characteristics were compared by race using Fisher's exact and Pearson's chi-square to compare categorical variables and Wilcoxon rank sum to evaluate continuous covariates. We determined the covariate-adjusted impact of year and race on surgery, using logistic regression models with a race year interaction term. RESULTS: Among the 647 men with non-metastatic PCa, 269 received care during the pandemic and 378 prior. Surgery was significantly less likely in Black men (1.3% v 25.9%;p<0.001), despite similar COVID-19 risk factors, biopsy Gleason grade group, and comparable surgery rates prior (17.7% vs. 19.1%;p=0.75). Black men had higher PSA (8.8 vs. 7.2 p=0.04) and were younger (38.2% vs. 24.4% <60 yr;p=0.09). Regression results demonstrated an 94% reduced odds of surgery (OR=0.06, 95% CI 0.007-0.43;p=0.006) for Black patients, with no change for White patients (OR=1.41, 95% CI 0.89-2.21;p=0.142), after adjusting for covariates. Changes in surgical volume varied by site (33% increase to complete shutdown), with sites that experienced the largest reduction in cancer surgery, caring for a greater proportion of Black patients (figure). CONCLUSIONS: In a large multi-institutional regional collaborative, odds of prostatectomy declined only among Black patients during the initial wave of the COVID-19 pandemic. While localized prostate cancer does not require immediate treatment, this study illuminates systemic inequities within healthcare. Public health efforts are needed to fully recognize the unintended consequence of diversion of cancer resources to the pandemic in order to develop balanced mitigation strategies as viral rates continue to fluctuate.

Prostate cancer treatment disparities during the COVID-19 pandemic, lessons from a multi-institutional collaborative

Background: Minority communities have been disproportionately affected by COVID-19, however the impact of the pandemic on prostate cancer (PCa) treatment is unknown. To that end, we sought to determine the racial impact on PCa surgery during the first wave of the COVID-19 pandemic. Methods: After receiving institutional review board approval, the Pennsylvania Urologic Regional Collaborative (PURC) database was queried to evaluate practice patterns for Black and White patients with untreated non-metastatic PCa during the initial lockdown of the COVID-19 pandemic (March-May 2020) compared to prior (March-May 2019). PURC is a prospective collaborative, which includes private practice and academic institutions within both urban and rural settings including regional safety-net hospitals. As data entry was likely impacted by the pandemic, we limited our search to only practices that had data entered through June 1, 2020 (5 practice sites). We compared patient and disease characteristics by race using Fisher's exact and Pearson's chi-square to compare categorical variables and Wilcoxon rank sum to evaluate continuous covariates. Patients were stratified by risk factors for severe COVID-19 infection as described by the CDC. We determined the covariate-adjusted impact of year and race on surgery, using logistic regression models with a race∗year interaction term. Results: 647 men with untreated nonmetastatic PCa were identified, 269 during the pandemic and 378 from the year prior. During the pandemic, Black men were significantly less likely to undergo prostatectomy compared to White patients (1.3% v 25.9%;p < 0.001), despite similar COVID-19 risk-factors, biopsy Gleason grade group, and comparable surgery rates prior (17.7% vs. 19.1%;p = 0.75). White men had lower pre-biopsy PSA (7.2 vs. 8.8 vs. p = 0.04) and were older (24.4% vs. 38.2% < 60yr;p = 0.09). The regression model demonstrated an 94% decline in odds of surgery(OR = 0.06 95%CI 0.007-0.43;p = 0.006) for Black patients and increase odds of surgery for White patients (OR = 1.41 95%CI 0.89-2.21;p = 0.142), after adjusting for covariates. Changes in surgical volume varied by site (33% increase to complete shutdown), with sites that experienced the largest reduction in cancer surgery, caring for a greater proportion of Black patients. Conclusions: In a large multi-institutional regional collaborative, odds of PCa surgery declined only among Black patients during the initial wave of the COVID-19 pandemic. While localized prostate cancer does not require immediate treatment, the lessons from this study illuminate systemic inequities within healthcare, likely applicable across oncology. Public health efforts are needed to fully recognize the unintended consequence of diversion of cancer resources to the pandemic in order to develop balanced mitigation strategies as viral rates continue to fluctuate.

Digital monitoring of paediatric patients with chronic recurrent multifocal osteomyelitis at a national orthopaedic centre

Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is a paediatric inflammatory bone condition requiring close monitoring by a multi-disciplinary team throughout childhood. Many UK patients are seen at the Royal National Orthopaedic Hospital, Stanmore for more than a decade of specialist management. Prior to the recent COVID crisis, we recognised need for more frequent monitoring without the inconvenience of cross-country travel and so piloted an online system of monitoring CRMO. Method: An online assessment form was created using the GDPR-compliant Qualtrics system after consultation with CRMO paediatricians and a specialist nurse. 3 medical students telephoned parents of 31 patients to pilot the assessment form. Responses indicating issues were then referred to the CNS for follow-up. Results: Response data confirmed need for close monitoring with 26% of respondents being seen quarterly, 29% reporting pain greater than 6/ 10, 29% having side-effects and 30% finding current treatment ineffective. 74% of respondents found online assessment extremely/very useful and 58% preferred it to face-to-face appointments. Conclusions: A digital CRMO monitoring tool can successfully identify patients with both new and ongoing issues. In the COVID and post- COVID era, digital tools can closely monitor patients with chronic conditions like CRMO whilst improving quality of life by reducing need for face-to-face appointments.