Long-term outcomes of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer.

BACKGROUND: Perioperative blood transfusion in patients with colorectal cancer has been associated with increased cost, morbidity, mortality, and decreased survival. Five years ago, a transfusion reduction initiative (TRI) was implemented. We sought to evaluate the 5-year effectiveness and patient outcomes before and after the TRI. METHODS: Patients who underwent colorectal resection for adenocarcinomas before (January 2006 to October 2009) and after the TRI (November 2009 to December 2013) were reviewed. RESULTS: A total of 484 patients were included; 267 and 217 patients were in the pre- and post-TRI groups, respectively. Decreased overall transfusion rates were sustained throughout the entire post-TRI era (17% vs 28%, P = .006). Three-year colorectal cancer disease-free survival rates were similar in the pre- and post-TRI eras at 85.3% (95% confidence interval [CI]: 79.9 to 89.3) and 81.6% (95% CI: 71.9 to 88.2), respectively. Three-year disease-free survival rate was lower in those receiving BTs vs those without BTs at 78.4% (95% CI: 65.7 to 86.8) vs 85.3% (95% CI: 80.4 to 89.1), respectively. CONCLUSIONS: A TRI remains a safe, effective way to reduce blood utilization in colorectal cancer surgery.

Making the Case to Study the Volume-Outcome Relationship in Hematologic Cancers.

The positive relationship between the volume of health services (hospital and physician) and health-related outcomes is established in the complex surgical treatment of cancers and certain nononcologic medical conditions. However, this topic has not been systematically explored in the medical management of cancers. We summarize the limited current state of knowledge about the volume-outcome relationship in the management of hematologic cancers and provide reasons why further research on this subject is necessary. We highlight the relatively low annual volume of hematologic cancers in the United States, the increasing complexity of making a diagnosis due to constant change in classification and prognostication, the rapid availability of novel agents with unique mechanisms of action and toxicities, and the proliferation of treatment guidelines distinct to each disease subtype. We also discuss the potential implications pertaining to medical practice and trainee education, including effects on quality of care, access and referral patterns, and subspecialty training.

Management of neutropenic fever during a transition from traditional hematology/oncology service to hospitalist care.

OBJECTIVES: Increasingly, hospitalists across the United States provide primary inpatient care for almost all subspecialty patients, including hematology and medical oncology. Febrile neutropenia (FN) is a serious condition often seen as a complication of cytotoxic chemotherapy or in patients with underlying bone marrow defects. The purpose of this study was to document the change of inpatient management of a common admission diagnosis during a transition of providers from hematologists/oncologists to the use of hospitalists in a tertiary care medical center, and to compare the appropriateness of treatment and outcomes over a period of 5.5 years of this transition. METHODS: The medical records of all patients with neutropenia at a community-based teaching hospital during a period of conversion from hematologist/oncologist to hospitalist coverage were retrospectively reviewed. Patients with fever and absolute neutrophil counts of less than 500/ microL (.5 x 10(9)/L) on admission were included. Study cases were divided into 3 groups by admission date, roughly demarcating the nascent hospitalist era, the era of transition to hospitalist, and the mature hospitalist era. Management of FN during these eras was compared. RESULTS: Three hundred ninety-nine inpatients were identified as neutropenic. Of these, 184 did not meet case-inclusion criteria. The remaining 215 cases were included in the study. The internal medicine hospitalist service admitted less than 10% of this population in 2003, but by 2007-2008 it admitted over 90%. The use of 4th-generation cephalosporins and carbapenems increased over time (P = .027), and the infectious disease service was consulted more frequently over time (P = .007). Outcomes varied due to changes in underlying disease states, use of hospice services, and changes in the types of patients hospitalized with FN. Morbidity decreased due to the change in the type and nonantibiotic therapy of cases, but inappropriate antimicrobial treatment was unusual, and septic morbidity or mortality related to inappropriate therapy was too rare to compare through these eras. CONCLUSION: Over the 3 eras compared, care of most neutropenic fever patients was transferred from specialists to hospitalists. Care became more uniform, guideline based, and used more infectious disease consultation, and mortality decreased. Complex changes in the types and treatments of cancer, neutropenia therapy, and in the types of patients hospitalized with FN prevent any conclusion of added value for this change in the type of primary provider management.

Outcomes and complications after splenectomy for hematologic disorders.

BACKGROUND: Splenectomy is generally a second-line therapy in patients with immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia (AHA) refractory to medical therapy. Our objective was to evaluate outcomes after splenectomy for these disorders. METHODS: A retrospective review of the medical records of patients who underwent splenectomy for ITP or AHA from January 1, 1996, to December 31, 2010 was completed. RESULTS: Sixty patients met the study criteria: 45 with ITP and 15 with AHA. The mean age was 49.4 ± 21.7 years; 63% were women. Initially, 91% and 93% of ITP and AHA patients experienced a complete response (P = .999); however, 17% of ITP and 29% of AHA patients relapsed (P = .443). Sixty-four percent of patients responded after relapse for a complete response rate of 85% (82% in ITP and 93% in AHA, P = .427). Thirty-day and long-term complication rates were 10% and 5%, respectively. There were no splenectomy-related 30-day mortalities. CONCLUSIONS: Splenectomy for ITP and AHA resulted in favorable response rates with low morbidity and is an effective adjunct in the management course of patients failing to achieve or sustain responses with medical therapy.

The impact of an integrated transfusion reduction initiative in patients undergoing resection for colorectal cancer.

BACKGROUND: Perioperative blood transfusions in patients with colorectal cancer are associated with increased cost, morbidity, mortality and decreased survival. In 2009, a 3-part transfusion reduction initiative (TRI) was introduced. The hypothesis was that this would decrease transfusions without increasing complications in patients undergoing elective resection for colorectal cancer. METHODS: After institutional review board approval was obtained, the medical records of patients who underwent colon resection before (January 2006 to October 2009) and after (November 2009 to March 2011) the TRI were reviewed. RESULTS: Three hundred sixty-eight patients were included, 272 and 96 in the pre-TRI and post-TRI groups, respectively. Transfusion rates decreased in the post-TRI group compared with the pre-TRI group (15% vs 28%, P = .011). Median postoperative hemoglobin levels among transfused patients were 8.4 and 7.3 g/dL in the pre-TRI and post-TRI groups, respectively (P = .009). There was no difference in complications or 30-day mortality. Transfused patients with stages I to III adenocarcinoma had worse 4-year survival (P < .05). CONCLUSIONS: Perioperative transfusions in colorectal cancer surgery decreased after the implementation of a TRI. Complication rates did not change. Perioperative transfusions were associated with worse survival in patients with stages I to III cancer.

Maintenance rituximab following induction chemo-immunotherapy for mantle cell lymphoma: long-term follow-up of a pilot study from the Wisconsin Oncology Network.

Mantle cell lymphoma (MCL) is challenging to manage, with a median survival of 3-5 years. While intensive strategies are often appropriate for younger patients, these approaches are often not appropriate for older patients. In 2006, we reported our initial results using modified R-hyperCVAD (rituximab with hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with maintenance rituximab. The complete response rate was 64%, and median progression-free survival (PFS) 37 months. Herein, we update our results, now with a median follow-up of 62 months. The median PFS is unchanged and the median overall survival (OS) is 70 months. The proportion of patients surviving at 5 years is 62%, comparable to studies using intensive strategies in similar patient populations. No late toxicities were noted in our cohort. These long-term results suggest that the modified R-hyperCVAD regimen with maintenance rituximab is an excellent option for older patients with newly diagnosed mantle cell lymphoma.

Rituximab and CHOP chemotherapy plus GM-CSF for previously untreated diffuse large B-cell lymphoma in the elderly: a Wisconsin oncology network study.

PURPOSE: Human recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) may potentiate rituximab activity by upregulating CD20 expression and activating effector cells necessary for antibody-dependent cellular cytotoxicity. GM-CSF was combined with standard rituximab + CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) chemotherapy (R-CHOP) in the treatment of elderly patients with de novo diffuse large B-cell lymphoma (DLBCL). PATIENTS AND METHODS: Thirty-eight patients over the age of 60 years with newly diagnosed DLBCL were treated with R-CHOP every 21 days for 6-8 cycles and GM-CSF 250 µg/m2 per day on days 3-10. Patients were evaluated for response after cycles 4, 6, and 8. The primary endpoint was the rate of complete response, and secondary endpoints were progression-free survival (PFS), event-free survival, and overall survival (OS). RESULTS: Thirty-eight patients were enrolled, with a median age of 72 years, and 29% of patients having high-risk disease (International Prognostic Index [IPI] score ≥ 4). A complete or unconfirmed complete response (CR) was achieved in 53% of patients. After a median follow-up of 51.1 months, the 3-year PFS and OS were 78% and 84%. Twenty-one percent of patients discontinued protocol treatment because of chemotherapy-related toxicity and 16% because of GM-CSF toxicity. Dose intensity for planned chemotherapy cycles was 81.1%. CONCLUSION: These data suggest that survival outcomes may be modestly improved when GM-CSF is combined with R-CHOP in the treatment of elderly DLBCL. GM-CSF had toxicity precluding planned administration in 16% of patients, which may limit usefulness of this agent. Further investigation of GM-CSF in combination with rituximab-containing chemotherapy is warranted.

Circulating endothelial cells in patients with chronic lymphocytic leukemia.

Angiogenesis is increased in B-cell chronic lymphocytic leukemia (B-CLL). We wanted to quantify and characterize the circulating endothelial cells (CECs) in patients with B-CLL and correlate with plasma angiogenesis-related factors. Using a four-color flow cytometry, we prospectively analyzed the CEC in the whole blood of 20 healthy controls and 20 patients with B-CLL. We quantified (CD45-/CD31+/CD146+) and characterized the CECs according to whether they were apoptotic (annexin stain) or activated (CD106+). We also measured plasma levels of vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF-2), and thrombospondin-1 (TSP-1). Most patients (90%) had Rai stages 0-2 at the time of diagnosis. As a group, B-CLL patients had higher number of CECs (median of 26.5 cells/ml) compared (P = 0.04) to healthy controls (18.5 cells/ml). However, only four (20%) patients had elevated CEC counts, defined as >/=2 SD of the control mean (>/=53 cells/ml). The proportions of apoptotic (P = 0.83) and activated (P = 0.12) CECs were similar in both groups. B-CLL patients had higher FGF-2 (P < 0.001), lower TSP-1 (P = 0.004), and similar VEGF (P = 0.27) plasma levels. The number of CECs was not associated with Rai stage, absolute lymphocyte count, or levels of angiogenesis-related factors. CECs are increased in only a small fraction of B-CLL patients in our cohort with low rates of apoptosis and activation. While no correlation was found between CECs and clinical features, more studies in a larger patient sample size and advanced disease are necessary.

Cholecystectomy and acquired factor VIII inhibitor coagulopathy.

The purpose of this study was to describe the outcome of patients undergoing surgery with recognized and unrecognized factor VIII inhibitor. The setting was a tertiary care center with a community-based general surgery training program. Two patients with acquired factor VIII inhibitor coagulopathy required cholecystectomy. Interventions included intravenous immunoglobulin (IVIG) and factor VIII transfusions. An elderly patient undergoing urgent open cholecystectomy for acute cholecystitis exsanguinated despite postoperative recognition and treatment of factor VIII inhibitor. A second patient with known factor VIII inhibitor underwent laparoscopic cholecystectomy with perioperative transfusions of factor VIII and IVIG. No hemorrhage occurred, but cost to the patient exceeded 50,000 dollars. Acquired factor VIII inhibitor coagulopathy is rare and potentially lethal. Preoperative recognition and appropriate hematologic intervention is crucial to achieve a successful outcome.

Honing an advance care planning intervention using qualitative analysis: the Living Well interview.

Advance care planning requires an explicit and comprehensive discussion of patient values and conceptualization of quality of life. The Living Well open-ended interview intervention was developed to help patients and their health care agents to engage in a meaningful discussion of values so that decisions made in the last year of life are made with the patients' values in mind. We used qualitative and quantitative analysis to streamline this 10-question interview, and to generate hypotheses for future research. Interviews with 52 terminally ill patients were coded according to methodological weaknesses and content (support, spirit/feelings, palliative care, and quality of life). Node analysis revealed that three primary and three backup/probe questions yielded information that minimized misinformation, sampled from all four content areas, led to discussions of importance for good planning and decision-making, and may have led to earlier hospice admission than the national average. Two emerging themes, Generativity (passing on values or assets to the next generation) and essence (simple pleasures in everyday life), and were then quantitatively analyzed. People who mentioned generativity tended to be older, had a longer length of hospice stay, and a longer time to death after interview, compared to those who did not mention the theme. People who mentioned essence also tended to be older, but tended to have a shorter length of hospice stay and a shorter time to death after the interview. We conclude that this interview may improve access to hospice, and that generativity and essence are worthwhile themes for future research.